Life transitions and relevance of healthy living in late adolescence

Abstract

Using a cross-sectional qualitative design involving focus groups and interviews, we sought to gain a more detailed understanding of adolescents’ physical activity, eating habits and health perceptions during the transition from secondary school (or high school) to work. Based on thematic analyses, three themes were extracted: (1) perceptions of lifestyle and health, (2) changes in priorities and (3) passive acceptance of internal and external influences on physical activity and diet. Poor diet and physical inactivity appeared to reflect participants’ amotivation towards health behaviours, reluctance to divert from perceived peer norms and efforts to assert independence from parents.

Keywords

adolescence diet eating behaviour exercise behaviour lifestyle

Introduction

The prevalence of overweight and obesity continues to rise in industrialized nations, thus heightening the importance of promoting healthy lifestyles (Finucane et al., 2011). Between 1995 and 2007, the yearly average increase in obesity prevalence rates for 16 and 18 year olds in the United Kingdom was reported as being 4.8 per cent for boys and 7.0 per cent for girls, with rises projected to reach 8.0 per cent for boys and 9.7 per cent for girls by 2015 (Stamatakis et al., 2010). As people who are obese from a young age will be living with accumulated excess body fat for a longer period, it has been argued that preventing obesity during adolescence may be of greater importance than prevention in adulthood (Finucane et al., 2011).

Most instances of obesity are attributed to a lifestyle that combines excessive energy intake with insufficient physical activity (US Department of Health and Human Services, 2008). During adolescence, these factors are strongly influenced by increases in the consumption of fast food and high-fat snacks (Harris et al., 2006) that are often coupled with increases in sedentary behaviours and/or low levels of physical activity (US Department of Health and Human Services, 2008). Health behaviours are rarely a priority for young people (Allen et al., 2007), which may partly explain the limited success of school-based and public health promotion programmes that focus on health as a motivational driver in young samples (e.g. Kubik et al., 2005; Piggin and Lee, 2011).

Past work has identified that the changes in habits and priorities that occur during life transitions are potentially harmful to health, for example, in triggering weight gain following events such as marriage (Jeffery and Rick, 2002) or starting college (Anderson et al., 2003; Racette et al., 2005). Adolescents undergo a number of life transitions, including institutional (school to work or higher education), environmental (moving out of home) and social (making new friends, cohabitation) (Poobalan et al., 2009). These are marked by increasing independence and autonomy as well as identity development (Nelson et al., 2008). Past work assessing the effect of the transition from school has generally focussed on weight gain in college students (e.g. Anderson et al., 2003; Racette et al., 2005). Up to 70 per cent of students are reported to increase in weight during the first two years of college (Racette et al., 2005), and the incidence of overweight and obesity can double by the end of the first semester (Anderson et al., 2003). However, little is known about what happens to the health behaviours of the often more disadvantaged young people who do not attend college after leaving school (Nelson et al., 2008).

Although life transitions can signify marked deteriorations in health behaviours, they also represent a period of great potential for adaptive and volitional health behaviour changes. Indeed, the habit discontinuity hypothesis (Verplanken et al., 2008) suggests that when the environment changes, cues to behaviour that underpin our automatic behaviours, or habits, also become disrupted. As a result, behaviour becomes more volitional and aligned with intentions and attitudes, allowing new habits to form. It is this potential for intervention during life transitions that makes them particularly interesting to study.

In exploring the factors that facilitate or hinder young people to volitionally engage in health behaviours such as physical activity and healthy eating during key transitions, an understanding of their motivation is important. Therefore, to facilitate a more informed research design, and aid in the interpretation of the findings against the background of past research, we applied the framework of self-determination theory (SDT; Deci and Ryan, 2000). SDT is a contemporary theory of human motivation within which a multidimensional perspective to motivation is used with several behavioural regulations posited that vary in their inherent quality (Standage and Ryan, 2012). That is, autonomous forms of motivation whereby people engage due to interest and/or personal value (high quality) are contrasted with behaviours regulated by controlled types of motivation in which internal and/or external pressures guide action (low quality) (see Deci and Ryan, 2000).

