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Health Conception and
Health Promotion in Blue
Collar Workers
by Marilyn M. Bagwell, PhD, RN, and Helen A. Bush, PhD, RN
Health conception and health promotion behaviors were measured in 160 blue collar workers
ages 18 to 65, focusing on factors influencing
blue collar workers' participation in health promotion programs. Results of LatTrey's Health
Conception Scale (LHCS) and Pender's Health
Promoting Lifestyle Profile (HPLP) indicated:
• Health responsibility and interpersonal support were significantly greater for women than
for men.
• Exercise was significantly greater for younger
workers than for older workers.
• Nutrition was significantly greater for older
workers than for younger workers.
• Health conception was significantly greater
for younger women and for older men.
• A significant relationship exists between
health conception and health promoting lifestyle.
Dr. Bagwell is Associate Professor, College of
Nursing, Arizona State University West,
Phoenix, AI. Dr. Bush is Professor ofNursing
Emerita, Texas Woman~ University and
Adjunct Professor, School ofNursing,
University of Texas atArlington, Arlington, TX.
• Role and self actualization were significantly
greater for older workers than for younger
Results suggest gender, age, and concept of
health are important when planning health promotion programs at an industrial site.
uring the past 20 years, many workplace health
promotion programs have been instituted and,
generally, have had some success in goal achievement. Major goals of programs have been increasing
health awareness and changing health behaviors (Fowler,
1994). Some benefits of participation have included
reduced health care costs; improved health, fitness, and
productivity; reduced absenteeism; increased job satisfaction; and enhanced self responsibility (Bulaclac, 1996;
Pencak, 1991; Saphire, 1995).
Corporations have been proactive in initiating health
promotion program participation. However, the number
of employees who have maintained participation in a
program have not been as encouraging (Blue, 1995).
Thus, program planners continue to seek ways to
improve programs. One method of improvement is to
individualize programs according to job category
(Desmond, 1993).
One category of worker, the blue collar worker, has
been a neglected group. This has occurred although blue
collar workers may have a greater need for health promotion programs than white collar employees. Alexy
(1990) maintained negative behaviors (e.g., inactivity;
use of cigarettes, alcohol, and drugs) were increased in
blue collar groups.
Sorensen's (1996) research results showed blue collar workers were less likely to report participating in
health promoting activities than white collar workers. In
agreement, Lusk (1995) reported blue collar workers
were significantly lower than skilled trade and white collar workers in health promoting lifestyles. The role of
occupational health nurses is to assume leadership in
increasing blue collar workers' knowledge about and participation in health promotion programs.
The purpose of this study was to discover factors that
may influence blue collar workers' participation in health
promoting programs. Blue collar workers were defined as
men and women ages 18 to 65 involved in manual work
and included linemen, assemblers, electronic technicians,
maintenance technicians, and electricians. The following
research hypotheses were tested:
• There is a significant difference between the scores of
adult blue collar women and men on the Laffrey
Health Conception Scales (LHCS) (Laffrey, 1986) and
the Health Promotion Lifestyle Profiles (HPLP)
(Walker, 1987).
• Among developmental age groups of blue collar
workers, there is a significant difference in scores on
the LHCS and the HPLP.
• There is a significant interaction between the scores
on the LHCS and HPLP of blue collar worker men and
• Among developmental age groups of blue collar
workers, there is a significant relationship between
scores on the LHCS and the HPLP.
• There is a significant difference between the developmental age groups of blue collar workers regarding the
relationship between scores on the LHCS and the
Efforts to increase participation in health promotion programs have included attending to organizational climate and personal health characteristics (Sloan,
1988), increasing health promotion awareness, providing supportive environments (Selleck, 1989), analyzing
organizational productivity, evaluating employee well
being (Heerwagen, 1995), informing workers of health
resources (Cloetta, 1992), and involving workers in program planning (Green, 1988). The health risk appraisal
(Adams, 1995; Hyner, 1995) and a personalized health
profile (Vasse, 1998) were offered as ways to increase
workers' awareness of the link between lifestyle and illness, and to assist in planning appropriate
teaching/learning concepts and counseling. Bertera
(1990) maintained the need to reach spouses, shift
workers, employees at small sites, and to balance what
is popular at the moment with methods to reduce risks
in workers' later years.
