a master’s thesis for oth-670- research seminar ii

Running head: ADOLESCENT WELLNESS & PHYS. EX.

The Effects of Physical Activity on Adolescent Well-being

Julia Christian, OTS & Lisa Slade, OTS

The Sage Colleges

School of Health Sciences

April 14th 2016

ADOLESCENT WELLNESS & PHYS. EX. 2


A Master’s Thesis for OTH-670: Research Seminar II

Presented to the Faculty of the Department of Occupational Therapy

The Sage Colleges

School of Health Sciences

In Partial Fulfillment of the Requirements for the

Degree of Master of Science in Occupational Therapy

Julia Christian, OTS & Lisa Slade, OTS

_________________________

Brittney Muir, PHD

Research Advisor

_________________________

Theresa Hand, OTD, OTR/L, CHT

Program Director, Occupational Therapy



Statement of Original Work:

I represent to The Sage Colleges that this dissertation and abstract (title listed above) is

the original work of the author and does not infringe on the copyright or other rights of

others.

____________________________ _______________

Julia Christian Date of Signature

____________________________ _______________

Lisa Slade Date of Signature


Permission for The Sage Colleges to release work:

I hereby give permission to The Sage Colleges to use my work (title listed above) in

the following ways:

■ Place in the Sage College Libraries electronic collection and make publically

available for electronic viewing by Sage-affiliated patrons as well as all general

public online viewers (i.e. “open access”).

■ Place in the Sage College Libraries electronic collection and share

electronically for InterLibrary Loan purposes.

■ Keep in the departmental program office to show to other students, faculty

or outside individuals, such as accreditors or licensing agencies, as an

example of student work.


Abstract

The lack in physical activity of adolescents in the United States is a highlighted

concern for youth today. The benefits of physical activity are endless and with child

obesity rates rising the need for programs to promote preventive health is imperative. It

is the role of occupational therapist in community settings to promote healthy living and

provide ample opportunities for individuals to engage in activities that enhance overall

wellness. The purpose of this study was to develop the association of physical activity to

universal wellness of adolescents, while exploring the opportunities and barriers (cost,

limited opportunities, time spent doing other things, transportation, fear of failure) of

physical activity on adolescent’s occupations (academics, socialization, eating habits, and

sleep) in the Capital Region of New York State. A mixed method cross-sectional paper

survey was distributed to 9-12th graders from Ichabod Crane High School and Catholic

Central High School. Adolescent’s physical activity score showed positive relationships

with decrease stress and academic success. Motivating factors to engage in physical

activity included parent engagement and friendship. The top barrier preventing

adolescents from engaging in physical activity was limited time due to homework. In

order for occupational therapist to push for community preventative health programs,

these barriers and motivating factors that contribute to physical activity need to be

addressed to find the best-fit program for this population.

Suggested Keywords: physical activity, adolescents, physical wellness, mental wellness,

occupational therapy


Table of Contents Introduction ..............................................................................................................................7LiteratureReview....................................................................................................................8TrendsofPhysicalActivityinAdolescentsinUS....................................................................8TheImpactofPhysicalActivityontheWellnessofAdolescents.......................................9Thecopingself&essentialself. ..............................................................................................................11Thecreativeself:thinking,emotions,control,positivehumor,work. ..................................14Thephysicalself:physicalactivity,nutrition&sleep...................................................................17Thesocialself:friendships. ......................................................................................................................19

EnvironmentalFactorsthatRelatetoPhysicalActivity.................................................... 21TheNeedforOccupationalTherapyinAdolescentsPopulations..................................22Purpose..............................................................................................................................................22TheoreticalPerspective ...............................................................................................................23DefinitionofTerms........................................................................................................................ 23

Methods ................................................................................................................................... 23Design.................................................................................................................................................23ResearchQuestions ....................................................................................................................... 24EthicalProcedures......................................................................................................................... 24Setting ................................................................................................................................................24Participants ......................................................................................................................................25DataCollection ................................................................................................................................ 25DataAnalysis ...................................................................................................................................26

Results ...................................................................................................................................... 27RepresentationofPAQS ...............................................................................................................27ImpactofWellnessQuestionsonPAQS ..................................................................................28RelationshipsofPAQSandWellnessAcrossGenderandSchool ...................................28BarrierstoPhysicalActivity .......................................................................................................30

Discussion ............................................................................................................................... 31References............................................................................................................................... 36Appendix.................................................................................................................................. 44


Introduction

A highlighted concern for youth in United States today is the lack of physical

activity in their daily lives. Physical activity is described by the Center for Disease

Control & Prevention (CDC) as participating in 60 minutes of activity that increases

one’s heart rate (2014). Throughout the United States 15.2 % of adolescents have

reported not participating in physical activity of any kind on at least one day out of the

seven day week span (CDC, 2014). Physical activity is imperative during adolescence

because this population is at risk for developing co-morbid diseases and mental illnesses

during adolescence that can follow them into adulthood (Southern, Loftin, Suskind,

Udall, Blecker, 1999). Interventions typically don’t occur until after problems develop,

leading to a decline in overall wellness. The Affordable Care Act has pushed many

health care professions into creating preventative care programs on a community basis

(Persch, Lamb, Metzler, & Fristad, 2015). Recently published literature within the field

of occupational therapy has looked at the understudied population of adolescents and has

pointed out a need for preventive care of this high-risk population, specifically in mental

and physical health (Arbesman, Bazyk, & Nochajski, 2013; Persch et al., 2015). Inquiry

into the types of physical activity (cardiovascular exercise, stretching, and strength

training) that adolescents engage in and its effects on wellness would help provide a

foundation for occupational therapists to learn more about this understudied population.

Providing interventions to adolescents as a preventative approach to this massive

epidemic could cut healthcare costs and provide longevity to adolescent’s life into

adulthood (Sothern, Loftin, Suskind, Udall, & Blecker, 1999).


