Nursing & Health Sciences Volume 7 Issue 2 Page 107 - June 2005 doi:10.1111/j.1442-2018.2005.00227.x
Research Article
Gender differences in health habits and in motivation for a healthy lifestyle among Swedish university students
Margareta I. K. von Bothmer1,2, assistant professor, phd, mscn, rnt and Bengt Fridlund1,2,3 professor, phd, rnt
The aim of the present study was to investigate gender differences in students' health habits and motivation for a healthy lifestyle. The sample of students comprised a probability systematic stratified sample from each department at a small university in the south-west of Sweden (n = 479). A questionnaire created for this study was used for data collection. Self-rated health was measured by number of health complaints, where good health was defined as having less than three health complaints during the last month. A healthy lifestyle index was computed on habits related to smoking, alcohol consumption, food habits, physical activity and stress. Female students had healthier habits related to alcohol consumption and nutrition but were more stressed. Male students showed a high level of overweight and obesity and were less interested in nutrition advice and health enhancing activities. The gender differences are discussed in relation to the impact of stress on female students' health, and the risk for male students in having unhealthy nutritional habits in combination with being physically inactive and drinking too much alcohol.
INTRODUCTION
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Health-related behavior in early life influences later risks for lifestyle-related disorders. It is therefore important to investigate health behaviors among young people. University students represent a major segment of the young adult population (Leslie et al., 1999). It makes sense to focus on them in a study of associations between health, motivation for a healthy lifestyle and different health habits in order to improve health promotion activities targeting this group. Students comprise a homogenous and accessible population, which is also relatively healthy. This minimizes the bias related to the influence of illness on health behaviors (Steptoe & Wardle, 2001). The way people assess their own health has been shown to be a good predictor of mortality in many population studies. The predictive power of self-rated health is strong, irrespective of measurement method; one of them is self-rated symptoms (Bue Bjorner et al., 1996).
The major determinants of health are socioeconomic determinants, lifestyle and physical environment (World Health Organization [WHO], 2003). Lifestyle related risk factors, acknowledged in the report, are unhealthy nutrition, physical inactivity, tobacco use and use of alcohol and illicit drugs (WHO, 2003). Macintyre et al. (1996) discussed if women really have higher morbidity than men and argued that an important gender difference was that women suffered more from psychological distress, and men more from physical ailments, while Lahelma et al. (1999) noticed that women showed poorer health but men had more severe ill-health with increasing age.
The gender differences in health according to Denton et al. (2004) are attributable to differing structural (socioeconomic, age, social support, family arrangement) context and to different exposure to lifestyle (smoking, drinking, exercise, diet) and psychosocial (critical life events, stress, psychological resources) factors. Denton et al. (2004) showed that women's health was more influenced by structural and psychosocial determinants such as stress and lower levels of self-esteem, mastery and sense of coherence, while men's health was more affected by health behaviors such as smoking, drinking and physical activity.
To develop health education and health promotion initiatives targeting students, it is important to have detailed knowledge about the health of students and their health related behaviors, and factors that influence these such as knowledge, attitudes, personal resources, motivation for a healthy lifestyle and social support. To our knowledge, few studies have been performed on health and health behavior from a gender perspective among university students. Three examples are: a study by Steptoe and Wardle (2001) showed that students from Western Europe had a healthier lifestyle than students from Eastern Europe regarding smoking, alcohol consumption and diet, and that students from Eastern Europe were more depressed and reported lower social support than students from Western Europe, but no gender differences were discussed. Another study showed that Lithuanian students were more depressed and reported lower social support than students from Spain and Germany (Stock et al., 2003). The gender difference highlighted in the Stock et al. study was that female students reported more health complaints, especially psychosomatic complaints, than male students (Stock et al., 2003). A third study comparing leisure-time physical activity in university students from 23 countries revealed a gender difference, with a higher proportion of men (28%versus 19%, P < 0.001) being physically active at a recommended level (Haase et al., 2004).
The aim of the present study was to investigate gender differences in students' health habits and motivation for a healthy lifestyle built on the following research questions: Are there any gender differences in healthy habits? Are there any gender differences in motivation for a healthy lifestyle? Are there any gender differences in self-rated health? Does motivation for a healthy lifestyle have any association with self-rated health?