Gottlieb (1992) reported baseline behavior information for planning health promotion programs for blue
collar workers is lacking. The researchers found
friends' behavior, risk taking, and interpersonal experiences were related to health promotion activities. Public monitoring, intershop competition, and activity
based incentives were used with blue collar workers by
King (1988) in a study that resulted in increased exerNOVEMBER 1999, VOL. 47. NO. 11
cise and fitness and decreased weight. Bertera's (1990,
1993) large comprehensive studies on absences showed
blue collar workers who participated in a health promotion program had a 14% decline in disability days during 2 years, as opposed to a 5.8% decline at control
sites. Additionally, there was a $2.05 return for every
dollar invested in the program by the end of the second
year of operation.
Among blue collar workers, predictors of health promotion behaviors were health status and self efficacy (i.e.,
the expectation one can perform a behavior successfully)
(Desmond, 1993; Weitzel, 1989). Self efficacy also was
found to be a predictor by Wilson (1997). When comparing blue collar and white collar workers, Nourjah (1994)
found blue collar workers had less knowledge about cardiac heart disease risk factors, less favorable risk factors
status, and poorer health practices. Lusk (1995) found
younger people reported more exercise than older people.
Laffrey examined the following concepts in relation
to health conception: self actualization (1985a), body
weight (1983), health behavior (1985b, 1990), health
promotion (1985a), and role integration (1986). In the
1990 study of health behavior in men and women, ages
22 to 88, Laffrey acknowledged men and women did not
differ in health behaviors related to nutrition, exercise,
relaxation, sleep/rest, personal hygiene, and psychological well being. Walker (1988) revealed older adults had
higher scores in overall health promoting lifestyles and in
health responsibility, nutrition, and stress management
than both young and middle age people. In a later study,
Pender (1990a) again found older women who participated in a company fitness program had healthier lifestyle
patterns than other participants.
TheoretIcal Framework
Three theories were united to form the interrelationships that describe the phenomenon of health conception
(Laffrey, 1986) and health promotion (Pender, 1982)
from the life cycle perspective (Buhler, 1968). The influence of growth and development events helps explain the
relationship of health conception and health promotion
behaviors. Health conception (i.e., the individual's definition of health) and the interrelationship of the individual's developmentally based goals lead to changes in
health promotion behaviors throughout the phases of the
life cycle. The Figure displays the process as perceived
by the authors.
Laffrey (1986) used Smith's (1981) four models of
health-elinical, role, adaptive, and eudaimonistic-to
define health. Pender's (1982) health promotion model is
comprised of six concepts: self actualization, health
responsibility, interpersonal support, nutrition, exercise,
and stress management. Definitions are presented in the
Buhler (1968) determined five developmental phases of life. The first phase begins at birth and proceeds to
approximately age 16. It is a time of learning and experimenting. The second phase includes the period between
ages 17 and 28, during which time the individual experiences uncertainty while beginning the process of contact
GOAL ORIENTATION .... _.._.._.._.._..~ HEALTH CONCEPTION .... _.._.._.._..+ HEALTH PROMOTION
O· 16 Experimenting
17• 28 Expanding
29 • 48 Defining
49 - 64 Producing
65-··· Self-actualizing
Absence of lllness
Adaptation to Change
Exuberant Well-being
Interpersonal Support
conception motivate
continuance of
health promoting
Healthpromoting activities continue
Figure. Life goals, health conception, and health promotion process.
Definitions of Laffrey's and Pender's Concepts
Laffrey (1986a)
Health conception
Pender (1982)
Health promotion
Health responsibility
Interpersonal support
Stress management
The individual's perception of health.
Absence of disease, illness, or symptoms.
Abilityto perform one's usual tasks.
Adjusting to change and stress.
Exuberant well being.
Developing an individual's resources that maintain and enhance well being.
Positive approach that leads individuals toward the realization of their highest
potential for wellness.
Responsibility for one's own health, learning about health, and seeking
professional assistance when necessary.
Expectations of significant others, families, and health professionals related to
health behaviors.
Supplying adequate and appropriate nutrients to one's body.
Conditioning process for physical fitness.
Controlling health damaging effects of demands made on one's body.
with reality. In the time period from approximately ages
29 to 48, the individual determines a definite attitude
toward life and experiences many fruitful activities. During the fourth phase, approximately from ages 49 to 64,
the individual is moving from a needs perspective to a
realization of duties and goal. The fifth phase begins at
approximately age 65 and extends indefinitely. It is a
time of critical self assessment.
