CLINICAL SCHOLARSHIP

Examining Self-Care Behaviors and Their Associated Factors

Among Adolescent Girls With Dysmenorrhea: An Application of
Orems Self-Care Deficit Nursing Theory
Cho Lee Wong, PhD, RN1 , Wan Yim Ip, PhD, RN2 , Kai Chow Choi, PhD3 , & Lai Wah Lam, PhD, RN4
1 Professional Consultant, The Chinese University of Hong Kong, Hong Kong
2 Associate Professor, The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong
3 Assistant Professor, The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong
4 Professional Consultant, The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong

Key words Abstract

Dysmenorrhea, Orems self-care deficit nursing
theory, path analysis, self-care
Correspondence
Dr. Cho Lee Wong, Room 628, Esther Lee
Building, The Chinese University of Hong Kong,
Hong Kong.
E-mail: jojowong@cuhk.edu.hk
Accepted: February 2, 2015
doi: 10.1111/jnu.12134
Purpose: To test a hypothesized model that examines the relationship be-
tween selected basic conditioning factors, self-care agency, and self-care behav-
iors among adolescent girls with dysmenorrhea using Orems self-care deficit
nursing theory as a framework.
Design: This was a predictive correlational study conducted with a total of
531 secondary school girls.
Methods: Self-care agency, self-care behaviors, and 11 variables that have
been theoretically or empirically justified in previous studies as relevant to
basic conditioning factors were selected and collected by means of structured
questionnaires. Path analyses were performed to test the hypothesized linkages
among variables.
Findings: Path analysis revealed that age and received menstrual educa-
tion had both direct and indirect effects through self-care agency on self-care
behaviors. Mothers and fathers educational level, pain intensity, and self-
medication used when experiencing dysmenorrhea only affected the self-care
behaviors directly.
Conclusions: This is the first study that provided information about the rela-
tionship between basic conditioning factors, self-care agency, and self-care be-
haviors among adolescent girls with dysmenorrhea. Knowledge of the factors
influencing self-care behaviors in these adolescent girls will assist healthcare
professionals in developing effective interventions to promote self-care and
ameliorate the adverse impact of this condition.
Clinical Relevance: Interventional strategies that aim at promoting self-care
behaviors among adolescent girls with dysmenorrhea should strengthen girls
self-care agency and should target those with a younger age, higher pain inten-
sity, mother with a higher educational level, father with a lower educational
level, and those who do not take self-medication for dysmenorrhea.

Dysmenorrhea is a common menstrual problem among
adolescent girls (Banikarim, Chacko, & Kelder, 2000;
Bettendorf, Shay, & Tu, 2008). Prevalence rates have
been reported ranging from 20% to 90% (Campbell &
McGrath, 1999; Davis, Westhoff, OConnell, & Gallagher,
2006). Dysmenorrhea is a distressing condition affecting
not only the academic and social aspects of adolescent
girls, but it is also the leading cause of their short-term
school absenteeism (Banikarim et al., 2000). Adolescent
girls prefer performing self-care to relieve their discom-
fort instead of seeking medical advice (Chiou & Wang,
2008; Lau, Yu, Cheung, & Leung, 2000). The important

