A predictive model of hopefulness for adolescents

JOURNAL OF ADOLESCENT HEALTH 2004;35:478 – 485

ORIGINAL ARTICLE

A Predictive Model of Hopefulness for Adolescents MARY ANN CANTRELL, Ph.D., R.N. AND PAUL LUPINACCI, Ph.D.

Purpose: To develop a predictive model of hopefulness using the variables of age, gender, and self-esteem among a sample of adolescents with cancer and a sample of healthy adolescents. Methods: Forty-five healthy adolescents were individually matched with 45 adolescents with cancer on the basis of gender and age. Of the 90 subjects included in this study, 48 were male and 42 were female; half of the males (n ⴝ24) and half of the females (n ⴝ 21) had cancer. Perceived level of self-esteem was measured using the Coppersmith Self-Esteem Inventory (SEI), and their degree of hopefulness was measured with the Hopefulness Scale for Adolescents (HSA). Data were analyzed using the Statistical Analysis System (SAS) Version 8. Results: Adolescents’ perceived level of self-esteem and hopefulness did not differ by gender or disease status. Patients with cancer had a significantly higher mean hopefulness score than healthy subjects (p ⴝ .031), and those adolescents with cancer did not have a lower perceived sense of self-esteem than healthy adolescents. The correlation coefficients between SEI and HSA were statistically significant for females with cancer, r ⴝ 0.723 (p < .001) and for healthy females, r ⴝ 0.676 (p < .001). In contrast, the correlations between SEI and HSA for males were not statistically significant. A model was constructed to predict a subject’s hopefulness score that included the variables of self-esteem (p < .001), gender (p ⴝ .001), disease status (p ⴝ .005), and the interaction between self-esteem and gender (p ⴝ .002). Conclusions: The findings of this study demonstrate that hopefulness is a coping strategy used by female adolescents, both healthy and ill, that is closely related to their perceived sense of self-esteem. © Society for Adolescent Medicine, 2004

From the College of Nursing (M.A.C.) and Department of Mathematical Sciences, Villanova University, Villanova, Pennsylvania (P.L.). Address correspondence to: Dr. Mary Ann Cantrell, Assistant Professor, College of Nursing, Villanova University, 800 Lancaster Avenue, Villanova, PA 19085-1690. E-mail: mary.ann.cantrell@ villanova.edu Manuscript accepted February 6, 2004. 1054-139X/04/$–see front matter doi:10.1016/j.jadohealth.2004.02.011

KEY WORDS:

Self-esteem Hopefulness Gender Adolescents

Healthy and chronically ill adolescents use a variety of coping strategies, such as hopefulness, that are associated with their psychosocial development, specifically, perceived level of self-esteem. Effective coping and psychosocial development have been associated with school performance, a healthy lifestyle, and positive peer relationships among healthy adolescents [1– 4]. Among adolescents with a chronic illness, such as cancer, effective coping and psychosocial development have been associated with increased quality of life and improved treatment outcomes [5–7]. Self-esteem has been identified as a vital component in the achievement of an ego-identity status, which is the cornerstone of successful psychosocial development in the adolescent period [8]. Recent findings have indicated that higher levels of selfesteem are associated with more effective ways of coping, such as problem-focused coping among healthy adolescents [9 –12]. Age and gender differences have been identified in coping and stress management [12,13], and have been found to be important factors influencing self-image among healthy adolescent samples [14]. Educators believe that higher levels of self-esteem are expected to produce more positive outcomes relative to a successful educational experience. Among a sample of 593 high school students, self-esteem related to school and home life correlated significantly with selected academic variables such as grade point average, academic standing and absenteeism [2]. A healthy self-esteem is required to address the many challenges in developing an effective self-care © Society for Adolescent Medicine, 2004 Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010

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agency before entering adulthood [15]. A negative relationship between self-esteem and negative health behaviors exists, such that children with higher levels of self-esteem become involved in fewer negative health behaviors and the intent to engage in them in the future [16]. The relationships among self-esteem, hopefulness, and positive health practices have also received empirical support in recent investigations [3,4,17].

