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The relationship between self-esteem and health promoting behaviors in working women Stone, Sharon Ann 1990

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THE RELATIONSHIP BETWEEN SELF-ESTEEM AND HEALTH PROMOTING BEHAVIORS IN WORKING WOMEN By SHARON ANN STONE B.Sc.Ng.Ed., The U n i v e r s i t y o f Ottawa, 1972 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (Health S e r v i c e s P l a n n i n g and A d m i n i s t r a t i o n ) i n THE FACULTY OF GRADUATE STUDIES Department of Health Care and Epidemiology We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA J u l y 1990 @ S h a r o n Ann Stone, 1990 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of lt£AuTif ^ ^ / b t g r r ^ c a g 1 / The University of British Columbia Vancouver, Canada DE-6 (2/88) ABSTRACT To date, the undertaking o f h e a l t h promoting behaviors i n working women i s an issue which has not been e x p l o r e d i n any depth. T h i s i s s u e has become p a r t i c u l a r l y important because of two p a r a l l e l phenomena - the r a p i d expansion o f the numbers of women i n the workforce, and the growing i n t e r e s t i n h e a l t h promotion - which have emerged i n Canada i n the l a s t twenty years or so. As w e l l , f a c t o r s which may r e l a t e to the undertaking of h e a l t h promoting behaviors have been hypothesized and i n v e s t i g a t e d to some extent, but have not y e t been f u l l y determined. Self-esteem has been proposed as one m o t i v a t i o n a l f a c t o r i n the undertaking o f h e a l t h promoting b e h a v i o r s . The present study has sought to determine the extent to which s e l f - e s t e e m , working c o n d i t i o n s , and demographic f a c t o r s , are r e l a t e d to the undertaking of h e a l t h promoting behaviors i n working women. The conceptual model used i s a mod i f i e d v e r s i o n of Pender's (1982) Health Promotion Model i n which a feedback mechanism operates, r e i n f o r c i n g the performance o f h e a l t h promoting behavior as s e l f - e s t e e m l e v e l s grow, and e q u a l l y , r e i n f o r c i n g s e l f - e s t e e m l e v e l s a c c o r d i n g i i i to the extent to which h e a l t h promoting behaviors are undertaken. Subjects of a random sample of 500 female union members working i n the g r e a t e r Vancouver area were mailed a q u e s t i o n n a i r e package. The q u e s t i o n n a i r e s asked f o r data on present l e v e l s of s e l f - e s t e e m , h e a l t h promoting behaviors p r e s e n t l y undertaken, and demographic and working c o n d i t i o n f a c t o r s . F o l l o w i n g a repeat m a i l i n g , the f i n a l number of responses a v a i l a b l e for a n a l y s i s was 229 (46%). Simple l i n e a r r e g r e s s i o n a n a l y s i s r e v e a l e d t h a t s e l f - e s t e e m was p r e d i c t i v e of h e a l t h promoting behaviors i n a g l o b a l sense, and, i n p a r t i c u l a r , of s e l f - a c t u a l i z a t i o n , h e a l t h r e s p o n s i b i l i t y , e x e r c i s e , and n u t r i t i o n . However, n e i t h e r demographic v a r i a b l e s , nor the number of hours worked per week, were found to be p r e d i c t i v e of h e a l t h promoting b e h a v i o r s . Although the study s u f f e r e d from a l i m i t a t i o n due to a low response r a t e , the sample was determined to be b r o a d l y r e p r e s e n t a t i v e of the union p o p u l a t i o n . T h e r e f o r e , these study r e s u l t s may be g e n e r a l i z e d to other urban, u n i o n i z e d females s h a r i n g s i m i l a r demographic c h a r a c t e r i s t i c s . i v TABLE OF CONTENTS Page No. Ab s t r a c t i i Table o f Contents i v L i s t o f Tables v i L i s t o f F i g u r e s v i i i Acknowledgement i x CHAPTER I. I n t r o d u c t i o n 1.1 Overview 1 1.2 Research Questions 4 1.3 O r g a n i z a t i o n 5 CHAPTER I I . T h e o r e t i c a l Framework 11.1 A M o d i f i e d V e r s i o n o f Pender's Health Promotion Model 6 11.2 Self-Esteem as i t R e l a t e s to the Conceptual Model 13 CHAPTER I I I . Self-Esteem and the Undertaking of Health Promoting Behaviors 111.1 D e f i n i t i o n A r i s i n g from E m p i r i c a l S t u d i e s 17 111.2 R e l a t i o n s h i p Between Self-Esteem and S e l f - C o n c e p t 18 111.3 Formation o f Self-Esteem 19 111.4 A l t e r a t i o n s i n L e v e l s o f Self-Esteem 21 111.5 Self-Esteem i n the Recent L i t e r a t u r e 24 111.6 Health Promoting Behaviors 27 111.7 Self-Esteem and Health Promoting Behaviors 30 111.8 Self-Esteem and Other S u b - v a r i a b l e s o f Health Promoting Behaviors 32 CHAPTER IV. Working Women and T h e i r Health IV.1 Women a t Risk 37 IV.2 Women i n the Workforce 39 IV.3 Working Womens• Health 40 IV.4 Working Women and Health Promotion 45 IV.5 Working Women and Self-Esteem 48 V CHAPTER V. Methodology V . l Research Questions 51 V.2 Research Design 51 V.3 Sample 52 V.4 Data C o l l e c t i o n 53 V.5 Instruments 54 V.6 Data A n a l y s i s and S t a t i s t i c a l Methods 57 CHAPTER VI. R e s u l t s VI.1 I n t r o d u c t i o n 61 VI.2 D e s c r i p t i v e S t a t i s t i c s 61 VI.3 I n f e r e n t i a l S t a t i s t i c a l R e s u l t s 67 VI.4 Other R e s u l t s 76 CHAPTER VII. D i s c u s s i o n V I I . l Main Research Question 81 VII.2 Secondary Research Question 89 VII.3 L i m i t a t i o n s VII.3.1 Low Response Rate 90 VII.3.2 Range R e s t r i c t i o n s o f Independent V a r i a b l e s 94 VII.3.3 Secondary Research Question 95 CHAPTER V I I I . Summary VIII.1 I n t r o d u c t i o n 98 VIII.2 C o n c l u s i o n s 99 VIII.3 Recommendations 101 VIII.4 I m p l i c a t i o n s 103 References 105 Appendices Appendix A l I n t r o d u c t o r y L e t t e r 115 Appendix A2 Union L e t t e r 116 Appendix A3 Q u e s t i o n n a i r e I n s t r u c t i o n s 117 Appendix A4 Rosenberg Self-Esteem Scale 118 Appendix A5 L i f e s t y l e P r o f i l e 119 Appendix A6 Q u e s t i o n n a i r e Number Three 120 Appendix B Reminder Note 123 Appendix C Sample S i z e Estimates f o r T Tests and B i v a r i a t e C o r r e l a t i o n s 124 LIST OF TABLES v i Page No. Table VI.1 Table VI.2 Demographic C h a r a c t e r i s t i c o f Sample Means, Standard D e v i a t i o n s , and Range o f Values f o r Continuous V a r i a b l e s 62 64 Table VI.3 Table VI.4 Table VI.5 Comparison o f Age, and Hours o f Work per Week f o r 1982 Union Data and f o r Present Study D e s c r i p t o r s o f I n j u r y / D i s a b i l i t y / C h r o n i c Disease P r e v e n t i n g E x e r c i s e Reported By Subjec t s R e l a t i o n s h i p Among Minor Independent V a r i a b l e s and Major Independent V a r i a b l e (Self-Esteem) 6 5 67 68 Table VI.6 R e l a t i o n s h i p Among Minor Independent V a r i a b l e , L i v i n g S i t u a t i o n (by sub-group), and Major Independent V a r i a b l e , Self-Esteem 71 Table VI.7 Table VI.8 Table VI.9 Table VI.10 R e l a t i o n s h i p Among Minor Independent V a r i a b l e s and Major Dependent V a r i a b l e (Health Promoting Behaviors) 72 R e l a t i o n s h i p Among Minor Independent V a r i a b l e , L i v i n g S i t u a t i o n (by sub-group), and Major Dependent V a r i a b l e , Health Promoting Behaviors 73 R e l a t i o n s h i p Between Major Independent V a r i a b l e , Self-Esteem, and Major Dependent V a r i a b l e , Health Promoting Behavior O v e r a l l , and I t s S i x Subscales 75 R e l a t i o n s h i p Between Independent V a r i a b l e , I n j u r y , and E x e r c i s e Subscale o f Health Promoting L i f e s t y l e s P r o f i l e 77 Table VI.11 R e l a t i o n s h i p Between Smoking Status and H e a l t h Promoting Behaviors 78 v i i Table VI.12 R e l a t i o n s h i p Between the Recency o f Q u i t t i n g Smoking, and Health Promoting Behavior 79 LIST OF FIGURES v i i i Page No. F i g u r e 2.1 An Adaptation of Pender's Health Promotion Model 7 F i g u r e 2.2 A M o d i f i e d V e r s i o n o f Pender's Health Promotion Model 12 i x ACKNOWLEDGEMENT I am g r a t e f u l to L a r r y Stoffman, D i r e c t o r o f Occu p a t i o n a l Health and Sa f e t y , United Food and Commercial Workers Union o f B.C., and h i s s t a f f members, Karen and Kay, f o r t h e i r c o o p e r a t i o n i n the data c o l l e c t i o n phase o f t h i s r e s e a r c h . My husband i s a p p r e c i a t e d f o r h i s moral support throughout, and h i s a s s i s t a n c e with data e n t r y . For t h e i r a s s i s t a n c e i n packaging q u e s t i o n a i r e s , I thank A l a n and Margery Hargrove. To the women who responded to my q u e s t i o n n a i r e package, I a l s o extend my a p p r e c i a t i o n . I acknowledge the generous c o n t r i b u t i o n o f my t h e s i s committee members, Dr. John Milsum. Dr. Sam Sheps, and Dr. Clyde Hertzman, f o r c o n s i s t e n t l y p r o v i d i n g me with v a l u a b l e feedback and support throughout the r e s e a r c h process. Dr. Milsum a l s o c o n t r i b u t e d e s s e n t i a l e d i t i n g s k i l l s . L a s t l y , I am e s p e c i a l l y g r a t e f u l to Sandra Wiggins f o r her advic e and guidance with the s t a t i s t i c a l a n a l y s i s . 1 CHAPTER ONE INTRODUCTION I.1 Overview T r a d i t i o n a l l y , h e a l t h has been d e f i n e d i n terms of absence of i l l n e s s , u s i n g a medical model. In the l a s t ten to f i f t e e n y e a r s , i n c r e a s i n g importance has been placed on d e f i n i n g h e a l t h so that i t i n c l u d e s p r e v e n t i v e and promotive a c t i v i t i e s . The Lalonde r e p o r t (1974) introduced some of these concepts to Canadians, and o u t l i n e d a l i n k a g e between m o r t a l i t y r a t e s and l i f e s t y l e s . That r e p o r t served to usher i n a new e r a of thought about h e a l t h and i t s determinants. Emphasis was placed on what i n d i v i d u a l s c o u l d do f o r themselves, not only to prevent i l l n e s s , but to promote wellness w i t h i n themselves. Modern e f f o r t s to d e s c r i b e and c o n c e p t u a l i z e a h e a l t h model, as d i s t i n c t from a medical one, may be dated roughly from the 1950's (Rosenstock, 1974). A h e a l t h b e l i e f model of p r e v e n t i v e h e a l t h care was formulated by Rosenstock, Hochblaum, L e v e n t h a l , and Kegeles by the end of the 1960's (Maiman and Becker, 1974). T r a v i s (1977) developed the i l l n e s s / w e l l n e s s 2 continuum i n 1973. Pender (1982) saw a d i s t i n c t i o n between p r o t e c t i v e or p r e v e n t i v e behaviors and h e a l t h promoting behaviors. She d e s c r i b e s p r e v e n t i v e behaviors as being " d i r e c t e d toward d e c r e a s i n g the p r o b a b i l i t y of encountering i l l n e s s by a c t i v e p r o t e c t i o n of the body a g a i n s t unnecessary s t r e s s o r s or d e t e c t i o n of i l l n e s s a t an e a r l y stage" (Pender, 1982, p.16). Health promoting behaviors are d e s c r i b e d as being " d i r e c t e d toward s u s t a i n i n g or i n c r e a s i n g the l e v e l of w e l l - b e i n g , s e l f - a c t u a l i z a t i o n , and f u l f i l l m e n t of a g i v e n i n d i v i d u a l or group" (Pender, 1982, p.16). Dunn (1977) d e s c r i b e d the goal of h e a l t h promoting behavior as going beyond p r e v e n t i o n to high l e v e l w e l l n e s s . L i t t l e r e s e a r c h has been done on the f a c t o r s a s s o c i a t e d with h e a l t h promoting b e h a v i o r s . S e l f -esteem has been proposed as a v a r i a b l e which i s a m o t i v a t i n g f a c t o r i n h e a l t h promoting behaviors (Pender, 1982). Pender's theory i n c o r p o r a t e d the view t h a t " b e l i e f i n p e r s o n a l worth allows i n d i v i d u a l s to spend time on self-improvement" (1982, p.69). Maslow (1954, 1968) f e l t t h a t a l l people have a need to esteem or value themselves. He p l a c e d s e l f - e s t e e m second only 3 to s e l f - a c t u a l i z a t i o n on the top of the h i e r a r c h i a l pyramid o f b a s i c human needs i n t h i s m o t i v a t i o n a l theory. Today, h e a l t h promotion has become a buzzword. Health l i t e r a t u r e i s r e p l e t e with i n f o r m a t i o n on the su b j e c t . The F e d e r a l Government has taken i n i t i a t i v e s i n the area of h e a l t h promotion by: 1) e s t a b l i s h i n g a Health Promotion D i r e c t o r a t e ; 2) sponsoring i n t e r n a t i o n a l conferences on the s u b j e c t ; 3) deve l o p i n g s t r a t e g i e s f o r Canadian implementation; 4) p u b l i s h i n g p e r i o d i c a l s ; 5) commissioning r e s e a r c h p r o j e c t s . Other Canadian o r g a n i z a t i o n s such as the Canadian P u b l i c Health A s s o c i a t i o n have supported h e a l t h promotion concepts by forming a h e a l t h promotion d i v i s i o n and sponsoring p r o j e c t s such as the Strengthening Community Health p r o j e c t ( B h a t t i , 1989). Another p a r a l l e l phenomenon, has been the growing numbers of women who have r e c e n t l y j o i n e d the p a i d workforce. Working women now rep r e s e n t a l a r g e p a r t o f the l a b o r f o r c e i n Canada. Approximately, 1,754,000 women entered the l a b o r f o r c e between 1974 and 1984, r e p r e s e n t i n g a f i f t y percent i n c r e a s e (Labour Canada, 1985-86). I t can be p o s i t e d that the dramatic 4 in c r e a s e s i n women working o u t s i d e the home probably have had or w i l l have some k i n d o f impact on the h e a l t h of these women. Although there i s c o n f l i c t i n g o p i n i o n over whether womens' h e a l t h i s a f f e c t e d by employment o u t s i d e the home, on the whole, i t appears that women who are employed have good h e a l t h (Verbrugge, 1984; Jennings, Mazark, and McKinlay, 1984). Only one study has d e s c r i b e d the r e l a t i o n s h i p between s e l f - e s t e e m and h e a l t h promoting behaviors i n working women. Th i s t o p i c w i l l t h e r e f o r e be ex p l o r e d i n t h i s study. I.2 Research Questions The o b j e c t i v e o f t h i s r e s e a r c h i s to explo r e the r e l a t i o n s h i p between s e l f - e s t e e m and the undertaking o f h e a l t h promoting behaviors i n working women, u s i n g a d e s c r i p t i v e , c r o s s - s e c t i o n a l design. Two q u e s t i o n s w i l l be addressed. The main q u e s t i o n i s : 1. What i s the r e l a t i o n s h i p between s e l f - e s t e e m , demographic v a r i a b l e s , working c o n d i t i o n s , and the extent to which working women undertake h e a l t h promoting behaviors? A secondary q u e s t i o n i s : 2. To what extent do women who work o u t s i d e the home undertake h e a l t h promoting behaviors? 5 I . 3 O r g a n i z a t i o n Chapter Two w i l l p r o v i d e a conceptual framework to be used f o r the study. A review o f the l i t e r a t u r e c o n c erning s e l f - e s t e e m , i t s d e f i n i t i o n and formation, as w e l l as h e a l t h promoting behaviors and t h e i r l i n k a g e with s e l f - e s t e e m , w i l l be undertaken i n Chapter Three. Chapter Four w i l l focus on working women and t h e i r h e a l t h , and w i l l review any pre v i o u s r e s e a r c h done i n co n n e c t i o n with working women and se l f - e s t e e m , and working women and h e a l t h promoting b e h a v i o r s . The data c o l l e c t i o n process, i n c l u d i n g the r e s e a r c h design, sample, procedure, and instruments used, w i l l be d e s c r i b e d i n Chapter F i v e . Chapter S i x w i l l present the r e s u l t s o f the data a n a l y s i s , and a d i s c u s s i o n of these w i l l be presented i n Chapter Seven. F i n a l l y , Chapter E i g h t , w i l l summarize the study, p r e s e n t i n g recommendations, i m p l i c a t i o n s , and study c o n c l u s i o n s . 6 CHAPTER TWO THEORETICAL FRAMEWORK II . 1 . A MODIFIED VERSION OF PENDER'S HEALTH PROMOTION  MODEL A number of models which d e s c r i b e the determinants of h e a l t h behaviors have been developed (Becker, 1974: Pender, 1982; K e r s e l l & Milsum, 1985; Pender, 1987). The t h e o r e t i c a l framework f o r t h i s study i s based on Pender's Health Promotion Model (1982). A schematic r e p r e s e n t a t i o n o f i t appears below, F i g 2.1. In d e v e l o p i n g t h i s model, Pender i n c o r p o r a t e d s t r u c t u r a l elements of the Health B e l i e f Model (Becker, 1974) together with a model known as the M o d i f i e d Health B e l i e f Model which she had developed i n 1982. The model i n F i q u r e 2.1 suggests t h a t m o t i v a t i o n p l a y s a key r o l e i n i n i t i a t i n g and s u s t a i n i n g h e a l t h promoting behaviors. The major sources o f m o t i v a t i o n for human behavior are e i t h e r a c t u a l i z i n g or s t a b i l i z i n g tendencies (Pender, 1982). S t a b i l i z i n g tendencies maintain homeostasis w i t h i n the i n d i v i d u a l , whereas a c t u a l i z i n g tendencies aim a t a c h i e v i n g change. 7 MOTIVATION 4 I n d i v i d u a l P e r c e p t i o n s Importance o f h e a l t h  P e r c e i v e d c o n t r o l D e s i r e f o r competence \ Sel f -awareness; [ S e l f - e s t e e m ' D e f i n i t i o n o f h e a l t h  P e r c e i v e d h e a l t h s t a t u s Perce ived b e n e f i t s of h e a l t h promoting behaviors M o d i f y i n g L i k e l i h o o d F a c t o r s of A c t i o n i Demographic v a r i a b l e s (age, sex. rac e , e t h n i c i t y . e d u c a t i o n , income, o c c u p a t i o n P e r c e i v e d b a r r i e r s to a c t i o n I n t e r p e r s o n a l ( u n a v a i l a b i l i t y , v a r i a b l e s c o s t , ( e x p e c t a t i o n s inconvenience, of s i g n i f i c a n t extent o f l i f e o t h e r s , f a m i l y change r e q u i r e d ) p a t t e r n s o f h e a l t h c a r e , L i k e l i h o o d o f i n t e r a c t i o n s t a k i n g h e a l t h with h e a l t h promoting p r o f e s s i o n a l s ) a c t i o n T S i t u a t i o n a l Cues to a c t i o n v a r i a b l e s (awareness of ( h e a l t h p o t e n t i a l f o r promoting growth, advice o p t i o n s from o t h e r s . a v a i l a b l e , mass media) p r i o r experience with h e a l t h promoting a c t i o n s ) DECISION-MAKING PHASE ACTION PHASE Fi g u r e 2.1 An Ad a p t a t i o n o f Pender's Health Promotion Model (Pender, 1982) 8 growth and maturation. Health promoting behaviors are m a n i f e s t a t i o n s of a c t u a l i z i n g tendencies, because i t i s these t h a t d r i v e the i n d i v i d u a l towards s p e c i f i c a c t i v i t i e s r e s u l t i n g i n w e l l being. The reader i s r e f e r r e d to the model i n F i g u r e 2.1 as a v i s u a l a i d f o r the f o l l o w i n g d i s c u s s i o n o f the framework for the study. The four main determinants of h e a l t h promoting behavior are d e s c r i b e d as: i n d i v i d u a l p e r c e p t i o n s , modifying f a c t o r s of i n d i v i d u a l p e r c e p t i o n s , p e r c e i v e d b a r r i e r s and cues to a c t i o n . The f i r s t two determinants are p a r t of a d e c i s i o n -making phase, and the second two of an a c t i o n phase. The decision-making phase i n v o l v e s the i n t e r a c t i o n of i n d i v i d u a l p e r c e p t i o n s and modifying f a c t o r s . I n d i v i d u a l p e r c e p t i o n s t h a t f a c i l i t a t e or s u s t a i n h e a l t h promoting behavior a r e : the importance o f h e a l t h , p e r c e i v e d c o n t r o l , d e s i r e f o r competence, s e l f -awareness, s e l f - e s t e e m , h e a l t h from the p e r s p e c t i v e of a c t u a l i z a t i o n , p e r c e i v e d h e a l t h s t a t u s , and p e r c e i v e d b e n e f i t s of h e a l t h promoting be h a v i o r s . Demographic v a r i a b l e s , i n t e r p e r s o n a l v a r i a b l e s and s i t u a t i o n a l v a r i a b l e s are the modifying f a c t o r s that 9 modify the i n d i v i d u a l ' s l i k e l i h o o d o f undertaking h e a l t h promoting behaviors by i n f l u e n c i n g the i n d i v i d u a l p e r c e p t i o n s . E q u a l l y however, the e i g h t i n d i v i d u a l p e r c e p t i o n s j u s t d e s c r i b e d and i l l u s t r a t e d i n F i g . 