Physical Activity Levels and Healthy Lifestyle Behaviors of High School Students

ABSTRACT


Introduction
Healthy lifestyle behaviors pertain to the individuals' evaluation of all behaviors affecting their physical and mental health, their adoption of responsibilities for their health, and the arrangement of their daily activities (EsraÇiçek, 2017).These are the behaviors through which individuals assume responsibilities for a sufficient and balanced diet, stress management, regular physical activity, self-fulfillment, interpersonal relations, and the protection and development of health (Aksoy & Aydın Özkan, 2016).
Among these behaviors, physical activity, which is key to a healthy life, is defined as a body movement that is generated by skeletal muscles and causes the individual to spend energy (Mburu-Matiba, 2015;Tavazar, 2014).This definition covers all body movements from hobbies to daily life activities, all sports branches, free time activities, housework, walking, and cycling (Miles, 2007).
Regular physical activity has a large effect on health across the lifetime.The major effects of regular physical activity are the maintenance of the energy balance along with the rising metabolic rate, protection of bone health, and reduction of incidence rates of chronic diseases including cardiovascular diseases, metabolic syndrome, hypertension, and type-2 diabetes.Additionally, regular physical activity has positive effects on psychological health by the reduction of the risk of having anxiety and depression, enhancing self-esteem and self-confidence, promoting academic success, the improvement of the quality of life, and the enhancement of life satisfaction (FitzGerald, 2015;Mburu-Matiba, 2015;Ojiambo, 2013).In light of the above, moderate-intensity physical activities are recommended for adolescents for a minimum of 60 minutes every day.Strength activities to be performed at least twice a week to empower the muscles and bones should be among the activity preferences (Miles, 2007).
All across the world, physical immobility ranks fourth among risk factors that are likely to lead to death.Physical immobility is estimated to be the root cause of approximately 21%-25% of the cases of breast cancer and colorectal cancer, 27% of the cases of diabetes, and 30% of the cases of ischemic heart disease (T.C.Sağlık Bakanlığı Türkiye Halk Sağlığı Kurumu-Turkish Republic Ministry of Health Turkiye Public Health Agency, 2014).Factors affecting this situation, such as age, gender, and genetics, cannot be altered whereas several risk factors related to chronic diseases can be changed (Tagoe & Dake, 2011).If physical activity, as one of the significant factors that can be changed, is performed regularly, this will provide individuals the opportunity to develop a healthy lifestyle by helping them enhance physical fitness and endurance (Turkmen et al., 2013).
Adolescence is a period, which covers 10-19 years of age and during which big changes in social interactions and relations take place besides physical and psychological changes (World Health Organization (WHO), 2019).The most general feature of this period is that adolescence is a process during which adolescents' behaviors and attitudes develop, and also, adolescents can adopt unhealthy lifestyle behaviors likely to harm themselves or others while they can acquire positive healthy lifestyle behaviors as well (EsraÇiçek, 2017;NilüferTuğut, 2010).
As of the end of 2020, the total number of the child population was 22,750,657 in Turkey.Male children made up 51.3% of the child population while female children formed 48.7% of the child population in Turkey.As per the United Nations definition, the percentage of the child population formed by children aged 0-17 years was found as 27.2% of the general population in Turkey in 2020 (Turkish Statistical Institute, 2021).Analyzing the health behaviors of students in adolescence period, making efforts to eliminate negative health behaviors and promote positive health behaviors, reducing barriers to physical activity, advocating physical activity, and making physical activity a regular habit are important to the health of the individual, family, and society because behaviors and habits adopted in this period can be continued during adulthood mostly, and directly affect the health, safety, peace, and success of society (Çavuş et al., 2017).
A recent research study in Turkey found that 41.4% of the males aged 12-14 years and 44.6% of the males aged 15-18 years never did exercise whilst these percentages were 69.8% and 72.5% for females aged 12-14 years and females aged 15-18 years, respectively.Besides, it was identified that 26.2% of the males and 7.0% of the females aged 12-14 years did regular exercise whilst 14.6% of the males and 9.9% of the females aged 15-18 years did (Hacettepe University Faculty of Health Sciences Department of Nutrition and Dietetics, 2019).
The developing and changing societal structure, technology, and needs caused nurses' roles to change as well.Nurses who are constantly in interaction with individuals in several settings such as primary healthcare services, hospitals, schools, and workplaces have an enormous advantage in having easy access to adolescents (NilüferTuğut, 2010).Accessing adolescents is of paramount importance as healthrelated permanent behaviors are adopted in the adolescence period and adolescents will form the building blocks of the future society (Ozakgul et al., 2016).Therefore, nurses should target the young population in their health-supporting efforts to promote health and develop behaviors and raise the welfare of the community (Lee & Loke, 2005).Nurses' initiatives to develop adolescent health and equip the adolescent with healthy lifestyle behaviors are of utmost importance.Identifying adolescents' negative health behaviors and attitudes, equipping them with healthy life awareness, and supporting them on topics intended for positive health behaviors, such as regular physical activity, nutrition, and the establishment of effective interpersonal communication can be cited as examples of these initiatives (Aksoy & Aydın Özkan, 2016;HaticeTambağ, 2011).
This research was planned to analyze the relationship between physical activity levels and healthy lifestyle behaviors of high school students.In the context of the analysis of the relationship between physical activity levels and healthy lifestyle behaviors of high school students, offering guidance to interventions to be implemented to increase adolescent physical activity, encouraging adolescents, who will represent the majority of the future population, to adopt healthy life and regular physical activity habits, and contributing to the nursing literature and the prospective studies on the topic were targeted in this research.

