Iranian Journal of Sociology, 2008, 2 (1): 190-227 Gender Differences in Health-related Knowledge and Beliefs and their Relationships with Health-related Behaviors Mohammad Esmaeil Riahi: Assistant Professor- University of Mazandaran Abstract Objectives: The main objectives of this study are to describe and explain gender & national differences in health related knowledge & beliefs, and their impacts on health behaviors of university students in Iran (Mazandaran University) and India (Panjab University), with special emphasis on psychosocial factors. Methods: Survey method is been used for conducting the present study. By means of multi– stage sampling procedure, 504 students from both the universities have been selected randomly, to fill up the self- administered questionnaire consists of two scales regarding health related knowledge & beliefs ,and some questions about health-related behaviors such as personal hygiene , physical exercise , dietary habits , preventive medical checkups, alcohol consumption, and smoking. Results: The main findings of the present study can be summarized as follows: 1) The university students in India compared with their counterparts in Iran were more aware of risk factors involved in certain diseases (higher rates of health knowledge), while men and women students did not differ in this respect. 2) The university students in both countries were not different in terms of health beliefs, while women compared with men students were more conscious of the importance of certain behaviors for health maintenance (higher rates of health beliefs). 3) Association between health knowledge and healthrelated behaviors was found to be weak and non significant; while a very strong and significant association between health beliefs and health related behaviors was observed. Discussion: Improving health beliefs of students rather than their health knowledge, is an essential step in order to increase their positive health-related behaviors. Keywords: Gender, Gender differences, health knowledge, health beliefs, health behaviors, University students, Iran, India 1) Introduction Health is one of the most vital but taken-for granted qualities of everyday life. There is good evidence that health is a major basis of human progress and that lack of it, is one of the predisposing factors of national decay. As Cockerham (1989: 2) rightly points out: while a person’s social class, income, and access to goods and services are highly important, the quality of one’s life, ultimately depends upon one’s level of health.” In light of the role of health in happiness, efficiency, and well-being, it seems that every social group and society strive for the betterment of health of its members. 1 Overall, the most important determinants of the health status can be summarized as follows: heredity and genetic composition; socio-demographic characteristics (such as age, marital status, place of residence, etc.); socio-economic status (such as education, income, and employment); Socio-cultural factors (gender, religion, ethnicity); gender inequality; health knowledge and health beliefs; health-related behaviors (such as smoking, alcohol consumption, physical exercise, and dietary habits); political economy; poverty and malnutrition; access to health services and facilities; and physical environment. A combination of factors than just one of them determines the health status of individuals and societies. Among the above mentioned factors, this study focuses on health knowledge and beliefs and their impacts on the health behaviors. The literature on associated factors with health beliefs and knowledge identified some psychosocial factors. For instance, Weissfeld and colleagues (1990) found that sociodemographic markers of social disadvantage (e.g., black race, or low SES) appeared to associate with favorable health beliefs, that is, with health beliefs often associated with health promoting behaviors. They, specifically, found that blacks expressed greater concern about health (health concern). Significant gender, ethnic, and acculturation differences were found among beliefs related to frequency of condom use in the past year by Norris and others (1994) in Midwest (USA). A cross-cultural study of beliefs about smoking among teenaged females by Hanson (1999) also showed that beliefs related to attitudes about smoking differed among three ethnic groups. The findings of this study suggested that specific beliefs distinguish between smokers and nonsmokers and that some beliefs differ by ethnicity. Jobanputra and Furnham (2005) studying the cultural differences in beliefs about health and illness found that Gujarati Indian immigrants agreed with items reflecting supernatural explanations of ill health more than indigenous British Caucasian participants. Awasthi and colleagues (2006) conducted a study on health beliefs of cervix cancer patients and found that individual and psychosocial causes were more strongly represented in the belief system of patients than environmental or supernatural causes. Additionally, Munro and others (2007) in assessing the impact of training on mental health nurses’ therapeutic knowledge found a significant group effect on knowledge about co-morbidity. The training programme was effective in improving participants’ knowledge of alcohol, drugs, and co-morbidity. Likewise, Bassey et. al (2007) found gender differences in health knowledge about HIV. 2 Accordingly, they identified a great disparity between male (73.7%) and female (28.9%) respondents on knowledge about HIV. On the other hand, many studies have been conducted to find out associations between health knowledge and beliefs with health-related behaviours. A brief review of literature in this respect shows that findings of studies conducted on health knowledge in relation to health-related behaviours (HRBs) were not consistent and stable, but health beliefs had a strong and consistent relationship with health-related behaviors. For example, a few studies highlighted how health knowledge is related to decrease in health risk behaviors (Dittmar et al. 1980), and an increase in health-promoting behaviors (Fleetwood and Packa, 1991). It also influences dietary behavior (Harnack et al., 1997); and or brings about reduction in alcohol consumption, improvement of physical activity (Wardle and Steptoe, 1991), and treatment-seeking behaviour by women reported depression symptoms (Simmons et. Al, 2007). Despite of these supportive evidences regarding influence of health knowledge on HRBs, however, some research findings point out that mere information of the hazards of health risk behaviors is not a sufficient condition for the avoidance of risk-taking behaviors. For example, no relationship could be found between health knowledge and reduction in smoking (Wardle, 1992; Jones et. al., 1992; Small, 1994; Steptoe & Wardle, 1992; Kapoor et al., 1995; Yassin et al., 1998; Kurtz et al, 1972); or alcohol consumption (Steptoe and Wardle, 1992). Further, according to Lopez et al. (1992) there exist many contradictions between the theoretical acquisition of health knowledge and the observed frequency of high-risk behaviors. Similarly, Avis et al. (1990) concluded that knowledge does not lead to risk reducing behavior in cardiovascular diseases as well as sun-protective behaviors. However, majority of the studies on health beliefs confirmed the positive relationship between health beliefs and health behaviors. Rather, it has been observed that unlike health knowledge, there has been a constant relationship between health beliefs and health behaviors. According to Monneuse et al. (1997) knowledge of the significance of behaviour seems to be closely associated with health related behaviors. Similarly, Steptoe and Wardle (1992) come to the conclusion that health beliefs consistently showed a positive association with health practices. Cody and Lee (1990) consider health beliefs as a significant variable in predicting health behaviors. Calan 3 and Rutter (1988) also show that a change in the health beliefs could result in the improvement of health behaviors. Thus, the above studies show that people’s beliefs on health matters have an important effect on what they do about health, namely; their health behavior. Abroms and colleagues (2003) also concluded that males and females differed in their beliefs that motivated their sunscreen use. Holt and others (2003) in the studying association between spirituality, breast cancer beliefs and mammography utilization among African American found that the belief dimension of spirituality played a more important role in adaptive breast cancer beliefs and mammography utilization that did the behavioural dimension. A research done by Riley-Doucet (2005) showed that family dyads with beliefs that pain was controllable had less symptom distress than dyads with beliefs that pain was not controllable. Moreover, Lee and colleagues (2007) revealed that the