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Self-Care Behaviors for Dysmenorrhea
role of self-care in relieving dysmenorrhea has also
been reported (Cheng & Lin, 2010; Wong & Ip, 2012;
Wong, Lai, & Tse, 2010). However, little is known about
how adolescent girls exercise self-care and the factors
associated with it. Understanding adolescents self-care
behaviors and their associated factors could help health-
care professionals to identify potentially harmful or
ineffective behaviors, and therefore formulate appropri-
ate management and education plans (Hillen, Grbacac,
Johnston, Straton, Keogh, 1999).
This study was guided by Orems self-care deficit nurs-
ing theory. According to Orem (2001), a person initi-
ates and performs self-care for maintaining life, healthful
functioning, and well-being. He or she must acquire self-
care agency for self-care, and self-care agency is influ-
enced by basic conditioning factors (BCFs). BCFs include
age, gender, developmental state, environmental factors,
family system factors, sociocultural factors, health state,
pattern of living, healthcare system factors, and availabil-
ity of resources (Orem, 2001). These BCFs may influence
an individuals ability to participate in self-care activities
or modify the kind or amount of self-care required. On
the basis of Orems theory and literature review, poten-
tial variables of BCFs postulated as influencing self-care
behaviors or self-care agency of adolescent girls suffering
from dysmenorrhea were identified.
The relationship among age, self-care agency, and self-
care behaviors of adolescent girls suffering from dysmen-
orrhea was initially examined. Previous studies proposed
that self-agency and self-care behaviors likely increase as
girls increase in age (Moore, 1993; Zhimin, 2003). How-
ever, other studies (Cull, 1996; Dashiff, McCaleb, & Cull,
2006; McCaleb & Cull, 2000) documented a negative cor-
relation between age and disease-related self-care.
Family system factors are commonly defined as
mothers and fathers occupation and education, living
situation, marital status, birth order, and social and emo-
tional support (Moore & Pichler, 2000). Adolescent girls
usually sought advice regarding dysmenorrhea self-care
from their mothers (Chiou & Wang, 2008); educated
mothers may also provide detailed information regarding
dysmenorrhea (Finlay, Jones, & Kreitman, 2000); thus,
a mothers educational level possibly influenced the self-
care of adolescent girls suffering from dysmenorrhea. A
fathers educational level also possibly influenced self-
care (Cull, 1996; McCaleb & Cull, 2000).
For sociocultural factors, Orem (2001) did not provide
a definition for it but included culture, education, occupa-
tion, and experiences as sociocultural factors without fur-
ther elaboration. In Chinese culture, illness occurs when
there is an imbalance between yinyang, hotcold, dry
wet, as well as qi and holism (Ma, 1999). Menstrual
symptoms, such as dysmenorrhea, can be interpreted as
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Wong et al.
weakness in the general health of women and is caused
by blood and qi stagnation that results in an imbal-
ance of yin and yang in the body. Given that culture de-
termines the ways in which symptoms, such as menstrual
pain, were handled (McMaster, Cormie, & Pitts, 1997),
culturally specific self-care behavior on dysmenorrhea,
such as the use of herbal remedies and acupressure, were
reported in previous studies (Cheng, Lu, Su, Chiang, &
Wang, 2008; Wong et al., 2010). However, the influence
of culture on self-care agency and behavior of dysmenor-
rhea are difficult to assess using a quantitative approach;
a qualitative approach is required to develop insights into
the influence of culture on both aspects (Orem, 2001).
For instance, adolescent girls with a high family in-
come may be more resourceful than those with low
family income; thus, the former may exhibit a higher
level of self-care agency and self-care behavior than
the latter (Baker & Denyes, 2008). However, using a
multiple regression model to predict self-care behaviors,
Chang and Chuang (2012) found that the socioeconomic
condition of the family was not significantly associated
with dysmenorrhea self-care behaviors among adolescent
Taiwanese girls.
Measurement of the health state has been either gen-
eral, such as the presence or absence of health problems
