|Year : 2015 | Volume
| Issue : 2 | Page : 185-190
Effectiveness of participatory adolescent strategic health action (PASHA) for lifestyle modification among adolescents
Asha P Shetty1, Ratna Prakash2, MN Nagendra Prakash3
1 Department of Paediatric Nursing, Yenepoya Nursing College, Yenepoya University, Mangalore, Karnataka, India
2 Department of Medical and Surgical Nursing, Pal Nursing College, Dehradun, Uttarakahand, India
3 Department of Medical Sociology, Himalayan University, Dehradun, Uttarakahand, India
|Date of Web Publication||16-Dec-2015|
Asha P Shetty
Department of Paediatric Nursing, Yenepoya Nursing College, Yenepoya University, Deralakatte, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Lifestyle modification is one of the methods to promote healthy lifestyle among adolescents. In this study, the researcher planned to develop, implement and evaluate a need based Participatory Adolescent Strategic Health Action (PASHA) for lifestyle modification among selected adolescents. Materials and Methods: An evaluative approach with Quasi experimental one group pretest post test design (time series) was adopted. Sample constituted 103 adolescents, aged 12-17 years studying in high schools and pre university colleges of Udupi district selected based on convenient sampling. Data was gathered using reliable and valid tools. Results: The mean combined preventive health lifestyle score among all adolescents increased from 75.65-81.56. Similarly the number of adolescents with healthy lifestyle score also increased from 28.2-53.4% after practicing for 180 days. Analysis of all the components of lifestyle showed that the adolescents had adopted healthy lifestyle practices in all the components of lifestyle. The number of adolescents with combined health status score also showed an increase from 31.1-54.4% after implementing PASHA practice. Analysis of reported outcome among subjects indicated that PASHA was motivating to improve their lifestyle practices. Conclusion: PASHA was found to be effective in lifestyle modification of adolescents. It is reiterated that when lifestyle modification is to be done, a strategy to improve self directedness and self efficacy should be adopted.
Keywords: Adolescents, lifestyle modification, preventive health, self efficacy, self directedness
|How to cite this article:|
Shetty AP, Prakash R, Nagendra Prakash M N. Effectiveness of participatory adolescent strategic health action (PASHA) for lifestyle modification among adolescents. Arch Med Health Sci 2015;3:185-90
|How to cite this URL:|
Shetty AP, Prakash R, Nagendra Prakash M N. Effectiveness of participatory adolescent strategic health action (PASHA) for lifestyle modification among adolescents. Arch Med Health Sci [serial online] 2015 [cited 2019 May 27];3:185-90. Available from: http://www.amhsjournal.org/text.asp?2015/3/2/185/171901
| Introduction|| |
It is evident that lifestyle diseases are not only affecting adults or elderly but also the younger generation. The illnesses what used to be the senior citizens health concerns have not only become common, but are also affecting younger population.
The world is home to 1.2 billion individuals aged 10-19 years. India has the largest national population of adolescent's that is 243 million, accounts for almost 20% of the country's population. Thus having more than 243 million adolescents is the key challenge that India faces in ensuring the nutritional, health and educational needs of this population.  With advanced technology adolescent health has become serious concern for the society. Therefore, focusing attention both on adolescence and on risk factors with their roots in adolescence makes sense. Adolescent health efforts should emphasize prevention because so much of the disease burden is preventable and because prevention is a particularly cost-effective strategy in relation to adolescents, given the long duration over which benefits will be reaped and adolescents' greater openness to change than adults. 
Current educational system makes adolescents prone for lot of health risk and change of routine lifestyle. Parental pressure on study, society's expectation etc. place them at high risk for sleeplessness, unhealthy food intake, junk food at inappropriate time, tension/stress, no time for physical activity. Studies related to lifestyle modification among adolescents are deficient in India. Keeping in view of the magnitude of lifestyle affecting health problems of adolescents in India, and the effect it will have on future adults, this study is aimed at developing and evaluating the effectiveness of a need based Participatory Adolescent Strategic Health Action (PASHA) for the lifestyle modification of adolescents.
| Materials and Methods|| |
Study had an evaluative approach and the research design selected was quasi-experimental one group pretest post test design (time series). According to Polit and Beck.  (2008) in a time series design, information is collected over an extended period, and an intervention is introduced during that period (p.267).
