Determination of Healthy Lifestyle Behaviors of High School Students

Healthy lifestyle behaviors can be defined as all the behaviors believed and applied by individuals to be healthy, maintain health and be protected from diseases. This study aims to determine the healthy lifestyle behaviors of high school students studying at the high schools in the Province of Elazig, Turkey. The study population of this descriptive study consists of students studying at the high schools located in the Cumhuriyet neighborhood located in the city center of the Province of Elazig. Simple random sampling method was used to select 459 students among the 9, 10, 11 and 12 graders studying at that high school the study sample consists of these 459 students. As a data collection tool, a Personal Information Form, which includes items for students' socio-demographic information, and the Healthy Lifestyle Behaviors Scale-II were used. The study findings indicated that students adopted the healthy lifestyle behaviors moderately. Variables such as gender, type of school, grade, family income, paternal education status were found to be effective on the healthy lifestyle behaviors.


Introduction
Health behavior is expressed as any activity or behavior believed, and performed to be healthy as well as the behaviors performed by healthy individuals to prevent diseases [1].Healthy lifestyle behaviors (HLSB) can be defined as all the behaviors believed and adopted by individuals to be healthy, maintain health, and be protected from diseases [2].Individuals who adopt healthy lifestyle behaviors are able to improve and sustain their well-being.Therefore, the development of healthy lifestyle behaviors is the basis of disease prevention, and maintaining health [3].
Being healthy is a fundamental right of every human being; and, ensuring and maintaining this well-being is the main goal of healthcare workers as well as the individuals themselves.In order to acquire health promoting behaviors, individuals need to have self-control, and should be disposed to do perform these behaviors.This is because, positive health behaviors should be acquired and maintained in order to improve health [4].Pender (1982) stated that a healthy lifestyle is necessary for improving health.Health-enhancing behaviors include behaviors to be performed by individuals themselves for improving their well-being and ensuring self-actualization.A healthy lifestyle should not only focus protection against diseases but also the behaviors that increase well-being throughout life.Healthy lifestyle behaviors also include adequate and balanced diet, stress management, adequate and regular exercises, non-smoking, health responsibility, and hygienic measures [5].
Individuals need to avoid, pay attention, and prevent certain situations when adopting a healthy lifestyle, and need to demonstrate certain behaviors more.They need to refrain from risky health behaviors as well as maintaining the positive health behaviors.
A positive health behavior is defined as planned behaviors aimed at protecting the health of individuals actively, whereas risky health behaviors is defined as the attitudes, and behaviors that deteriorates health due to acquired incorrect and incomplete information and observations.For a healthy life, people should be able to control their own behavior, accommodate correct behaviors, make their own decisions, and resolve negative situations [6].
Starting from the first years in school, individuals' self-awareness increases with increasing age, and years in school.Given the age of the individual, the high school period can be considered the time that individuals develop a complete self-awareness.Examining the health behavior of young people in this period, teaching the correct health behaviors to protect and maintain their health, and supporting them in the lacking areas is of great importance.According to the data of Turkish Statistical Institute in 2014, the number of students in secondary education in Turkey is 2,906,291.Considering the Province of Elazig, the number of students in secondary education is 28,262, including the students in the districts and villages [7].The high school period is characterized by rapid physical, psychological and Determination of Healthy Lifestyle Behaviors of High School Students social changes experienced simultaneously.During this period, the change processes are decisive on behaviors that affect health.In other words, the level of future health of young people is closely related to how the change process is experienced in this period of life.The World Health Organization (WHO) reports that nearly two thirds of the early deaths and one third of the total disease burden in adults is associated with negative health behaviors such as smoking habit acquired during adolescence, lack of physical activity, unprotected sex, and violence [8].According to the literature, unhealthy diet, and physical inactivity are common among young people in Turkish society [9] [10].
This study aims to determine the healthy lifestyle behaviors of high school students.As an important contribution, this study attempts to reveal the extent of healthy lifestyle behaviors adopted by the individuals during this period, which is critical for established healthy lifestyle behaviors.

