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Turkish Adolescent Health Risk Behaviors and Self-Esteem

Article in Social Behavior and Personality An International Journal · March 2011

DOI: 10.2224/sbp.2011.39.2.219

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SOCIAL BEHAVIOR AND PERSONALITY, 2011, 39(2), 219-228
© Society for Personality Research (Inc.)
DOI 10.2224/sbp.2011.39.2.219

TURKISH ADOLESCENT HEALTH RISK BEHAVIORS

AND SELF-ESTEEM

EMINE GEÇKIL AND ÖZLEM DüNDAR

Adiyaman University, Adiyaman, Turkey

We examined health risk behaviors and self-esteem of 1,361 adolescents in Adiyaman, Turkey.
The data were obtained using the Health Risk Behaviors Scale (HRBS; Çimen & Savaşer,
2003) and the Rosenberg Self-Esteem Scale (SES; Rosenberg, 1965). The most frequent
predictor of risky behavior in adolescents was physical activity. Nutrition, psychosocial,
hygiene, and substance abuse issues were also significant predictors of risky behavior. The
results indicated that age, year at school (grade), gender, self-esteem, and school performance
all had a strong impact on health risk behaviors. Adolescents must be made aware of health
risk issues associated with physical activity, nutrition, hygiene, and substance abuse.

Keywords: health risk behavior, adolescent, physical activity, self-esteem, nutrition, hygiene.

Adolescence is a period of growth and development bridging childhood and

adulthood. The physical and emotional changes in this period influence behaviors
that affect health (Yannakoulia, Karayiannis, Terzidou, Kokkevi, & Sidossis,
2004) in that adolescence is a time of risk taking and experimentation (Dowdell
& Santucci, 2003). It is also a critical period, because lifestyle patterns for health
behaviors are frequently tested and/or acquired during adolescence (Dowdell &
Santucci; Yannakoulia et al.).
Researchers have shown that adolescents experiment with cigarette smoking
and substance abuse, are not very physically active often become obese, and
many have insufficient sexual knowledge (Alikasifoglu et al., 2002; Çimen &

Emine Geçkil, PhD, Assistant Professor, and Özlem Dündar, Lecturer, School of Health, Adiyaman
University, Adiyaman, Turkey.
Appreciation is due to reviewers including: Mehmet Top, Hacettepe University, Ankara, Turkey,
Email: mtop@hacettepe.edu.tr; Belgin Akin, Selcuk University, Konya, Turkey, Email: belak1@
hotmail.com
Please address correspondence and reprint requests to: Emine Geçkil, School of Health, Adiyaman
University, Adiyaman 02040, Turkey. Phone: +90 416 223-3003; Fax: +90 416 223-3005; Email:
egeckil@adiyaman.edu.tr

219
220 ADOLESCENT HEALTH RISK BEHAVIORS AND SELF-ESTEEM

Savaşer, 2003; Geçkil & Yıldız, 2006; Ege, Akın, & Altuntuğ, 2008). Smoking
rates have been found to vary from 13% to 35% among Turkish high school
students (Alikasifoglu et al., 2002; Geçkil & Yıldız, 2006; Kara, Hatun, Aydoğan,
Babaoğlu, & Gökalp, 2003). International researchers have also shown that
adolescents behave in ways that pose risks for their continuing good health in
such areas as substance abuse, violence, sexuality, nutrition, and physical activity
(Dowda, Ainsworth, Addy, Saunders, & Riner, 2001; Michael & Ben-Zur, 2007;
Ruangkanchanasetr, Plitponkarnpim, Hetrakul, & Kongsakon, 2005; Yannakoulia
et al., 2004). Health risk behaviors of adolescents have been found to be associated
with age, grade, perceived health status, and perceived school performance (De
Bruijn, Kremers, van Mechelen, & Brug, 2005; Ruangkanchanasetr et al., 2005;
Yorulmaz, Aktürk, Dağdeviren & Dalkiliç, 2002).
Self-esteem is considered to be one of the variables with the greatest potential
for inhibitory or promotional influence on health behaviors (De Bruijn et al.,
2005; Yarcheski, Mahon, & Yarcheski, 1997). Torres, Fernández, and Maceira
(1995) found significant positive correlations between general health behaviors
and self-esteem in both 12 to 13 and 16 to 17 year olds. Källestål, Dahlgren, and
Stenlund (2006) found a relationship between self-esteem and tooth-brushing
behavior during adolescence. Yorulmaz et al. (2002) described how self-esteem
is an important factor that affects the behaviors of adolescents.
Mortality and morbidity during childhood and adolescence can result from
health risk behaviors. The objective in this study was to examine the relationship
between the health risk behaviors and self-esteem levels of adolescents in
Adıyaman, Turkey.