(Callaghan, 2006), or specific to the disease condition,
such as duration of illness (Ailinger & Dear, 1993) or
pain intensity (Zadinsky & Boyle, 1996). The regularity of
the menstrual cycle, duration of menstruation, and pain
intensity were possibly related to self-care behaviors to-
ward dysmenorrhea (Chang & Chuang, 2012; Chia et al.,
2013).
Patterns of living encompass all the actions people per-
form daily (Orem, 2001). Limitation in daily activities af-
fects self-care, and the relationship of these activities with
self-care was also noted in previous studies (Chia et al.,
2013; Ortiz, 2010). The healthcare system is character-
ized by disciplines, such as nursing and medicine (Orem,
2001). Study has suggested that medical consultation re-
garding dysmenorrhea influences self-care (Chiu, Wang,
Hsu, & Liu, 2013).
Availability of resources influences the means to meet
self-care measures (Orem, 2001). Prior experience of re-
ceiving menstrual education may influence the adop-
tion of self-care behaviors for dysmenorrhea (Chiu et al.,
2013); however, Chang and Chuang (2012) found that
knowledge about dysmenorrhea was not significantly
correlated with the adoption of self-care behavior among
adolescent girls. Few studies reported that adolescent girls
from Western countries prefer self-medication for dys-
menorrhea (Agarwal & Venkat, 2009; OConnell, Davis
& Westhoff, 2006). However, self-medication is not un-
der the construct of self-care among adolescent girls with
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Wong et al.
dysmenorrhea in Hong Kong (Wong, Ip, Choi, & Shiu,
2013). Thus, further research is required to test the rela-
tionship between self-medication and self-care behavior
in a local context. Likewise, self-care agency influences
self-care, as explained in Orems theory and previous
studies (Slusher, 1999; Callaghan, 2006).
In summary, previous studies support the proposition
and provide inconclusive evidence with regard to the re-
lationship between BCFs, self-care agency, and self-care.
However, no study to date was found to examine the
role that BCFs and self-care agency play in the dysmen-
orrhea self-care behaviors. Even though existing theo-
ries provide insight into the factors necessary for self-care
behavior, this should be tested before conclusions are
made. Accordingly, a total of 13 variables were assessed.
Eleven of these variables were BCFs, which included age,
two family system factors (mothers educational level
and fathers educational level), one sociocultural factor
(family income), three health state factors (regularity of
menstrual cycle, duration of menstruation, and pain in-
tensity), one pattern of living factor (limitations in daily
activities due to dysmenorrhea), one healthcare system
Figure 1. A hypothesized model of self-care behaviors and their associated factors among adolescent girls with dysmenorrhea.
Journal of Nursing Scholarship, 2015; 47:3, 219227.
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Self-Care Behaviors for Dysmenorrhea
factor (medical consultation for dysmenorrhea), and two
related to the availability of resources (received men-
strual education and self-medication used when expe-
riencing dysmenorrhea). The remaining variables were
self-care agency and self-care behaviors for dysmen-
orrhea. A hypothesized model of self-care behaviors
and their associated factors among adolescent girls with
dysmenorrhea was proposed (Figure 1).
Methods
Design and Sample
A cross-sectional, descriptive correlational design with
a predictive approach was utilized to investigate the
correlates of self-care behaviors among Hong Kong
adolescent girls with dysmenorrhea. The sample size
determination was based on a power analysis in the
assessment of the root-mean-square error of approxi-
mation (RMSEA), one of the most commonly reported
fit indices of path analysis (MacCallum, Browne, &
Sugawara, 1996). A convenience sample of 531 girls was
recruited from three secondary schools. Participants were
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13 years old or older and had experienced pain during
the last three cycles. Girls who reported a history of
gynecological disease or surgery or suffered from severe
disease were excluded.
Instruments
The Adolescent Dysmenorrhic Self-Care Scale.
The Adolescent Dysmenorrhic Self-Care Scale (ADSCS)