The study was conducted in Udupi District in the state of Karnataka. Udupi district has three taluks namely Udupi, Kundapur and Karkala, covering 146 Grampanchayats in 255 villages and four towns. The population is homogenous in terms of occupation, socio economic status, literacy, food habits and health related beliefs and practices.  Convenient sampling technique was adopted and adolescents with any previously diagnosed acute or chronic health problem and were on treatment and those with physical handicaps, mental retardation, cerebral palsy were excluded from the sample.
Questionnaires used for data gathering were developed by the investigator. A questionnaire on Preventive health Lifestyle practices (r = 0.97); Preventive health action Self efficacy rating scale (r = 0.94); and self directed preventive health action rating scale were used. Data were collected using above mentioned proforma were scored and thus the scores obtained were categorized into 'healthy score', 'moderately healthy score' and 'poor score'.
The concepts of David A Kolb's  learning style and Bandura  formed the basis for lifestyle modification in this study.
Development and Implementation of need based PASHA
Based on the lifestyle activities of the subjects and their health status indicators, participatory adolescent strategic health action (PASHA) for lifestyle modification to promote preventive health activities was designed.
The participants work was involved to identify their own need with a sense of freedom of choice and decision making and therefore it was participant' centered approach rather than researcher centered approach.
Participants were given a pre-test with tool on preventive health lifestyle assessment questionnaire. After pre-test, they were involved in a goal setting game in the form of snake and ladder, an indoor board game. This game was designed, aiming to help them to be familiar with healthy lifestyles and goal setting for lifestyle modification. The participants were divided in groups of four or five members. As they participated together it became a collective effort to implement strategic preventive health action. Each group was given a board game, dice and required counters. Game rules were explained to the subjects. The winner of each group was rewarded while reaching "finish" square of the board game.
By making them participate in the game health awareness was created to modify the lifestyle for preventive health by the investigator. Based on the health awareness, subjects were able to set the goals.
Followed by this, participants were involved in goal setting discussion. In initiating goal setting discussion, a question used by Stanford Medical School's Dr. Kate Lorig, an international leader in helping patients cope with chronic disease was made use of.  Adolescents were asked "Is there anything you would like to do this week to improve your health?" This question made adolescents to choose the activity they were motivated to change and formed basis for setting lifestyle change goal. Goal setting with the help of the investigator as facilitator made the adolescents to develop specific action plans for which they were self responsible. They were also advised to take help if they needed any other facilitator other than investigator. But majority of the study samples considered the investigator as their facilitator.
Adolescents were also given 0-10 point scale in PASHA, to be specific about how confident they are that they can carry out their planned actions to meet the goal setting. For example, in oral hygiene, brushing twice a day for at least five times in a week. Adolescents were encouraged to make their desired action plans, which were more specific and possible to evaluate by them, no matter how minor actions planned were. The adolescents were monitored for their preventive health action based lifestyle regularly. The impact of PASHA was analyzed in duration of 30 days, 90 days and at the end of 180 days.
| Results|| |
The sample consisted of 103 adolescents of which 54.4% were females 45.6% were males. Among them majority of the subjects (88.3%) were non vegetarians. Regarding the other demographic characteristics 72.80% belonged to nuclear family and the others were from the extended and joint family background. Majority (51.5%) were studying in XI standard whereas in VIII and IX standard the remaining 25 each (24.3%) were studying. Majority of them 60 (58.3%) belonged to lower socio economic status.
Effectiveness of participatory adolescent strategic health action (PASHA) on modification of lifestyle
Data was analyzed to find out in which area there was significant improvement. Improvement in mean dietary score was gradual. The mean dietary score showed improvement on the 30 th day. There was a minor reduction in mean score on 90 th day but the score considerably improved and registered an increase on 180 th day (13.21) compared with score the on 30 th day (12.01). The mean score of physical activity showed a consistent increase in the measurement during the 3 stages; on 30 th , 90 th and 180 th days (11.14; 11.97; 12.78; 13.09 respectively).
The mean score of personal hygiene consistently increased as the days of PASHA practice progressed from 30-90 and 90-180 days. Mean sleeping habit score measure indicated an increase on the 30 th and 90th days but reduced after that. Mean score of T V viewing showed an increase on the 30 th and 90 th day. Whereas the there was a reduction on the 90 th day. The increase in the TV viewing score indicates reduction in the duration of TV viewing. Mean psycho social activity score after 180 days was higher than the measured score on 90 th day.
