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Thesis Nurs. 1995 S561r
c.2
Shrefler, Marcheta.
The relationship of
hardiness to
1995.
The Relationship of Hardiness to Health-Promoting Behaviors
by
Marcheta Shrefler, BSN RN
Submitted in Partial Fulfillment of the Requirements
for the Master of Science in Nursing Degree
Approved By:
Chairperson, Thesis dommittee
Edinboro University of Pennsylvania
7s
Date
Committee Member
Date
Committee Member
Date
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Abstract
The purpose of this study was to investigate the direction and strength
of the relationship between the personality trait of hardiness and the practice
of health-promoting behaviors. The literature review covers the background
of definitive research dealing with the concepts of hardiness and health
promotion. A sample population (n=66) was drawn from teachers of a local
school district. The volunteer subjects were asked to complete the Health-
Related Hardiness Scale and the Health-Promoting Lifestyle Profile. Paired
scores from these instruments were then analyzed using the Pearson r
correlation technique. The result of this correlation (r= 0.481) is significant at
the .05 level.
ii
Acknowledgements
I wish to express my sincere appreciation to my advisor, Dr. Charlotte
Paul for her support and guidance throughout this process; and to the other
members of my committee, Dr. Dawn Snodgrass and Mrs. Pat Nosel, for
their time, guidance and expertise. I also wish to thank Dr. Walt Strosser for
his statistical advice , and Linda Cylenica for her editing services. A special
thank you goes out to my husband Larry for being there when I needed
encouragement, a kind word, and a hot meal; and to my children, Nathan
and Elizabeth, for their computer training and technical assistance. Where
would I be without you?
M.S.
April, 1995
iii
Table of Contents
Chapter
1
2
3
Page
Introduction
1
Background
1
Statement of the Problem
4
Null Hypothesis
5
Assumptions
5
Limitations
5
Definitions of Terms
5
Review of the Literature
7
The Concept of Hardiness
7
Health Promoting Behaviors
17
Methodology
26
Sample and Setting
26
Instrumentation
26
Data Collection
31
Analysis of Data
32
4
Presentation and Analysis of Data
33
5
Conclusion
39
Discussion
39
Recommendations
44
References
45
Appendices
50
iv
List of Tables and Graphs
Number
Page
Table 4.1
Range, Mean, and Standard Deviation for
Age, Years of Experience, Hardiness
and Lifestyle Scores
34
Graph 4.1
Distribution of Scores from the Health-Related
Hardiness Scale
35
Graph 4.2
Distribution of Scores from the Health-Promoting
Lifestyle Profile
36
Graph 4.3
Hardiness-Lifestyle Scatterplot
38
v
1
Chapter 1
Introduction
Background of the Problem
In the last decade, the importance of successful employee health
promotion programs has gained acceptance across the country. The
identification of several factors about health and illness has led to the
recognition of health promotion as a significant part of our health care
delivery system. The success of these programs depends on an
understanding of the motivational forces and barriers which influence an
individual’s health behavior.
The complicated nature of our society in general has been seen as a
contributing factor to high levels of stress among individuals. Literature has
successfully linked the occurrence of stressful events with the onset of
illness. Stress in the work place has been the subject of much of the
research that has been done on stress-related illness. The phenomenon of
burnout has been studied in relation to a variety of professions. For example,
teachers in public school systems have reported increasing levels of work-
related stress. This may be due in part to the complicated nature of student
populations as well as a frequent lack of community support.
While research has linked the occurrence of stressful life events to the
onset of illness, this same type of research has also led to the identification
of individuals who, in spite of high levels of stress, have remained healthy.
This discovery has caused researchers to look for insulating traits, also
2
known as resistance resources, which seem to buffer the individual from life
crises. These resources include personality traits and social support
systems.
One such personality trait has been labeled hardiness (Kobasa,
1979). Studies by Kobasa and associates have described the hardy
individual as one that possesses an internal locus of control, a strong sense
of commitment to self, and the ability to feel challenged rather than
threatened by life’s changes. Hardiness appears to buffer the individual
from stress-related illness by improving both coping skills as well as the use
of social resources. In so doing, hardiness decreases the effect of illness
vulnerability and stressful events (Kobasa, Maddi, & Kahn, 1982).
The leading causes of morbidity and mortality in the United States are
chronic health problems, many of which have behavior based etiologies and
are often linked to stressful lifestyles. Included in this list are cardiovascular
diseases, malignancies, cerebrovascular diseases, and chronic obstructive
pulmonary disease. Because of the lack of curative therapies for chronic
diseases, control of these illnesses can be accomplished only through
behavior changes. Obviously, prevention is preferable, but this also relies
on healthy lifestyle practices. Primary prevention has focused on counseling
and educative efforts designed to change behaviors. Health promotion
focuses on basic positive behaviors including physical exercise, nutritional
eating habits, development of social support, and use of stress management
and relaxation techniques (Pender, 1987). These activities promote a
higher state of health and well-being while reducing risk factors for certain
3
illnesses.
The expense of long-term control of chronic disease has served as a
motivational force in the development of employee health-promotion
programs within business and industry. Organizations within the service
sector have also begun to show an interest. Public school systems, for
example, are beginning to see the importance of a high level of health and
well-being among staff members as one aspect of promoting quality
education while reducing employee absentee rates and containing health
care costs.
While the importance of health-promotion programs has been
established, the success of such programs is often in question. An
understanding of the motivational factors for, and barriers to, positive health
behaviors is necessary to validate any health education program. The
Health Belief Model and variations of it, such as Pender’s Health Promotion
Model, attempt to describe the relationship between these motivations and
barriers and the actions that an individual takes toward health. The concept
of hardiness, with its components of commitment, control, and challenge,
can be seen as being similar to the cognitive/perceptual factors of self-
efficacy and control which have been identified by Pender (Rummel, 1991).
Hardy persons tend to believe that they can control life’s events, they have a
deep involvement or commitment to the activities of their lives, and they view
changes in their lives as a challenge . It is possible that individuals with a
hardy personality might be more likely to conscientiously practice positive
health behaviors, while individuals who are less hardy might exaggerate a
4
predisposition to illness by engaging in negative health practices such as
smoking or excessive use of alcohol (Daniel, 1987). Since health
professionals need to identify factors which contribute to an individual’s
health related behavior, the relationship of hardiness to these behaviors
needs to be clarified. If there is a positive relationship between hardiness
and participation in health-promoting behaviors it may be important to
identify those individuals who are less hardy so that a health promotion
program can focus on their need for commitment, control, and challenge.
Purpose of the Study
The purpose of this study is to investigate the strength and direction of
the relationship between the personality trait of hardiness and the practice of
health promoting behaviors.
Statement of the Problem
This research will attempt to determine the strength and direction of
the relationship between the level of personality hardiness among public
school teachers and their practice of health-promoting behaviors.
5
Null Hypothesis
There is no relationship between hardiness and health-promoting
behaviors among public school teachers.
Assumptions
Assumptions of this study were based on the premise that:
1. Hardiness is a legitimate personality trait.
2. Hardiness can be evaluated.
3. Engaging in health-promoting behaviors can result in
a higher level of health and well-being.
4. Subjects would answer the surveys honestly.
Limitations
Subjects consist of a convenience sample of teachers from three
elementary schools within an urban school district. Therefore, the results
can not be generalized to the larger population.
Definitions of Terms
1. Health-Promoting Behavior - According to Pender(1987), this
6
includes physical exercise, nutritional eating practices, development of
social support, and the use of stress management and relaxation
techniques. This behavior is measured by the Health-Promoting Lifestyle
Profile.
2. Lifestyle - In the context of health - discretionary activities with
significant impact on health status that are a regular part of one’s daily
pattern of living (Wiley & Camacho, 1980).
3. Health stressor - any event or situation perceived as threatening to
one’s health (Pollock & Duffy, 1990).
4. Hardiness - an inherent health-promoting personality characteristic
that assists an individual in coping with stressful life events. As identified by
Suzanne Kobasa(1979), it is composed of commitment, control, and
challenge. This personality characteristic is measured by the HealthRelated Hardiness Scale.
5. Commitment - the desire to become actively involved in ongoing
life events (Kobasa, 1979; Kobasa et al., 1982).
6. Control - to believe and act as if one has influence over the course
of life events (Kobasa, 1979).
7. Challenge - the belief that change rather than stability is normal in
life and acts as a stimulus for growth (Kobasa et al., 1982).
7
Chapter 2
Review of the Literature
The purpose of this study is to investigate the strength and direction of
the relationship between the personality trait of hardiness and the practice of
health-promoting behaviors. This literature review will cover the background
of definitive research regarding the concept of personality hardiness, as
originally proposed by Kobasa and associates. It will include a discussion of
research that has been done to test the validity of hardiness as a personality
trait, including studies done in the fields of social-psychology, nursing, and
related health professions. Particular attention will be paid to the
development and testing of Pollock’s health-related hardiness concept. Also
being reviewed is the concept of health promotion, including the
development of Pender’s Health Promotion Model. Instrumentation related
to both of these concepts will be discussed along with examples of their use
in other studies.
The Concept of Hardiness
Lawrence Hinkle (1974) reported on a series of longitudinal studies
that he and his associates carried out for the Division of Human Ecology at
Cornell University Medical College. According to Hinkle, these studies were
conducted to determine how health is affected by changes in cultural or
social milieu or changes in interpersonal relationships. This research
8
showed that the onset of illness coincided with periods of high stress. It also
identified a group of healthy people who had experienced similar significant
life stress without developing illness. It was suggested that these healthy
people possessed an insulating personality trait which allowed them to
experience these changes without a strong emotional or psychological
response.
Antonovsky (1974) conducted a study for the purpose of developing
an instrument that would measure both life crises and resistance resources.
He identified a set of variables which appeared to buffer an individual from
life crises. These resistance resources included: “(1) homeostatic flexibility;
(2) ties to concrete others; and (3) ties to total community” (p.252). He saw
this as being consistent with Selye’s general adaptation concept.
In a series of studies, Kobasa and associates (1979, 1981,1982,
1983) looked at the possible mediating effects of personality characteristics
on stressful life events. The central proposition of these studies was that
persons who experience high levels of life stress without becoming ill
possess a personality structure which differentiates them from individuals
who become sick under stress. This personality trait was labeled as
hardiness and the concept was based primarily on an existential theory of
psychology. A person with a hardy personality was seen as possessing
three general characteristics: (1) a belief that he can control or influence the
events of his experience, (2) an ability to feel deeply involved in or
committed to the activities of his life, and (3) the acceptance of change as an
exciting challenge to further development (Kobasa, 1979).
9
Consequently, the personality trait of hardiness was considered to
have three dimensions, including control, commitment, and challenge.
The
characteristic of control was further described to include several
components; the first, decisional control, is the ability to choose among
various courses of action to handle stress; the second, cognitive control, is
the ability to interpret, appraise, and incorporate various stressful events into
one’s life plan; the third, coping skill, is the possession of suitable
responses to stress which were developed through a motivation to achieve
in all areas of life (Kobasa,1979). An internal locus of control allows the
hardy individual to recognize that he has the power to influence the outcome
of life events.
A committed person was further described as having a belief
system that minimizes the perceived threat of a stressful event. He has a
strong sense of purpose and feels an involvement with others, allowing him
to turn to others for help when needed. Most importantly, he not only has a
strong sense of commitment to self, but he is also able to recognize his
values, goals, and priorities. This enables him to make an accurate
assessment of the threat posed by a particular stressor. The characteristic of
challenge was further described as the ability of a person to feel positive
about change. This individual acts as a catalyst in his own environment, and
thus has experience in responding to the unexpected. Persons with this
characteristic have been called change seekers who value interesting
experiences: they are able to be cognitively flexible. Again, this allows them
to more accurately assess the threat of a new situation. The combined traits
of control, commitment, and challenge in the hardy individual theoretically
•
•
10
.u
minimize the potential for stress induced illness. Kobasa does not attempt to
describe the nature of physiological mechanisms and their links to
personality that determine the stress-illness relationship; she cites the need
for more sophisticated stress research before this consideration can be
made.
Kobasa(1979) acknowledged that the personality trait of hardiness is
not the only variable that influences an individual’s response to stress. She
indicated that a variety of psychological, social, physiological, and
environmental factors play a role in the stress-illness relationship. Her
studies looked at the relationship of demographic characteristics and health
perceptions to individual responses.
It was suggested that although
hardiness, social support, and social assets are all variables that improve
coping, the personality trait of hardiness is the most influential (Kobasa et al.,
1982) .
A schematic diagram was designed to depict these relationships
(see Appendix 1). In this diagram, hardiness is seen as having a direct
impact on both coping and on the use of social resources which, in turn,also
effects coping (Kobasa & Puccetti,1983).
The series of studies by Kobasa and associates (1979, 1981, 1982,
1983) utilized a complex set of instrumentation. The subjects were business
executives from middle and upper level management positions who were
exclusively male and white. They were asked to complete a series of
questionnaires that measured stressful life events, illness symptoms,
demographic characteristics, and hardiness. Medical reports were also
examined to determine family health histories. The instrument used to
measure stress was an adaptation of the Schedule of Life Events (Holmes &
Rahe, 1967). illness symptoms were measured by the Seriousness of
Illness Survey (Wyler et al., 1968). Six different scales were used to
measure hardiness. Included were the alienation from self and alienation
from work scales (Maddi et al., 1979), the security scale from California Life
Goals Evaluation Schedule (Hahn, 1966), the cognitive structure scale of
the Personality Research Firm (Jackson, 1974), the external locus of control
scale (Rotter et al., 1962), and the powerlessness scale of the Alienation
Test (Maddi et al.,1979). From the review of medical records, a parent’s
illness score was established as a means of determining predisposition to
various illnesses. The demographic characteristics which were studied
included age, education, job level, length of time at job level, religion,
ethnicity, and marital status. Through the series of studies, this
instrumentation was revised and modified. Lambert, Lambert, Kipple, &
Mewshaw (1989) referred to unpublished works from 1984 that offer second
and third generation instruments.
In discussing the findings in this series of studies, the authors
emphasized the following points. The results support the view that
hardiness functions as a resistance resource (Kobasa, 1979, Kobasa,
Maddi, & Courington, 1981; Kobasa et al., 1982; Kobasa & Puccetti, 1983).
Hardiness has its strongest buffering effect when stressful life events mount
(Kobasa et al., 1982). While a history of parental illness will indicate
vulnerability to disease, and the causal effects of stressful life events are
short lived; the presence of hardiness will decrease the effects of both
illness vulnerability and stressful events (Kobasa et al., 1981). When
12
looking at the interaction between social support and hardiness, distinctions
must be made between various kinds of social resources including assets,
family support, and employer support. Lazarus’s model of coping (1966)
was referenced to explain the relationship between the function of family
support and coping (Kobasa & Puccetti, 1983). The researchers
emphasized the need for further study of these relationships in order to
better explain how some persons stay healthy is spite of stressful life events.
They proposed a need to develop a “multidimensional systems model for
research on stress, resistance, and health” (p.849).
There has been criticism of the hardiness studies. Funk and Houston
(1987) questioned the appropriateness of the statistical analysis. They
proposed that it is not hardy people who are stress resistant, but non-hardy
people who are psychologically maladjusted or neurotic. Nursing research
by Topf (1987) failed to provide evidence of the stress buffering effects of
hardiness. This was seen as providing support for Funk and Houston’s
(1987) criticism. In discussing this criticism, however, Rhodevolt and Zone
(1989) reported that research consistently reports reliable differences
between hardy and non-hardy individuals, and that such research can be
valuable as long as attention is paid to the conceptual and methodological
issues. Williams and Wiebe (1992) attempted to clarify the question of
neuroticism and hardiness. Their findings did support the positive
relationship between hardiness and adaptive coping, but there also
appeared to be influence from neuroticism in the relationship of coping and
hardiness with self-reported illness. It was pointed out that the findings in13
support of hardiness were most consistent with males.
Another significant limitation to the understanding of this concept
results from the fact that Kobasa and associates studied only a male
population. Shepperd and Kashani (1991) studied the relationship of
hardiness, gender, and stress to health in adolescents. They found support
for the relationship of hardiness and health for males, but not for females.
Lambert and Lambert (1987) pointed out that nursing research has made
attempts to determine the validity of hardiness with females; this process has
continued. Johnson-Saylor (1991) reported on a study of hardiness as one
of the possible predictors of healthy behaviors in women. It was found that
the negative effects of hostility and anger were stronger than the positive
association between hardiness and healthy behaviors.
Much of the nursing research on hardiness has dealt with its
relationship to well-being among nurses (McCranie et al., 1987; Rich &
Rich, 1987; Boyle et al., 1991). This research pays particular attention to
burnout among female staff and critical care nurses. The theory that
hardiness acts as a buffer against the harmful effects of stress was at least
partially supported by these studies. Again, the results point out the need to
further clarify the significance of hardiness as a resistance factor among the
female population. Langema (1990) Included hardiness as a variable in
studying work stress among female nurse educators. She utilized Kobasa's
hardiness personality inventory (1982). Pagana (1990) studied the
relationship of hardiness and social support in the Identification of stress
among nursing students in their initial clinical setting. The results of this
study support the hypothesis that persons low in hardiness tend to feel more
threatened by new experiences.
Repeated studies serve to clarify the concept of hardiness and its
relationship to health. Lambert and associates (1989) studied the
relationship of social support and hardiness to well-being in women with
arthritis. Discussion of these results pointed out the need to identify and
intervene with women who are less hardy than others. It also raised the
possibility of hardiness training as a valuable intervention. Stockstill and
Callahan (1991) studied hardiness in a population of dental patients with
temporomandibular disorders. They found that patients with the diagnosed
disorder were less hardy than a control group of subjects without the
disorder. Carey and associates (1991) referred to findings that family
hardiness is an important resource for family members that are caring for an
oncology patient.
There have been studies conducted to determine the relationship
between hardiness and health behaviors. Daniels (1987) noted that past
research found a link between both hardiness and the stress-illness
relationship as well as health behaviors and the stress-illness relationship.