Literature Review

The discussion of adolescents and the impact of physical activity on their wellness

has been a topic of great interest within American society today. Physical activity has

become a missing piece for youth wellness programs (Rachele, Cuddihy, Washington, &

McPhail, 2014). This literature review looks at physical activity on adolescent wellness,

and describes the universal term of wellness. The following also addresses the

connections to the role of occupational therapy with health and wellness and health

management within the adolescent population, an under researched population in

occupational therapy literature (Whitney & Hilton, 2013).

Trends of Physical Activity in Adolescents in US

A sedentary lifestyle, as explained by Lumsdon & Mitchell (1999) has become

the recent trend amongst adolescents in the U.S., due to the changing demands on their

occupational roles (as cited in Ziviani, Scott, & Wadley, 2004). An obesity epidemic has

affected children and adolescents of the twenty first century due to these sedentary

lifestyles (Iannotti & Wang, 2013). It was found that on an average school day 32.5% of

students are engaging in watching television or playing video/ computer games (41.5%)

for three hours (CDC, 2014). A solution to the problematic trend has been the increase in

youth physical activity programs across the nation, “as the preventative focus of

contemporary health care moves to target younger age groups” (Rachele et al., 2014,

p.282). According to the American Medical Association the prevalence of obesity in the

U.S. is high, with one third of adults and 17% of children obese, however the number of

obese people in U.S. has leveled off since 2003 (Ogden, Carroll, Kit, & Flegal, 2014).

Current trends have been identified in the typical adolescent lifestyle that show factors


that can result in obesity with the most common factor reported being a lack in physical

activity (Iannotti & Wang, 2013). Physical activity is just one factor of a total of five

factors, including creative self, the coping self, the social self, the essential self of

wellness, that all overlap each other and affect one another in a positive way (Myers &

Sweeney, 2008).

The Impact of Physical Activity on the Wellness of Adolescents

Wellness is a holistic and multidimensional term that can be identified by many

definitions and models. There is limited evidence of a gold-standard definition of

wellness (Rachele et al, 2014). Within the discipline of occupational therapy wellness is

defined as

“… a context for living, a state of being, a place from which to come as

individuals commit themselves to improve life for all humanity….As a context for

living, wellness is not limited to getting something more for oneself; rather, it

becomes the possibility that one’s life, health, and well-being contributes to the

health and well-being of others” (Johnson, 1985, p.130).

Measuring wellness is a dynamic process and is an essential part when evaluating clients

with in the field of occupational therapy. A model used in therapeutic disciplines to

describe wellness is the Indivisible Self-Model of Wellness (IS-Wel), which describes

five descriptors of “self” that pertain to wellness. These factors include the creative self,

the coping self, the social self, the essential self, and lastly the physical self (Rachele et

al., 2014). Although this model is not used within the field of occupational therapy, it has

been used in multiple studies over the past 15 years as well as in counseling evaluations

and interventions across professions within the mental health field (Myers & Sweeney,


2008). Each of the factors within this model has its own characteristics that are

associated with it. The creative self deals with thinking, emotions, control, work, and

positive humor (Rachele et al., 2014). The coping self includes leisure, stress worth, self

management, and realistic beliefs while the social self holds one's relationships like love

and friendship. A person's essential self holds true to who they are spiritually and

culturally, along with self-care. Lastly, the physical self is described as the dimensions of

exercise and nutrition in which one engages (Rachele et al., 2014).

“Occupational Therapy Scope of Practice” (2014) identifies all factors of a

person’s wellness at any stage of life from birth to death. The role of occupational

therapy has been addressed within populations that have limitations related to their

occupational performance across many settings. However, a recent American

Occupational Therapy Association position paper promoted the idea of prevention of

disease and disability (AOTA, 2001). Lifestyle redesign programs are a prevention idea

that occupational therapists have developed, which act as a preventive measure to at risk

populations like the elderly. These programs address the physical and mental diseases

that affect wellness of the geriatric population (Jackson, Carlson, Mandel, Zemkw &

Clark, 1998). Gondoli (1999, p.231) describes adolescence as a “phase of life with great

potential for wellness” in which occupational therapists can assist in promoting.

However, studies addressing the adolescent population are overlooked within

occupational therapy research (Whitney & Hilton, 2013; Scaletti, 1999). The current

literature indicates that wellness is strongly associated with physical activity specifically

for adolescents in coping with stress (Brown & Siegal, 1988; Calfas, & Taylor, 1994;

Norris, Carroll, & Cochrane, 1992), increased self-esteem (Altintas & Asci, 2008; Calfas,


& Taylor, 1994), decreased risk taking behaviors (Delisle, Werch, Wong, Bian, &

Weiler, 2010; Audrain-McGovern, Rodriguez & Moss, 2003; Rehm & Shield, 2013),

increased social interaction (Peterson, Lawman, Wilson, Fairchild, & Van Horn, 2013;

Ullrich & Smith, 2008; Smith, 2003), academia (Wi-Young So, 2012; Van Dijk, De

Groot, Savelberg, Van Acker, & Kirschner, 2014), sleep (Brand, Gerber, Beck,

Hatzinger, Puhse, & Holsboer-Trachsler, 2009; Singh, Clements, & Fiatarone, 1997) and

eating habits (Brooks, Smeeton, Chester, Spencer, Klemera, 2014). All of these are

aspects of wellness that are looked at in the “Occupational Therapy Practice Framework”

(2014).

The coping self & essential self.

The wellness component embodies the idea that the body, mind, spirit, emotions

and environment are interdependent, and that health is a state of balance (Johnson, 1986).

The occupational therapy profession was founded on such belief that if one is ill it is due

to an imbalance of one or more of these factors (Johnson, 1986). Two big components to

a person’s coping self is self-worth and their ability to cope with stress. These are vital

factors to look at as an occupational therapist because they can provide indicators for

unhealthy lifestyles (Norris, Carroll, & Cochrane, 1991; Hilyer, Wilson, Dillon, & Caro,

1982; Merikangas, He, Burstein, Swanson, Avenevoli, Cui, Benjet, Georgiades, &

Swendsen, 2010). Stress can come from many areas within an adolescent's life. It could

be the result of increased expectations of independence, taking on additional roles within

the family, major life events, and or traumatic life events like losing a parent. As

children become adolescents they begin to experience more of these stressors in their

lives, and if they are unable to cope with this stress it could lead to possible onset of


illness (Brown, 1991). Finding outlets to alleviate stress is imperative during this age.