The components of life style practice scores were computed to arrive at the combined preventive health lifestyle practice score. The combined lifestyle practice score before and after implementation of PASHA was analyzed. Data is presented in line graph [Figure 1].
|Figure 1: Line graph showing estimated marginal means of combined mean preventive health lifestyle score before and after implementation of PASHA|
Click here to view
The data presented in [Figure 1] shows that the mean combined lifestyle score among all adolescents before implementation of PASHA was 75.65 which registered an increase to 81.56 after 180 days of practice of PASHA. Similarly, the number of adolescents with healthy lifestyle also increased from 28.2-53.4% after practicing for 180 days. Data is presented in [Figure 2].
|Figure 2: Cylindrical diagram showing distribution of adolescents based on combined preventive health lifestyle score category|
Click here to view
As indicated in [Figure 2], there was gradual increase in the number of adolescents in combined healthy lifestyle score. The post PASHA score showed two striking improvements. Not only the score of each participant during the PASHA practice increased, but also the number of adolescents in the higher score category of preventive health lifestyle increased. Thus there was an improvement in the preventive lifestyle during all the 3 stages through the 30 th day and 90 th day to 180 th day.
The distribution of respondent score in 6 components of the Preventive Health Life style practice before and after PASHA Practice indicated that there is increase in the score of all the six components of life style after 30 days of PASHA compared to the score before the PASHA Practice. As described before, three important observations emerge from the data.
The data presented in [Table 1] shows that there was a significant difference between combined preventive health lifestyle score before adoption of PASHA and after 180 days of implementation of PASHA (6.194; P = 0.001). The result indicates that variation in preventive health lifestyle score had slow improvement during first 30 days and 90 days of PASHA practice. (0.58; P > 0.05) however, there was a significant difference after 180 days of PASHA practice. The difference in preventive health lifestyle scores after implementation of PASHA was significant from 90 days and 180 days (2.718; P = 0.002).
- The increase in the life style score after 30 days of PASHA practice in all the 6 components of life style is sustained during the 90 th and 180 days. This shows that the participants of PASHA continued to adopt the modified lifestyle at the 180 th day.
- The number of participants having poor lifestyle score moved to the moderate score as the days progressed in modified lifestyle practice. Similarly the number of participants with moderate score reduced and the number of Participants in healthy score category increased which means, there was a consistent movement among the participants to higher categories of lifestyle score as the number of days of PASHA practice progressed.
- The regular adoption of the modified lifestyle leading to the sustained healthy life style among the participants of PASHA.
- Further analysis was done to find out whether there was any significant improvement in preventive health lifestyle scores before and after implementation of PASHA. Post Hoc Bonferroni test was computed to find between which assessments the group gained significantly. The data is presented in [Table 1].
|Table 1: Post Hoc Bonferroni test showing the pair wise comparisons of the preventive health lifestyle scores of adolescents' before and after the implementation of PASHA n = 103|
Click here to view
The data presented in [Table 2] shows that F value (F = 9415.079, P < 0.001) is significant at P = 0.001 level. It can be inferred that there was a significant difference in preventive health lifestyle scores of adolescents before and after implementation of PASHA. Thus it is concluded that the difference in subsequent assessment of preventive health lifestyle score was related to modification and practice of preventive health lifestyle and not by chance. Hence participatory adolescent strategic health action was effective in improving the preventive health lifestyle of adolescents.
|Table 2: Repeated measures of ANOVA showing the tests of between subject effects of preventive health lifestyle score among adolescents before and after implementation of PASHA n = 103|
Click here to view
Improvement in health status score before and after implementation of PASHA among adolescents
The percentage of underweight adolescents before practice of PASHA was 57.3% whereas, after practice of PASHA the number came down to 55.30%. Similarly there was increase in percentage of normal weight of adolescents from 41.70-43.70%. However, there was no change in obese group. Before implementation of PASHA there were 98.10% subjects with anemia. After practice of PASHA the percentage came down to 70.90%. Similarly percentage of adolescents with normal hemoglobin increased from 1.90-29.10%. There was no major difference in blood pressure levels among selected adolescents before and after implementation of PASHA. The adolescents who had healthy physical status before PAHSA were only 1.0% increased to 15.50% after the practice.
The percentage of adolescents in good mental health status score was 53.4 before PASHA. After adopting PASHA practice, this percentage increased to 68.00; similarly, the adolescents with good social health status score increased from 72.8-93.2%; percentage of adolescents good sexual health status score increased from 64.1-76.7% and the number with good spiritual health status score increased from 88.3-95.1% after implementation of PASHA.