METHOD
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Design and setting
A descriptive comparative design was used, with questionnaires as the means of data collection. The study was carried out in the south-west of Sweden at a small university with 5000 students.
Sample and selection
The sample of students comprised a probability systematic stratified sample from each department at the university. Eligible students were those studying on a full-term basis. Selecting every tenth person on each class list, starting with a randomly chosen number, made the systematic sampling. The sample comprised 479 students and the response rate was 69%, ensuing 332 returned questionnaires.
Instrumentation
An instrument was created for this study to cover areas that are deemed important for studying health and health habits. Face and content validity of the questionnaire was established through building the questionnaire on literature reviews of issues related to health, health habits and motivation for a healthy lifestyle. The instrument comprised questions on sociodemographics, health complaints, motivation for a healthy lifestyle, and on different health habits. The instrument covered the following areas and number of items (Table 1):
Sociodemographics: gender, age, height, weight, family situation (living alone or with partner or parent, having children or no children), father's education, mother's education, department at university, term; nine questions. Body mass index (BMI, kg/m2) was calculated on self-reported weight and height. Underweight was defined as BMI 19.0, normal weight as BMI 19.1 24.9, overweight as BMI 25.0 29.9, and obesity as BMI =" type="#_x0000_t75"> 30.0 (Lowry et al., 2000).
Health complaints (headache, stomach ache, cold, flu, symptoms from muscles, back pain, anxiety, coughing, fatigue, sleeplessness, stress, constipation, diarrhea, allergy etc.). The question was: 'Have you, during the last month, been bothered by any of the following symptoms?' (listed as above); 16 questions. Response alternatives were 'yes' and 'no'. The 'yes' answers were computed together for each individual and formed the composite scale 'Health complaints', which was then reversed and presented as self-rated health. Good health was defined as having less than three symptoms during the last month, and poor health as having more than seven symptoms.
Motivation for a healthy lifestyle: comprised three areas, namely willingness to participate in health promotion activities, attitudes towards changing lifestyle, and recent changes in health related habits. These formed a 'motivation for healthy lifestyle index'.
Questions related to health habits: tobacco use, alcohol consumption, food habits, physical activity, and stress. A healthy lifestyle index was constructed by summing the number of healthier options for each individual (Steptoe & Wardle, 2001). Respondents were classified in three categories of healthy lifestyle; poor (0 1 healthy habit), medium healthy (2 3 healthy habits) and healthy (4 5 healthy habits).
Weight concern: three questions; satisfied with actual weight, ought to weigh less, and ought to weigh more.
Sexual life: two questions; satisfied with sexual life and having access to satisfying sexual life. Answers from these two questions were computed and formed a three-level satisfaction with sexual life scale (low, medium and highly satisfied).
Social network and social support: seven questions, reflecting social support availability, social support satisfaction and social support. The answers were computed and the social support index was scaled in low, medium and high level of social support/network.
All questions, if not otherwise noted, were put on a seven-point semantic differential scale with endpoints: 'strongly disagree' and 'strongly agree'.
The questionnaire was tested with a pilot study on 50 nursing students and some revisions were made, that is, the exclusion of 34 superfluous questions and the addition of three response options on health complaints and 10 options for recent changes in health related habits instead of one open question. The internal consistency was tested with Cronbach's alpha reliability coefficient and was acceptable at 0.73. The instrument is hereafter called the Health and Health Habits Instrument (3HI).
Data collection
Permission was obtained from the Vice Chancellor of the university, as the university did not have a separate ethical committee. Before permission was given, the Vice Chancellor requested information about the research aims, procedures and reporting of results, and then gave permission on condition that the students did not have any objections. All respondents were informed about confidentiality, freedom to participate and the right to withdraw from the study at any point. The information sheet also informed participants about the aim of the study, the use of code numbers and the researchers.
The address list was acquired from the student union. The questionnaire was successfully sent by post with a stamped envelope attached to 479 students and 332 responded, four of them with blank questionnaires. To encourage quick and full answers, students who returned the first 100 completed questionnaires were offered a small incentive (lottery ticket). All questionnaires were sent back to the researchers with anonymity preserved. Code numbers were used to facilitate reminders. Reminders were sent to 225 students after 2 weeks and resulted in 60 additional responses. No further reminder was sent as it was at the end of the term, and it was considered unlikely that the students would respond later.