The initial availability sample consisted of 400 blue
collar workers, ages 18 to 65, in two industrial plants in a
southwestern city of the United States. Managers gave
study questionnaires to workers. TWo hundred thirty-seven
questionnaires were returned by mail to the researchers,
with 24 incomplete. Of the remaining 213 respondents
with complete questionnaires, 6 (3%) were ages 19 to 25,
123 (58%) were ages 26 to 44, and 84 (39%) were ages 45
to 65. The number in the age 19 to 25 group was insufficient for inclusion in the study. From the remaining 207
respondents, a sample of 160 participants was selected
using a table of random numbers to derive four groups of
40 subjects each. The groups were younger women (ages
26 to 44), older women (ages 45 to 65), younger men (ages
26 to 44), and older men (ages 45 to 65).
Anonymity and confidentiality of each participant
were assured. Each data collection packet contained a
statement at the top of the first instrument which stated
the participant's completion and return of the instruments
was considered consent to be a study participant. Participants were requested specifically not to place an identifying name on the instruments. Confidentially was protected because only the investigators had access to the
instruments. The researchers obtained permission to conduct the study from the participating industrial plants.
All participants were employed full time. One hundred thirty-five participants were white, 15 were Hispanic, 7 were African American, and 3 reported "other." One
hundred six were married, 33 were divorced, 19 were single, and 2 were widowed. Incomes ranged from $10,000
to more than $50,000.
The educational level ranged from completion of
grammar school to college graduation, with 47% having
earned some college credits. Thus, the majority of participants were white, married, and had completed some college hours. Women earned from $10,000 to $20,000
(34%) and $25,000 to $40,000 (37%), while $30,000 to
$50,000 was the income range for 61% of the men.
Three data collection instruments were used including the Laffrey Health Conception Scale (LHCS) (Laffrey, 1986), the Health Promoting Lifestyle Profile
(HPLP) (Walker, 1987), and a researcher developed
demographic data form which requested ethnicity, marital status, education, and income.
The LHCS has 28 items. Content validity was established by eight nurse experts (Laffrey, 1986). Initial construct validity was determined via factor analysis on the
28 items. Thirty-five registered nurses constituted the
sample for a test-retest. The reliability coefficient after 1
week was .84 (Laffrey, 1986).
The HPLP is a 48 item instrument (Walker, 1987).
The 48 items were put into a principal axis factor analysis, with six factors extracted and obliquely rotated. The
factors included self actualization, health responsibility,
exercise, nutrition, interpersonal support, and stress management. The factors account for 47.1 % of the variance
(Walker, 1987). The Cronbach's (1951) alpha for the 48
items was .922.
Data Analysis
The first, second, and third hypotheses were tested
using a two way analysis of variance on total scores and
each subscale of the LHCS and the HPLP. The critical
value of the F ratio was determined using the .05 level of
The Pearson product moment correlation coefficient
statistic (r) was applied to the fourth and fifth hypotheses.
For the fifth hypothesis, the Fisher's z transformation and
a comparison between the independent rs were conducted.
NOVEMBER 1999,VOL. 47, NO. 11
Gender. The first research hypothesis, testing for gen-
der differences, was not accepted. No significant differences were found between men and women on total health
conception and total health promoting lifestyles, or on the
four subscales of health conception. This means in defining health and in overall health promoting behaviors the
men and women in the present study were similar. However, a significant difference existed between men and
women related to health responsibility (p =.004) and interpersonal support (p =.028), with women having a higher
mean score on both concepts. This finding agrees with
Duffy (1996), Heidrich (1998), Lusk (1995), and O'Quinn
(1995) and indicates health responsibility and interpersonal support have been the province of women. Women were
expected to nurture their families and administer health
care, and to seek and find closeness within their circle of
women friends and relatives. Traditionally, women have
had responsibility for their families' health and for interactions in families and communities.
Age. The second research hypothesis, which tested
for differences based on age, was accepted only for exercise (p = .044) and nutrition (p = .021). In terms of nutrition, the older group had a higher mean score than the
younger group, supporting other studies (Lusk, 1995;
Pender, 1988). Older workers have reached the age at
which friends, relatives, and acquaintances are experiencing high blood pressure, heart attacks, high cholesterol, strokes, and other health problems. They are aware
these health problems can be lessened through improved
nutrition. Conversely, the younger group had higher
scores on exercise than the older group, as found in other
studies (Duffy, 1996; Lusk, 1995). The finding may be
attributed to the increasingly social nature of physical
exercise with health spas, group practice for marathons,
and aerobic exercise, for example, which offer interaction
as well as exercise. Also, a well toned body and an
increased level of energy resulting from exercise can be
an asset in social and employment requirements.