METHOD

PARTICIPANTS
This descriptive study was conducted during April and May 2006 in Adıyaman,
which is located in southeastern Turkey. The sample size was calculated by using
the formula [n = Nt2σ2/d2 (N–1) + t2σ2] (Sümbüloğlu & Sümbüloğlu, 2002). N
= the total population of high school students in Adıyaman and this was 14,307,
t = 1.96 for 95% of students the confidence level, σ = 8 standard deviation of
previous study (Çimen & Savaşer, 2003) and d = 0.5 the deviation from ± mean.
The sample was composed of 1,361 adolescents (655 girls and 706 boys), aged
from 14 to 19 years. Participants were randomly selected from 9th to 11th grade
students attending five high schools.

LEGAL ETHICAL CONSENT

Ethical permission for the study was obtained prior to collecting data, by
contacting and receiving approval from the education directorships of the
province and district involved.
 ADOLESCENT HEALTH RISK BEHAVIORS AND SELF-ESTEEM 221
PROCEDURE
The data were collected by the authors using the Health Risk Behaviors Scale
(HRBS; Çimen & Savaşer, 2003), the Rosenberg Self-Esteem Scale (SES;
Rosenberg, 1965), and a questionnaire that included nine questions concerning
independent variables of age, gender, school, perceived school performance, and
perceived health status.

HEALTH RISK BEHAVIORS

Çimen and Savaşer (2003) developed the Health Risk Behaviors Scale for
adolescents aged between 15 and 18, and the scale has been determined to be
valid and reliable. The HRBS consists of five subscales: psychosocial − 10 items
(such as approaches to problem solving, communication skills, and relationships
with peers or family), nutrition − 11 items (such as having breakfast regularly,
number of meals consume per day, and consumption of vegetables, fruits, or
meats), physical activity − 4 items (such as walking, cycling, and taking part in
team sports), hygiene − 5 items (such as bathing, washing hands, and brushing
teeth), and substance abuse − 5 items (such as smoking, episodic drinking, and
addictive drug use). These 35 items are rated on a 5-point scale (1 = never,
5 = always) summed to form a total scale and converted to a percentage. A
higher score indicates a greater health risk. Çimen and Savaşer found that the
Cronbach’s alpha for this scale was .86. The Cronbach’s alpha for the sample in
this study was .69.

SELF-ESTEEM
Self-esteem was measured using the Turkish version (Çuhadaroğlu, 1985;
Uyanık Balat & Akman, 2004) of the Rosenberg Self-Esteem Scale (Rosenberg,
1965). Cronbach’s alpha coefficient for this scale was found to be between .77
and .88 (Rosenberg; Uyanık Balat & Akman), and it was .77 for the sample in
this study. A 4-point scale (strongly disagree to strongly agree) was used for the
10 items and the range of scores possible is from 1 to 40. High scores indicate
high self-esteem.

STATISTICAL ANALYSIS
Health risk behaviors and self-esteem were chosen as the dependent variables,
and gender, age, school performance, and perceived health status as the
independent variables of this study. Independent samples t test was used for
analysis of the relationships. One-way analysis of variance (ANOVA) was
used to analyze the association between dependent and other variables. The
relationship between health risk behaviors and self-esteem was analyzed using
the Pearson correlation test. Self-esteem was dichotomized into a measure of low
(below median) self-esteem as performed by Nelson and Gordon-Larsen (2006).
222 ADOLESCENT HEALTH RISK BEHAVIORS AND SELF-ESTEEM

A level of p < .05 was considered statistically significant.

RESULTS

TABLE 1
DEMOGRAPHIC CHARACTERISTIC OF ADOLESCENTS

Characteristics n %

Gender
Girl 655 48.1
Boy 706 51.9
Age (Years)*
14−16 737 54.2
17−19 624 45.8
Perceived health status
High 877 64.5
Middle 376 27.6
Low 108 7.9
Perceived school performance
Good 529 38.9
Moderate 600 44.1
Poor 232 17.0
Self esteem**
Low 760 55.8
Medium/High 601 44.2