Material and Methods
The research population comprised a total of 396 students in the ninth, tenth, eleventh, and twelfth grades at the two high schools located in the district of Tortum of Erzurum province of Turkey.The entire population was reached in the study sample; however, the research was completed with 371 students, excluding 25 students who did not agree to participate in the research or did not attend the school when the research was carried out.After the receipt of permissions from school administrations and approvals from students' and parents, data collection forms were administered to students in the fall semester of the 2017-2018 academic year.

Data Collection Tools
The research data were collected with the Personal Information Form, the Physical Activity Questionnaire for Adolescents, and the Health-Promoting Lifestyle Profile-II.
The Personal Information Form Personal information form was designed to identify each high school student's socio-demographic characteristics including age, gender, height, weight, parents' education levels, parents' occupations, monthly household income level, and family type.

The Physical Activity Questionnaire for Adolescents (PAQ-A)
Crocker et al. developed the PAQ-A and performed its validity and reliability study (CROCKER et al., 1997).The Turkish version of the PAQ-A created by Tanır was used in this study (HalilTanır, 2014).Cronbach's alpha coefficient was calculated as 0.76 for the PAQ-A.In this study, Cronbach's alpha coefficient was found as 0.87 for the PAQ-A.
The PAQ-A comprised nine questions rated from 1 to 5, and a score of 5 points shows the highest level of physical activity whilst a score of 1-point points to the lowest level of physical activity.The mean of scores obtained by a participant from all PAQ-A questions is the total physical activity score of the individual participant.Participant adolescents are categorized as inactive, moderately active, and active according to the reference PAQ-A scores (Uçar, 2014).

The Health-Promoting Lifestyle Profile-II (HPLP-II)
The scale that was originally developed by Walker et al. (1987) was revised in 1996 as the HPLP-II, and Bahar et al. performed the validity and reliability study for the HPLP-II in Turkey (Bahar et al., 2008).The HPLP-II has 52 questions and 6 sub-scales, that is, Spiritual Development, Health Responsibility, Physical Activity, Nutrition, Interpersonal Relations, and Stress Management.All HPLP-II questions are rated as per a four-point Likert-type scale (Never: 1, Sometimes: 2, Frequently: 3, Regularly: 4).Minimum and maximum scores to be obtained from the overall HPLP-II are consecutively 52 and 208 points (Aksoydan & Çakır, 2011).Cronbach's alpha coefficient for the HPLP-II was 0.92, and thus the HPLP-II had high-level reliability (Aksoydan & Çakır, 2011;Bahtiyar, 2017).In this study, Cronbach's alpha coefficient was found as 0.91 for the HPLP-II.

Ethical Aspect of the Research
Each phase of the study was carried out in full compliance with ethical principles.This study approved by first from the Ethics Committee of Cumhuriyet University (No: 30182376-044).Besides, each student included in the sample consented in written format and verbally to participate in the research, and likewise, the informed consent for the participation was received from the parents.

Statistical Analysis
The Statistical Package for Social Science version 22.0 was used for the statistical analysis of the study data.In this respect, descriptive statistics were calculated, and the Kolmogorov-Smirnov test was utilized to check whether the research data were normally distributed.Next, the student's t-test and the one-way analysis of variance (ANOVA) were used for the normally distributed data whilst the chi-squared test was used for data without normal distribution.Besides, correlation analysis was utilized to find out the relationship between the two variables.Statistical significance was identified if the p-value was below 0.05.

