Salutogenesis as a framework for improving health resources of adolescent boys

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1 Scandinavian Journal of Public Health, 2009; 37: ORIGINAL ARTICLE Salutogenesis as a framework for imroving health resources of adolescent boys MICHAL BRONIKOWSKI & MALGORZATA BRONIKOWSKA Deartment of Methodology of Teaching Physical Education, University of Physical Education, Poznan, Poland Abstract Background and aims: A salutogenetic aroach may lay an imortant role in develoing adolescent understanding of health. On the basis of sense of coherence the study examined the relationshis between self-assessed hysical fitness and actual erformed cardioresiratory fitness. Methods: Data were collected from 199 boys aged 13, randomly assigned to either an exerimental or a control grou. Frequency of out-of-school moderate-to-vigorous hysical activity (MVPA) was self-rated by uils while cardioresiratory fitness was measured using 20-meter Shuttle Run test (20SRT) from the battery of Eurofit. Sense of coherence was measured with a SOC-13 questionnaire. A three semesters (15 months) intervention into a hysical education rogramme, based on the Hellison s Teaching Resonsibility through Physical Activity (TRPA) model, was introduced in the exerimental grou. Results: In the exerimental grou ost-test examination revealed that cardioresiratory fitness had imroved significantly as the number of minutes comleted in 20SRT increased. A similar situation was observed in the case of sense of coherence. No such findings were observed in the control grou, and in a osttest comarison both the average results in 20SRT and in sense of coherence were statistically (50.05) lower than in the exerimental grou. Conclusions: A health-related hysical education rogramme based on develoing individual resonsibility through self-lanned out-of-school activity can rovide uils with substantially more hysical activity during the day (and thus imrove cardioresiratory fitness) when it is based on self-determined and individualized objectives. Key Words: Adolescent boys, cardioresiratory fitness, salutogenesis, self-assessment Introduction The concet of salutogenesis is gradually relacing the biomedical athogenic aradigm in many areas of health such as nursing, education, child care or reventive medicine. Antonovsky s sense of coherence (SOC) as a main theoretical construct of salutogenesis [1] reresents a framework that relates to the significance of resistance resources for revention of health, focusing on factors determining good health and well-being. According to Antonovsky [1] it is based on an adequate selfevaluation, internal motivation for self-develoment through challenging leisure-time interests and social suort when needed, which should be considered as imortant in relation to meeting the demands of everyday life as external resources such as oortunities to study, access to friends or an environment roviding oortunities for leisuretime activities. Theoretical assumtions are that sufficient coordinated resources during childhood and adolescence allow growth of a strong SOC [2 4]. Divided into three comonents: (a) comrehensibility, (b) manageability and (c) meaningfulness, SOC is a global orientation that exresses the extent to which one has a ervasive and enduring though dynamic feeling of confidence that the stimuli deriving from one s internal and external environments in the course of living are structured, redictable and exlicable; the resources are available to meet the demands osed by the stimuli and these demands are challenges worthy of investment and engagement [1]. Taylor [5] in her meta-analysis of Corresondence: Michal Bronikowski, Zaklad Metodyki Wychowania Fizycznego, University School of Physical Education (AWF), Ul.Krolowej Jadwigi 27/38, Poznan, Poland. Tel: þ Fax: þ bronikowski.michal@w.l (Acceted 12 March 2009) ß 2009 the Nordic Societies of Public Health DOI: /

2 526 M. Bronikowski & M. Bronikowska research studies on the effectiveness of such an aroach oints out that salutogenesis aims to strengthen rotective factors and therefore may be useful in reventive and develoing interventions. Eriksson and Lindström [4] confirm that SOC strengthens resilience and develos ositive subjective health and as such is worthy of being imlemented much more than it has been to date. During the change from childhood to adolescence the influence from eers and other social factors (e.g. the media) increases and less attention is aid to arenting and schooling factors. It is during this eriod when understanding of health and also a sense of coherence are concetualized [1,5 7]. It is well documented that health in adolescence is associated with a broad comosite of backgrounds medical, sychological, social and health behaviour. In the study by Breidablik et al. [8] higher selfesteem was associated with better self-rated health in both genders and it was concluded that otential health romotion rogrammes should include both the avoidance of negative factors and the