fear-avoidance beliefs factor is an important biopsychosocial variable in predicting future disability level and return to complete work capacity in patients with neck pain. Increasing attention has been paid over the last two or three decades to the contribution of behaviors to health. Today, many of the major health problems, such as heart disease and cancer, are seen as attributable to individual behavior patterns (Macintyre, 1986: 407). The prevalence of chronic diseases is showing an upward trend almost all over the world, including the developing countries, because of shifting of patterns of disease in these countries. People in the developing countries, especially the middle and high social classes, are exposed to chronic, non-communicable diseases attributable to health related behaviors. Therefore, it is the right time that the developing countries increase the awareness of their population about health risk behaviors (to increase health knowledge and to improve health beliefs) and take appropriate steps; to avoid the onset of epidemic form of non-communicable diseases that are likely to emerge in a big way as the status of these societies improves. Although different social and cultural factors such as income, employment, education, age, ethnicity, and class have been found to play an important role in the construction of differences in terms of health-related knowledge, beliefs, and behaviors, but it can be presumed that gender is one of the most important factors influencing health related behaviors in each social group as well as society. Accordingly, in the past three decades, the issue of gender differences in health and illness has gained popularity as 4 a subject of research among social scientists. The survey of literature on gender differences on health status of different societies reveals that women suffer more from disease in their lifetime, but men die early; women live longer, yet they seem to be sicker. Further, many research studies found that in general, women are more likely than men to adopt healthier habits and perform positive health behaviors. Overall, the main problem that this study is trying to focus on is to understand the nature of variations in health related knowledge and beliefs of university students and their associations with health related behaviors. This study has attempted a twofold comparison in health related knowledge, beliefs and behaviors, that is, by gender and nationality at the same time. It tries to find out how far health related knowledge and beliefs of male and female university students in Mazandaran University (Iran) and Panjab University (India) differ and which factors affect these differences? In the other words, in this study, gender differences in health related knowledge and beliefs of university students in Iran and India were described and explained by means of several socio-psychological and cultural factors. Therefore, the main questions which this study tries to answer are: - Are there any gender differences in health-related knowledge and beliefs of university students in the total sample as well as within each university context? - What are the associated factors, which influence these differences? - And how far health knowledge and beliefs act as positive predictors of health related behaviors? 2) Theoretical Framework The study of gender differences in health/illness has been approached from a number of perspectives. In general, these perspectives can be broadly put into two, namely: Biomedical and Socio-medical. According to the Biomedical perspective it is hypothesized that observed gender differences in health are the product of biologically based inherited risks (Kandrack, 1991: 579). In the biomedical model state of health is a biological fact (immutable, real, independent) and ill health is caused by biological calamities (Moon and Gillespie, 1996: 83). The Socio-medical perspective on the other hand, hypothesizes that gender differences in health can be explained in terms of social and cultural factors (Kandrack, 1991, 579). The Socio-medical model looks at state of 5 health as socially constructed, varied, uncertain, and diverse. It considers social factors as the causes of ill health, which can be identified through beliefs, and interpretations built upon custom and social constraints (Moon and Gillespie, 1996: 183). The present study makes use of the socio-medical perspective to explain gender differences in health related knowledge, beliefs and behaviors of university students in Iran and India. Within the broad framework of the socio-medical approach, there are several approaches such as socialization theory, social role theory, and social position and socio-economic status. 2-1) Socialization Theories Socialization is the complex learning process through which individuals develop selfhood and acquire the knowledge, skills, and motivation required for participation in social life (Mackie, 1990: 61). In socialization theory, some social groups or organizations such as family, peer groups, school, and mass media are considered as agents of socialization. Family socialization forms the basis of many of our health beliefs and behaviors. Many parents attempt to provide a healthy role model. This may lead to health enhancing behavioral change by parents. Maintenance of health damaging behavior may also result from the pressure of parenthood, particularly where material circumstances are poor and resources are low. Even family related life events may contribute more positively to lifestyle change (Penny et al., 1994: 113-4). Overall, the family system plays a major role in children’s learning of health related knowledge, beliefs, and behaviors. From amongst the different socialization theories, two most important ones have been explained briefly below: 2-1-1) Social Learning theory Social learning theory, which has been most substantially articulated by Bandura (1977, 1986), emphasizes the notion that behaviors are gradually acquired and shaped as a response to the positive and negative consequences of those behaviors. In summary, social learning theorists argue that gender role behaviors, are learned by reinforcement (rewards and punishments) and observational learning. Children are rewarded or punished by their parents and society for exhibition behaviors appropriate to their gender role. As a result, gender-appropriate behaviors take on greater value for the child and are exhibited with greater frequency (Eccles, 2000: 455). Social learning 6 theory places more emphasis on environmental influences. Accordingly, health promotion or risk behaviors are socially learned and purposeful behavior, results from interplay of social–environmental and personal perceptions and influences. For example, this theory conceptualizes that alcohol use as a socially learned, purposive, and functional behavior results from the interplay between socio-environmental factors and personal perceptions (Gonzalez, 2000: 4). In this regard, parents may influence their children’s drinking through both direct modeling of alcohol use and the transmission of parental values about drinking (Jung, 2001: 164). In the study of health related behaviors, social learning theory as a cognitive view emphasizes expectancies that we form about the positive/negative effects of each health related behavior. For example, to have a belief in medical check up, one has to first learn the social norms regarding the beliefs of others about it. Thereafter, one looks at the situation in which the check up affects the health of the individual. Thus, one learns the effects of regular medical check up through his/her health status. 2-1-2) Health Locus of Control The construction of health locus of control was derived from the social learning theory developed by Rotter in 1966. From this theory, Rotter developed the locus of control construct, consisting of internal-external rating scale (www.med.usf.edu). The locus of control construct refers to the degree to which an individual believes the occurrence of reinforcements is contingent on his/her own behavior. Theoretical basis of locus of control relies on individual differences between how people perceive events as a result of their own behavior or endurance characteristics (internal), or as being controlled by some other variables like chance, luck, fate, or authority (external). Health locus of control is “a concept that refers to an individual’s views regarding the relative control he/she has over his/her health condition (Pacther et al, 2000:716). Externals refer to the belief that one’s health condition is under the control of powerful others, or is determined by fate, luck, or chance, but internals refer to the belief that one’s health condition is directly the result of one’s behavior. Internals are prone to obtain proper nutrition, exercise, rest, stress reduction, and to adopt prevention/enhancement strategies to maintain/improve the state of their health. External individuals are liable to exhibit behaviors, which are less action-oriented, and appropriate response to the state of their health may not occur (www. members. tripod. com). 