One possible outlet is through high physical activity. The findings of two studies showed

evidence that adolescents and college students with low levels of physical activity

actually had more onset of illness throughout the year during periods of stress, than those

with higher levels of physical activity (Brown & Siegel, 1988; Brown, 1991). Physical

activity can also decrease depressive/anxiety symptoms (Motl, Birnbaum, Kubik, &

Dishman, 2004).

Those who are unable to cope with stress are more likely to suffer from

psychiatric disorders like depression/anxiety than those with better coping skills. The

incidence of depression and anxiety in U.S. adolescents was reported through research,

with 31.9% of adolescent meeting the criteria for anxiety disorder and 11.7% for major

depressive disorder (Merikangas et al., 2010). This prevalence in child psychiatric

epidemiology has caused an influx of research for treatment (Merikangas et al., 2010).

Treatment programs that include physical activity have demonstrated significant

improvements in mental well-being within communities (Malcolm, Evans-Lacko, Little,

Henderson, & Thornicroft, 2013), psychiatric clinics (Craft & Landers, 1998), schools

(Norris, Douglas, Cochrane, 1991), and juvenile facilities (Hilyer, Wilson, Dillon, Caro,

Jenkins, Spencer, Meadows & Booker, 1982), all of which are areas that occupational

therapists find themselves working in (Occupational Therapy Scope of Practice, 2014).

The types of physical activity used in community interventions included elements of

gardening, gym class, and walking groups (Malcolm et al., 2013). Common intervention

programs that have been implemented suggest that 10 minutes of flexibility exercises, a

strength development program and a cardio portion significantly decrease stress/anxiety


and depression (Hilyer et al., 1982). The intensity of the exercise is also important as

high intensity exercise significantly decreased stress/anxiety in adolescents compared to

moderate exercise and flexibility exercise (Norris, Douglas, Cochrane, 1991).

Interventions like this show the positive effects physical activity can have on mental

health.

In relation to wellness and the essential self of adolescents, there are consistent

findings in research for variables of self-esteem and self-concept in comparison with

physical activity (Altintaş & Aşçi, 2008). Physical activity level in relation to self-

esteem was looked at within multiple dimensions of sport competence, body

attractiveness, physical condition, physical strength, and physical self-worth.

Adolescents who engage in high physical activity showed higher physical self-esteem

specifically with sport competence and physical condition from their less active

counterparts (Altintaş & Aşçi, 2008).

Gender is another important component to essential self; which has been

identified to have a direct effect on adolescent engagement in physical activity (Altintas

& Asci, 2008; F. Brooks, 2007). Throughout the years our society and cultural

expectations have gender stereotyped boys and girls. Boys are typically expected to

engage in sports that demand more physical expenditure than girls’ sports. American

culture has typically expected women to be more on the conservative side. Many

adolescent girls are not encouraged to join a “masculine” sport that will make them look

and act less feminine. Instead they are encouraged to join supports such as gymnastics or

volleyball that can be aesthetically pleasing. In American society there are less women

role model athletes for adolescent girls than there are for boys (Altintas & Asci, 2008).


Physical activity can decrease by 75% when girls enter their adolescent years.

Many of the activities that they engaged in as a youth have diminished. The lack of

physical exercise or activity is linked to obesity. Adolescent girls in physical education

class are interacting with adolescent boys who are competitive and dominate the activity.

Adolescent girls would rather stand by and watch the boys play than be criticized by their

male peers. Girls have opted for less competitive sports that do not take place in public

spaces and the physical activities that girls are choosing to participate in are more

sedentary. Types of physical activities that girls are choosing to participate in are a part

of their leisure pursuits (Brooks, F., 2007).

The creative self: thinking, emotions, control, positive humor, work.

The creative self is based on the notion that what one thinks affects their emotions

as well as their body. The complexity of one's creative self is based on thinking,

emotions, control, positive humor, and work (Myers & Sweeny, 2008). Control is the

ability to perceive one's own influence on events in one's own life, which is the main

concept behind risk-taking behaviors (Myers & Sweeney, 2008). Adolescence is a time

of trial and error, where risk-taking behaviors like alcohol consumption, cigarette and

drug use become more evident and habitual in their lives. The CDC reports that in 2013,

34.9% of adolescence had consumed alcohol and 23.4% had used marijuana, 30 days

prior to taking the survey. If adolescents lack the ability to control these behaviors and

engage further it can lead to detrimental health effects like cancer, heart, lung, liver and

kidney diseases (Rehm & Shield, 2013), which will limit their abilities to engage in daily

life occupations.


Adolescents who engaged in higher levels of vigorous physical activity (VPA)

had a significant decrease in the amount and frequency of marijuana that was consumed,

compared those who engaged into low levels of physical activity (Delisle, Werch, Wong,

Bian & Weiler, 2010). Cigarette smoking had similar findings for frequency and amount

of cigarette smoking, for adolescents who engaged at high levels of VPA compared to

lower levels of physical activity (Delisle et al., 2010; Audrain-McGovern, Rodriguez &

Moss, 2003; Pyle, McQuivey, Brassington & Steiner, 2003). The odds of those

adolescents who progressed to smoking actually decreased by 50% after physical activity

was implemented (Audrain-McGovern, Rodriguez & Moss, 2003). Thus physical

activity protects adolescents from becoming continuous smokers.

Competitive sports clubs provide a certain motivation and work ethic for

adolescents to work hard on and off the field. Academically they strive to excel in the

classroom and have high future expectations towards work and happiness as well as

within their sport (Gisladottir, Matthiasdottir, & Kristjansdottir, 2013). There is a

growing body of research that looks at physical activity in schools (Rasberry, Lee, Robin,

Laris, Russell, Coyle, & Nihiser, 2011). This is because of the constant changes in

academic curriculum (Rasberry et al., 2011), which has resulted in schools not meeting

the standard time of 60 minutes of moderate to vigorous exercise on most days of the

week during physical education class (Rachele et al., 2014). Simons-Morton, Taylor,

Snider, et al., (1994) “revealed that physical education specialists provided students with

only 3 min of moderate to vigorous physical activity per physical education class; that is

less than 10% of class time” (as cited in Sallis, McKenzie, Alcaraz, Kolody, Faucette, &


Hovell, 1997, p.1328). In some cases, even when physical education was provided, many

children and adolescents wouldn't participate.