romotion of ositive factors in different sheres of life. Body concern, health-comromising behaviour and hysical activity (PA) are all indeendently significantly associated with self-rated health [9]. At the same time it is one of the rimary aims of hysical education curricula designers to find ways to develo the selfconfidence and self-esteem of children. However, to modify health behavioural atterns, cognitive rocesses should be activated first. Since the aim of the intervention was to develo a long-lasting healthrelated attitude it seemed reasonable to use a model that could hel to develo ersonal resonsibility. Hellison s [10] Teaching Resonsibility through Physical Activity model (TRPA), which aims to develo one s sense of resonsibility through the following hases: (1) irresonsibility, (2) self-control, (3) involvement, (4) self-resonsibility, (5) caring, seemed worthy of testing in a school setting. The findings of revious studies [11,12] indicate that the chances for develoment of moral reasoning and social resonsibility without secially designed curricular contents (either through school or community rogrammes) are low, limited or incidental at least. Hammond-Diedrich and Walsh [13] have tested Hellison s model in a cross-age teaching rogramme develoed to romote the leadershi of selected youth (11 15 year olds) from underserved communities. Findings suggest that when given leadershi oortunities the youth leaders exerienced ersonal growth and advanced their leadershi skills. Education in schools has to coe with the tension between individual exectations and general interest of a society. The dissonance is articularly visible in the case of health romotion (including hysical and health education). Regular moderate to vigorous hysical activity (MVPA), meaning hysical activity between 140 and 160 heart beats er minute [14] develos fitness and ositively influences other health indicators (e.g. self-esteem and self-assessment). Searching for new alternative otions for hysical education to enhance leisure-time MVPA seems essential. Therefore it was the urose of this study to examine the relationshis between self-rated subjective health and objectively measured level of healthrelated fitness as an outcome of self-determined and self-lanned out-of-school leisure-time PA. In our research Antonovsky s [1,7] salutogenetic aroach to health combined with the Hellison s model of develoing one s resonsibility served as a theoretical framework for increasing health on the basis of self-determined objectives in hysical education. Methods Particiants Particiants included 199 adolescent boys assigned to randomly selected exerimental (n ¼ 84) and control grous (n ¼ 115). All measures were adjusted for baseline biological age of mean maturation rate, assessed by a qualified hysician. The average age was years old. Instruments A re-test/ost-test, two-grou design was emloyed. It was hyothesized that if an aroriate aroach to setting individual targets and objectives in the area of health-related activities is alied to every uil based on the salutogenetic aroach and emloying Hellison s [10] Teaching Resonsibility through Physical Activity (TRPA) model, this will cause changes in attitude, which will result in an increase of frequency of undertaking leisure-time MVPA and thus imrove cardioresiratory fitness. The changes of the level of cardioresiratory fitness were measured by the number of minutes comleted in 20-meters Shuttle Run test (20SRT) from the battery of the Eurofit test [15]. Puils were tested twice in a school gymnasium during regular PE classes. Pre-testing took lace in the first month of a school year and a ost-test examination was carried out after three semesters (15 months). Other variables were obtained by administration of the Self-reorted Physical Activity questionnaire with a revious month frequency of MVPA recall [16]. In its Polish adatation a question on the

3 revious month s MVPA recall was verified in an exerimental study on year old students daily PA [17], where the questionnaire s reliability was evaluated by reeating the same rocedure of administration with the same grou of students within two weeks a test retest design. The questionnaire included also a closed question on selfassessed fitness. The question had four categories: more fit than eers, as fit as eers, less fit than eers, unfit. For the Sense of Coherence (SOC-13), the short version of a questionnaire [1] with its three comonents: manageability (SOC-Ma), meaningfulness (SOC-Me) and comrehensibility (SOC-Co) was used. The range of scores was: oints in total sense of coherence (SOC-13), 4 20 oints in sense of manageability (SOC-Ma) and meaningfulness (SOC-Me) and 5 25 oints in sense of comrehensibility (SOC-Co). Salutogenesis as a framework for imroving health resources of adolescent boys 527 Both questionnaires were distributed in re-test and ost-test examinations arallel to the 20SRT testing. The examined samle was classified by the mean values of 20SRT and by BMI. Statistical analyses Both quantitative