The effect of a stress management educational program on the knowledge, attitude, behavior, and...

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Research Brief

Abstract

This study examined the effects of a wellness-oriented stress management educational program on the knowledge, attitude, behaviors, and stress levels of college students. A 2-week stress management program was designed and presented to the treatment group. Subjects in the treatment group and the no-treatment control group completed a matched pretest, posttest, and 4-week delayed posttest. Results revealed a significant increase in knowledge of stress arid coping, attitude of self-efficacy in coping, and frequency of coping behaviors within the treatment group. Gains were maintained at a 4-week follow-up. Stress levels of students in both groups did not change significantly.

Conclusions were that stress management education was important for college students because of increased stress due to academic demands and an increased number of developmental challenges inherent in college life; that the wellness model provided an educationally oriented framework which was helpful in integrating and interrelating information pertaining to stress management and was readily understood by college students: and that subjects in the treatment group significantly (p<.05) increased their knowledge of stress and coping, attitude of self-efficacy in coping, and self-reported frequency of coping behaviors.

Introduction

College life requires students to make many adjustments, including adjustments to increases in academic demands, changes in the source and amount of social support, increases in individual responsibility and decision-making regarding lifestyle, career direction, finances, and management of schedules (Downey, 1983, Gill, 1985; Lang, 1982; Ramsey, Greenberg, & Hale, 1989). According to Ramsey et al. (1989), some researchers believe that "college years may be the most stressful in one's life."

At the same time that college life places greater demands on students, it also provides greater opportunities for personal development and self-realization. Opportunities that exist for enjoying greater independence, individual decision-making, academic achievement, formation of social networks, career development, and establishment of healthy lifestyle patterns are challenges that can be met with enthusiasm and success. In meeting the challenges inherent in college life, students are forming the foundation of their adult coping skills (Downey, 1983). Health educators, along with other health professionals on campus, can assist college students in successfully meeting the challenges and opportunities of the college years.

The wellness model as described by Hettler (1980) is a useful framework for stress management education for several reasons. As a conceptual foundation, the wellness model shares the same goals as stress management-overall well-being and self-responsibility (Archer, Probert, & Gage, 1987; Cotton, 1990). It provides a comprehensive health systems framework into which new research from health psychology, exercise physiology, behavioral medicine, nutrition, sociology, and other fields could easily be integrated.

Methods

The purpose of this study was to assess the effects of a wellness-oriented stress management educational program on the knowledge of stress and coping, self-reported frequency of coping behaviors, attitude of self-efficacy, and stress levels of college students.

In this study, a non-equivalent control group design was used. The treatment group consisted of 132 volunteers from three sections of HPER 260, a Personal and Community Health class. The control group consisted of 39 volunteers from three sections of HPER 108, including two sections of aerobic rhythms and one section of physical conditioning. All subjects were students at the University of Kansas during the Spring semester of 199 1. The treatment group received a stress management educational program during six 50-minute class periods over a 2-week period. The educational program was provided during regular class periods of the course. The control group received no treatment.

The outline for the six-session wellness oriented stress management program consisted of,

Session 1: Introduction to Stress Management Definition of stress; Health consequences of stress; Mechanisms of the stress response; Psychological model of stress management-Helplessness versus control; and Hardiness

Session II: Wellness and Aspects of Stress Management in the Physical Dimension of Health- Definition of wellness and the dimensions of health; Role of exercise in stress management; Role of nutrition in stress management; Avoiding stress-producing substances; Role of adequate rest; Role of good posture; Role of relaxation techniques

Session III: Aspects of Stress Management in the Emotional Dimension of Health - Characteristics of stress: hardy personalities; cognitive restructuring: building high self-esteem, benefits of laughter and tears

Sessions IV & V: Aspects of Stress Management in the Intellectual Dimension of Health- Role of goal orientation in stress management-, Steps in time management; Steps in stressor evaluation; Steps in problem-solving

Session VI: Aspects of Stress Management in the Social Dimension of Health -Importance of social ties; Social characteristics of stress: hardy people; empathy; assertiveness; conflict resolution

Four instruments were used in this study: 1) a 2O-item questionnaire assessing knowledge of stress and coping, 2) a 10-item questionnaire assessing attitude of self-efficacy in coping, 3) a 13-item questionnaire assessing self-reported frequency of coping behaviors, and 4) an 11-item scale measuring stress level. The first three instruments were developed by the investigators. The instrument selected to measure the stress level of subjects was the stress scale of the Quick Stress Inventory, a batch-processed computer stress assessment developed by Dr. Allen Press of the University of Kansas.