Hopefulness and Its Role in Developmental Maturity Hopefulness is one coping strategy used by both healthy and chronically ill adolescents that is associated with their psychosocial development [18 –20]. Among adolescents with cancer, hopefulness was found to be a protective factor [5,6,21], supporting Erikson’s [22] theoretical assertion that adolescents re-experience previous stages of psychosocial development. Jevne [23] identified the concept of hope as being part of a class of concepts that includes coping, faith, resilience and empowerment, and considered hope to be essential in living with a chronic illness. Hope has been found to be one component in individuals’ affective responses to stress and transitions by making one’s existing circumstances more bearable [24]. Hendricks [3] argues that having hope reinforces positive physiological and psychological functioning, whereas its absence is associated with a premature failure in functioning. The purpose of this study was to build a predictive model of hopefulness by examining the relationships among age, gender, self-esteem and hopefulness among a sample of adolescents with cancer and a matched sample of healthy adolescents, and to test if these relationships differ among the two groups. The research questions of the study were: (a) Does the nature of the relationship among self-esteem and hopefulness differ between healthy adolescents and adolescents with cancer?; and (b) Do gender, age, health status and perceived self-esteem predict the level of hopefulness among healthy adolescents and adolescents with cancer? The theoretical framework for this study was based upon developmental theory and past research. It is posited that a positive relationship exists between the abstract concepts of developmental processes and coping, which is influenced by stage of adolescence and gender. Developmental processes are theoretically defined as self-esteem, which is a personal judgment of worthiness expressed in the attitudes an individual holds

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Table 1. Stage of Adolescence and Gender for the Total Sample Stage Gender Male n % within gender % within stage % of total Female n % within gender % within stage % of total Total n % of total

Early

Middle

Late

Total

20 41.7 62.5 22.2

26 54.2 48.1 28.8

2 4 50.0 2.2

48 100.0 53.3 53.2

12 28.6 37.5 13.3

28 66.6 51.8 31.1

2 19.0 40.0 2.2

42 100.0 46.6 46.6

32 35.6

54 60.0

4 4.4

90 100

toward himself and is a reflection of an individual’s perceived success [25]. Coping was theoretically defined as hopefulness, a belief that a personal, positive, self-defined future exists [6]. Institutional review board (IRB) approval for access to the sample of adolescents with cancer was obtained from The Children’s Hospital of Philadelphia. For access to the sample of healthy adolescents, IRB approval was obtained from a suburban Philadelphia adolescent medicine clinic. The researchers also obtained IRB approval from Villanova University.

Methods A survey approach was used to collect data from adolescents during a regularly scheduled clinic visit at both sites. Potential subjects were approached and invited to participate before being seen by a health care provider. A cover letter describing the study was provided to eligible adolescents upon entering the clinic. If the adolescent verbally agreed to participate, written consent was obtained from the adolescent and his or her parent. To further ensure anonymity of participants, each set of questionnaires was numbered, and the adolescent and parent were made aware of this procedure. Criteria for all subjects to enter this study were: (a) between the ages of 12 and 21 years, (b) no major health or developmental problems (excluding the diagnosis of cancer), and (c) ability to read and write English. In this study, 45 healthy adolescents were individually matched with 45 adolescents with cancer on the basis of gender and age. Demographic data for the 90 study participants are reported in Table 1. All of the