Data analysis
All analysis was carried out using the Statistical Package for Social Sciences, version 10.0 (SPSS, Chicago, IL, USA). Descriptive statistics were used to illustrate the preliminary information. Chi-squared statistic was used as a test of independence between groups, and Phi-coefficient or Cram¨¦r's V index was used as a measure of association to quantify the strengths of the relationships (Norusis, 1998). Statistical significance was denoted by P < 0.05.
RESULTS
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Description of the sample
The sample comprised 49% women and 51% men (Table 2). Seventy-one percent were younger than 30 years of age and the majority (59%) lived by themselves. Seventy-six percent did not have children. More women than men had a partner and had children.
Self-rated health
The most common reported symptoms among the students were stress (60%), tiredness (57%), headache (52%) and pain in the back and neck (51%) (Table 3). Female students reported stress, tiredness and headache more than male students did. No significant differences in self-rated health were found between younger and older students, or between students with or without children.
Health-related lifestyle
Female students showed a higher degree of healthy habits (P < 0.001, Cramer's V: 0.23) (Table 4). The mean smoking rate was 22% (20% for female students, 24% for male students). There was an association between smoking and alcohol use (P < 0. 01; Cramer's V: 0.24) in the male population. There was a difference in attitudes towards smoking among female and male students, in that female smokers who smoked more than 10 cigarettes/day thought they smoked too much (P < 0.05, Cramer's V: 0.42).
There was a significant difference between alcohol use by female and male students (P < 0.001, Cramer's V: 0.59). The overall mean alcohol intake per occasion was four drinks per occasion and the mean frequency was 2 3 times a month, which matched up to 2.22 units/week for female students and 4.79 units/week for male students. Abstainers comprised 4% of the student population. Fifteen percent of the students used alcohol in heavy quantities, and 40 out of 48 were men. Students who drank more often also consumed larger quantities at each occasion (women: P < 0.01, Cram¨¦r's V: 0.28; men: P < 0.001, Cram¨¦r's V: 0.29). Men used alcohol more often than women did (P < 0.01, Cram¨¦r's V: 0.24) and in higher quantities (P < 0.001, Cram¨¦r's V: 0.50). The heavy consumers were found among students who were single and without children. Ten out of 18 male students with heavy alcohol consumption reported stomach pain (P < 0.01, Cram¨¦r's V: 0.27) and eight out of 19 reported sleeping problems (P < 0.01, Cram¨¦r's V: 0.26). It was more common among male students to have the opinion that drinking is a part of student life (P < 0.01, Cram¨¦r's V: 0.20) and that use of alcohol makes it easier to socialize (P < 0.001, Cram¨¦r's V: 0.22). There was no significant association between reported anxiety and alcohol consumption.
Female students had healthier nutritional habits than male students (P < 0.001, Cram¨¦r's V: 0.26) (Table 4). There was no association between students' nutritional habits and their knowledge of healthy food. Male students had poorer knowledge than female students about healthy food (P < 0.01, Cram¨¦r's V: 0.34). Male students were more overweight and obese than female students (P < 0.001; Cram¨¦r's V: 0.27), with 30% being overweight and obese compared to 13% among female students. Male students' mean BMI was significantly greater than that of female students (23.84 ¡À 2.61 vs 22.27 ¡À 2.67, P < 0.001, Cram¨¦r's V: 0.27). Sixty-one percent among overweight and obese male students were satisfied with their own weight. Among the students with normal BMI, 64% of female students (n = 79) and 76% of male students (n = 87) were dissatisfied with their weight, with women wanting to weigh less.
Seventy-one percent of the students exercised regularly; there was no difference between female and male students (Table 4). Of 65 female students with a high level of physical activity, 91% (n = 59) were non-smokers (P < 0.01, Cram¨¦r's V: 0.24). Male students experiencing low social support did exercise at a low level (P < 0.05, Cram¨¦r's V: 0.22). Co-habiting female students who were satisfied with their social support did physical exercise at a higher level than those who did not experience social support (P < 0.01, Cram¨¦r's V: 0.37). The level of physical activity was associated with access to good facilities for exercising (female students: P < 0.01, Cram¨¦r's V: 0.25; male students P < 0.001, Cram¨¦r's V: 0.37).