Reliability scores included a coefficient alpha of .53 for the knowledge questionnaire, a coefficient alpha of .58 for the attitude questionnaire, and a coefficient alpha of .76 for the behavior questionnaire. The low reliability scores for the knowledge and attitude scales were considered limitations of the study and should be considered when generalizing the findings. The internal reliability of the Quick Stress Inventory was a coefficient alpha of .86.

The research was approved by the University of Kansas Advisory Committee on Human Experimentation. Data collection began with administration of the pretest prior to the 2-week stress management education program. Following the 2-week educational program, the posttest was administered. The delayed posttest was administered 4 weeks after the posttest. Data collection for the treatment group occurred within their regularly scheduled class periods. Data collection for the control group occurred either within their regularly scheduled class period or in the University of Kansas Wellness Center during the same time frame. Students enrolled in HPER 260 who chose not to participate in the study received the same instuction as the treatment group but did not participate in the assessments.

T-tests were used to measure differences within groups in two of the four measures, knowledge and attitude, on the posttest compared to the pretest and on the delayed posttest compared to the posttest. T-tests were also used to measure differences within groups in all four measures, knowledge, attitude, behavior, and stress levels, on the delayed posttest compared to the pretest.

Analysis of covariance was used to measure differences between treatment and control groups in two of the four measures, knowledge and attitude, at posttest using the pretest scores as the covariate and at delayed posttest using posttest scores as the covariate. An analysis of covariance was also used to measure differences between treatment and control groups in all four measures, knowledge, attitude, behavior, and stress levels, at delayed posttest using the pretest as the covariate.

Results

According to the t-tests, increases in knowledge of stress and coping within the treatment group were significant between pretest and posttest (p=.000) and between pretest and delayed posttest (p=.000). A significant decrease in knowledge scores within the treatment group between posttest and delayed posttest (p=.046) reflected a failure to maintain increased knowledge during the 4 week follow-up period.

According to the analysis of covariance, the knowledge of stress and coping scores within the treatment group were significantly higher than the control at posttest (p=.000) using the pretest as the covariate (Table 1), and at delayed posttest (p=.000) using the pretest as the covariate (Table 2). This is consistent with a previous study by Ramsey et al. (1989) in which a stress management educational program resulted in knowledge increases within the treatment group but not in the control group.

The results supported the effectiveness of a stress management educational program for increasing knowledge of stress and coping among college students. This is consistent with a previous research study by Ramsey et al. (1989) in which a stress management educational program for college students increased knowledge between pretest and posttest (p=.001) and from pretest to 30-day followup (p=.001).

Attitude of self-efficacy in coping
According to the t-tests, increases in attitude of self-efficacy within the treatment group were significant between pretest and posttest (p=.000) and between pretest and delayed posttest (p=.000). There was no significant difference between posttest and delayed posttest, indicating that the increase in self-efficacy was maintained during the four-week followup. There were no significant differences in attitude of self-efficacy between tests within the control group. According to the analysis of covariance, the attitude scores of the treatment group were significantly higher than the control at posttest (Table 1) (p=.000) and at delayed posttest (Table 2) (p=.006), using the pretest as the covariate. The difference between the attitude scores of the treatment and control group and the significant increases in attitude scores among the treatment group confirmed the effectiveness of a wellness-oriented stress management educational program in enhancing a sense of self-efficacy in coping with stress among college students.

These results supported findings from a previous study by Ramsey et al. (1989) regarding the effectiveness of stress management education for increasing attitudes of self-efficacy among college students. Ramsey et al. (1989) reported an increase in self-efficacy among the treatment group at posttest (p=.03), a change which was not maintained at 30-day followup.