7 2-2) Social Role Theory (SRT) Social role theory focuses on studies of learned behavior of men and women in society by means of their social and gender roles. Gender role theory derives from the general concept of social role. It refers to the shared expectations that apply to persons who occupy a certain social position as members of a particular social category. In this manner, gender roles are those shared expectations that apply to individuals on the basis of their socially identified sex. Accordingly, people hold expectations about the behaviors that are appropriate to an individual because they identify the person as a member of the social category that consists of either females or males (Eagly, 2000: 448). In the area of health and illness, social role theory attempts to understand how the multifaceted nature of men and women’s lifestyle affects their health and well being (Pavalko and Woodbury, 2000). According to Nathanson (1975) women report more illness than men because it is culturally more acceptable from them to be ill; and the sick role is relatively compatible with women’s other role responsibilities, and incompatible with those of men, and also women’s assigned social roles are more stressful than those of men; consequently women experience more illness. Gove (1984) develops the ‘fixed role’ hypothesis and its relationship to men’s health. According to this idea the roles of men tend to be more structured or fixed than the roles of women. It is argued that highly structured or fixed roles tend to be causally related to good mental health and low rates of morbidity. Gender differences in health knowledge, beliefs, and behaviors can be attributed to gender role socialization, gendered expectations and obligations that determine appropriate or misappropriate behaviors for men and women, and influence health status of individuals. A common explanation of the decline in sex differences in smoking in western societies focuses on the consequences of gender equality. Narrowing sex differences in smoking in times of increasing gender equality and strengthening values of female independence, leads to the inference that the new found freedom and higher status of women have prompted the undesirable behavior of smoking (Pampel, 2001: 388). 2-3) Social position and socio-economic status The influence of socio-economic status on health related knowledge, beliefs, and behaviors have been well documented. Lower socio-economic status individuals have lower level of knowledge about risk factors of diseases, they are not deeply believed to 8 importance of healthy lifestyle on health status, and they participate in fewer positive health behaviors; for example, exercise, maintaining healthy body weight and change their negative health behavior such as smoking at a slower rate than higher socioeconomic status individuals. Recent research indicates that social location in status hierarchies is an important conditioning factor for the allocation of resources, opportunities, and constraints that influence knowledge, beliefs and behaviors related to health (Crzywacz and Marks, 2001; 203). People in lower socio-economic strata tend to be disadvantaged in a broad array of biomedical, environmental, behavioral, and psychosocial risk factors for health, which mediates the relationship between socioeconomic position and health. House (2001: 134) also points out that socio-economic status determines and shapes individual’s exposure to and experience of virtually all known psychosocial, and many biomedical risk factors for health. Thus socio-economic positions are originally fundamental causes that shape exposure to and experience of most diseases and risk factors for health. Overall, several social, psychological, and biological mechanisms have been hypothesized to underlie the socio-economic status–health relationship. One set of hypotheses centers on the ways that socio-economic status may influence health status through its effect on shaping the individual’s day-to-day lifestyle and health-affecting behaviors, such as diet, sleep, exercise, smoking, drinking, and drug use. Another pathway through which socio-economic status and health are hypothesized to influence each other is by way of socio-economic status differences in exposure to psychological stress and distress. Another obvious way is through differences in occupational conditions (Mulatu and Schooler, 2002: 23). The present study, proposes to test the efficacy of all these approaches in explaining gender related differences in health knowledge, beliefs, and behaviors of university students in Iran and India. 3) Data and Methods 3-1) Survey Design The universe of this study relates to formally enrolled university students in Iran and India. For the present study, which is incidentally cross-national study, separate 9 samples of university students were obtained from Mazandaran University (in north of Iran, Babolsar) and Panjab University (in north of India, Chandigarh). The ultimate nature of the sampling procedure resembles the multi-stage sampling procedure. At the first stage, Mazandaran University in Iran and Panjab University in India were selected. Then, various and as much as possible similar departments in each university (Law, Sociology, Economics, Commerce and Management, Physical Education, Languages, Humanities, History, Political Sciences, Psychology, Botany, Mathematics, Physics, Chemistry, Biology, Geology, and Chemical Engineering) were selected in the second stage, and at the final stage, the samples of study were chosen randomly from the students of each department who were present in the classroom when sampling was in operation. For the purpose of sampling, rough estimates of the total student population in these universities were obtained. These estimates showed that nearly 27915 students in all were enrolled in both the universities. Thereafter, it was decided to limit the size of the sample to roughly 500 respondents from both the universities and around 250 from each of them. In Mazandaran University the total size of the sample was 263 representing 7.2% of the total population; and in Punjab University the total size of the sample came to 241, after eliminating the incomplete questionnaires, representing 7.6% of the total population of students. 3-2) Data Collection Data collection was done when the classes were going on and all those students who were attending the classes on those particular days were distributed the questionnaires with the presumption that all students enrolled would be present in the classroom. Thus, ensuring the randomness of the sample, classroom setting was also considered ideal for approaching the students because the students could be explained the purpose of the study, given instructions about filling the questionnaires, and since the questionnaires were distributed after seeking the cooperation of the teachers and the authorities, a good response rate was expected. The main instrument of data collection used in this study was the self-administered questionnaire, which was developed using a combination of questions derived from previous research studies, particularly Wardle & Steptoe (1991), Steptoe & Wardle (1992), Callaghan (1996), Ross & Wu (1995), Douglas et al (1997), Patrick et al (1997), 10 Pietila et al (1995), and Fennell (1997). Then every effort was made to adopt these questions within the cultural contexts of Iran and India. A total of 43 question items were included, among which 16 items referred to socio-demographic characteristics; 19 items related to health behaviors, and 6 items related to psychosocial variables (such as health locus of control, health concern, etc.). Further, the health knowledge questions were in a multiple choice format, with one correct answer for each question; while the health beliefs index consisted of five-point Likert type items. Finally, this study used one questionnaire in two languages due to the nature of the study population: a Persian version was used in Iran, and an English version in India. 3-3) Methods of Data Analysis Data were analysed by using the statistical package for social sciences (SPSS). Reliability analysis was conducted for testing the reliability of scales and indices. Internal consistency of these sections of the questionnaire was calculated by using cronbach alpha techniques. Descriptive statistics was applied to portray the current status of subjects in demographic and socio-cultural characteristics, as well as socioeconomic status of their families. Analytical statistics (Student’s t-test and one-way analysis of variance, ANOVA) were used to assess gender and national differences in health related knowledge and beliefs, and also to determine significant factors associated with each health related knowledge and beliefs. 