2.1, operate i n the re v e r s e d i r e c t i o n so as to i n f l u e n c e the i n t e r p e r s o n a l v a r i a b l e s , and s i t u a t i o n a l v a r i a b l e s . The i n t e r a c t i o n o f i n d i v i d u a l p e r c e p t i o n s with modifying f a c t o r s may be seen i n the f o l l o w i n g example. A young woman p e r c e i v e s her h e a l t h s t a t u s ( i n d i v i d u a l p e r c e p t i o n ) to be poor due to o b e s i t y and i n a c t i v i t y . Her aunt, who a l s o b e l i e v e s t h i s to be the case, i n f l u e n c e s the young woman to engage i n a r e g u l a r e x e r c i s e program as w e l l as a weight l o s s program ( e x p e c t a t i o n s o f s i g n i f i c a n t o t h e r s ) . The ni e c e ' s l e v e l o f income (demographic f a c t o r ) allows her to proceed with the e x e r c i s e and weight l o s s programs, assuming t h a t fees and c o s t s are i n v o l v e d i n these programs. A f t e r engaging i n the two programs f o r s e v e r a l months, the nie c e i s s u c c e s s f u l i n a c h i e v i n g 50% o f her goals f o r weight l o s s and e x e r c i s e . Although o r i g i n a l l y , her aunt t h i n k s she should c o ntinue u n t i l the 100% t a r g e t s are achieved, the niece convinces the aunt that her p e r c e i v e d h e a l t h s t a t u s has improved s i g n i f i c a n t l y by p o i n t i n g out how much b e t t e r she f e e l s , and the programs are subsequently dropped. Thus, an i n d i v i d u a l p e r c e p t i o n has, i n t u r n , i n f l u e n c e d the e x p e c t a t i o n o f a s i g n i f i c a n t o t her. Determinants of whether an i n d i v i d u a l takes h e a l t h promoting a c t i o n i n the a c t i o n phase o f the model i n c l u d e the p e r c e i v e d b a r r i e r s to a c t i o n and cues to a c t i o n . P e r c e i v e d b a r r i e r s are d e s c r i b e d as u n a v a i l a b i l i t y , c o s t , inconvenience, and the extent of l i f e change r e q u i r e d . Cues to a c t i o n i n c l u d e an awareness o f the p o t e n t i a l f o r growth, advi c e from o t h e r s , and mass media. As the o r i g i n a l model i n F i q u r e 2.1 shows, there i s an i m p l i c i t e x p e c t a t i o n t h a t matters proceed u n i d i r e c t i o n a l l y from l e f t to r i g h t . In i t s s i m p l e s t i n t e r p r e t a t i o n , t h i s model i n d i c a t e s t h a t p e r c e i v e d h e a l t h s t a t u s (as an example of an i n d i v i d u a l p e r c e p t i o n ) would determine whether an i n d i v i d u a l undertakes e x e r c i s e (as an example of a h e a l t h promoting b e h a v i o r ) . Pender s t a t e s , however, t h a t the a c t i o n phase can precede the decision-making phase. In other words, an i n d i v i d u a l c o u l d e x e r c i s e and subsequently f e e l t h a t t h e i r h e a l t h s t a t u s has improved as a r e s u l t of the e x e r c i s e . T h i s concept i s not i n c l u d e d i n the schema of Pender's model. Other h e a l t h behavior models have i n d i c a t e d a feedback loop which p r o v i d e s an e x p l a n a t i o n of the m o t i v a t i o n of an i n d i v i d u a l to continue to undertake health-promoting behaviors ( K e r s e l l & Milsum, 1985). In the v e r s i o n of Pender's model below (Figure 2.2), which has been m o d i f i e d by t h i s w r i t e r , j u s t such a feedback mechanism i s i l l u s t r a t e d . T h i s m o d i f i e d v e r s i o n may be a more acc u r a t e v e r s i o n of r e a l i t y . 12 I n d i v i d u a l P e r c e p t i o n s M o d i f y i n g F a c t o r s Importance of h e a l t h Perce ived c o n t r o l D e s i r e f o r competence Sel f-awarenessL—, Self-esteem D e f i n i t i o n of h e a l t h e r c e i v e d h e a l t h s t a t u s P e r c e i v e d b e n e f i t s o f h e a l t h promoting behaviors Demographic v a r i a b l e s (age, sex, race, e t h n i c i t y , e d u c a t i o n , income, o c c u p a t i o n I n t e r p e r s o n a l var i a b l e s ( e x p e c t a t i o n s of s i g n i f i c a n t o t h e r s , f a m i l y p a t t e r n s o f h e a l t h c a r e , i n t e r a c t i o n s with h e a l t h p r o f e s s i o n a l s ) S i t u a t i o n a l v a r i a b l e s ( h e a l t h promoting o p t i o n s a v a i l a b l e , p r i o r experience with h e a l t h promoting a c t i o n s ) L i k e l i h o o d of A c t i o n P e r c e i v e d b a r r i e r s to a c t i o n ( u n a v a i l a b i l i t y , c o s t , inconvenience, extent o f l i f e change required)^ L i k e l i h o o d o f t a k i n g h e a l t h promoting a c t i o n Cues to a c t i o n (awareness of p o t e n t i a l f o r growth, advice from o t h e r s , mass media) DECISION-MAKING PHASE ACTION PHASE Fi g u r e 2.2 A M o d i f i e d V e r s i o n of Pender's Health Promotion Model (Stone, 1990) c 13 II.2 SELF-ESTEEM AS IT RELATES TO THE CONCEPTUAL  MODEL Self-esteem i s seen as one of the e i g h t m o t i v a t i o n a l f a c t o r s a f f e c t i n g the decision-making phase of h e a l t h promoting behavior. Three main c a t e g o r i e s o f f a c t o r s modify the i n d i v i d u a l ' s s e l f -esteem: demographic, i n t e r p e r s o n a l , and s i t u a t i o n a l (see F i g u r e 2.2). The demographic f a c t o r s i n c l u d e age, sex r a c e , e t h n i c i t y , e d u c a t i o n , income, and o c c u p a t i o n . The i n t e r p e r s o n a l f a c t o r s i n c l u d e e x p e c t a t i o n s o f s i g n i f i c a n t o t h e r s , f a m i l y p a t t e r n s o f h e a l t h c a r e , and i n t e r a c t i o n s with h e a l t h p r o f e s s i o n a l s . The s i t u a t i o n a l f a c t o r s i n c l u d e a v a i l a b l e h e a l t h promoting o p t i o n s , and p r i o r experience with h e a l t h promoting a c t i o n s . As an example, an i n d i v i d u a l who has access to worksite h e a l t h promotion programs sponsored by her employer, and who has f r i e n d s who tend to i n v i t e her to p a r t i c i p a t e with them i n a c t i v i t i e s such as yoga c l a s s e s (both being i n t e r p e r s o n a l v a r i a b l e s ) , may f e e l b e t t e r about h e r s e l f , r e c o g n i z i n g t h a t she i s f o r t u n a t e to have many o p p o r t u n i t i e s f o r h e a l t h promotion 14 p a r t i c i p a t i o n . A c c o r d i n g to the model d e p i c t e d i n F i q u r e 2 . 2 , an i n d i v i d u a l ' s s e l f - e s t e e m has an impact on f a m i l y p a t t e r n s o f h e a l t h c a r e , i n t e r a c t i o n s with h e a l t h p r o f e s s i o n a l s , and on the e x p e c t a t i o n s o f s i g n i f i c a n t o t h e r s (the i n t e r p e r s o n a l f a c t o r s d e s c r i b e d p r e v i o u s l y ) . The i n d i v i d u a l ' s view of the h e a l t h promoting o p t i o n s a v a i l a b l e to her, as w e l l as any p r i o r experience which she has had with h e a l t h promoting a c t i o n s (the s i t u a t i o n a l f a c t o r s d e s c r i b e d above) are a l s o i n f l u e n c e d by her l e v e l o f se l f - e s t e e m . For example, i f an i n d i v i d u a l thought h i g h l y o f h e r s e l f , she would be more l i k e l y to b e l i e v e that she c o u l d undertake h e a l t h promoting behaviors i n a v a r i e t y of ways - through e x e r c i s e , s t r e s s management techniques, p o s i t i v e n u t r i t i o n a l s t r a t e g i e s e t c . In c o n t r a s t , an i n d i v i d u a l who d i d not have a very high o p i n i o n o f h e r s e l f , might have 'tunnel v i s i o n ' when c o n s i d e r i n g h e a l t h promotion o p p o r t u n i t i e s . She might r u l e out most o p t i o n s , f e e l i n g t h a t i t i s onl y p o s s i b l e f o r her to c a r r y out one type of a c t i v i t y . I t i s i n t e r e s t i n g to note t h a t , while the model a s s e r t s a two-way d i r e c t i o n a l flow between 15 i n t e r p e r s o n a l v a r i a b l e s and s e l f - e s t e e m and e q u a l l y so between s i t u a t i o n a l v a r i a b l e s and s e l f - e s t e e m , the flow i s u n i d i r e c t i o n a l o n l y i n the case of demographic v a r i a b l e s . That i s , the model i n F i g u r e 2.2 i d e n t i f i e s demographic f a c t o r s or v a r i a b l e s as p r e d i c t o r s of the l i k e l i h o o d of t a k i n g h e a l t h promoting a c t i o n through t h e i r i n t e r m e d i a r y i n f l u e n c e on s e l f - e s t e e m and other of the e i g h t i n d i v i d u a l p e r c e p t i o n s . S t a t e d d i f f e r e n t l y , the s e l f - e s t e e m of an i n d i v i d u a l , having been i n f l u e n c e d by demographic f a c t o r s a s s o c i a t e d with that i n d i v i d u a l , i s then p r e d i c t i v e of whether the i n d i v i d u a l w i l l undertake h e a l t h promoting behaviors. The model does not a s s e r t , however, t h a t the s e l f -esteem of an i n d i v i d u a l has an impact on demographic f a c t o r s . T h i s may be a shortcoming of Pender's model. I n t u i t i v e l y , i t would seem as though the s e l f - e s t e e m of an i n d i v i d u a l might i n f l u e n c e that i n d i v i d u a l ' s c h o ice of o c c u p a t i o n , l e v e l of e d u c a t i o n , and l e v e l of income, to some ext e n t . Other demographic f a c t o r s such as age, sex, r a c e , e t h n i c i t y would not, of course, be a l t e r a b l e by s e l f - e s t e e m . However, how an i n d i v i d u a l f e e l s about h e r s e l f with regard to these four f a c t o r s , would be r e l a t e d to her s e l f - e s t e e m . As p r e v i o u s l y mentioned, s e l f - e s t e e m i s one of the e i g h t p o s s i b l e determinants (envisoned by Pender, 1982) of the l i k e l i h o o d of t a k i n g h e a l t h promoting a c t i o n . The u n d e r l y i n g assumption i s t h a t i n d i v i d u a l s who value themselves w i l l be more l i k e l y to take the time necessary f o r self-improvement, expressed as h e a l t h promoting behaviors. Once the i n d i v i d u a l has made the d e c i s i o n to take h e a l t h promoting a c t i o n (to perform a h e a l t h promoting b e h a v i o r ) , that i n d i v i d u a l may be rewarded with f e e l i n g s of i n c r e a s e d s e l f - e s t e e m which may, i n t u r n , i n f l u e n c e a d e c i s i o n to repeat the health, promoting behavior. This i s i l l u s t r a t e d i n the feedback loop between the a c t i o n phase and the decision-making phase i n the modified v e r s i o n of Pender's model (F i q u r e 2.2). 17 CHAPTER THREE SELF-ESTEEM AND THE UNDERTAKING OF HEALTH PROMOTING BEHAVIORS SELF-ESTEEM I I I . l D e f i n i t i o n A r i s i n g From E m p i r i c a l S t u d i e s Rosenberg, Coopersmith and Z i l l e r made important e a r l y c o n t r i b u t i o n s to t h e o r i e s on s e l f - e s t e e m which were based on e m p i r i c a l s t u d i e s . Rosenberg (1965) s t u d i e d the dynamics of the development of a p o s i t i v e s e l f - i m a g e d u r i n g adolescence. He saw s e l f - e s t e e m as "the e v a l u a t i o n which the i n d i v i d u a l makes and c u s t o m a r i l y maintains with regard to h i m s e l f . " (1965, p.64) T h i s a t t i t u d e expresses approval or d i s a p p r o v a l . Coopersmith a l s o saw s e l f - e s t e e m i n the same l i g h t - as a "personal judgment o f worthiness that i s expressed i n the a t t i t u d e s the i n d i v i d u a l holds toward h i m s e l f " . (1967, p.5) Coopersmith performed a l o n g i t u d i n a l study o f normal boys and found t h a t they c o u l d be c a t e g o r i z e d i n three groups, as p o s s e s s i n g high, medium or low l e v e l s o f s e l f - e s t e e m . 18 Z i l l e r saw s e l f - e s t e e m as a s o c i a l c o n s t r u c t , that i s s e l f - e v a l u a t i o n emerges l a r g e l y w i t h i n a s o c i a l frame of r e f e r e n c e . However, Z i l l e r , Rosenberg and Coopersmith a l l agreed t h a t high l e v e l s of s e l f - e s t e e m are important f o r p e r s o n a l i t y i n t e g r a t i o n (Wells & Marwell, 1976). Wells and Marwell (1976) summarized Rosenberg and Coopersmith 1s approach to s e l f - e s t e e m as " i f s e l f i s thought of as a s e t of r e f l e x i v e a t t i t u d e s , s e l f - e s t e e m can be d e s c r i b e d as the e v a l u a t i v e component of each of these a t t i t u d e s , or as the t o t a l i t y of a l l such e v a l u a t i o n s " (p. 18). I I I . 2 R e l a t i o n s h i p Between Self-Esteem and S e l f - Concept S e l f - c o n c e p t i s a much broader n o t i o n than s e l f -esteem (Gergen, 1971; Gecas, 1972; Coopersmith, 1967; Rosenberg, 1979; Buck i n Roy, 1984; D r i e v e r i n Roy, 1984). D r i e v e r sees s e l f - c o n c e p t d i v i d e d i n t o v a r i o u s components which can g e n e r a l l y be c l a s s i f i e d as the p h y s i c a l s e l f , the i n t e l l e c t u a l s e l f , the m o r a l - e t h i c a l s e l f , the emotional s e l f , and the s o c i a l s e l f . The e v a l u a t i v e dimension of each of these components i s c a l l e d s e l f - e s t e e m . " S e l f - c o n c e p t / ( t h e n ) i s h o w i n d i v i d u a l s s e e t h e m s e l v e s , w h e r e a s s e l f - e s t e e m i s h o w i n d i v i d u a l s f e e l a b o u t w h a t t h e y s e e w i t h i n t h e c o m p o n e n t s o f t h e i r s e l f - c o n c e p t " ( T a f t , 1 9 8 5 , p . 7 8 -7 9 ) . I I I . 3 F o r m a t i o n o f S e l f - E s t e e m R o s e n b e r g ( 1 9 8 1 ) c l e a r l y s t a t e s t h a t s e l f - c o n c e p t i s " n o t p r e s e n t a t b i r t h b u t a r i s e s o u t o f s o c i a l e x p e r i e n c e a n d i n t e r a c t i o n . . . " ( p . 5 9 3 ) . H e f u r t h e r d e s c r i b e s t w o d i f f e r e n t s o c i a l a p p r o a c h e s t o s e l f -c o n c e p t : 1 ) t h e b i o g r a p h i c a l a p p r o a c h , w h i c h d e s c r i b e s s e l f - c o n c e p t a s a " s t a b l e , e n d u r i n g f e a t u r e o f p e r s o n a l i t y " ( p . 5 9 3 ) , a n d 2 ) t h e s i t u a t i o n a l a p p r o a c h , w h i c h d e s c r i b e s s e l f - c o n c e p t a s a " s h i f t i n g , a d j u s t i v e p r o c e s s o f s e l f - p r e s e n t a t i o n i n s o c i a l i n t e r a c t i o n " ( p . 5 9 4 ) . R o s e n b e r g s u b s c r i b e s t o t h e f o r m e r a p p r o a c h , a l t h o u g h h e s t a t e s t h a t f u n d a m e n t a l c h a n g e s i n s e l f -c o n c e p t o c c u r t h r o u g h m i d d l e c h i l d h o o d a s w e l l a s e a r l y a n d l a t e a d o l e s c e n c e ( 1 9 7 9 ) . B e c a u s e s e l f - e s t e e m i s p a r t o f t h e b r o a d e r n o t i o n o f s e l f - c o n c e p t , i t m a y b e d e d u c e d t h a t s e l f - e s t e e m a l s o d e v e l o p s o u t o f s o c i a l e x p e r i e n c e a n d i n t e r a c t i o n . 20 F u r t h e r , Rosenberg (1981) d e s c r i b e s three p r i n c i p l e s of s e l f - e s t e e m f o r m u l a t i o n which c l e a r l y i n d i c a t e t h a t s e l f - e s t e e m i s not present a t b i r t h . These three p r i n c i p l e s a r e : r e f l e c t e d a p p r a i s a l s - meaning t h a t i f we p e r c e i v e t h a t others r e s p e c t us then we w i l l have high s e l f - e s t e e m , and our s e l f - e s t e e m w i l l be low i f we p e r c e i v e t h a t others do not r e s p e c t us; s o c i a l  comparison - we l e a r n about o u r s e l v e s by comparison with o t h e r s , and t h i s leads us to r a t e o u r s e l v e s i n r e l a t i o n to o t h e r s ; s e l f - a t t r i b u t i o n - we observe our o v e r t behavior as a means of drawing c o n c l u s i o n s about our inner motives, s t a t e s or t r a i t s i . e . I get high marks i n s c h o o l ; t h e r e f o r e I am a good student. Other authors seem to concur with the c o n c l u s i o n that s e l f - e s t e e m a r i s e s out of s o c i a l experience and i n t e r a c t i o n . Franks and M a r o l l a (197G) i d e n t i f y two processes which are necessary to the development of s e l f - e s t e e m : 1) the l o o k i n g - g l a s s s e l f or r e f l e c t e d a p p r a i s a l s of others which the authors term "outer s e l f - e s t e e m " ; and 2) f e e l i n g s of e f f i c a c y and  competence d e r i v e d from s e l f - p e r c e p t i o n s of one's own  a c t i o n s on the environment or "inner s e l f - e s t e e m " . This f i r s t p rocess, the " l o o k i n g - g l a s s s e l f " , was f i r s t i d e n t i f i e d b y C o o l e y i n 1 9 0 2 , a n d h a d b e e n t h e b a s i s o f b e l i e f o f t h e f o r m a t i o n o f s e l f - e s t e e m u n t i l t h e 1 9 7 0 ' s w h e n o t h e r e l e m e n t s b e l i e v e d t o c o n t r i b u t e t o t h e d e v e l o p m e n t o f s e l f - e s t e e m w e r e t h e o r i z e d ( F r a n k s & M a r o l l a , 1 9 7 6 ) . G e c a s a n d S c h w a l b e ( 1 9 8 3 ) s u p p o r t e d F r a n k s a n d M a r o l l a ' s t h e o r y o f t h e d u a l w a y o f d e v e l o p m e n t o f s e l f - e s t e e m . T h e y w e r e p a r t i c u l a r l y i n t e r e s t e d i n i n n e r s e l f - e s t e e m , a n d p r o p o s e d t h a t e f f i c a c y - b a s e d s e l f - e s t e e m w a s a r e s u l t o f t h e i n d i v i d u a l a c t i n g o n t h e e n v i r o n m e n t a s a c a u s a l a g e n t , t r a n s f o r m i n g t h e e n v i r o n m e n t , a n d d e r i v i n g s e l f - e s t e e m f r o m t h e e x p e r i e n c e . I I I . 4 A l t e r a t i o n s i n L e v e l s o f S e l f - E s t e e m T h e r e i s s o m e d i s a g r e e m e n t a s t o t h e t i m e f r a m e o f t h e f o r m a t i o n o f s e l f - e s t e e m . C o o p e r s m i t h ( 1 9 6 7 ) b e l i e v e d t h a t a n i n d i v i d u a l a r r i v e d a t a g e n e r a l a p p r a i s a l o f s e l f - w o r t h t h a t r e m a i n s f a i r l y s t a b l e s o m e t i m e b e f o r e m i d d l e c h i l d h o o d . C r o u c h a n d S t r a u b ( 1 9 8 3 ) , o n t h e o t h e r h a n d , s e e a d u l t h o o d a s t h e p o i n t i n t i m e w h e n " t h e b a s i c l e v e l o f s e l f - e s t e e m a p p e a r s t o b e f i r m l y e s t a b l i s h e d a n d r e l a t i v e l y u n c h a n g e a b l e " ( p . 6 5 ) . T h e y d o , h o w e v e r , d i s t i n q u i s h b e t w e e n a fundamental l e v e l o f s e l f - e s t e e m which they c a l l " b a s i c s e l f - e s t e e m " - the s e l f - e s t e e m which i s l a i d down i n e a r l y l i f e , and s e l f - e s t e e m which i s f u n c t i o n a l - t h i s l a t t e r i s over and above the fundamental l e v e l and may change "markedly from moment to moment and day to day" (p.65). According to these authors, f u n c t i o n a l s e l f -esteem can, a t some times, s u b s t a n t i a l l y exceed b a s i c s e l f - e s t e e m , although i n times o f s t r e s s , i t can re g r e s s so that f u n c t i o n a l s e l f - e s t e e m i s lower than b a s i c s e l f - e s t e e m . I t i s hypothesized t h a t " f u n c t i o n a l " s e l f - e s t e e m can be a l t e r e d through l i f e events and educ a t i o n . In summarizing the use of instruments to measure s e l f - e s t e e m , Wells and Marwell (1976) p o i n t out th a t most c l i n i c a l measurement to date has been a measure of "c h r o n i c or c h a r a c t e r i s t i c l e v e l s o f s e l f - e s t e e m " (p.246). The concept of s e l f - e s t e e m has thus been seen as an enduring concept. However, some experimental manipulations have been c a r r i e d out, and are presumably based on the assumption that s e l f - e s t e e m i s dynamic and has "acute or temporally v a r i a b l e l e v e l s " . Wells and Marwell do not agree with t r e a t i n g s e l f - e s t e e m as a dynamic concept f o r s e v e r a l reasons. Perhaps the most important i s t h a t "the conceptual s p e c i f i c a t i o n s u n d e r l y i n g s e l f - e s t e e m m a n i p u l a t i o n are not a v a i l a b l e " (p.249). Thus, r e s e a r c h e r s have not been able to l i n k the o p e r a t i o n a l i z a t i o n of s e l f - e s t e e m with the t h e o r e t i c a l concept of s e l f - e s t e e m as a temporally v a r i a b l e , dynamic concept. As w e l l , e t h i c a l i s s u e s r e g a r d i n g the m a n i p u l a t i o n of s e l f - e s t e e m are seen by Wells and Marwell as almost insurmountable. In summary. Wells and Marwell b e l i e v e that "there i s a p o t e n t i a l l y d e v e l o p i n g consensus t h a t the t h e o r e t i c a l l y most meaningful use of the concept 'self-esteem' a p p l i e s to a g l o b a l , p e r s i s t e n t , i f not immutable c h a r a c t e r i s t i c of the i n d i v i d u a l " (p.251). E p s t e i n (1973) has proposed a theory to e x p l a i n the r e l a t i v e s t a b i l i t y of s e l f - e s t e e m l e v e l s . He b e l i e v e s t h a t there are two fundamental opposing tendencies w i t h i n the i n d i v i d u a l which r e s u l t i n o v e r a l l balance and s t a b i l i t y . These tendencies are based on the f a c t t h a t the i n d i v i d u a l a c t s so that he w i l l f e e l good. The f i r s t tendency induces the i n d i v i d u a l to r a i s e h i s s e l f - e s t e e m so that he f e e l s good. The second tendency a c t s on the i n d i v i d u a l so that he attempts to a v o i d a drop i n s e l f - e s t e e m which would r e s u l t i n f e e l i n g bad. Thus, the i n d i v i d u a l when e v a l u a t i n g h i m s e l f , avoids u n r e a l i s t i c a l l y high e x p e c t a t i o n s so that he w i l l n e i t h e r s i n k low nor r i s e high i n h i s e v a l u a t i o n of h i m s e l f . The r e s u l t i s a r e l a t i v e s t a b i l i t y i n h i s se l f - e s t e e m . I I I . 