Total 1,361 100.00

Notes: *M = 16.36, SD = 1.13 years; ** Mdn = 29

Demographic characteristics of the adolescents are shown in Table 1. The

mean HRBS total score for the group from a possible 100 was 43.0 (SD = 6.7).
The highest scores were on the physical activity subscale. In other words, the
most risk behaviors of the adolescents occurred in the area of physical activity.
According to the results nutrition, psychosocial, hygiene, and substance abuse
were other areas of risk. The mean of the SES scores from a possible score of 40
was 29.0 (SD = 4.4).
Males’ total HRBS scores were higher than females’ scores. Males had more
risk behaviors than did females in psychosocial, hygiene, and substance abuse
subscales than females. Females took more risks than males did in the areas of
nutrition and physical activity. No statistical difference was found between the
SES scores of males and females (see Table 2).
 ADOLESCENT HEALTH RISK BEHAVIORS AND SELF-ESTEEM 223
TABLE 2
RELATIONSHIPS AMONG HRBS TOTAL, SES, AND GENDER OF ADOLESCENTS

Scales Gender Statistics

Group Female (n = 655) Male (n = 706)
M ± SD M ± SD M ± SD t p

HRBS total 43.0 ± 6.7 42.0 ± 5.9 44.0 ± 7.3 -5.288 .000*
HRBS subscales
Psychosocial 42.4 ± 11.7 38.0 ± 8.9 46.5 ± 12.4 -14.411 .000*
Physical activity 54.9 ± 15.6 60.2 ± 14.1 49.9 ± 15.2 12.918 .000*
Nutrition 51.9 ± 9.1 53.1 ± 9.7 50.8 ± 8.4 4.721 .000*
Hygiene 32.6 ± 10.8 30.6 ± 10.0 34.5 ± 11.2 -6.665 .000*
Substance abuse 25.5 ± 11.20 23.1 ± 7.8 27.7 ± 13.2 -7.612 .000*
SES 29.0 ± 4.4 28.8 ± 4.5 29.2 ± 4.3 -1.543 .123

Notes: HRBS: Health Risk Behaviors Scale (Higher score indicates more serious risk to health in
behaviors); SES: Self-Esteem Scale (Higher score indicates greater self-esteem).
* p < .001.

TABLE 3
RELATIONSHIPS AMONG HRBS TOTAL, SES, AND CHARACTERISTICS OF ADOLESCENTS

Descriptive characteristics HRBS total SES

M ± SD Statistics M ± SD Statistics

Age (years)
14-16 42.0 ± 6.5 t = -6.347 28.9 ± 4.4 t = -.993
17-19 44.3 ± 6.8 p < .000* 29.1 ± 4.4 p = .321
Perceived health
Excellent 41.9 ± 6.3 F = 40.664 29.9 ± 4.1 F = 56.908
Fair 44.4 ± 6.7 p = .000* 27.8 ± 4.1 p = .000*
Poor 47.0 ± 7.4 1<2<3 26.3 ± 5.4 1>2>3
School performance
Good 41.9 ± 6.2 F = 21.660 29.8 ± 4.7 F = 19.610
Fair 43.2 ± 6.7 p = .000* 28.8 ± 4.0 p = .000*
Poor 45.3 ± 7.3 1<2<3 27.8 ± 4.4 1>2>3

Notes: * p < .001

Scores gained on the HRBS for adolescents aged between 17 and 19 years were
higher than the scores of adolescents aged between 14 and 16 years. The SES
scores for both groups were not statically different (see Table 3).
An inverse correlation between health risk behaviors and perceived health
status was found. Adolescents’ total HRBS scores decreased as perceived health
status improved. However, there was a correlation between perceived health
status and SES scores of adolescents.
There was also a significant correlation between health risk behaviors and
school performance. Adolescents whose school performance was poor had the
224 ADOLESCENT HEALTH RISK BEHAVIORS AND SELF-ESTEEM

highest total HRBS scores. As school performance improved, SES scores also
increased.
Adolescents with lower self-esteem had more health risk behaviors. Their
total HRBS scores and scores for all subscales were higher than were those
for adolescents with medium or high self-esteem (Table 4). There was also a
significant inverse correlation between adolescents’ total HRBS scores and their
SES scores (r = -.30, p < .001).
TABLE 4
ASSOCIATIONS BETWEEN THE HEALTH RISK BEHAVIORS SCALE AND THE
ROSENBERG SELF-ESTEEM SCALE
Self-esteem Statistics
Low Medium-High
n = 760 n = 601
Scales* M ± SD M ± SD t p
HRBS total 44.2 ± 6.6 41.6 ± 6.6 7.079 .000***
HRBS subscales
Psychosocial 43.5 ± 11.2 41.0 ± 12.1 3.889 .000***
Physical activity 57.0 ± 15.5 52.1 ± 15.3 5.766 .000***
Nutrition 52.8 ± 8.8 50.8 ± 9.3 4.116 .000***
Hygiene 34.2 ± 11.4 30.6 ± 9.7 6.303 .000***
Substance abuse 26.1 ± 11.7 24.7 ± 10.4 2.407 .015**
Notes: * r = -.30, p < .001 (Correlation between HRBS and SES); ** p < .05; ***p < .001