She viewed hardiness and health behaviors as resistance resources and
saw a particular interest in the possible interactions between the two.
Results of her study did show a positive correlation between hardiness and
health behaviors. Pollock (1989) attempted to determine the relationship
between hardiness and adaptation to chronic illness aiong with heaith-
promotion activities. Pearson correlations of the hardiness scores and majoj
variables in Pollock’s study found a significant positive relationship between
the presence of hardiness and engagement in health-promotion activities.
This study also found significant relationships between the presence of
hardiness and higher levels of perceived health status and the use of social
resources, thus supporting the indirect effects of hardiness on health.
In a series of studies, Pollock (Pollock, 1989; Pollock & Duffy, 1990;
Pollock, Christian, & Sands, 1990) attempted to further clarify the
relationship between hardiness and health within an adaptation model. She
views the concept of hardiness as having a particular significance for
nursing, in that nursing attempts to promote adaptive responses in
individuals with actual or potential health problems (1989). She noted that
while past studies, including those of Kobasa and associates, supported the
effects of hardiness on stress, their relevance to nursing was limited. She
cited the need to clarify the relationship between hardiness and health and
to improve on measurement techniques. In an effort to accomplish these
goals, a health-related hardiness concept was proposed.
Pollock contends that the major differences in the health-related
hardiness concept and Kobasa’s concept can be found first in the definitions
of the three dimensions of control, commitment, and challenge, and second
in the measurement of these factors (Pollock & Duffy, 1990). Placed in the
context of health, control is defined as “the use of ego resources necessary
to appraise, interpret, and respond to health stressors' (PottocK, ,989. p.55).
Commitment is viewed as oommitment to sett and "is evidenced as the
motivation for active involvement in promoting one’s health and the
16
competence to deal with health problems” (Pollock & Duffy, 1990, p.219).
Challenge is then defined as the appraisal of a health stressor as being
potentially beneficial rather than threatening (Pollock, 1989). There is some
evidence that studies by Pollock and Duffy support a two dimensional
construct for hardiness rather than the originally hypothesized three
(Tartasky, 1993). This would combine the concepts of challenge and
commitment into one dimension that, with the dimension of control, would
form the construct of hardiness.
The next step in the development of the health-related hardiness
concept was the formulation of an instrument that utilized positive indicators
to measure the presence of control, commitment, and challenge. This is in
contrast to Kobasa’s scale which includes such negative indicators as the
absence of powerlessness scale to measure control, the absence of
alienation from work and self to measure commitment, and a low need for
security being indicative of a high sense of challenge (Pollock, 1989). The
original Health-Related Hardiness Scale (HRHS) has been analyzed and
modified several times. Pollock has used it in studies of individuals with
chronic illness as well as with adults who describe themselves as healthy. It
found to be an appropriate tool to measure hardiness or its
has been
Individual components In both well Individuals and In those with chronic
Illness (Pollock, 1989). The current version ot the scale consists ot 34 Items
on a six point Llked-type scale, m a personal communication, Po»ock(1994)
advised that current research
yield further revisions.
Health-Promoting Behaviors
17
Chronic illnesses with behavior based etiologies have been identified
as the leading causes of death in the United States. Recognition of this
concept has led to an upsurgence in the study of health promotion with
regard to its significance to our health care delivery system. The Human
Population Laboratory of the California State Department of Health and
Human Services began investigating the relationship between lifestyle and
physical health based on the hypothesis that certain components of lifestyle
have significant impact on an individual’s overall health status (Wiley &
Camacho, 1980). An important part of this research included the Alameda
County Study which was reported on by Belloc and Breslow (1972). This
study of a sample of the adult population of Alameda County, California in
1965 identified seven lifestyle variables or health practices which were
significantly associated with physical health. These variables included
hours of sleep, physical exercise in leisure time, alcohol consumption,
cigarette smoking, obesity, eating between meals, and having regular
breakfasts. Wiley and Camacho reported on a follow-up study of this same
sample population which was done to determine whether it is possible to
predict future health outcomes from past behaviors. They reported findings
that demonstrated an association between health practices measured in
1965 and health status reported nine years later. They defined lifestyle as a
arouo of discretionary activities which are a part of an individual’s pattern of
daily living. The study was done within the context of a theoretical
background which views the concept of host resistance to disease.
18
In 1979 the Surgeon General’s Report, Healthy PeoplefUS Dept, of
HE&W, 1979), ranked the leading causes of death for adults as heart
disease, cancer, stroke, cirrhosis of the liver, and accidents. This report also
indicated that unhealthy lifestyles were responsible for approximately 50%
of deaths in the United States yearly. Five categories of negative behaviors
that influence health were targeted for health promotion programs. These
categories included smoking, coping with stress, drug and alcohol use,
nutritional habits, and exercise patterns. By 1991, The Surgeon General’s
Report, Healthy People 2000 (US Dept, of HE&W , 1991) cited reductions in
the death rate for heart disease, stroke, and unintentional injuries. It credited
increases in high blood pressure detection and control, a decline in cigarette
smoking, increased awareness of the role of cholesterol and dietary fats,
increased use of seat belts, and lower speed limits for these changes. On
the other hand, it also reported rising rates for syphilis and HIV infection,
while cancer, heart disease, and unintentional injuries remain the leading
causes of death. All of these health problems are associated with risk factors
related to lifestyle. So, while health promotion programs have made some
progress, it is still evident that certain lifestyle changes need to be
encouraged. This report defines the role of health services to include patient
education, counseling, and screening. It recognizes the difficulties
associated with lifestyle changes, and sites several factors that must be
considered when attempting to facilitate change. These include
socioeconomic status, the environment, community norms, media images
,
19
an coverage, advertising, work site standards, and access to health care
and counseling.
While the need for health-promotion programs is apparent, the
success of individual programs depends on an understanding of healthrelated behavior. Health care professionals must look at those factors which
prompt a person to not only initiate health-promotion activities, but also to
incorporate them as part of their habitual behavior. Dishman (1982), in a
discussion of long term exercise behaviors, reported that while 85% of
individuals report that they “feel better” after initiating an exercise program,
50% of these same individuals discontinue the program within the first six
months. Based on a review of the available literature regarding healthrelated exercise, Dishman (1982) identified three factors which influence
long term adherence to an exercise program. These include the
characteristics of the exerciser, the exercise setting, and the person-setting
interface. He proposed the development of diagnostic tools to be used in a
clinical setting to predict adherence to a regimen.
Several theoretical models have been proposed to explain the
process whereby individuals recognize the responsibility for their own health
and also practice those recommended behaviors. These include, among
others, the Health Belief Model, Social Learning Theory, Attitude-behavior
Theory, and Triander’s Theory of Social Behavior (Sloan, Gruman, &
Allegrante, 1987). The Health Belief Model has been widely referred to in
health promotion literature. In its original form it describes actions taken by a
healthy individual to prevent illness (Bulluogh & Bullough, 1990). The
Rosenstock model of this theory includes perceptions of disease
20
susceptibility and threat, perceived benefits of preventive action, and
barriers to preventive care. It also includes the modifying factors of
demographic variables,sociopsychologic variables, and structural variables,
with cues to action. These factors are felt to exert a combined influence on
the likelihood of an individual taking preventive health action (Bullough &
Bullough).
Nola Pender (1987) has developed a modification of the Health Belief
Model which she refers to as the Health Promotion Model. In its
development, she differentiates between health protecting behavior and
health promoting behavior. While a perceived threat of illness or disease
may influence preventive behaviors, she proposes that it has little or no
motivational significance to health promoting behaviors, which stem from a
desire for growth and quality of life. The Health Promotion Model is based
on social cognitive theory in which cognition operates interactively with
affect, actions, and environmental events to determine behavior (Pender,
Walker, Sechrist, & Frank-Stromberg, 1990). The model identifies
relationships among three components which have been labeled as (1)
cognitive/peroeptual factors, (2) modifying factors , and (3) variables
affecting the likelihood of action. The mode! was designed to serve three
main functions, including organisation of concepts, generation of testable
hypotheses, and integration of research findings into a coherent pattern
(Pender, 1987).
There are three components found in the Health Promotion Model
21
(see Appendix 2). First, the cognitive/perceptual factors are identified as the
primary motivational mechanisms, and are shown to have a direct influence
on the likelihood of engaging in health promoting behaviors (Pender, 1987).
These factors include the importance of health, perceived control of health,
perceived self-efficacy, definition of health, perceived health status,
perceived benefits of health-promoting behaviors, and perceived barriers to
health promoting behaviors. These factors are considered to be flexible
and amenable to change (Pender et al., 1990). Second, the modifying
factors are seen as having an indirect influence on behaviors through their
direct influence on the cognitive/perceptual factors. These factors include
demographic characteristics, biologic characteristics, interpersonal
influences, situational factors, and behavioral factors. The third component
of the HPM includes certain cues to action which are seen to have a direct
effect on behaviors. These cues may originate internally or from the
environment through such things as conversations with others or mass
media information (Pender, 1987).
Rummel (1991) considered the personality trait of hardiness to be
similar to Pender’s cognitive/perceptual factors of self-efficacy and control.
The similarities are obvious when the hardiness dimensions of control,
commitment, and challenge are defined and analyzed.Within the framework
of the hardiness concept, hardiness includes such things as the belief of an
individual that he can control or influence his life experiences, the ability to
feel deeply involved or committed to life’s activities, and the possession of
22
the confidence necessary to accept life’s changes as a challenge (Kobasa,
1979). Within the HPM, perceived control of health is defined as the belief
that health is self-determined, influenced by powerful others, and/or the
result of chance or fate. Self-efficacy is defined as the belief that one has the
skill and competence to carry out specific actions (Pender et al„ 1990).
Based on the premise of these similarities, the Health Promotion Model
provided the framework for Rummel’s study of the relationship of health
value and hardiness to health-promoting behavior in nurses. The results of
her study showed a positive relationship between hardiness and health
promoting behavior; in fact, within the boundaries of this study, hardiness
emerged as the strongest predictor of such behavior. An additional
cognitive/perceptual factor - perceived health status - was also found to be
related to health-promoting behavior.
Several other studies have been conducted in an effort to test the
Health Promotion Model’s usefulness in explaining health-promoting
behaviors. Pender, Walker, Sechrist, and Frank-Stromberg (1990) studied
589 individuals enrolled in employer sponsored health promotion programs.
Results of the study showed that four of the cognitive-perceptual variables
and three modifying factors combined to explain 31% of the variance in
health promoting lifestyle. The authors pointed to the need for continued
model testing and development. Weitzel (1989) looked at the relationship
between four of the cognitive-perceptual variables and selected
demographics to health promoting behavior among 179 blue-collar workers.
She found that each of the variables was predictive of health-promotive
23
behaviors, providing support for the model. Gillis and Perry (1991) studied
the relationship between physical activity and health-promoting behavior in
mid life women. The research questions for this study were framed within
the Health Promotion Model. Although 57.6% of the variance in behavior
was explained by the model variables, the magnitude of unexplained
variance lead the authors to conclude that other variables not tested in this
study influence health-promoting behaviors. A test of the model using
LISREL (a linear structural relation analysis) yielded weak significant effects,
explaining little of the variance in behavior. Further study was suggested to
explore the possibility that demographic and biological characteristics may
have a direct, rather than an indirect effect on behavior (Johnson, Ratner,
Bottorff,& Hayduk, 1993). In an attempt to develop a causal model to guide
nursing intervention in the workplace, Lusk and Keleman (1993) began
preliminary testing of the Health Promotion Model to see if it explained use
of hearing protection. Findings were consistent with the model. They
reported positive correlations between the use of protection and several of
the model’s cognitive-perceptual factors. Demographic characteristics were
related to the definition of health and barriers to use , but not directly to
behaviors. In a study of health-promoting lifestyles in older persons, Duffy
(1993) reported findings that supported the relationships posited in the
Health Promotion Model. She concluded that the model is useful in
increasing understanding of lifestyles and guiding research regarding
health-promotion activities for older adults.
Discussions of Pender’s Health Promotion Model by various authors
24
generally show support for its usefulness. They do however, acknowledge
difficulty in testing its relationships and a need for further study to clarify the
effects of a range of variables. In discussing Pender’s cues to action, Palank
(1991) agrees that they have a direct influence on behavior, but finds
difficulty with the model in that it is hard to determine the impact of diverse
variables on general lifestyle patterns. It is suggested that it may be better to
look at individual behaviors such as exercise, smoking, etc. Fleury (1992)
acknowledges that nursing research has demonstrated empirical support for
several of the relationships proposed in the model, but points out that the
large number of variables make the total HPM difficult to test, therefore
limiting it’s potential. She agrees that additional testing may provide
continued substantiation for the model. In a discussion of strategies for
promoting a healthy dietary intake, Herron (1991) critiqued three employee
health promotion programs that are based on elements similar to those
presented in the model. The HPM is viewed as a workable model on which
to base such programs.
The Health-Promoting Lifestyle Profile was developed by Walker,
Sechrist, and Pender (1987) as an instrument to measure health-promoting
lifestyle activity. It is based on the Health Promotion Model’s premise that
health-protecting and health-promoting behavior can be viewed as
complementary components of a healthy lifestyle. While instruments are
available to measure health hazards or provide risk appraisals, Pender saw
the need to measure actions that serve to enhance wellness, self
actualization, and fulfillment. She originally constructed the Lifestyle and
25
Health Habits Assessment (LHHA) for this purpose. Items for the initial
Health-Promoting Lifestyle Profile (HPLP) were taken from the LHHA. The
items and format were revised based on results of pilot studies (Walker,
Sechrist, & Pender, 1987). Psychometric testing done by this group yielded
results that suggest that the HPLP is valid and reliable for use. This
instrument has been used in a variety of studies including those by Pender,
Walker, Sechrist, and Frank-Stromberg (1990), Weitzel (1989), Duffy (1993),
Gillis (1991), and Rummel (1991).
26
Chapter 3
Methodology
Pender s Health Promotion Model provided the conceptual framework
for this study. The concept of hardiness was viewed as a cognitive/
perceptual factor within that model. The study was designed to determine
the relationship between the cognitive/perceptual factor of hardiness and
health-promoting behavior among public school teachers.
Sample and Setting
A convenience sample for this study was drawn from a group of
public school teachers employed by an urban school district in western
Pennsylvania. The sample included men and women ranging in age from 21
to 61 years. All of the subjects possessed at least a bachelor’s degree, with
the majority holding additional graduate credits. They worked in one of three
elementary schools. Inclusion in the study was voluntary and based on the
individual’s willingness to complete and return the confidential
questionnaires.
Instrumentation
The Health-Promoting Lifestyle Profile was used to measure healthpromoting behavior. This 48-item rating scale was developed by Walker et
(
)• It utilizes a four point response format to measure the frequency of
self-reported behaviors in the areas of self-actualization, health
responsibility, exercise, nutrition, interpersonal support, and stress
management. All items pertain to one of these six areas or subscales and
are scored on a scale of 1 to 4 based on responses: never = 1; sometimes
= 2; often = 3; routinely = 4. Walker (personal correspondence, 1994)
recommends obtaining scores for overall health-promoting lifestyle by
calculating a mean on the individual’s responses to all 48 items, while
scores for the six subscales are obtained similarly by summing the
responses to subscale items and dividing by the number of items on the
subscale.
Walker, Sechrist, and Pender (1987) described the development and
testing of the Health-Promoting Lifestyle Profile (HPLP). The original HPLP
was based on Pender’s Lifestyle and Health Habits Assessment (LHHA),
which incorporated ideas from a variety of studies regarding the relationship
of lifestyle to health. The LHHA contained 100 items arranged into 10
categories. These categories included: General Health Practices, Nutrition,
Physical/Recreational Activity, Sleep, Stress Management, SelfActualization, Sense of Purpose, Relationships with Others, Environmental
Control, and Use of the Health Care System.The initial or pilot form of the
HPLP consisted of items taken directly from the LHHA. The instrument was
given to a convenience sample of 173 nursing students to evaluate item
clarity and response variance and to estimate reliability. Content validity was
then evaluated by four nursing faculty familiar with health promotion
Following this examination, revisions were made; the resulting
instrument contained 107 items
Empirical validation on the HPLP, including item analysis and factor
analysis, followed. Data were obtained from a convenience sample of 952
volunteers. The sample included men and women who ranged in age from
18 to 88 years; their educational levels ranged from eighth grade to a
professional degree; their median income placed them socioeconomically in
the middle class . Thirty-five items were eliminated due to the item analysis;
most of those were concerned with undesirable practices to be eliminated.
Factor analysis of the remaining 70 items resulted in a grouping of the items
into six subscales rather than the original ten. Twenty-two additional items
that did not clearly fit into one of the six subscales were then eliminated,
leaving a remaining 48 items. Factor analysis of these 48 items supported
the construct validity of the instrument. The alpha reliability coefficient for
the total instrument was .922, indicating a high internal consistency, while
tests for reliability on each of the subscales yielded alpha coefficients
ranging from .702 to .904, an acceptable range. Test-retest reliability with a
sample of 63 adults at a two week interval yielded a Pearson r of .926 for the
total scale and a range of .808 to .905 for the subscales, indicating stability
in the instrument. An examination of the distribution of subjects’ scores
showed that the possible range of scores was widely used and standard
deviations were moderate in size, indicating that the instrument appears to
be able to detect variability in the frequency of self-reported lifestyle activities
(Walker et al., 1987).
The Health-Related Hardiness Scale (HRHS) was used to measure29
the hardiness characteristic in each subject. The tool consists of 34 items on
a 6 point Likert-type scale, with a response of 1 indicating strong
disagreement with the statement, while 6 indicates strong agreement . The
scale can be used to measure the unitary construct of health-related
hardiness and/or two dimensions of commitment/challenge and control.
Twenty items cover the dimension of commitment/challenge, while the other
fourteen factors deal with control. For this study, the total HRHS scores were
obtained. Possible scores ranged from 34 to 204 with high scores indicating
the presence of hardiness. The scale contains 18 negatively worded items,
therefore scoring for these items needed to be reversed (Pollock, personal
correspondence, 1994).