5 Self-Esteem i n the Recent L i t e r a t u r e In the medical and n u r s i n g l i t e r a t u r e , A v i l l i o n (1986) found that no s i g n i f i c a n t c o r r e l a t i o n between c l i e n t p e r c e i v e d b a r r i e r s and s e l f - e s t e e m when l o o k i n g a t the s e l f - e s t e e m l e v e l s of wheelchair-bound i n d i v i d u a l s . B r i l l h a r t (1986) ex p l o r e d the p r e d i c t o r s of s e l f - a c c e p t a n c e f o r p h y s i c a l l y d i s a b l e d a d u l t s . Her c o n c l u s i o n s were t h a t knowledge of d i s a b i l i t y and p e r c e i v e d p h y s i c a l r e a l i t y (the r e a l i s t i c self-image) were found to be p r e d i c t o r s o f s e l f - a c c e p t a n c e f o r p h y s i c a l l y d i s a b l e d a d u l t s . Given t h a t s e l f - e s t e e m has been i d e n t i f i e d as perhaps the most important item o f i n f o r m a t i o n r e g a r d i n g s e l f - c o n c e p t (Rosenberg, 1965), and t h a t the e v a l u a t i v e dimension of each of the f i v e components of s e l f - c o n c e p t i s c a l l e d s e l f - e s t e e m ( D r i e v e r i n Roy, 1976), the l i t e r a t u r e on s e l f - c o n c e p t i s a l s o e x p l o r e d 2 5 i n t h i s chapter. In a sample o f 103 upper-middle c l a s s women, Rutledge (1987) found that s e l f - c o n c e p t was p o s i t i v e l y and s i g n i f i c a n t l y a s s o c i a t e d with frequency o f b r e a s t s e l f - e x a m i n a t i o n . The T o t a l p'* of the Tennessee S e l f -Concept Scale (TSCS), which measures the s e l f - e s t e e m component of s e l f - c o n c e p t , was used to measure s e l f -concept . Many s t u d i e s have e x p l o r e d the r e l a t i o n s h i p between s e l f - c o n c e p t and the h e a l t h promoting behavior of e x e r c i s e . For example, Vincent (1976) sought to determine i f d i f f e r e n c e s e x i s t e d i n s e l f - c o n c e p t scores among 460 c o l l e g e women grouped as a l t h l e t e s , n o n a t h l e t e s , p h y s i c a l e d u c a t i o n majors, ge n e r a l c o l l e g e students, p a r t i c i p a n t s i n high school c o m p e t i t i v e a t h l e t i c programs, and n o n p a r t i c i p a n t s i n these programs. Women who were p h y s i c a l e d u c a t i o n majors, and women who were p a r t i c i p a n t s i n c o m p e t i t i v e high school a t h l e t i c programs, had s i g n i f i c a n t l y higher scores than other groups. Most s t u d i e s support the n o t i o n t h a t p h y s i c a l f i t n e s s and s e l f - c o n c e p t are *For f o o t n o t e , r e f e r to the end of Chapter Three 26 c o r r e l a t e d . (Hanson & Nedde 1974; Leonardson & G a r g i u l o , 1978; Massie & Shephard 1971; Morgan, Roberts, Brand & Feinerman 1970; Brown, Morrow & L i v i n g s t o n , 1982). In c o n t r a s t , E i c k h o f f , Thorland and Ansorge (1983) found t h a t there was no p s y c h o l o g i c a l improvement a f t e r t r a i n i n g i n young a d u l t women except f o r those with low i n i t i a l f i t n e s s s t a t u s . P s y c h o l o g i c a l improvement was measured u s i n g the Tennessee Self-Concept s c a l e i n many of these s t u d i e s , i n c l u d i n g the one which d i d not f i n d a c o r r e l a t i o n . In some cases, (Brown, Morrow & L i v i n g s t o n , 1982; and E i c k h o f f , Thorland & Ansorge, 1983) two p s y c h o l o g i c a l aspects o f the Tennessee S e l f -Concept Scale were used - The T o t a l P o s i t i v e ( T o t a l P), and the P h y s i c a l S e l f ( P h y s s e l f ) . The T o t a l P r e f l e c t s the l e v e l o f general p o s i t i v e s e l f - e s t e e m , while the P h y s s e l f r e f l e c t s how i n d i v i d u a l s view t h e i r body, s t a t e o f h e a l t h , p h y s i c a l appearance, p h y s i c a l s k i l l s , and s e x u a l i t y . Thus, there appears to be a r e l a t i o n s h i p between s e l f - e s t e e m and e x e r c i s e as measured by the T o t a l P o s i t i v e aspect o f the Tennessee Se l f - C o n c e p t S c a l e . I t i s not c l e a r whether the T o t a l P t e s t instrument measures the fundamental l e v e l o f s e l f - e s t e e m ( b a s i c s e l f - e s t e e m ) , or the dyn a m i c / f u n c t i o n a l l e v e l o f s e l f - e s t e e m . The i s s u e o f whether s e l f - e s t e e m i s a s t a t i c or dynamic concept remains unresolved i n the l i t e r a t u r e . Wells and Marwell (1976) have concluded t h a t the concept i s b a s i c a l l y s t a t i c . However, some authors ( E i c k o f f e t a l . , 1983; Brown e t a l . , 1982; Hanson e t a l . , 1974), i n conducting pre and post t e s t i n g o f 'the t o t a l p o s i t i v e s e l f ( T o t a l P of the Tennessee S e l f -Concept Scale) or s e l f - e s t e e m , appear to hold the b e l i e f t h a t the concept i s m o d i f i a b l e . I I I . 6 Health Promoting Behaviors Various r e s e a r c h e r s have e x p l o r e d the r e l a t i o n s h i p between h e a l t h promoting behaviors and m o t i v a t i o n a l f a c t o r s other than s e l f - e s t e e m . For example. Brown, Muhlenkamp, Fox and Osborn (1983) sought to i d e n t i f y the r e l a t i o n s h i p among h e a l t h b e l i e f s , h e a l t h values and h e a l t h promotion a c t i v i t y . Health-promoting behaviors were measured by the Personal L i f e s t y l e A c t i v i t i e s Q u e s t i o n n a i r e (developed by the authors) which focused on s a f e t y , n u t r i t i o n , p r e v e n t i o n , substance use, r e l a x a t i o n , and e x e r c i s e . 28 Health b e l i e f s were measured using the M u l t i d i m e n s i o n a l Health Locus of C o n t r o l Scale (MHLC). While the MHLC s c a l e was not p r e d i c t i v e f o r h e a l t h i n f o r m a t i o n seeking a c t i v i t i e s such as t a k i n g c l a s s e s , r e a d i n g or g a t h e r i n g i n f o r m a t i o n from watching T.V., i t was p r e d i c t i v e f o r broadly focused h e a l t h promotion a c t i v i t i e s i . e . e x e r c i s i n g r e g u l a r l y , and e a t i n g foods from each food group d a i l y . These r e s u l t s must be i n t e r p r e t e d c a u t i o u s l y due to the nonrandom sampling methods used. These f i n d i n g s were supported when Yoder, Jones and Jones (1985) found that i n d i v i d u a l s who expressed b e l i e f i n h e a l t h promotion behavior were more l i k e l y to p r a c t i c e them than were those who d i d not express such a b e l i e f . Muhlenkamp, Brown and Sands (1985) found t h a t s e l f - r e p o r t e d h e a l t h promotion a c t i v i t i e s were not r e l a t e d to h e a l t h value. The 175 study p a r t i c i p a n t s were c l i e n t s of a n u r s i n g c l i n i c which focused on h e a l t h promotion l o c a t e d i n the southwestern U.S. Although p a r t i c i p a n t s were not s e l e c t e d randomly, they c o n s t i t u t e d approximately 20% of the c l i n i c c l i e n t e l e . H e alth value was measured with a m o d i f i e d v e r s i o n of Rokeach's Value Survey. P a r t i c i p a n t s were asked to 29 rank order h e a l t h and f i v e other values (happiness, r e s p e c t , harmony, freedom, accomplishment). Health promotion a c t i v i t i e s were measured u s i n g the Personal L i f e s t y l e A c t i v i t i e s Q u e s t i o n n a i r e (Brown e t a l , 1983). S e l f - r e p o r t i n g r e v e a l e d t h a t women were more l i k e l y than men to engage i n h e a l t h promotion a c t i v i t i e s . However, when o b j e c t i v e measures of number of h e a l t h promotion v i s i t s to the c l i n i c were used, the r e v e r s e was t r u e . L a f f r e y (1986) s t u d i e d p e r c e i v e d weight, p e r c e i v e d h e a l t h s t a t u s , h e a l t h c o n c e p t i o n , and h e a l t h behavior c h o i c e s i n normal and overweight a d u l t s . Health promotion reasons were g i v e n as the r a t i o n a l e f o r choosing h e a l t h behaviors j u s t as o f t e n i n overweight p a r t i c i p a n t s as i n normal weight p a r t i c i p a n t s . In a study of 179 blue c o l l a r workers, W e i t z e l (1989) determined t h a t importance of h e a l t h , p e r c e i v e d h e a l t h -l o c u s - o f - c o n t r o l , h e a l t h s t a t u s , and s e l f - e f f i c a c y were p r e d i c t i v e of health-promoting behaviors. In p a r t i c u l a r , " s u b j e c t s who p e r c e i v e d themselves to be i n b e t t e r h e a l t h , and who h e l d a stronger b e l i e f i n t h e i r own a b i l i t i e s to s u c c e s s f u l l y perform b e h a v i o r s , engaged i n more health-promoting behaviors than t h e i r 30 c o u n t e r p a r t s . " Health-promoting behaviors were measured u s i n g the Health Promoting L i f e s t y l e P r o f i l e (HPLP) (Walker, S e c h r i s t & Pender, 1987). II I . 7 Self-Esteem and Health Promoting Behaviors Only two s t u d i e s have been found which deal s p e c i f i c a l l y with the r e l a t i o n s h i p between s e l f - e s t e e m and h e a l t h promoting b e h a v i o r s . Muhlenkamp and Sayles (1986), i n attempting to i d e n t i f y r e l a t i o n s h i p s among p e r c e i v e d s o c i a l support, s e l f - e s t e e m , and p o s i t i v e h e a l t h p r a c t i c e s , found that both s e l f - e s t e e m and s o c i a l support are p o s i t i v e i n d i c a t o r s of l i f e - s t y l e . They s t u d i e d 55 men and 43 women with an age range of 18 to 67. L i f e - s t y l e was measured with the Personal L i f e s t y l e Q u e s t i o n n a i r e (Muhlenkamp & Brown, 1983) which measures s i x areas of h e a l t h p r a c t i c e s -n u t r i t i o n , e x e r c i s e , r e l a x a t i o n , s a f e t y , substance use, and h e a l t h promotion. (Health promotion r e f e r r e d to a c t i v i t i e s such as y e a r l y p h y s i c a l and d e n t a l examinations, b r e a s t s e l f - e x a m i n a t i o n s , and maintenance of a p p r o p r i a t e weight). These s i x areas are somewhat d i f f e r e n t than the areas t e s t e d i n the Health Promotion L i f e s t y l e P r o f i l e developed by Walker, S e c h r i s t and 31 Pender (1987). I t should a l s o be noted t h a t the a c t i v i t i e s d e f i n e d by Muhlenkamp and Brown's s c a l e as h e a l t h promotion a c t i v i t i e s ( y e a r l y p h y s i c a l and d e n t a l examimations and b r e a s t s e l f - e x a m i n a t i o n s ) would be c l a s s i f i e d by Pender as behaviors a s s o c i a t e d with d i s e a s e p r e v e n t i o n , r a t h e r than h e a l t h promotion. Pender's d e f i n i t i o n of h e a l t h promoting behavior i s more u s e f u l than Mulenkamp and Browns' because i t d i f f e r e n t i a t e s between behaviors a s s o c i a t e d with h e a l t h promotion and those a s s o c i a t e d with i l l n e s s p r e v e n t i o n . A r e c e n t study by Duffy (1988) e x p l o r e d the r e l a t i o n s h i p s among p e r c e i v e d h e a l t h l o c u s of c o n t r o l , s e l f - e s t e e m , and p e r c e i v e d h e a l t h s t a t u s and t h e i r degree of p r e d i c t a b i l i t y v i s a v i s health-promoting l i f e s t y l e a c t i v i t i e s . The p o p u l a t i o n surveyed comprised 600 middle-aged female employees of a l a r g e southwestern U.S. u n i v e r s i t y . The Rosenberg Self-Esteem Scale (RSE) was used to measure s e l f - e s t e e m , and the HPLP was used to measure s i x major c a t e g o r i e s of h e a l t h promoting a c t i v i t i e s -s e l f - a c t u a l i z a t i o n , h e a l t h r e s p o n s i b i l i t y , n u t r i t i o n , e x e r c i s e , i n t e r p e r s o n a l support, and s t r e s s management. 3 2 Subjects whose subscale scores were high f o r s e l f -a c t u a l i z a t i o n , n u t r i t i o n , e x e r c i s e and i n t e r p e r s o n a l support, a l s o scored high on s e l f - e s t e e m , i n t e r n a l h e a l t h - l o c u s - o f - c o n t r o l , and h e a l t h s t a t u s . Those s u b j e c t s whose subscale scores were high f o r h e a l t h r e s p o n s i b i l i t y , n u t r i t i o n and s t r e s s management, were o l d e r i n age, r e p o r t e d poor past h e a l t h s t a t u s , scored low i n b e l i e f i n chance as a determinant of h e a l t h , and had high h e a l t h concern s c o r e s . In summary, s e l f - e s t e e m has been demonstrated to be p r e d i c t i v e o f l i f e s t y l e behaviors i n two s t u d i e s . However, i n Duffy's study, i t i s p r e d i c t i v e o n l y f o r c e r t a i n h e a l t h promoting behaviors - s e l f -a c t u a l i z a t i o n , n u t r i t i o n , e x e r c i s e , and i n t e r p e r s o n a l support. In Mulenkamp and S a y l e s ' study, i t was demonstrated to be p r e d i c t i v e o f n u t r i t i o n , e x e r c i s e , r e l a x a t i o n , s a f e t y , substance abuse, and a c t i v i t i e s such as y e a r l y p h y s i c a l and d e n t a l examinations, b r e a s t s e l f - e x a m i n a t i o n s , and a p p r o p r i a t e weight maintenance. I I I . 8 Self-Esteem and Other S u b - v a r i a b l e s o f Health  Promoting Bahaviors A s i g n i f i c a n t amount of r e s e a r c h has focussed on 3 3 the r e l a t i o n s h i p between s e l f - a c t u a l i z a t i o n and s e l f -esteem as w e l l as the r e l a t i o n s h i p between i n t e r p e r s o n a l support and s e l f - e s t e e m . Maslow d e f i n e s s e l f - a c t u a l i z a t i o n as: "an episode, or a s p u r t i n which the powers of the person come together i n a p a r t i c u l a r l y e f f i c i e n t and i n t e n s e l y enjoyable way, and i n which he i s more i n t e g r a t e d and l e s s s p l i t , more open f o r experience, more i d i o s y n c r a t i c , more p e r f e c t l y e x p r e s s i v e or spontaneous, or f u l l y f u n c t i o n i n g , more c r e a t i v e , more humorous, more ego-transcending, more independent of h i s lower needs, e t c . He becomes i n these episodes more t r u l y h i m s e l f , more p e r f e c t l y a c t u a l i z i n g h i s p o t e n t i a l i t i e s , c l o s e r to the core of h i s Being, more f u l l y human." (Maslow, 1968, p.97) The a s s o c i a t i o n between s e l f - e s t e e m and e x e r c i s e as noted i n the l i t e r a t u r e has been d e s c r i b e d p r e v i o u s l y (see S e l f - E s t e e m ) . Most of the r e s e a r c h i n the area of s o c i a l support ( i n t e r p e r s o n a l r e l a t i o n s h i p s ) i n d i c a t e s support f o r a l i n k a g e with s e l f - e s t e e m (Caplan, 1974; Cobb, 1976; Andrews e t a l , 1978; Henderson et a l , 1978; Henderson, 1980; M i l l e r & Ingham, 1976; W i l l i a m s e t a l , 1981; Swann & Predmore, 1985; H o b f o l l , Nadler & Leiberman, 1986; and Vinokur, Caplan & Schul, 1987). Only one study l o c a t e d d i d not support t h i s a s s o c i a t i o n . In t h i s . Held (1981) s t u d i e d teenage pregnancy, s e l f -esteem and s o c i a l networks i n White, Black and Mexican-Americans. She found t h a t s e l f - e s t e e m scores were h i g h e s t among Black women keeping babies and a t t e n d i n g s c h o o l . However, the s o c i a l network f o r these women was not as stro n g as i t had been before the pregnancy. The author does not draw any c l e a r c o n c l u s i o n s from t h i s study. The l i t e r a t u r e on the r e l a t i o n s h i p between s e l f -esteem and s e l f - a c t u a l i z a t i o n i s l e s s c l e a r c u t . Reddy and Beers (1977) determined t h a t the higher the s e l f -concept, the g r e a t e r the s e l f - a c t u a l i z a t i o n i n a study on s e l f - a c t u a l i z a t i o n through s e n s i t i v i t y t r a i n i n g . Ibrahim and Morrison (1976) s t u d i e d a t h l e t e s from both high school and c o l l e g e and compared them to non-a t h l e t e s to determine s e l f - c o n c e p t and s e l f -a c t u a l i z i n g t r a i t s . No s i g n i f i c a n t d i f f e r e n c e s were seen between female a t h l e t e s and female non-athletes a t the high school l e v e l i n s e l f - c o n c e p t and s e l f -a c t u a l i z a t i o n , nor was there a s i g n i f i c a n t d i f f e r e n c e between male a t h l e t e s and male n o n - a t h l e t e s a t the c o l l e g e l e v e l i n the two t r a i t s . In a study which i n v e s t i g a t e d the r e l a t i o n s h i p between s e l f - a c t u a l i z a t i o n and h e a l t h c o n c e p t i o n , and t h e i r a b i l i t y to p r e d i c t h e a l t h behavior c h o i c e , L a f f r e y (1985) found t h a t there was no r e l a t i o n s h i p between the promotiveness * of h e a l t h behavior c h o i c e and s e l f - a c t u a l i z a t i o n . Study p a r t i c i p a n t s were a d u l t s (95 men and women) randomly s e l e c t e d from Midwestern suburban households i n the U.S. Health behavior c h o i c e was measured by an instrument (Health Behavior Choice Scale) which d i s t i n g u i s h e d among reasons f o r c h o i c e s . Reasons for c h o i c e s were c a t e g o r i z e d as e i t h e r p r e v e n t i v e , maintenance, or promotive a c c o r d i n g to t h e i r a s s o c i a t i o n with i l l n e s s - p r e v e n t i n g , h e a l t h -m a i n t a i n i n g , or health-promoting behaviors. In summary, there i s some support f o r an a s s o c i a t i o n between e x e r c i s e and s e l f - e s t e e m , and i n t e r p e r s o n a l support and s e l f - e s t e e m . These are two of the p o s s i b l e s i x h e a l t h promoting behaviors d e s c r i b e d by Pender i n her Health Promoting L i f e s t y l e P r o f i l e (HPLP). As noted above however, on l y two s t u d i e s c o u l d be found which a c t u a l l y d eal with the r e l a t i o n s h i p between s e l f - e s t e e m and g e n e r a l h e a l t h promoting behaviors (Muhlenkamp & S a y l e s , 1986; Duffy, 1988). Here, s e l f - e s t e e m has been shown to be p r e d i c t i v e of c e r t a i n h e a l t h promoting a c t i v i t i e s . *For f o o t n o t e , r e f e r to the end of Chapter Three 36 Footnotes 1 The TSCS c o n s i s t s o f 100 items, 90 of which c o n t r i b u t e to the s e l f - c o n c e p t s c o r e s . S e l f - c o n c e p t measurement i s broken i n t o f i v e c a t e g o r i e s ( s u b s e l v e s ) : 1) P h y s i c a l S e l f ; 2) M o r a l - E t h i c a l S e l f ; 3) Personal S e l f ; 4) Family S e l f ; 5) S o c i a l S e l f . The P or P o s i t i v e scores measure s e l f - e s t e e m l e v e l s f o r each o f these f i v e s u b s e l v e s . When the f i v e scores are summed, the t o t a l r e p r e s e n t s the T o t a l P score or the general l e v e l o f se l f - e s t e e m . •^The promotiveness o f h e a l t h behavior c h o i c e r e f e r s to the reason behind the ch o i c e o f h e a l t h behavior being a s s o c i a t e d with h e a l t h promotion, r a t h e r than maintenance or p r e v e n t i o n . For example, the respondent was asked to choose one of the f o l l o w i n g : I t r y to get enough s l e e p to a) achieve a higher l e v e l o f w e l l - b e i n g b) r e s i s t i l l n e s s I f the respondent chose a ) , t h i s was an i n d i c a t i o n t h a t the reason f o r s e l e c t i n g t h a t p a r t i c u l a r h e a l t h behavior was f o r h e a l t h promotiveness, while a b) ch o i c e i n d i c a t e d an i l l n e s s p r e v e n t i v e r a t i o n a l e . 