Results
A total of 371 high school students were included in the study.Results were addressed in light of the students' certain personal characteristics and the breakdown of scores obtained by students from scales used in the study.Of all students, 32.9% were in the ninth grade, 38.5% had four or more siblings, 65% stayed at the boarding school, 65% had a normal weight, 88.7% had no health problem, 84.6% had no obstacle preventing them from performing physical activity in the last week, and 46.4% were moderately active (Table 1).Although the physical activity levels of the students were found to be in positive correlation with gender and the place of residence (p<0.001,0.031, respectively), these levels had no significant correlation with the other variables (Table 2).Of all students, 35.0%walked for exercise once or twice, 35.6% jogged once or twice, and 41.8% played volleyball once or twice, however, for the most part, students did not perform other types of physical activities during the last seven days (Table 3).Mean HPLP-II score of students' was found to be 113.29±20.86 points, thus, the students obtained a medium-level mean score from the HPLP-II (Table 4).There was a statistically significant weak positive relationship between physical activity and healthy lifestyle behaviors (p<0.05)(r:0.466)(Table 5).Hence, an increase in healthy lifestyle behaviors was found to be accompanied by an elevation of the physical activity level and vice versa.

Discussion
This study revealed a positive correlation between the healthy lifestyle behaviors and physical activity of high school students.A similar study showed that 70.7% of the male and 86.4% of the female adolescents were inactive (Aksoydan & Çakır, 2011).Present study found that 47.7% of the male students were moderately active and 51.5% of the female students were inactive.Hence females were found to be more immobile than males, and having a large number of sports places conducive to physical activity at the school in comparison to home and having a large number of physical activities and team sports in the physical training course affected the physical activity levels of students who stayed at the boarding school.
Vast majority of the students performed no physical activity in their free time during the last seven days, only 35.0% of the students walked for exercise once or twice, 35.6% of them jogged once or twice, and 41.8% of them played volleyball once or twice (Table 3).Tavazar et al. reported that 38.2% of the high school students were not involved in any sports branch at all, and the branches of sports played most by students were successively soccer (19.9%), volleyball (13.0%), and basketball (11.5%) (Tavazar, 2014).The reasons for the gradual increase in physical immobility is considered as the factors such as the students' limited financial opportunities, restricted free time due to the examinations and courses, the insufficiency of spaces where students would perform different sports activities, the allocation of time to smartphones and internet.Besides since the majority of the students stayed at the boarding school this can be another restrictive point.
The HPLP-II measures health-promoting behaviors in connection with students' healthy lifestyles.Thus, high scores of HPLP-II shows that young individuals have high intention levels of having and acquiring health-promoting behaviors (Bahar et al., 2008;Bebiş et al., 2015).Recent studies with HPLP-II reported the mean HPLP-II scores 118.25±15.48-128.51±26.30points between the high school students (Bahtiyar, 2017;EsraÇiçek, 2017;Karadamar et al., 2014;Kefeli Çol & Altay, 2021;Ozakgul et al., 2016;ŞenayAras Doğan, 2018).In accordance with the literature mean HPLP-II scores of 113.29±20.86 points (Table 4) in this study showed a medium-level HPLP-II score.The slight difference can be attributed to the geographic features of the study location which had limited facilities due to the seasonal and physical conditions.
Health responsibility is defined as the responsibility felt actively by individuals for their well-being and health state (Bahar et al., 2008).In our study, the mean HPLP-II Health Responsibility Sub-Scale scores was found 16.14±4.75points which is classified as low level (Table 4).Students obtained the lowest mean score from the HPLP-II Health Responsibility Sub-Scale.This situation is thought to be stemmed by the small number of courses on health education in school curriculum.The mean HPLP-II Health Responsibility Sub-Scale scores were revealed 16.5±3.9-18.3±4.9 points in similar studies (EsraÇiçek, 2017;Karadamar et al., 2014;Ozakgul et al., 2016).Therefore, adolescents need support to complete their cognitive development processes in order to take the responsibility for their health.In our study, having a low-level health responsibility is an expected result, and it may have stemmed from the increase in the feeling of independence, inner conflicts, and the search for identity triggered by the adolescence period and the fact that students did not yet complete their cognitive development processes (Marconcin et al., 2021).
The HPLP-II Physical Activity Sub-Scale evaluates at which level the individuals perform exercises and physical activities regularly (Marconcin et al., 2021).In the adolescence period during which rapid growth and development occur, performing and advocating physical activities are of paramount importance to the acquirement of the habit of regular physical activity throughout the lifetime (Kefeli Çol & Altay, 2021).In our study, the mean of high school students' HPLP-II Physical Activity Sub-Scale scores was found as 16.25±4.80points (Table 4).This score was lower than the one obtained in the study performed on high school students by Karadamar et al. (17.7±4.8 points) whereas it was higher than the other similar researches (Akoğuz Yazici, 2022;EsraÇiçek, 2017;Karadamar et al., 2014;Ozakgul et al., 2016;ŞenayAras Doğan, 2018).In the relevant literature, it is discerned that physical activity health behaviors were generally at low levels.It is expected that students will become dynamic and energetic in this period and students in the middle and late adolescence periods will obtain a high mean score from the Physical Activity Sub-Scale (Marconcin et al., 2021).Finding a mean Physical Activity Sub-Scale score that is lower than expected in our study can be explained by the fact that students spent most of their time at school, sports spaces at the school and in its surroundings were insufficient, and students preferred technological tools such as computer, internet, and mobile phone to the regular physical activity.