Data Collection
The study population of this descriptive study consists of students studying at the high schools located in the Cumhuriyet neighborhood in the city center of the Province of Elazig in the 2015-2016 academic year.The sample of the study consists of 459 students, selected using the simple random sampling method among the 9 th , 10 th , 11 th and 12 th graders studying at the specified high school.
As a data collection tool, a Personal Information Form, which includes items for students' demographic information, such as age, gender, parental education status, and parental occupation status, and the "Healthy Lifestyle Behaviors Scale-II (HLBS)"were used.

Healthy Lifestyle Behaviors Scale
The Healthy Lifestyle Behaviors Scale was developed by Walker, Sechrist, and Pender in 1987, and measures behaviors of individuals that improve their well-being associated with a healthy lifestyle [11].The Turkish reliability and validity study of the scale was conducted by Esin in 1997 and Akça in 1999 [5] [12].In Esin's study, the first version of the 48-item scale was used, whereas Akça's study has used the second version of the scale, which consists of 52 items.This study also uses the 52-item scale, which its validity and reliability study was carried out by Akça.This 4-point Likert type scale has "never", "sometimes", "often" and "regularly" choices, and consists of six sub-scales, which are: "health responsibility", "physical activity", "diet", "spiritual development", "interpersonal relationships" and "stress management".The lowest and highest scores of the scale are 52 and 208 respectively.It is considered that students' healthy lifestyle behaviors increase with the increasing total score.

Statistical Analysis
Data were analyzed using a SPSS software package, and numbers, percentages averages, and standard deviation were used for the analysis.In the analysis, independent samples t-test and ANOVA was used, and multiple comparisons were performed using the LSD test.P<0.05 was accepted as the level of significance.

Findings
Demographic characteristics of the students included in the study were given in Table 1.Considering the demographic characteristics of the students included in the research, it was found that the majority (79.7%) was Anatolian High School students, the number of male students was greater than the number of female students, 38.3% of the students' family income was 2000TL and above, and fathers of 28.5% of the high school students were high school graduates.It was determined that fathers of 28.3% of the students were civil servant, and economic status of the 85.4% was at moderate level (Table 1).The comparison of HLBS and sub-scale scores of the students in terms of gender is shown in Table 2.There was no significant difference in the health responsibility, spiritual development, interpersonal relations, and stress management sub-scales in terms of gender, whereas the difference was significant in the physical activity and diet sub-scales (p<0.05).Looking at the HLBS and sub-scale scores of the students included in the study in terms of their years in school (Table 3), there was no significant difference in the health responsibility and diet sub-scales; however, a significant difference was found in the spiritual development, interpersonal relations, and stress management sub-scales (p<0.05).This difference was stemmed from the 12th graders for the stress management and physical activity sub-scales, and from the 10th graders for the spiritual development and interpersonal relationships sub-scales.Considering the HLBS and sub-scale score distributions of the students in terms of monthly family income (Table 4), a significant difference was only found in the diet sub-scale (p<0.05).The difference in question was caused by the group, whose monthly income is lower than 499 TL, and the mean diet score of this group was lower than other groups.The distribution of the scores of the students in the HLBS, and its sub-scales according to the paternal education status is shown in Table 5.A significant difference was found in the HLBS spiritual development sub-scale scores of the students.The spiritual development score of the group, which has the literate paternal education status was lower than of the other groups.The distribution of the scores of the surveyed students in the HLBS and sub-scales according to the paternal occupation is shown in Table 6.There was no significant difference in health responsibility, diet, spiritual development, interpersonal relations, and stress management sub-scale scores of the students, whereas a significant difference was found in the physical activity sub-scale (p<0.05).The difference in question was caused by the group with self-employed paternal occupation, and the mean score of this group was the lowest.Looking at the HLBS and sub-scale score distributions of the students in terms of the economic status variable (Table 7), a significant difference was found in the health responsibility, physical activity, diet, interpersonal relationships, and stress management sub-scales.The difference in question was caused by the student group that has the lowest level economic status (p<0.05).