37 CHAPTER FOUR WORKING WOMEN AND THEIR HEALTH IV.1 WOMEN AT RISK Some documentation i s a v a i l a b l e r e g a r d i n g the he a l t h r i s k s to which women are exposed. In p a r t i c u l a r , the Health Promotion Survey, the Canada F i t n e s s Survey, and the Canada Health Survey, a l l of which have been conducted w i t h i n the l a s t f i f t e e n y e ars, p rovide v a l u a b l e i n s i g h t r e g a r d i n g the h e a l t h r i s k s of Canadian women. Stevens (1985), i n reviewing the data from the Canada Health Survey of 1978-79, and the Canada F i t n e s s Survey o f 1981, noted that women were d i s p r o p o r t i o n a t e l y exposed to the r i s k of inadequate e x e r c i s e and to inadequate b r e a k f a s t . S t a t i s t i c s Canada's Health Promotion Survey o f 1985 poi n t e d to the major h e a l t h r i s k s to women as being t h e i r high consumption of s l e e p i n g p i l l s and t r a n q u i l l i z e r s , and p o t e n t i a l a l c o h o l abuse. The consumption of s l e e p i n g p i l l s and t r a n q u i l l i z e r s among women i s higher than among men. 38 The v a r i o u s h e a l t h problems which were s e l f -r e p o r t e d by women i n the Canada Health Survey ( L a p i e r r e , 1984) were anemia, t h y r o i d d i s o r d e r s , headache, a r t h r i t i s , rheumatism, mental d i s o r d e r s and other u n s p e c i f i e d problems. T h i r t e e n percent o f the 'other u n s p e c i f i e d problems' c o n s i s t o f pregnancy and i t s r e l a t e d problems, c o n t r a c e p t i o n , and d i s e a s e s o f the r e p r o d u c t i v e system, a l l of which r e q u i r e d e i t h e r medical c o n s u l t a t i o n s or drug use. There i s c o n f l i c t i n g o p i n i o n among r e s e a r c h e r s r e g a r d i n g whether smoking among teenage g i r l s has r i s e n d i s p r o p o r t i o n a t e l y to that among teenage boys ( G r i t z , 1984; C o l l i s h a w , 1985). In c o n t r a s t , there has been no such d i s p u t e i n o l d e r age groups. C o l l i s h a w (1985) notes t h a t the percentage of young women i n t h e i r twenties who smoke on a d a i l y b a s i s has r i s e n d i s p r o p o r t i o n a t e l y to young males of the same age du r i n g the years between 1982 and 1985. Women attempt s u i c i d e more f r e q u e n t l y than men, although they are l e s s s u c c e s s f u l a t i t ( L a p i e r r e , 1984) . Waldron (1983) determined t h a t behaviors due to sex d i f f e r e n c e s l e d to d i f f e r e n c e s i n mo r b i d i t y and 39 m o r t a l i t y . Males tend towards p h y s i c a l d a r i n g and i l l e g a l behavior which r e s u l t i n more h e a l t h r i s k s . Waldron noted however, t h a t c u l t u r a l o r i e n t a t i o n p l a y s a r o l e i n r i s k y h e a l t h behaviors. Waldron's comment on c u l t u r e i s a reminder that sex d i f f e r e n c e s may not be the only f a c t o r which c o n t r i b u t e to r i s k y h e a l t h behavior. IV.2 WOMEN IN THE WORKFORCE A r e c e n t phenomenon which has a r i s e n w i t h i n the same timeframe as the blossoming p u b l i c i n t e r e s t i n hea l t h y l i f e s t y l e s i s the l a r g e number of women who have l e f t home to j o i n the Canadian labor f o r c e . Approximately 1,754,000 women entered the lab o r f o r c e between 1974 and 1984, r e p r e s e n t i n g a f i f t y percent i n c r e a s e (Labour Canada, 1985-86). Today, 44.4% of a l l those employed i n Canada are women ( S t a t i s t i c s Canada, Nov. 1989). As of November, 1989, 645,000 women were employed i n B.C. This f i q u r e r e p r e s e n t s 44.9% of a l l employed workers i n the same year ( S t a t i s t i c s Canada, Nov. 1989). Women have g r a v i t a t e d towards the s e r v i c e i n d u s t r i e s . In 1985, the m a j o r i t y o f working women ( 5 9 . 5 % ) i n C a n a d a w e r e f o u n d i n c l e r i c a l , s a l e s o r s e r v i c e o c c u p a t i o n s . I n B r i t i s h C o l u m b i a , t h e c o r r e s p o n d i n g p r o p o r t i o n w a s 6 4 p e r c e n t i n t h e s a m e y e a r . T h i s p e r c e n t a g e h a s r e m a i n e d r e l a t i v e l y s t a b l e . I n 1 9 8 9 , 6 1 . 8 % o f t h e f e m a l e B . C . l a b o r f o r c e w a s e m p l o y e d i n c l e r i c a l , s a l e s o r s e r v i c e o r i e n t e d o c c u p a t i o n s . I t i s c l e a r t h a t w o m e n h a v e e n t e r e d t h e C a n a d i a n w o r k f o r c e t o t h e e x t e n t t h a t t h e i r n u m b e r s a l m o s t e q u a l t h o s e o f m e n w o r k i n g i n C a n a d a . T h e s a m e i s t r u e f o r w o m e n i n B r i t i s h C o l u m b i a . M o r e o v e r , t h e n u m b e r s o f w o m e n r e l a t i v e t o m e n a r e e x p e c t e d t o b e o n t h e i n c r e a s e i n t h e 2 1 s t c e n t u r y ( B e z o l d e t a l , 1 9 8 6 ) . O n e c a n a s s u m e o n t h e b a s i s o f p a s t t r e n d s t h a t t h i s m e a n s a n e v e r i n c r e a s i n g e x p a n s i o n o f w o m e n i n t h e w o r k p l a c e . T h e i m p l i c a t i o n s f o r t h i s p h e n o m e n o n w i t h r e g a r d t o w o m e n ' s h e a l t h a r e d e a l t w i t h i n t h e n e x t s e c t i o n . I V . 3 W O R K I N G W O M E N S ' H E A L T H T h e t r e n d s o u t l i n e d a b o v e r e p r e s e n t a n i m p o r t a n t s o c i a l a n d e c o n o m i c p h e n o m e n o n . T h e s e t r e n d s m a y a l s o r e p r e s e n t a p o t e n t i a l f o r a s u b s t a n t i a l h e a l t h s t a t u s c h a n g e . I t c a n b e p o s i t e d t h a t t h e d r a m a t i c i n c r e a s e s 41 i n women working o u t s i d e the home probably have had or w i l l have some kind of impact on the h e a l t h of these women. Therefore, the l i t e r a t u r e was searched to determine the s t a t e o f h e a l t h of working women. Verbrugge (1984) examined data from four p e r i o d s (1977-1978, 1975-1976, 1972-1973, 1961-1963) of the Na t i o n a l Health Interview Survey which has been conducted a n n u a l l y i n the U.S. s i n c e 1957. This survey looked a t the p h y s i c a l h e a l t h of c l e r i c a l workers. Verbrugge noted t h a t c u r r e n t l y employed c l e r i c a l workers had b e t t e r h e a l t h than nonemployed people. This may be a m a n i f e s t a t i o n o f the 'healthy worker e f f e c t ' . O v e r a l l , gender had no impact on the h e a l t h s t a t u s o f working i n d i v i d u a l s . Health, however, d i f f e r e d d r a m a t i c a l l y a c c o r d i n g to job c l a s s e s . White c o l l a r workers had the best h e a l t h p r o f i l e ( i e . low i n j u r y r a t e s , and few major c h r o n i c l i m i t a t i o n s ) . Blue c o l l a r women had the h i g h e s t r e s t r i c t e d a c t i v i t y and h o s p i t a l r a t e s of a l l c l a s s e s . C l e r i c a l womens' h e a l t h was found to be good r e l a t i v e to a l l employed women, with D e t r o i t being the e x c e p t i o n (Health i n D e t r o i t study o f 1978). Moreover, marriage seemed to confer some a d d i t i o n a l degree o f happiness to female c l e r i c a l 42 workers. This f i n d i n g i s c o n s i s t e n t with other r e s e a r c h (Baruch, 1984). Waldron (1983) notes t h a t womens1 jobs are l e s s d i r e c t l y hazardous to t h e i r h e a l t h than mens 1 jobs. However, gender d i f f e r e n c e s a s i d e , Waldron r e p o r t s that employment had n e i t h e r harmful nor b e n e f i c i a l e f f e c t s on the gene r a l h e a l t h o f women i n a n a t i o n a l sample of married, middle-aged women. Labor f o r c e p a r t i c i p a t i o n was shown to have b e n e f i c i a l e f f e c t s on h e a l t h f o r unmarried white women, and f o r b l a c k women with c h i l d r e n i n a l o n g i t u d i n a l study of middle-aged female s u b j e c t s . (Waldron & Jacobs, 1989). The purpose o f the study was to analyze the r e l a t i o n s h i p s between r o l e s ( l a b o r f o r c e p a r t i c i p a n t , spouse, parent) and h e a l t h t r e n d s . Data were obtained from a p r e v i o u s l y completed n a t i o n a l sample of n o n i n s t i t u t i o n a l i z e d women ( N a t i o n a l L o n g i t u d i n a l Surveys of Labor Market E x p e r i e n c e ) , using data from the 1977-1982 p e r i o d . The study concluded that the " h e a l t h e f f e c t s o f s p e c i f i c r o l e s v a r i e d depending on the woman's race and other r o l e s she h e l d " (Waldron & Jacobs, 1989, p. 18). In a study i n v e s t i g a t i n g the a s s o c i a t i o n between h e a l t h and employment s t a t u s , Jennings, Mazark, and McKinlay (1984) found t h a t employed women had the fewest h e a l t h problems and r e p o r t e d the fewest i l l n e s s b ehaviors while the unemployed group r e p o r t e d the most h e a l t h problems and the most i l l n e s s behavior. Homemakers r e p o r t e d i n t e r m e d i a t e l e v e l s . T h i s study i n c l u d e d a random sample o f 8114 women aged 45 -54 i n Massachusetts. The authors r e c o g n i z e d t h a t a healthy worker e f f e c t may have confounded the r e s u l t s o f the study. In other words, i l l h e a l t h may e x p l a i n why women leave and do not r e t u r n to the labor f o r c e . Thus, i t would not be s u r p r i s i n g to f i n d t h a t women who work a t home are not as hea l t h y as women who are employed o u t s i d e the home. This comment i s true of many s t u d i e s c i t e d . J o u g l a e t a l . (1983) expl o r e d the e f f e c t of employment on h e a l t h s t a t u s i n a group o f women from a c o l l e g e town i n the south of France. The sample c o n s i s t e d of married women aged 25-50 years who were subsequently d i v i d e d i n t o two groups a c c o r d i n g to t h e i r employment s t a t u s . Only minor d i f f e r e n c e s due to the e f f e c t of employment on h e a l t h s t a t u s , such as r e p o r t e d f a t i g u e , overwork and nervousness, were noted i n the 4 4 g r o u p o f e m p l o y e d w o m e n . N a t h a n s o n ( 1 9 8 0 ) d e m o n s t r a t e d t h a t e m p l o y e d w o m e n h a v e h i g h e r o v e r a l l l e v e l s o f p e r c e i v e d h e a l t h t h a n h o u s e w i v e s . T h e y a r e a l s o " l e s s l i k e l y t o e n g a g e i n i l l n e s s b e h a v i o r , a s i n d e x e d b y r e s t r i c t e d a c t i v i t y d a y s a n d p h y s i c i a n v i s i t s " , ( p . 4 6 7 ) G i e l e ( 1 9 8 2 ) s u m m a r i z e s t h e a v a i l a b l e r e s e a r c h o n t h e r e l a t i o n s h i p o f e m p l o y m e n t o u t s i d e t h e h o m e t o w o m e n ' s h e a l t h s t a t u s a s f o l l o w s : " E m p l o y e d w o m e n e x p e r i e n c e h i g h e r l e v e l s o f s u b j e c t i v e h e a l t h s t a t u s t h a n h o u s e w i v e s a n d e n g a g e i n l e s s i l l n e s s b e h a v i o r , a l t h o u g h t h e f o r m e r b e n e f i t i s c o n f i n e d p r i m a r i l y t o w o m e n w h o a r e l e s s w e l l e d u c a t e d a n d / o r u n m a r r i e d " ( p . 6 8 ) . I n r e s t u d y i n g t h e d a t a f r o m t h e C a n a d a H e a l t h S u r v e y o f 1 9 7 8 - 7 9 , a n d d a t a f r o m t h e H e a l t h D i v i s i o n o f S t a t i s t i c s C a n a d a , L a p i e r r e ( 1 9 8 4 ) c o n c l u d e d t h a t " f o r m o s t o f t h e v a r i a b l e s s t u d i e d , e x p e c i a l l y t h o s e r e l a t e d t o m e n t a l h e a l t h , w o r k o u t s i d e t h e h o m e s e e m s t o h a v e a p o s i t i v e e f f e c t o n w o m e n ' s w e l l - b e i n g " ( p . 1 ) . M c D a n i e l ( 1 9 8 7 ) s t a t e s t h a t i t i s i n c o r r e c t t o a s s u m e t h a t w o r k i n g w o m e n f a c e f e w e r h e a l t h r i s k s t h a n m e n . T h u s t h e i r o c c u p a t i o n a l h a z a r d s i n c l u d e : e x p o s u r e o f 45 c l e r i c a l workers to hazardous l e v e l of ozone and methanol from copying machines, exposure of h e a l t h c a r e workers to back i n j u r i e s and AIDS, and exposure of o p e r a t i n g room personnel to m i s c a r r i a g e and cancer from a n a e s t h e s i a . On the other hand, Bryant (1986) found that there was no a s s o c i a t i o n between employment and a b o r t i o n r i s k i n a case c o n t r o l study of 334 women. Women who work may a l s o face sexual harassment. This job r i s k has o b v i o u s l y been r e c o g n i z e d as r e a l and c o n t i n u i n g , s i n c e the Province of Quebec has d e c l a r e d that sexual harassment i s a compensable work i n j u r y (McDaniel, 1987). In summary, although there i s some c o n f l i c t i n g o p i n i o n over whether womens' h e a l t h i s a d v e r s e l y or p o s i t i v e l y a f f e c t e d by employment o u t s i d e the home, as i d e from the 'healthy worker e f f e c t ' , o n the whole i t appears t h a t women who are employed have good h e a l t h . While t h e i r degree of r i s k a s s o c i a t e d with t h e i r employment has yet to be determined, some authors, such as McDaniel, b e l i e v e i t to be r e l a t i v e l y h i gh. IV.4 WORKING WOMEN AND HEALTH PROMOTION Much i n t e r e s t has been demonstrated i n the 4 6 d e v e l o p m e n t o f w o r k s i t e h e a l t h p r o m o t i o n p r o g r a m s i n t h e l a s t t e n y e a r s ( C h r i s t e n s o n & K i e f h a b e r , 1 9 8 8 , B e z o l d e t a l . , 1 9 8 6 ) . " M o s t m a j o r U . S . c o r p o r a t i o n s e i t h e r h a v e d e v e l o p e d h e a l t h p r o m o t i o n p r o g r a m s o r h a v e t h e m s e r i o u s l y u n d e r c o n s i d e r a t i o n " ( B e z o l d e t a l . , 1 9 8 6 ) . T h e N a t i o n a l S u r v e y o f W o r k s i t e H e a l t h P r o m o t i o n A c t i v i t i e s w a s c a r r i e d o u t i n t h e U . S . i n 1 9 8 5 , a n d d e m o n s t r a t e d t h a t w o r k s i t e s o f 5 0 o r m o r e e m p l o y e e s h a d a n ' a b u n d a n c e ' o f h e a l t h p r o m o t i o n a c t i v i t i e s ( C h r i s t e n s o n e t a l . , 1 9 8 8 ) . P a r t i c i p a t i o n i n w o r k s i t e h e a l t h p r o m o t i o n p r o g r a m s h a s b e e n l a r g e l y a f u n c t i o n o f w o r k p l a c e s o c i o - e c o n o m i c s t r a t i f i c a t i o n ( B l o z o i s e t a l , 1 9 8 8 ) ; i n p a r t i c u l a r , w h i t e c o l l a r o r m a n a g e m e n t / o f f i c e e m p l o y e e s h a v e g e n e r a l l y b e e n i n v o l v e d i n w o r k s i t e h e a l t h p r o m o t i o n a c t i v i t i e s w h i l e b l u e c o l l a r o r f a c t o r y / p r o d u c t i o n e m p l o y e e s h a v e n o t . B l o z o i s e t a l ( 1 9 8 8 ) f o u n d t h a t g e n d e r w a s r e l a t e d t o f i t n e s s m e m b e r s h i p i n a s t u d y o f b l u e c o l l a r w o r k e r s ( 2 2 % m a l e v s . 1 4 % f e m a l e ) . T h e t y p e s o f a c t i v i t i e s o f f e r e d a t t h e f i t n e s s c e n t r e m a y h a v e a b e a r i n g o n t h e a s s o c i a t i o n b e t w e e n g e n d e r a n d m e m b e r s h i p . A c t i v i t i e s o f f e r e d a t t h e c e n t e r i n c l u d e d s t a t i o n a r y b i c y c l i n g , 4 7 a e r o b i c s , weight t r a i n i n g , rowing machine, walking and jog g i n g , and i t i s onl y i n the l a s t seven years or so that these a c t i v i t i e s have been embraced by females. As a r e s u l t of worksite h e a l t h promotion surveys, i t i s known that working women do p a r t i c i p a t e i n h e a l t h promotion a c t i v i t i e s . Spilman (1988) t e s t e d a model of i n t e n t i o n a l h e a l t h - r e l a t e d behaviors to determine i f p a r t i c i p a t i o n of w h i t e - c o l l a r men and women i n worksite h e a l t h promotion programs c o u l d be p r e d i c t e d . He found t h a t women p a r t i c i p a t e d i n more worksite h e a l t h promotion programs than men, and that they p a r t i c i p a t e d more a c t i v e l y than men i n 'health treatment' programs. Health treatment programs i n t h i s study were d e f i n e d as weight l o s s , smoking, low back p a i n , and s t r e s s c o n t r o l management programs. Spilman suggests that the reason f o r more female p a r t i c i p a t i o n i n 'health treatment' programs i s because women monitor t h e i r h e a l t h more c l o s e l y than men. In summary, the r e l a t i o n s h i p o f working women and h e a l t h promoting behaviors i s an iss u e which has not been e x p l o r e d i n any depth - p a r t i c u l a r l y with regard to those women whose h e a l t h promotion a c t i v i t i e s are performed at a s i t e other than work. I t i s known. 4 8 h o w e v e r , t h a t w o m e n w h o w o r k d o p a r t i c i p a t e i n w o r k s i t e h e a l t h p r o m o t i o n a c t i v i t i e s ; i n f a c t , t h e y p a r t i c i p a t e m o r e a c t i v e l y i n s o m e t y p e s o f p r o g r a m s a n d i n m o r e p r o g r a m s t h a n d o w o r k i n g m e n . I V . 5 W O R K I N G WOMEN A N D S E L F - E S T E E M S t u d i e s r e g a r d i n g t h e i m p a c t o f e m p l o y m e n t o n w o m e n s 1 s e l f - e s t e e m c a r r i e d o u t i n t h e l a s t d e c a d e s u p p o r t t h e n o t i o n t h a t e m p l o y m e n t e n h a n c e s w o m e n s ' s e l f - e s t e e m ( N a t h a n s o n , 1 9 8 0 ; M a c k i e , 1 9 8 3 ; M e d d i n , 1 9 8 6 ; P u g l i e s i , 1 9 8 9 ) . I n t h e c a s e o f M e d d i n , o n l y a s i n g l e i n d i c a t o r o f d e p r e s s i o n a n d o f s a t i s f a c t i o n w i t h s e l f w a s u s e d t o m e a s u r e t h e s e c o n c e p t s . H o w e v e r , s a t i s f a c t i o n w i t h s e l f a n d t h e t o o l u s e d t o m e a s u r e i t , m a y n o t b e a n a p p r o p r i a t e e x p r e s s i o n o f s e l f - e s t e e m . I n t h e t o o l , r e s p o n d e n t s w e r e a s k e d t o r a t e t h e i r d e g r e e o f s a t i s f a c t i o n w i t h s e l f , o n a s c a l e r a n g i n g f r o m 0 t o 1 0 0 , t h e h i g h e s t n u m b e r ( 1 0 0 ) i n d i c a t i n g c o m p l e t e s a t i s f a c t i o n . P u g l i e s i ( 1 9 8 9 ) s t a t e s : " R e s e a r c h p r o v i d e s s t r o n g e v i d e n c e t h a t e m p l o y e d w o m e n ( m a r r i e d a n d u n m a r r i e d ) h a v e , i n f a c t , l o w e r r a t e s o f p s y c h o l o g i c a l d i s t r e s s a n d / o r d e p r e s s i o n t h a n m a r r i e d w o m e n w h o a r e n o t employed o u t s i d e the home". She explo r e d the impact of employment as a s o c i a l r o l e on womens' we l l being u s i n g s e l f - e s t e e m and s o c i a l support as i n t e r v e n i n g v a r i a b l e s . Using a sample s i z e of 1299, and c o n t r o l l i n g f o r age, educati o n , and income, P u g l i e s i determined t h a t employment i n c r e a s e s the l e v e l o f s e l f -esteem, and t h e r e f o r e , w e l l - b e i n g . No d i s t i n c t i o n was made between f u l l time and p a r t time job p a r t i c i p a t i o n . In t h i s study, P u g l i e s i used an index composed from Rosenberg's Self-Esteem s c a l e to measure s e l f - e s t e e m . Baruch (1984) reviewed the r o l e o f employment and womens' w e l l - b e i n g , p a r t i c u l a r l y with regard to s e l f -concept. The r e l a t i o n s h i p of s e l f - e s t e e m to s e l f -concept has a l r e a d y been d e s c r i b e d (see Self-Esteem), that i s , s e l f - e s t e e m i s the e v a l u a t i v e dimension of the v a r i o u s components which make up the concept of s e l f -concept . Baruch d i s t i n g u i s h e s between the happiness, s a t i s f a c t i o n and s e l f - c o n c e p t components of w e l l - b e i n g i n her review of the l i t e r a t u r e . She notes t h a t marriage i s l i n k e d with o n l y two of the components of w e l l - b e i n g - happiness and s a t i s f a c t i o n . She concludes that "...as a source of s e l f - e s t e e m and p r o t e c t i o n 50 a g a i n s t a n x i e t y and d e p r e s s i o n , marriage i s of l i t t l e h elp; here, a good job i s the key" (1984, p. 175). Employment, then, p o s i t i v e l y a f f e c t s s e l f - c o n c e p t , and t h e r e f o r e w e l l - b e i n g . I t i s to be expected t h a t working women w i l l have higher l e v e l s o f s e l f - e s t e e m than women who do not work o u t s i d e the home. Paid employment has been found to have a b e n e f i c i a l e f f e c t on d i v o r c e d and separated women's we l l - b e i n g for Mexican-American women (Krause & Markides, 1985). This f i n d i n g may not be g e n e r a l i z a b l e , however, g i v e n the sampling l i m i t a t i o n of the study. The authors used a three g e n e r a t i o n r e s e a r c h d e s i g n and sampled Mexican Americans l i v i n g i n San Antonio, Texas. They s p e c i f i e d t h a t there was reason to b e l i e v e that three g e n e r a t i o n f a m i l y members who r e s i d e d i n the same urban area were 'more t r a d i t i o n a l ' than those f a m i l y members who d i d not l i v e g e o g r a p h i c a l l y as c l o s e . 51 CHAPTER FIVE METHODOLOGY V.1 Research Questions T h i s study addresses the f o l l o w i n g r e s e a r c h q u e s t i o n s : 1. What i s the r e l a t i o n s h i p between s e l f - e s t e e m , demographic v a r i a b l e s , working c o n d i t i o n s , and the e x t e n t to which working women undertake h e a l t h promoting behaviors? 