Pollock and Duffy (1990) described the development and testing of
the Health-Related Hardiness Scale. They pointed out that the scale is
based on Pollock’s health-related hardiness construct which integrates
concepts from coping, adaptation, and developmental tasks of adulthood,
along with a refinement of Kobasa’s definitions of commitment, challenge,
and control. Initial items were written to indicate the presence, rather than
absence, of the hardiness dimensions. Several items were taken from the
Multidimensional Health Locus of Control Scale. The first version of the
HRHS consisted of 48 items measured on a 6 point Likert scale. It was given
to a sample of 53 graduate nursing students to pretest for readability, clarity,
meaning, and response variance.
Changes were made based on this
evaluation, including the addition of three new items. The resulting 51 item
scale was further evaluated by a panel of three experts for congruence with
the health-related hardiness definitions of control, commitment, and
challenge, yielding an intraclass correlation of .92. To test the scale for
convergent validity, a pilot study of 50 healthy adults was given both
Kobasa’s (1979) Hardiness Scale and the HRHS. The resulting correlation
of .54 was statistically significant, indicating that, while sufficiently different
from Kobasa s scale , the HRHS did measure hardiness. Item analysis and
reliability estimates were then done. Ten items failed to meet the criterion
level and were dropped.
The 41 item scale was then administered to a sample of 389 subjects
who had been diagnosed with one of three chronic illnesses. A principal
components analysis of the results supported two dimensions of hardiness
rather than the originally hypothesized three. Since commitment and
challenge items loaded together, they were considered to be one
dimension, with the second dimension being control. Of the 41 items, 34
loaded on these two factors, with 20 items covering challenge/commitment
while 14 items pertained to control (Pollock & Duffy, 1990). Internal
consistency reliabilities are high at .91 for the total 34 item scale, and .87
for both the challenge/commitment and control subscales (Pollock, personal
communication, 1994). The HRHS was then administered to a subgroup of
150 subjects at two separate intervals of approximately six months. The test-
retest reliability was .76, indicating satisfactory stability ( Pollock & Duffy).
Permission for the use of both of these instruments was obtained
through personal correspondence with their respective authors. Pollock and
Walker both requested that they be credited with the development of the 31
instruments. Pollock also requested that she receive an abstract of the
proposed research, along with results of the study and a copy of reliability
and validity estimates obtained. She specified that no further psychometric
analysis be done on the instrument.
Along with completion of The Health-Related Hardiness Scale and
The Health-Promoting Lifestyle Profile, subjects were asked to provide
specific demographic information including age, sex, marital status, ethnic
background, educational level, and years of experience with the district.
Data Collection
In order to obtain permission to conduct this study within the school
district, a written request for permission was submitted to the Director of
Pupil Services along with a completed form required by the district and
copies of each of the questionnaires. When permission was granted, each
of the principals of the individual schools was contacted personally. The
was described and permission was requested to contact their
teachers through the public address and interschool mail systems. This was
met with approval in each of the three schools. The school nurse then
agreed to act as a facilitator by distributing and collecting the questionnaires
from the teachers in her building.
Each subject was given a packet which included a cover letter,
demographic
related questions, and a copy of each of the instruments with
on
instructions for their completion. The cover letter introduced the researcher,
briefly described the study, insured confidentiality, and requested the
participant’s assistance with the research by completing and returning the
enclosed questionnaires. The subjects were not asked to include their
names. The packets were placed in the teachers’ school mailboxes by the
researcher. On the day that the packets were distributed, an announcement
was included in the regular morning announcements made by the principals
informing the teachers that the packets had been placed in their mailboxes
and asking for their cooperation in completing them. The teachers were
asked to complete and return the questionnaires to the school nurse within
five days. A second announcement was made midweek and again on the
due date to request their completion and return.
Data Analysis
In order to determine the relationship between hardiness and health
promoting activities the paired scores from the Health-Related Hardiness
Scale and the Health-Promoting Lifestyle Profile for all of the subjects were
plotted on a scatter diagram and analyzed using the Pearson r correlation
technique. The significance interval level was set at .05. To determine the
strength of association the value of r2 was then computed.
33
Chapter 4
Presentation and Analysis of Data
The purpose of this study was to determine the direction and the
strength of the relationship between the personality trait of hardiness and the
practice of health promoting behaviors among public school teachers. It was
hypothesized that there is a significantly positive relationship between
hardiness and health promoting behaviors. In order to test this hypothesis, '
The Health-Related Hardiness Scale (HRHS) and The Health-Promoting
Lifestyle Profile (HPLP) were administered to a sample population of public
school teachers. The paired scores from these instruments were then
analyzed using the Pearson r correlational technique with the significance
level set at .05.
The data was collected by distributing questionnaire packets which
included the Health-Related Hardiness Scale and the Health-Promoting
Lifestyle Profile to a sample of eighty teachers from three elementary
schools within an urban school district. These packets also included an
introductory letter along with a request for specific demographic information
including age, sex, marital status, ethnic background, educational level, and
number of years of employment with the school district. Of the eighty
packets that were distributed, sixty-seven were returned. One of the 67
returned packets was discarded because it was incomplete, therefore 66
pairs of scores were analyzed.
A majority, or 51 of the 66 subjects included in the study were
34
female.The range in age was from 21 to 61 years, the mean age being 41.3
years with a standard deviation of 9.85 years (see Table 4.1). A total of 48
subjects indicated that they were married, of the 17 single subjects, 2 were
widowed females and 1 was a divorced male. All of the subjects held at
least a bachelors degree while 48 of them had a masters degree or better.
They were all full time employees of the district, their years of employment
ranging from 0.5 to 34 years with the mean being 13.3 years (see Table 4.1).
Responses to the item “ethnic background” varied to include race or country
of origin. When these responses were analyzed to indicate race only, one
subject was black while the remaining 65 were Caucasian.
RANGE, MEAN, AND STANDARD DEVIATION FOR
TABLE 4.1
AGE. YEARS OF EXPERIENCE, HARDINESS, AND LIFESTYLE SCORES
AGE
YRS/EXP
HARDINESS
LIFESTYLE
Minimum
21.000
0.500
117.000
1.667
Maximum
61.000
34.000
193.000
3.667
Mean
41.303
13.341
162.182
2.914
Stand dev
9.853
9.418
19.418
0.439
n of cases
66
66
66
66
35
The scores were tabulated for The Health-Related Hardiness Scale
by adding the number of the response for each item; possible responses
ranged from 1 for strongly disagree to 6 for strongly agree. Scores for the
negatively worded items were reversed with strongly disagree being
awarded a value of 6 while strongly agree items were valued at 1. The
possible range in scores is from 34 to 204. The actual range in scores for
these subjects was a low of 117 and a high of 193. The mean score was
162.18 with a standard deviation of 19.418 points (see Graph 4.1).
[
—[
I______ i
120
140
160
]—
i
180
hardiness
Graph 4.1
DISTRIBUTION of scores from the health-related
HARDINESS SCALE
36
Scoring The Health-Promoting Lifestyle Profile involved assigning a
numerical value to each of the four possible responses. Items were scored
as Never(N) = 1, Sometimes (S) = 2, Often (O) =3, Routinely (R) = 4. An
overall score for the profile was then obtained by calculating a mean of the
individual’s responses to all 48 items, as directed by the authors. The
possible range of scores for this profile is from 1 to 4. The actual range for
this sample was a low of 1.667 and a high of 3.667. The mean score was
2.914 with a standard deviation of 0.439 (see Graph 4.2).
]----______ i_
1.5
2.0
2.5
3.0
3.5
I
4.0
LIFESTYLE
Graph 4.2 JDISTBIBUTIQNOFSCQBESJROM the health-promoting
IIFFSTYLE profile
37
The paired scores from the Health-Related Hardiness Scale and The
Health-Promoting Lifestyle Profile for each subject were then plotted on a
scatter diagram (see Graph 4.3). The general orientation of the scatterplot
is from the lower left corner to the upper right corner, indicating a positive
relationship. The paired scores were then analyzed using the Pearson r
correlation technique. With the significance level being set at .05, values of r
for a sample population of 66 must be at least .250 to reject the null
hypothesis that the correlation equals zero. This analysis yielded an r of
0.481, thus supporting the hypothesis that there is a significant positive
relationship between scores on the Health-Related Hardiness Scale and
scores on the Health-Promoting Lifestyle Profile for this sample. In order to
determine the strength of association, the value of r2 was computed to be
.231 indicating that 23% of the variance in scores on the Health-Promoting
Lifestyle Profile can be explained by scores on The Health-Related
Hardiness Scale.
The data as analyzed indicate a significant association between
hardiness and the practice of health-promoting behaviors. Generally
speaking, when hardiness scores are high, a higher number of health
promoting behaviors are practiced.
38
4.0
L
I
F
E
S
T
Y
L
E
3.5
3.0
.
f
i .•
2.5
2.0
1.5 *100
120
140
160
180
200
HARDINESS
Graph 4.3 HARDINESS - LIFESTYLE SCATTERPLOT
Chapter 5
39
Conclusion
This study was designed to determine the direction and strength of
the relationship between the personality trait of hardiness and the practice of
health-promoting behaviors among a group of public school teachers.
Hardiness was viewed as a cognitive/perceptual factor within the framework
of Pender’s Health Promotion Model. It was hypothesized that there is a
positive relationship between hardiness and health-promoting behaviors. In
order to test this hypothesis a convenience sample of teachers from three
elementary schools was asked to complete the Health-Related Hardiness
Scale and the Health-Promoting Lifestyle Profile. The paired scores from
these instruments were then analyzed according to the Pearson r
correlational technique. The correlation between hardiness and lifestyle
(health-promoting behaviors) was 0.481, significant at a level of .05.
Discussion
The results of this study must be interpreted cautiously due to the use
of a convenience sample of volunteer subjects. While the sample size of 66
meets the size requirements for a sample proportion to be within .05 of the
population proportion with a 95% level of confidence.it is small compared to
samples used in similar studies. There are other limitations as well. A
sample that is predominately female and educated at a masters degree level
may be representative of many elementary school teacher populations,
40
however, it can not be seen as descriptive of the general population of
public school teachers. Obviously, blacks and other minorities are poorly
represented by this sample with only one subject indicating a black ethnic
background. As with any convenience sample, these limitations make
generalization to the larger population risky.
Research in the behavioral sciences is limited by the complexities of
human psychology. Measurement of human attitudes and behaviors is
always difficult. The instruments used in this study were selected with care,
their development and testing had been carried out by their authors using
stringent scientific methods, their validity and reliability estimates are high
(Pollock & Duffy, 1990; Walker et al., 1987). In spite of this, it is always
necessary to be aware of the possibility that the instruments may not provide
a true measurement of an individual’s attitudes and behaviors before
interpreting the results. While the Health-Related Hardiness Scale in its
present form has been found to be an appropriate tool to measure hardiness
in both well individuals and those with chronic illnesses, Pollock(1994)
advised that current research will probably yield further revisions to the
scale.
The scores on The Health-Promoting Lifestyle Profile from this study
are consistent with scores reported from previous studios. Scores tor the
HPLP ranged from 1.667 to 3.667 with a mean score of 2.914. Gillis and
Pern, (1990) reported mean scores of 2.635 for an experimental group and
2.729 lor a control group. (These scores were originally reported as raw
scores of 126.50 and 131.01 but were converted by calculating the mean to
facilitate comparison here.) Pender, Walker, Sechrist, and Frank-Stromborg
(1990) reported mean scores from two different samples as 2.82 and 2.86
with standard deviations for both of .39. Weitzel (1989) reported mean
scores of 2.571 with a standard deviation of .447. Past scores from the
current version of the Health-Related Hardiness Scale were not reported in
the referenced literature as the reported studies were concerned primarily
with validity and reliability estimates and correlations to other variables
(Pollock & Duffy, 1990).
The results of this study show a significantly positive correlation
between the presence of hardiness in an individual and the practice of
health promoting behaviors. These results suggest that individuals who
possess a high level of psychological hardiness may be more apt to engage
in health promoting behaviors. This study considered hardiness to be
similar to the cognitive/perceptual factors of self-efficacy and control within
Pender’s Health Promotion Model. In this model these factors are said to
have a direct influence on the likelihood of engaging in health promoting
behaviors. The results of this study seem to support this concept. When an
individual believes that he can control or influence his life experiences,
feels deeply involved or committed to himself, and possesses the confidence
to accept life’s changes as a challenge, he may be more inclined to
incorporate health-promoting behaviors into his lifestyle.
Previous studies also found a positive relationship between
hardiness and health-promoting behavior. Daniels (1987) viewed hardiness
and health promotion as resistance resources; the results of her study
showed a weak but positive correlation between the two. Pollock (1989) did
extensive studies on adaptation to chronic illness; she reported a significant
positive relationship between hardiness and engagement in health
promotion activities among individuals that described themselves as healthy
in spite of a variety of chronic illnesses (r = .23, p<.05). Rummel (1991)
utilized the Health-Related Hardiness Scale and the Health-Promoting
Lifestyle Profile to study health promoting behaviors among nurses; she
reported results that supported her hypothesis predicting a positive
relationship between hardiness and health promoting behaviors.
To determine the strength of association between the two variables of
hardiness and health-promoting behavior the value of r2 was computed to
equal .231 indicating that 23% of the variance in health-promoting behaviors
can be explained by hardiness. While this is a significant percentage it
becomes apparent that other variables also influence behaviors. The Health
Promotion Model suggests the possibility of several cognitive/perceptual
factors that may have a direct influence on behavior (see Appendix 2).
Along with self efficacy and perceived control of health which are similar to
hardiness, the list also includes: the importance of health, definition of
health, perceived health status, perceived benefits of health-promoting
behaviors, and perceived barriers to health-promoting behaviors. The
model also lists modifying factors which are seen as having an indirect
influence on behaviors (see Appendix 2), including demographic
characteristics, interpersonal influences, situational factors, and behaviorai
factors. Research which attempts to clarify the role of each of these factors43
both independently and as they interact with each other will provide
valuable information in planning health-promotion programs.
Based on the positive correlation between hardiness and health
promoting behaviors found in this study, it is possible to suggest that the
evaluation of an individual’s level of hardiness may be a significant aspect of
assessing client needs when planning nursing interventions as part of a
health-promotion program. Before making this type of decision however,
other questions need to be answered. If an individual with a hardy
personality is more likely to practice positive health behaviors, may it also be
true that individuals who score low on the hardiness scale exaggerate a
predisposition to illness by engaging in negative health practices? Can
personality hardiness be taught or enhanced through interventions by
nurses or other health care professionals? Are there other factors that
outweigh hardiness in their ability to predict health promoting behaviors?
While it appears that the personality trait of hardiness plays a significant role
in the choice to incorporate health-promoting behaviors into one’s lifestyle,
these questions, and possibly others, need to be answered. Further
research in this area can only enhance our understanding of the relationship
between hardiness and lifestyle, and Improve upon our ability to plan and
implement effective health-promotion programs.
Recommendations
44
1. Further research to clarify the relationship of hardiness and health
promoting behavior utilizing a larger, randomly selected sample.
2. Research that continues attempts to improve on the measurement
of personality hardiness.
3. Research that attempts to clarify the relationship of hardiness to
various demographic factors.
4. Development and testing of interventions designed to enhance
personality hardiness.
5.
Research that continues to study the correlation between other
factors listed in the Health Promotion Model and health-promoting behavior.
45
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47
Arthritis’ Imano i ’ an? ^syc^°'°9ical Well-Being in Women with
Arthntisjmaqe: Journal of Nursing Scholarship. 21. 128-131.
Langema, D. (1990). Impact of Work Stress on Female Nurse Educators.
Image: Journal of Nursing Scholarship.22. 159-162.
Lazarus, R.S. (1966). Psychological Stress and the Coping Process. New
York: McGraw-Hill.
Lusk, S., & Kelemen, M. (1993). Predicting Use ofHearingProtection.Public
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Maddi,S., Kobasa.S., & Hoover,M. (1979). An Alienation Test. Journal of
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McCranie, E., Lambert, V., & Lambert, C. (1987). Work Stress, Hardiness,
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374-378.
Pagana, K. (1990). The Relationship of Hardiness and Social Support to
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D
lc unuffvM (1990). The Health-Related Hardiness Scale:
P°"2vetopmem
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48
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dUU-xjU4.
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49
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50
Appendices
Appendix 1
Stressful
Life Events
Personality
Hardiness
51
Strain
--a
Illness
v Successful
/Coping
Use of Social
Resources
Hardiness, social resources, and the stress-resistance process (Kobasa, Puccetti.1983)
Appendix 2
CognitivePerceptual
Factors
Modifying
Factors
Importance of
Health
Demographic
Characteristics
Perceived control of
Health
52
Participation in
health-promoting
behavior
Biologic
Characteristics
Perceived selfefficacy
Definition of Health
Interpersonal
Influences
Perceived health
status
Situational Factors
Perceived benefits
of health-promoting
behaviors
Likelihood of
engaging in health
promoting
behaviors
—I1L__
Behavioral Factors
Cues to Action
Perceived barriers
to health-promoting
behaviors
Health Promotion Model
Pender, N. (1987):
Health Promotion in Nursing Practice
Dear Colleague,
Appendix 3
53
In an attempt to complete requirements for a master’s
degree in nursing, I am conducting a research project
which will study health promoting activities and beliefs
among public school teachers. As.......................................
I am aSkjng for yOur help in completing this
project. Please take time to complete the enclosed
questionnaires and then return them within one week to the
school nurse in your building. Please be assured that,
should you choose to complete the questionnaires, the
results will be used solely for research purposes and will
remain entirely confidential.
Thank you so much for your efforts in helping me to
complete this project. If you have any questions or
concerns please feel free to contact me daily from 2:30 to
3:15 PM at 871-6520 or 871-6465.
Sincerely,
Marcheta Shrefler R.N.