Empirical evidence supports the notion that autonomous motivation promotes adaptive health behaviours, well-being and functioning (Deci and Ryan, 2000; Ng et al., 2012; Standage and Ryan, 2012; Teixeira et al., 2012). Within SDT, autonomous motivation and behaviours are facilitated by social contexts that are supportive of three basic psychological needs (i.e. for autonomy, competence and relatedness). In contrast, social contexts that thwart basic psychological needs are hypothesized to lead to controlled forms of motivation or passive engagement in activities/behaviours. As healthy development entails moving towards greater autonomy (Deci and Ryan, 2000), SDT may be particularly pertinent to adolescents during their transition to adulthood as they explore and experience greater awareness and adjustment in regard to self-ownership in new facets of their life (e.g. financial and occupational aspects). At the same time, there are shifting and changing socializing agents that will aid in this development to the extent that they are supportive (rather than thwarting) of the young person’s basic psychological needs.

The purpose of this work was to examine the views, reasons and priorities of young people in relation to diet, physical activity and their attitudes towards making healthy choices at the point in which they leave school for work or work-based learning. This population is important to study as without higher education young people will potentially attain a lower socio-economic status and be exposed to greater future health risk (Pampel et al., 2010). A qualitative design was adopted to explore the young people’s experiences in depth. As this work was undertaken as a precursor to the development of an intervention to promote healthy lifestyles (cf. Gillison et al., 2014), this qualitative approach also allowed us to incorporate participant views into the intervention design (i.e. adolescents can make substantial contributions towards the development and effective implementation of intervention programmes that directly impact their lives; Wilson et al., 2005).

Methods

Participants

A total of 16 participants aged 16–19 years (12 male) were recruited from four community settings across rural and urban areas in south west England. Participants were eligible to take part if they had left school within the last 12 months for employment or work-based learning. Those planning to continue onto higher education or returning to school to pursue further academic qualifications were not eligible. Two participants had left school during the previous year (one to take up a full-time job and one remained unemployed), and all other participants had left school in the previous 2 months and were either looking for work or planning to start vocational training in the autumn. Groups ranged in size from three to six participants. All participants were of white British ethnicity, and 75 per cent were male.

Design

A cross-sectional qualitative research design was used to meet the exploratory aims of the study. Semi-structured focus groups were used in order to discuss young peoples’ views on physical activity, diet and health. Focus groups were considered preferable to interviews as (1) young people may be less willing to talk to a researcher one-to-one than with friends and less confident in articulating their views, (2) better quality information is likely and (3) additional insight is likely to be gained by discussion and interaction between group members (Creswell, 2007). Although contextualization is less feasible when reporting on the outcome of focus groups (e.g. individual contributors may not answer all questions), trustworthiness of the data benefits from a statement’s subsequent discussion (and potential agreement/dismissal) from the wider group.

Interview schedule

The focus-group interview schedule was devised based on reviews of the literature, and with a view to forming the basis of the design of a future lifestyle intervention. Discussion was directed towards three issues: (1) influences on diet, (2) influences on physical activity and (3) changes in lifestyle anticipated and experienced after leaving school.

Procedure

Ethical approval was granted by the local institutional ethics committee. Three youth clubs and an information and advice service for young people were approached to provide access. Youth workers at these sites identified and approached young people who met the inclusion criteria to invite them to take part in the study and arranged a date at the venue for the focus groups to take place. On occasions when only one participant was available for a scheduled focus-group session, individual interviews were conducted; three focus groups and three interviews were conducted in total. Participants were informed that their participation was optional, that their contributions would be anonymous and that they were free to withdraw at any time.