2. To what ext e n t do women who work o u t s i d e the home undertake h e a l t h promoting behaviors? V.2 Research Design The study d e s i g n i s a d e s c r i p t i v e , c r o s s -s e c t i o n a l survey and i s abl e to demonstrate a s s o c i a t i o n o n l y . T h i s method was chosen as there was no c o n s i s t e n t evidence i n the l i t e r a t u r e o f an a s s o c i a t i o n between the major independent v a r i a b l e , self-esteem, and the major dependent v a r i a b l e , the undertaking of health promoting behaviors. Thus, t h i s b a s i c h y p o t h e s i s - g e n e r a t i n g step was necessary. Otherwise, a de s i g n with the p o t e n t i a l to demonstrate c a u s a l i t y . would have been s e l e c t e d . V.3 Sample The sample f o r t h i s study was s e l e c t e d randomly from a membership l i s t o f the United Food and Commercial Workers' Union of B r i t i s h Columbia. T h i s p a r t i c u l a r union was chosen because o f i t s l a r g e female membership, geographic s u i t a b i l i t y , and i t s a b i l i t y to pr o v i d e a r e l a t i v e l y homogeneous sample o f non-p r o f e s s i o n a l women with a mid to low socio-economic s t a t u s i n t h e i r own r i g h t , l i v i n g i n an urban area. Thus, a t l e a s t some extraneous v a r i a b i l i t y f a c t o r s c o u l d be c o n t r o l l e d f o r ex ante. The c r i t e r i a f o r i n c l u s i o n i n the pool of t a r g e t p o p u l a t i o n was t h a t s u b j e c t s be females r e s i d i n g i n the Greater Vancouver area. A random l i s t o f 500 s u b j e c t s conforming to these requirements was then computer-generated by the s t a f f a t the l o c a l Vancouver Union O f f i c e . ' * The United Food and Commercial Workers' Union r e p r e s e n t s 15,000-16,000 workers i n B r i t i s h Columbia and i s a p r o v i n c i a l branch o f a n a t i o n a l and i n t e r n a t i o n a l union. Approximately s i x t y per cent of the B.C. membership are female, and most female members *For f o o t n o t e , r e f e r to the end of Chapter F i v e 53 i n B.C. are c a s h i e r s by o c c u p a t i o n . The sample was designed to r e p r e s e n t a r e l a t i v e l y homogeneous group with the major p r o p o r t i o n o f the group having an o c c u p a t i o n of c a s h i e r from grocery s t o r e c h a i n s , and a very minor p r o p o r t i o n being home support workers. V.4 Data C o l l e c t i o n The i n i t i a l m a i lout to the 500 s u b j e c t s was posted mid-November, 1989. The mailout package c o n s i s t e d of a l e t t e r o f i n t r o d u c t i o n r e q u e s t i n g s u b j e c t s ' p a r t i c i p a t i o n i n the study, a s u p p o r t i n g l e t t e r from the Union signed by the D i r e c t o r of Oc c u p a t i o n a l Health and S a f e t y , * a q u e s t i o n n a i r e package f o r data c o l l e c t i o n purposes, and a s e l f - a d d r e s s e d and stamped envelope f o r r e t u r n purposes (see Appendix A f o r samples). A second mailout, which i n c l u d e d a l l of the p r e v i o u s l y contents p l u s a red reminder note, was sent to the same s u b j e c t s a t the end of the f i r s t week i n January, 1990. The reminder note (see Appendix B) asked s u b j e c t s to complete and r e t u r n o n l y one o f the two q u e s t i o n n a i r e packages, e i t h e r the o r i g i n a l mailed i n November, or the followup mailed i n January. As a poor response was a n t i c i p a t e d around the Christmas *For f o o t n o t e , r e f e r to the end o f Chapter F i v e 54 season, the second mailout was not sent u n t i l e a r l y i n the new year. Response from the f i r s t m ailout i n d i c a t e d t h a t some s u b j e c t s were not completing the f l i p s i d e o f one of the t e s t instruments, presumably, because they were not e x p l i c i t l y t o l d to do so. T h i s q u e s t i o n n a i r e was m o d i f i e d f o r the second mailout, so t h a t i t a l e r t e d s u b j e c t s to the requirement f o r t u r n i n g to the f l i p s i d e o f the page. E i g h t e e n unopened packages were r e t u r n e d from the f i r s t mailout by Canada Post due to i n c o r r e c t addresses. Since updated addresses were not a v a i l a b l e , e i g h t e e n new s u b j e c t s were randomly s e l e c t e d and i n f o r m a t i o n packages sent to them. V.5 Instruments The q u e s t i o n n a i r e package of the mailout c o n s i s t e d of two t e s t instruments - the Rosenberg Self-Esteem Scale (RSE), and the H e a l t h Promoting L i f e s t y l e s P r o f i l e (HPLP), as well as a three page q u e s t i o n n a i r e on demographics and working c o n d i t i o n s (see Appendix A). Respondents were asked to answer the two t e s t instruments p r i o r to responding to the ten item q u e s t i o n n a i r e on demographics and working c o n d i t i o n s . 55 The r a t i o n a l e f o r t h i s request was that i f s u b j e c t s grew t i r e d of responding and consequently r e t u r n e d incomplete q u e s t i o n n a i r e packages, the most important i n f o r m a t i o n on the major v a r i a b l e s would n e v e r t h e l e s s have been c o l l e c t e d . A. Rosenberg Self-Esteem Scale T h i s s c a l e measures s e l f - e s t e e m and c o n s i s t s of ten measures answered on a f i v e p o i n t L i k e r t s c a l e with responses r a n g i n g from " s t r o n g l y agree" to " s t r o n g l y d i s a g r e e " . P o t e n t i a l scores range from 10 to 40, higher scores being i n d i c a t i v e of higher l e v e l s of s e l f - e s t e e m when re v e r s e s c o r i n g i s used. In the Rosenberg s c a l e , the s e l f - a c c e p t a n c e aspect o f s e l f -esteem i s measured. Rosenberg (1965) used t h i s s c a l e to measure l e v e l s o f s e l f - e s t e e m i n a d o l e s c e n t s (5,077 high school j u n i o r s and s e n i o r s from New York s t a t e ) . The r e p r o d u c i b i l i t y c o e f f i c i e n t was .92 and the s c a l e a b i l i t y c o e f f i c i e n t was .72. Duffy (1988) used Rosenberg's s c a l e to measure s e l f - e s t e e m i n a study o f 262 a d u l t women between the ages of 35 and 65 years. T h i s study r e p o r t e d a c o e f f i c i e n t alpha o f .88. B. Health Promoting L i f e s t y l e s P r o f i l e T h i s 48 item instrument measures s i x p o s i t i v e h e a l t h b e h a v i o r s - s e l f - a c t u a l i z a t i o n , h e a l t h r e s p o n s i b i l i t y , exercise, n u t r i t i o n , i n t e r p e r s o n a l support, and stress management. Each of the items has a p o t e n t i a l maximal score o f four with a minimal score o f one. The p o s s i b l e range o f scores i s 48 to 192. Higher scores i n d i c a t e a higher frequency o f h e a l t h behavior a c t i v i t y . Although t h i s i s a r e c e n t l y developed instrument, i t has been shown to have a high i n t e r n a l c o n s i s t e n c y (alpha= .922 f o r t o t a l , .702 to .904 f o r su b s c a l e s ) and r e l i a b i l i t y (r= .926 f o r t o t a l , .808 to .905 f o r the s u b s c a l e s ) (Walker, S e c h r i s t and Pender, 1987). C. Demographic and Working C o n d i t i o n s Q u e s t i o n n a i r e The demographic and working c o n d i t i o n s q u e s t i o n n a i r e i s composed o f nine q u e s t i o n s designed to e l i c i t responses on v a r i a b l e s other than s e l f - e s t e e m which may p r e d i c t the undertaking o f h e a l t h promoting be h a v i o r s . A te n t h q u e s t i o n on c u r r e n t smoking s t a t u s , a negative h e a l t h behavior, i s asked as a check on the v a l i d i t y o f the responses to the Health Promoting L i f e s t y l e P r o f i l e . Items asked i n the HPLP are r e f l e c t i v e o f p o s i t i v e h e a l t h behaviors. I t i s a n t i c i p a t e d t h at the r e s u l t s o f the HPLP w i l l be 57 i n v e r s e l y r e l a t e d with the response to the q u e s t i o n on c u r r e n t smoking s t a t u s . The other nine q u e s t i o n s concern: o c c u p a t i o n , hours o f work/week, l e v e l o f e d u c a t i o n completed, number of c h i l d r e n i n the immediate f a m i l y , c h i l d r e n l i v i n g a t home, ages of c h i l d r e n l i v i n g a t home, l i v i n g s i t u a t i o n (alone, or with c h i l d r e n or other a d u l t ) , e t h n i c background, h e a l t h r e l a t e d programs i n the workplace, and c u r r e n t i n j u r y , p h y s i c a l d i s a b i l i t y or c h r o n i c d i s e a s e which would prevent e x e r c i s i n g . In order to prevent b i a s on the p a r t of the r e s e a r c h e r , the R.S.E. t e s t instrument was scored by a d i f f e r e n t i n d i v i d u a l than was the H.P.L.P. t e s t instrument. V.6 Data A n a l y s i s and S t a t i s t i c a l Methods The main r e s e a r c h q u e s t i o n to be answered i n t h i s study was: What i s the r e l a t i o n s h i p between s e l f -esteem, demographic v a r i a b l e s , working c o n d i t i o n s , and the e x t e n t to which working women undertake h e a l t h promoting behaviors? In order to answer t h i s c o r r e l a t i o n a l q u e s t i o n , i t was necessary to determine whether an a s s o c i a t i o n e x i s t e d among the dependent and 58 independent v a r i a b l e s . The s t a t i s t i c a l method used was r e g r e s s i o n a n a l y s i s . Because a s s o c i a t i o n among the independent v a r i a b l e s c o u l d confound the r e s u l t s of a r e g r e s s i o n a n a l y s i s between the dependent and the independent v a r i a b l e s , the independent v a r i a b l e s were f i r s t examined f o r a s s o c i a t i o n s . A t t e s t was used, as the data met the three c o n d i t i o n s o f : 1) i n t e r v a l l e v e l data of the v a r i a b l e on which the groups were being compared; 2) normal d i s t r i b u t i o n of the v a r i a b l e , s e l f -esteem; 3) equal group v a r i a n c e s . An alpha l e v e l o f .01 r a t h e r than .05 was s e t to compensate f o r the l a r g e number of t t e s t s being c a r r i e d out. One-way a n a l y s i s o f v a r i a n c e (ANOVA) was conducted to measure the d i f f e r e n c e s between the means of the s e l f - e s t e e m scores f o r those v a r i a b l e s with more than two groups. ANOVA t e s t i n g was c a r r i e d out as the three b a s i c assumptions o f : 1) mutually e x c l u s i v e groups; 2) normal d i s t r i b u t i o n o f the dependent v a r i a b l e ; 3) homogeneity of v a r i a n c e s o f the groups, were met. The f u r t h e r requirement t h a t continuous data f o r the dependent v a r i a b l e be used, was a l s o s a t i s f i e d before one-way a n a l y s i s of v a r i a n c e was conducted. Where r e s u l t s from parametric t e s t i n g i n d i c a t e d t h a t the v a r i a n c e s f o r the groups being t e s t e d were unequal, a non-parametric method, the Wilcoxon-Rank-Sum was used. A Pearson r c o r r e l a t i o n was determined f o r the minor continuous independent v a r i a b l e , age, and the major continuous independent v a r i a b l e , s e l f - e s t e e m as the f o l l o w i n g four assumptions were met: 1) sample was r e p r e s e n t a t i v e o f the p o p u l a t i o n to which the i n f e r e n c e was made; 2) age and s e l f - e s t e e m were normally d i s t r i b u t e d ; 3) h o m o s c e d a s t i c i t y ; 4 ) the r e l a t i o n s h i p between age and s e l f - e s t e e m was l i n e a r . Pearson r c o r r e l a t i o n s were a l s o conducted on the major independent v a r i a b l e , s e l f - e s t e e m , and the major dependent v a r i a b l e , h e a l t h promoting b e h a v i o r s , as we l l as the s i x su b s c a l e s of h e a l t h promoting behaviors. Once a d e t e r m i n a t i o n o f p o t e n t i a l i n t e r a c t i o n e f f e c t s among independent v a r i a b l e s was made, and any a s s o c i a t i o n among the independent v a r i a b l e s and the major dependent v a r i a b l e had been determined, the r e g r e s s i o n model was formulated based on any v a r i a b l e s which were s i g n i f i c a n t l y a s s o c i a t e d . Footnotes 'No demographic data were a v a i l a b l e on union membership p r i o r to s e l e c t i o n f o r study i n c l u s i o n . T h e r e f o r e , i t was not p o s s i b l e to s t r a t i f y the women in t o c a t e g o r i e s and then randomly s e l e c t from w i t h i n these c a t e g o r i e s with the i d e a t h a t , should a poor response r a t e be r e a l i z e d , f u r t h e r checks on non-respondents c o u l d be made to determine i f the sample was b i a s e d . ^ D i r e c t c o n t a c t with union members was not p e r m i t t e d . A l e t t e r of support f o r the r e s e a r c h , signed by the D i r e c t o r o f O c c u p a t i o n a l H e a l t h and S a f e t y , was t h e r e f o r e , c o n s i d e r e d to be a key f a c t o r which would c o n t r i b u t e to the success o f the data c o l l e c t i o n . 61 CHAPTER SIX RESULTS VI.1 I n t r o d u c t i o n A t o t a l o f 235 completed q u e s t i o n n a i r e packages were r e t u r n e d . S i x o f these were deemed to be unusable as more than 20% o f the i n f o r m a t i o n i n e i t h e r the Rosenberg Self-Esteem Scale or the Health Promoting L i f e s t y l e s P r o f i l e had not been completed by the s u b j e c t . T h e r e f o r e , the sample s i z e f o r the data a n a l y s i s was 229, r e p r e s e n t i n g a response r a t e o f 45.8%. G e n e r a l l y , the demographic and working c o n d i t i o n q u e s t i o n n a i r e was f u l l y completed by the s u b j e c t s . The s t a t i s t i c a l a n a l y s i s performed on the c o l l e c t e d data used the SAS s t a t i s t i c a l package (SAS/STAT guide f o r pers o n a l computers, 1987). VI.1 D e s c r i p t i v e S t a t i s t i c s The demographic c h a r a c t e r i s t i c s o f the sample are d e s c r i b e d i n Table VI.1 ( c a t e g o r i c a l v a r i a b l e s ) , and Table VI.2 (continuous v a r i a b l e s ) . Wherever m i s s i n g values were found i n the R.S.E. or H.P.L.P. instruments, the mean of the group f o r t h a t p a r t i c u l a r 62 item was s u b s t i t u t e d . The R.S.E. instrument was r e v e r s e scored so t h a t high scores would be an i n d i c a t o r o f high s e l f - e s t e e m . T h i s ensured c o n s i s t e n c y with the d i r e c t i o n o f the H.P.L.P. s c o r i n g . TABLE VI.1 Demographic C h a r a c t e r i s t i c s o f Sample (N=229) V a r i a b l e s Frequency Percent Occupation c a s h i e r c l e r k home support worker other more than one o c c u p a t i o n Hours o f work/week 0-32 33-40 Ed u c a t i o n high s c h o o l or l e s s more than high school C h i l d r e n L i v i n g a t Home Yes No L i v i n g S i t u a t i o n at l e a s t 1 other a d u l t , no c h i l d r e n at l e a s t 1 other a d u l t , with c h i l d r e n l i v e alone (no other a d u l t ) , no c h i l d r e n 24 10.6 l i v e alone (no other a d u l t ) , with c h i l d r e n 7 3.1 155 18 4 41 11 67.7 7.9 1.7 17.9 4.8 89 140 38 61 125 104 54. 45, 53 175 23.2 76.8 138 58 60 . 8 25. 6 (c o n t i n u i n g ) TABLE VI.1 (continued) 63 Demographic C h a r a c t e r i s t i c s o f Sample (N=229) Variables Frequency Percent Health Related Programs Yes No 3 225 1.3 98.7 I n j u r y yes no 28 198 12, 87, Smoking never ex c u r r e n t 122 57 49 53, 25, 21. Most o f the respondents were young (mean age of 27.8 years) c a s h i e r s (67.7%) who worked f u l l time (61.1% worked 33-40 hours per week), l i v e d with another a d u l t and were c h i l d l e s s (60.8%). Only 45.4% o f the group were educated beyond high s c h o o l . Of those who had c h i l d r e n who were l i v i n g a t home with them (23.2%), the c h i l d r e n tended to have high mean ages (8.6 to 15 y e a r s ) . Respondents had r e l a t i v e l y high s e l f - e s t e e m l e v e l s (mean of 32, with a p o t e n t i a l range being 10-40), and a l l some undertook h e a l t h promoting behaviors' (range o f 72-177 with a p o t e n t i a l range o f 48-192). 64 TABLE VI.2 Means, Standard D e v i a t i o n s , and Range o f Values for Continuous V a r i a b l e s (N =229) Variable Mean SD Med Min Max Range Age 27.8 7.6 26 17 59 42 Year Quit Smoking 84.9* 5.0 86* 69 90 21 Children i n Imed. Family Age o f C h i l d l (n=55) 9.7 7.1 9 0 26 26 Age o f C h i l d 2 (n=28) 10. 1 5.2 10 0 21 21 Age o f C h i l d 3 (n=8) 8.6 3.4 8 5 16 11 Age o f C h i l d 4 (n=l) 15.0 0.0 15 15 15 0 Age o f C h i l d 5 (n=l) 13.0 0.0 13 13 13 0 Self-Esteem 32.0 4.5 32 19 40 21 Health Promoting Behavior 126.6 18.7 125 72 177 105 S e l f - A c t u a l i z a t i o n 39.4 6.5 40 21 52 31 Health R e s p o n s i b i l i t y 20.5 5.0 20 10 35 25 E x e r c i s e 11.5 4.2 11 5 20 15 N u t r i t i o n 15.9 4.1 16 7 24 17 I n t e r p e r s o n a l Support 22.6 3.6 22 13 28 15 S t r e s s Management 16.8 3.5 17 10 28 18 * r e f e r s to the years, 1984, 1986 Table VI.3 compares 1982 Union data on two demographic c h a r a c t e r i s t i c s with the r e s u l t s from t h i s study. The percentages f o r each o f the c a t e g o r i e s o f the v a r i a b l e , hour of work/week are very s i m i l a r . There are some d i f f e r e n c e s i n the age c a t e g o r i e s , with the women i n the present study being g e n e r a l l y younger than the 1982 union p o p u l a t i o n . 65 TABLE VI.3 Comparison o f Age, and Hours of Work per Week f o r 1982 : Union Data and Present Study 1982 Present Study V a r i a b l e s % Frequency % Cum. % Age * under 20 y r s 5 14 6.1 6.1 20-29 y r s 41 145 63.6 69.7 30-39 y r s 36 45 19.8 89.5 40-49 y r s 16 22 9.6 99. 1 50+ y r s 6 2 .8 100.0 Hours Work/Wk ** 0-16 14 24 10.5 10.5 17-32 28 65 28.4 38.9 33-40 55 139 60.7 99.6 two c a t e g . * * * 1 .4 100.0 *approximate percentages o n l y **1982 c a t e g o r i e s were 0-19, 20-30, 31-40 ***more than one category o f hours was i n d i c a t e d by the respondent A f t e r viewing the frequency t a b l e s based on the o r i g i n a l l y measured c a t e g o r i e s , c e r t a i n v a r i a b l e s were c o l l a p s e d i n t o more l o g i c a l and compact c a t e g o r i e s f o r ease o f subsequent a n a l y s i s . S p e c i f i c a l l y , the two c a t e g o r i e s o f 0-16, and 17-32, w i t h i n the v a r i a b l e , hours o f work/work, were combined i n t o a s i n g l e c a t e g o r y , 0-32. The v a r i a b l e e d u c a t i o n was r e -c a t e g o r i z e d from i t s o r i g i n a l s i x d i v i s i o n s to form j u s t two c a t e g o r i e s : h i g h s c h o o l or l e s s ( i n c l u d i n g elementary s c h o o l , some high s c h o o l , and high s c h o o l ) . 66 and more than high school ( i n c l u d i n g community c o l l e g e , some u n i v e r s i t y , and u n i v e r s i t y ) . C l o s e to 68% of the s u b j e c t s responded t h a t t h e i r occupation was cashier. Because o f t h i s high p r o p o r t i o n , t h i s v a r i a b l e was not i n c l u d e d i n f u r t h e r a n a l y s i s . Almost 99% o f the sample d i d not have health related programs a t the worksite. T h i s v a r i a b l e was, t h e r e f o r e , not i n c l u d e d i n f u r t h e r data a n a l y s i s . Only 12.4% of the sample responded a f f i r m a t i v e l y to the q u e s t i o n "are you c u r r e n t l y s u f f e r i n g from an i n j u r y , or do you have a p h y s i c a l d i s a b i l i t y or c h r o n i c d i s e a s e which would prevent you from e x e r c i s i n g ? 1 ' (shown as injury i n Table VI.4). Consequently, o n l y a d e s c r i p t i v e a n a l y s i s o f the type o f i n j u r y , as shown i n Table VI.4., r a t h e r than a n a l y s i s a c c o r d i n g to i n j u r y type, was pursued. S e v e r a l o f the s u b j e c t s r e p o r t e d more than one i n j u r y which prevented them from e x e r c i s i n g . For example, one s u b j e c t r e p o r t e d a neck i n j u r y and lupus, another r e p o r t e d t o r n ankle ligaments as w e l l as broken t o e s , and a t h i r d r e p o r t e d c a r p a l tunnel syndrome and f i b r o c y t i s . Others were vague r e g a r d i n g t h e i r i n j u r y i . e . surgery. 67 TABLE VI.4 D e s c r i p t o r s o f I n j u r y / D i s a b i l i t y / C h r o n i c Disease P r e v e n t i n g E x e r c i s e as Reported by Subjec t s ( N = 2 8 ) c a r a c c i d e n t back problems neck problems shoulder problems l e g i n j u r y checkers elbow broken toes t o r n ankle ligament or past s p r a i n e d ankles t e n d o n i t i s i n w r i s t s c a r p a l t unnel syndrome lupus f i b r o c y t i s d e g enerating d i s c asthma surgery baby due imminently rheumatoid a r t h r i t i s The e t h n i c v a r i a b l e was e l i m i n a t e d from the study. Poor d e s i g n o f the e t h n i c q u e s t i o n i n the q u e s t i o n n a i r e generated c o n f u s i n g responses which proved too d i f f i c u l t to c a t e g o r i z e with any k i n d o f c e r t a i n t y . 6.3 I n f e r e n t i a l S t a t i s t i c a l R e s u l t s Table VI.5 i l l u s t r a t e s the r e l a t i o n s h i p among the minor independent v a r i a b l e s and the major independent v a r i a b l e , self-esteem. TABLE VI.5 68 R e l a t i o n s h i p Among Minor Independent V a r i a b l e s and Major Independent V a r i a b l e (Self-Esteem) <N=229) V a r i a b l e s Test S t a t i s t i c R e s u l t Self-esteem, e d u c a t i o n t=-0.48 p=. 63 Self-esteem, hours o f work/wk t=0.35 p=.73 Self-esteem, i n j u r y t=-1.41 p=. 16 Self-esteem, age Pearson r r=.0041 p> .05 Self-esteem, time o f response* ANOVA F =1.25 (2,226)** p = . 