3-4) Operationalization of Variables 3-4-1) Health Knowledge Researcher developed an index of health knowledge or risk awareness by presenting a matrix of six health problems (heart diseases, lung cancer, breast cancer, high blood pressure, hepatitis, and tuberculosis) and nine health related risk factors (smoking, alcohol consumption, stress, adding extra salt to meals, consumption of extra fat, drinking excess coffee, physical inactivity, consumption of polluted water, and receiving blood). Subjects were asked to tick the appropriate box if they were of the opinion that the health problem was influenced by the factor in question. The overall reliability coefficient for knowledge test in the overall sample was .9116 suggesting very high internal consistency of the test. 11 3-4-2) Health Beliefs It can be defined as the given importance of a series of behaviors for health maintenance by in individuals. Subjects were asked to rate the importance of 16 behaviors for health maintenance on the index. Some of these 16 items were; brushing teeth regularly, regular physical exercise, consuming fruit and green vegetables, avoidance of extra salt, sugar, animal fat, alcohol, and smoking. Beliefs concerning the importance of behaviors for health were assessed by summated scores obtained on belief items for each subject. The overall reliability coefficient for the belief index for the overall sample was .8640, indicating very high internal consistency of the index. 3-4-3) Health-related behaviors (HRBs) HRBs are those activities, which perform by individual for maintenance and/or improvement of his/her health status as well as prevent from onset of disease. An important point is that HRBs are those performed at an asymptomatic stage. In the present study, we focused on six health-related behaviors, namely; personal hygiene, dietary habits, physical exercise, preventive medical checkup, smoking, and alcohol consumption. 3-4-4) Health Related Behaviors (HRBs) of Family In order to find out how far HRBs of respondents were influenced by current patterns of HRBs in their families, respondents were asked to identify how many persons in their families observe HRBs in the study, such as: exercising, healthy dietary habits, personal hygiene, regular medical checkups, smoking, drinking, etc. 3-4-5) Multidimensional Health Locus of Control (MHLC) The Multidimensional Health Locus of Control (MHLC) belief scale was used in this study to measure beliefs about health behavior. Respondents were presented with a list of statements designed to gauge their views about an individual’s ability to control health matters. Health locus of control was assessed using the multidimensional health locus of control scales devised by Wallston, Wallston, and De Vellis (1978), which modified on 1998 by Wallston (www.Vanderbit.edu/nursing /kwallston/ mhlcscales .htm ). The MHLC have shown adequate internal consistency in the previous studies (Steptoe and Wardle, 2001). In this study it shows the internal consistency of .6592 12 3-4-6) Health Concern Health concern or value for health is the value that individuals place on health as a priority in their lives. Research shows positive association between the value for health with health related behaviors (Steptoe & Wardle, 2001), and tendency in quitting smoking (Greenlund et al., 1997). This index was constructed by two items, including; ‘all things considered, good health is the most important thing to have’, and ‘I always think about my health. 3-4-7) Socio-economic Status of Family Socio-economic status was used here to refer to inequality in ranking regarding education, income, and job positions of parents. In each country a three-item scale was used for the qualification of the individual respondents on different levels of socioeconomic status. The scores allocated to educational status of parents, job position of parents, and total monthly income of the family. 3-4-8) Socio-demographic Variables These variables are measured on a nominal or categorical basis, simply by dividing them into two or three groups, such as gender (0=male, 1=female), university (0=Mazandaran University, 1= Panjab University), nativity (0=urban areas, 1=rural areas), type of residence (0=with family, 1= far away from family), level of study (0=undergraduate, 1= postgraduate). 3-5) Hypotheses - There is a significant association between level of education and health knowledge. - There is a significant association between type of residence and health knowledge. - There is a significant association between socioeconomic status of family and health knowledge. - There is a significant association between nationality and health knowledge. - There is a significant association between nativity and health knowledge. - There is a significant association between gender and health knowledge. - There is a significant association between nativity and health beliefs. - There is a significant association between gender and health beliefs. 13 - There is a significant association between health concern and health beliefs. - There is a significant association between health locus of control and health beliefs. - There is a significant association between health behaviors of family and health beliefs. - There is not significant association between health knowledge and health-related behaviors. - There is significant association between health beliefs and health-related behaviors. 3-6) Theoretical Model Level of Education (Undergraduate/Postgraduate) Type of Residence (Staying or far away from Family) Socioeconomic Status of Family Health Knowledge Nationality (Iranian/Indian) Nativity (Urban/Rural) Health Related Behaviors Gender (Male/Female) Health Concern Health Beliefs Health Locus of Control Health behaviors of Family 4) Results 4-1) Health Knowledge 4-1-1) University Level Differences in Health Knowledge The analysis of inter-university data shows some differences as can be seen from table one. These differences have been calculated only for the correct answers. On the whole, students of PU were more aware of risk factors involved in all six diseases listed in table one than their counterparts in MU, particularly in relation to hepatitis, tuberculosis, high blood pressure, and lung cancer. In fact, on all the diseases mentioned in the table, PU students endorsed the right risk factors more often than the MU students. 14 Table 1) Distribution of Health Knowledge among the Students at Mazandaran University (MU) and Panjab University (PU)(Percentage of correct answers) Diseases (%) Risk Factors Heart Lung Breast High blood disease cancer cancer pressure Average Hepatitis Knowledge TB MU PU MU PU MU PU MU PU MU PU MU PU MU PU Smoking 92.0 75.9 96.0 93.3 59.1 36.7 53.2 60.0 9.4 56.6 29.7 47.1 56.6 61.6 Alcohol consumption 60.4 78.6 17.9 27.8 14.6 18.9 51.5 84.8 10.4 50.9 6.8 22.5 26.9 47.2 Stress 92.2 87.9 33.5 63.3 41.4 35.6 85.5 96.1 17.5 60.0 23.9 49.5 49.0 65.4 Extra salt 48.9 49.0 32.9 54.1 30.8 56.1 78.1 88.2 16.3 52.3 23.5 49.6 38.4 58.2 Excessive coffee 37.2 44.2 20.2 35.3 21.6 33.3 16.0 69.4 13.1 43.4 18.7 42.1 16.4 44.6 Animal fat 67.9 79.4 26.5 40.8 11.2 12.3 54.4 65.5 16.6 31.7 22.2 41.4 33.1 45.2 Polluted water 26.2 36.5 18.4 28.3 19.9 42.1 24.1 40.0 31.7 70.2 5.8 15.6 21.0 39.7 Receiving blood 25.5 36.2 25.1 40.2 21.6 40.5 16.8 33.0 37.3 57.1 24.5 27.9 25.1 39.1 Physical inactivity 87.3 71.8 25.1 40.5 24.9 40.2 64.2 55.2 20.1 39.7 23.9 31.5 40.9 46.5 Average knowledge 59.7 62.1 32.8 47.1 30.6 35.1 49.3 65.7 19.2 51.4 19.9 36.3 35.3 49.6 To find out how far these university level differences in health knowledge were significant, ‘Student’s t-test’ was applied. Table2) University Level Differences in Health Knowledge Awareness of risk factors for illness Mazandaran University Panjab University TN Mean value Std. Deviation N Mean value 1.7907 90 5.27 4.98 Std. Deviation value df 1.8904 .364 284 .716 5.59 255 .000 .010 Sig. Heart disease 196 5.36 Lung cancer 180 3.06 2.4118 77 Breast cancer 170 2.75 1.5416 71 3.36 1.7091 2.61 239 High blood pressure 178 4.42 1.8374 75 5.73 1.7268 5.25 251 .000 Hepatitis 175 1.81 2.2871 75 5.09 3.0632 8.32 248 .000 Tuberculosis 178 1.92 1.9223 78 3.51 2.4428 5.08 254 .000 Total Health Knowledge 156 20.0 9.2676 68 28.8 9.9079 6.24 222 .000 15 2.7553 Results of t-test show that students of PU compared to students of MU were more aware of risk factors related to lung cancer, breast cancer, high blood pressure, hepatitis, and tuberculosis. The only non-significant difference was observed in case of heart disease. Overall, the mean values of MU and PU students on the total health knowledge indicates that PU students had more knowledge of risk factors for all the six diseases listed in table as compared to MU students (Figure 1). 