Twenty-seven percent of the student population showed high stress, with female students showing more stress than men (P < 0.01, Cram¨¦r's V: 0.18). There was an association between perceived stress and number of health complaints (P < 0.001, Cram¨¦r's V: 0.32 for women; 0.35 for men). Male students were more dissatisfied with sexual life than female students (P < 0.001; Cram¨¦r's V: 0.26) (Table 4). There was an association among men between healthy lifestyle index and number of health complaints (P < 0.001, Cram¨¦r's V: 0.29); a healthier lifestyle was associated with fewer health complaints, but this association was not found among women, where instead those with a healthy lifestyle had more health complaints. Perceived social support was associated with fewer symptoms for women (P < 0.01, Cramer's V: 0.28).
Motivation for a healthy lifestyle
Women participated more in health activities than men did (P < 0.001, Cram¨¦r's V: 0.23). There were significant differences between male and female students in interest in health promoting activities. Female students were more interested than male students in changing their dietary habits, levels of physical activity and practicing relaxation (P < 0.001, Cram¨¦r's V: approximately 0.23). Very few students (between 2% and 4%) were interested in smoking cessation activities or in getting advice on alcohol consumption. The 'Motivation for healthy lifestyle index' showed that female students were more motivated for a healthy lifestyle than male students (P < 0.001, Cram¨¦r's V: 0.27).
The 'Motivation for healthy lifestyle index' did not show statistically significant associations with smoking, alcohol consumption or food habits, but had a positive association with physical activity (P < 0.01, Cram¨¦r's V: 0.28 for female students, and P < 0.001, Cram¨¦r's V: 0.36 for male students). A high level of stress among female students was associated with a high level of motivation (P < 0.01, Cram¨¦r's V: 0.27).
There was an association for female students between self-rated health and motivation for a healthy lifestyle in that higher motivation was associated with more health complaints (P < 0.01, Cram¨¦r's V: 0.25). Closely related to the motivation index is number of health activities, which, among women, showed a negative association with self-rated health (P < 0.01, Cram¨¦r's V: 0.24). Women reporting a high degree of health improving activities suffered more than men from headache (P < 0.05, Cram¨¦r's V: 0.23), stomach pain (P < 0.01, Cram¨¦r's V: 0.25) and stress (P < 0. 05, Cram¨¦r's V: 0.26).
DISCUSSION
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Methodological issues
The technique of sampling and data collection is deemed to be applicable to the aim of the study. The sample was of a large enough size, and was equal in size between genders. The attrition rate was an acceptable 31%. The sample is not population representative as it comprised university students, and therefore caution in generalization of the results is necessary. University students are better educated than a population-based sample and also younger, and lifestyle behaviors in terms of smoking, drinking alcohol, eating poorly and being physically inactive do not show up their effects on health in a short time perspective. As students probably will be the leaders of tomorrow, their health related activities are of particular interest. Being well-educated and rather healthy, students comprise a suitable sample for investigating health habits, as the variability due to ill health and education is minimized. The results would be able to generalize to other student populations, at least in Sweden, according to the stratified and systematic sampling procedure. As the study is cross-sectional no conclusions can be drawn on trends in health behaviors among university students over time, such as Steptoe et al. (2002) have shown, but the results can indicate important areas for further research and practice in student health promotion activities.
A limitation of the present study could be that health was measured only by self reports. Conversely, it has been convincingly shown that self-rated health predicts mortality and that reporting of symptoms is a valid method in assessing self-rated health (Bue Bjorner et al., 1996).
The reliability of self-reported health habits could be questioned, but self report measures are looked upon as both practical and ethical means to gather data, although biases due to social desirability and poor recall are possible (Christiansen et al., 2002). The absolute intake of alcohol is generally underestimated by using questionnaires, but this kind of measure may be reliable for ranking purposes (Townshend & Duka, 2002). The estimated alcohol consumption in this study is probably too low, but probably correct in ranking individuals to high versus low consumption groups.
The internal consistency of this newly established instrument showed a moderately good accuracy (Kerlinger, 1986) and the instrument (3HI) merits a further development by being used and validated in future research on similar and dissimilar populations.