was used to assess the adolescent girls self-care be-
haviors toward dysmenorrhea (Hsieh, Gau, Mao, & Li,
2004). Girls were asked to rate themselves on a 6-point
Likert scale, with higher scores reflecting higher level
of self-care behavior being practiced. The ADSCS has
been translated into Chinese-Cantonese and validated
in Hong Kong adolescent girls with dysmenorrhea with
good reliability (Cronbachs = 0.94; Wong et al., 2013).
In this study, the Cronbachs coefficient for the entire
scale was 0.92.
The Exercise of Self-Care Agency Scale. The Ex-
ercise of Self-Care Agency Scale (ESCAS) was used to
assess the self-care ability of an individual (Kearney &
Fleischer, 1979). It has been translated into Chinese-
Cantonese and validated in Hong Kong adolescent girls
with dysmenorrhea (Wong, Ip, & Shiu, 2012). The 35-
item Chinese-Cantonese version (CC-ESCAS) measured
four aspects of self-care agency: self-concept, knowledge
and information seeking, passivity, and motivation. The
reliability of the CC-ESCAS was good, with a Cronbachs
of 0.92 (Wong et al., 2012). The Cronbachs coeffi-
cient of the entire scale in this study was 0.91.
The Demographic Information Sheet. The de-
mographic information sheet, consisting of 11 items, was
developed by the researchers with reference to previous
literature to gather information related to selected BCFs
(Chiou & Wang, 2008).
Procedure
Ethical approval was obtained from the ethics research
committee of the study institution. All form two to seven
secondary school female students were given a written
information sheet in their classrooms. The researcher dis-
tributed a set of self-administered anonymous question-
naires to those who agreed to participate, including a
demographic information sheet, the CC-ESCAS, and the
CC-ADSCS.
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Wong et al.
Data Analysis
Data were analyzed using SPSS version 19.0 (SPSS
Inc., Chicago, IL, USA) and LISREL Version 8.8 (Scien-
tific Software International, Inc., Skokie, IL, USA), and
the level of significance was set at p < .05. Descriptive
statistics were used to summarize the selected BCFs and
all continuous variables, namely the CC-ESCAS and CC-
ADSCS scores of the participants.
Path analysis was used to examine the relationship
between selected BCFs, self-care agency, and self-care
behaviors (see Figure 1). Parameters of the path model
were estimated by the robust maximum likelihood
method, which allows violation of the multivariate nor-
mality assumption (Satorra & Bentler, 1994). The overall
fit of the path model was examined by the goodness-of-
fit indices, including a nonsignificant chi-square value,
the RMSEA, standardized root mean square residual
(SRMR), non-normed fit index (NNFI), comparative fit
index (CFI), and adjusted goodness-of-fit indices (AGFI;
Schermelleh-Engel, Moosbrugger, & Muller,
2003). RM-
SEA and SRMR below 0.08 indicating an acceptable fit.
The values of AGFI, CFI, and NNFI usually ranged from
0 to 1, with AGFI 0.90 and CFI and NFI 0.97, indi-
cating a good fit to data (Schermelleh-Engel et al., 2003).
The overall model fit was determined by theoretical
consideration, as well as by adding new paths based on
modification index, and by deleting insignificant paths.
Results
Basic Conditioning Factors, Self-Care Agency,
and Self-Care Behaviors
The ages of the girls ranged from 13 to 19 years
(mean = 15.69, SD = 1.4). Their mean pain intensity in
the previous three menstrual cycles was 5.48 (SD = 2.2),
measured by the pain visual analogue scale. The selected
BCFs, self-care agency, and self-care behaviors of the par-
ticipants are summarized in Table 1.
The Path Model
Path analyses were performed to examine the rela-
tionship between selected BCFs, self-care agency, and
self-care behaviors. The chi-square was 44.95 and degree
of freedom (df) was 9, with a significant chi-squared
test result (p = .00). The goodness-of-fit indices for the
hypothesized model were RMSEA = 0.09, AGFI = 0.74,
CFI = 0.98, NNFI = 0.79, and SRMR = 0.05. The results
suggested the model did not fit the data. In order to
improve the goodness-of-fit of the model, the model
was revised according to the modification index as well
as in conjunction with theoretical justification. The
largest modification index (62.94) was from the received
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Wong et al. Self-Care Behaviors for Dysmenorrhea