4-1-2) Gender Differences in Health Knowledge Table 3) Gender Distribution of Respondents’ Health Knowledge (Percentage of correct answers) Diseases Lung Breast cancer cancer Average High blood pressure Hepatitis Knowledge TB Men Women Men Women Men Women Men Women Men Women Men Women Men Women Risk Factors Heart disease Smoking 84.3 86.7 93.4 95.9 57.9 44.4 54.5 57.1 26.8 23.8 32.0 40.4 58.1 58.0 Alcohol consumption 59.4 76.7 28.2 15.6 13.0 18.7 64.1 66.0 24.5 22.4 7.5 16.1 32.8 35.9 Stress 87.4 93.1 46.9 40.3 52.9 66.4 91.7 88.3 32.9 29.4 35.0 29.7 57.8 57.9 Extra salt 43.6 54.9 43.4 36.8 42.7 35.8 76.3 88.7 31.3 25.3 36.6 28.4 45.7 45.0 Excessive coffee 36.8 43.2 29.6 21.5 30.6 20.4 36.9 43.2 23.4 23.9 26.9 26.7 30.7 29.8 Animal fat 68.8 77.2 33.5 29.7 9.0 14.2 58.0 59.6 26.1 17.7 33.9 23.2 38.2 36.9 Polluted water 30.0 29.8 24.6 19.3 28.4 16.0 26.9 32.1 42.8 52.2 11.9 7.1 27.9 26.1 Receiving blood 30.7 21.8 33.3 27.7 29.3 27.2 21.7 23.2 40.0 51.1 27.4 24.1 30.4 29.2 Physical inactivity 80.7 81.0 34.5 26.8 33.1 27.1 65.4 55.5 25.3 28.7 28.8 24.7 44.6 40.7 Average Knowledge 57.9 62.7 40.8 34.8 33.0 31.1 55.1 57.1 30.3 30.5 26.6 24.5 40.6 40.2 A number of gender differences were found in relation to; alcohol consumption and adding extra salt to meals for heart disease (59.4% and 43.6% men as against 76.7% and 54.9% women respectively); smoking and animal fat for breast cancer (57.9% and 9.0% men as against 44.4% and 14.2% women respectively); adding extra salt to meal and physical inactivity for high blood pressure (76.3% and 65.4% men as against 88.7% and 55.5% women respectively); consumption of polluted water and receiving blood for 16 hepatitis (42.8% and nd 40.0% men m as against 52.2% and 51.1% wom women respectively); and finally smoking and alcohol alco consumption for tuberculosis (32.0% .0% and 7.5% men as against 40.4% and 16.1% % women respectively). Overall, women were w more aware of risk factors involved in hea eart disease and high blood pressure than th men, while men were more aware of risk fa factors involved in lung cancer, breast cancer, ca hepatitis, and tuberculosis. erences in Health Knowledge (Awareness of risk factors for diseases) Table 4) Gender Differe Awareness of risk factors for illness Men Women N Mean M v value Deviation Heart disease 145 5 5.05 Lung cancer 130 3 3.95 Breast cancer 126 High blood pressure T T- N Mean value Deviation 1.7511 141 5.62 1.8499 2.6468 127 3.32 2.6544 3 3.08 1.6877 115 2.76 126 4 4.69 1.6794 127 Hepatitis 126 2 2.84 2.7744 Tuberculosis 128 2 2.47 Total Health Knowledge 116 2 22.75 Std. Std. Val alue N Sig. 2.67 2.6 284 .008 1.90 1.9 255 .057 1.5179 1.55 1.5 239 .122 4.92 2.0938 .966 .96 251 .335 124 2.75 3.1303 .265 .26 248 .791 2.1662 128 2.34 2.2673 .479 .47 254 .632 9.5094 108 22.86 11.0178 .075 .07 222 .941 However, the apparent ge gender differences in knowledge of disea ease inducing factors were statistically non-signifi nificant (see table 4). Gendered awareness ess of risk factors was significant only for heartt d disease. Thus, women students were e more m aware of risk factors involved in heart dis isease as compared to men students. Figure 1)) Gender and National Differences in Health Knowledge 30 Mean value 25 20 15 10 5 0 MU PU Men 17 Women Overall, it is clear that there were no significant differences between men and women students as regards their knowledge of risk factors in the selected diseases, as evident from t-value (.075) not significant even at 0.05 level (Figure 1). 4-1-3) Links between Health Knowledge and Health Behavior An effort was also made to find out the linkages between health knowledge and health related behaviors of individuals on selected diseases. The data in table 5 shows nonsignificant relationship between health knowledge and health behaviors of respondents. Table 5) Association between Health Knowledge and Health Related Behaviors Mean Knowledge about Physical activity Smoking Alcohol Consumption Excessive coffee Extra salt Extra Animal fat Frequency of Health-related Behaviors No exercise 2.63‫٭‬ Less active Nonsmoker Light smoker 3.31 Nondrinker 3.26 Light drinker 1.95 1-3 cups 3.75 Always 2.23 Always 2.50 1.90 Moderately active 2.70 Highly active Moderate smoker 3.40 2.64 Strong Smoker 2.75 Moderate drinker 1.80 Heavy drinker 2.16 1.72 Less than Rarely one cup 2.20 1.59 Mostly Sometimes Rarely 2.45 2.52 2.57 Mostly Sometimes Rarely 2.61 2.26 1.91 Never 1.69 Never 3.18 Never 2.33 F N Sig. 2.39 296 .068 .359 317 .783 .315 293 .814 289 .122 1.41 298 .228 1.67 294 .156 1.95 ‫ ٭‬Mean values of health knowledge about relationship between physical activity and some diseases For example, there were no significant differences between the knowledge of smoking as a contributory factor in lung cancer and its influence in making a person give up smoking. In other words, there were no significant differences between smokers and non-smokers in terms of knowledge of harmful effects of smoking. Similarly, drinking or non-drinking was not significantly associated with awareness of the influence of alcohol on illness. It is interesting to note that heavy drinkers were more aware of alcohol hazards (mean knowledge=2.16) than non-drinkers (1.95), though the F-ratio was not significant. This suggests that drinkers are more aware of the possible harmful consequences of alcohol than non-drinkers, and that knowledge did not function as a deterrent. The same association holds for every item concerning adding salt to meals, consumption of extra fat, frequency of drinking excessive coffee, and physical activity. 18 4-1-4) Factors Associated with Health Knowledge Table 6) Factors Associated with Health Knowledge in the Overall Sample Associated Factors Mean Values of Health Knowledge in Different Categories F N Sig. University Mazandaran University ‫٭‬ 20.2 Panjab University 28.8 39.0 223 .000 Level of education Undergraduate students 21.5 Postgraduate students 26.6 10.9 223 .001 Type of residence Far away from family 25.2 Staying with family 21.8 5.25 215 .023 Urban Rural 19.7 5.48 222 .020 31.2 6.28 208 .000 10.2 211 .000 13.4 210 .000 Nativity SES Father’s education Mother’s education Low 17.3 23.7 Medium 22.4 High Less than middle school Middle & high school Graduate & postgraduate 12.0 21.5 25.6 Less than middle school 14.2 Middle & high school Graduate & postgraduate 26.5 22.2 ‫ ٭‬Mean values of health knowledge rated by each category of students As can be seen from table 6, there exists a significant association between the level of health knowledge and the university of respondents, level of education, type of residence, nativity, subject of study, father’s education, mother’s education, and SES of respondent’s family. 4-2) Health Beliefs 4-2-1) University Level Differences in Health Beliefs University-wise data reveals that 55.7 % students of MU as against 54.8% students of PU gave high importance to health maintenance behaviors. Three health related behaviors which have been assigned the highest importance for maintenance of health were regular brushing of teeth (91.1%), abstaining from smoking (81.9%), and eating fruit (79.0%). The three behaviors, which were given least importance, were annual dental check-up (49.7%), eating fish and poultry (42.8%), and annual check up for blood pressure (41.6%). 19 Table 7) Distribution of Health Beliefs among the Students of Mazandaran University and Panjab University Level of Health Beliefs (Given importance of behaviors for health maintenance) List of Behaviors Mazandaran University (%) Panjab University (%) Low Medium High Low Medium High Brush teeth regularly 0.8 13.7 85.6 ---- 2.9 97.1 Annual dental checkup 19.8 23.7 56.5 22.6 35.1 42.3 Regular physical exercise 9.7 17.4 73.0 9.7 25.3 64.7 7-8 hours sleep daily 3.1 20.6 76.3 4.6 13.9 81.5 Eating breakfast every day 8.9 17.4 73.6 4.7 13.1 82.2 Eating green vegetables 6.8 21.3 71.9 2.9 10.9 86.2 Eating fruit 2.3 19.5 78.2 2.5 17.6 79.9 Eating milk & dairy products 8.4 18.6 73.0 5.1 18.6 76.3 Eating fish and poultry 6.1 30.4 63.5 54.5 26.0 19.6 Annual blood pressure checkup 31.0 22.0 47.0 42.5 21.9 35.6 Not to smoke 13.0 3.2 83.8 16.3 3.9 79.8 Drink no alcohol 12.0 11.5 76.5 15.0 9.0 76.0 Avoid extra fat 16.7 28.7 54.6 19.9 14.3 65.8 Avoid excess salt 15.8 23.6 60.6 16.3 27.9 55.8 Avoid excess coffee 21.4 23.0 55.6 18.3 26.4 55.3 Avoid excess sugar 18.6 26.7 54.7 14.9 23.4 61.7 Mean 12.1 32.2 55.7 15.6 29.6 54.8 The university-wise data reveals some variations. Students of MU gave the highest importance to regular brushing of teeth, non-smoking and eating fruit, while the students of PU believed that regular brushing of teeth ,eating green vegetables, and having breakfast regularly were the three most important behaviors, respectively. On the other hand, students of MU gave the least importance to avoiding too much sugar, avoiding extra fat and annual check up for blood pressure, whereas annual dental checkup, annual blood pressure checkup, and eating fish and poultry were believed to be the least important behaviors for maintenance of health by students of PU. The average 20 ratings given by students