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adolescents in the healthy sample were white, and only three of the adolescents in the sample with cancer were identified as belonging to a minority. The age range for subjects was 12 to 18 years (M ⫽ 14.98, SD ⫽ 1.67). The sample was selected from patients who had been undergoing treatment (chemotherapy and/or radiation) for at least 6 months or who had been off treatment for a year or less. The rationale for excluding patients who have not undergone at least 6 months of treatment was based on the findings of Hinds et al [7], who found that adaptation indicators were lowest at 4 weeks and highest at 6 months after starting chemotherapy. The rationale for including adolescents who have been off treatment for a year or less was based upon the consideration that many treatment protocols are only 6 months in length and treatment effects experienced from the majority of protocols can require medical intervention for several months after treatment is completed. In addition, follow-up care and evaluation occur at least monthly, thus intense medical care continues for approximately 1 year after treatment. Of the 45 adolescents in the study who had cancer, most of them were on active treatment, with 34 (75%) of the adolescents receiving either chemotherapy and/or radiation; 11 adolescents (24%) were off treatment. The average time in treatment ranged from 6 months to 3 years (M ⫽ 9.5 months, SD ⫽ 6.8). The average length of time off treatment was 4.5 months. Age at diagnosis ranged from 12 to 17 years (M ⫽ 14.2 years, SD ⫽ 1.5). Among the adolescents with cancer, 22 (49%) were being treated for leukemia. Three of these 22 adolescents had received a bone marrow transplant. Hodgkin’s Disease was the second type of cancer diagnosed among the study participants, with 10 (22%) of the study participants being treated for a diagnosis of Hodgkin’s Disease. The remaining 13 (29%) had varying diagnoses of solid tumors. Perceived level of self-esteem was measured using the Coppersmith Self-Esteem Inventory (SEI) and their amount of hopefulness measured using the Hopefulness Scale for Adolescents. The SEI (Form C) is a norm-referenced measure, which has 25 items to assess perceptions of peers, parents, school, and self among adolescents. The test-retest reliability coefficients of the SEI have been reported to be 0.88 [25,26], 0.80 and 0.82 [27], and 0.76 to 0.85 [28]. The Cronbach alpha coefficient for the instrument’s internal consistency has been reported as 0.84, and the split-half reliability as 0.80 [29]. The Hopefulness Scale for Adolescents (HSA) is a 24-item visual analogue scale that has been com-

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Table 2. Self-esteem and Hopefulness Among Adolescents SEI

HSA

Subjects

n

Mean

SD

Mean

SD

Females with cancer Healthy females Males with cancer Healthy males

21 21 24 24

78.3 79.8 77.5 83.3

16.2 14.1 13.2 12.7

1928.0 1782.8 1978.5 1871.3

263.5 324.4 229.6 255.4

pleted by more than 700 adolescents, both ill and healthy, ranging in ages from 12 to 21 years, with reported hopefulness scores ranging from 393 to 2400 [6]. Gender differences have been reported in HSA scores with females tending to score lower than males, yet these differences are not statistically significant when the age of the adolescent is considered [5]. In general, older adolescents have higher hopefulness scores. Hinds [5] reported internal consistency values for the scale using Cronbach alpha coefficient to be 0.88, 0.93, indicating moderately strong reliability for samples of adolescents with cancer, and 0.92, 0.93 and 0.88 for healthy adolescents. The reliability coefficients for the scale reported by other researchers among healthy adolescents have been 0.90 [30] and 0.73 [31]. Evidence of content and construct validity for the scale has been also been reported [32]. The mean value for self-esteem and hopefulness for each of the four subgroups of subjects, females with cancer, healthy females, males with cancer, and healthy males were calculated. Because the groups were matched, a Student’s paired t-test for both self-esteem and hopefulness were used to compare the mean responses between adolescents with cancer and healthy adolescents by gender. Analyses to measure the correlation between the self-esteem and the hopefulness for each of the four subgroups were conducted, as well. Finally, a model to predict a subject’s HSA score using the subject’s self-esteem score, gender, age, and disease status as independent variables was constructed.

Results Table 2 summarizes the mean values for self-esteem (SEI) and hopefulness (HSA) among the four subgroups in the sample. Paired Student’s t-tests were used to compare the mean SEI score and mean HSA score for the healthy subjects and the subjects with cancer by gender, and none were statistically significant. Likewise, there were no statistical differences

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481

Figure 1. Plots of HSA versus SEI for subgroups.