These results seem to support Buhler's (1968) statement that social and cultural conditions affect developmental life stages. For the younger group, physical exercise is an activity that provides tangible changes, but
reading labels to discover nutritional and chemical con-
tent (i.e., a cognitive activity) may lack immediacy. The
older group, in the critical assessment stage, may be more
aware of the effect of types of food on energy level, bodily functions, and mental outlook because of their experiences with health problems. Walker (1988) identified five
major health promoting lifestyles among older adults,
depicting a heterogeneous group, with varying needs for
health promotion programming.
Gender and age. The third research hypothesis was
accepted only for the strength of health conception,
which was greater (p = .030) for younger women and
older men. Younger women and older men believed the
ability to perform their assigned roles-occupational,
familial, and social-and the ability to adjust effectively
to changing environmental circumstances and stressors,
meant they were healthy. Some research findings agreed
with the present results about younger women (Meleis,
1989; Woods, 1988). No differences were found in men
or women of any age in total health promoting lifestyles.
This finding does not concur with Duffy (1993) and Pender (1988, 1990b), who found differences between and
among younger and older men and women.
Health conception and health promoting lifestyle. The
fourth research hypothesis, which tested for a relationship
between health conception and health promoting lifestyle,
revealed a significant relationship (r .2266, p .002)
between the concepts and was accepted. Individuals in the
sample who had higher scores related to their definition of
health had higher scores on their health promoting lifestyle,
supporting the findings of Gillis (1994) and Laffrey
(1985a). This finding was expected because life experiences suggest individuals who believe being in good health
means the ability to perform one's role, to adapt to changing conditions and life events, and to strive for overall well
being, do practice health behaviors. The health behaviors
tested were the components of Pender's (1982) model
including self actualization, health responsibility, interpersonal support, nutrition, exercise, and stress management.
Age and health conception and health promoting
lifestyle. The fifth research hypothesis tested for differences between younger and older individuals related to
the relationship between health conception and health
promoting lifestyle. One significant difference was found
in role and self actualization (r =.3987, p =.05, z =2.41),
with older workers scoring higher on the two concepts.
Thus, older adults in the study perceived they had a positive approach to the realization of their highest potential
for wellness. This finding reflects Buhler's (1968) statements about the appreciation of self actualization in middle age and older individuals, and also other classic life
cycle theorists whose research supports Buhler's studies
(Erikson, 1963; Havighurst, 1972; Kuhlen, 1968;
Maslow, 1970; Neugarten, 1968; Peck, 1968).
Nurses planning worksite health promotion programs for blue collar workers should be aware of the differing results in studies and gain the cooperation of men
and women workers of various ages in planning all areas
of a health promotion program (Green, 1988; Heerwagen, 1995; Lovato, 1990). Additionally, pencil and paper
instruments (i.e., LHCS, HPLP), health risk appraisals,
and personalized health profiles may be used as assessment tools to plan individual programs.
Because Walker (1988) found such wide variation in
older groups of individuals, supported by growth and
development theorists, older workers should be requested specifically to help with program planning. Theorists
who have studied the course of human life agree as individuals age, they become more individualized and
require unique planning and care.
The present study, along with other research,
strengthens the knowledge base available to program
planners for younger workers, older workers, and men.
Younger workers need teaching/learning programs to
assist with nutritional knowledge and actions, and older
workers need individualized worksite exercise programs.
The male role traditionally has included an expectation of
physical vigor and strength and has viewed intimacy and
closeness as a weakness. Thus, men need carefully
planned, implemented, and evaluated programs which
support the concept of self responsibility for their own
and their families' health, and also assist them to further
develop their interpersonal relationships. Sonenstein
(cited in Thomas, 1998) stated:
There are a lot of creative, innovative people trying
different approaches around the country. One of the
clear themes that has surfaced is that you can't just
get up and lectureto a groupof guys abouthow they
haveto be responsible. All of theseprograms are trying to get kidsto redefine whotheyare, whatit means
to be men, and to workon relationship skills.