Written consent was obtained from all participants prior to taking part, and all those completing an interview or focus group received a £5 cinema voucher as an incentive. Interviews and focus groups were recorded using a digital voice recorder and transcribed verbatim. The focus groups and interviews took place in July and August (i.e. after the end of the school year).

Data analysis

Interviews were analysed using thematic analysis organized by the framework method of qualitative analysis (Ritchie and Spencer, 1993) as such an approach provides a means to identify differences and similarities in order to produce structured outputs across the data (Gale et al., 2013). Although we do not claim data saturation, the framework approach has been frequently applied in health research and is preferable to other methods of analysis when working with homogeneous samples and when data are based on similar health-related topics (Gale et al., 2013). Transcripts were first read and re-read to facilitate familiarization, and commonalities between accounts were then used to derive raw data themes. Themes were derived inductively and selected from recurrent observations in the interview/focus-group data. Additionally, we used a deductive approach to extract themes based on theoretical propositions within SDT, and populate established themes (Braun and Clarke, 2006). Raw data themes capturing manifest or latent content were categorized into two higher order dimensions (main and sub-themes). Transcripts were analysed by the first author (S.K.), and subsequently read and reviewed by the second author (F.G.). Both authors contributed to the specification and organization of themes, enabling discussion of coding and themes to ensure that alternative interpretations were considered before final themes were agreed. The purpose was not to arrive at a consensus, but to ensure that interpretations were well grounded within the interview content.

Results

Dimensions

Three dimensions emerged reflecting partici-pants’ (1) perceptions of lifestyle and health, (2) changes in priorities relating to an increased sense of independence and personal responsibility following school, and (3) passive acceptance of internal and external influences on physical activity and diet.

Perceptions of lifestyle and health

The first dimension reflected how young people viewed their lifestyle in relation to their health (see Figure 1). Several participants reported a general understanding and awareness of the concepts underlying health and healthy living (‘I appreciate health education more after leaving school’). For example, participants identified a range of health risk behaviours including smoking, drinking, taking drugs and eating poorly, and readily assessed their own lifestyles in relation to these. Eight participants felt that they were leading a healthy lifestyle, three believed their lifestyle to be unhealthy and a further three reported that their lifestyle contained both healthy (e.g. being physically active, enjoying physical activities in different social forms; ‘we just get together and play football and muck about’) and unhealthy aspects (e.g. eating fast food).

Figure 1.

Dimension 1 – perceptions of lifestyle and health.

Participants expressed a general dislike of school-based health education, which was perceived as ineffective (‘I think it is pointless trying to get people involved by … going to talk to them [school kids] about it, it’s having to do something about it’) and patronizing (‘In school they treat you like you were three’). They also questioned the effectiveness of the health advice that they received from family at home, as parental behaviours appeared to be inconsistent with the health messages conveyed (‘They [parents] are pushing their child not to eat fatty foods, but when their back’s turned they’ll just eat it [fatty foods] anyway, so what’s the point?’). Participants indicated that they themselves should be the ones responsible for making their own health choices (‘You’ve got to make your own decisions in life’).

Only three participants considered health to be relevant to the choices they made. Of these, two participants were planning to join the army where the values of such a context are endorsed (‘I need to keep fit physically … [for the] army’; ‘I need to stay healthy for my future job’). These participants appeared to have personally integrated the value and benefit that eating a healthy diet and regular exercise holds for their job, but recognized that this concern separated them from their peers for whom health was not valued or relevant. A further sub-group of young people expected to get physical activity through their jobs through taking manual work or roles that involved being on their feet all day (e.g. catering; ‘I’ll be probably doing quite a lot of physical activity as I’ll be doing catering, so you’ll be like walking around the kitchen and stuff’). Despite acknowledging that this level of intensity of activity may not be sufficient for health and fitness (‘I know I will be physically active, but I don’t know if it keeps me healthy in the future’), this sub-group appeared to feel that their occupational activity excused them from needing to make further conscious effort to be active, endorsing the notion that health may not a key driver for health-related behaviours in young people. In contrast to the army recruits, for these young people physical activity was seen as a by-product of work rather than a route to better performance, and appeared to undermine the perceived importance of engagement in regular physical activity at a health-enhancing intensity.