and qualitative data were collected and analyzed to exlore relationshis between deendent and intervening variables. t-test and chi-square analyses were emloyed to determine the contribution of the secially designed intervention to assess changes of cardioresiratory fitness by means of 20SRT. The level of significance was set at For the urose of this aer the relationshi between self-assessment and self-determined and declared frequency of undertaking leisure-time MVPA and cardioresiratory fitness both before and after exerimental rogramme was analyzed. Procedure A quasi-exerimental intervention with a comarison of exerimental grous, randomly selected and allocated for the urose of the study arallel control grous was used with a duration of 15 months. During four lessons of hysical education er week the teacher used at least one activity er lesson including the following teaching strategies: teacher talk, modelling (being), reinforcement, reflection time and student sharing to imrove the levels of self-control, involvement, self-resonsibility and caring-resonsibility of uils [10]. Additionally a secially self-designed, ersonalized form Planning of Leisure-time Physical Activity was used. Every uil could lan the amount of time and choose from a rovided range of choices including five team and five individual sorts, and tye of leisure-time out-ofschool PA he was willing to commit himself to for each two-week eriod. It was checked and evaluated every two weeks by a teacher and a uil together for the concordance of the lanned and actual undertaken activities, with resonsibility relying on the uil for accuracy of the lan and its accomlishments as a art of Hellison s model of TRPA. Those uils who fulfilled their obligation for undertaking PA as lanned in their out-of-school time received an extra reward grade once a month. Because uils were asked to undertake activities of moderate-to-vigorous intensity, all uils were informed about which activities are considered MVPA and were taught how to measure their heart rate (taken manually with two fingers at the carotid artery in the neck) to assess intensity of an activity. Ethics As all articiants were under 16 years of age all arents were informed about the urose of the study and given a written notice to be signed and returned to the main researcher. They were also notified that the study was aroved by the National Bioethical Committee. Results Table I contains mean and standard deviation for hysical characteristics (height, weight), classification of BMI and mean values of 20SRT in minutes comleted. For examined boys there were no significant differences between the control grou and the exerimental grou in the re-test and the averages for height and weight and BMI of both grous were laced at aroximately the 50th ercentile and in the case of 20SRT at the 25th ercentile for this age category of the Polish male oulation [18]. In the ost-test comarison of the grous observations revealed a similar increase in height, weight and BMI and there was no significant difference between the grous. The only substantial and significant difference (50.05) was noticed in the results of 20SRT in the number of minutes comleted. Boys from the exerimental grou held an average of 7.5 minutes, which laced them near the 50th ercentile curve line, and overcame the average result of the control grou by 1.3 minutes, whose average score in 20SRT laced them under 25th ercentile for this age category [18].

4 528 M. Bronikowski & M. Bronikowska Pre-test examination of self-assessment of hysical fitness in relation to the declared frequency of undertaking leisure-time MVPA revealed that the highest ercentage of boys articiating in MVPA less than once a week were in the unfit category (50%). It was also this category which had the fewest boys undertaking leisure-time MVPA five to seven times a week. The highest ercentage of those declaring articiation in MVPA five to seven times a week was observed among boys rating themselves as more fit than eers (Figure 1). Post-test analysis in the control grou has shown changes within each category of self-assessed hysical fitness. Eighty-seven er cent of boys from the unfit category admitted articiating in outof-school MVPA less frequently than once a week, and in the less fit than eers category the ercentage was 47%. The highest ercentage, 62%, of boys who declared that they undertook MVPA five to seven times a week in their leisure-time was observed in the category more fit than eers (Figure 2). Whereas in the exerimental grou it was 50% of boys from the unfit category who declared undertaking MVPA five to seven times a week in out-of-school time and another 50% who admitted doing such activities two to four times a week. In the more fit than eers category 83% declared such activity five to seven times a week. In other categories it was more or less one third of frequency in each grou (Figure 3). Comarison of re-test scores in SOC-13 indicated no major differences between the grous. The only significant