Coping Behaviors
Within the treatment group, there was a significant increase in frequency of coping behaviors at 4-week delayed posttest (p=.000). There was no significant change among the control group in frequency of coping behaviors from pretest to delayed posttest. Analysis of covariance showed a greater frequency of coping behaviors among the treatment group compared to the control group at delayed posttest (Table 2) using the pretest as the covariate. The results suggested positive impact of a stress management educational program on frequency of coping behaviors among college students. This finding supported a previous study by Ramsey et al. (1989) which found an increase in self-reported practice of time management, cognitive restructuring, and relaxation behaviors following a stress management education program (p=.001). These changes were maintained at followup.

Stress Level
Previous research found decreases in stress level measured with several different types of assessments. Significant decreases in trait anxiety and debilitative academic anxiety were reported following a semester long course in stress management by Romano (1984). Shellenberger, Turner, Green, and Cooney (1986) found decreases in psychosomatic symptoms and increases in mental health following a 10-week stress management course. Sime, Ansorge, Olsen, Parker, and Lukin (1987) and Hudesman, Beck, and Smith (1987) found decreases in anxiety. Deffenbacher and Shepard (1989) found significant decreases in anxiety, anger, physiological reactivity, fear, and stress symptoms. Ramsey et al. (1989) found decreases in daily hassles, stress symptoms, and stress arousal for both treatment and control. This study used self-report to measure stress level, however, its findings did not support results of previous studies regarding significant decreases in stress levels following stress management interventions with college students.

In this study, stress levels were assessed at the pretest and at delayed posttest on the assumption that changes in stress levels at delayed posttest would be more meaningful than changes at the immediate posttest. However, stress levels did not change significantly from pretest to delayed posttest for either group (p=.51 1 for treatment and p=.255 for control), a fact which may have been influenced by mediating factors such as the timing of the delayed posttest within the semester and the use of students in an exercise class for a large portion of the control group.

The lack of expected decreases in stress level within the treatment group probably reflected the timing of the delayed posttest within the semester. The delayed posttest was administered during the last week of the semester when, according to research on college stressors (Bush, Thompson, & Van Tubergen, 1985), stress levels might be expected to rise significantly due to increased number of academic deadlines and approaching final exams. If it can be assumed that stress levels should have increased during the final week of the semester, the stress management educational program may have helped the subjects in the treatment group to maintain their stress levels nearly unchanged from pretest levels.

The lack of significant changes in stress level within the control group, assuming that they should have risen during the formal week of the semester, may have reflected the stress-reducing effect of aerobic fitness training in a large portion of the control group. Support for this idea was provided by the literature on the stress-reducing effects of aerobic conditioning (Cotton, 1990; Girdano & Everly, 1986; Holmes, in press) and by a rise in stress level among males in the control group of this study, all but one of whom were recruited from a lecture-oriented physical conditioning class rather than the aerobic classes.

Summary and Recommendations

A 2-week stress management program was taught to 132 students enrolled in a college level Personal and Community Health course during the Spring semester of 199 1. Results from this study suggest that college students are in need of stress management programs and that a stress program structured around the wellness concept can produce significant changes. Significant differences were noted in knowledge of stress and coping, attitude of self-efficacy, and self-reported frequency of coping behaviors, but not in stress level. The knowledge increase for the treatment group was part of a college class. The coping behaviors utilized in this study included diet, drug use, problem identification, worrying, time management, being kind and supportive to yourself, exercise, relaxation exercises, acceptance of situations, and humor. Students reported practicing more of these behaviors after participating in this 2-week program. Even though a reduction in stress level was not achieved as a result of this program, the fact that the stress levels did not increase during finals week was a credit to the program.

Future research should examine the effects of stress management education on incidence of stress-related symptoms, frequency of physician visits, academic performance, mental and physical health, trait and state anxiety, academic anxiety, physiological reactivity, alcohol and drug use, social satisfaction, and career direction. Future studies should examine the effects of a stress management education program on different populations such as primary- and secondary-age children, the elderly, teenage mothers, and economically disadvantaged minorities. Future studies should also attempt to control for stress-producing variables, such as the approach of finals, or stress-reducing variables, such as participation in aerobics outside the planned treatment.