Most of the literature within this domain applied to elementary school students

and less to high school students (Sallis, 1997; Randall, 2003). In regard to occupational

therapy there has been an increase in studies over the past four years of children and

youth, due to the substantial proportion of occupational therapy practitioners, 26.9 %,

working with children and youth in schools and in early intervention. There is an

increasing trend of intervention studies within the area of children and youth, however, a

review of 11 articles looking at occupational intervention and effectiveness showed only

two intervention studies that looked at adolescence (Whitney & Hilton, 2013). Outside

of the domain of occupational therapy, there is still limited research on adolescents. The

data that is available is mainly self-reported and shows a positive correlation between

vigorous physical activity and academic performance in Korean males (So, 2012). The

complexity of the association between physical activity and academic achievement

involves many factors like academic year, physical activity, volume and intensity, and

school grade all have an effect (Van Dijk, De Groot, Savelberg, Van Acker, & Kirschner,

2014). Significantly, this research found that total physical activity was positively

associated with executive functioning, which was found to correlate with academic

achievement (Van Dijk et al., 2014). There has been no data that suggests negative

effects of physical activity on academia and those school districts that incorporate a type

of physical activity intervention within the curriculum are only benefiting their students

(Rasberry, 2011).


The physical self: physical activity, nutrition & sleep.

Physical activity in adolescents has increased over time, with reports of engaging

in more physical activity in 2009-2010 than in 2001-2002 (Iannotti & Wang, 2013). TV

shows like The Biggest Loser and recent Nike fit apps have tried to push and motivate

Americans into finding their physical self. The main concepts behind the physical self

are habits of exercise and nutrition, according to Myers & Sweeny(2008). The benefits

exercise and nutrition have on the physical self are beneficial especially to those

adolescents with physical disabilities (Persch et al., 2015). Children that spend time in

wheelchairs engage in weight-bearing activities such as the standing experience, which

has a positive effect on digestive health, cardiopulmonary health, and bone density

(Chad, Bailey, McKay, Zello, & Snyder, 1999). An example of an intervention is the

Fitkids program, which has been implemented to provide children and adolescents with

chronic diseases with one hour of health-related fitness, two times a week for three

months, and then one hour per week during months four through six. The program shows

significant improvements in the adolescents’ aerobic fitness, anaerobic fitness, muscle

strength, and walking capacity over time (Kotte, de Groot, Winkler, Huijgen & Takken,

2014).

The benefits of physical activity are not limited to just those who are impaired.

All groups of adolescents can benefit from physical activity because it is an effective way

to fight against chronic diseases such as coronary heart disease, high blood pressure,

colon cancer, diabetes mellitus, and obesity (Delisle, Werch, Wong, Bian, & Weiler,

2010). Another seen benefit of physical activity includes increased bone growth and


increased amounts of growth hormone, which are vital during adolescent growth (Field,

2012).

As with physical activity, nutrition also is a key aspect to wellness that has

noticeable obesogenic behaviors in adolescents today. Over the past two decades

research has shown that fewer and fewer adolescents take time to eat breakfast, and have

increased their caloric intake by consuming soft drinks, fruit drinks, and eating unhealthy

snacks (Iannotti & Wang, 2013). Obesity has been associated with these poor eating

habits along with low levels of physical activity and high levels of sedentary behavior

(Iannotti & Wang, 2013). Healthy eating habits have been observed in adolescents who

engaged in physical activity for at least 60 minutes per day. These adolescents have

shown higher rates of consuming breakfast on the weekdays and weekends, consumed

more fruits and vegetables, and had lower BMI (Iannotti & Wang, 2013). Literature

shows that adolescents who engaged in high physical activity eat breakfast more

regularly than adolescents who engaged in medium to low physical activity (Brooks et

al., 2014). Eating habits of those adolescents who engaged in high physical activity ate

fruit and vegetables at least twice a week as compared to those adolescents who engaged

in medium and low physical (Brooks et al, 2014).

Adolescents engaged in high physical activity also watched less TV and ate fewer

sweets and drank fewer sweetened beverages (Iannotti & Wang, 2013). Obesogenic

behaviors that were found included maximized consumption of energy-dense snacks and

sweetened beverages along with consuming breakfast less than five times per week

(Iannotti & Wang, 2013). Occupational therapists must look at these habits and find

solutions into improving nutrition (Persch et al, 2015), because by engaging in these


obesogenic behaviors, adolescents lead themselves down a pathway of mental and

physical problems, of which can carry over into adulthood (Iannott & Wang, 2013).

Although sleep habits are not mentioned in the wellness model described by

Myers & Sweeny (2008), it is vital aspect of overall wellness, especially in adolescents.

It is also an essential aspect of a person that is looked at in the “Occupational Therapy

Practice Framework” (2014). The National Institute of Health (NIH) has identified

adolescents and young adults (ages 12-25) as a population at high risk for “problem

sleepiness” (National Sleep Foundation, 2000, p.2). Survey data shows that “26 % of

students report sleeping 6.5 hours or less each school night” (National Sleep foundation,

2000, p.2). Favorable sleep patterns were found in those adolescents who engaged in

high exercise levels (Brand, Gerber, Beck, Hatzinger, Pushe, & Holsboer-Trachsler,

2010). The results showed that for mood, sleep quality, and restoring sleep, athletes had

higher scores than the control group. Favorable sleep patterns of “shortened sleep onset

latency, a smaller number of awakenings after sleep onset were observed in the athlete”

along with “higher concentration during the day, and lower tiredness during the day”

(Brand et al., 2010, p.136). Occupational therapists can educate adolescents on the

importance of sleep and make suggestions in regard to environment and participation in

physical activity to encourage favorable sleep patterns (Persch et al, 2015).