29 Self-esteem, l i v i n g s i t u a t i o n ANOVA F =.46 (3,223)** p=.71 *the three p e r i o d s o f time d u r i n g which the s u b j e c t s r e t u r n e d the q u e s t i o n n a i r e s (1= Nov.20- Dec.4/89, 2= Dec.5/89 - Jan.5/90, 3= a f t e r second mailout, Jan.6/90 on) **degrees of freedom T t e s t s were used as the s t a t i s t i c a l method f o r comparing d i f f e r e n c e s i n mean s e l f - e s t e e m s c o r e s f o r the two e d u c a t i o n groups, the hours o f work/week groups, and the i n j u r y groups. Table VI.5 shows t h a t there was no d i f f e r e n c e between the means o f any o f 69 these three groups. An a l p h a l e v e l o f .01 r a t h e r than .05 was s e t to compensate f o r the l a r g e number o f t t e s t s being c a r r i e d out. One-way a n a l y s i s o f v a r i a n c e (ANOVA) was the s t a t i s t i c a l t e s t conducted to measure the d i f f e r e n c e s between the means of the s e l f - e s t e e m scores f o r the three time groups, and the four l i v i n g s i t u a t i o n groups. The three time groups r e l a t e d to the p e r i o d s d u r i n g which the s u b j e c t s r e t u r n e d the q u e s t i o n n a i r e s : 1) Nov. 20 - Dec. 4/89; 2) Dec. 5/89 - Jan. 5/90; 3) a f t e r the second mailout, Jan. 6/90 on. The four l i v i n g s i t u a t i o n groups were: 1) l i v i n g with a t l e a s t one other a d u l t , no c h i l d r e n ; 2) l i v i n g with a t l e a s t one other a d u l t , with c h i l d r e n ; 3) l i v i n g alone (no other a d u l t ) , no c h i l d r e n ; 4) l i v i n g alone (no other a d u l t ) , with c h i l d r e n . No d i f f e r e n c e s were found among any of the group means. A Pearson r c o r r e l a t i o n was determined f o r the minor continuous independent v a r i a b l e , age, and the major continuous independent v a r i a b l e , s e l f - e s t e e m . As noted i n Table VI.5, there was no r e l a t i o n s h i p between age and s e l f - e s t e e m . As no d i f f e r e n c e s had been d e t e c t e d i n these 70 r e s u l t s , f u r t h e r i n v e s t i g a t i o n was done to determine i f other v a r i a b i l i t y e x i s t e d among independent v a r i a b l e s . The v a r i a b l e , l i v i n g s i t u a t i o n , was r e - c a t e g o r i z e d so th a t two new groups were formed: l i v i n g with s i g n i f i c a n t o t h e r s , and l i v i n g with k i d s . Each o f these new groups c o n t a i n e d two subgroups (see Table VI.6). Subsequently, Wilcoxon-Rank-Sum t e s t i n g was c a r r i e d out on these two v a r i a b l e s and s e l f - e s t e e m . T h i s non-parametric methodology was chosen because the assumption of homogeneity o f v a r i a n c e s necessary f o r parame t r i c methods was v i o l a t e d . The r e s u l t s i n Table VI.6 i n d i c a t e that each of the two random samples has been drawn from p o p u l a t i o n s having s i m i l a r s e l f - e s t e e m d i s t r i b u t i o n s . Further breakdown o f the l i v i n g s i t u a t i o n v a r i a b l e , then, d i d not i n d i c a t e a s i g n i f i c a n t d i f f e r e n c e between the ranked means o f s e l f - e s t e e m i n the ' l i v i n g with s i g n i f i c a n t o t h e r s ' (with c h i l d r e n , or without c h i l d r e n ) groups. Nor was there a s i g n i f i c a n t d i f f e r e n c e between the ranked means o f s e l f - e s t e e m i n the ' l i v i n g with k i d s ' (with s i g n i f i c a n t o t h e r , or without s i g n i f i c a n t other) groups. 71 TABLE VI.6 R e l a t i o n s h i p Among Minor Independent V a r i a b l e , L i v i n g S i t u a t i o n (by sub-group), and Major Independent V a r i a b l e , Self-Esteem. V a r i a b l e s S t a t i s t i c a l T e s t R e s u l t Alpha L e v e l Self-esteem, Wilcoxon-Rank-Sum p=.58 .05* L i v i n g with S i g n i f i c a n t Others (with and without k i d s ) Self-esteem, Wilcoxon-Rank-Sum p=.41 .05* L i v i n g with Kids (with and without s i g n i f . o t h e r s ) *two s i d e d The next step was an e x p l o r a t i o n o f the p o s s i b l e a s s o c i a t i o n among the minor independent v a r i a b l e s and the major dependent v a r i a b l e , h e a l t h promoting b e h a v i o r s , Table VI.7. Any o f the v a r i a b l e s which appeared to be s i g n i f i c a n t l y a s s o c i a t e d , would then be i n c l u d e d i n the r e g r e s s i o n model. Health promoting b e h a v i o r s were measured u s i n g the H.P.L.P. 72 TABLE VI.7 R e l a t i o n s h i p Among Minor Independent V a r i a b l e s and Major Dependent V a r i a b l e (Health Promoting Behaviors) (N=229) Variables Test S t a t i s t i c Result Health promoting b e h a v i o r s , e d u c a t i o n t=-0.62 p=. 54 Health promoting b e h a v i o r s , hours o f work/wk t=1.17 p=. 24 Heal t h promoting b e h a v i o r s , i n j u r y H e alth promoting b e h a v i o r s , age H e a l t h promoting b e h a v i o r s , time o f response* H e a l t h promoting b e h a v i o r s , l i v i n g s i t u a t i o n t=-0.41 Pearson r r=-0.087 ANOVA F =1.47 (2,226)** ANOVA F =.47 (3,223)** p=. 68 p=. 19 p=. 23 p=.71 *the three p e r i o d s o f time d u r i n g which the s u b j e c t s r e t u r n e d the q u e s t i o n n a i r e s (1= Nov.20- Dec.4/89, 2= Dec.5/89 - Jan.5/90, 3= a f t e r second m a i l o u t , Jan.6/90 on) **degrees o f freedom Once again , none o f the above s t a t i s t i c a l t e s t s proved s i g n i f i c a n t , i n d i c a t i n g t h a t there was no r e l a t i o n s h i p between any o f the minor independent v a r i a b l e s and the g l o b a l H.P.L.P. score f o r t h i s p a r t i c u l a r sample. As a f u r t h e r check on p o t e n t i a l a s s o c i a t i o n s between the major dependent v a r i a b l e and the minor independent v a r i a b l e s , Wilcoxon-Rank-Sum t e s t i n g was conducted on the r e - c a t e g o r i z e d l i v i n g s i t u a t i o n v a r i a b l e , Table VI.8. T h i s non-parametric s t a t i s t i c a l method was necessary because the v a r i a n c e s o f each o f the two groups, l i v i n g with s i g n i f i c a n t o t h e r , and l i v i n g with k i d s , were unequal. TABLE VI.8 R e l a t i o n s h i p Among Minor Independent V a r i a b l e , L i v i n g S i t u a t i o n (by sub-group) and Major Dependent V a r i a b l e , Health Promoting Behaviors (H.P.B.) (N=229) V a r i a b l e s S t a t i s t i c a l T e s t R e s u l t Alpha L e v e l H.P.B., Wilcoxon-Rank-Sum p=.46 .05* L i v i n g with S i g n i f i c a n t Others (with and without k i d s ) H.P.B., Wilcoxon-Rank-Sum p=.40 .05* L i v i n g with Kids (with and without s i g n i f . o t h e r s ) *two s i d e d 74 Both Wilcoxon-Rank-Sum r e s u l t s , Table V I . 8 , i n d i c a t e t h a t the two random samples had been drawn from p o p u l a t i o n s with s i m i l a r H.P.B. d i s t r i b u t i o n s . There was no s i g n i f i c a n t d i f f e r e n c e between the ranked means o f the h e a l t h promoting behavior v a r i a b l e s i n the l i v i n g with s i g n i f i c a n t o t h e r s ' groups, or the l i v i n g with k i d s ' groups. The next major step i n the data a n a l y s i s was the a c t u a l simple l i n e a r r e g r e s s i o n a n a l y s i s which was done to determine the r e l a t i o n s h i p between the major independent v a r i a b l e , self-esteem, and the major dependent v a r i a b l e , global health promoting behaviors. As w e l l , each o f the s i x h e a l t h promoting behavior subscales was t e s t e d f o r a s s o c i a t i o n with s e l f - e s t e e m . A Pearson r c o e f f i c i e n t was determined f i r s t , to ensure that there was a l i n e a r component to the r e l a t i o n s h i p between v a r i a b l e s . P r i o r to the r e g r e s s i o n a n a l y s i s , the nominal l e v e l v a r i a b l e s were dummy coded to al l o w f o r meaningful i n t e r p r e t a t i o n . The same assumptions r e q u i r e d f o r c o r r e l a t i o n a l a n a l y s i s were a p p l i e d to the r e g r e s s i o n a n a l y s i s . 75 TABLE VI.9 R e l a t i o n s h i p Between Major Independent V a r i a b l e ( S e l f -esteem), and Major Dependent V a r i a b l e (Health Promoting Behaviors) O v e r a l l , and i t s S i x Subscales V a r i a b l e s r P Self-esteem, Health promoting behaviors .52 . 27 < .001 Self-esteem, S e l f - a c t u a l i z a t i o n .68 .47 < .001 Self-esteem, Health r e s p o n s i b i l i t y .22 .04 < .001 Self-esteem. E x e r c i s e . 21 .04 < .001 Self-esteem, N u t r i t i o n . 17 .03 < .007 Self-esteem. I n t e r p e r s o n a l support . 33 . 10 < .001 Self-esteem, S t r e s s management . 35 . 12 < .001 As shown i n Table VI.9, there was an a s s o c i a t i o n between s e l f - e s t e e m and h e a l t h promoting b e h a v i o r s . A C o e f f i c i e n t o f d e t e r m i n a t i o n Ra', o f .27 i n d i c a t e d t h a t 27 percent o f the t o t a l v a r i a b i l i t y i n g l o b a l h e a l t h promoting behaviors had been accounted f o r by s e l f -esteem. Within the s i x s u b s c a l e s o f g l o b a l h e a l t h promoting b e h a v i o r s , s e l f - e s t e e m accounted f o r 47 percent o f the t o t a l v a r i a b i l i t y o f s e l f -76 a c t u a l i z a t i o n , 12 percent o f s t r e s s management, 10 percent o f i n t e r p e r s o n a l support, 4 percent o f h e a l t h r e s p o n s i b i l i t y , 4 percent o f e x e r c i s e , and 3 percent of n u t r i t i o n . S c a t t e r p l o t s were used to i n v e s t i g a t e any p o s s i b l e i n t e r a c t i o n between v a r i a b l e s . The s i x v a r i a b l e s which were examined f o r t h e i r i n t e r a c t i o n with s e l f - e s t e e m and h e a l t h promoting b ehaviors were: e d u c a t i o n group, hours o f work/week group, i n j u r y group, time o f response group, s i g n i f i c a n t o t h e r group, k i d s group. No i n t e r a c t i o n was found. T h e r e f o r e , no f u r t h e r r e g r e s s i o n m o d e l l i n g or a n a l y s i s was pursued. VI.4 Other R e s u l t s A number of s i d e i s s u e s were pursued. An e a r l i e r examination of the d i f f e r e n c e s between the means i n g l o b a l h e a l t h promoting behaviors and i n j u r y r e s u l t e d i n no s i g n i f i c a n t d i f f e r e n c e . However, a d i f f e r e n c e i n the means between i n j u r y and the e x e r c i s e s ubscale of h e a l t h promoting behaviors would be expected i n t u i t i v e l y , and so a t t e s t was conducted to determine i f t h i s was a c t u a l l y so. 77 TABLE VI.10 R e l a t i o n s h i p Between Independent V a r i a b l e , I n j u r y , and E x e r c i s e s u b s c a l e o f He a l t h Promoting L i f e s t y l e s P r o f i l e V a r i a b l e s T e s t S t a t i s t i c R e s u l t I n j u r y , E x e r c i s e t= -1.94 p=.05 Table VI.10 shows that there was, indeed, a s i g n i f i c a n t d i f f e r e n c e , with those i n d i v i d u a l s who c l a i m i n j u r y doing l e s s e x e r c i s e than those who do not c l a i m to have an i n j u r y . Subsequently, a s c a t t e r p l o t was c r e a t e d to determine whether there were any i n t e r a c t i o n e f f e c t s between e x e r c i s e and s e l f - e s t e e m a c c o r d i n g to i n j u r y or n o n - i n j u r y . The r e s u l t s demonstrated t h a t , o f the i n d i v i d u a l s who have an i n j u r y , there i s no a s s o c i a t i o n between e x e r c i s e and s e l f - e s t e e m (r=.08). Of the i n d i v i d u a l s who do not have an i n j u r y , there i s an a s s o c i a t i o n between e x e r c i s e and s e l f - e s t e e m (r=.23). As e x e r c i s e and s e l f - e s t e e m e x p l a i n o n l y four percent o f the v a r i a n c e (Table VI.9), and as the above a n a l y s i s was i n p u r s u i t o f a s i d e i s s u e o n l y , no f u r t h e r a n a l y s i s was done with the v a r i a b l e , i n j u r y group. 78 Information on a key negative h e a l t h behavior, smoking, had been gathered i n the q u e s t i o n n a i r e f o r the purpose o f determining i f there was a r e l a t i o n s h i p between a negative h e a l t h behavior, and the H.P.L.P. r e s u l t s which t e s t e d f o r p o s i t i v e h e a l t h b e h a v i o r s . I t was a n t i c i p a t e d t h a t the r e s u l t s of the H.P.L.P. q u e s t i o n n a i r e would be i n v e r s e l y r e l a t e d with the response to the negative h e a l t h behavior. The r e s u l t o f a one-way a n a l y s i s o f v a r i a n c e i s presented i n Table VI.11. TABLE VI.11 R e l a t i o n s h i p between Smoking Status and H e a l t h Promoting Behaviors V a r i a b l e s T e s t S t a t i s t i c R e s u l t Smoking*, Health ANOVA p=.09 promoting F =2.36 behaviors (2,225)** *smoking i s s u b d i v i d e d i n t o 3 c a t e g o r i e s : never, ex, present **degrees o f freedom Group n Mean 1. never 122 128.45 2. ex 57 126.61 3. pre s e n t 49 121.63 79 As Table VI.11 i n d i c a t e s , whether or not an i n d i v i d u a l has never smoked, i s a c u r r e n t smoker, or i s an ex-smoker, does not reach s i g n i f i c a n c e as an e f f e c t on the undertaking o f h e a l t h promoting behaviors i n t h i s study. To e x p l o r e the i s s u e f u r t h e r , the ex smokers were s p l i t i n t o those who had q u i t p r i o r to 1989, and those who q u i t i n 1989 or l a t e r . The recency of q u i t t i n g smoking and health promoting behaviors was examined u s i n g a Wilcoxon-Rank-Sum t e s t , as the groups had unequal v a r i a n c e s , Table VI.12. TABLE VI.12 R e l a t i o n s h i p between the Recency of Q u i t t i n g Smoking, and Health Promoting Behaviors V a r i a b l e s S t a t i s t i c a l Test Result Alpha L e v e l Recency of Wilcoxon-Rank-Sum p=.00 36 .05 q u i t t i n g smoking*. Health promoting behaviors *two groups: 1) p r i o r to 1989 (n=40) 2) 1989 or l a t e r (n=15) The p value of .00 36 i n d i c a t e s t h a t those who q u i t b e f o r e 1989 tend to engage i n more h e a l t h promoting behaviors as r e p o r t e d i n the H.P.L.P. t e s t instrument. Footnotes 'a score of 48 i n d i c a t e s no h e a l t h promoting behaviors were undertaken. 81 CHAPTER SEVEN DISCUSSION VII.1 Main Research Question The main r e s e a r c h q u e s t i o n which was addressed i n t h i s study was: "What i s the r e l a t i o n s h i p between s e l f -esteem, demographic v a r i a b l e s , working c o n d i t i o n s , and the e x t e n t to which working women undertake h e a l t h promoting b e h a v i o r s ? " . The r e s u l t s o b t a i n e d from the study suggest t h a t s e l f - e s t e e m i s p r e d i c t i v e o f h e a l t h promoting b e h a v i o r s , which i s c o n s i s t e n t with the m o t i v a t i o n a l theory proposed by Pender (1982), and the mod i f i e d v e r s i o n o f the model shown i n F i g u r e 2.2. Self - e s t e e m i s a l s o p r e d i c t i v e o f s p e c i f i c h e a l t h promoting b e h a v i o r s , l i s t e d i n ranked order o f a s s o c i a t i o n : s e l f - a c t u a l i z a t i o n , s t r e s s management, i n t e r p e r s o n a l support, h e a l t h r e s p o n s i b i l i t y , e x e r c i s e , and n u t r i t i o n . The l a t t e r r e s u l t s are c o n s i s t e n t with Duffy's (1988) f i n d i n g s . In her study o f 262 working women, u s i n g the same t e s t instruments as i n t h i s study, Duffy determined t h a t s e l f - e s t e e m was p r e d i c t i v e f o r s e l f - a c t u a l i z a t i o n , n u t r i t i o n , e x e r c i s e , and i n t e r p e r s o n a l support. Duffy's r e s u l t s may not be g e n e r a l i z a b l e because o f her low response r a t e o f 44 82 percent. T h i s problem a l s o e x i s t s i n the present study, and i s addressed f u r t h e r under VII.3.1. S e l f - a c t u a l i z a t i o n was the h e a l t h promoting behavior which shared the g r e a t e s t v a r i a n c e with s e l f -esteem. As s t a t e d e a r l i e r (V.2), no attempt was made i n the d e s i g n of the study to demonstrate c a u s a l i t y . Thus, o n l y an a s s o c i a t i o n , and not i t s d i r e c t i o n , c o u l d be determined between s e l f - e s t e e m and s e l f -a c t u a l i z a t i o n . The s e l f - a c t u a l i z a t i o n v a r i a b l e warrrants d i s c u s s i o n because o f i t s r e l a t i v e l y high degree o f p r e d i c t a b i l i t y . The f o l l o w i n g items i n the Heal t h Promoting L i f e s t y l e P r o f i l e t e s t e d f o r s e l f -a c t u a l i z a t i o n : 1. L i k e myself 2. Am e n t h u s i a s t i c and o p t i m i s t i c about l i f e 3. F e e l I am growing and changing p e r s o n a l l y i n p o s i t i v e d i r e c t i o n s 4 . F e e l happy and content 5. Am aware o f my pe r s o n a l s t r e n g t h s and weaknesses 6. Work toward long-term g o a l s i n my l i f e 7. Look forward to the f u t u r e 8. Am aware o f what i s important to me i n l i f e 9. Respect my own accomplishments 10. F i n d each day i n t e r e s t i n g and c h a l l e n g i n g 11. F i n d my l i v i n g environment p l e a s i n g and s a t i s f y i n g 12. Am r e a l i s t i c about the go a l s that I s e t 13. B e l i e v e t h a t my l i f e has purpose The authors o f the Health Promoting L i f e s t y l e P r o f i l e (Walker, S e c h r i s t , & Pender, 1987) have not d e f i n e d s e l f - a c t u a l i z a t i o n , or any o f the other f i v e 83 h e a l t h promoting behaviors measured by the H.P.L.P. The q u e s t i o n s i n the H.P.L.P. however, presumably r e f l e c t t h e i r n o t i o n o f s e l f - a c t u a l i z a t i o n . Maslow s t a t e s t h a t h e a l t h y people are motivated " p r i m a r i l y by trends towards s e l f - a c t u a l i z a t i o n " (1962, p.25), and t h e i r observed c l i n i c a l c h a r a c t e r i s t i c s a r e : "1. S u p e r i o r p e r c e p t i o n o f r e a l i t y . 2. Increased acceptance o f s e l f , o f o t h e r s and of nature. 3. Increased s p o n t a n e i t y . 4 . Increase i n problem-centering. 5. Increased detachment and d e s i r e f o r p r i v a c y . 6. Increased autonomy, and r e s i s t a n c e to e n c u l t u r -a t i o n . 7. G r e ater f r e s h n e s s o f a p p r e c i a t i o n , and r i c h n e s s of emotional r e a c t i o n . 8. Higher frequency of peak experience. 9. Increased i d e n t i f i c a t i o n with human s p e c i e s . 10. Changed ... i n t e r p e r s o n a l r e l a t i o n s . 11. More democratic c h a r a c t e r s t r u c t u r e . 12. G r e a t l y i n c r e a s e d c r e a t i v e n e s s . 13. C e r t a i n changes i n the value system." (p. 26, 1962) The q u e s t i o n s i d e n t i f i e d i n the the H.P.L.P. as being r e p r e s e n t a t i v e o f s e l f - a c t u a l i z a t i o n , appear to be c o n s i s t e n t with Maslow*s d e s c r i p t i o n o f observable s e l f - a c t u a l i z a t i o n c h a r a c t e r i s t i c s o f an i n d i v i d u a l . The f i n d i n g s i n t h i s study are a l s o c o n s i s t e n t with Maslow's m o t i v a t i o n a l theory (1962), which p l a c e s s e l f -a c t u a l i z a t i o n h i e r a r c h i a l l y above the need f o r s e l f -esteem. According to Maslow, i n d i v i d u a l s w i l l meet the more b a s i c s u r v i v a l needs p r i o r to being able to devote 84 energy to meeting the more s o p h i s t i c a t e d needs such as l o v e and b e l o n g i n g , s e l f - e s t e e m , and f i n a l l y s e l f -a c t u a l i z a t i o n . G e n e r a l l y , Maslow sees i n d i v i d u a l s meeting t h e i r needs i n t h i s pyramidal f a s h i o n . I n d i v i d u a l s would n e c e s s a r i l y f i r s t possess s e l f - e s t e e m before t h e i r s e l f - a c t u a l i z a t i o n needs c o u l d be met. Respondents o f t h i s p a r t i c u l a r study g e n e r a l l y had high l e v e l s of s e l f - e s t e e m . I t i s not s u r p r i s i n g then, that s e l f - e s t e e m was p r e d i c t i v e of s e l f - a c t u a l i z a t i o n . The evidence i n t h i s study a l s o suggests t h a t the demographic v a r i a b l e s of age, e d u c a t i o n , and l i v i n g s i t u a t i o n , i n c l u d i n g l i v i n g with s i g n i f i c a n t o t h ers and l i v i n g with k i d s , are not p r e d i c t i v e of h e a l t h promoting b e h a v i o r s ; n e i t h e r i s the working c o n d i t i o n v a r i a b l e , number o f hours worked per week. These f i n d i n g s are n e i t h e r s u p p o r t i v e of Pender's model of m o t i v a t i o n i n undertaking h e a l t h promoting behaviors (Pender, 1982), nor o f the modified v e r s i o n of Pender's model ( F i g u r e 2.2). They are , however, c o n s i s t e n t with Duffy's r e s u l t s (1988). Duffy found t h a t demographic v a r i a b l e s do not i n f l u e n c e h e a l t h promoting b e h a v i o r s . The s u b j e c t s i n Duffy's study represented a r e l a t i v e l y homogeneous group: mostly married (60.1%), white 85 (93.5%), very w e l l educated (72.7% had a Master's or D o c t o r a l degree), with an age range o f 35-65 yea r s , and a mean age of 45.5 years. 