Discussion
In our study, there was a significant difference in the mean total score, in the diet sub-scale score, and in the physical activity sub-scale score in terms of the gender variable, and the mean scores of the male students was found to be higher than of female students (Table 2).There have been numerous studies that support our findings.In a study by Karadamar (2010) conducted with high school students, the mean total score and the mean diet and exercise sub-scale scores of male students were found to be higher than of female students; and, in a study by Ünalan et al. (2007), male students were found to exercise more than female students, and the difference was significant.In a study by Geçkil and Yıldız (2006) conducted with high school students, the mean total score of the male students were found to be higher than the mean scores of the female students; and in a study by Berçin (2010) the mean self-actualization, exercise, diet, and total scores of male students were found to be higher; similarly, a study by Sanchez et al. (2007) found that male students tend to exercise more than female students [13]  reported that gender has no effect on the mean healthy lifestyle scale score [22] [23].
Considering the scores of the surveyed students in the sub-scales in terms of the grade variable, a significant difference was found in the physical activity, spiritual development, interpersonal relations, and stress management sub-scales (Table 3).The mean physical activity and stress management sub-scale scores of the 12 th graders were the lowest and 10 th graders had the lowest scores in the mean spiritual development and interpersonal relationships sub-scales.It can be said that the fact that 12 th graders were about to take a college exam, which will designate their future, causing more stress, making them unable to cope; and the responsibility for studying intensively keeps them allocating sufficient time for a physical activity.The high school period coincides with the adolescence.The adolescence is a period characterized by intense emotional fluctuations, and tension.Perceptions of young people about themselves, environment and the world also change during this period, and they seek to redress balance between many issues.Being in the early adolescence, may lead 10 th graders to feel themselves inadequate in the spiritual development and communication sub-scales.
Another finding of our research is that the mean diet sub-scale score of the HLBS scale was the lowest in the lowest-income group (Table 4).It can be said that this difference is normal in the diet sub-scale, in which the nutritional habits are very closely related with the level of income under the present conditions.
In our study, a significant difference was found in the spiritual development sub-scale scores of the high school students in terms of paternal education status (Table 5).This difference stems from the group having a literate father without any formal education.The spiritual development score of these students was the lowest.It's observed that spiritual development scores of the students increase with increasing paternal level of education.The level of consciousness increases as the level of education increases, and the parents that are able to improve themselves are able to help their children, support, and offer guidance more than the others.It was concluded in a study by Karadamar (2010) that the level of education of fathers was effective on the exercise and interpersonal support sub-scales; and, Binay's (2012) study reported that students' total scores increase with the increasing level of education of their fathers; in addition, the study by Kocaakman (2009) reported that the students, whose fathers have been graduated from a college, have higher self-actualization and stress management scores [13] [24] [25].
According to the study results, it was found that high school students adopt healthy lifestyle behaviors moderately; and, variables such as gender, type of school, grade, family income, and paternal education status were found to be effective on the healthy lifestyle behaviors.Transforming the healthy lifestyle behaviors into a habit is extremely important for maintaining and improving well-being.It is possible to take the advantage of reaching masses of young people at school by an effective school health program in order to help them acquire knowledge, positive attitudes and behaviors in relation with health as well as staying away from risky health behaviors.School health team should make an effort to create a behavioral change in young people, and create an environment that supports healthy living.In this way, change in young people's lifestyles can be facilitated.

Table 1 .
Distribution of Demographic Characteristics of the Students

Table 2 .
The Distribution of the Scores of Students in the HLBS and its Sub-Scales According to the Gender Variable

Table 3 .
The Distribution of the Scores of Students in the HLBS and its Sub-Scales According to the Grade Variable

Table 4 .
The Distribution of the Scores of Students in the HLBS and its Sub-Scales According to the Family Income Level Variable

Table 5 .
The Distribution of the Scores of Students in the HLBS and its Sub-Scales According to the Paternal Education Status Variable

Table 6 .
The Distribution of the Scores of Students in the HLBS and its Sub-Scales According to the Paternal Occupation Variable

Table 7 .
The Distribution of the Scores of Students in the HLBS and Sub-Scales According to the Economic Status Variable