To denote the importance of statistically significant results, they were reported together with Cram¨¦r's V or Phi (for two-dimensional tables) as a measure of the magnitude in association, although chi-squared based measures are difficult to interpret (Norusis, 1998). According to Kerlinger (1986), a correlation between 0.20 and 0.30 could be of interest when n is larger than 100. Because the sample comprised more than 300 students, and such big samples easily give statistically significant results, these are only reported if they are combined with a magnitude estimate =" type="#_x0000_t75"> 0.20 (with some exemption).
Result issues
There were no statistically significant differences in level of self-rated health among female and male students. Stress was negatively related to self-rated health both for women and men, but women reported more stress-related symptoms than men, such as headache, tiredness and pain in the back and neck. This is in line with other studies (Macintyre et al., 1996; Stock et al., 2003) and so is the excess in perceived stress by women (McDonough & Walters, 2001), who found that women's greater exposure to stress accounted only for a small proportion of the gender disparity in health. Female students had healthier habits than their male counterparts in relation to alcohol consumption and nutrition and were also more motivated for a healthy lifestyle, but this does not seem to have influenced their self-rated health. This could depend on their higher stress levels, which may override the benefits of a healthy lifestyle, or it could be interpreted in line with Carter and Kulbok (2002), who questioned the impact of motivation for health behaviors, depending on poor measurements of the construct. The multimodal influences on health behavior are still poorly understood (Meillier et al., 1997; Baumann et al., 2002) and there is a need to develop theories that can increase our knowledge and understanding of specific behaviors.
The healthy lifestyle index indicated that 28% of the students had a healthy lifestyle, which is not in line with Steptoe and Wardle's study (2001). The interrelationships between different health habits which is documented in other studies (Burke et al., 1997; Baumann et al., 2002) was found only between smoking and alcohol consumption for male students. This could depend on too small a sample in relation to the low levels of smoking and alcohol consumption in the sample, or on measurement bias, or it could be that clustering of unhealthy behaviors does not exist in this sample.
The prevalence of smoking is low compared to the prevalence among university students in many European countries (Steptoe et al., 2002). The gender differences in alcohol consumption and heavy alcohol consumption are found in other student populations (Webb et al., 1996; Burke et al., 1997; Demers et al., 2002) and also that heavy consumption is related to cultural norms among students which describe drinking as a normal part of student life (Demers et al., 2002). The level of alcohol consumption in this sample is far below the level reported in other studies (Gill, 2002) and so is the percentage of abstainers. In UK, 'pleasure' was the most commonly reported reason for drinking (Webb et al., 1996), while in this study 'making it easier to socialize' might reflect different cultural norms. As this reason was more common among men it could also be interpreted as means of building social confidence and coping with stress, as men interviewed in Davies et al.'s study (2000) suggested.
A noteworthy gender difference was in the prevalence of overweight and obesity, with 30% of the male students being overweight or obese compared to 13% of female students. The prevalence of obesity is much less than in American studies (Lowry et al., 2000) where 35% of students were found to be overweight or obese. However, the figures are noteworthy even in a Swedish setting, because the prevalence of obesity in Europe is estimated to be 15%, although the figures are quickly rising (Conference on Obesity, 2002; van der Wilk & Jansen, 2004). As in other studies (Steptoe et al., 1997; Lowry et al., 2000) females were more likely to perceive themselves as being slightly overweight, but in this study it was the male students who were more overweight but at the same time more satisfied with their current weight. Together with their unhealthy nutritional habits, relative disinterest in nutritional advice and low level of physical activity, this gives rise to concern about the future health for these men. This should be important to follow up in future studies.
The male students in this study showed lower levels of physical activity compared to students in 13 other European countries, whereas female students showed higher levels than half of the female populations in Steptoe et al.'s study (2002), although comparison may be biased by different classifications and measurements. Many studies have found that a social supportive environment is crucial for being physically active (Leslie et al., 1999; Ståhl et al., 2001; de Bourdeaudhuij & Sallis, 2002; Plotnikoff et al., 2004) as well as cultural norms and national economic development (Haase et al., 2004). The correlation between social support and physical activity shown in other studies (Ståhl et al., 2001; de Bourdeaudhuij & Sallis, 2002) could be confirmed in that male students experiencing low social support had lower levels of physical activity, while female students with high social support did exercise at a higher level. The association between physical activity and perceived access to these activities might be explained such as Ståhl et al. (2001) suggest, namely that active people make themselves aware of local opportunities for activities. A feasible way of promoting health in relation to physical activity would be as Plotnikoff et al. (2004) suggested, strengthening participation with others in physical activity.