Changes in priorities

Within this dimension, we identified two sub-themes: impact of environmental change on behaviour, and future plans and expectations (see Figure 2). Participants reported that one of the biggest changes in their post-school lives was a sense of greater independence and freedom. For example, participants emphasized that after leaving school, they were more able to make their own decisions in their lives and how they spend their time (‘I want to party’; ‘I want to have fun with mates’). However, despite the positive perceptions of increased freedom, participants perceived several negative effects of leaving school on their health behaviours. For example, participants acknowledged that being at school had helped them to maintain a healthier lifestyle in providing them with structure (‘I … never got in trouble, then as soon as I left school, you just lose the plot’; ‘If you are out at 11 o’clock … you wouldn’t usually do that on a school night … because you would think I have to be up at 7 or 8 in the morning’). Four participants expressed missing their time at school, and looked back on their school life as ‘easy’; everything was provided (‘a job on a plate’), and school functioned as a centre for experiencing social interactions (‘see your mates every day’).

Figure 2.

Dimension 2 – changes in priorities.

Money also became an important focus as participants wanted to be more independent by saving money or moving out from home (‘Mostly, I am on my own two feet then, I am not in my parents’ hands any more’). However, participants reported on the difficulty of finding appropriate part-time or full-time work and to implement future plans (‘I just thought I’d go out of school and get a job straight away. I have been calling people up every single day and still nothing … it is just not happening’). Overall, participants appeared to hold unrealistic expectations about job opportunities and found it challenging to implement personal plans after leaving school.

Passive acceptance of internal and external influences on physical activity and diet

The third theme related to the passive way in which participants accepted external influences on their health behaviours. The majority of participants exhibited a lack of interest and motivation towards being healthy, and expressed that a healthy lifestyle had little relevance or importance in their lives. Within this dimension, we identified two sub-themes: lack of importance and perceived effort (see Figure 3).

Figure 3.

Dimension 3 – passive acceptance of internal and external influences on physical activity and diet.

The majority of participants did not perceive health behaviours or health itself to be important as they did not foresee any immediate negative impact on their health or well-being (‘it’s not a big thing, is it really’). Furthermore, participants perceived that adopting a healthy lifestyle would take a lot of effort (‘being healthy is hard work’, ‘[it is] harder than being unhealthy’). Participants showed little motivation towards initiating physical activity (‘I am lazy’), and eating choices were largely dictated by convenience (i.e. low-effort options) and accessibility (‘I have easy access to fast food’) rather than quality.

Overall, the social environment appeared to have a greater impact on participants’ physical activities and dietary choices than their own volition; for example, the majority of participants (n = 10) felt that they had access to healthy meals prepared for them by their parents if they chose to eat at home (‘My dad is really into healthy eating and my mum is quite a good cook so they make sure I have healthy meals’), but many actively chose to eat away from home as a way of asserting independence (‘I never eat at home’) seemingly accepting that meals eaten outside the home tended to be less healthy without concern.

Discussion

Data from this work provide a snapshot of adolescents’ attitudes towards health behaviours at a time when they begin to expect and experience greater independence, and when the structure and support for healthy lifestyles that was previously provided by school is no longer available. Three themes were extracted: (1) perceptions of lifestyle and health, (2) changes in priorities and (3) passive acceptance of internal and external influences on physical activity and diet. Taken collectively, the three themes suggest that many young people do not perceive any compelling reason to protect their health through diet and exercise, potentially as threats to health seem too far in the future to make health-related behaviours a priority. Participants were largely content to allow their physical activity and dietary choices be dictated by convenience and other day-to-day priorities, such as asserting their independence and fitting in with friends.