The social self: friendships.

Friendships are a vital part to overall wellness because they provide emotional,

material, or informational support when needed, but they also shape and influence

behavior of an individual (Myers & Sweeney, 2008). “The Theory of Planned Behavior

(TPB) proposes that the social environment influences individual behavior via


perceptions of norms, and that these norms (as well as attitudes and perceptions of

behavioral control) subsequently predict intentions and behavior” (de La Haye, Robins,

Mohr, & Wilson, 2011, p.719). Adolescents look to their peers for self-assurance and

compare themselves to each other throughout their daily life. When they see their peers

joining in sporting activities, they themselves can be influenced to engage as well.

Research has shown a link with the idea that friends are a reflection of a person,

suggesting that obesity is contagious. Meaning if a person's friends take part in unhealthy

lifestyle choices, that person will also (de la Haye et al., 2011). Adolescents gravitate

towards peers that have the same level of physical activity, meaning that adolescents who

engage in physical activity look for active peer to associate himself or herself with (de la

Haye et al. 2011).

One’s network of friends can have a direct impact on the beliefs and attitudes

about physical activity (de la Haye et al., 2011). The correlations between cognitive

variables and subsequent physical activity behavior with in adolescents network of

friends was strong, the biggest effect was on attitudes and intentions toward exercise.

Adolescents were seen joining social groups that had similar beliefs and attitudes towards

physical activity (de la Haye et al., 2011). It was determined that youth physical activity

had direct correlation with physical activity of family members and best friends, however

best friends were seen as making the biggest impact on physical activity (Ullrich-French,

2009).

Although family members were not seen as making the biggest impact on

physical activity there has been some significant research done on family significance in

physical activity of adolescents (Brooks, 2014; Peterson et al., 2013). Both boys’ and


girls’ physical activity and vigorous exercise levels were significantly linked to

engagement in sport with family members (Brooks, 2014). Parental social support and

encouragement are significant external motivating factors for adolescents because they

supported the intrinsic motivation for adolescents to engage in physical activity

(Quarema, Palmeira, Martins, Minderico & Sardinha, 2014). Parents can encourage their

child to play sports or take the initiative to take walks or go for runs. Those parents that

engage in physical activity themselves can promote the same physically active lifestyle

for their children.

Environmental Factors that Relate to Physical Activity

A major environmental factor that needs to be addressed in adolescent’s

participation in physical activity is geographic location. Those adolescents who live in

remote rural areas might find fewer resources to engage in physical activity than those

adolescents who live in cities or suburbs that have gyms and community centers available

(Zheng, 2015). One’s geographic location can be a valid implication for possible social

economic status (SES), which can also be a factor that contributes to adolescent’s ability

to engage in physical activity (Zheng, 2015). Those adolescents who come from higher

economic backgrounds reported engaging in higher participation of physical activity,

which inevitably increases their overall wellness (Gisladottir et al., 2013). A notable

observation made was that adolescents who live in rural areas also reported having low

socio-economic status (SES), thus limited resources to afford gym memberships or fees

for extracurricular sports outside of school as compared to urban adolescents with higher

SES (Zheng, 2015). The environment is a vital aspect that is constantly looked at within


the field of occupational therapy. It can limit a persons ability to fulfill their overall

wellness self.

The Need for Occupational Therapy in Adolescents Populations

Occupational therapists, along with the rest of the health care disciplines, were put

to the test when the Patient Protection and Affordable Care Act (ACA) of 2010 was

passed. The challenge of the Triple Aim, a three factor framework of which the ACA is

based upon (Persch et al., 2015), pushed occupational therapy professionals to achieve

quality, efficiency, and cost-effectiveness within the healthcare system (Berwick, Nolan

& Whittington, 2008). This law has recognized the importance of preventive care

through community-based health care and school based health centers. It has been

proven that adolescence is an understudied population within the occupational therapy

discipline (Whitney & Hilton, 2013). Adolescence need for preventive care is great, due

to the constant threat of obesity and sedentary behavior surrounding them. With the use

of physical activity and its positive effects on overall wellness, occupational therapists

can provide opportunities for adolescents to engage in healthy habits throughout multiple

settings.

Purpose

The purpose of this study was to develop the association of physical activity and

the universal wellness of adolescents in the Capital Region of New York State. Our aim

is to explore the opportunities of physical activity and its overall effect on adolescent’s

occupation, based on the Model of Human Occupation. It is expected to see that those

adolescents who do engage in physical activity have an overall healthier well-being.

Outcomes of this study might include; those adolescents who engage in physical activity


will succeed in the classroom, are able to cope with stress, have healthier sleeping and

eating habits, and have a higher self-esteem. It is also likely to see these adolescents have

increased engagement in socialization with peers and less risky behaviors.

Theoretical Perspective

A common model used in occupational therapy is the Model of Human

Occupation (MOHO). The focus of this model is on “the person and how the

environment contributes to one’s source of motivation, patterns of behaviors, and

performance” (Cole & Turfano, 2008, p. 95). This model allows for the opportunity to

explore what motivates adolescents to engage in healthy habits that lead to overall

wellness. MOHO also looks at the environment and the effects it has on a person's

occupational performance. Adolescent’s performance of healthy living can easily be

correlated with the environment in which they live in.

Definition of Terms

Universal Wellness: integrity of the body, mind, spirit and emotions and is available in

the presence or absence of disease or disability (Johnson, 1987).

Physical Activity: any body of movement that requires energy expenditure, according to

the World Health Organization.

Occupation: an essential part of human nature that is manifested by active participation

in self-maintenance, work, leisure, play, and rest (Evans, 1987)

Methods

Design

A mixed method cross-sectional paper survey was used for this study. The survey

packet (parent consent, child assent, and survey) was handed out in an envelope during


homeroom to adolescents. The students took the survey packet home and filled out all

necessary information if they chose to participate. The students then returned the survey

packet to the locked box in the main office. Lisa Slade and Julia Christian, Occupational

Therapy Students at Sage College, secondary advisors to this study, checked the box

weekly and picked up any of the returned surveys.

