Research Article
A Study on the Applicability of the Health Action Process Approach to the Dietary Behavior of University Students in Shanxi, China

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Abstract

Objective

To confirm the applicability of the Health Action Process Approach in predicting and explaining the healthy dietary behavior of college students.

Design

Cross-sectional survey. The data were collected though the self-administrated questionnaires.

Setting

Eight universities in Shanxi province, China.

Participants

A total of 1,933 undergraduates were randomly selected using random cluster sampling from Shanxi, China (92.0% response; 31.7% males).

Main Outcome Measures

Each variable was measured using questionnaires.

Analysis

Data were analyzed by 2-sample t test, linear correlation, and path analysis. Significance was set at P < .05.

Results

Risk perception, self-efficacy, and positive expectancy began functioning during the intention formation stage (P < .01). Outcome expectancy, self-efficacy, and behavioral intentions had a predictive role in plan formation (P < .001). Action planning, positive expectancy, and self-efficacy were effective predictors of dietary behavior (P < .001). An action plan was a mediator between behavioral intention and dietary behavior; the mediation effect was 0.086.

Conclusions and Implications

As a first step, application of Health Action Process Approach to the dietary behavior of Chinese college students was confirmed. Future research expanding on this study could consider including additional sociodemographic factors in the model structure using a broader study population.

Introduction

College students can be considered the driving force behind the sustainable development of society as well as the builders of social development and scientific and technological advancement for whom health is a prerequisite for wellness in life and learning.1, 2 At this crucial stage, college students are under the great pressures of education, life, and employment; therefore, it is essential for their mental and physical health to promote responsible nutrition and dietary habits.3 According to several related surveys, 93.4% of college students' diets were imbalanced in Guangdong, China.4 Among 1,078 college students in Guangxi, China, 53.4% were less than healthy as a result of dietary nutrition disorders.5 Average dietary quality among college students was in a moderate state of imbalance in Shanxi, China, owing to the coexistence of moderate insufficient intakes (54.8%) and excessive intakes (80.0%) of specific foods.6 Whereas 6.8% of students had healthy diets, 65.9% had unhealthy diets in Chengdu.7 Lack of nutrition or dietary knowledge, as well as eating disorders, are common among college students.8, 9, 10 Thus, it is essential for researchers to explore an effective way to improve the dietary behavior of college students. Behavior change theories are useful guides for understanding how behaviors have changed.11 Among those various existing theories, the most prevalent ones are social learning theory,12 Social Cognitive Theory,13 the theories of reasoned action14 and planned behaviors,15 the transtheoretical model (TTM),16 and the Health Action Process Approach (HAPA).17 Compared with other models, the TTM and HAPA are phase models in which it is assumed that there are many possible behaviors, and that behavior is the result of intention.18 The TTM assesses an individual's readiness to act on a healthier behavior and provides strategies or processes to guide individual change toward action and maintenance. It is composed of the following constructs: stages of change, processes of change, self-efficacy, decisional balance, and temptations.16 The HAPA is a social cognition psychological model that may provide a foundation for further intervention,19 which can be considered as being a mixed phase model. There are 2 distinct stages in HAPA model: the motivational phase in which intention is formed and the volitional phase in which intention is translated into action (Figure 1).19, 20, 21 In the motivational phase, an individual's intention to implement a certain behavior is influenced by self-efficacy, outcome expectancy, and risk perception. Self-efficacy is the degree to which an individual perceives his capability to complete a particular behavior. Outcome expectancy refers to whether a person believes a certain behavior will cause a desired change. Risk perception refers to the perceived health threat or concern that requires action mobilization.22, 23 On the other hand, the volitional phase of the HAPA highlights action planning as the bridging variable between intention and behavior.24 To translate intention into behavior, intention with high self-efficacy also is necessary for an individual to set action plans that guide behavior.25 Existing studies have shown that the HAPA has a significant value for explaining and predicting the change of healthy behaviors, forming a new perspective on behavior research.26, 27, 28 International scholars have mainly used HAPA in the fields of physical exercise, diet, self-examination of breasts, and flossing.29, 30, 31 The HAPA was most widely used in the field of physical exercise behavior in China, where its applicability was validated.32, 33 In addition, the HAPA has been used to explore sexual behavior.34, 35 However, there are few validation studies concerning the dietary behavior of college students. Duan et al36 evaluated the efficacy of an 8-week Web-based intervention based on the HAPA to improve physical activity and fruit and vegetable intake in Chinese university students. Zhou37 verified the applicability of the HAPA model in the field of the healthy eating behavior of college students with methods of model verification and experimental intervention.

To verify the validity of the HAPA in predicting and explaining the engagement of college students in healthy dietary behavior, students from 8 universities in Shanxi, China, were randomly selected as respondents. Individual behaviors were divided into the pre-intention, intention, and action stages based on the HAPA. Based on those reports, it was hypothesized that the application of the HAPA in the dietary behavior of college students was effective and the predicting effect of different HAPA variables was disparate in different stages of dietary behavior.

Section snippets

Sample Size

The researchers randomly selected college students from institutions in Shanxi province for a pretest survey (27 boys and 33 girls). Data on students' nutrition knowledge and dietary behavior were extracted from questionnaires and their reliability and validity were verified. Overall Cronbach α = .81, with all 6 dimensions ≥ .66 (correlation coefficient, 0.36–0.87). Cronbach α (correlation coefficients) from each dimension were as follows: self-efficacy, α = .78 (0.48–0.77); outcome expectancy,

Analysis of Basic Results

In this study, the average age of all respondents was 19.92 ± 1.29 years, including 613 boys and 1,320 girls; average expenditure for food was about US $112.9/mo. Students who began their studies in either 2013 or 2014 accounted for a large proportion of all participants (69.2%). Han ethnicities accounted for 97.3% of respondents, whereas the rest were ethnic minorities of Manchu, Hui, Zhuang, Mongol, Tujia, Miao, Hakka, Li, Yi, Yao, or Dong descent. A total of 1,326 students were not the only

Discussion

This study confirmed the effectiveness of applying the HAPA to the dietary behavior of college students. The correlation analysis indicated that there was a significant correlation between the HAPA variables and dietary behavior. Analysis of the mediating effect suggested that action planning was the mediating variable between behavioral intention and dietary behavior, which proved the continuity of the HAPA in the dietary behavior of college students. These results were in line with

Implications for Research and Practice

This study confirmed the effectiveness of applying the HAPA to the dietary behavior of college students. Inclusion of additional factors that could influence students' dietary behavior in the model structure might increase verification for application of the HAPA to dietary behavior research. Studies on a larger scale, including college students from additional geographical and cultural areas, may further increase generalizability. The continuity of the HAPA and diversity of HAPA variables in

Acknowledgments

The study was supported and funded by the Ministry of Education in China, Research Projects of the Humanities and Social Sciences (No. 13YJCZH239), and the National Natural Science Foundation of China (No. 71403155). The authors thank the participants at each of the colleges.

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    Conflict of Interest Disclosure: The authors' conflict of interest disclosures can be found online with this article on www.jneb.org.

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