DISCUSSION

HEALTH RISK BEHAVIORS AND RELATED FACTORS

The most prevalent health risk behavior in adolescents was lack of physical
activity. In this study we found that the females were less physically active than
males. These findings support those of previous studies (Çimen & Savaşer, 2003;
Nelson & Gordon-Larsen, 2006; Yannakoulia et al., 2004; Young et al., 2007).
These data provide evidence of the adolescents not being involved in physical
activity to any great extent, particularly females. It is obvious that involvement
in organized activity during high school would be beneficial. It is necessary to
create various physical activity opportunities for all adolescents, especially for
females.
Secondly, risk behaviors of adolescents were common in the nutrition area
in our study. The literature also indicates that eating food that is not nutritious
(junk food) is a problem for all adolescents (Neumark-Sztainer, Paxton,
Hannan, Haines, & Story, 2006; Özmen, Çetinkaya, Ergin, Şen, & Erbay, 2007;
Phongsavan et al., 2005). We found that females experienced more risk behaviors
in nutrition than did males. Some other researchers have gained similar results
(Neumark-Sztainer et al., 2006; Özmen et al., 2007; Phongsavan et al., 2005;
Yannakoulia et al., 2004).
 ADOLESCENT HEALTH RISK BEHAVIORS AND SELF-ESTEEM 225
Another problem prevalent among adolescents was risky psychosocial
behaviors, followed by hygiene and substance abuse problems. We found that
males in this study showed more health risk behaviors than females did in
psychosocial, hygiene, and substance abuse areas. Similarly, in many studies it
has been reported that males were at greater risk for substance abuse, hygiene,
and psychosocial behaviors (Çimen & Savaşer, 2003; Erci, 1999; Kara et al.,
2003; Källestål et al., 2006; Ruangkanchanasetr et al., 2005). We found that the
adolescents in this study who were performing well at school had fewer health
risk behaviors than did poor school performers. This finding is consistent with
the literature (Källestål et al., 2006; Ruangkanchanasetr et al., 2005; Yorulmaz
et al., 2002). As we expected the adolescents who perceived their health status
as excellent had fewer health risk behaviors. These findings are consistent with
previous studies in which relationships between healthy behaviors and school
performance or perceived health were found (Çimen & Savaşer, 2003; Källestål
et al., 2006; Ruangkanchanasetr et al., 2005; Yarcheski et al., 1997; Yorulma, et
al., 2002).

SELF-ESTEEM AND RELATED FACTORS

No relationship was found in this study between self-esteem and age. This
result is similar to that of Yarcheski and Mahon (1989). We also found no
significant difference between the SES scores of males and females and this
finding is supported by the findings of some other researchers (e.g., Uyanık Balat
& Akman, 2004; Yarcheski et al., 1997).

THE ASSOCIATION BETWEEN HEALTH RISK BEHAVIORS AND SELF-ESTEEM

We found an important relationship between self-esteem and health risk
behaviors of the adolescents in this study. Those whose self esteem was lower
got higher scores for behaviors that were a risk to their health and there was a
significant inverse correlation between total HRBS scores and SES scores. Various
researchers have also previously found that there was a significant relationship
between health behaviors and self-esteem of adolescents (Källestål et al., 2006;
Neumark-Sztainer et al., 2006; Ruangkanchanasetr et al., 2005; Yarcheski et al.,
1997). It is important to strengthen the self-esteem of adolescents to reduce their
risk health behaviors.
The greatest risk of behaviors that would be injurious to good health to these
adolescents was related to physical activity and nutrition, along with health risk
behaviors associated with gender, poor self-esteem, poor school performance,
and older age. In the light of these findings we believe that developing social,
educational, and sports programs to improve health behaviors in the areas of
physical activity and nutrition would be advantageous, especially for females. For
males, the focus should be on decreasing risk behaviors related to psychosocial,
226 ADOLESCENT HEALTH RISK BEHAVIORS AND SELF-ESTEEM

hygiene, and substance abuse. The knowledge obtained from the present study
may be useful for health professionals and teachers developing health promotion
programs for adolescents.

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