Table 1. Summary of Selected Basic Conditioning Factors (BCFs) NNFI = 1.0, SRMR = 0.02), with all individual paths
significant at p < .05, indicated that the final model fit to
Total (N = 531)
the data. The standard path coefficients and proportions
Selected BCFs n (%) of variance of the endogenous variables explained (R2 )
are shown in a path diagram (see Figure 2). The final
Age (years)
model accounted for 46% and 25% of the variance of
Mean, SD 15.69 1.4
Fathers educational level self-care behaviors and self-care agency, respectively.
Secondary or below 438 82.5 The total effects, both direct and indirect, of the selected
University or above 93 17.5 BCFs of self-care behaviors are shown in Table 2.
Mothers educational level
Secondary or below 461 86.8
University or above 70 13.2 Discussion
Family income (HK$)
The present study is the first to adopt Orems self-care
<20,000 318 59.9
20,001 213 40.1 deficit nursing theory to investigate the relationship be-
Menstrual cycle tween selected BCFs, self-care agency, and self-care be-
Regular (2135 days) 421 79.3 haviors in adolescent girls with dysmenorrhea. Previous
Irregular (1620 days/3640 days/other) 110 20.7 studies only assumed a simple associative relationship be-
Menstruation duration (days) tween BCFs and self-care behaviors (Chang & Chuang,
Mean, SD 5.54 1.07
2012; OConnell et al., 2006). There is a lack of re-
Pain intensity in the past 3 months (010)
search investigating the interrelationships among these
Mean score, SD 5.48 2.2
Limitation of daily activities due to dysmenorrhea variables. Additionally, knowledge about non-Western
Not affected 61 11.5 girls in this context is even scarcer. The incorporation
Affected 470 88.5 of a comprehensive set of BCFs allows a more thor-
Received menstrual education ough investigation of this phenomenon. The final model
No 222 41.8 accounted for 46% and 25% of the variance of self-
Yes 309 58.2
care behaviors and self-care agency, respectively. Using
Medical consultation for dysmenorrhea
path analysis to analyze all the variables simultaneously,
No 503 94.7
Yes 28 5.3 the results show an overall path model linking the se-
Self-medication for dysmenorrhea in the past 3 months lected BCFs, self-care agency, and self-care behaviors
No 442 83.2 with a directional pathway. This can help to enhance the
Yes 89 16.8 understanding of the interrelationships between these
Chinese-Cantonese Adolescent Dysmenorrhic Self-Care variables. Six basic conditioning factors were identified
Scale
as affecting the adoption of self-care behaviors among
Mean score, SD 124.0 31.6
adolescent girls with dysmenorrhea. Four BCFs (pain, fa-
Chinese-Cantonese Exercise of Self-Care Agency Scale
Mean score, SD 85.7 16.7 thers educational level, mothers educational level, and
self-medication) were not mediated by self-care agency.
Age and received menstrual education significantly influ-
menstrual education to self-care agency. Because this ence the self-care behaviors, and they are mediated by
parameter is meaningful and theoretically sound, a direct self-care agency.
path from received menstrual education to self-care The positive relationship between self-care agency
agency was added. An inspection of the t-value found and self-care behaviors in this study supports Orems
that paths (from regularity of menstrual cycle, duration theory. Indeed, previous studies have found that self-care
of menstruation, limitation in daily activities due to agency is associated with self-care behaviors (Anderson,
dysmenorrhea, and medical consultation to self-care be- 2001; Callaghan, 2006); the results not only add to the
havior) were insignificant and thus they were removed. growing body of evidence that self-care agency signifi-
Though further deleting the nonsignificant path from cantly influences self-care behaviors, but also highlight
family income to self-care agency and self-care behavior the significance of self-care agency as a mediator in pro-
would enhance the goodness-of-fit of the model, they moting self-care behaviors among adolescent girls with
were kept for future comparisons in different samples dysmenorrhea. This model also helps to enlarge our
of socioeconomic background. The final model obtained knowledge of certain girls characteristics or BCFs, such
is presented in Figure 2. The insignificance of the chi- as their mothers and fathers educational level, their age,
squared test result (p = .38) and the goodness-of-fit and pain level, which would affect their adoption of self-
indices (RMSEA = 0.02, AGFI = 0.92, CFI = 1.00, care behaviors.