of MU and PU about the importance of different behaviors for health are shown in table 8, which are ranked according to their aggregate means. Table 8) University Level Differences in Health Beliefs Mazandaran University (MU) Panjab University (PU) Tvalue df Sig. .4903 6.13 455 .000 4.24 1.4310 .538 478 .591 239 4.31 .8497 1.52 499 .127 .9629 239 4.39 .8427 4.61 500 .000 4.14 .8895 238 4.27 .9133 1.64 498 .102 251 4.20 1.2628 233 4.14 1.3901 .510 482 .610 Eating breakfast daily 258 4.03 1.0204 236 4.29 .8964 2.92 492 .004 Eating milk& dairy products 263 4.07 .9855 236 4.21 .9763 1.59 497 .112 Regular exercise 259 4.05 1.0806 238 3.86 1.0613 1.91 495 .056 Avoid extra fat 258 3.59 1.1540 231 3.78 1.4252 1.63 487 .103 Avoid excess salt 259 3.68 1.1846 233 3.66 1.2869 .202 490 .840 Avoid excess sugar 258 3.56 1.2083 235 3.77 1.2885 1.85 491 .064 Avoid excess coffee 252 3.52 1.2732 235 3.62 1.2931 .838 485 .403 Annual dental check up 262 3.55 1.2545 239 3.29 1.1979 2.37 499 .018 Eating fish& poultry 263 3.84 .9543 235 2.37 1.2798 14.3 430 .000 Annual blood pressure check up 255 3.19 1.3313 233 2.87 1.4453 2.51 486 .012 Total Health Beliefs 221 63.3 10.69.8 208 62.2 10.0073 1.07 427 .281 List of Behaviors N Mean value Std. deviation Brush teeth regularly 263 4.41 Not to smoke 247 Eating fruit N Mean value Std. deviation .7516 240 4.76 4.31 1.3020 233 262 4.20 .8448 Eating green vegetables 263 4.01 7-8 hours sleep daily 262 Drink no alcohol Significant university level differences were found for six items listed in table, of which for three items (annual dental checkup, annual checkup for blood pressure, and eating fish& poultry) students of MU had higher mean values than students of PU; whereas for three other items, namely eating breakfast every day, eating fruit, and eating green vegetables, students of PU scored higher mean values as compared to their counterparts in MU. Also, there were no significant differences for the remaining ten 21 items. However, there were no significant university level differences (T-value= 1.07) when all the health beliefs were taken together, though the mean values of MU students were higher (63.3) than that of PU students (62.2). 4-2-2) Gender Differences in Health Beliefs The data on gender differences in health beliefs shows that on the whole 64.6% men as against 69.3% women students gave high importance for health related behaviors listed in table 9. This indicates a higher level of importance given by women to health related behaviors for maintenance of health as compared to their men counterparts. Table 9) Gender Distribution of respondents’ health beliefs Level of Health Beliefs Men (%) List of behaviors Women (%) Low Medium High Low Medium High Brush teeth regularly 0.8 6.6 92.6 ---- 10.4 89.6 Annual dental checkup 25.2 31.4 43.4 17.4 27.0 55.6 Regular physical exercise 7.4 19.3 73.3 11.8 23.2 65.0 7-8 hours sleep daily 4.1 19.0 76.9 3.5 15.9 80.6 Eating breakfast every day 3.8 15.1 81.1 9.8 15.6 74.6 Eating green vegetables 5.3 18.1 76.5 4.6 14.7 80.7 Eating fruit 2.9 21.0 76.1 1.9 16.3 81.8 Eating milk & dairy products 4.9 20.2 74.9 8.6 17.2 74.2 Eating fish and poultry 27.5 30.8 41.7 30.2 26.0 43.8 Annual blood pressure checkup 40.6 22.6 36.8 32.5 21.3 46.2 Not to smoke 12.6 3.8 83.7 16.3 3.3 80.1 Drink no alcohol 14.2 14.6 71.3 12.7 6.1 81.1 Avoid extra fat 19.0 25.7 55.3 17.5 18.3 64.3 Avoid too much salt 18.3 32.8 49.0 13.9 18.7 67.3 Avoid excessive coffee 20.4 29.6 50.0 19.4 19.8 60.7 Avoid too much sugar 16.6 31.1 52.3 17.1 19.4 63.5 Total health beliefs 14.1 21.3 64.6 13.6 17.1 69.3 Gender wise data reveals some variations. Overall, women have paid more attention to eating fruit and avoiding alcohol for health maintenance while men have given more importance to non smoking and having breakfast regularly in this regard. Both men and 22 women considered brushing teeth regularly as the most important behavior for maintenance of health. Table 10) Gender Differences in Health Beliefs Men .6530 260 Annual dental checkup 242 3.26 1.2367 259 Regular exercise 243 4.08 1.0171 254 7-8 hours sleep daily 242 4.14 .9228 258 Eating breakfast daily 238 4.27 .8561 256 Eating green vegetables 243 4.13 .9086 259 Eating fruit 243 4.18 .8640 258 Eating milk & dairy products 243 4.17 .9332 256 Eating fish and poultry 240 3.15 1.3182 258 Annual blood pressure checkup 239 2.85 1.3377 249 Not to smoke 239 4.33 1.2695 241 Drink no alcohol 240 4.05 1.3418 244 Avoid extra fat 237 3.57 1.2719 252 Avoid too much salt 241 3.48 1.2352 251 Avoid excessive coffee 240 3.45 1.2264 247 Avoid too much sugar 241 3.56 1.2203 252 Total health beliefs 219 61.21 9.8262 210 4.58 Standard Deviation Number 4.58 Mean Value Standard Deviation 243 Number Brush teeth regularly Behaviors Mean Value List of Women .6725 N Sig. .074 501 .941 TValue 3.58 1.2117 2.98 499 .003 3.85 1.1169 2.37 495 .018 4.27 .8800 1.62 498 .105 4.05 1.0560 2.60 492 .009 4.25 .9394 1.53 500 .125 4.32 .8291 1.85 499 .064 4.11 1.0284 .676 497 .499 3.15 1.3568 .025 496 .980 3.22 1.4255 2.99 486 .003 4.21 1.4539 .955 478 .340 4.29 1.2995 1.97 482 .049 3.81 1.3043 1.98 487 .048 3.85 1.2059 3.33 490 .001 3.68 1.3273 1.98 485 .048 3.85 1.2720 1.99 491 .046 64.31 10.6976 3.13 427 .002 The data in table 10 shows that on the whole, the highest mean values were for brushing teeth regularly, followed by non smoking, and eating fruit; while the lowest mean values were for annual dental check up, followed by eating fish and poultry, and annual blood pressure checkup. However, significant gender differences were found for nine items listed in the table, of which for seven items (annual dental checkup, annual 23 blood pressure checkup,, n non-drinking alcohol, avoidance of anim imal fat; excess salt; coffee, and sugar) women en had higher mean values than men.. In two items that is, regular exercise and havin ving breakfast men students scored high gher mean values as compared to women stude dents. There were no significant gender er differences for the remaining seven. It implies es that in general, women students gave e more importance to health maintenance behavio viors than men. It can be inferred from the he above analysis that by and large men and wome men students differ on their ‘health beliefs’ fs’ (Figure 2). Figure 2) 2 Gender and National Differences in Health Beliefs 70 Mean value 60 50 40 30 20 10 0 MU PU Men Women 4-2-3) Links between Heal ealth Beliefs and Health Behaviors In the present study, the q question of whether variations in the prevalence pr of healthrelated behaviors were ass ssociated with the level of beliefs aboutt iimportance of those behaviors for health main intenance was analysed. Similar to prev revious studies, clear associations were observed ed for almost all items included in this study udy. As can be seen from the table, ta for all items (except avoidance of excessive coffee) a significant association could uld be seen between the frequency or inte tensity of carrying out the behavior and the mean an values of the associated belief. For example, ex people who brush their teeth twice or more m times daily believe (mean value was as 4.74) this behavior to be more important than n those who brush their teeth once a day ay (4.56), who in turn believe it to be more impo portant than those who brush their teeth h less frequently than once per day (3.88). F-ratio tio for this association comes out to be sig significant at .01 level of confidence (F = 13.0,, N = 500, P <. 01). It implies that there th exist significant 24 differences in belief rankings according to frequency of brushing teeth, indicating strong influence of health beliefs on healthy behavior on this item. Table 11) Association between Health Beliefs and Health-related Behaviors Mean Health Beliefs about Frequency of Health-related Behaviors 2 times or more a day 4.74‫٭‬ Always Once a day Once a week Rarely or never 4.56 Once per every 2-3 days 3.88 4.00 4.12 Mostly Sometimes Rarely Never 4.53 4.24 3.82 3.27 3.65 Once a day or more 4.52 Once a day or more 4.43 Once a day or more 4.37 Regularly Every 2-3 days About once a week Rarely or never 3.99 Every 2-3 days 3.90 About once a week 4.05 Every 2-3 days 4.07 About once a week 4.16 Mostly 4.08 Sometimes About once a month 3.57 About once a month 3.71 About once a month 3.84 Rarely 3.37 3.92 3.68 3.38 2.62 Always 3.81 Mostly 3.50 Sometimes 3.66 Rarely 3.88 Never 3.31 Always Mostly Sometimes Rarely Never 3.35 Always 3.13 Mostly 3.56 Sometimes 3.85 Rarely 3.84 Never Avoid too much sugar 3.21 3.47 3.31 3.87 4.01 More than 3 cups 2.33 1-3 Cups 3.30 Less than one cup 3.37 Rarely Never Avoid excessive coffee 3.57 3.60 Brush teeth regularly Eating breakfast daily Eating green vegetables Eating fruit Eating milk & dairy products Annual blood pressure checkup Avoid extra fat Avoid too much salt Drink no alcohol Not to smoke 4.40 Rarely or never N Sig. 13.0 500 .000 2.91 483 .000 15.2 4.28 Heavy drinker 3.08 Heavy smoker 4.16 Moderately