Healthy eating habits play a key role in the promotion of growth and development, the renewal of cells and the continuation of their functions, and the development of healthy behaviors.Eating well can help protect against chronic diseases, which can emerge in adolescence and continue in adulthood, such as diabetes, hypertension, cardiovascular diseases, and certain types of cancer (Değerli & Yiğit, 2020;Musavian et al., 2014).In our study, the mean of high school students' HPLP-II Nutrition Sub-Scale scores was identified as 17.82±4.00points (Table 4).This finding is parallel to those in the relevant literature.Upon the review of other studies performed on high school students, it is discerned that the finding of our study is similar to the one in the study by Çiçek (17.7±3.7 points) and is lower than those obtained in the study by Karadamar et al. (20.2±3.9 points) and the study by Bahtiyar (23.10±4.12 points) (EsraÇiçek, 2017;Karadamar et al., 2014;Kefeli Çol & Altay, 2021).Considering that the eating habit is a behavior adopted in early periods, it can be alleged that the above finding may have resulted from the failure to continue the regular eating habit in the family, which is the first place to acquire this habit, and later at schools.Also, the above finding can be obtained as the education system offered at schools did not focus adequately on healthy eating and students could not comprehend the importance of eating well.
Spiritual development is a unifying power beyond the individual's self-existence, which is also affected by physical development of the body (Bahtiyar, 2017).In our study, the mean of high school students' HPLP-II Spiritual Development Sub-Scale scores was found as 22.92±5.03points (Table 4).This figure is lower than those obtained in relevant studies performed on high school students (Bahtiyar, 2017;Kefeli Çol & Altay, 2021;Ozakgul et al., 2016).On the other hand, in this study, high school students obtained the highest mean score from the Spiritual Development Sub-Scale.The spiritual development process begins earlier in life and is affected by several societal constructs such as family and school (Kefeli Çol & Altay, 2021).It can be considered that the finding of our study was affected by factors such as beliefs and value judgments of the family and society of high school students, strong family ties, positive life perspective, and the level of satisfaction.
The Interpersonal Relations Sub-Scale evaluates individuals' relations with family, friends, and inner circle and the level of continuity of these relations (Bahtiyar, 2017).In our study, the mean of high school students' HPLP-II Interpersonal Relations Sub-Scale scores was 22.13±4.76points (Table 4), and as per this finding, students had high-level interpersonal relations.This can be explained by the fact that relations with friendship groups came forward and increased in adolescence period.The finding of our study is lower than most of the similar studies on high school students (Bahtiyar, 2017;Bebiş et al., 2015;Karadamar et al., 2014;Ozakgul et al., 2016).However, this result is higher than the one obtained in the performed on high school students by Çiçek (17.3±3.4 points) (EsraÇiçek, 2017).
Stress management is the way of the individual identifies physiological and psychological resources and takes action to reduce tension or control it effectively (30).In our study, the mean of high school students' HPLP-II Stress Management Sub-Scale scores was found as 18.04±4.09points (Table 4).This figure is similar to those found in the study performed on high school students by Özakgül et al. (18.69±3.89points) but it is lower than those obtained in the study performed on high school students by Karadamar et al. (20.5±3.7 points) and the study conducted on adolescents by Bebiş et al. (19.54±5.23 points) (BEBİŞ et al., 2015;Karadamar et al., 2014;Ozakgul et al., 2016).The individual in the adolescence period is exposed to intense stress due to physical, phycological, and social changes and developmental duties, identity confusion, the growing importance of relations with the family and peers, and the increase of anxiety and problems stemming from school and examinations (Parikh et al., 2019).Therefore, empowering adolescents to cope with stress positively can enable them to solve existing problems better and look toward the future healthier.
A weak positive relationship between physical activity and healthy lifestyle behaviors was demonstrated in this work (p<0,001, Table 5).In this regard, when there is an increase in the physical activity level, healthy lifestyle behaviors also increase.Hence, regular physical activity that is inhabited as earlier as in adolescence, has a significant place in the development of healthy lifestyle behaviors (ÖzlemDuran, 2014).

Limitations
This study has the limitation of including a particular geographic location of Türkiye.Although the sample size of the study is quite high, due to the local characteristics of the location, further research effort with larger number of participants from different geographic areas is required for a better understanding of the overall condition.

Table 1 .
Descriptive characteristics of the participants (n=371)

Table 2 .
Students' physical activity levels as per their certain descriptive characteristics (n=371)

Table 3 .
Frequencies of physical activities performed by students in their free time during the last seven days in the context of the PAQ-A (n=371)