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Self-Care Behaviors for Dysmenorrhea Wong et al.

Age R 2 = 0.46

0.14*

Mothers
educational level -0.28* Self-care behaviors
0.36*
Fathers
educational level 0.29*

0.07
Family income

-0.15*

Pain intensity 0.14*

*
0.05

0.30*
Received menstrual
education 0.30*

R 2 = 0.25
Self-medication for
dysmenorrhea
0.32* Self-care agency

Figure 2. Path diagram relating selected basic conditioning factors, self-care agency, and self-care behaviors among adolescent girls with dysmenorrhea.

Table 2. Summary of Standardized Direct, Indirect, and Total Effects of Chinese culture, mothers have taken on the role of bear-
the Selected Basic Conditioning Factors on Self-Care Behaviors ing all the responsibility for their children and deal with
Self-care behavior every aspect of their care, which results in overprotec-
Variables on the tion. Although some studies demonstrated that mothers
final path model Direct effect Indirect effect Total effect were the main source of knowledge for menstruation
issues (Chan, Yiu, Yuen, Sahota, & Chung, 2009; Davis
Age 0.14 0.11 0.25
Mothers higher -0.28 -0.28 et al., 2006), it appears that educated mothers in Hong
educational level Kong not only pass their knowledge to their daughters,
Fathers higher 0.29 0.29 but also do it for them. As a result, adolescent girls
educational level rely on their mothers to care for all their menstruating
Pain intensity -0.15 -0.15 problems and seldom perform self-care. These findings
Received menstrual 0.14 0.10 0.24
highlight the need to recognize the mothers educational
education
level as a major element for influencing adolescent
Self-medication 0.30 0.30
girls self-care behaviors; interventions should not only

p < .05. help mothers to increase their knowledge and self-care

In relation to the measurement of family system
factors, contrary to the widely held notion that mothers
educational level would promote self-care behaviors for
their daughters, our results revealed a negative effect
of mothers educational level on the self-care behaviors
of her daughters. Such an effect may be caused by the
parenting style of Chinese mothers. Influenced by the
skills related to dysmenorrhea, but also educate them
to facilitate their daughters to perform self-care instead
of performing care for them. In contrast, girls who have
a comparatively well-educated father were reported to
have a higher level of self-care behavior. The result was
consistent with the finding of McCaleb and Cull (2000)
that as the fathers education level increased, so did self-
care practices of adolescents. It is possible that educated