Our findings are congruent with past research (e.g. Allen et al., 2007; Nelson et al., 2008), but also generate new insight. First, and while health was not a sufficient reason for young people to change their behaviour, all participants were knowledgeable and aware of what represents a healthy lifestyle. If this finding extends to the wider population of school-leavers, it suggests that health promotion initiatives based on increasing ‘health-related’ knowledge may be ineffective in promoting adaptive health behaviour changes. Second, and in relation to physical activity, we found that young people of both genders were not predisposed against healthy choices as long as they did not conflict with other priorities; most of the young men and women interviewed enjoyed exercising in some form and reported that they would exercise with friends when offered the opportunity (e.g. play football, walk, dance, swim). However, a number of participants did not feel confident in trying to create such opportunities in case of rejection (i.e. fear of alienation of oneself or ideas). Similarly in terms of diet, participants argued that they often ate junk food just to fit in with peers (i.e. rather than being a desired or likeable food), as it appeared to be the most convenient or only available option when eating outside the home. Thus, our findings suggest that young people are less averse to healthy behaviours than commonly believed. Future work exploring the potential to shift norms and environments to make healthy choices easier in social settings is warranted.

Theoretical interpretations

An objective of this work was also to explore young people’s motivation towards healthy eating and physical activity. Accordingly, we examined whether interpreting the findings through the lens of SDT could lend further insight. Although research with younger British adolescents has shown physical activity to be predicted by autonomous forms of motivation (see Standage and Ryan (2012) for a discussion), participants in this work made very few references to personal motives for physical activity or dietary behaviours themselves. Instead, they explained their choices in terms of contextual factors, driven by other priorities. This lack of interest in physical activity and dietary activities suggests that they were generally passively engaged, which is a characteristic of being amotivated (i.e. seeing no benefit of a course of action; cf. Deci and Ryan, 2000). On the occasions when physical activity and dietary choices were given consideration, albeit limited, behaviour was guided by controlled reasons (or low quality types of motivation) such as conforming to social and parental pressures (e.g. fitting in with friends, avoiding parental control).

The social context/environment during the transition from school was one in which young people felt that expressing concern about health behaviours, and carrying out health behaviours, would conflict with peer-approved activities. As individuals are more likely to accept and internalize the values and norms espoused by socializing agents such as their peers, for whom they feel a sense of connection and belonging (Deci and Ryan, 2000), the context could very feasibly have undermined their need for relatedness. Indeed, past work shows that being part of an active group of friends is a main impetus for adolescents to be physically active (Kubik et al., 2005), and a disruption or decline in social interactions and relatedness to peers has been shown to result in lower physical activity levels in young adults (Moller et al., 2010). While social norms in the home appeared to contrast with peer norms (i.e. promoted healthier behaviours as the norm), for those young people engaged in attempting to demonstrate their independence from parents, rejecting parental dietary values, for example, may have been an easy way to emphasize this. Again, this is consistent with findings in other domains indicating that health risk behaviours are more prevalent in young people in the process of trying to assert their independence (Borawski et al., 2003). It is important at this juncture to point out that from an SDT perspective, the asserting of healthy independence requires interpersonal supports for the person’s basic needs for relatedness, competence and autonomy. With the latter need in mind, within SDT, autonomy and independence are considered as conceptually orthogonal constructs; it is the experience of autonomy (rather than dependence or independence) that will predict well-being, adjustment and optimal functioning (Deci and Ryan, 2000).

There were a number of exceptions to the presence of amotivation, whereby maintaining a healthy lifestyle was perceived to contribute towards a personally valued goal; this was largely restricted to army recruits who appreciated and internalized the relevance of health and fitness for their careers. This finding further supports the notion that young people are able to adopt a healthy lifestyle and implement their existing knowledge if there is sufficient rationale and informational support to do so.