Lastly, women should be rewarded for continuing
their healthy lifestyles for themselves and working for
the health of families and communities.
Before health promotion programs specific to blue
collar workers can be developed, implemented, and evaluated successfully, the knowledge base needs further systematic inquiry. This is important particularly in relation
to planning, participation, and maintenance of participation for this group. The use of the LHCS and the HPLP
requires further study with blue collar workers of all ages
and both genders to include different cultural and socioeconomic subgroups to further substantiate or refute
extant research results, some of which are in conflict.
Qualitative research methodologies to understand
blue collar workers' daily experiences and needs yield
information which may be recovered only obliquely by
quantitative approaches. Interviews could validate the
concepts of the LHCS and HPLP, and any other hidden
concepts important to blue collar workers. For example,
the interviews conducted by Woods (1988) revealed Laffrey's (1986) four major concepts, as well as nine others,
. including three integral to Pender's (1982) health promotion model. In addition to individual interviews, focus
groups are beneficial in collecting pertinent data, partieAAOHN JOURNAL
ularly blue collar workers' perspectives related to self
responsibility for healthful status and self care.
Interviews, discussions, and other qualitative methods assist in rectifying a possible lack of understanding in
co~unication and collaborative planning. Appropriate
planmng could lead to nursing actions grounded in blue
collar culture.
Although blue collar workers have a greater need for
workplace health promotion programs than white collar
workers, they have been a neglected group. The need is
underscored by inactivity and increased use of cigarettes,
alcohol, and drugs. According to the literature, blue collar workers are not participating in workplace health promotion programs.
The few studies which have been conducted with a
focus on blue collar workers have shown workers who
participated in a health promotion program had a 14%
decline in disability days during 2 years, as opposed to a
5.8% decline at control sites. In addition, the studies
reflected program participants had an increase in exercise
and fitness and a decrease in weight. In general, program
objectives were aimed at improving workers' awareness
about their own health and the effects of their lifestyles
on their health, learning about and use of health
resources, and actions to promote and maintain their
health. Most important is baseline behavior information
for planning health promotion programs for blue collar
workers has been lacking.
Results of the present study, along with other studies, provide information for nurses who deliver services
for blue collar workers (see Sidebar on this page).
Literature focusing on the lack of participation of
workers in worksite health promotion programs reports
organizational climate, as well as personal health characteristics, need to be considered to increase participation.
Workers, including shift workers, employees at small
sites, and spouses need to be involved in planning, implementing, and evaluating programs. Because a wide variation was found in older groups of individuals related to
health promotion, older workers should be requested
specifically to help with program planning.
Lusk (1995) stated "blue collar workers have the
greatest need for assistance in enhancing their health
awareness and practices." Occupational health nurses
have the best opportunity to contribute to important
changes focused on raising the quality of health care for
blue collar workers.
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NOVEMBER 1999, VOL. 47, NO. 11
Program Planning Issues
with Blue Collar Workers
• Older women employees had healthier lifestyle
patterns than other workers.
• Women were more likely than men to participate in
a health promoting program.
• Hispanic women had the highest scores in
interpersonal support and self actualization but the
lowest scores in exercise.
• Women had higher scores related to health
responsibility, exercise, and interpersonal support
than men.
• Men reported more exercise behaviors than women.
• Men, more than women, need to strengthen their
knowledge base related to health promotion.
• Men need programs to learn health responsibility
and principles of interpersonal relationships.
• Younger blue collar workers had higher scores on
exercise than older workers.
• Older blue collar workers had higher scores on
nutrition than youngerworkers.
• Older adults have varying needs for health
promotion programming.
• Younger blue collar women and older men have
strongerbeliefs about role performance and
adaptation to change.
• Younger women who are more positive about role
integration perceived their health to be better and
had fewer symptoms.
• Older individuals scored higher on health
responsibility, exercise, nutrition, and stress
management than younger men and women.
• Older workers had higher scores on role
performance and self actualization than younger
• Younger workers need teaching/learning programs
to assist with nutritional knowledge and actions.
• Older workers need individualized worksite exercise
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What Does This Mean For
Workplace Application?
When developing. specific health promotion
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maintenance of participation. it is important to
• Women are more likely to participate in health
promoting programs.
• Men need more knowledge about health
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• Younger workers need teaching/learning programs
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