Research Questions

Central Question: Is there an association of physical activity and the universal wellness of

adolescents?

1. How does physical activity affect socialization with peers?

2. What impact does physical activity have on adolescent self esteem & stress?

3. What effect does physical activity have on adolescent’s academics?

4. What motivates adolescents to engage in physical activity?

5. What limits adolescent’s ability to engage in physical activity?

6. How do environmental affect adolescents engagement in physical activity?

Ethical Procedures

The study was reviewed and approved by the IRB, along with certificate of

completion of the National Institute of Health (NIH). Parent consent forms were sent

with the survey packet. Parent’s consent was given for the researchers to use and analyze

the data. Child assent was also given for the researchers to use the data collected. This

survey was voluntary and anonymous.

Setting

Catholic Central High School & Ichabod Crane High School students were

surveyed at the schools.


Participants

9-12th graders, male and female, age ranging from 13-18 from n= 618 (Ichabod

Crane High School) and n= 323 (Catholic Central High School). The selection process

for this population was random and optional for those who wished to participate. From

the total n=941 available adolescents, n=34 choose to participate in the study. Two of

these participants did not have parental consent and so their surveys were not used. The

total participants involved n=32 was separated by demographic of school in Table 1.

Data Collection

The data collected from the locked boxes at Catholic Central High School and

Ichabod Crane High School identifies adolescent’s physical activity level within the last

seven days. The survey is a modified version of the Physical Activity Questionnaire-

Adolescents (PAQ-A) with an added wellness component (Appendix A). The PAQ-A is

a self-reported measure that is low cost, time efficient, reliable and valid assessment for

large-scale studies. It provides a physical activity score for adolescents that will be used

to compare their universal wellness. The researchers developed the universal wellness

questions to this survey. The surveys were distributed to the schools and were asked to

have their students complete the survey and drop it in the locked box in the main office. It


was made clear that taking this survey was optional. The surveys were picked up from

the lock boxes at the school. They were placed in a binder where the use of a master

code sheet allowed for organized knowledge of consent given by parent and child. The

code sheet was kept separate from the surveys to allow for the participants to remain

anonymous.

Data Analysis

All data was entered into a three tab excel spreadsheet. The first tab collected all

the scores that correspond to the physical activity score, while the second tab collected all

the scores that correspond to the wellness score, and the third tab had all the qualitative

data. The quantitative data was examined using into SPSS statistical analysis software.

Descriptive statistics such as gender, school and grade level were run to analyze the

major trends in demographic information. Regression analysis was computed between

PAQs and wellness questions 9 (sleep), 10 (stress), 11 (risk taking), 13 (friendship), 17

(healthy eating behaviors), 18 (unhealthy eating behaviors), 19 (academic success), 20

(grades), 21 (concentration), 22 (self-esteem), 23 (self-esteem), 24 (self-esteem). A

second regression analysis was done on PAQS and questions 9 (sleep), 10 (stress), 11

(risk taking behaviors), 13 (friendship), 20 (grades) and other variables such as school,

parent engagement, and gender. Other regression analysis tests were done on 13

(friendship), 22 (self-esteem), and 23 (self-esteem), which was then followed by a

regression analysis of 22 (self-esteem) and 23 (self-esteem) on question 13 (friendship).

The variables of school and gender split the data accordingly, and a 2-tailed

Pearson’s correlation were ran with each of the following variables: 9 (sleep), 10 (stress),

11 (risk taking), parent engagement, 13 (friendship), 17 (healthy eating behaviors), 18


(unhealthy eating behaviors), 19 (academic success), 20 (grades), 21 (concentration), 22

(self-esteem), 23 (self-esteem), 24 (self-esteem) in comparison to PAQS in order to look

for if any one variable shows a relationship to adolescent PAQS. Averages of PAQS

scores were identified and turned in percentages to show the PAQS of the adolescents.

Answers to question 16 (prevention to physical activity) were placed on a separate

Excel sheet and divided up into 9 components of prevention. A tally was taken on how

many adolescents responded to each component, allowing researchers to identify

significant areas of prevention to physical activity. A second Excel sheet collected the

open-ended questions to risk taking behaviors, motivation to engage in physical activity,

and barriers to engage in physical activity. The answers to these questions will be

considered in the discussion.

Results

Representation of PAQS

A representation of percentage of PAQS across the data is depicted in Figure 1,

showing that 47% of adolescents had a PAQS between 3-3.99 out of 6, while only 3% of

adolescents had a PAQS between 4-4.99, and 0 % of the participants score a PAQS of 5-

6.


Impact of Wellness Questions on PAQS

Linear regression analysis was performed to show how the questions regarding

wellness impacted PAQS. When all wellness questions; 9 (sleep), 10 (stress), 11 (risk

taking), 13 (friendship), 17 (healthy eating behaviors), 18 (unhealthy eating behaviors),

19 (academic success), 20 (grades), 21 (concentration), 22 (self-esteem), 23 (self-

esteem), 24 (self-esteem) were included in the regression, PAQS was not predicted, F

(12)=1.475, p=.217. However when certain wellness questions 9 (sleep), 10 (stress), 11

(risk taking), 13 (friendship), 20 (grades) were the only questions looked at against PAQS

with inclusion of other variables such as school, parent engagement, and gender, a

variance of 54.7% was identified and a significant relationship was shown, F(8)=3.469,

p=.009. A second regression analysis was done on the wellness data to see what

questions adolescents identified as wellness. The results suggests that questions 13

(friendship), 22 (self-esteem), and 23 (self-esteem) show the most significance to

adolescent wellness, F(3)=3.004, p=.047, and that 24% of these questions explain the

variance of PAQS. Question 13 (friendship), showed the most significance in predicting

PAQS out of the three questions that adolescents identified as wellness with a p=.019.

Out of the 3 questions regarding friendship and self esteem, self esteem was identified as

essential to friendship with a variance of 31.5%, F(2)=6.660, p=.004.