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Wong et al.
fathers would have positive attitudes and would not
impose any social restrictions on dysmenorrhea self-care
behaviors or treat them as a taboo; thus, girls are more
likely to perform self-care behaviors.
In relation to the measurement of health state and age,
negative associations were evident for pain and self-care
behaviors. The higher the pain level, the less self-care be-
haviors girls adopted. This may be because girls expect
the pain as a normal part of the menstrual cycle or they
tolerate the pain without resorting to self-care strategies.
Nevertheless, the exact mechanism should be explored in
further detail by using a qualitative approach. Mean-
while, the age of adolescent girls has a positive impact
on self-care agency and self-care behaviors. Although this
result was not supported by previous studies (McCaleb
& Cull, 2000; OConnell et al., 2006), the finding of this
study is reasonable, as with increasing age, girls self-care
capability (self-care agency) increases and so do their self-
care behaviors.
In relation to the availability of resources, self-
medication was found to have a positive impact on
self-care behaviors. In this study, only 16.8% of girls
self-medicated for dysmenorrhea. This was comparable
to the results of two local studies (Wong et al., 2013;
Wong et al., 2012), but relatively lower than those found
in other countries, which report higher rates of self-
medication (OConnell et al., 2006). Self-medication is
not commonly employed in our sample, probably be-
cause girls perceive it as using prescription drugs and
therefore associated with side-effects. Lack of knowledge
about medication may also be a contributing factor. De-
spite the fact that self-medication was assumed as a kind
of self-care behavior (Ortiz, 2010), current findings re-
veal a positive effect of self-medication on self-care be-
haviors. These results are in accordance with a previous
finding that self-medication was not under the construct
of self-care behaviors in Chinese adolescent girls with
dysmenorrhea (Wong et al., 2013). This may be due to
the fact that adolescent girls regard taking medication as
a kind of medically orientated behavior that requires a
doctors prescription or advice instead of a self-initiated
behavior.
With regard to menstrual education, receiving men-
strual education has a positive impact on both self-care
agency and self-care behaviors. This finding is similar to
the findings reported by Chang and Chen (2008), which
indicated that greater menstrual preparation and greater
menstrual knowledge are significant predictors of pos-
itive menstrual healthcare behavior among elementary
level female students. The provision of more information
increases the likelihood of adoption of self-care behaviors
(Chang & Chuang, 2012; Chiou & Wang, 2008).
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Self-Care Behaviors for Dysmenorrhea
This study likewise provides implications for clinical
practice. Although some of the identified BCFs are non-
modifiable (pain, fathers educational level, mothers ed-
ucational level, and age), a nurse could incorporate the
findings of this study to identify adolescent girls who are
at risk for self-care deficit and to develop an assessment
tool to screen those who are at risk for lower level of self-
care behavior, namely girls with a higher pain level, a
younger age, or a mother with a higher educational level,
and those who do not use self-medication, so that an in-
dividualized plan of care could be delivered to preempt
the development of self-care deficits.
Moreover, this model can help to deepen our under-
standing of the effect of BCFs on self-care behaviors and
the mediating role of self-care agency, so that tailor-made
interventions can be designed to target the modifiable
BCFs and to modify the mediating variable in order to
change the outcome. Among the identified BCFs, self-
medication and received menstrual education are modifi-
able. Thus, the nurse could collaborate with both primary
and secondary schools to design an educational interven-
tion to educate girls about dysmenorrhea, and to promote
their use of self-medication and therefore their self-care
behaviors toward dysmenorrhea. Besides, an interven-
tion to improve girls knowledge and self-care agency,
such as promoting their self-concept and knowledge and
information-seeking skills, could be effective in changing
the outcome.
The strength of this study was the use of a theoretical
model to guide the research. Orems theory provided
insight into how BCFs and self-care agency influence the
performance of self-care behaviors. Knowledge gener-
ated from this study provides the foundation to identify
girls at risk for self-care deficit, the data also indicating
the importance of self-care agency and its effect on
self-care behaviors. The results also contribute to the
theoretical development and confirm the application of
Orems theory in understanding self-care in the Chinese
context. As Orem (2001) continues to encourage theory
testing research related to BCFs on self-care, more
research is recommended to further describe BCFs as
well as other potential factors that are associated with
self-care behaviors, using qualitative interviews.
This study has some limitations. First, only female sec-
ondary students with dysmenorrhea from local schools
who could communicate in Cantonese or Chinese were
recruited; therefore, it may not be possible to generalize
the findings to those who speak English or study in
International School. Second, despite the selection of
variables and that their operational definitions were con-
sidered and justified based on extensive literature review
related to menstruation-related or adolescent studies,
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there might have been other important variables not
selected for this study. This could also be reflected by the
fact that there was a 54% variance in self-care behaviors
not explained by the path model. Nevertheless, to in-
clude too many variables would lead to a lack of focus in
the study. Besides, adolescent girls might be reluctant to
complete a questionnaire with too many items. However,
there are obviously grounds for including these variables
in future studies.
Conclusions
Notwithstanding these limitations, the findings pro-
vide the foundation for future research and applications.
The results provide an initial understanding of self-care
behaviors and their associated factors among adolescent
girls with dysmenorrhea. Knowledge of the interrelation-
ships of the variables gives us a better understanding of
this phenomenon. Although further qualitative study will
be needed to support and illuminate these quantitative
findings, this is one of the first studies to examine fac-
tors affecting self-care behaviors in adolescent girls. Con-
sequently, this study will contribute to clinical application
and result in a foundation for future intervention studies
to identify important BCFs and promote self-care agency
to achieve optimal self-care behaviors in adolescent girls
with dysmenorrhea.
Clinical Resource
r World Health Organization website: http://apps.
who.int/medicinedocs/en/d/Js2218e/1.html
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