Based on combined health status score there was a considerable increase in number of adolescents. The number of adolescents before implementation of PASHA was 32 (31.1%) which increased to 56 (54.4%) after implementation of PASHA.
In order to find the significant difference in the health status score before and after implementation of PASHA 't' test was computed. The data is presented in [Table 3].
|Table 3: Mean, Mean Difference, Standard Error of Difference 't' value of combined health status score before and after the implementation of PASHA among adolescents n = 103|
Click here to view
The data presented in [Table 3] shows that the mean combined health status score after implementation of PASHA was 12.48 which was 10.55 before implementation of PASHA. The computed 't' value (t (204) = -5.112) is significant at 0.001 indicating that there was a significant difference in combined health status score of adolescents before and after implementation of the PASHA. Thus it can be inferred that PASHA was effective in improving combined health status score of adolescents.
Improvement in health awareness among adolescents
Adolescents 80 (77.70%) had good health awareness score after implementation of PASHA compared to 55 (53.4%) before PASHA practice. In order to find the significant gain in health awareness score 't' value was computed. It indicated that the mean health awareness score after implementation of PASHA was 104.16, higher than pre PASHA that is, 98.05. The computed 't' value (t (204) = 119.86) is significant at 0.001 indicating that there was a significant difference in health awareness before and after implementation of PASHA. Thus it is concluded that adolescents improved their health awareness after implementation of PASHA. Hence PASHA was effective in improving health awareness score among adolescents. Thus regular adoption of PASHA was possible because of improvement in preventive health awareness.
Reported outcome by adolescents
Adolescents' reported outcome through the success stories were analyzed. Data presented indicated that 100% of the adolescents expressed PASHA as motivating to improve their lifestyle practices. It was also mentioned that it not only influenced them, but 44.66% of them mentioned that it helped in improving health practices of their family members also. About 21.35% of the adolescents were of the opinion that it helped them to improve the health practices of children in their neighborhood. Thus, overall PASHA was considered to be effective among adolescents in modifying the lifestyles.
Preventive Health Action Self Efficacy (PHASE) scores and Self Directed Preventive Health Action (SDPHA) scores of adolescents
Data indicated that the mean PHASE scores on 90 days and 180 days after implementation of PASHA were higher than at 30 days after PASHA. However the difference in mean PHASE scores during 90 days and 180 days was negligible. Similarly, with regard to SDPHA scores among adolescents, on 180 day was higher than that of 30 th day, though there was no significant increase in SDPHA scores from 90 th -180 th day. This tendency indicates that when the lifestyle modification is sustained (for a longer duration) for 90 days and more, such a lifestyle is going to be a regular part of life activity.
Further analysis was done to find out between which measurement there was significant improvement in subsequent scores. The data showed that there was a significant difference between PHASE scores on 30 th (1.757; P = 0.02) and 180 th day (2.097; P = 0.007). However difference between 90 th day and 180 th day was not significant (0.034; P = 1.00). It shows that significant difference existed between 30 th and 180 th day. It can be inferred that the PHASE scores of adolescents increased from 30 th and 180 th day indicating that the modified life style practice is sustained.
The pattern of improvement in score in the duration of after 30 days, 90 days and again after 180 days also showed that the variation in score was higher between 30 and 90 days compared to 90 days and 180 days. However there was a significant improvement in score on 180 th day.
The SDPHA scores among adolescents indicated that there was considerable improvement between 30 th day and on 180 day. The number of adolescents with high SDPHA scores on the 30 th day was 22 (21.4%). This number increased to 51 (49.5%) on 180 th day. Similarly adolescents with moderate self directed score on 30 th day was, 78.6% which reduced to 50.5% on 180 th day.
| Discussion|| |
The PASHA was found to be effective in modification of lifestyle practices and health status of selected adolescents of this study. To date, the evidence based interventions for adolescent lifestyle modification are deficient in India. The present study is part of effort in this direction and is relevant in the Indian context. However, lifestyle modification is the only alternative for preventive health and for promoting preventive health lifestyle. Developing preventive health culture will reduce unnecessary expenditure on health, reduce wastage of human resources and also it will reduce governments' burden on health expenditure. Thus it is the surest way for better quality of life. In the direction of innovative approaches to promote lifestyle modification, this was a planned action by the investigator to begin a pathway in the field of adolescent preventive health. Studies related to lifestyle practice modification for adolescents in particular are sparse in the international literature.