The association among women between social support and self-rated health is in line with other studies (Broadhead et al., 1983; Denton & Walters, 1999; Denton et al., 2004). Surprisingly, few associations were found between social support and health, and between social support and health habits. This may reflect poor measurements of social support although it was assessed to cover the complexity of the construct (Broadhead et al., 1983; Denton & Walters, 1999).
A negative association was found among women between the level of health activities, level of healthy lifestyle habits and self-rated health, and this is surprising. What we do not know is the direction of the association. It could be that more health activities lead to more symptoms, or conversely, that more symptoms lead you to engage in more health activities. Women who were more engaged in health activities also more frequently reported headache, stomach pain and stress. It could be hypothesized that a high level of involvement in health activities acts as an additional stressor for female university students, in a situation which is perhaps already perceived as stressful.
The association in the female population between high motivation and a high level of health complaints tells nothing about the direction. It could be interpreted as ill health fuels the motivation, or that factors other than motivation are influencing health related behaviors. One part of the 'motivation for a healthy lifestyle' index was interest in participating in different health promoting activities, and female students were significantly more interested than men. This could relate to men experiencing more barriers in seeking health services due to their need to conceal vulnerability and need to be independent, as suggested by Davies et al. (2000). Motivation may be an influencing factor on health behavior, but Carter and Kulbok (2002) found that motivation did not have a significant effect in over half of the studies in the review, and they discussed if this may depend on poor measurement of the motivation construct or that motivation in fact is not an essential determinant of health behaviors. The suggestion from Carter and Kulbok (2002) to develop the motivation concept and its measurement in future research in order to determine the meaning and scope of motivation for health behaviors is sustained by the findings in this study.
A limitation of this study is that it only describes the association between self-rated health and individual health habits and not social and environmental health determinants. It is easier to change health related behaviors when you also experience changes in social life (Meillier et al., 1997), thus student health organizations could take advantage of this knowledge in targeting motivational initiatives for health promotion among students in relation to smoking, physical activity, nutrition, alcohol consumption and coping with stress.
CONCLUSIONS AND RECOMMENDATIONS
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This study showed no gender differences in overall self-rated health, but female students reported more stress, headache and tiredness than male students did. The factors that most influenced self-rated health among male students were stress, alcohol consumption and nutritional habits; among female students it was stress. An unexpected finding was that healthy habits and a high motivation for a healthy lifestyle were associated with poorer health among female students. The cause of the association is not known. That health problems lead to greater engagement in health enhancing activities is as probable an explanation as that too high involvement in health activities can act as a stressor and thereby induce health problems. This finding needs to be investigated further, preferably in prospective, longitudinal studies.
The university students in this study were practicing healthy habits around the same level as students in other Western European countries. They showed healthier behaviors related to smoking and alcohol use than other students, but their nutritional habits were poor. Especially alarming is that male students tend to be overweight or obese and at the same time wanting to weigh more even when the BMI was normal, and not interested in getting nutritional advice. This gives concerns for the future. Being physically active was strongly associated with access to facilities for exercising. One way to promote students' health would be to create facilities for sporting and calisthenics at university campuses, which could also increase communal physical activity.
Not many associations between self-rated health and other health determinants than stress were found. Perceived social support was beneficial for female students' health, while a high level of physical activity was associated with more health complaints. Motivation for a healthy lifestyle was, in this study, not an important factor for practicing healthy behaviors. The concept of motivation needs further development.
Ideally, the research should use large, community-based samples rather than university students, and have prospective and longitudinal designs to make causal conclusions possible. This cross-sectional study gives some ideas for future research on factors influencing health among university students, especially how stress and motivation influence health and healthy habits.
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Nursing & Health Sciences Volume 7 Issue 2 Page 107 - June 2005