difference found was the sense of manageability (SOC-Ma) in favour of the exerimental grou. The mean values of 45.2 ts. in the control grou and 46.4 ts. in the exerimental grou are both reasonably high and reresent mean values for this age category as obtained by Zwoliński et al. [19] in a oulation study on Polish youth (Table II). Post-test analysis roved differences in all variables (50.05). There was a significant increase of mean values in the exerimental grou in sense of coherence (SOC-13) as well as in all three of its comonents. Whereas in the control grou a decrease of average values was observed, aart from the sense of meaningfulness (SOC-Me), which stayed on the same level, though still lower than in the exerimental grou and thus roving substantial difference in the ost-test. Discussion To achieve ublic health goals hysical education has to rovide regular and adequate doses of PA during hysical education classes and to romote such Table I. Comarison of hysical characteristics of control and exerimental grous in re-test/ost-test analysis (t-test). Pre-test Post-test Variable Exerimental Exerimental Height [cm] Weight [kg] BMI [kg/m 2 ] SRT [mean/min] Self-assessment of hysical fitness and frequency of undertaking MVPA-boys re-test examination 80 (%) More fit than eers As fit as eers Less fit than eers Unfit Less than 1 a week 2 4 times a week 5 7 times a week Figure 1. Self-assessment of hysical fitness and frequency of leisure-time MVPA re-test (n ¼ 199; 2 ¼ ; ¼ ).

5 activities outside school. But findings from studies world-wide indicate that these aims are not fulfilled, ushing hysical education as a school subject into a defensive osition [20]. At the same time, the growing revalence of obesity and the lowering level of hysical fitness in youth may have some roots in insufficient stimulation of health-related comonents, esecially cardioresiratory fitness during PA. This has led to the changes in recommendations concerning vigorous intensity exercise from a recommendation of 20 minutes three times a week through 30 minutes on most days of the week, [21] to most Salutogenesis as a framework for imroving health resources of adolescent boys 529 recently 60 minutes or more of MVPA every day [22]. Findings from revious similar exerimental rogrammes roved that if the increases in PA are sufficient, hysical fitness should be imroved [23,24]. Also, Mandigout et al. [25] found that only rogrammes with continuous activity, organized on the basis of three sessions er week, with min at intensity above the stimulating threshold, enhance VO2max in reubertal boys and girls. This aer investigates relationshis between SOC, self-assessed fitness and one of the hysiological resources of health cardioresiratory fitness. 100 Self-assessment of hysical fitness and frequency of undertaking MVPA-boys exerimental grou ost-test examination 80 (%) More fit than eers As fit as eers Less fit than eers Unfit Less than 1 a week 2 4 times a week 5 7 times a week Figure 2. Self-assessment of hysical fitness and frequency of leisure-time MVPA in the exerimental grou ost-test (n ¼ 84; 2 ¼ 27.33; ¼ ). 100 Self-assessment of hysical fitness and frequency of undertaking MVPA-boys control grou ost-test examination 80 (%) More fit than eers As fit as eers Less fit than eers Unfit Less than 1 a week 2 4 times a week 5 7 times a week Zla Figure 3. Self-assessment of hysical fitness and frequency of leisure-time MVPA in the control grou ost-test (n ¼ 115; 2 ¼ 13.32; ¼ ). Table II. Comarison of the level of coherence (ts.) of control and exerimental grous in re-test/ ost-test analysis (t-test). Pre-test Post-test Variable Exerimental Exerimental SOC SOC-Ma SOC-Me SOC-Co

6 530 M. Bronikowski & M. Bronikowska According to Antonovsky [1] individuals with high SOC will tend to araise demands as redictable and comrehensible. Therefore it was assumed that boys with high SOC would undertake out-of-school MVPA more frequently if they receive individualized edagogical suort from a PE teacher. This enables them to understand and see health-related rofits of PA both in the short term and the long term. However, it was imortant to test associations of self-assessed PA and fitness with erformance in endurance running. Self-reorted questionnaires of PA have been confirmed to be reliable and valid tools of assessing one s level of activity [16] but when it comes to hysical fitness sometimes subjective assessment does not match objectively measured reality, esecially at the lower school grades. Sollerhed et al. [26] found that among variables associated with high selferceived hysical fitness were low age, high erformance in endurance running, high self-reorted PA, ositive self-erceived body function and high selfcometence in hysical education. Authors suggested that correlation between uils self-erceived cometence in hysical education and actual measured hysical erformance, between the selferceived fitness and endurance erformance and between self-reorted PA and hysical erformance could be a form of concurrent