64.6% had a spouse l i v i n g with them, 43.3% had c h i l d r e n l i v i n g with them, and a l l respondents were employed by the same u n i v e r s i t y . The r e s u l t i n g homogeneity may have r e s t r i c t e d the range of the values i n the study sample. The present study may s u f f e r from the same l i m i t a t i o n . Although the s t r a t e g i e s o f random s e l e c t i o n , the i n c l u s i o n o f extraneous v a r i a b l e s as p a r t o f the study, and p l a n n i n g f o r homogeneity o f r e s e a r c h s u b j e c t s , were employed i n an attempt to prov i d e maximum assurance o f i n t e r n a l v a l i d i t y , the homogeneity which was achieved may have masked the p o t e n t i a l v a r i a b i l i t y o f the minor independent v a r i a b l e s . The q u e s t i o n a r i s e s as to whether there was enough power to d e t e c t h e a l t h promoting behavior d i f f e r e n c e s , i n t h a t no s i g n i f i c a n t d i f f e r e n c e s were determined i n any o f the independent v a r i a b l e s , except f o r s e l f -esteem. Power, as the a b i l i t y to d e t e c t r e l a t i o n s h i p s among v a r i a b l e s , depends s t r o n g l y on the sample s i z e , being i n c r e a s e d when a l a r g e sample s i z e i s used. 86 S t r e i n e r (1986), r e f e r r i n g to l i n e a r r e g r e s s i o n , suggests t h a t "a good r u l e of thumb i s t h a t the sample s i z e , or number o f data p o i n t s , should be a t l e a s t f i v e times the number of independent v a r i a b l e s " to ensure adequate power (p.63). In t h i s study, nine minor independent v a r i a b l e s (age, e d u c a t i o n , hours of work/week, l i v i n g s i t u a t i o n , l i v i n g with s i g n i f i c a n t o t h e r s , l i v i n g with k i d s , i n j u r y , smoking, and time of response), and one major independent v a r i a b l e , ( s e l f -esteem) were t e s t e d . T h e r e f o r e , 45 s u b j e c t s were needed, and the sample s i z e meets t h i s requirement. The power a v a i l a b l e f o r the s t a t i s t i c a l t e s t s , was a l s o determined u s i n g t a b l e s f o r t e s t s o f d i f f e r e n c e s of two independent means, and b i v a r a t e c o r r e l a t i o n s ( P o l i t & Hungler, 1987) (see Appendix C). Since no other estimate of e f f e c t s i z e c o u l d be found i n the l i t e r a t u r e , a c o n s e r v a t i v e value of .50 was used ( P o l i t & Hungler, 1987) f o r the b i v a r i a t e c o r r e l a t i o n s . A c cording to the b i v a r i a t e c o r r e l a t i o n t a b l e s i n Appendix C, u s i n g a sample s i z e o f 75, an e f f e c t s i z e o f .5, and an alpha of .05, 99% power w i l l be achieved. Because a sample s i z e o f 229 was a c t u a l l y used, the a v a i l a b l e power f o r the c o r r e l a t i o n a l t e s t i n g ( s e l f -87 esteem and h e a l t h promoting b e h a v i o r s , s e l f - e s t e e m and age) was g r e a t e r than 99%. The power that was a v a i l a b l e f o r the t t e s t s conducted on the major independent v a r i a b l e , s e l f -esteem, and the minor independent v a r i a b l e s , was determined u s i n g 1/2 a standard d e v i a t i o n o f s e l f -esteem (1/2 of 4.51) i n the c a l c u l a t i o n s f o r the e f f e c t s i z e , g i v i n g an e f f e c t s i z e o f .5*. From the t a b l e s f o r t t e s t s (Appendix C), i t was determined t h a t , u s i n g an alpha o f .01, and a sample s i z e o f 94, a power of 80% was achieved. Thus, the a v a i l a b l e power f o r a l l t t e s t v a r i a b l e s , except l i v i n g s i t u a t i o n and i n j u r y , was 80%. However, i f one standard d e v i a t i o n were used i n the c a l c u l a t i o n s f o r the e f f e c t s i z e , o n l y 37 s u b j e c t s would be r e q u i r e d to achieve a power o f .80. Since more than 37 were used i n the l i v i n g s i t u a t i o n v a r i a b l e , the power achieved was a t l e a s t 80%. Power f o r the v a r i a b l e , i n j u r y , however, was somewhere between 60 and 70 percent. These r e s u l t s were a l s o true f o r the t t e s t s conducted on the major dependent v a r i a b l e , h e a l t h promoting b e h a v i o r s , and the minor independent v a r i a b l e s . Thus an adequate amount of power was a v a i l a b l e f o r *For f o o t n o t e , r e f e r to the end of Chapter Seven 88 a l l t e s t s conducted on the data i n t h i s study, with the e x c e p t i o n o f the v a r i a b l e s , s e l f - e s t e e m and i n j u r y , and h e a l t h promoting behaviors and i n j u r y . I t i s t h e r e f o r e , u n l i k e l y that a true d i f f e r e n c e was missed. I t should a l s o be noted, t h a t although no s i g n i f i c a n t d i f f e r e n c e was found between h e a l t h promoting behaviors and i n j u r y , there was one between e x e r c i s e and i n j u r y . As might be expected, a r e l a t i o n s h i p was found to e x i s t between i n j u r y and e x e r c i s e . The a n t i c i p a t e d d i r e c t i o n of the r e s u l t s was a l s o supported: women who r e p o r t e d i n j u r i e s or c h r o n i c i l l n e s s e s which might prevent them from e x e r c i s i n g , a l s o r e p o r t e d doing l e s s e x e r c i s e than those who d i d not c l a i m i n j u r y . The evidence o f t h i s a s s o c i a t i o n was r e a s s u r i n g i n l i g h t of the l a c k o f a s s o c i a t i o n between h e a l t h promoting behaviors and any o f the other demographic and working c o n d i t i o n v a r i a b l e s . I t was a n t i c i p a t e d t h a t respondents who had never smoked, or who were ex-smokers would have a p o s i t i v e a s s o c i a t i o n with h e a l t h promoting b e h a v i o r s . The r e s u l t s d i d not c o n f i r m t h a t t h i s was the case. However, there was a r e l a t i o n s h i p between recency o f 89 q u i t t i n g smoking and h e a l t h promoting b e h a v i o r s . Those who had claimed to have q u i t a longer time ago, claimed to be undertaking more h e a l t h promoting behaviors than more r e c e n t ex-smokers. The time frame i n which the s u b j e c t s responded i n r e t u r n i n g the completed q u e s t i o n n a i r e , was not found to have i n f l u e n c e d the s c o r e s o f e i t h e r the s e l f - e s t e e m or h e a l t h promoting behavior t e s t instruments. There was very l i t t l e v a r i a n c e among responses, whether answered i n November, 1989 or i n A p r i l , 1990, or anytime i n between. From t h i s r e s u l t , one might assume that i f a t h i r d m a i l o u t would have been conducted with a view to i n c r e a s i n g the response r a t e , i t s r e s u l t s would have been s i m i l a r to those c o l l e c t e d e a r l i e r . T h e r e f o r e , the r e s u l t s r e p o r t e d i n t h i s study may be r e p r e s e n t a t i v e of the p o p u l a t i o n from which the sample was drawn, d e s p i t e the low response r a t e . VII.2 Secondary Research Question The secondary r e s e a r c h q u e s t i o n addressed i n t h i s study i s : "To what ext e n t do women who work o u t s i d e the home undertake h e a l t h promoting b e h a v i o r s ? " The mean score f o r g l o b a l h e a l t h promoting behaviors o f the 90 women i n t h i s study i s 126.6; the range i s 72-177, while the p o t e n t i a l range i s 48-192. A score o f 48 i n d i c a t e s t hat no h e a l t h promoting behaviors are undertaken. The mean valu e s f o r each o f the s i x sub s c a l e s are shown i n Table VI.2. However, other than s t a t i n g t h a t the urban working women who p a r t i c i p a t e d i n t h i s study d i d r e p o r t undertaking some h e a l t h promoting b e h a v i o r s , no other c o n c l u s i o n can be drawn. Th i s p o i n t i s e l a b o r a t e d i n s e c t i o n VII.3.3. VII.3 L i m i t a t i o n s VII.3.1 Low Response Rate The most s e r i o u s l i m i t a t i o n o f the study i s the low response r a t e o f 45.8%. Because the study r e s u l t s were g e n e r a l l y not s i g n i f i c a n t , t h i s i s o f p a r t i c u l a r concern, although t h i s concern i s somewhat m i t i g a t e d as an adequate amount o f power was a v a i l a b l e . R e s u l t s which are marginal or near marginal i n c o n j u n c t i o n with a low response r a t e , are cause f o r concern as to whether the r e s u l t s r e f l e c t the sampling frame; i f not, the r e s u l t s w i l l not be g e n e r a l i z a b l e . On the other hand, g e n e r a l l y i t appears as though enough power was a v a i l a b l e . Thus, the marginal r e s u l t s found i n t h i s study, probably r e f l e c t the f a c t t h at true d i f f e r e n c e s were not missed. At l e a s t two q u i t e d i f f e r e n t i n t e r p r e t a t i o n s may be p l a c e d on the v o l u n t e e r b i a s a s s o c i a t e d with the low response r a t e i n t h i s study. F i r s t , i f the respondents were 'complainers• and b e l i e v e d that the study might demonstrate t h e i r tough working c o n d i t i o n s , or s t r e s s on the job, they would be committed to responding so t h a t t h e i r viewpoints c o u l d be heard. In t h i s case, i t i s p o s s i b l e that the s u b j e c t s who responded were those with low s e l f - e s t e e m . A number of anecdotal o b s e r v a t i o n s on the author's p a r t , however, support the n o t i o n t h a t t h i s i n t e r p r e t a t i o n i s i n c o r r e c t . F i r s t , those respondents who sent i n u n s o l i c i t e d comments along with t h e i r q u e s t i o n n a i r e s , appeared, from t h e i r remarks, to be c o n f i d e n t i n d i v i d u a l s . Second, the mean score f o r s e l f - e s t e e m i n the sample was 32, from a p o t e n t i a l range o f 10-40. T h i s suggests that the s u b j e c t s who p a r t i c i p a t e d i n the study had f a i r l y h igh l e v e l s of s e l f - e s t e e m . T h i r d , the i n t r o d u c t o r y l e t t e r (Appendix A l ) c l e a r l y s t a t e s t h a t the study i s not designed to have d i r e c t b e n e f i t s f o r the respondents. A second i n t e r p r e t a t i o n o f the poor response r a t e stems from v o l u n t e e r ism due to hig h l e v e l s o f s e l f -esteem. That i s , i n d i v i d u a l s who regard themselves h i g h l y , are more l i k e l y to respond to the q u e s t i o n n a i r e package. T h i s e x p l a n a t i o n i s probably more a p p l i c a b l e . A t h i r d e x p l a n a t i o n , which cannot be r u l e d out, may be that there i s a b i p o l a r d i s t r i b u t i o n due to the sample, f e a t u r i n g both complainers and those with h i g h s e l f -esteem l e v e l s . However, the histogram from the study r e s u l t s d i d not i n d i c a t e t h i s to be the case. There i s a l s o the p o s s i b i l i t y t h a t , i f there i s an a s s o c i a t i o n between s e l f - e s t e e m and h e a l t h promoting b e h a v i o r s , and the v o l u n t e e r b i a s d e s c r i b e d above ( v o l u n t e e r i s m due to high l e v e l s o f self-esteem) i s present, then the mean sco r e s f o r h e a l t h promoting behaviors i n the sample w i l l a l s o be a r t i f i c i a l l y high. I f the r e s u l t s from the sample c o u l d be compared with the sampling frame, then a d e t e r m i n a t i o n o f the ex i s t e n c e / n o n - e x i s t e n c e o f a b i a s due to the low response r a t e c o u l d be made. U n f o r t u n a t e l y , except f o r a few sketchy demographics r e g a r d i n g age, and hours of work/week o f Union members, t h i s i n f o r m a t i o n was not a v a i l a b l e from the Union. In 1982, a survey had been c a r r i e d out on 1800 male and female union members (L. Stoffman, p e r s o n a l communication, November 1, 1989). Seventy percent o f the members were women. Table VI.3 compares the i n f o r m a t i o n o b t a i n e d i n the 1982 survey, and t h a t o b t a i n e d i n t h i s study. From Table VI.3 i t can be seen t h a t the percentages a s s o c i a t e d with hours o f work per week are q u i t e s i m i l a r i n the 1982 and 1990 survey r e s u l t s , d e s p i t e s l i g h t l y d i f f e r e n t c a t e g o r i e s . The age v a r i a b l e p r e s e n t s o n l y one major d i s s i m i l a r i t y , the 40+ range being 22% i n 1982, and 10.4% i n 1990. The percentage o f s u b j e c t s under age twenty i s s i m i l a r . In both surveys, the g r e a t e s t percentage i s found i n the age range o f 20-29 years, and the second h i g h e s t percentage i n the 30-39 year range. The percentage of respondents i n the 20-39 year range i s very s i m i l a r , 77% i n 1982, and 83.4% i n the present study. Although the i n f o r m a t i o n from the 1982 Union survey covers o n l y two demographic c h a r a c t e r i s t i c s , i t appears to match c l o s e l y with those same c h a r a c t e r i s t i c s sampled i n the p r e s e n t study. The data suggest that the sample drawn f o r t h i s study i s not r a d i c a l l y d i f f e r e n t from the union p o p u l a t i o n . T h i s 94 f i n d i n g somewhat m i t i g a t e s the concern about the low response r a t e , and supports the n o t i o n o f g e n e r a l i z a b i l i t y o f the f i n d i n g s i n t h i s study to other urban, working, female p o p u l a t i o n s with s i m i l a r demographic c h a r a c t e r i s t i c s . VII.3.2 Range R e s t r i c t i o n s o f Independent V a r i a b l e s Age, e d u c a t i o n a l l e v e l , hours o f work per week, l i v i n g s i t u a t i o n , i n j u r y , and time o f response d i d not demonstrate an a s s o c i a t i o n with h e a l t h promoting b e h a v i o r s . As s u f f i c i e n t power was a v a i l a b l e to conduct the s t a t i s t i c a l t e s t i n g , another e x p l a n a t i o n must be found f o r the l a c k o f e f f e c t o f these independent v a r i a b l e s i f , indeed, they are s i g n i f i c a n t f a c t o r s . R e s t r i c t e d range would be another cause; the more l i m i t e d the range, the g r e a t e r the d i f f i c u l t y i n d e t e r m i n i n g d i f f e r e n c e s which are a c t u a l l y present. T h i s may be due to the l i m i t e d sample s i z e , or i t may be r e f l e c t i v e of r e a l i t y i n t h a t the sample i s , indeed, r e p r e s e n t a t i v e of the p o p u l a t i o n from which i t was drawn. T h i s would mean t h a t the p o p u l a t i o n r e a l l y i s , on the whole, young, being employed as c a s h i e r s , most of whom work a t l e a s t 31 hours per week. The range of 95 each v a r i a b l e would be n a t u r a l l y l i m i t e d due to the homogeneity of the p o p u l a t i o n . The o n l y other study which t e s t e d f o r s i m i l a r v a r i a b l e s (Duffy, 1988), d i d not r e p o r t the range o f value s f o r s e l f - e s t e e m and h e a l t h promoting b e h a v i o r s . T h e r e f o r e , a comparison to determine s i m i l a r i t y o f range of v a l u e s , i s not p o s s i b l e . However, Duffy d i d d e s c r i b e the demographic c h a r a c t e r i s t i c s o f the respondents i n her study (see s e c t i o n V I I . l ) , and i t appears that the sample s t u d i e d was homogeneous, with a l i m i t e d range o f v a l u e s . I t seems l i k e l y t h a t the range o f values i n the present study i s a l s o n a t u r a l l y r e s t r i c t e d due to the homogeneity o f the sample. VII.3.3 Secondary Research Question Only l i m i t e d c o n c l u s i o n s can be drawn with regard to the secondary r e s e a r c h q u e s t i o n f o r two reasons. F i r s t , the study d e s i g n d i d not take i n t o c o n s i d e r a t i o n the need f o r comparison o f working womens' responses with those o f women who work a t home. Consequently, no r e l e v a n t data was c o l l e c t e d . Second, no l i t e r a t u r e c o u l d be found which p r o v i d e d i n f o r m a t i o n r e g a r d i n g the undertaking o f h e a l t h promoting behaviors measured by the Health Promoting P r o f i l e L i f e s t y l e i n women who work a t home. The answer to the q u e s t i o n ; "To what exte n t do women who work o u t s i d e the home undertake h e a l t h promoting b e h a v i o r s ? " w i l l t h e r e f o r e be l i m i t e d to o b s e r v a t i o n s d e r i v e d from d e s c r i p t i v e s t a t i s t i c s . These are d e s c r i b e d i n VII.2. 9 7 Footnotes C a l c u l a t i o n of Estimated E f f e c t : e stimated p o p u l a t i o n group d i f f e r e n c e s e stimated p o p u l a t i o n SD For t t e s t s i n v o l v i n g Self-esteem as a v a r i a b l e : 2. 255 estimated e f f e c t = = .5 4.51 9 8 CHAPTER EIGHT SUMMARY VIII.1 I n t r o d u c t i o n The o b j e c t i v e o f t h i s study has been to ex p l o r e the r e l a t i o n s h i p between s e l f - e s t e e m and the undertaking o f h e a l t h promoting behaviors i n working women. Two r e s e a r c h q u e s t i o n s have been e x p l o r e d : 1. What i s the r e l a t i o n s h i p between s e l f - e s t e e m , demographic v a r i a b l e s , working c o n d i t i o n s , and the e x t e n t to which working women undertake h e a l t h promoting behaviors? 2. To what extent do women who work o u t s i d e the home undertake h e a l t h promoting behaviors? The c o n c e p t u a l framework used f o r t h i s study i s a mod i f i e d v e r s i o n o f Pender's Proposed Health Promotion Model ( F i q u r e 2.2). In t h i s model, h e a l t h promoting be h a v i o r s are viewed as m a n i f e s t a t i o n s o f human a c t u a l i z i n g t e ndencies. M o t i v a t i o n p l a y s a c r i t i c a l r o l e i n i n i t i a t i n g and s u s t a i n i n g h e a l t h promoting b e h a v i o r s . Self-esteem i s seen as one of the e i g h t m o t i v a t i o n a l f a c t o r s a f f e c t i n g the decision-making phase o f h e a l t h promoting behavior. The u n d e r l y i n g assumption i s th a t i n d i v i d u a l s who value themselves. 99 w i l l be more l i k e l y to take the time necessary f o r self-improvement expressed as h e a l t h promoting b e h a v i o r s . A p o s i t i v e , r e i n f o r c i n g c y c l i c a l p a t t e r n may a l s o be e s t a b l i s h e d , as the i n d i v i d u a l i s rewarded with f e e l i n g s o f i n c r e a s e d s e l f - e s t e e m which, i n t u r n , i n f l u e n c e the d e c i s i o n to repea t the h e a l t h promoting behavior. E q u a l l y , a negative r e i n f o r c i n g c y c l e may be i n i t i a t e d . Demographic, i n t e r p e r s o n a l , and s i t u a t i o n a l f a c t o r s a l s o i n f l u e n c e the d e c i s i o n to undertake h e a l t h promoting behavior. 8.2 Co n c l u s i o n s The undertaking o f h e a l t h promoting behaviors i n working women i s an i s s u e which has o n l y been e x p l o r e d i n a l i m i t e d f a s h i o n . T h i s i s p a r t i c u l a r l y t r u e o f those women who engage i n h e a l t h promoting behaviors i n a l o c a t i o n other than t h e i r w o r k s i t e . I t i s known t h a t women i n the United S t a t e s a c t i v e l y p a r t i c i p a t e i n work s i t e h e a l t h promotion programs, where programs are a v a i l a b l e . In the Canadian study undertaken by the author, o n l y 1.3% of the respondents i n d i c a t e d t h a t there were h e a l t h r e l a t e d programs a v a i l a b l e a t the wor k s i t e , y e t a l l women i n t h i s study r e p o r t e d t h a t 100 they engaged i n h e a l t h promoting b e h a v i o r s . These p o s i t i v e h e a l t h behaviors were o b v i o u s l y undertaken o u t s i d e the worksite m i l i e u . The extent to which the women undertook them, the second r e s e a r c h q u e s t i o n o f t h i s study, c o u l d not be c l a r i f i e d , other than to note t h a t the mean score f o r h e a l t h promoting behaviors f o r these women was 126.6 out o f a p o t e n t i a l range o f 48 to 192. U n f o r t u n a t e l y , no l i t e r a t u r e was found on non-working womens' h e a l t h promoting behaviors which c o u l d be used f o r comparison. The most t h a t can be s a i d i s that the women who responded to t h i s p a r t i c u l a r study do engage i n h e a l t h promoting b e h a v i o r s . Employment has been r e p o r t e d i n the l i t e r a t u r e to enhance womens' s e l f - e s t e e m . The women i n t h i s study have r e l a t i v e l y high l e v e l s o f s e l f - e s t e e m , but whether t h i s i s due to t h e i r employment s t a t u s c o u l d not be determined i n t h i s study. (Indeed, i t was not a p a r t of the r e s e a r c h q u e s t i o n . ) The r e s u l t s o f t h i s study suggest that s e l f -esteem i n the urban working women p a r t i c i p a t i n g i n t h i s study, i s p r e d i c t i v e o f t h e i r g l o b a l h e a l t h promoting b e h a v i o r s , as we l l as of t h e i r s p e c i f i c h e a l t h promoting behaviors o f : 1) s e l f - a c t u a l i z a t i o n , 2) 101 h e a l t h r e s p o n s i b i l i t y , 3) e x e r c i s e , 4) n u t r i t i o n , 5) s t r e s s management, and 6) i n t e r p e r s o n a l support. In c o n t r a s t , the demographic and working c o n d i t i o n f a c t o r s of age, ed u c a t i o n , l i v i n g s i t u a t i o n (with and without k i d s , with or without s i g n i f i c a n t o t h e r s ) , and number of hours worked per week, do not appear to i n f l u e n c e the undertaking o f h e a l t h promoting b e h a v i o r s . Since i t has been determined t h a t the sample ob t a i n e d i n t h i s study i s bro a d l y r e p r e s e n t a t i v e o f the sampling frame ( s e c t i o n VII.3.1), the study r e s u l t s may be g e n e r a l i z e d to other u n i o n i z e d females working i n an urban environment, s h a r i n g s i m i l a r demographic c h a r a c t e r i s t i c s . 