Before beginning the enclosed questionnaires, please
read the instructions carefully and provide the information
requested on the bottom of this sheet.
M
Thanks again!
About yourself...
Your age
ethnic background -----years with the district
your sex
,maritalstatus
educational level-----------------J
(bachelor’s/masters,etc.)
Appendix 4
54
Number
HEALTH-RELATED HARDINESS SCALE
Instructions:
This is a questionnaire designed to determine the way in which
different people view certain important issues related to their
health. Each item is a belief statement with which you may agree
or disagree. Beside each statement is a scale which ranges from
strongly disagree (1) to strongly agree (6). For each item we
would like you to circle the number that represents the extent to
which you disagree or agree with the statement. Please make sure
that you answer every item and that you circle only one number per
item. Thank you for taking the time to complete this
questionnaire .
DISAGREE
AGREE
S
T
R
0
N
G
L
Y
M
0
D
E
R
A
T
E
L
Y
S
L
I
G
H
T
L
Y
S
L
I
G
H
T
L
Y
M
0
D
E
R
A
T
E
L
Y
S
T
R
0
N
G
L
Y
1. Involvement in health promotion
activities is stimulating.
1
2
3
4
5
6
2. I can avoid illness if I take
care of myself.
1
2
3
4
5
6
1
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
3. I find it difficult to be
enthusiastic about good health.
4. Luck plays a big part in determining
how soon I will recover from an
illness.
-r to maintain
5. No matter how hard I try
accomplish
my health, my efforts will
v1
very little.
1
6. I am in control of my health.
7. I admire people who work hard to
improve their health.
1
2
DISAGREE
s
T
R
0
N
G
L
Y
Number
AGREE
M
O
D
E
R
A
T
E
L
Y
S
L
I
G
H
T
L
Y
S
L
I
G
H
T
L
Y
M
O
D
E
R
A
T
E
L
Y
S
T
R
O
N
G
L
Y
8. Good health is more important to
me than financial security.
1
2
3
4
5
6
9. My good health is largely a
matter of good fortune.
1
2
3
4
5
6
1
2
3
4
5
6
11. I find it boring to eat and exercise
1
properly to maintain my health.
2
3
4
5
6
12. The main thing which affects my
health is what I myself do.
1
2
3
4
5
6
13. Changes taking place in health
care are not exciting to me.
1
2
3
4
5
6
14. I find people who are involved in
health promotion interesting.
1
2
3
4
5
6
15. Setting goals for health is
unrealistic.
1
2
3
4
5
6
16. Most things that affect my health
happen to me by accident.
1
2
3
4
5
6
17. Changes taking place in health care
1
will have no effect on me.
2
3
4
5
6
18. If I get sick, it is my own behavior
that determines how soon I get well.l
2
3
4
5
6
19. I do not find it interesting to
learn about health.
1
2
3
4
5
6
20. I will stay healthy if it's meant
to be.
1
2
3
4
5
6
21. I am not interested in exploring
new ways to improve my health.
1
2
3
4
5
6
10. No matter what I do, I'm
likely to get sick.
3
22. No matter what I do, 5
if‘ I am going
to get sick, I will get sick.
DISAGREE
S M S
T 0 L
R D I
0 E G
N R H
G A T
L T L
Y E Y
L
Y
Number
AGREE
S M
L 0
I D
G E
H R
T A
L T
Y E
L
Y
S
T
R
0
N
G
L
Y
1
2
3
4
5
6
1
2
3
4
5
6
24. The current focus on health promotion is
a fad that will probably disappear. 1 2
3
4
5
6
25. No matter how hard I work to promote
health for society, it never seems
to improve.
1
2
3
4
5
6
26. Our society holds no worthwhile
goals or values about health.
1
2
3
4
5
6
27. If I take the right actions, I
can stay healthy.
1
2
3
4
5
6
28. I get excited about the possibility
1
of improving my health.
2
3
4
5
6
29. I am determined to be as healthy as
1
I can be.
2
3
4
5
6
30. When my health is threatened,, I
that must
view it as a challenge
c__ I"
be overcome.
1
2
3
4
5
6
31. I read everything I can about
health.
1
2
3
4
5
6
32. I can be as healthy as I want to be.l
2
3
4
5
6
33. When something goes wrong with my
health, I do every thing I can to
get at the root of the problem.
1
2
3
4
5
6
1
2
3
4
5
6
23. I feel no need to try to maintain
my health because it makes no
difference anyway.
34. i have little influence over my
health.
Copyright, 1990, Susan E. Pollock, PhD
Appendix 5
57
LIFESTYLE PROFILE
Th'S ^estionnaire con’ains statements regarding your present way of life or personal
habits. Please respond to each item c?
as sccjr'td
accurately ««
as possible, and try not to skip any item. Indicate the
regularity with which you engage in each behavior^crrcnng:
N for never, S for sometimes, O for often, or R for routinely.
cr
U1
>
LU
z
Vi
LU
>
Z
LU
zo
Vi
£
to
LU
Z
H
□
O
Ct
1.
Eat breakfast.
N
S
O
R
2.
Report any unusual signs or symptoms to a physician.
N
S
O
R
3.
Like myself.
N
S
O
R
4.
Perform stretching exercises at least 3 times per week.
N
S
O
R
5.
Choose foods without preservatives or other additives.
N
S
O
R
6.
Take some time for relaxation each day.
N
S
O
R
7.
Have my cholesterol level checked and know the result.
N
S
O
R
8.
Am enthusiastic and optimistic about life.
N
S
O
R
9.
Feel I am growing and changing personally in positive directions.
N
S
O
R
10. Discuss personal problems and concerns with persons close to me.
N
S
O
R
11. Am aware of the sources of stress in my life.
N
S
O
R
N
S
O
R
13. Exercise vigorously for 20-30 minutes at least 3 times per week.
N
S
O
R
14. Eat 3 regular meals a day.
N
S
O
R
Read articles or books about promoting health.
N
S
O
R
16. Am aware of my personal strengths and weaknesses.
N
S
O
R
17. Work toward long-term goals in my life.
N
S
O
R
18. Praise other people easily for their accomplishments.
N
S
O
R
12.
15.
Feel happy and content.
19.
Read labels to identify the nutrients in packaged food.
N
S
O
R
20.
Question my physician or seek a second opinion when I do not agree with
recommendations.
N
S
O
R
21.
Look forward to the future.
N
S
O
R
22.
Participate in supervised exercise programs or activities.
N
S
O
R
23.
Am aware of what is important to me in life.
N
S
O
R
co
III
Z
c
UJ
>
UJ
Z
UJ
UJ
s
z
Z
o
co
O
t
O
N
S
o
R
N
S
O
R
N
S
O
R
N
S
O
R
D
AC
24.
Enjoy touching and being touched by people close to me.
25.
Maintain meaningful and fulfilling interpersonal relationships.
26.
Include roughage/fiber (whole grains, raw fruits, raw vegetables) in my diet.
27.
Practice relaxation or meditation for 15-20 minutes daily.
28.
Discuss my health care concerns with qualified professionals.
N
S
O
R
29.
Respect my own accomplishments.
N
S
O
R
30.
Check my pulse rate when exercising.
N
S
O
R
N
S
O
R
31. Spend time with close friends.
32.
Have my blood pressure checked and know what it is.
N
S
O
R
33.
Attend educational programs on improving the environment in which we live.
N
S
O
R
34.
Find each day interesting and challenging.
N
S
O
R
35.
Plan or select meals to include the “basic four” food groups each day.
N
S
O
R
36.
Consciously relax muscles before sleep.
N
S
O
R
N
S
O
R
Engage in recreational physical activities (such as walking, swimming, soccer,
bicycling).
N
S
O
R
39.
Find it easy to express concern, love and warmth to others.
N
S
O
R
40.
Concentrate on pleasant thoughts at bedtime.
N
S
O
R
41.
Find constructive ways to express my feelings.
N
S
O
R
N
S
O
R
N
S
O
R
N
S
O
R
37. Find my living environment pleasant and satisfying.
38.
42. Seek information from health professionals about how to take good care of
myself.
43.
Observe my body at least monthly for physical changes/danger signs.
44. Am realistic about the goals that I set.
45.
Use specific methods to control my stress.
N
S
O
R
46.
Attend educational programs on personal health care.
N
S
O
R
47.
Touch and am touched by people I care about.
N
S
O
R
48.
Believe that my life has purpose.
N
S
o
R
use thlsstTaleniay be ob^ne^from- Heilt^
Illinois 60115.
Department of Nursing
Graduate Program
The City University jof New York
250 Bed Ford-Park Boulevard West
Bronx, NY 10468-1589
Appendix 6
H
Lehman
(718) 960-8374
FAX (718) 960-8488
College
Dear Colleague:
Spring, 1994
Thank you for your interest in the Health Related Hardiness Scale
(HRHS).
7 am happy to make this instrument available to you for
research
as a wa
way
of collecting
collectino data
Ha-j-a from
fr-n-m various populations.
,
y °f
The requirements for using this instrument are listed below.
After I receive this form and a copy of your abstract, I will
mail
coPy of the instrument.
My policy , is to grant permission to use the HRHS for research
purposes if I:
1. receive an abstract of the proposed research;
2 .
am assured of receiving the results of the study;
3. receive a copy of the reliability and validity estimates
obtained;
4.
am assured that no further psychometric analyses will be
done; and
5.
am credited with authorship in any use, associated
report, or publication involving the instrument.
I agree to the above requirements and have enclosed an abstract
of my proposed research.
Date:
Signed:
Name:.
Address:
73-—2)
City & State:
Telephone: (work/^^j4)
AO.—
~
—
_________
. (home)(
Sincerely,
,
Susan E. Pollock, PhD, RN, FAAN
Professor and Director of the
Graduate Program
Lehman College, Division of Nursing
250 Bedford Park Boulevard West
Bronx, NY 10468-1589
Appendix 7
Lehman
College
Department of Nursing
Graduate Program
The City University of New York
250 Bedford Park Boulevard West
Bronx, NY 10468-1589
'
(718) 960-8374
FAX (718) 960-8488
Spring, 1994
Dear Colleague:
Enclosed is the Health-Related Hardiness Scale (HRHS) and scoring
instructions you requested. I have also included a summary of the
latest psychometric information.
For more information on the
development and psychometric evaluation of the HRHS, please refer
to Pollock & Duffy (1990), the health-related hardiness scale:
Development and psychometric analysis, Nursing Research, 39(4).
218-222.
There is no cost involved with using the HRHS. I only ask that you
supply me with a copy of your research results (as described in the
contract letter) and that I am credited with development of the
scale. Please be advised that while this is the current version of
the HRHS, there will likely be future revisions based upon results
of current research.
Please keep me informed of your progress and any change in address.
Good luck with your research and I look forward to hearing from
you.
Sincerely,
Susan E. Pollock, PhD, RN, FAAN
Professor and Director of the
Graduate Program
Lehman College, Division of Nursing
250 Bedford Park Boulevard West
Bronx, N.Y. 10468-1589
718-960-8378
Appendix 8
61
HEALTH-RELATED HARDINESS SCALE
The Health-Related Hardiness Scale (HRHS) was developed to
measure the hardiness construct in health-related research. The
current version contains 34 items on a six point Likert-type scale.
Depending on the purpose of the investigation, the scale can be
used to measure the unitary construct of health-related hardiness
and/or the two dimensions of commitment/challenge (20 items) or
control (14 items).
Results of a principal components analysis with chronically
ill subjects (N=389) supported these two dimensions. The first
factor (20 items) encompassed the dimensions of commitment and
challenge, while the second factor (14 items) accounted for the
control dimension. The two factors explained 32.1% of the
initially extracted common variance.
Internal consistency
reliabilities (Cronbach’s alpha) for the 34-item HRHS are .91, and
.87 for both the 20-item commitment/challenge subscale and the 14item control scale. Test-retest reliability (N= 150) for six months
was .76 for the total HRHS, and .74 and .78 for the
commitment/challenge and control scales respectively.
Commitment and challenge items loading together suggest that
they are more closely related and not discrete dimensions in a
health specific context.
In other words, commitment to adjusting
to a health stressor such as chronic illness is also the challenge.
Persons are challenged (rather than threatened) when confronted
with a health stressor, which in turn, becomes a personal
;;
y..
Hardy individuals dealing with a chronic health
commitment
problem may not separate health into discrete categories but
appraise the condition as a challenge because they are committed to
maintaining their health.
Scores for the total HRHS range: from 34 to 204 with high
Scoring
Negatively worded items
scores indicating presence of hardiness.
indicated
by
an
asterisk;
scoring
for
these items need to be
are i....
reversed.
CONTROL
2 , 4*, 6, 9*, 10*,
12 , 15*, 16*, 18,
20*, 22*, 27,
32 , 34*
Susan E. Pollock, PhD, 1990.
COMMITMENT
CHALLENGE
5*, 7,
23*, 25*, 26*,
29, 31
1/ 3*, 8,
11*, 13*, 14,
17*, 19*, 21*, 24*
28, 30, 33
HEALTH-PROMOTI^^^IMLe PROFILE
62
Dear Colleague:
We are pleased to reply to
Promoting Lifestyle Profile your request for information about our Healthn order to, respond promptly to the large volume
of correspondence we receive, we have found it
it necessary to prepare this standard
letter containing information that is commonly
sought. We hope that you will
feel free to write or call as
necessary
to
obtain
any further information that
you may need.
The Health-Promoting Lifestyle Profile measures
health-promoting behavior,
conceptualized as a multidimensional pattern of self-initiated actions and
perceptions that serve to
t maintain
. . . or enhance the level of wellness,
selfactualization and fulfillment of the individual,
-------- - This 48-item summated behavior
rating scale employs a 4-point response format to measure the frequency of self
reported health-promoting behaviors in the domains of self-actualizacion, health
responsibility, exercise, nutrition, interpersonal support and stress management.
It was developed for use in research within the framework of the Health Promotion
Model (Pender, 1987), but has subsequently been employed for a variety of other
purposes as well. The development and psychometric evaluation of the English
language versions were described by Walker, Sechrist and Pender (1987) and scores
among the initial study sample were reported by Walker, Volkan, Sechrist and
Pender (1988) .
The translation and psychometric evaluation of the Spanish
language version as well as scores among a Hispanic sample were reported by
Walker, Kerr, Pender and Sechrist (1990).
Copyright of both English and Spanish language versions of the instrument is held
by Susan Noble Walker, EdD, RN, FAAN, Karen R. Sechr is t, PhD, RN, FAAN and Nola
J. Pender, PhD, RN, FAAN. You have our permission to copy and use the enclosed
Heal th-Promoting Lifestyle Profile for non-commercial data collection purposes
such as research or evaluation projects provided that content is not altered in
any way and the copyright/permission statement at the end is retained, The
instrument also may 1be reproduced in the appendix of a thesis, dissertation or
research grant proposal without further permission, Reproduction for any other
purpose, including the publication of study results, is prohibited without
specific permission from the authors.
There is no charge for such authorized use, but we would appreciate receiving
notification of your intent to use the instrument and a report of your completed
It is particularly useful
to know of any
study/proj ect for our files.
r
use of the instrument so that we can maintain an accurate
publications reporting
complete listing, To facilitate record keeping, all information should be sent
to:
Susan Noble Walker, Ed.D., R.N., F.A.A.N.
Professor
University of Nebraska Medical Center
College of Nursing
600 South 42nd Street
Omaha, Nebraska 68198-5330
(402) 559-6561
interest in using the ffesTth-Prowting Lifestyle Profile
We thank you for your
with your efforts.
and wish you imuch''success
--- Sincerely,
Susan Noble Walker
Karen R. Sechrist
Nola J. Pender
Appendix 10
63
HEALTH-PROMOTING LIFESTYLE PROFILE
Scoring Instructions:
Items are scores as Never (R)
Sometimes (S)
Often (0)
Routinely (R)
-
1
2
3
4
A score for overall health-promoting lifestyle is obtained by calculating a mean
of the individual's responses to all 48 items; six subscale scores are obtained
similarly by summing the responses to subscale items and dividing by the number
of items on the subscale. The use of means rather than sums of scale items is
recommended to retain the 1 to 4 metric of item responses and to allow meaningful
comparisons of scores across subscales. The items included on each scale are as
follows:
Health-Promoting Lifestyle
1 to 48
Self-actualization
3, 8, 9, 12, 16, 17, 21, 23, 29, 34, 37, 44, 48
Health Responsibility
2, 7, 15, 20, 28, 32, 33, 42, 43, 46
Exercise
4, 13, 22, 30, 38
Nutrition
1, 5, 14, 19, 26, 35
Interpersonal Support
10, 18, 24, 25, 31, 39, 47
Stress Management
6, 11, 27, 36, 40, 41, 45
References
Pender, N. J. (1987). Health promotion in nursing practice (2nd ed. ) .
CT: Appleton & Lange.
Norwalk,
Walker, S. N. , Sechrist, K. R. , & Pender, N. J. (1987). The Health-Promoting
Lifestyle Profile: Development and psychometric characteristics. Nursing
Research, 36.(2), 76-81.
" “R. , &
' ~Pender, N. J. (1988). HealthWalker, S. N. , Volkan, K. , Sechrist, K.
Comparisons
with young and middle-aged
promoting lifestyles of older adults:: C
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Advances
Nursing. Science
, 11
(1), 76-90.
adults , correlates
andinpatterns
A-----------------
Walker S N. , Kerr, M. J.» Pender, N. J., & Sechrist, K. R. (1990). A Spanish
language version’of the Health-Promoting Lifestyle Profile. Nursing Research,
39(5), 268-273.
9/90: snw
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1. .promoting Lifestyle Profile
Healthof Lifestyle Profile
List
c.2
Shrefler, Marcheta.
The relationship of
hardiness to
1995.