demonstrated in the mean self-esteem and hopefulness scores among early, middle and late adolescents. However, when all of the subjects were pooled together to compare all of the healthy subjects to all of the subjects with cancer, the difference between the mean HSA scores was statistically significant (p ⫽ .031). The subjects with cancer had a significantly higher mean HSA score than the healthy subjects. This contradiction in results may be a product of the small sample sizes used in each of the subgroups. Among the sample of adolescents with cancer, the results of correlation analyses revealed no significant correlation between age at diagnosis or length of time in treatment for either self-esteem or hopefulness. However, whether the adolescents were off or on treatment did correlate to self-esteem scores (r ⫽ ⫺.325, p ⫽ .05) at the two-tailed level of significance. Adolescents who were off treatment had signifi-

cantly higher mean SEI scores as compared with those who were receiving active treatment. The Pearson correlation coefficient between SEI and HSA for all 90 subjects in the study was 0.387, which was statistically significant (p ⬍ .001). However, when the correlation coefficients were examined by gender and disease status, the relationship between self-esteem and hopefulness was statistically significant only for female subgroups: females with cancer, r ⫽ 0.723 (p ⬍ .001) and healthy females, r ⫽ 0.676 (p ⬍ .001). These findings indicate a strong, positive, linear relationship between SEI and HSA for both female subgroups. In contrast, the correlations between SEI and HSA were not statistically significant for the male subgroups: males with cancer, r ⫽ 0.181 (p ⫽ .396) and healthy males, r ⫽ 0.045 (p ⫽ .836). Figure 1 graphically demonstrates these correlations. The graphs for the female subgroups

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Table 3. Regression Equation for Subgroups Subgroup Females with cancer Healthy females Males with cancer Healthy males

Model HSA HSA HSA HSA

⫽ ⫽ ⫽ ⫽

869.8 ⫹ 13.4 728.4 ⫹ 13.4 1814.2 ⫹ 2.3 1672.8 ⫹ 2.3

SEI SEI SEI SEI

show an upward trend and hence, significant correlations were observed for each of these two groups. However, both of the graphs involving the male subgroups demonstrate no pattern between the two variables and hence, the correlations were not significant. The model to predict hopefulness scores included SEI (p ⬍ .001), gender (p ⫽ .001), disease status (p ⫽ .005), and the interaction between SEI and gender (p ⫽ .002). Eliminating nonsignificant variables one at time derived the model. All model assumptions were verified and met. Because the relationships between HSA and SEI were different for the various gender and disease status combinations, the interactions between SEI and gender, SEI and disease status, and the three-way interaction between SEI, gender, and disease status were included in constructing the model. This allowed for each of the four subgroups to have its own regression line. Table 3 provides the formula for computing the least squares regression line for each of the four groups, and Figure 2

Figure 2. Least squares regression by subgroup.

graphically depicts them. Within Figure 2, it should be noted that the slope of the regression line is the same for both of the female subgroups, as is the slope of both of the males’ regression lines. Examining the females first, their slope indicates that for every 1-point increase in their SEI score, the predicted HSA score increases by 13.4 points. This applies for both the healthy subjects and those with cancer. However, there is a shift downward for the healthy subjects. The predicted HSA score for the healthy females is 141.4 points lower than that of a female with cancer. The same results are noted for the males: the slope of both of the male subgroups’ lines is 2.3, which is much smaller than that of the females. This was anticipated because there was not a significant correlation between HSA and SEI in males. Their slope indicates that for every 1-point increase in SEI score, the predicted HSA score increases by 2.3 points. Again, there is a downward shift for healthy subjects. The predicted HSA score for healthy males is again 141.4 points lower than that of the males with cancer.

Discussion Influence of Gender, Age, and Disease Status on Self-esteem and Hopefulness Self-esteem scores among males and females, healthy and ill adolescents, and early-, middle- and late-stage