Some of the points raised by participants suggest that the passive approach taken to diet and physical activity may reflect a more general tendency to withdraw or passively engage in various life domains at this disruptive period. For example, a number of participants reported the difficulty that they experienced in directing other aspects of their lives as a result of losing the structure that school had provided; that is, without a fixed point in the day, they found it hard to plan other activities (e.g. arranging to spend time with friends, getting up in the morning). Most participants thought that getting a job and keeping up with friends would be easy after leaving school. Yet, the reality was that the majority spent the summer relatively detached from friends and with no job or alternative plans, even if only temporarily. Their amotivation in this regard may reflect a lack of support for their three basic needs as they (1) lack the competence to behave with a sense of volition and congruence in directing their own lives as they had anticipated (autonomy), (2) experience detachment from friendship groups (relatedness) and (3) experience undermining of their autonomous motivation through the sudden loss of structure (i.e. which if provided in an autonomy-supportive way is a scaffolding to the development of competence; Standage and Ryan, 2012) and agency experienced on completion of school. Research would do well to examine how best to provide support and/or develop new supports for young people’s basic needs at this key transition point. Such work would provide valuable insight into how practitioners can support on-going well-being and adjustment.

Despite displaying some amotivation towards physical activity for health reasons, a positive finding was that most participants appeared to retain some intrinsic motivation towards sports and social forms of exercise (e.g. enjoyment of football or dance). In these instances, physical activity appeared to be incidental, and engagement aligned with autonomous motivation towards leisure activities/sport in general. As such, the promotion of physical activity as a means of spending enjoyable time with peers, rather than improving health, may prove more acceptable and/or relevant to young people. It is also more likely that such activities would be incorporated into their new routines on leaving school. These findings are congruent with SDT in suggesting that it is the inherent and intrinsic aspects of activities (e.g. for fun, satisfaction, promoting challenge and affording opportunities for new experiences/exploration) that determine adaptive and maintained behaviours. Research examining interventions that support the inherent fun and enjoyment of activities, promote challenge and afford opportunities for new experiences/exploration would be particularly insightful with young people in light of our findings (see Standage and Ryan (2012) for a discussion around need-supports in this regard).

Limitations

This study is somewhat limited by its cross-sectional design, which allows exploration of participants’ experiences and behaviours during the transition phase, but not beyond this time period. A longitudinal design incorpora-ting re-assessments would provide valuable insight into participants’ changing priorities, adjustment to their new environment and the process of habit formation. The sample characteristics may have also limited the scope of the results as 75 per cent of the participants were male, and all participants were from a single ethnic group (white British).

Conclusion

The transition from school to work or work-based learning is an important period when adolescents can form new physical activity and dietary habits. The young people taking part in this study largely reported an absence of goals or motives for enacting health-related behaviours unless fitness was a specific requirement of a desired job. Although physical activity (particularly sport or dance) was enjoyed for its own sake by many participants indicating some level of intrinsic motivation, the challenge remains to get young people to purposefully and more readily design such into their lives.

This work showed that adolescents experienced a lack of structure in their lives as a whole and lacked a sense of competence that they could be the authors of their own lifestyle decisions (i.e. amotivation towards health behaviours appeared to reflect a global level of amotivation). Future work would be useful to explore whether the provision of structure with supports for basic psychological needs can support health and lifestyle adjustments during the school-to-work transition. From a SDT perspective, this may be best achieved by focussing on the inherent aspects of the activities/tasks (e.g. fun, creativity, exploration, mastery).

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the National Prevention Research Initiative (Phase 2) (; award: G0701878). The Funding Partners relevant to this research are: British Heart Foundation; Cancer Research UK; Department of Health; Diabetes UK; Economic and Social Research Council; Food Standards Agency; Medical Research Council; Research and Development Office for the Northern Ireland Health and Social Services; Chief Scientist Office, Scottish Executive Health Department; The Stroke Association; Welsh Assembly Government and World Cancer Research Fund.

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