validity. But this had to be measured and comared. In our study the change in self-assessed hysical fitness in favour of the exerimental grou coincided with significantly imroved results in endurance running (cardioresiratory fitness) and high SOC. One of the limitations of the study is the question of whether it was an effect of the introduced intervention or its cause; in other words were the changes of behaviour urosive or reactive. A otential exlanation of the generally lower results in the control grou may be found in the relatively high level of coherence found in the re-test examination. When combined with high self-assessment of hysical fitness and reasonably good scores in endurance running this might have resulted in seeing no sense and no need of any further develoment of one s hysical caacity in the control grou because its initial level was already satisfying. But it may also be caused by the lack of adequate amount of MVPA or a rimarily insufficient below-moderate level of intensity, which even with the reasonable frequency of PA did not bring ositive changes of cardioresiratory fitness. A lower level of SOC in the ost-test examination in the control grou could be exlained by the findings of Zwoliński et al. [19] who noticed a decline of mean SOC results with increasing age category in both genders, esecially after the age of 15. On the other hand it is also a major gain of the study. We can say that the higher initial SOC the better the erceived health in general, but it is difficult to maintain without roerly designed edagogical suort. This has to be based on romotion of health resilience through building of a ositive subjective state of health. Results of the control grou lead to the conclusion that traditional hysical education (lacking develoment of individual resonsibility, like the one in Hellison s model) fails to fulfil its role in this rocess, leaving uils with overestimated assessment of hysical fitness not matching their actual erformance measured in the endurance running. Whereas in the exerimental grou enhanced individualized edagogical suort from a PE teacher aimed at develoment of uils resonsibility and increased involvement in PA, esecially in the category of unfit and less fit than eers (among whom more boys declared undertaking MVPA in out-of-school time in the ost-test than in the re-test) roved to be effective in causing ositive changes in cardioresiratory fitness. Without teaching strategies, develoing a sense of coherence (and esecially a sense of meaningfulness) no matter how hysically stimulating hysical education rogrammes are [23 25] they will be mere hysical stimulation. Long-term effects on cognitive araisal seem doubtful if no sense of individual resonsibility for own health is develoed. Otimistic findings of the intervention introduced in the exerimental grou with arallel decrease of results in the control grou should alert health-related curricula designers (e.g. hysical educators, health romotion secialists) and divert their attention to develoing rogrammes able to realize more individualized objectives matching ersonalized caacities. Also, the results of other interventions [11,12,27,28] have indicated that exosure to the curriculum models based on develoment of ersonal resonsibility roduce increased ositive interactions and more accurate self-assessment of one s abilities. Develoing a sense of coherence in the context of self-determined and self-lanned PA gives ositive effects and not only rovides additional suort for the salutogenetic model but also romote healthy well-being and its associations with hysiological resource comonents (imroved cardioresiratory fitness). Therefore in school hysical education, guided and suervised ractice in the lanning of own PA should be emloyed by PE teachers and/or health educators. Recommended riorities for PA during childhood include develoment of basic movement skills and behaviours. In adolescence the emhasis of rogrammes ought to be stressed on develoment of social and emotional needs by

7 roviding challenges that are worth undertaking and thus allowing adolescents to take resonsibility from the moment of choosing a task until its fulfilment. And to achieve this it is essential to cooerate with uils in establishing goals and individual objectives. It is also reasonable to rovide leadershi oortunities and listen to uils feedback. Through secially designed edagogical tasks resonsibility has to gradually shift from an external source such as a teacher towards the uils themselves, and finally allowing the uils to become self-directed. Perhas further research studies could not only exlore the effectiveness of teaching strategies in romoting changes on health-related behaviours but also combine it with the use of teaching styles at different age categories. This would hel to indicate how much deends on the organization of a task, how much on the strategy in which the task is delivered and how much on the erson that is delivering it. 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