References

Archer, J. Jr., Probert, B.S., & Gage, L. (1987). College students' attitudes toward wellness. Journal of College Student Personnel, 28, 311-317.

Bush, H.S., Thompson, M., & Van Tubergen, N. (1985). Personal assessment of stress factors for college students. Journal of School Health, 55, 370-375.

Cotton, D.H.G. (1990). Stress management: An integrated approach to therapy. New York: Bruner/Mazel.

Deffenbacher, J.L., & Shepard, J.M. (1989). Evaluating a seminar on stress management. Teaching of Psychology, 16, 79-81.

Downey, A. (1983). Identification of students' preventive health care needs and interests as a foundation for health education program planning at the health center. Unpublished master's thesis, University of Maryland, College Park.

Gill,W.E.(1985). Stress on the college campus. Emporia,KS: Emporia State University. (ERIC Document Reproduction Service No. ED 256 278)

Girdano, D.A., & Everly, G.S., Jr. (1986). Controlling stress and tension: A holistic approach 2nd ed.). Englewood Cliffs, NJ: Prentice Hall.

Hettler, B. (1 980). Wellness promotion on a university campus. Journal of Health Promotion & Maintenance, 3, 77-95.

Holmes, D. S. (In press). Aerobic fitness and the response to psychological stress. In Seraganian, P. (Ed.) Physical Fitness and Psychological Functioning. New York: Wiley.

Hudesman, J., Beck, P., & Smith, C.M. (1987). The use of stress reduction training in a college curriculum for health science students. Psychology, A Quarterly Journal of Human Behavior, 24, 55-59.

Lang, D. (1982). Integrating a stress management mini-course into a personal health course. Emporia, KS: Emporia State University. (ERIC Document Reproduction Service No. 228 179)

Pelletier, K.R. (1977). Mind as healer, mind as slayer: A holistic approach to preventing stress disorders. New York: Dell.

Ramsey, S.A., Greenberg, J.S., & Hale, J.F. (1989). Evaluation of self-instructional program in stress management for college students. Health Education. 20, 8-13.

Romano, J.L. (1984). Stress management and wellness: Reaching beyond the counselor's office. The Personnel and Guidance Journal, 62, 533537.

Shellenberger, R., Turner, J., Green, J., & Gooney, J.B. (1986). Health changes in a biofeedback and stress management program. Clinical Biofeedback and Health, 9, 23-34.

Sime, W.E., Ansorge, C.J., Olsen, J., Parker, C., & Lukin, M. (1987). Coping with mathematics anxiety: Stress management and academic performance. Journal of College Student Personnel, 28, 431-437.

Tolmnan, R., & Rose, S.D. (1985). Coping with stress: A multi-modal approach. Social Work,.30, 151-158.

Table 1
Results of one-way ANCOVA comparing knowledge and attitude
posttest scores, using the pretest as a covariate

Variable Group N Adjusted M df F- P
ratio

Treatment 132 14.91646
Knowledge 1,168 23.09 .000*

Control 39 12.87375

Treatment 132 3.82583
Attitude 1,167 15.69 .000*
Control 39 3.49608

*p <.05

Table 2
Results of one-way ANCOVA comparing knowledge, attitude,
behavior, and stress level delayed posttest scores,
using the pretest as a covariate

Variable Group N Ad- df F-ratio P
justed M

Treatment 132 14.56457
Knowledge 1,168 20.46 .000*
Control 39 11.47855

Treatment 132 3.82223
Attitude 1,168 7.89 .006*
Control 39 3.53953

Treatment 132 3.43639
Behavior 1,168 8.07 .005*
Control 39 3.22989

Treatment 132 2.63960
Stress Level 1,168 .81 .369*
Control 39 2.72767
*p <.05

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By Robert Walker and Arvella Frazier

Robert Walker is an Assistant Professor and Coordinator of Health Education at the University of Kansas Health, Physical Education and Recreation Department, Lawrence, Kansas 66045. Arvella Frazier is a Graduate Student at The University of Kansas.

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