Relationships of PAQS and Wellness Across Gender and School

A Pearson correlation was performed to show a PAQS relationship against

questions 10 (stress), parent engagement, 13 (friendship), and 19 (academic success),

using different variables including gender and school to split the data. Stress, question

10, was looked at with and without gender (Figure 2). All adolescents showed a


significance (p<.05) of PAQS and stress, however a weak correlation (R= .372) was

found (Figure 2A). Females showed a significant relationship between PAQS and stress

(p<.01) with a moderate correlation (R=.509) compared to their male counterparts, whose

data showed no significant relationship (p>.05)(Figure 2B).

The two schools; Catholic Central High School (CCHS) and Ichabod Crane

Central High School (ICCHS) were compared by looking at PAQS to parent engagement

(Figure 3A), academic success (Figure 3B), and friendship (Figure 3C). Parent

engagement and PAQS showed a significant moderate correlation (p<.01, R=.556) in

CCHS adolescents. Academic success showed a significant strong negative relationship

(p<. 05,R=.654) to PAQS at ICCHS. Friendships relationship to adolescents PAQS

showed a strong positive correlation at ICCHS (p<.001, R=.889).


Barriers to Physical Activity

Adolescent prevention to engaging in physical activity had 9 components that

represented common barriers (Figure 4). Of the adolescents that responded (N=23),

N=17 responded with homework being the top reason to not engaging in physical

activity. The bottom response with N=2 adolescents identified being to scared to try out

for a sport and gyms being to expensive as reasons they don’t engage in physical activity.


Discussion

This mixed method cross-sectional paper survey investigation identified

adolescent physical activity level and showed an association between physical activity

and aspects of wellness within occupations does exist. Specifically what was seen by the

results was a relationship between physical activity and friendships, which corresponded

to adolescent self-esteem. Adolescents of this study identified wellness as friendship and


self-esteem. These aspects were linked with increased physical activity within the

adolescent population.

Descriptive factors that were examined were gender, schools, and grade level.

Findings from this investigation provided insight to many of the researcher questions.

The most significant finding was that in the past 7 days those adolescents with higher

physical activity scores also had higher engagement with friends while doing physical

activity at ICCHS. Unexpectedly, we found a negative association between academics

success and PAQ score with ICCHS students. Looking at the findings for CCHS it

showed there was no relationship between a higher PAQ score and adolescents having

academic success. However, there was a strong association between PAQS and parent

engagement for students at CCHS. Gender was also a factor in the investigation; it

showed that girls who had a higher PAQ score were less stressed. Surprisingly there was

not an association between PAQ scores for males in relation to stress.

The researchers found that less than half of the adolescents surveyed at CCHS

and ICCHS, scored a physical activity rating of 3-3.99 in the past seven days, which is

considered moderate engagement in physical activity. The investigation into physical

activity barriers was most affected by adolescents not having enough time to be

physically active due to homework. The second leading cause of decreased physical

activity was that adolescents are spending their leisurely time watching TV and playing

video games.

The open-ended results of the investigation have added to the literature supporting

the belief that physical activity is beneficial to adolescents. Physical activity does not

only prevent chronic diseases in adolescents but has a positive relationship on certain


aspects of well-being such as friendships contributed to self-esteem (de la Haye et al.,

2011), academics (Van Dijk et al., 2014; Gisladottir, Matthiasdottir, & Kristjansdottir,

2013), and parent involvement (Brooks, 2004). One aspect of our investigation that was

different than the literature was academic success. Our survey determined that a higher

PAQ score did not result in higher academic success at ICCHS. The lack of academic

success at ICCHS may have been the result of fewer survey participants than compared to

CCHS. The researchers believe that this was not a proper representation of overall

academic success with physical activity scores with ICCHS students.

An open-ended question regarding risk-taking behaviors was addressed in survey,

due to present literature that found adolescents who engaged in higher risk taking

behaviors were less physically active (Delisle, Werch, Wong, Bian & Weiler, 2010).

From our investigation we could not link a positive relationship between more physical

activity and less risk taking behaviors because of the lack in responses. Those who

responded identified that alcohol, marijuana, cigarettes, and poor eating habits during

times of stress contributed to risk taking behaviors. These risk taking behaviors did not

affect their physical activity level.

Adolescents reported that their physical activity level was affected by

environmental factors such as geographic location. The literature supports that location

is a barrier for adolescents who want to engage in physical activity (Zheng, 2015).

Adolescents in our study and in comparing research identify living too far away and

having limited to no transportation as barriers to participating in physical activity, such as

fitness centers. Occupational therapists could occupy this space by developing a home

exercise programs to complete when adolescents are unable to exercise within their


community. With schools that provide a late bus option, an occupational therapist could

offer after school physical activities with adolescents in a weight room or gymnasium.

Adolescents who do not have transportation could benefit from an occupational therapist

commuting to their community, and providing physical activities at a local park. This

would give adolescents who cannot participate in physical activities at school the

opportunity to do so within their community with friends.

Lastly, we found that motivation was a factor that positively relates to physical

activity level. Parents, friends, family, and future goals such as getting into a desired

school were all external motivators for engaging in physical activity. Internal motivating

factors that were described include: wanting to be physically fit, looking good, and

relieving stress. Occupational therapists are educated on the Model of Human

Occupations, which looks at a person’s motivation. Occupational therapists can work

with adolescents to find out what physical activity motivates them and set up a schedule

to implement this into their daily activities.

There are important study limitations in this investigation. The information

reported by adolescents was self reported questionnaire. Adolescents could have reported

a skewed perception of their physical activity, resulting in untruthful results. Second, the

students had a limited time to fill the survey out and get it back to the school, therefore

shortage of time could have been a factor. Future research is important within this

population, specifically in the occupational therapy discipline. Areas of wellness should

be thoroughly researched include the affects of physical activity on nutrition, sleep, and

risk taking behaviors. Socio-economic status and the disadvantages of adolescents living

in a low-economic community should be further investigated as well. Currently,


occupational therapists rarely work with the adolescent population. The inclusion of

occupational therapist in adolescent lives could improve overall wellness for this high-

risk population.