active 4.25 Moderate drinker 3.14 Moderate smoker 3.16 Less active 3.89 Light drinker 497 .000 6.98 497 .000 10.3 494 .000 14.1 465 .000 2.47 470 .043 3.55 Never 4.59 Highly active Physical exercise 3.60 Rarely or never F 3.27 Light smoker No exercise 3.63 Nondrinker 4.33 Non-smoker 3.68 4.31 7.39 .988 482 483 472 .001 .000 .414 13.2 496 .000 14.4 465 .000 3.03 468 .029 ‫ ٭‬Mean values of health beliefs about the importance of brushing teeth regularly for health. The same association holds for every item concerning having breakfast, regular exercise, eating green vegetables, fruit, milk & dairy products, annual blood pressure check up, non smoking, non drinking, avoiding extra fat, salt, and sugar. On the whole, 25 there was a significant association between total health beliefs and health-related behaviors that is behaviors that were believed to be more important for health maintenance, carried out by more individuals than behaviors which were believed to be less important. In other words, those who scored higher on health belief values positively practiced better health behaviors. The findings of present study are in line with those studies conducted by Wardle and Steptoe, 1991; Calnan and Rutter (1988); Steptoe and Wardle (1992); Courtenay (2002); Cody and Lee (1982); Osaka et al. (1999); Steptoe et al. (2002); Kurtz et al. (1992); Callaghan (1995); Gorin (1992); Harnack et al. (1997); and Monneuse et al. (1997). 4-2-4) Factors Associated with Health Beliefs As can be seen from table, there is significant association between level of health beliefs with gender, nativity, health behaviors of family, health locus of control, and health concern. The data shows that health beliefs were higher among women students and students who were residents of urban areas. Also it was higher for those whose families observed higher level of positive lifestyle, students who enjoyed a good sense of control, and those who were more concerned about their health status. Table 12) Factors Associated with Health Beliefs in the Overall Sample Associated Factors Mean values of health beliefs in different categories Gender Men Nativity Health locus of control Health concern Health behaviors of family 61.2‫٭‬ Urban 63.5 Slightly internal 57.0 Low 59.3 N Sig. Women 64.3 9.81 428 .002 Rural 60.4 6.85 422 .009 3.10 399 .046 3.21 422 .023 4.60 371 .001 Moderately internal 62.4 Medium 60.7 F Strongly internal 63.6 High 63.6 Very high 64.3 Very low Low Medium High Very high 58.5 61.0 63.4 66.3 65.1 ‫٭‬Mean values of health beliefs rated by each category of students 5) Discussion On the basis of the above analysis, it was found that differences in health knowledge of PU and MU students were quite significant; while the differences in health beliefs were non significant. In other words, awareness of students of PU and MU about 26 the various health related risk factors was different. It was generally observed that students of PU were more aware of risk factors involved in certain diseases than the students of MU. However, in terms of health beliefs, students of MU and PU gave almost the same importance to health maintenance behaviors. However, significant differences existed in some items, namely students of PU compared with students of MU gave more importance to regular brushing of teeth, eating breakfast daily, and eating green vegetables; while students of MU gave more importance to annual dental check up, eating fish and poultry, and annual blood pressure check up. Further, in line with previous studies no significant gender differences in health knowledge could be observed. In other words, awareness of men and women students about some risk factors for illness was similar, except about heart disease about which women students showed more awareness of risk factors for heart disease than men students. In relation to health beliefs, men students differed significantly from women who gave more importance to behaviors such as annual dental checkups, annual blood pressure measurement, avoiding alcohol; animal fat; excess salt; coffee; and sugar as health enhancing measures. On the other hand, men students believed regular exercise and eating breakfast daily as more important for their health maintenance. Also, in line with previous studies association between health knowledge and health related behaviors was found to be weak and non significant; while a very strong and significant association between health beliefs and health related behaviors was observed. It implies that health knowledge does not lead necessarily to risk reducing or healthenhancing behaviors, while health beliefs, to a large extent, improve the health related behaviors. Finally, it was found that there exist significant associations between health knowledge and some factors such as, being a student of PU, being postgraduate students, living in urban areas, living far away from family, having more educated father and mother, and belonging to higher SES families. Further, some other factors such as being a woman, living in urban areas, belonging to more healthy families, enjoying a good sense of control, and being more concerned about personal health were associated with higher level of health beliefs. The results in the present study are in line with those reported by Wardle and Steptoe (1991); Kurtz et al., (1992), Kapoor et al., (1995); and Avis et al., (1996). All these studies confirmed that both smokers and nonsmokers were well informed about 27 the adverse effects of smoking indicating that mere provision of information on hazards of smoking may not be enough to reduce the prevalence of smoking. These findings are also supported by other studies such as those of Kurtz et al., (1992); Naslund and Fredrikson (1993); Frost (1992); Avis et al., (1990); and Jerkegren et al., (1999). All these studies indicate a weak and non-significant relationship between health knowledge and health behaviors, suggesting that health knowledge does not necessarily lead to risk reducing behaviors. These findings are consistent with previous studies about gender differences on health beliefs. For example, Steptoe and Wardle (1992) found that gender differences in belief ratings were uniform across eight European countries, for instance, in all these countries; women rated fat avoidance and moderation in alcohol consumption as more important than men. Similarly Courtney et al. (2002) who conducted a study on gender/ethnic differences on health beliefs and behaviors found that men students had significantly riskier beliefs in diet, substance use, medical compliance, and preventive care than women students. Also, Cody and Lee (1989) found that women scored significantly higher than men on skin protection knowledge, intension, and behavior. In the light of the results of this study and also those of other studies, association between health knowledge and health related behavior is inconsistent and non significant, while health beliefs have significant and consistent association with health behaviors of students. This finding strongly suggests that, although knowledge remains an important factor that must be addressed in health education programmes, in order to motivate young college students to take appropriate prevention measures when exposed to unhealthy behaviors, educational efforts must focus primarily on the formation of attitudes and beliefs towards health related behaviors. Prevention approaches based on social learning theory have emphasized developing social and personal skills in youth and young adults to enable them to resist pro-drug and unhealthy environmental and peer pressures. Therefore, educational efforts directed toward young college/university students should include strategies that help reduce the influence of the peer group. Further, all health interventions by the authorities have to adopt multi-pronged strategies to improve health knowledge, health beliefs, health concern, and health related behaviors. 