The Relationship of Hardiness to Health-Promoting Behaviors
by
Marcheta Shrefler, BSN RN
Submitted in Partial Fulfillment of the Requirements
for the Master of Science in Nursing Degree
Approved By:
Chairperson, Thesis dommittee
Edinboro University of Pennsylvania
7s
Date
Committee Member
Date
Committee Member
Date
-75
tip J) 57^ /
c.a
Abstract
The purpose of this study was to investigate the direction and strength
of the relationship between the personality trait of hardiness and the practice
of health-promoting behaviors. The literature review covers the background
of definitive research dealing with the concepts of hardiness and health
promotion. A sample population (n=66) was drawn from teachers of a local
school district. The volunteer subjects were asked to complete the Health-
Related Hardiness Scale and the Health-Promoting Lifestyle Profile. Paired
scores from these instruments were then analyzed using the Pearson r
correlation technique. The result of this correlation (r= 0.481) is significant at
the .05 level.
ii
Acknowledgements
I wish to express my sincere appreciation to my advisor, Dr. Charlotte
Paul for her support and guidance throughout this process; and to the other
members of my committee, Dr. Dawn Snodgrass and Mrs. Pat Nosel, for
their time, guidance and expertise. I also wish to thank Dr. Walt Strosser for
his statistical advice , and Linda Cylenica for her editing services. A special
thank you goes out to my husband Larry for being there when I needed
encouragement, a kind word, and a hot meal; and to my children, Nathan
and Elizabeth, for their computer training and technical assistance. Where
would I be without you?
M.S.
April, 1995
iii
Table of Contents
Chapter
1
2
3
Page
Introduction
1
Background
1
Statement of the Problem
4
Null Hypothesis
5
Assumptions
5
Limitations
5
Definitions of Terms
5
Review of the Literature
7
The Concept of Hardiness
7
Health Promoting Behaviors
17
Methodology
26
Sample and Setting
26
Instrumentation
26
Data Collection
31
Analysis of Data
32
4
Presentation and Analysis of Data
33
5
Conclusion
39
Discussion
39
Recommendations
44
References
45
Appendices
50
iv
List of Tables and Graphs
Number
Page
Table 4.1
Range, Mean, and Standard Deviation for
Age, Years of Experience, Hardiness
and Lifestyle Scores
34
Graph 4.1
Distribution of Scores from the Health-Related
Hardiness Scale
35
Graph 4.2
Distribution of Scores from the Health-Promoting
Lifestyle Profile
36
Graph 4.3
Hardiness-Lifestyle Scatterplot
38
v
1
Chapter 1
Introduction
Background of the Problem
In the last decade, the importance of successful employee health
promotion programs has gained acceptance across the country. The
identification of several factors about health and illness has led to the
recognition of health promotion as a significant part of our health care
delivery system. The success of these programs depends on an
understanding of the motivational forces and barriers which influence an
individual’s health behavior.
The complicated nature of our society in general has been seen as a
contributing factor to high levels of stress among individuals. Literature has
successfully linked the occurrence of stressful events with the onset of
illness. Stress in the work place has been the subject of much of the
research that has been done on stress-related illness. The phenomenon of
burnout has been studied in relation to a variety of professions. For example,
teachers in public school systems have reported increasing levels of work-
related stress. This may be due in part to the complicated nature of student
populations as well as a frequent lack of community support.
While research has linked the occurrence of stressful life events to the
onset of illness, this same type of research has also led to the identification
of individuals who, in spite of high levels of stress, have remained healthy.
This discovery has caused researchers to look for insulating traits, also
2
known as resistance resources, which seem to buffer the individual from life
crises. These resources include personality traits and social support
systems.
One such personality trait has been labeled hardiness (Kobasa,
1979). Studies by Kobasa and associates have described the hardy
individual as one that possesses an internal locus of control, a strong sense
of commitment to self, and the ability to feel challenged rather than
threatened by life’s changes. Hardiness appears to buffer the individual
from stress-related illness by improving both coping skills as well as the use
of social resources. In so doing, hardiness decreases the effect of illness
vulnerability and stressful events (Kobasa, Maddi, & Kahn, 1982).
The leading causes of morbidity and mortality in the United States are
chronic health problems, many of which have behavior based etiologies and
are often linked to stressful lifestyles. Included in this list are cardiovascular
diseases, malignancies, cerebrovascular diseases, and chronic obstructive
pulmonary disease. Because of the lack of curative therapies for chronic
diseases, control of these illnesses can be accomplished only through
behavior changes. Obviously, prevention is preferable, but this also relies
on healthy lifestyle practices. Primary prevention has focused on counseling
and educative efforts designed to change behaviors. Health promotion
focuses on basic positive behaviors including physical exercise, nutritional
eating habits, development of social support, and use of stress management
and relaxation techniques (Pender, 1987). These activities promote a
higher state of health and well-being while reducing risk factors for certain
3
illnesses.
The expense of long-term control of chronic disease has served as a
motivational force in the development of employee health-promotion
programs within business and industry. Organizations within the service
sector have also begun to show an interest. Public school systems, for
example, are beginning to see the importance of a high level of health and
well-being among staff members as one aspect of promoting quality
education while reducing employee absentee rates and containing health
care costs.
While the importance of health-promotion programs has been
established, the success of such programs is often in question. An
understanding of the motivational factors for, and barriers to, positive health
behaviors is necessary to validate any health education program. The
Health Belief Model and variations of it, such as Pender’s Health Promotion
Model, attempt to describe the relationship between these motivations and
barriers and the actions that an individual takes toward health. The concept
of hardiness, with its components of commitment, control, and challenge,
can be seen as being similar to the cognitive/perceptual factors of self-
efficacy and control which have been identified by Pender (Rummel, 1991).
Hardy persons tend to believe that they can control life’s events, they have a
deep involvement or commitment to the activities of their lives, and they view
changes in their lives as a challenge . It is possible that individuals with a
hardy personality might be more likely to conscientiously practice positive
health behaviors, while individuals who are less hardy might exaggerate a
4
predisposition to illness by engaging in negative health practices such as
smoking or excessive use of alcohol (Daniel, 1987). Since health
professionals need to identify factors which contribute to an individual’s
health related behavior, the relationship of hardiness to these behaviors
needs to be clarified. If there is a positive relationship between hardiness
and participation in health-promoting behaviors it may be important to
identify those individuals who are less hardy so that a health promotion
program can focus on their need for commitment, control, and challenge.
Purpose of the Study
The purpose of this study is to investigate the strength and direction of
the relationship between the personality trait of hardiness and the practice of
health promoting behaviors.
Statement of the Problem
This research will attempt to determine the strength and direction of
the relationship between the level of personality hardiness among public
school teachers and their practice of health-promoting behaviors.
5
Null Hypothesis
There is no relationship between hardiness and health-promoting
behaviors among public school teachers.
Assumptions
Assumptions of this study were based on the premise that:
1. Hardiness is a legitimate personality trait.
2. Hardiness can be evaluated.
3. Engaging in health-promoting behaviors can result in
a higher level of health and well-being.
4. Subjects would answer the surveys honestly.
Limitations
Subjects consist of a convenience sample of teachers from three
elementary schools within an urban school district. Therefore, the results
can not be generalized to the larger population.
Definitions of Terms
1. Health-Promoting Behavior - According to Pender(1987), this
6
includes physical exercise, nutritional eating practices, development of
social support, and the use of stress management and relaxation
techniques. This behavior is measured by the Health-Promoting Lifestyle
Profile.
2. Lifestyle - In the context of health - discretionary activities with
significant impact on health status that are a regular part of one’s daily
pattern of living (Wiley & Camacho, 1980).
3. Health stressor - any event or situation perceived as threatening to
one’s health (Pollock & Duffy, 1990).
4. Hardiness - an inherent health-promoting personality characteristic
that assists an individual in coping with stressful life events. As identified by
Suzanne Kobasa(1979), it is composed of commitment, control, and
challenge. This personality characteristic is measured by the HealthRelated Hardiness Scale.
5. Commitment - the desire to become actively involved in ongoing
life events (Kobasa, 1979; Kobasa et al., 1982).
6. Control - to believe and act as if one has influence over the course
of life events (Kobasa, 1979).
7. Challenge - the belief that change rather than stability is normal in
life and acts as a stimulus for growth (Kobasa et al., 1982).
7
Chapter 2
Review of the Literature
The purpose of this study is to investigate the strength and direction of
the relationship between the personality trait of hardiness and the practice of
health-promoting behaviors. This literature review will cover the background
of definitive research regarding the concept of personality hardiness, as
originally proposed by Kobasa and associates. It will include a discussion of
research that has been done to test the validity of hardiness as a personality
trait, including studies done in the fields of social-psychology, nursing, and
related health professions. Particular attention will be paid to the
development and testing of Pollock’s health-related hardiness concept. Also
being reviewed is the concept of health promotion, including the
development of Pender’s Health Promotion Model. Instrumentation related
to both of these concepts will be discussed along with examples of their use
in other studies.
The Concept of Hardiness
Lawrence Hinkle (1974) reported on a series of longitudinal studies
that he and his associates carried out for the Division of Human Ecology at
Cornell University Medical College. According to Hinkle, these studies were
conducted to determine how health is affected by changes in cultural or
social milieu or changes in interpersonal relationships. This research
8
showed that the onset of illness coincided with periods of high stress. It also
identified a group of healthy people who had experienced similar significant
life stress without developing illness. It was suggested that these healthy
people possessed an insulating personality trait which allowed them to
experience these changes without a strong emotional or psychological
response.
Antonovsky (1974) conducted a study for the purpose of developing
an instrument that would measure both life crises and resistance resources.
He identified a set of variables which appeared to buffer an individual from
life crises. These resistance resources included: “(1) homeostatic flexibility;
(2) ties to concrete others; and (3) ties to total community” (p.252). He saw
this as being consistent with Selye’s general adaptation concept.
In a series of studies, Kobasa and associates (1979, 1981,1982,
1983) looked at the possible mediating effects of personality characteristics
on stressful life events. The central proposition of these studies was that
persons who experience high levels of life stress without becoming ill
possess a personality structure which differentiates them from individuals
who become sick under stress. This personality trait was labeled as
hardiness and the concept was based primarily on an existential theory of
psychology. A person with a hardy personality was seen as possessing
three general characteristics: (1) a belief that he can control or influence the
events of his experience, (2) an ability to feel deeply involved in or
committed to the activities of his life, and (3) the acceptance of change as an
exciting challenge to further development (Kobasa, 1979).
9
Consequently, the personality trait of hardiness was considered to
have three dimensions, including control, commitment, and challenge.
The
characteristic of control was further described to include several
components; the first, decisional control, is the ability to choose among
various courses of action to handle stress; the second, cognitive control, is
the ability to interpret, appraise, and incorporate various stressful events into
one’s life plan; the third, coping skill, is the possession of suitable
responses to stress which were developed through a motivation to achieve
in all areas of life (Kobasa,1979). An internal locus of control allows the
hardy individual to recognize that he has the power to influence the outcome
of life events.
A committed person was further described as having a belief
system that minimizes the perceived threat of a stressful event. He has a
strong sense of purpose and feels an involvement with others, allowing him
to turn to others for help when needed. Most importantly, he not only has a
strong sense of commitment to self, but he is also able to recognize his
values, goals, and priorities. This enables him to make an accurate
assessment of the threat posed by a particular stressor. The characteristic of
challenge was further described as the ability of a person to feel positive
about change. This individual acts as a catalyst in his own environment, and
thus has experience in responding to the unexpected. Persons with this
characteristic have been called change seekers who value interesting
experiences: they are able to be cognitively flexible. Again, this allows them
to more accurately assess the threat of a new situation. The combined traits
of control, commitment, and challenge in the hardy individual theoretically
•
•
10
.u
minimize the potential for stress induced illness. Kobasa does not attempt to
describe the nature of physiological mechanisms and their links to
personality that determine the stress-illness relationship; she cites the need
for more sophisticated stress research before this consideration can be
made.
Kobasa(1979) acknowledged that the personality trait of hardiness is
not the only variable that influences an individual’s response to stress. She
indicated that a variety of psychological, social, physiological, and
environmental factors play a role in the stress-illness relationship. Her
studies looked at the relationship of demographic characteristics and health
perceptions to individual responses.
It was suggested that although
hardiness, social support, and social assets are all variables that improve
coping, the personality trait of hardiness is the most influential (Kobasa et al.,
1982) .
A schematic diagram was designed to depict these relationships
(see Appendix 1). In this diagram, hardiness is seen as having a direct
impact on both coping and on the use of social resources which, in turn,also
effects coping (Kobasa & Puccetti,1983).
The series of studies by Kobasa and associates (1979, 1981, 1982,
1983) utilized a complex set of instrumentation. The subjects were business
executives from middle and upper level management positions who were
exclusively male and white. They were asked to complete a series of
questionnaires that measured stressful life events, illness symptoms,
demographic characteristics, and hardiness. Medical reports were also
examined to determine family health histories. The instrument used to
measure stress was an adaptation of the Schedule of Life Events (Holmes &
Rahe, 1967). illness symptoms were measured by the Seriousness of
Illness Survey (Wyler et al., 1968). Six different scales were used to
measure hardiness. Included were the alienation from self and alienation
from work scales (Maddi et al., 1979), the security scale from California Life
Goals Evaluation Schedule (Hahn, 1966), the cognitive structure scale of
the Personality Research Firm (Jackson, 1974), the external locus of control
scale (Rotter et al., 1962), and the powerlessness scale of the Alienation
Test (Maddi et al.,1979). From the review of medical records, a parent’s
illness score was established as a means of determining predisposition to
various illnesses. The demographic characteristics which were studied
included age, education, job level, length of time at job level, religion,
ethnicity, and marital status. Through the series of studies, this
instrumentation was revised and modified. Lambert, Lambert, Kipple, &
Mewshaw (1989) referred to unpublished works from 1984 that offer second
and third generation instruments.
In discussing the findings in this series of studies, the authors
emphasized the following points. The results support the view that
hardiness functions as a resistance resource (Kobasa, 1979, Kobasa,
Maddi, & Courington, 1981; Kobasa et al., 1982; Kobasa & Puccetti, 1983).
Hardiness has its strongest buffering effect when stressful life events mount
(Kobasa et al., 1982). While a history of parental illness will indicate
vulnerability to disease, and the causal effects of stressful life events are
short lived; the presence of hardiness will decrease the effects of both
illness vulnerability and stressful events (Kobasa et al., 1981). When
12
looking at the interaction between social support and hardiness, distinctions
must be made between various kinds of social resources including assets,
family support, and employer support. Lazarus’s model of coping (1966)
was referenced to explain the relationship between the function of family
support and coping (Kobasa & Puccetti, 1983). The researchers
emphasized the need for further study of these relationships in order to
better explain how some persons stay healthy is spite of stressful life events.
They proposed a need to develop a “multidimensional systems model for
research on stress, resistance, and health” (p.849).
There has been criticism of the hardiness studies. Funk and Houston
(1987) questioned the appropriateness of the statistical analysis. They
proposed that it is not hardy people who are stress resistant, but non-hardy
people who are psychologically maladjusted or neurotic. Nursing research
by Topf (1987) failed to provide evidence of the stress buffering effects of
hardiness. This was seen as providing support for Funk and Houston’s
(1987) criticism. In discussing this criticism, however, Rhodevolt and Zone
(1989) reported that research consistently reports reliable differences
between hardy and non-hardy individuals, and that such research can be
valuable as long as attention is paid to the conceptual and methodological
issues. Williams and Wiebe (1992) attempted to clarify the question of
neuroticism and hardiness. Their findings did support the positive
relationship between hardiness and adaptive coping, but there also
appeared to be influence from neuroticism in the relationship of coping and
hardiness with self-reported illness. It was pointed out that the findings in13
support of hardiness were most consistent with males.
Another significant limitation to the understanding of this concept
results from the fact that Kobasa and associates studied only a male
population. Shepperd and Kashani (1991) studied the relationship of
hardiness, gender, and stress to health in adolescents. They found support
for the relationship of hardiness and health for males, but not for females.
Lambert and Lambert (1987) pointed out that nursing research has made
attempts to determine the validity of hardiness with females; this process has
continued. Johnson-Saylor (1991) reported on a study of hardiness as one
of the possible predictors of healthy behaviors in women. It was found that
the negative effects of hostility and anger were stronger than the positive
association between hardiness and healthy behaviors.
Much of the nursing research on hardiness has dealt with its
relationship to well-being among nurses (McCranie et al., 1987; Rich &
Rich, 1987; Boyle et al., 1991). This research pays particular attention to
burnout among female staff and critical care nurses. The theory that
hardiness acts as a buffer against the harmful effects of stress was at least
partially supported by these studies. Again, the results point out the need to
further clarify the significance of hardiness as a resistance factor among the
female population. Langema (1990) Included hardiness as a variable in
studying work stress among female nurse educators. She utilized Kobasa's
hardiness personality inventory (1982). Pagana (1990) studied the
relationship of hardiness and social support in the Identification of stress
among nursing students in their initial clinical setting. The results of this
study support the hypothesis that persons low in hardiness tend to feel more
threatened by new experiences.
Repeated studies serve to clarify the concept of hardiness and its
relationship to health. Lambert and associates (1989) studied the
relationship of social support and hardiness to well-being in women with
arthritis. Discussion of these results pointed out the need to identify and
intervene with women who are less hardy than others. It also raised the
possibility of hardiness training as a valuable intervention. Stockstill and
Callahan (1991) studied hardiness in a population of dental patients with
temporomandibular disorders. They found that patients with the diagnosed
disorder were less hardy than a control group of subjects without the
disorder. Carey and associates (1991) referred to findings that family
hardiness is an important resource for family members that are caring for an
oncology patient.
There have been studies conducted to determine the relationship
between hardiness and health behaviors. Daniels (1987) noted that past
research found a link between both hardiness and the stress-illness
relationship as well as health behaviors and the stress-illness relationship.
She viewed hardiness and health behaviors as resistance resources and
saw a particular interest in the possible interactions between the two.
Results of her study did show a positive correlation between hardiness and
health behaviors. Pollock (1989) attempted to determine the relationship
between hardiness and adaptation to chronic illness aiong with heaith-
promotion activities. Pearson correlations of the hardiness scores and majoj
variables in Pollock’s study found a significant positive relationship between
the presence of hardiness and engagement in health-promotion activities.