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Appendix

Physical Activity Questionnaire This survey will help identify what physical activity you engage in and how it may or may not affect your academics, self-esteem, stress level, social engagement and sleep. This is not a test and is voluntary and confidential. You may skip and not answer any question that gives you feelings of discomfort or distress. Please do your best to answer correctly and best to your knowledge. General Questions: School: ______ Gender: M____ F____ Age: _____ Grade: _____ Physical Activity Questions: These questions are based on your level of physical activity from the last 7 days. Definition of Physical Activity: any bodily movement that requires energy expenditure. 1. Physical activity in your spare time: Have you done any of the following activities in the past 7 days (last week)? If yes, how many times? (Mark only one circle per row.) No 1-2 3-4 5-6 7 times or more Skipping __ __ __ __ __ Rowing/canoeing __ __ __ __ __ In-line skating __ __ __ __ __ Tag __ __ __ __ __ Walking for exercise __ __ __ __ __ Bicycling __ __ __ __ __ Jogging or running __ __ __ __ __ Aerobics __ __ __ __ __ Swimming __ __ __ __ __ Baseball, softball __ __ __ __ __ Dance __ __ __ __ __ Football __ __ __ __ __ Badminton __ __ __ __ __ Skateboarding __ __ __ __ __ Soccer __ __ __ __ __ Street hockey __ __ __ __ __ Volleyball __ __ __ __ __ Floor hockey __ __ __ __ __ Basketball __ __ __ __ __ Ice skating __ __ __ __ __ Cross-country skiing __ __ __ __ __ Ice hockey __ __ __ __ __ Other: _______________ __ __ __ __ __ _______________ __ __ __ __ __


2. In the last 7 days, during your physical education (PE) classes, how often were you very active (playing hard, running, jumping, throwing)? (Check one only.)

I don’t do PE __ Hardly ever __ Sometimes __ Quite often __ Always __ 3. In the last 7 days, what did you normally do at lunch (besides eating lunch)? (Check one only.)

Sat down (talking, reading, doing schoolwork) __ Stood around or walked around __ Ran or played a little bit __ Ran around and played quite a bit __ Ran and played hard most of the time __

4. In the last 7 days, on how many days right after school, did you do sports, dance, or play games in which you were very active? (Check one only.) None __ 1 time last week __ 2 or 3 times last week __ 4 times last week __ 5 times last week __ More than 6 times last week __ 5. In the last 7 days, on how many evenings did you do sports, dance, or play games in which you were very active? (Check one only.)

None __ 1 time last week __ 2 or 3 times last week __ 4 times last week __ 5 times last week __ More than 6 times last week __ 6. On the last weekend, how many times did you do sports, dance, or play games in which you were very active? (Check one only.) None __ 1 time __ 2-3 times __ 4-5 times __ 6 or more times __


7. Which one of the following describes you best for the last 7 days? Read all five statements before deciding on the one answer that describes you. All or most of my free time was spent doing things that involve little physical effort__ I sometimes (1-2 times last week) did physical things in my free time __ I often (3-4 times last week) did physical things in my free time __ I quite often (5-6 times last week) did physical things in my free time __ I very often (7 or more times last week) did physical things in my free time __ Do not need to fill out. For office use only. PAQS _____/8 8. Mark how often you did physical activity (like playing sports, games, doing dance, or any other physical activity) for each day last week. None Little bit Medium Often Very Monday ____ ____ ____ ____ ____ Tuesday ____ ____ ____ ____ ____ Wednesday ____ ____ ____ ____ ____ Thursday ____ ____ ____ ____ ____ Friday ____ ____ ____ ____ ____ Saturday ____ ____ ____ ____ ____ Sunday ____ ____ ____ ____ ____ 9. In the last 7 days, did you sleep more than 8 hours?

Always __ Very Often __ Sometimes __ Rarely __ Never __

10. In the last 7 days, how many times have you used physical activity as an outlet to decrease your stress level? None __ 1 time last week __ 2 or 3 times last week __ 4 times last week __ 5 times last week __ More than 6 times last week __


11. In the last 7 days, have you engage in any risk taking behaviors such as, alcohol, drugs, stealing, violence towards others(people or animals), as an outlet to decrease your stress level? None __ 1 time last week __ 2 or 3 times last week __ 4 times last week __ 5 times last week __ More than 6 times last week __ 12. Please describe what risk taking behaviors you engage in if any?

13. In the past 7 days how frequently did you engage with friends while doing physical activity?


14. Did your parents within the past 7 days encourage you to engage in physical activity? Always __

Very Often __ Sometimes __ Rarely __ Never __

15. Were you sick last week?

Yes____ No____ If yes, did this prevent you from engaging in physical activity last week?

Yes _____ No_____ 16. What things prevent you from doing physical activities besides sickness/disability? Check all that apply. Limited options of interested physical activities at my school ___ No transportation ___ Too expensive__ No gyms around me __ Scared to try out for sports___ Fear of failure__ Limited time due to job___ Limited time due to homework___


Netflix, Hulu & TV watching, video games___ 17. After exercising I normally tend to eat healthier foods like veggies, fruit, whole grains, and protein? Always __ Very Often __ Sometimes __ Rarely __ Never __ 18. If I don’t exercise I normally tend to eat foods that are high in sugar and saturated fats like, cookies, candy, chicken tenders, and fries? Always __ Very Often __ Sometimes __ Rarely __ Never __ 19. Do you feel like you academically succeed in the classroom?


20. What grades do you earn in your classes? A __

A-B __ B __ B-C __ C __ C-D __

F __ 21. Do you struggle concentrating in class?


22. I feel failure in life…

Always __ Very Often __ Sometimes __


Rarely __ Never __

23. When I look in the mirror I am usually unhappy with how I look… Always __ Very Often __ Sometimes __ Rarely __ Never __

24. I tend to be quiet even when I feel strongly about something… Always __ Very Often __ Sometimes __ Rarely __ Never __

25. For those who do engage in physical exercise daily what motivates you to do so? If you don’t engage in daily physical activity please leave this question blank and proceed to question 22.

26. For those that don’t engage in physical exercise please explain why?

a master’s thesis for oth-670- research seminar ii

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