28 However, further studies are needed for monitoring progress in enhancing health knowledge & beliefs, reducing critical health risk behaviors, or improvement in positive health habits among young students. The periodic research studies in this area and at the cross-national levels would be necessary to establish priority areas for future interventions and to monitor their effects. Further, a national study among the university students of each country on a larger scale, with the cooperation of all institutions for higher education could make a significant contribution to the literature and the future health of college/university students in Iran and India. Further studies, of course, can be conducted on other socio-economic groups of society to compare the results with the university students and finding out the place of students in health hierarchy. Finally, in order to clarify which factors best explain cross-national differentials observed in health related behaviors, future research needs to go beyond the set of determinants available for the current study and strike into the more subtle aspects of health related behaviors across settings. ☼References: - Abroms L., et al., (2003). Gender differences in young adults’ beliefs about sunscreen use. Health Education & Behavior, Vol. 30(1): 29-43. - Avis NE, McKinlay JB., & Smith KW. (1990). Is cardiovascular risk factor knowledge sufficient to influence behavior?. Am.J Prev Med, 6, 137-44. - Awasthi P., et al., (2006). Health beliefs and behavior of cervix cancer patients. Psychology and Developing Societies, 18, 1. - Bassey EB. et. Al., (2007). Knowledge of and attitudes to AIDS among traditional birth attendants in rural communities in Cross River State, Nigeria. Int Nurs Rev, 54(4): 354-8. - Callaghan, Patrick. (1996). A Preliminary survey of nurse’s health-related behaviors. Int J Nurs Stud, 32(1), 1-15. - Calnan M., & Rutter DR. (1988). Do health beliefs predict health behavior: a follow-up analysis of breast self-examination. Social Science & Medicine, 24, 463-5. - Cockerham, William C. (1989). Medical sociology. New Jersey: Printice-Hall Inc. - Cody R., & Lee C. (1990). Behaviors, beliefs, and intentions in skin cancer prevention. J Behavioral Medicine, 13(4), 373-89. - Courtenay WH., Mccreary DR., & Merighi, JR. (2002). Gender and ethnic differences in health beliefs and behaviors. Journal of Health psychology, 7(3), 219-31. - Crzywacz JG., & Marks NF. (2001). Social inequalities and exercise during adulthood: toward an ecological perspective. J Health and Social Behavior, 42, 202-20. - Dittmar SS., Haughey BP., O’Shea RM., et al. (1989). Health Practices of nursing students: a survey. Health Values. 12 (2), 24-31. - Douglas KA., Collins JL., Warren C., et al. (1997). Results from the 1995 national college health risk behavior survey. J American College Health, 46, 55-69. 29 - Eagly, Alice H. (2000). Gender roles. In: Alan E Kazdin. Encyclopedia of psychology. Vol. 3. New York: Oxford University Press. pp 448-53. - Eccles, Jacquelynne S. (2000). Gender Socialization. In: Alan E Kazdin. Encyclopedia of psychology. Vol. 3. New York: Oxford University Press. pp 455-7. - Fennell R. (1997). Health behaviors of students attending historically black colleges and universities. Journal of American College Health, 46, 109-17. - Fleetwood J., & Packa DR. (1991). Determinants of health promoting behavior in adults. J Cardiovase Nurs, 5(2), 67-79. - Frost R. (1992). Cardiovascular risk modification in the college students: Knowledge, attitudes, and behavior. J Gen Inter Med, 7(3), 317-20. - Gonzalez, Gerardo M. (2000). An integrated theoretical framework for individual responsibility and institutional leadership in preventing alcohol and drug abuse on the college campus. www.edc.org/hec/pubs/theorybook/Gonzalez.html. - Gorin SS. (1992). Student nurse opinions about the importance of health promotions practices. J Community Health, 17(6), 367-75. - Greenlund KJ., Johnson CC., Webber LS., et al. (1997). Cigarette smoking attitudes and first use among third-through sixth-grade students. American Journal of Public Health, 87 (8), 1345-8. - Hanson Mary Jane S. (1999). Cross-cultural study of beliefs about smoking among teenaged females. Western Journal of Nursing Research, 21(5): 631-651. - Harnack L., Block G., Subar A., et al. (1997). Association of cancer prevention-related nutrition knowledge, beliefs, and attitudes of prevention dietary behavior. Am J Diet Association, 97(9), 957-65. - Holt Cheryl L. et al., (2003). Spirituality, breast cancer beliefs and mammography utilization among urban African American women. Journal of Health Psychology, 8(3): 383-396. th - House, James S. (2001). Understanding social factors and inequalities in health: 20 century progress and 21th century prospects. Journal of Health and Social Behavior, 43, 125-42. - Jerkegren E., Sandrieser L., Brandberg Y., et al. (1999). Sun-related behavior and Melanoma awareness among Swedish university students. Eur J Cancer Prev, 8, 27-34. - Jobanputra R & Furnham A. (2005). British Gujarati Indian immigrants’ and British Caucasians’ beliefs about health and illness. International Journal of Social Psychiatry, 51(4): 350-364. - Jones DH., Harel Y., & Levinson RM. (1992). Living arrangements, knowledge of health risks and stress as determinants of health behavior among college students. J Am Coll Health, 41(2), 43-8. - Jung J. (2001). Psychology of alcohol and other drugs: A research perspective. California (USA): SAGE Publications. - Kandrack MA., Grant KR., & Segall A. (1991). Gender differences in health related behavior: some unanswered questions. Social Science & Medicine, 32 (5): 579-90. - Kapoor SK., Anand K., & Kumar G. (1995). Prevalence of tobacco use among school and college going adolescents of Haryana. India J Pediatr, 62, 461-66. - Kurtz ME., Johnson SM., & Ross-Lee B. (1992). Passive smoking: directions for health education among Malaysian college students. Int J Health services, 22(3), 555-65. - Lee, Kwok-Chung. et al., (2007). The role of fear-avoidance beliefs in patients with neck pain. Clinical Rehabilitation, 21: 812-821. - Lopez, Gonzalez ML., Najera MP., Lopez NC., et al. (1992). Adolescence at risk: a health survey among pre-university students. Gac Sanit, 6(31), 157-63. - Macintyre, Sally. (1986). The Patterning of health by social position in contemporary Britain: directions for sociological research. Social Science & Medicine, 23, 393-415. - Mackie, Marlene. (1990). Socialization. In: Robert Hagedorn. Sociology. Toronto: Halt, Reinhart and Winston of Canada, pp61-69. - Monneuse MO., Bellisle F., & Koppert G. (1997). Eating habits, food and health related attitudes and beliefs reported by French students. Eur J Clin Nutrition, 51(1), 46-53. - Moon G., & Gillespie R. (1996). Society and Health. London: Routledge. 30 - Munro A, et al., (2007). Assessing the impact of training on mental health nurses’ therapeutic attitudes and knowledge about co-morbidity. Int J Nurs Stud, 44(8): 1430-8. - Naslund GK., & Fredrickson M. (1993). Health behavior, Knowledge and attitudes among Swedish university students. Scand J Psychol, 34(3), 197-211. - Norris, Anne E. et al., (1994). Condom beliefs in urban, low income, African American and Hispanic youth. Health Education Quarterly, 21(1), 39-53. - Osaka R., Nanakorn S., Sanseeha L., et al. (1999). Healthy dietary habits, body mass index, and predictors among nursing students, northeast Thailand. Southeast Asian Trop Med Pub Health, 30(1), 115-121. - Pacther, Lee M, et al. (2000). Factors and subscale structure of parental health locus of control instrument. Social Science & Medicine, 50, 715-21. - Patrick K., Covin, Jennifer R., Fulop M., et al. (1997). Health risk behaviors among California college students. Journal of American College Health, 45, 265-72. - Pavalko EK., & Woodbury S. (2000). Social roles as process: care giving careers and women’s health. J Health Soc Behav. 412, 91-105. - Penny GN., Bennett P., & Herbert M. (1994). Health psychology: A lifespan perspective. Switzerland: Harwood academic Publishers. - Pietila AM., Hentinen M., & Myhrman A. (1995). The health behavior of Northern Finnish men in adolescence and adulthood. Int J Nurs Stud, 32 (30), 325-38. - Riley-Docut C. (2005). Beliefs about the controllability of pain. Journal of Family Nursing, 11(3): 2254-41. - Ross, C E., & Wu, CL. (1995). The links between education and health. American Sociological Review, 60, 719-45. - Simons L.A, et al., (2007). Low-income rural women and depression: factors associated with self-reporting. American Journal of Health Behaviors, 31(6): 657-666. - Small SP. (1994). The smoking behavior of grade ten students. Can J Cardiovasc Nurs, 5(2), 3-10. - Steptoe A., & Wardle J. (1992). Cognitive predictors of health behavior in contrasting regions of Europe. Br J Clin Psychol, 31, 485-502. - Steptoe A., Wardle J. Cui W, et al. (2002). Trends in smoking, diet, physical exercise, and attitudes toward health in European university students from 13 countries 1990-2000. Preventive Medicine, 35(2), 97-104. - Steptoe, A., & Wardle, J. (2001). Health behavior, risk awareness, and emotional well being in students from Eastern Europe and Western Europe. Social Science & Medicine, 53, 1621-30. - Wallston K. (1998). Multidimensional health locus of control (MHLC) scales. www.vanderbilt. Edu/nursing/kwallston/mhlcscales.htm. - Wardle J., & Steptoe A. (1991).The European health and behavior survey: rationale, methods, and initial results from the United Kingdom. Social Science & Medicine, 33(8): 925-36. - Weissfeld Joel L, et al., (1990). Health beliefs in population: The Michigan blood pressure survey. Health Education Quarterly, 17(2): 141-155. - Yassine N., Bartal M., & Biaze M. (1999). Smoking among medical students in Casablanca. Rev Mal Respir, 16(1), 59-64. - www.med.usf.edu/kmbrown/locus-of-control-overview.htm - www.members.tropid.com/vandom-sage/intro-htm 31