8.3 Recommendations A number of recommendations are suggested f o r fu t u r e s t u d i e s . The f i r s t two address t e c h n i c a l problems which were a n t i c i p a t e d by the author, but not able to be r e s o l v e d p r i o r to the i n i t i a t i o n o f the study. The l a s t two address the need f o r f u r t h e r i n v e s t i g a t i o n o f the r e l a t i o n s h i p between s e l f - e s t e e m , demographic f a c t o r s , and the undertaking o f h e a l t h promoting b e h a v i o r s : 102 In f u t u r e study p o p u l a t i o n s , as many demographic c h a r a c t e r i s t i c s as p o s s i b l e should be known. Th i s would enable the r e s e a r c h e r to comprehensively compare the sample with the sampling frame to determine i f sample c h a r a c t e r i s t i c s were t y p i c a l o f the p o p u l a t i o n from which the sample was drawn. At l e a s t three mailouts o f study q u e s t i o n n a i r e s should be c a r r i e d out to ensure an adequate response r a t e . T h i s recommendation assumes t h a t adequate funding would be a v a i l a b l e . Future s t u d i e s should be designed to i n c l u d e l e s s homogeneous groups o f working women so t h a t the e f f e c t o f demographic f a c t o r s on h e a l t h promoting behaviors c o u l d be determined. Future s t u d i e s should be conducted to compare the r e l a t i o n s h i p between s e l f - e s t e e m and the undertaking o f h e a l t h promoting b e h a v i o r s , on women i n two separate p o p u l a t i o n s , namely those who work o u t s i d e the home, and those who are not i n the workforce. 103 8 . 4 I m p l i c a t i o n s The concept o f s e l f - e s t e e m as a m o d i f i a b l e v a r i a b l e has not been c l a r i f i e d i n the l i t e r a t u r e . I t s c o n c e p t u a l i z a t i o n as e i t h e r ' b a s i c ' ( s t a t i c ) , or as ' f u n c t i o n a l ' (dynamic), i s an important i s s u e f o r fu t u r e r e s e a r c h . As a s t a t i c concept, s e l f - e s t e e m would be viewed as an independent v a r i a b l e which c o u l d i n f l u e n c e h e a l t h promoting b e h a v i o r s . As a dynamic concept, s e l f - e s t e e m would be viewed as a dependent v a r i a b l e , i n f l u e n c e a b l e by other v a r i a b l e s . In t h i s study, s e l f - e s t e e m has been viewed t h e o r e t i c a l l y as having the p o t e n t i a l both to modify, and be mo d i f i e d by behavior ( F i g u r e 2.2); although o p e r a t i o n a l l y , i t was i d e n t i f i e d as independent. Because t h i s study i s c r o s s - s e c t i o n a l i n de s i g n , a d e t e r m i n a t i o n o f whether s e l f - e s t e e m i s a s t a t i c or dynamic concept, c o u l d not be addressed. T h i s i s s u e w i l l be l e f t to other r e s e a r c h e r s . There i s no evidence to show t h a t the sample o f women i n t h i s study i s d i f f e r e n t than the study p o p u l a t i o n . 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"Comparison of s e l f - c o n c e p t o f c o l l e g e women a t h l e t e s and p h y s i c a l e d u c a t i o n majors." Research Q u a r t e r l y . 47, 3, 218-225, 1976. Vinokur, A., Caplan, R. & Y. Schul. "Determinants of p e r c e i v e d s o c i a l support: i n t e r p e r s o n a l t r a n s a c t i o n s , p e r s o n a l outlook, and t r a n s i e n t a f f e c t i v e s t a t e s . " J o u r n a l of P e r s o n a l i t y and  S o c i a l Psychology. 53, 6, 1137-1145, 1987. Waldron, I. "Sex d i f f e r e n c e s i n i l l n e s s i n c i d e n c e , p r o g n o s i s and m o r t a l i t y : i s s u e s and evidence." S o c i a l Sciences and Medicine. 17, 16, 1103-1123, 1983. 114 Waldron, I. & Jacobs, J . " E f f e c t s o f m u l t i p l e r o l e s on womens*s h e a l t h - evidence from a n a t i o n a l l o n g i t u d i n a l study." Women & Health. 15, 1, 3-19, 1989. Walker, S., S e c h r i s t , K. & N. Pender. "The h e a l t h -promoting l i f e s t y l e p r o f i l e : development and psychometric c h a r a c t e r i s t i c s . " Nursing Research. 36, 2, 75-81, 1987. W e i t z e l , M. "A t e s t of the h e a l t h promotion model with blue c o l l a r workers". Nursing Research. 38_, 2, 99-104, 1989. Wells, E. & Marwell, G. (1976). Self-esteem: i t s  c o n c e p t u a l i z a t i o n and measurement. B e v e r l y H i l l s , CA: Sage P u b l i c a t i o n s . W i l l i a m s , A., Ware, J . & C. Donald. "A model of mental h e a l t h , l i f e events, and s o c i a l supports a p p l i c a b l e to g e n e r a l p o p u l a t i o n s . " J o u r n a l of He a l t h and  S o c i a l Behaviour. 22, 324-326, 1981. Yoder, L., Jones, S. & P. Jones. "The a s s o c i a t i o n between h e a l t h care behavior and a t t i t u d e s " . Health Values: A c h i e v i n g High L e v e l Wellness. 9 4, 24-31, 1985. 115 Appendix A l #89- 10764 Guildford Dr Surrey, B.C., V3R 1W6 November 15, 1989. Dear Working Woman, My name i s Sharon Stone. I am doing research about womens' health promoting behaviors and how women fe e l about themselves, as part of the Master's of Science program at the University df B r i t i s h Columbia. I need volunteers to take part i n t h i s study. P a r t i c i p a t i o n involves reading t h i s l e t t e r , which explains the project, and f i l l i n g out three b r i e f questionnaires. You should be able to complete a l l three i n no more than t h i r t y minutes. The questionnaires are not a tes t , but rather a survey of how you f e e l about yourself and what kinds of health promoting behaviors you do. The questionnaire on health promoting behaviors i s c a l l e d the Health Promoting L i f e s t y l e P r o f i l e , and the one on how you f e e l about yourself i s the Rosenberg Self-Esteem Scale. The t h i r d , "Questionnaire Number 3", asks for some important background information on you. I ask you then to a s s i s t me i n my research by f i l l i n g out these questionnaires. However, you are under no obligation to p a r t i c i p a t e , and there i s no possible penalty for not doing so. If you do decide to pa r t i c i p a t e and then change your mind while you are f i l l i n g out the questionnaires, you may withdraw by simply not sending me your responses. Please do not place your name on the questionnaires. This means that you cannot be i d e n t i f i e d and thus your responses w i l l be t o t a l l y anonymous. As well, I w i l l be tr e a t i n g a l l information which i s sent to me i n a confidential manner. Once I have used the information which you have sent me, I w i l l destroy i t . Upon completing the questionnaires, w i l l you please mail them to me i n the stamped self-addressed envelope with which you w i l l be provided. Please f i l l out the form e n t i t l e d Questionnaire Number 3 A F T E R you have completed the other two. You may be wondering how I was able to get i n contact with you. I asked your Union for assistance, and because i t believes that t h i s research may be helpful for working women, i t provided me with a randomly selected l i s t from i t s computer. The Union has given permission for me to contact you and ask you to pa r t i c i p a t e i n t h i s study with the understanding that your p a r t i c i p a t i o n i s voluntary, anonymous, and that a l l information obtained from the study w i l l be kept c o n f i d e n t i a l . Although the study i s not designed to have d i r e c t benefits for you personally, you may be interested i n knowing the r e s u l t s . Copies w i l l be available through your Union, or you may c a l l me at 581-5006 should you wish. Thank you for your time and cooperation. Sincerely, Sharon Stone 116 Appendix A2 6 November, 1989 Dear member: Your u n i o n approved a r e q u e s t from the U n i v e r s i t y o f B r i t i s h Columbia to ask randomly s e l e c t e d women from the lower mainland ar e a i f they would l i k e to be p a r t of the a t t a c h e d h e a l t h promotion s u r v e y . In r e t u r n f o r t h i s a s s i s t a n c e , the U n i v e r s i t y o f B r i t i s h Columbia w i l l share any g e n e r a l f i n d i n g s with us which may of i n t e r e s t to our g e n e r a l membership. Of c o u r s e , i t i s our u n d e r s t a n d i n g t h a t your p a r t i c i p a t i o n i s t o t a l l y v o l u n t a r y and anonymous. We are p l e a s e d to a s s i s t i n t h i s r e s e a r c h which may be of b e n e f i t to a l l working women and look forward to the r e s u l t s of the survey. Yours s i n c e r e l y , 0 L a r r y Stoffman D i r e c t o r , O c c u p a t i o n a l H e a l t h & S a f e t y 117 A p p e n d i x A 3 Q U E S T I O N N A I R E P A C K A G E This is the three part questionnaire package which you are asked to complete in the study on the relationship between self-esteem and health promoting behaviors in working women. Part One is the Rosenberg Self-Esteem Scale. Part T w o is the Heal th Promoting Lifestyle Questionnaire. Please fi l l out these two before completing the third part which is entitled Questionnaire N u m b e r Three. It should take you no more than thirty minutes to fill out all three parts. If you complete this questionnaire package, it wil l be assumed that y o u have given your consent to participate in this project. D O N O T P U T Y O U R N A M E O N T H E Q U E S T I O N N A I R E S . Your responses will be kept confidential, but, in any case y o u cannot be identified. O n l y members of the research team will be reading the information in the three questionnaires. A l l the information collected from this study wil l be destroyed upon completion of the project. Once you have completed all three questionnaires, please forward them in the envelope provided to: Sharon Stone #89 - 10764 Guildford Drive Surrey. B.C. V3R 1W6 Thank you for your assistance. 118 Appendix A4 R O S E N B E R G SELF-ESTEEM S C A L E P l e a s e check t h e answer w h i c h d e s c r i b e s how you f e e l now: 1. On t h e w h o l e , I am s a t i s f i e d w i t h m y s e l f . S t r o n g l y Agree Agree D i s a g r e e S t r o n g l y D i s a g r e e 2 . A t t i m e s I t h i n k I am no good a t a l l . S t r o n g l y Agree Agree D i s a g r e e S t r o n g l y D i s a g r e e 3. I f e e l t h a t I have a number o f good q u a l i t i e s . S t r o n g l y Agree Agree D i s a g r e e S t r o n g l y D i s a g r e e 4 . I am a b l e t o do t h i n g s as w e l l as most o t h e r p e o p l e . S t r o n g l y Agree Agree D i s a g r e e S t r o n g l y D i s a g r e e 5. I f e e l I do not have much t o be p r o u d o f . S t r o n g l y Ag ree Ag ree D i s a g r e e S t r o n g l y D i s a g r e e 6. I c e r t a i n l y f e e l u s e l e s s a t t i m e s . S t r o n g l y Ag ree Ag ree D i s a g r e e S t r o n g l y D i s a g r e e 7. I f e e l t h a t I am a p e r s o n o f w o r t h , a t l e a s t on an e q u a l p l a n e w i t h o t h e r s . S t r o n g l y Agree Ag ree D i s a g r e e S t r o n g l y D i s a g r e e 8. I w i s h I c o u l d have more r e s p e c t f o r m y s e l f . S t r o n g l y Ag ree Ag ree D i s a g r e e S t r o n g l y D i s a g r e e 9. A l l i n a l l , I am i n c l i n e d t o f e e l t h a t I am a f a i l u r e . S t r o n g l y Ag ree Ag ree D i s a g r e e S t r o n g l y D i s a g r e e 10 . I t a k e a p o s i t i v e a t t i t u d e t owa rd m y s e l f . S t r o n g l y lAg ree Ag ree D i s a g r e e S t r o n g l y D i s a g r e e 119 Appendix A5 LIFESTYLE PROFILE D IRECT IONS : This quest ionna i re conta ins statements regarding your present way of life or personal habits. P lease respond to each item as accurate ly as possible, and try not to sk ip any item. Indicate the regularity with which you engage in each behav ior by c i rc l ing : N for never, S for somet imes, O for often, or R for routinely. ui 5 2 UJ — -r NEVER SOMETI z z 1 NEVER SOMETI OFTE ROU1 1. Eat breakfast. N S O R 2. Report any unusual s igns or s ymptoms to a phys ic ian. N S 0 R 3. Like myself. N S o R 4. Perform stretching exerc i ses at least 3 t imes per week. N s o R 5. Choo se foods without preservatives or other additives. N s o R 6. Take some time for relaxat ion each day. N s 0 R 7. Have my cholesterol level c hecked and know the result. N s o R 8. Am enthusiast ic and opt imis t ic about life. N s . o R 9. Feel I am growing and chang i ng per sona l l y in posit ive directions. N s 0 R 10. Discuss personal p rob lems and conce rn s with persons c lose to me. N s o R 11. Am aware of the sources of stress in my life. N s o R 12. Feel happy and content. N s o R 13. Exerc i se v igorously for 20-30 minutes at least 3 t imes per week. N s o R 14. Eat 3 regular meals a day. N s o R 15. Read articles or books about p romot ing health. 1 N s o R 16. Am aware of my personal strengths and weaknesses. N s o R 17. Work toward long-term goa l s in my life. N s 0 R 18. Praise other people eas i ly for their a ccomp l i s hment s . N s o R 19. Read labels to identify the nutr ients in packaged food. N s o R 20. Ques t i on my phys ic ian or seek a s e c o n d op in i on when 1 do not agree with recommendat ions . N s 0 R 21. Look forward to the future. N s o R 22. Part ic ipate in superv i sed exerc i se p rog rams or activities. N s o R 23. A m aware of what is important to me in life. (j^lc^ N s o R 1 1 9 A > UJ S UJ oc z z UJ > UJ s UJ t-UJ o u. o z o cc 24. Enjoy touch ing and being touched by people c lose to me. N S o R 25. Maintain meaningful and fulfi l l ing interpersonal relationships. N S 0 R 26. Include roughage/fiber (whole grains, raw fruits, raw vegetables) in my diet. N S 0 R 27. Pract ice relaxation or meditation for 15-20 minutes daily. N s 0 R 28. D i scuss my health care concerns with qual i f ied professionals. N s 0 R 29. Respect my own accompl i shments . N s 0 R 30. Check my pulse rate when exerc is ing. N s 0 R 31. Spend time with c lose friends. N s 0 R 32. Have my blood pressure checked and know what it is. N s 0 R 33. Attend educat ional programs on improving the environment in-which we live. N s 0 R 34. Find each day interesting and chal leng ing. N s 0 R 35. Plan or select meals to inc lude :ne "bas ic four " food groups each day. N s 0 R 36. Con sc i ou s l y relax musc les before sleep. N s 0 R 37. Find my living environment pleasant and satisfying. N s 0 R 38. Engage in recreational phys ical activities (such as walk ing, swimming, soccer, b icyc l ing). N s 0 R 39. Find it easy to express concern, love and warmth to others. N s 0 R 40. Concentrate on pleasant thoughts at bedtime. N s 0 R 41. Find construct ive ways to express my feelings. N s 0 R 42. Seek information from health profess ionals about how to take good care of myself. N s 0 R 43. Observe my body at least monthly for phys ica l changes/danger signs. N s 0 R 44. A m realistic about the goals that I set. N s o R 45. Use speci f ic methods to contro l my stress. N s o R 46. Attend educat iona l programs on personal health care. N s o R 47. Touch and am touched by people I care about. N s 0 R 48. Bel ieve that my life has purpose. IM s o R «• S. Walker, K. Sechrist. N Pender. 1985. Reproduction without author's express written consent is not permitted. Permission to use this scale may be obtained from: Health Promotion Research Program, School of Nursing, Northern Illinois University. DeKalb. Illinois 60115. 120 Q U E S T I O N N A I R E N U M B E R T H R E E Appendix A 6 This is the third and final part of the questionnaire package which you are asked to complete in the study on the relationship between self-esteem and health promoting behaviors in working women. Please fill out the Rosenberg Self-Esteem Scale and the Health Promoting Lifestyle Profile before answering the questions on this form. P L E A S E C H E C K T H E M O S T A P P R O P R I A T E A N S W E R A N D FILL IN T H E B L A N K S W H E R E I N D I C A T E D . Study Number 1 2 3 DO NOT MARK  IN THIS COLUlv What is your occupation? (Check one) C A S H I E R C L E R K H O M E SUPPORT W O R K E R SERVICE C L E R K O T H E R • • • • • On average, how many hours do you work at your job per week? (Check one) • • • 0-16 H O U R S 17-32 H O U R S 32-40 H O U R S What educational level have you completed? (Check one) E L E M E N T A R Y S C H O O L SOME H I G H S C H O O L H I G H S C H O O L C O M M U N I T Y C O L L E G E S O M E UNIVERSITY U N I V E R S I T Y • • • • • • 121 -2-4. How many children do you have in your immediate family? (Put 0 if you have none) If you have children, are any living at home? (Check one) YES LZI N O If you have children at home, what are their ages? Appendix A 6 D O NOT MARK  IN THIS C O L U M N 5. What is your age? 6. What is your living situation? (Check one) LIVING WITH AT LEAST ONE OTHER ADULT, NO CHILDREN LIVING WITH AT LEAST ONE OTHER ADULT, WITH CHILDREN LIVING A L O N E (no other adult), NO CHILDREN LIVING A L O N E (no other adult), WITH CHILDREN 7. What is your ethnic background? For example, French Canadian, Chinese, Canadian Native Indian, Black. • • • • 8. Are there any health related programs at your workplace? For example, exercise programs, weight loss programs. (Check one) YES EH N O D If yes, please write down the type and nature of the programs. 10 11 12 13 14 ~ 1 5 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 3 122 9. Are you currently suffering from an injury, or do you have a physical disability or chronic disease which would prevent you from exercising? • N O • Appendix A 6 DO NOT MARK  IN THIS COLUV YES If YES, please describe 10. What is your smoking status? (Check one) N E V E R S M O K E D CH E X - S M O K E R LZI C U R R E N T S M O K E R LZ1 If you are an EX-SMOKER, what year did you quit? 32 34 33 35 G 123 Appendix B Dear Working Woman: You may remember the enclosed l e t t e r t h a t I wrote to you l a s t November i n which I asked you to p a r t i c i p a t e i n a r e s e a r c h p r o j e c t . I f you have a l r e a d y responded, please ignore t h i s reminder and do NOT respond again. However, i f you have not yet had a chance to r e t u r n your q u e s t i o n n a i r e package, and are prepared to do so, please send i t i n now. In case you have misplaced the o r i g i n a l i n f o r m a t i o n , I have e n c l o s e d another package f o r you. Please complete and r e t u r n o n l y ONE q u e s t i o n n a i r e package ( t h i s one OR the one you r e c e i v e d i n November). Thank you f o r your cooperation.Appendix C 124 Appendix Sample size* estimates for test of difference of two independent means Power Estimated Effectf .10 .75 .20 .25 .30 .40 .50 .60 .70 .80 Part A: a = .05 .60 977 434 244 156 109 61 39 27 20 15 .70 1230 547 308 197 137 77 49 34 25 19 .80 1568 697 392 251 174 98 63 44 32 25 .90 2100 933 525 336 233 131 84 58 43 33 .95 2592 1152 648 415 288 162 104 72 53 41 .99 3680 1636 920 589 409 230 147 102 75 58 PartB: a = .01 .60 1602 712 400 256 178 100 64 44 33 25 .70 1922 854 481 308 214 120 77 53 39 30 .80 2339 1040 585 374 260 146 94 65 48 37 .90 2957 1324 745 477 331 186 119 83 61 47 .95 3562 1583 890 570 396 223 142 99 73 56 .99 4802 2137 1201 769 534 300 192 133 98 75 • Sample size requirements for each group; total sample size would be twice the number shown. Sample size estimates for bivariate correlation Power Estimated Effect' .10 .75 .20 .25 .30 .40 .50 .60 .70 .80 Part A: a = .05 .60 489 218 123 79 55 32 21 15 11 9 .70 616 274 155 99 69 39 26 18 14 11 .80 785 349 197 126 88 50 32 23 17 13 .90 1050 468 263 169 118 67 43 30 22 17 .95 1297 577 325 208 145 82 53 37 27 21 .99 1841 819 461 296 205 116 75 52 39 30 Part B: a = .07 .60 802 357 201 129 90 51 33 23 17 14 .70 962 428 241 155 108 61 39 28 21 16 .80 1171 521 293 188 131 74 48 33 25 19 .90 1491 663 373 239 167 94 61 42 31 24 .95 1782 792 446 286 199 112 72 50 37 28 .99 2402 1068 601 385 267 151 97 67 50 39 • For bivariate correlations, the estimated effect (y) is the estimated population correlation (/?). Adapted from Pol i t and Hungler ( 1987) 

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