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adolescents did not statistically differ. Inconsistencies in published findings can be found about whether differences based on gender, age and disease status exist among adolescents’ perceived level of self-esteem. In general, past studies have suggested that females have lower levels of self-esteem [33,34]. Other studies, however, found no gender differences [10] as were found in this study. Likewise, there were no differences in perceived level of self-esteem among early, middle and late adolescents. These findings support those of several longitudinal studies, which suggest that there is a gradual increase in self-esteem throughout late childhood, with no decrease in the adolescent period. For example, Hinds [5], in a longitudinal study of adolescents with cancer, found that self-esteem measurements were stable over time and situations and did not contribute to the explanatory nature of the tested model. These findings challenge traditional developmental theory and past research that suggest that self-esteem is lowest among early adolescents owing to rapid physical and psychosocial developmental changes. A possible explanation for the inconsistencies of the influence of gender and age on adolescents’ self-esteem may be found in research that has suggested that adolescents follow a trajectory for their perceived level of self-esteem such as: (a) consistently high, (b) moderate and rising, (c) steadily decreasing, and (d) consistently low [8,34,35]. Thus, differences may reflect the projection path prescribed in which self-esteem may be stable over time for some adolescents, but vary for others, and are not owing to gender or age differences. In this study, there were no differences found between healthy adolescents and those with cancer in the reported levels of perceived self-esteem. The findings from past research that have compared self-esteem by disease status have also reported that adolescents with cancer do not have lower levels of self-esteem when compared with healthy adolescents [7,36] These results suggest that poor selfesteem is not necessarily associated with the diagnosis of cancer in the adolescent. Further research is needed to compare the effect disease status has on the relationship between self-esteem and illness among other samples of chronically ill adolescents. Overall, adolescents in the study had moderate to high levels of hopefulness, with healthy males having the highest mean hopefulness score. There were no statistical differences demonstrated between the mean hopefulness score in males with cancer and healthy males, and between females with cancer and healthy females. Hinds [5] noted that gender differ-

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ences among males and females have not been statistically significant when age is considered, consistent with the present study.

The Relationship Between Self-esteem and Hopefulness This study demonstrated that gender influenced the relationship between self-esteem and hopefulness such that the correlation between these two variables was strong and highly significant only for the female subgroups. Age, measured in adolescents’ chronological age reported, did not influence this relationship. Although no previous research could be found that examined the relationship between self-esteem and hopefulness by gender, Hendricks [3] reported that early adolescents who perceived themselves to have high self-esteem also had high levels of hopefulness. These findings support those of Brackney and Westman [18], who concluded that achieving psychosocial maturity was associated with greater hopefulness among healthy young adults. Likewise, self-esteem has been linked to coping strategies such as hopefulness that adolescents use when confronted with problems and when faced with situations that force decisions [3]. Several studies have reported gender differences in overall coping and adaptation abilities among healthy adolescent samples [13,37]. Past research has suggested that female adolescents seek more social support and focus more on relationships than do male adolescents. Frydenberg and Lewis [38] reported that male adolescents turn to sports and physical relaxation, whereas female adolescents turn to others and make more of connectedness and relationships in coping and tend to employ strategies related to hoping for the best and wishful thinking. Results of the present study support these findings.

Predictors of Hopefulness The model that was constructed in this study predicted a subject’s hopefulness with self-esteem, gender, disease status, and the interaction between selfesteem and gender. This model reflects the theoretical model proposed for study except for the influence of age on developmental processes and coping abilities. The findings that constructed the model are similar to those reported in existing studies. Hendricks [3] reported that within her Perceptual Health Promotion Determinants Model, hope is linked with self-esteem in that self-esteem had a direct effect on hope. Hendricks did not, however,

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report if gender differences existed in the relationship between self-esteem and hopefulness. The model developed in this study suggests that female adolescents, both healthy and diagnosed with cancer, use hopefulness as a coping mechanism that is strongly associated with their perceived level of self-esteem. Finally, self-esteem has been found to have a profound influence on health promoting behaviors among healthy adolescents [3,37]. Limitations of the Study Limitations of the study included a small sample size and a limited number of variables in the study’s theoretical model. Despite having a small sample size, statistically significant relationships were found for gender; however, no age differences were found owing to small cell sizes. If the study were to be replicated with a larger number of subjects, perhaps differences related to age differences would be found. Other major influences on adolescents’ perceived level of self-esteem that were not included in the model were physical maturational development and cognitive development. Likewise, confounders such as socioeconomic status, religion, and response to illness were not studied. Finally, the generalizibility of the findings is limited owing to most of the adolescents being white. Conclusions The model constructed in this study has application in clinical practice. The model supports current clinical practice and theoretical assertions, which suggest that interactions with adolescents, both healthy and ill, should be developmentally centered to support their perceived self-esteem and coping style. The findings of this research suggest that hopefulness is a coping strategy for female adolescents, which is closely related to their sense of self-esteem.

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