This study also found significant relationships between the presence of
hardiness and higher levels of perceived health status and the use of social
resources, thus supporting the indirect effects of hardiness on health.
In a series of studies, Pollock (Pollock, 1989; Pollock & Duffy, 1990;
Pollock, Christian, & Sands, 1990) attempted to further clarify the
relationship between hardiness and health within an adaptation model. She
views the concept of hardiness as having a particular significance for
nursing, in that nursing attempts to promote adaptive responses in
individuals with actual or potential health problems (1989). She noted that
while past studies, including those of Kobasa and associates, supported the
effects of hardiness on stress, their relevance to nursing was limited. She
cited the need to clarify the relationship between hardiness and health and
to improve on measurement techniques. In an effort to accomplish these
goals, a health-related hardiness concept was proposed.
Pollock contends that the major differences in the health-related
hardiness concept and Kobasa’s concept can be found first in the definitions
of the three dimensions of control, commitment, and challenge, and second
in the measurement of these factors (Pollock & Duffy, 1990). Placed in the
context of health, control is defined as “the use of ego resources necessary
to appraise, interpret, and respond to health stressors' (PottocK, ,989. p.55).
Commitment is viewed as oommitment to sett and "is evidenced as the
motivation for active involvement in promoting one’s health and the
16
competence to deal with health problems” (Pollock & Duffy, 1990, p.219).
Challenge is then defined as the appraisal of a health stressor as being
potentially beneficial rather than threatening (Pollock, 1989). There is some
evidence that studies by Pollock and Duffy support a two dimensional
construct for hardiness rather than the originally hypothesized three
(Tartasky, 1993). This would combine the concepts of challenge and
commitment into one dimension that, with the dimension of control, would
form the construct of hardiness.
The next step in the development of the health-related hardiness
concept was the formulation of an instrument that utilized positive indicators
to measure the presence of control, commitment, and challenge. This is in
contrast to Kobasa’s scale which includes such negative indicators as the
absence of powerlessness scale to measure control, the absence of
alienation from work and self to measure commitment, and a low need for
security being indicative of a high sense of challenge (Pollock, 1989). The
original Health-Related Hardiness Scale (HRHS) has been analyzed and
modified several times. Pollock has used it in studies of individuals with
chronic illness as well as with adults who describe themselves as healthy. It
found to be an appropriate tool to measure hardiness or its
has been
Individual components In both well Individuals and In those with chronic
Illness (Pollock, 1989). The current version ot the scale consists ot 34 Items
on a six point Llked-type scale, m a personal communication, Po»ock(1994)
advised that current research
yield further revisions.
Health-Promoting Behaviors
17
Chronic illnesses with behavior based etiologies have been identified
as the leading causes of death in the United States. Recognition of this
concept has led to an upsurgence in the study of health promotion with
regard to its significance to our health care delivery system. The Human
Population Laboratory of the California State Department of Health and
Human Services began investigating the relationship between lifestyle and
physical health based on the hypothesis that certain components of lifestyle
have significant impact on an individual’s overall health status (Wiley &
Camacho, 1980). An important part of this research included the Alameda
County Study which was reported on by Belloc and Breslow (1972). This
study of a sample of the adult population of Alameda County, California in
1965 identified seven lifestyle variables or health practices which were
significantly associated with physical health. These variables included
hours of sleep, physical exercise in leisure time, alcohol consumption,
cigarette smoking, obesity, eating between meals, and having regular
breakfasts. Wiley and Camacho reported on a follow-up study of this same
sample population which was done to determine whether it is possible to
predict future health outcomes from past behaviors. They reported findings
that demonstrated an association between health practices measured in
1965 and health status reported nine years later. They defined lifestyle as a
arouo of discretionary activities which are a part of an individual’s pattern of
daily living. The study was done within the context of a theoretical
background which views the concept of host resistance to disease.
18
In 1979 the Surgeon General’s Report, Healthy PeoplefUS Dept, of
HE&W, 1979), ranked the leading causes of death for adults as heart
disease, cancer, stroke, cirrhosis of the liver, and accidents. This report also
indicated that unhealthy lifestyles were responsible for approximately 50%
of deaths in the United States yearly. Five categories of negative behaviors
that influence health were targeted for health promotion programs. These
categories included smoking, coping with stress, drug and alcohol use,
nutritional habits, and exercise patterns. By 1991, The Surgeon General’s
Report, Healthy People 2000 (US Dept, of HE&W , 1991) cited reductions in
the death rate for heart disease, stroke, and unintentional injuries. It credited
increases in high blood pressure detection and control, a decline in cigarette
smoking, increased awareness of the role of cholesterol and dietary fats,
increased use of seat belts, and lower speed limits for these changes. On
the other hand, it also reported rising rates for syphilis and HIV infection,
while cancer, heart disease, and unintentional injuries remain the leading
causes of death. All of these health problems are associated with risk factors
related to lifestyle. So, while health promotion programs have made some
progress, it is still evident that certain lifestyle changes need to be
encouraged. This report defines the role of health services to include patient
education, counseling, and screening. It recognizes the difficulties
associated with lifestyle changes, and sites several factors that must be
considered when attempting to facilitate change. These include
socioeconomic status, the environment, community norms, media images
,
19
an coverage, advertising, work site standards, and access to health care
and counseling.
While the need for health-promotion programs is apparent, the
success of individual programs depends on an understanding of healthrelated behavior. Health care professionals must look at those factors which
prompt a person to not only initiate health-promotion activities, but also to
incorporate them as part of their habitual behavior. Dishman (1982), in a
discussion of long term exercise behaviors, reported that while 85% of
individuals report that they “feel better” after initiating an exercise program,
50% of these same individuals discontinue the program within the first six
months. Based on a review of the available literature regarding healthrelated exercise, Dishman (1982) identified three factors which influence
long term adherence to an exercise program. These include the
characteristics of the exerciser, the exercise setting, and the person-setting
interface. He proposed the development of diagnostic tools to be used in a
clinical setting to predict adherence to a regimen.
Several theoretical models have been proposed to explain the
process whereby individuals recognize the responsibility for their own health
and also practice those recommended behaviors. These include, among
others, the Health Belief Model, Social Learning Theory, Attitude-behavior
Theory, and Triander’s Theory of Social Behavior (Sloan, Gruman, &
Allegrante, 1987). The Health Belief Model has been widely referred to in
health promotion literature. In its original form it describes actions taken by a
healthy individual to prevent illness (Bulluogh & Bullough, 1990). The
Rosenstock model of this theory includes perceptions of disease
20
susceptibility and threat, perceived benefits of preventive action, and
barriers to preventive care. It also includes the modifying factors of
demographic variables,sociopsychologic variables, and structural variables,
with cues to action. These factors are felt to exert a combined influence on
the likelihood of an individual taking preventive health action (Bullough &
Bullough).
Nola Pender (1987) has developed a modification of the Health Belief
Model which she refers to as the Health Promotion Model. In its
development, she differentiates between health protecting behavior and
health promoting behavior. While a perceived threat of illness or disease
may influence preventive behaviors, she proposes that it has little or no
motivational significance to health promoting behaviors, which stem from a
desire for growth and quality of life. The Health Promotion Model is based
on social cognitive theory in which cognition operates interactively with
affect, actions, and environmental events to determine behavior (Pender,
Walker, Sechrist, & Frank-Stromberg, 1990). The model identifies
relationships among three components which have been labeled as (1)
cognitive/peroeptual factors, (2) modifying factors , and (3) variables
affecting the likelihood of action. The mode! was designed to serve three
main functions, including organisation of concepts, generation of testable
hypotheses, and integration of research findings into a coherent pattern
(Pender, 1987).
There are three components found in the Health Promotion Model
21
(see Appendix 2). First, the cognitive/perceptual factors are identified as the
primary motivational mechanisms, and are shown to have a direct influence
on the likelihood of engaging in health promoting behaviors (Pender, 1987).
These factors include the importance of health, perceived control of health,
perceived self-efficacy, definition of health, perceived health status,
perceived benefits of health-promoting behaviors, and perceived barriers to
health promoting behaviors. These factors are considered to be flexible
and amenable to change (Pender et al., 1990). Second, the modifying
factors are seen as having an indirect influence on behaviors through their
direct influence on the cognitive/perceptual factors. These factors include
demographic characteristics, biologic characteristics, interpersonal
influences, situational factors, and behavioral factors. The third component
of the HPM includes certain cues to action which are seen to have a direct
effect on behaviors. These cues may originate internally or from the
environment through such things as conversations with others or mass
media information (Pender, 1987).
Rummel (1991) considered the personality trait of hardiness to be
similar to Pender’s cognitive/perceptual factors of self-efficacy and control.
The similarities are obvious when the hardiness dimensions of control,
commitment, and challenge are defined and analyzed.Within the framework
of the hardiness concept, hardiness includes such things as the belief of an
individual that he can control or influence his life experiences, the ability to
feel deeply involved or committed to life’s activities, and the possession of
22
the confidence necessary to accept life’s changes as a challenge (Kobasa,
1979). Within the HPM, perceived control of health is defined as the belief
that health is self-determined, influenced by powerful others, and/or the
result of chance or fate. Self-efficacy is defined as the belief that one has the
skill and competence to carry out specific actions (Pender et al„ 1990).
Based on the premise of these similarities, the Health Promotion Model
provided the framework for Rummel’s study of the relationship of health
value and hardiness to health-promoting behavior in nurses. The results of
her study showed a positive relationship between hardiness and health
promoting behavior; in fact, within the boundaries of this study, hardiness
emerged as the strongest predictor of such behavior. An additional
cognitive/perceptual factor - perceived health status - was also found to be
related to health-promoting behavior.
Several other studies have been conducted in an effort to test the
Health Promotion Model’s usefulness in explaining health-promoting
behaviors. Pender, Walker, Sechrist, and Frank-Stromberg (1990) studied
589 individuals enrolled in employer sponsored health promotion programs.
Results of the study showed that four of the cognitive-perceptual variables
and three modifying factors combined to explain 31% of the variance in
health promoting lifestyle. The authors pointed to the need for continued
model testing and development. Weitzel (1989) looked at the relationship
between four of the cognitive-perceptual variables and selected
demographics to health promoting behavior among 179 blue-collar workers.
She found that each of the variables was predictive of health-promotive
23
behaviors, providing support for the model. Gillis and Perry (1991) studied
the relationship between physical activity and health-promoting behavior in
mid life women. The research questions for this study were framed within
the Health Promotion Model. Although 57.6% of the variance in behavior
was explained by the model variables, the magnitude of unexplained
variance lead the authors to conclude that other variables not tested in this
study influence health-promoting behaviors. A test of the model using
LISREL (a linear structural relation analysis) yielded weak significant effects,
explaining little of the variance in behavior. Further study was suggested to
explore the possibility that demographic and biological characteristics may
have a direct, rather than an indirect effect on behavior (Johnson, Ratner,
Bottorff,& Hayduk, 1993). In an attempt to develop a causal model to guide
nursing intervention in the workplace, Lusk and Keleman (1993) began
preliminary testing of the Health Promotion Model to see if it explained use
of hearing protection. Findings were consistent with the model. They
reported positive correlations between the use of protection and several of
the model’s cognitive-perceptual factors. Demographic characteristics were
related to the definition of health and barriers to use , but not directly to
behaviors. In a study of health-promoting lifestyles in older persons, Duffy
(1993) reported findings that supported the relationships posited in the
Health Promotion Model. She concluded that the model is useful in
increasing understanding of lifestyles and guiding research regarding
health-promotion activities for older adults.
Discussions of Pender’s Health Promotion Model by various authors
24
generally show support for its usefulness. They do however, acknowledge
difficulty in testing its relationships and a need for further study to clarify the
effects of a range of variables. In discussing Pender’s cues to action, Palank
(1991) agrees that they have a direct influence on behavior, but finds
difficulty with the model in that it is hard to determine the impact of diverse
variables on general lifestyle patterns. It is suggested that it may be better to
look at individual behaviors such as exercise, smoking, etc. Fleury (1992)
acknowledges that nursing research has demonstrated empirical support for
several of the relationships proposed in the model, but points out that the
large number of variables make the total HPM difficult to test, therefore
limiting it’s potential. She agrees that additional testing may provide
continued substantiation for the model. In a discussion of strategies for
promoting a healthy dietary intake, Herron (1991) critiqued three employee
health promotion programs that are based on elements similar to those
presented in the model. The HPM is viewed as a workable model on which
to base such programs.
The Health-Promoting Lifestyle Profile was developed by Walker,
Sechrist, and Pender (1987) as an instrument to measure health-promoting
lifestyle activity. It is based on the Health Promotion Model’s premise that
health-protecting and health-promoting behavior can be viewed as
complementary components of a healthy lifestyle. While instruments are
available to measure health hazards or provide risk appraisals, Pender saw
the need to measure actions that serve to enhance wellness, self
actualization, and fulfillment. She originally constructed the Lifestyle and
25
Health Habits Assessment (LHHA) for this purpose. Items for the initial
Health-Promoting Lifestyle Profile (HPLP) were taken from the LHHA. The
items and format were revised based on results of pilot studies (Walker,
Sechrist, & Pender, 1987). Psychometric testing done by this group yielded
results that suggest that the HPLP is valid and reliable for use. This
instrument has been used in a variety of studies including those by Pender,
Walker, Sechrist, and Frank-Stromberg (1990), Weitzel (1989), Duffy (1993),
Gillis (1991), and Rummel (1991).
26
Chapter 3
Methodology
Pender s Health Promotion Model provided the conceptual framework
for this study. The concept of hardiness was viewed as a cognitive/
perceptual factor within that model. The study was designed to determine
the relationship between the cognitive/perceptual factor of hardiness and
health-promoting behavior among public school teachers.
Sample and Setting
A convenience sample for this study was drawn from a group of
public school teachers employed by an urban school district in western
Pennsylvania. The sample included men and women ranging in age from 21
to 61 years. All of the subjects possessed at least a bachelor’s degree, with
the majority holding additional graduate credits. They worked in one of three
elementary schools. Inclusion in the study was voluntary and based on the
individual’s willingness to complete and return the confidential
questionnaires.
Instrumentation
The Health-Promoting Lifestyle Profile was used to measure healthpromoting behavior. This 48-item rating scale was developed by Walker et
(
)• It utilizes a four point response format to measure the frequency of
self-reported behaviors in the areas of self-actualization, health
responsibility, exercise, nutrition, interpersonal support, and stress
management. All items pertain to one of these six areas or subscales and
are scored on a scale of 1 to 4 based on responses: never = 1; sometimes
= 2; often = 3; routinely = 4. Walker (personal correspondence, 1994)
recommends obtaining scores for overall health-promoting lifestyle by
calculating a mean on the individual’s responses to all 48 items, while
scores for the six subscales are obtained similarly by summing the
responses to subscale items and dividing by the number of items on the
subscale.
Walker, Sechrist, and Pender (1987) described the development and
testing of the Health-Promoting Lifestyle Profile (HPLP). The original HPLP
was based on Pender’s Lifestyle and Health Habits Assessment (LHHA),
which incorporated ideas from a variety of studies regarding the relationship
of lifestyle to health. The LHHA contained 100 items arranged into 10
categories. These categories included: General Health Practices, Nutrition,
Physical/Recreational Activity, Sleep, Stress Management, SelfActualization, Sense of Purpose, Relationships with Others, Environmental
Control, and Use of the Health Care System.The initial or pilot form of the
HPLP consisted of items taken directly from the LHHA. The instrument was
given to a convenience sample of 173 nursing students to evaluate item
clarity and response variance and to estimate reliability. Content validity was
then evaluated by four nursing faculty familiar with health promotion
Following this examination, revisions were made; the resulting
instrument contained 107 items
Empirical validation on the HPLP, including item analysis and factor
analysis, followed. Data were obtained from a convenience sample of 952
volunteers. The sample included men and women who ranged in age from
18 to 88 years; their educational levels ranged from eighth grade to a
professional degree; their median income placed them socioeconomically in
the middle class . Thirty-five items were eliminated due to the item analysis;
most of those were concerned with undesirable practices to be eliminated.
Factor analysis of the remaining 70 items resulted in a grouping of the items
into six subscales rather than the original ten. Twenty-two additional items
that did not clearly fit into one of the six subscales were then eliminated,
leaving a remaining 48 items. Factor analysis of these 48 items supported
the construct validity of the instrument. The alpha reliability coefficient for
the total instrument was .922, indicating a high internal consistency, while
tests for reliability on each of the subscales yielded alpha coefficients
ranging from .702 to .904, an acceptable range. Test-retest reliability with a
sample of 63 adults at a two week interval yielded a Pearson r of .926 for the
total scale and a range of .808 to .905 for the subscales, indicating stability
in the instrument. An examination of the distribution of subjects’ scores
showed that the possible range of scores was widely used and standard
deviations were moderate in size, indicating that the instrument appears to
be able to detect variability in the frequency of self-reported lifestyle activities
(Walker et al., 1987).
The Health-Related Hardiness Scale (HRHS) was used to measure29
the hardiness characteristic in each subject. The tool consists of 34 items on
a 6 point Likert-type scale, with a response of 1 indicating strong
disagreement with the statement, while 6 indicates strong agreement . The
scale can be used to measure the unitary construct of health-related
hardiness and/or two dimensions of commitment/challenge and control.
Twenty items cover the dimension of commitment/challenge, while the other
fourteen factors deal with control. For this study, the total HRHS scores were
obtained. Possible scores ranged from 34 to 204 with high scores indicating
the presence of hardiness. The scale contains 18 negatively worded items,
therefore scoring for these items needed to be reversed (Pollock, personal
correspondence, 1994).