In a study on adolescents' behaviour modification it was reported that behaviour modification program was generally beneficial especially for females and non conduct disordered patients.  Wilson, Prapavesis (2009),  Sarvistani et al., (2009),  also reported that behavior modification can be used as an intervention among adolescents to promote healthy behavior.
Hein de Vries et al., (2006)  conducted a study on Belgian secondary school students in promoting specific action plans to promote sunscreen use and the need to increase feelings of self efficacy. In their study they emphasized to promote the support by friends and parents. Becher (2009)  also reported similar findings in study conducted at Ohio State University, that lifestyle modification through nutrition education and physical education programme (given for 6 weeks) does increase an adolescents' level of self efficacy toward healthy lifestyle behavior. The present study results agreed with the findings of Becher.
In the present study adolescents were followed up for a period of 6 months because if a behavior modification has to happen, the duration of practice of new behavior has to be converted into a habit. Through this adolescents mind will be favorable to that practice. Thus behavior modified to be a psychological habit for adolescents rather than physiological dependence. Therefore adolescents were assessed three times as a follow-up because there is a tendency for adolescents to revert back to old behavior. This calls for a meticulous action to prevent adolescent reverting back to old behavior. This shows life style modification is a highly challenging area.
| Conclusion|| |
The evaluation of effectiveness of PASHA on lifestyle score showed that the group participation approach yielded expected result in lifestyle modification. Therefore it can be concluded that preventive health action through lifestyle modification is possible when the individual electively undertakes new practices.
Based on the findings it is concluded that the benefit of improvement in lifestyle modification can be derived only if the subjects continue to sustain the practice for a longer duration of time. When subjects do not find the expected immediate improvement they may give up the practice. Hence it is necessary to insist on continuation of modified lifestyle behavior to experience the benefit. Lastly, it is concluded that any behavior modification program to be successful need to aim at improving self efficacy of the adolescents.
| References|| |
The state of the world′s children 2011. David Anthony, Editor; Chris Brazier, Principal writer. Adolescence: An Age of Opportunity. United Nations Children′s Fund (UNICEF); 2011. p. 23. These essays represent a selection of the full series of Perspectives available at www.unicef.org/sowc2011.
Lule E, Rosen JE, Singh S, Knowles JC, Behrman JR. Adolescent health programs. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, editors. Disease control priorities in developing countries. 2 nd
ed. Ch. 59. Washington: World Bank; 2006. p. 1114.
Polit DF, Beck CT. Nursing Research. Generating and Assessing Evidence for Nursing Practice. 8 th
ed. 2008. Philadelphia: Lippincot Wiliams & Wilkins. p 203.
Kolb DA. Experiential learning: Experience as the source of learning and development. Englewood Cliffs: Prentice-Hall Inc; 1984.
Bandura A. Self-efficacy: The exercise of control. New York: W. H Freeman Co; 1997.
Bodenheimer T, Davis C, Holman H. Helping patients adopt healthier behaviours. Clin Diabetes 2007;25:66-9.
al Ansari A, Gouthro S, Ahmad K, Steele C. Hospital-based behavior modification program for adolescents: Evaluation and predictors of outcome. Adolescence 1996;31:469-76.
Wilson AJ, Prapavessis H, Jung ME, Cramp AG, Vascotto J, Lenhardt L, et al
. Lifestyle modification and metformin as long-term treatment options for obese adolescents: Study protocol. BMC Public Health 2009;9:434.
Sabet Sarvestani R, Jamalfard MH, Kargar M, Kaveh MH, Tabatabaee HR. Effect of dietary behavior modification on anthropometric indices and eating behavior in obese adolescent girls. J Adv Nurs 2009;65:1670-5.
de Vries H, Mesters I, Riet JV, Willems K, Reubsaet A. Motives of Belgian adolescents for using sunscreen: The role of action plans. Cancer Epidemiol Biomarkers Prev 2006;15:1360-6.
Becher ST, Adolescents′ Self-Efficacy Toward Healthy Lifestyle Behaviors After Attending A School-Based Intervention Course Focused On Physical Activity And Healthy Eating. Dissertation submitted for the partial fulfillment of Degree Master of Science in the Graduate School of The Ohio State University. The Ohio State University; 2009.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]