Pollock and Duffy (1990) described the development and testing of
the Health-Related Hardiness Scale. They pointed out that the scale is
based on Pollock’s health-related hardiness construct which integrates
concepts from coping, adaptation, and developmental tasks of adulthood,
along with a refinement of Kobasa’s definitions of commitment, challenge,
and control. Initial items were written to indicate the presence, rather than
absence, of the hardiness dimensions. Several items were taken from the
Multidimensional Health Locus of Control Scale. The first version of the
HRHS consisted of 48 items measured on a 6 point Likert scale. It was given
to a sample of 53 graduate nursing students to pretest for readability, clarity,
meaning, and response variance.
Changes were made based on this
evaluation, including the addition of three new items. The resulting 51 item
scale was further evaluated by a panel of three experts for congruence with
the health-related hardiness definitions of control, commitment, and
challenge, yielding an intraclass correlation of .92. To test the scale for
convergent validity, a pilot study of 50 healthy adults was given both
Kobasa’s (1979) Hardiness Scale and the HRHS. The resulting correlation
of .54 was statistically significant, indicating that, while sufficiently different
from Kobasa s scale , the HRHS did measure hardiness. Item analysis and
reliability estimates were then done. Ten items failed to meet the criterion
level and were dropped.
The 41 item scale was then administered to a sample of 389 subjects
who had been diagnosed with one of three chronic illnesses. A principal
components analysis of the results supported two dimensions of hardiness
rather than the originally hypothesized three. Since commitment and
challenge items loaded together, they were considered to be one
dimension, with the second dimension being control. Of the 41 items, 34
loaded on these two factors, with 20 items covering challenge/commitment
while 14 items pertained to control (Pollock & Duffy, 1990). Internal
consistency reliabilities are high at .91 for the total 34 item scale, and .87
for both the challenge/commitment and control subscales (Pollock, personal
communication, 1994). The HRHS was then administered to a subgroup of
150 subjects at two separate intervals of approximately six months. The test-
retest reliability was .76, indicating satisfactory stability ( Pollock & Duffy).
Permission for the use of both of these instruments was obtained
through personal correspondence with their respective authors. Pollock and
Walker both requested that they be credited with the development of the 31
instruments. Pollock also requested that she receive an abstract of the
proposed research, along with results of the study and a copy of reliability
and validity estimates obtained. She specified that no further psychometric
analysis be done on the instrument.
Along with completion of The Health-Related Hardiness Scale and
The Health-Promoting Lifestyle Profile, subjects were asked to provide
specific demographic information including age, sex, marital status, ethnic
background, educational level, and years of experience with the district.
Data Collection
In order to obtain permission to conduct this study within the school
district, a written request for permission was submitted to the Director of
Pupil Services along with a completed form required by the district and
copies of each of the questionnaires. When permission was granted, each
of the principals of the individual schools was contacted personally. The
was described and permission was requested to contact their
teachers through the public address and interschool mail systems. This was
met with approval in each of the three schools. The school nurse then
agreed to act as a facilitator by distributing and collecting the questionnaires
from the teachers in her building.
Each subject was given a packet which included a cover letter,
demographic
related questions, and a copy of each of the instruments with
on
instructions for their completion. The cover letter introduced the researcher,
briefly described the study, insured confidentiality, and requested the
participant’s assistance with the research by completing and returning the
enclosed questionnaires. The subjects were not asked to include their
names. The packets were placed in the teachers’ school mailboxes by the
researcher. On the day that the packets were distributed, an announcement
was included in the regular morning announcements made by the principals
informing the teachers that the packets had been placed in their mailboxes
and asking for their cooperation in completing them. The teachers were
asked to complete and return the questionnaires to the school nurse within
five days. A second announcement was made midweek and again on the
due date to request their completion and return.
Data Analysis
In order to determine the relationship between hardiness and health
promoting activities the paired scores from the Health-Related Hardiness
Scale and the Health-Promoting Lifestyle Profile for all of the subjects were
plotted on a scatter diagram and analyzed using the Pearson r correlation
technique. The significance interval level was set at .05. To determine the
strength of association the value of r2 was then computed.
33
Chapter 4
Presentation and Analysis of Data
The purpose of this study was to determine the direction and the
strength of the relationship between the personality trait of hardiness and the
practice of health promoting behaviors among public school teachers. It was
hypothesized that there is a significantly positive relationship between
hardiness and health promoting behaviors. In order to test this hypothesis, '
The Health-Related Hardiness Scale (HRHS) and The Health-Promoting
Lifestyle Profile (HPLP) were administered to a sample population of public
school teachers. The paired scores from these instruments were then
analyzed using the Pearson r correlational technique with the significance
level set at .05.
The data was collected by distributing questionnaire packets which
included the Health-Related Hardiness Scale and the Health-Promoting
Lifestyle Profile to a sample of eighty teachers from three elementary
schools within an urban school district. These packets also included an
introductory letter along with a request for specific demographic information
including age, sex, marital status, ethnic background, educational level, and
number of years of employment with the school district. Of the eighty
packets that were distributed, sixty-seven were returned. One of the 67
returned packets was discarded because it was incomplete, therefore 66
pairs of scores were analyzed.
A majority, or 51 of the 66 subjects included in the study were
34
female.The range in age was from 21 to 61 years, the mean age being 41.3
years with a standard deviation of 9.85 years (see Table 4.1). A total of 48
subjects indicated that they were married, of the 17 single subjects, 2 were
widowed females and 1 was a divorced male. All of the subjects held at
least a bachelors degree while 48 of them had a masters degree or better.
They were all full time employees of the district, their years of employment
ranging from 0.5 to 34 years with the mean being 13.3 years (see Table 4.1).
Responses to the item “ethnic background” varied to include race or country
of origin. When these responses were analyzed to indicate race only, one
subject was black while the remaining 65 were Caucasian.
RANGE, MEAN, AND STANDARD DEVIATION FOR
TABLE 4.1
AGE. YEARS OF EXPERIENCE, HARDINESS, AND LIFESTYLE SCORES
AGE
YRS/EXP
HARDINESS
LIFESTYLE
Minimum
21.000
0.500
117.000
1.667
Maximum
61.000
34.000
193.000
3.667
Mean
41.303
13.341
162.182
2.914
Stand dev
9.853
9.418
19.418
0.439
n of cases
66
66
66
66
35
The scores were tabulated for The Health-Related Hardiness Scale
by adding the number of the response for each item; possible responses
ranged from 1 for strongly disagree to 6 for strongly agree. Scores for the
negatively worded items were reversed with strongly disagree being
awarded a value of 6 while strongly agree items were valued at 1. The
possible range in scores is from 34 to 204. The actual range in scores for
these subjects was a low of 117 and a high of 193. The mean score was
162.18 with a standard deviation of 19.418 points (see Graph 4.1).
[
—[
I______ i
120
140
160
]—
i
180
hardiness
Graph 4.1
DISTRIBUTION of scores from the health-related
HARDINESS SCALE
36
Scoring The Health-Promoting Lifestyle Profile involved assigning a
numerical value to each of the four possible responses. Items were scored
as Never(N) = 1, Sometimes (S) = 2, Often (O) =3, Routinely (R) = 4. An
overall score for the profile was then obtained by calculating a mean of the
individual’s responses to all 48 items, as directed by the authors. The
possible range of scores for this profile is from 1 to 4. The actual range for
this sample was a low of 1.667 and a high of 3.667. The mean score was
2.914 with a standard deviation of 0.439 (see Graph 4.2).
]----______ i_
1.5
2.0
2.5
3.0
3.5
I
4.0
LIFESTYLE
Graph 4.2 JDISTBIBUTIQNOFSCQBESJROM the health-promoting
IIFFSTYLE profile
37
The paired scores from the Health-Related Hardiness Scale and The
Health-Promoting Lifestyle Profile for each subject were then plotted on a
scatter diagram (see Graph 4.3). The general orientation of the scatterplot
is from the lower left corner to the upper right corner, indicating a positive
relationship. The paired scores were then analyzed using the Pearson r
correlation technique. With the significance level being set at .05, values of r
for a sample population of 66 must be at least .250 to reject the null
hypothesis that the correlation equals zero. This analysis yielded an r of
0.481, thus supporting the hypothesis that there is a significant positive
relationship between scores on the Health-Related Hardiness Scale and
scores on the Health-Promoting Lifestyle Profile for this sample. In order to
determine the strength of association, the value of r2 was computed to be
.231 indicating that 23% of the variance in scores on the Health-Promoting
Lifestyle Profile can be explained by scores on The Health-Related
Hardiness Scale.
The data as analyzed indicate a significant association between
hardiness and the practice of health-promoting behaviors. Generally
speaking, when hardiness scores are high, a higher number of health
promoting behaviors are practiced.
38
4.0
L
I
F
E
S
T
Y
L
E
3.5
3.0
.
f
i .•
2.5
2.0
1.5 *100
120
140
160
180
200
HARDINESS
Graph 4.3 HARDINESS - LIFESTYLE SCATTERPLOT
Chapter 5
39
Conclusion
This study was designed to determine the direction and strength of
the relationship between the personality trait of hardiness and the practice of
health-promoting behaviors among a group of public school teachers.
Hardiness was viewed as a cognitive/perceptual factor within the framework
of Pender’s Health Promotion Model. It was hypothesized that there is a
positive relationship between hardiness and health-promoting behaviors. In
order to test this hypothesis a convenience sample of teachers from three
elementary schools was asked to complete the Health-Related Hardiness
Scale and the Health-Promoting Lifestyle Profile. The paired scores from
these instruments were then analyzed according to the Pearson r
correlational technique. The correlation between hardiness and lifestyle
(health-promoting behaviors) was 0.481, significant at a level of .05.
Discussion
The results of this study must be interpreted cautiously due to the use
of a convenience sample of volunteer subjects. While the sample size of 66
meets the size requirements for a sample proportion to be within .05 of the
population proportion with a 95% level of confidence.it is small compared to
samples used in similar studies. There are other limitations as well. A
sample that is predominately female and educated at a masters degree level
may be representative of many elementary school teacher populations,
40
however, it can not be seen as descriptive of the general population of
public school teachers. Obviously, blacks and other minorities are poorly
represented by this sample with only one subject indicating a black ethnic
background. As with any convenience sample, these limitations make
generalization to the larger population risky.
Research in the behavioral sciences is limited by the complexities of
human psychology. Measurement of human attitudes and behaviors is
always difficult. The instruments used in this study were selected with care,
their development and testing had been carried out by their authors using
stringent scientific methods, their validity and reliability estimates are high
(Pollock & Duffy, 1990; Walker et al., 1987). In spite of this, it is always
necessary to be aware of the possibility that the instruments may not provide
a true measurement of an individual’s attitudes and behaviors before
interpreting the results. While the Health-Related Hardiness Scale in its
present form has been found to be an appropriate tool to measure hardiness
in both well individuals and those with chronic illnesses, Pollock(1994)
advised that current research will probably yield further revisions to the
scale.
The scores on The Health-Promoting Lifestyle Profile from this study
are consistent with scores reported from previous studios. Scores tor the
HPLP ranged from 1.667 to 3.667 with a mean score of 2.914. Gillis and
Pern, (1990) reported mean scores of 2.635 for an experimental group and
2.729 lor a control group. (These scores were originally reported as raw
scores of 126.50 and 131.01 but were converted by calculating the mean to
facilitate comparison here.) Pender, Walker, Sechrist, and Frank-Stromborg
(1990) reported mean scores from two different samples as 2.82 and 2.86
with standard deviations for both of .39. Weitzel (1989) reported mean
scores of 2.571 with a standard deviation of .447. Past scores from the
current version of the Health-Related Hardiness Scale were not reported in
the referenced literature as the reported studies were concerned primarily
with validity and reliability estimates and correlations to other variables
(Pollock & Duffy, 1990).
The results of this study show a significantly positive correlation
between the presence of hardiness in an individual and the practice of
health promoting behaviors. These results suggest that individuals who
possess a high level of psychological hardiness may be more apt to engage
in health promoting behaviors. This study considered hardiness to be
similar to the cognitive/perceptual factors of self-efficacy and control within
Pender’s Health Promotion Model. In this model these factors are said to
have a direct influence on the likelihood of engaging in health promoting
behaviors. The results of this study seem to support this concept. When an
individual believes that he can control or influence his life experiences,
feels deeply involved or committed to himself, and possesses the confidence
to accept life’s changes as a challenge, he may be more inclined to
incorporate health-promoting behaviors into his lifestyle.
Previous studies also found a positive relationship between
hardiness and health-promoting behavior. Daniels (1987) viewed hardiness
and health promotion as resistance resources; the results of her study
showed a weak but positive correlation between the two. Pollock (1989) did
extensive studies on adaptation to chronic illness; she reported a significant
positive relationship between hardiness and engagement in health
promotion activities among individuals that described themselves as healthy
in spite of a variety of chronic illnesses (r = .23, p<.05). Rummel (1991)
utilized the Health-Related Hardiness Scale and the Health-Promoting
Lifestyle Profile to study health promoting behaviors among nurses; she
reported results that supported her hypothesis predicting a positive
relationship between hardiness and health promoting behaviors.
To determine the strength of association between the two variables of
hardiness and health-promoting behavior the value of r2 was computed to
equal .231 indicating that 23% of the variance in health-promoting behaviors
can be explained by hardiness. While this is a significant percentage it
becomes apparent that other variables also influence behaviors. The Health
Promotion Model suggests the possibility of several cognitive/perceptual
factors that may have a direct influence on behavior (see Appendix 2).
Along with self efficacy and perceived control of health which are similar to
hardiness, the list also includes: the importance of health, definition of
health, perceived health status, perceived benefits of health-promoting
behaviors, and perceived barriers to health-promoting behaviors. The
model also lists modifying factors which are seen as having an indirect
influence on behaviors (see Appendix 2), including demographic
characteristics, interpersonal influences, situational factors, and behaviorai
factors. Research which attempts to clarify the role of each of these factors43
both independently and as they interact with each other will provide
valuable information in planning health-promotion programs.
Based on the positive correlation between hardiness and health
promoting behaviors found in this study, it is possible to suggest that the
evaluation of an individual’s level of hardiness may be a significant aspect of
assessing client needs when planning nursing interventions as part of a
health-promotion program. Before making this type of decision however,
other questions need to be answered. If an individual with a hardy
personality is more likely to practice positive health behaviors, may it also be
true that individuals who score low on the hardiness scale exaggerate a
predisposition to illness by engaging in negative health practices? Can
personality hardiness be taught or enhanced through interventions by
nurses or other health care professionals? Are there other factors that
outweigh hardiness in their ability to predict health promoting behaviors?
While it appears that the personality trait of hardiness plays a significant role
in the choice to incorporate health-promoting behaviors into one’s lifestyle,
these questions, and possibly others, need to be answered. Further
research in this area can only enhance our understanding of the relationship
between hardiness and lifestyle, and Improve upon our ability to plan and
implement effective health-promotion programs.
Recommendations
44
1. Further research to clarify the relationship of hardiness and health
promoting behavior utilizing a larger, randomly selected sample.
2. Research that continues attempts to improve on the measurement
of personality hardiness.
3. Research that attempts to clarify the relationship of hardiness to
various demographic factors.
4. Development and testing of interventions designed to enhance
personality hardiness.
5.
Research that continues to study the correlation between other
factors listed in the Health Promotion Model and health-promoting behavior.
45
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as mediators in the stress- illness relationship. Journal of Health and
Social Behavior, 22, 368-378.
Kobasa,S., Maddi,S., & Kahn.S. (1982). Hardiness and Health: A
Prospective Study. Journal of Personality and Social Psychology, 42,
168-177.
Kobasa S & Puccetti, M. (1983). Personality and Social Resources in
Stress Resistance. Journal of Personality and Social Psychology, 45,
839-850.
Lambert V & Lambert, C. (1987). Hardiness: It’s Development and
Relevance to Nursing. Image: Journal of Nursing Scholarship, 19, 92-
95.
Lamsu»0rt’ HamS?' 5S* G- 8 *-*»•<’«»>■ so*.
47
Arthritis’ Imano i ’ an? ^syc^°'°9ical Well-Being in Women with
Arthntisjmaqe: Journal of Nursing Scholarship. 21. 128-131.
Langema, D. (1990). Impact of Work Stress on Female Nurse Educators.
Image: Journal of Nursing Scholarship.22. 159-162.
Lazarus, R.S. (1966). Psychological Stress and the Coping Process. New
York: McGraw-Hill.
Lusk, S., & Kelemen, M. (1993). Predicting Use ofHearingProtection.Public
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Maddi,S., Kobasa.S., & Hoover,M. (1979). An Alienation Test. Journal of
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McCranie, E., Lambert, V., & Lambert, C. (1987). Work Stress, Hardiness,
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Pagana, K. (1990). The Relationship of Hardiness and Social Support to
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D
lc unuffvM (1990). The Health-Related Hardiness Scale:
P°"2vetopmem
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48
POl^'±iSto’^& Sands’D- (1990). Responses to Chronic
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ncacaiui, co,
dUU-xjU4.
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49
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50
Appendices
Appendix 1
Stressful
Life Events
Personality
Hardiness
51
Strain
--a
Illness
v Successful
/Coping
Use of Social
Resources
Hardiness, social resources, and the stress-resistance process (Kobasa, Puccetti.1983)
Appendix 2
CognitivePerceptual
Factors
Modifying
Factors
Importance of
Health
Demographic
Characteristics
Perceived control of
Health
52
Participation in
health-promoting
behavior
Biologic
Characteristics
Perceived selfefficacy
Definition of Health
Interpersonal
Influences
Perceived health
status
Situational Factors
Perceived benefits
of health-promoting
behaviors
Likelihood of
engaging in health
promoting
behaviors
—I1L__
Behavioral Factors
Cues to Action
Perceived barriers
to health-promoting
behaviors
Health Promotion Model
Pender, N. (1987):
Health Promotion in Nursing Practice
Dear Colleague,
Appendix 3
53
In an attempt to complete requirements for a master’s
degree in nursing, I am conducting a research project
which will study health promoting activities and beliefs
among public school teachers. As.......................................
I am aSkjng for yOur help in completing this
project. Please take time to complete the enclosed
questionnaires and then return them within one week to the
school nurse in your building. Please be assured that,
should you choose to complete the questionnaires, the
results will be used solely for research purposes and will
remain entirely confidential.
Thank you so much for your efforts in helping me to
complete this project. If you have any questions or
concerns please feel free to contact me daily from 2:30 to
3:15 PM at 871-6520 or 871-6465.
Sincerely,
Marcheta Shrefler R.N.
Before beginning the enclosed questionnaires, please
read the instructions carefully and provide the information
requested on the bottom of this sheet.
M
Thanks again!
About yourself...
Your age
ethnic background -----years with the district
your sex
,maritalstatus
educational level-----------------J
(bachelor’s/masters,etc.)
Appendix 4
54
Number
HEALTH-RELATED HARDINESS SCALE
Instructions:
This is a questionnaire designed to determine the way in which
different people view certain important issues related to their
health. Each item is a belief statement with which you may agree
or disagree. Beside each statement is a scale which ranges from
strongly disagree (1) to strongly agree (6). For each item we
would like you to circle the number that represents the extent to
which you disagree or agree with the statement. Please make sure
that you answer every item and that you circle only one number per
item. Thank you for taking the time to complete this
questionnaire .
DISAGREE
AGREE
S
T
R
0
N
G
L
Y
M
0
D
E
R
A
T
E
L
Y
S
L
I
G
H
T
L
Y
S
L
I
G
H
T
L
Y
M
0
D
E
R
A
T
E
L
Y
S
T
R
0
N
G
L
Y
1. Involvement in health promotion
activities is stimulating.
1
2
3
4
5
6
2. I can avoid illness if I take
care of myself.
1
2
3
4
5
6
1
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
3. I find it difficult to be
enthusiastic about good health.
4. Luck plays a big part in determining
how soon I will recover from an
illness.
-r to maintain
5. No matter how hard I try
accomplish
my health, my efforts will
v1
very little.
1
6. I am in control of my health.
7. I admire people who work hard to
improve their health.
1
2
DISAGREE
s
T
R
0
N
G
L
Y
Number
AGREE
M
O
D
E
R
A
T
E
L
Y
S
L
I
G
H
T
L
Y
S
L
I
G
H
T
L
Y
M
O
D
E
R
A
T
E
L
Y
S
T
R
O
N
G
L
Y
8. Good health is more important to
me than financial security.
1
2
3
4
5
6
9. My good health is largely a
matter of good fortune.
1
2
3
4
5
6
1
2
3
4
5
6
11. I find it boring to eat and exercise
1
properly to maintain my health.
2
3
4
5
6
12. The main thing which affects my
health is what I myself do.
1
2
3
4
5
6
13. Changes taking place in health
care are not exciting to me.
1
2
3
4
5
6
14. I find people who are involved in
health promotion interesting.
1
2
3
4
5
6
15. Setting goals for health is
unrealistic.
1
2
3
4
5
6
16. Most things that affect my health
happen to me by accident.
1
2
3
4
5
6
17. Changes taking place in health care
1
will have no effect on me.
2
3
4
5
6
18. If I get sick, it is my own behavior
that determines how soon I get well.l
2
3
4
5
6
19. I do not find it interesting to
learn about health.
1
2
3
4
5
6
20. I will stay healthy if it's meant
to be.
1
2
3
4
5
6
21. I am not interested in exploring
new ways to improve my health.
1
2
3
4
5
6
10. No matter what I do, I'm
likely to get sick.
3
22. No matter what I do, 5
if‘ I am going
to get sick, I will get sick.
DISAGREE
S M S
T 0 L
R D I
0 E G
N R H
G A T
L T L
Y E Y
L
Y
Number
AGREE
S M
L 0
I D
G E
H R
T A
L T
Y E
L
Y
S
T
R
0
N
G
L
Y
1
2
3
4
5
6
1
2
3
4
5
6
24. The current focus on health promotion is
a fad that will probably disappear. 1 2
3
4
5
6
25. No matter how hard I work to promote
health for society, it never seems
to improve.
1
2
3
4
5
6
26. Our society holds no worthwhile
goals or values about health.
1
2
3
4
5
6
27. If I take the right actions, I
can stay healthy.
1
2
3
4
5
6
28. I get excited about the possibility
1
of improving my health.
2
3
4
5
6
29. I am determined to be as healthy as
1
I can be.
2
3
4
5
6
30. When my health is threatened,, I
that must
view it as a challenge
c__ I"
be overcome.
1
2
3
4
5
6
31. I read everything I can about
health.
1
2
3
4
5
6
32. I can be as healthy as I want to be.l
2
3
4
5
6
33. When something goes wrong with my
health, I do every thing I can to
get at the root of the problem.
1
2
3
4
5
6
1
2
3
4
5
6
23. I feel no need to try to maintain
my health because it makes no
difference anyway.
34. i have little influence over my
health.
Copyright, 1990, Susan E. Pollock, PhD
Appendix 5
57
LIFESTYLE PROFILE
Th'S ^estionnaire con’ains statements regarding your present way of life or personal
habits. Please respond to each item c?
as sccjr'td
accurately ««
as possible, and try not to skip any item. Indicate the
regularity with which you engage in each behavior^crrcnng:
N for never, S for sometimes, O for often, or R for routinely.
cr
U1
>
LU
z
Vi
LU
>
Z
LU
zo
Vi
£
to
LU
Z
H
□
O
Ct
1.
Eat breakfast.
N
S
O
R
2.
Report any unusual signs or symptoms to a physician.
N
S
O
R
3.
Like myself.
N
S
O
R
4.
Perform stretching exercises at least 3 times per week.
N
S
O
R
5.
Choose foods without preservatives or other additives.
N
S
O
R
6.
Take some time for relaxation each day.
N
S
O
R
7.
Have my cholesterol level checked and know the result.
N
S
O
R
8.
Am enthusiastic and optimistic about life.
N
S
O
R
9.
Feel I am growing and changing personally in positive directions.
N
S
O
R
10. Discuss personal problems and concerns with persons close to me.
N
S
O
R
11. Am aware of the sources of stress in my life.
N
S
O
R
N
S
O
R
13. Exercise vigorously for 20-30 minutes at least 3 times per week.
N
S
O
R
14. Eat 3 regular meals a day.
N
S
O
R
Read articles or books about promoting health.
N
S
O
R
16. Am aware of my personal strengths and weaknesses.
N
S
O
R
17. Work toward long-term goals in my life.
N
S
O
R
18. Praise other people easily for their accomplishments.
N
S
O
R
12.
15.
Feel happy and content.
19.
Read labels to identify the nutrients in packaged food.
N
S
O
R
20.
Question my physician or seek a second opinion when I do not agree with
recommendations.
N
S
O
R
21.
Look forward to the future.
N
S
O
R
22.
Participate in supervised exercise programs or activities.
N
S
O
R
23.
Am aware of what is important to me in life.
N
S
O
R
co
III
Z
c
UJ
>
UJ
Z
UJ
UJ
s
z
Z
o
co
O
t
O
N
S
o
R
N
S
O
R
N
S
O
R
N
S
O
R
D
AC
24.
Enjoy touching and being touched by people close to me.
25.
Maintain meaningful and fulfilling interpersonal relationships.
26.
Include roughage/fiber (whole grains, raw fruits, raw vegetables) in my diet.
27.
Practice relaxation or meditation for 15-20 minutes daily.
28.
Discuss my health care concerns with qualified professionals.
N
S
O
R
29.
Respect my own accomplishments.
N
S
O
R
30.
Check my pulse rate when exercising.
N
S
O
R
N
S
O
R
31. Spend time with close friends.
32.
Have my blood pressure checked and know what it is.
N
S
O
R
33.
Attend educational programs on improving the environment in which we live.
N
S
O
R
34.
Find each day interesting and challenging.
N
S
O
R
35.
Plan or select meals to include the “basic four” food groups each day.
N
S
O
R
36.
Consciously relax muscles before sleep.
N
S
O
R
N
S
O
R
Engage in recreational physical activities (such as walking, swimming, soccer,
bicycling).
N
S
O
R
39.
Find it easy to express concern, love and warmth to others.
N
S
O
R
40.
Concentrate on pleasant thoughts at bedtime.
N
S
O
R
41.
Find constructive ways to express my feelings.
N
S
O
R
N
S
O
R
N
S
O
R
N
S
O
R
37. Find my living environment pleasant and satisfying.
38.
42. Seek information from health professionals about how to take good care of
myself.
43.
Observe my body at least monthly for physical changes/danger signs.
44. Am realistic about the goals that I set.
45.
Use specific methods to control my stress.
N
S
O
R
46.
Attend educational programs on personal health care.
N
S
O
R
47.
Touch and am touched by people I care about.
N
S
O
R
48.
Believe that my life has purpose.
N
S
o
R
use thlsstTaleniay be ob^ne^from- Heilt^
Illinois 60115.
Department of Nursing
Graduate Program
The City University jof New York
250 Bed Ford-Park Boulevard West
Bronx, NY 10468-1589
Appendix 6
H
Lehman
(718) 960-8374
FAX (718) 960-8488
College
Dear Colleague:
Spring, 1994
Thank you for your interest in the Health Related Hardiness Scale
(HRHS).
7 am happy to make this instrument available to you for
research
as a wa
way
of collecting
collectino data
Ha-j-a from
fr-n-m various populations.
,
y °f
The requirements for using this instrument are listed below.
After I receive this form and a copy of your abstract, I will
coPy of the instrument.
My policy , is to grant permission to use the HRHS for research
purposes if I:
1. receive an abstract of the proposed research;
2 .
am assured of receiving the results of the study;
3. receive a copy of the reliability and validity estimates
obtained;
4.
am assured that no further psychometric analyses will be
done; and
5.
am credited with authorship in any use, associated
report, or publication involving the instrument.
I agree to the above requirements and have enclosed an abstract
of my proposed research.
Date:
Signed:
Name:.
Address:
73-—2)
City & State:
Telephone: (work/^^j4)
AO.—
~
—
_________
. (home)(
Sincerely,
,
Susan E. Pollock, PhD, RN, FAAN
Professor and Director of the
Graduate Program
Lehman College, Division of Nursing
250 Bedford Park Boulevard West
Bronx, NY 10468-1589
Appendix 7
Lehman
College
Department of Nursing
Graduate Program
The City University of New York
250 Bedford Park Boulevard West
Bronx, NY 10468-1589
'
(718) 960-8374
FAX (718) 960-8488
Spring, 1994
Dear Colleague:
Enclosed is the Health-Related Hardiness Scale (HRHS) and scoring
instructions you requested. I have also included a summary of the
latest psychometric information.
For more information on the
development and psychometric evaluation of the HRHS, please refer
to Pollock & Duffy (1990), the health-related hardiness scale:
Development and psychometric analysis, Nursing Research, 39(4).
218-222.
There is no cost involved with using the HRHS. I only ask that you
supply me with a copy of your research results (as described in the
contract letter) and that I am credited with development of the
scale. Please be advised that while this is the current version of
the HRHS, there will likely be future revisions based upon results
of current research.
Please keep me informed of your progress and any change in address.
Good luck with your research and I look forward to hearing from
you.
Sincerely,
Susan E. Pollock, PhD, RN, FAAN
Professor and Director of the
Graduate Program
Lehman College, Division of Nursing
250 Bedford Park Boulevard West
Bronx, N.Y. 10468-1589
718-960-8378
Appendix 8
61
HEALTH-RELATED HARDINESS SCALE
The Health-Related Hardiness Scale (HRHS) was developed to
measure the hardiness construct in health-related research. The
current version contains 34 items on a six point Likert-type scale.
Depending on the purpose of the investigation, the scale can be
used to measure the unitary construct of health-related hardiness
and/or the two dimensions of commitment/challenge (20 items) or
control (14 items).
Results of a principal components analysis with chronically
ill subjects (N=389) supported these two dimensions. The first
factor (20 items) encompassed the dimensions of commitment and
challenge, while the second factor (14 items) accounted for the
control dimension. The two factors explained 32.1% of the
initially extracted common variance.
Internal consistency
reliabilities (Cronbach’s alpha) for the 34-item HRHS are .91, and
.87 for both the 20-item commitment/challenge subscale and the 14item control scale. Test-retest reliability (N= 150) for six months
was .76 for the total HRHS, and .74 and .78 for the
commitment/challenge and control scales respectively.
Commitment and challenge items loading together suggest that
they are more closely related and not discrete dimensions in a
health specific context.
In other words, commitment to adjusting
to a health stressor such as chronic illness is also the challenge.
Persons are challenged (rather than threatened) when confronted
with a health stressor, which in turn, becomes a personal
;;
y..
Hardy individuals dealing with a chronic health
commitment
problem may not separate health into discrete categories but
appraise the condition as a challenge because they are committed to
maintaining their health.
Scores for the total HRHS range: from 34 to 204 with high
Scoring
Negatively worded items
scores indicating presence of hardiness.
indicated
by
an
asterisk;
scoring
for
these items need to be
are i....
reversed.
CONTROL
2 , 4*, 6, 9*, 10*,
12 , 15*, 16*, 18,
20*, 22*, 27,
32 , 34*
Susan E. Pollock, PhD, 1990.
COMMITMENT
CHALLENGE
5*, 7,
23*, 25*, 26*,
29, 31
1/ 3*, 8,
11*, 13*, 14,
17*, 19*, 21*, 24*
28, 30, 33
HEALTH-PROMOTI^^^IMLe PROFILE
62
Dear Colleague:
We are pleased to reply to
Promoting Lifestyle Profile your request for information about our Healthn order to, respond promptly to the large volume
of correspondence we receive, we have found it
it necessary to prepare this standard
letter containing information that is commonly
sought. We hope that you will
feel free to write or call as
necessary
to
obtain
any further information that
you may need.
The Health-Promoting Lifestyle Profile measures
health-promoting behavior,
conceptualized as a multidimensional pattern of self-initiated actions and
perceptions that serve to
t maintain
. . . or enhance the level of wellness,
selfactualization and fulfillment of the individual,
-------- - This 48-item summated behavior
rating scale employs a 4-point response format to measure the frequency of self
reported health-promoting behaviors in the domains of self-actualizacion, health
responsibility, exercise, nutrition, interpersonal support and stress management.
It was developed for use in research within the framework of the Health Promotion
Model (Pender, 1987), but has subsequently been employed for a variety of other
purposes as well. The development and psychometric evaluation of the English
language versions were described by Walker, Sechrist and Pender (1987) and scores
among the initial study sample were reported by Walker, Volkan, Sechrist and
Pender (1988) .
The translation and psychometric evaluation of the Spanish
language version as well as scores among a Hispanic sample were reported by
Walker, Kerr, Pender and Sechrist (1990).
Copyright of both English and Spanish language versions of the instrument is held
by Susan Noble Walker, EdD, RN, FAAN, Karen R. Sechr is t, PhD, RN, FAAN and Nola
J. Pender, PhD, RN, FAAN. You have our permission to copy and use the enclosed
Heal th-Promoting Lifestyle Profile for non-commercial data collection purposes
such as research or evaluation projects provided that content is not altered in
any way and the copyright/permission statement at the end is retained, The
instrument also may 1be reproduced in the appendix of a thesis, dissertation or
research grant proposal without further permission, Reproduction for any other
purpose, including the publication of study results, is prohibited without
specific permission from the authors.
There is no charge for such authorized use, but we would appreciate receiving
notification of your intent to use the instrument and a report of your completed
It is particularly useful
to know of any
study/proj ect for our files.
r
use of the instrument so that we can maintain an accurate
publications reporting
complete listing, To facilitate record keeping, all information should be sent
to:
Susan Noble Walker, Ed.D., R.N., F.A.A.N.
Professor
University of Nebraska Medical Center
College of Nursing
600 South 42nd Street
Omaha, Nebraska 68198-5330
(402) 559-6561
interest in using the ffesTth-Prowting Lifestyle Profile
We thank you for your
with your efforts.
and wish you imuch''success
--- Sincerely,
Susan Noble Walker
Karen R. Sechrist
Nola J. Pender
Appendix 10
63
HEALTH-PROMOTING LIFESTYLE PROFILE
Scoring Instructions:
Items are scores as Never (R)
Sometimes (S)
Often (0)
Routinely (R)
-
1
2
3
4
A score for overall health-promoting lifestyle is obtained by calculating a mean
of the individual's responses to all 48 items; six subscale scores are obtained
similarly by summing the responses to subscale items and dividing by the number
of items on the subscale. The use of means rather than sums of scale items is
recommended to retain the 1 to 4 metric of item responses and to allow meaningful
comparisons of scores across subscales. The items included on each scale are as
follows:
Health-Promoting Lifestyle
1 to 48
Self-actualization
3, 8, 9, 12, 16, 17, 21, 23, 29, 34, 37, 44, 48
Health Responsibility
2, 7, 15, 20, 28, 32, 33, 42, 43, 46
Exercise
4, 13, 22, 30, 38
Nutrition
1, 5, 14, 19, 26, 35
Interpersonal Support
10, 18, 24, 25, 31, 39, 47
Stress Management
6, 11, 27, 36, 40, 41, 45
References
Pender, N. J. (1987). Health promotion in nursing practice (2nd ed. ) .
CT: Appleton & Lange.
Norwalk,
Walker, S. N. , Sechrist, K. R. , & Pender, N. J. (1987). The Health-Promoting
Lifestyle Profile: Development and psychometric characteristics. Nursing
Research, 36.(2), 76-81.
" “R. , &
' ~Pender, N. J. (1988). HealthWalker, S. N. , Volkan, K. , Sechrist, K.
Comparisons
with young and middle-aged
promoting lifestyles of older adults:: C
.*
Advances
Nursing. Science
, 11
(1), 76-90.
adults , correlates
andinpatterns
A-----------------
Walker S N. , Kerr, M. J.» Pender, N. J., & Sechrist, K. R. (1990). A Spanish
language version’of the Health-Promoting Lifestyle Profile. Nursing Research,
39(5), 268-273.
9/90: snw
Encl.:
1. .promoting Lifestyle Profile
Healthof Lifestyle Profile
List