Do demographic factors and a health-promoting lifestyle influence the self-rated health of college nursing students?

Healthcare professionals are role models in introducing health-promoting lifestyles to patients as well as to the public, and it has been shown that their own behaviours can influence how they counsel patients [1]. People leading unhealthy lifestyles not only contribute to high morbidity and reduced productivity in society, but can also be an economic burden on society [2]. Health promotions are largely concerned with the behaviour and lifestyle of individuals, as well with as the physical and social environment. Nevertheless, the main strategy is to promote a lifestyle conducive to health and to keep preventable conditions from developing [3]. Studies have shown an association between lifestyle factors such as alcohol use, smoking, and dietary habits and the incidence of cardiovascular diseases and diabetes, while the practice of safe sex has been related to a decline in the prevalence of HIV [4, 5]. A systematic review conducted in 2010 found empirical evidence that sedentary behaviours during childhood and adolescence, such as the excessive viewing of television and playing of electronic games and a lack of engagement in physical activities, are likely to shape an individual’s adult life [6]. In their systematic review and meta-analysis, Loef and Walach [7] concluded that the adoption of a combination of healthy behaviours, including refraining from smoking, engaging in regular exercise, maintaining an optimal body weight, and drinking less alcohol, was associated with a 66% reduction in mortality, resulting in a significant reduction in healthcare costs worldwide.

Eleven questionnaires were discarded because the amount of missing data exceeded 10% of the total items. In the end, 314 valid questionnaires were available for analysis.

Among the 314 participants, 169 students were from Year 2 and 145 students were from Year 5. The majority of the participants were female (78.3%) and living with their family (96.8%). About 71.7% of the students reported having a part-time job and most of those worked from 8 to 16 h per week. About one-fourth of the students held religious beliefs and around one-third had experienced a conflict with their family in the past month (Table 1).

Table 2 showed no significant differences in the overall score and in the subscales for spiritual growth (p = 0.891), physical activities (p = 0.807), health management (p = 0.884), nutrition (p = 0.182) and the overall score of HPLP-IICR (p = 0.404) between the junior and senior nursing students. There was a significant difference in health responsibility (p = 0.029), with the senior students performing much better than the junior students.

Table 3 presented that the relationships between SRH and the various subscales of the HPLP-IICR among all nursing students were statistically significant, with low to moderate positive correlations between SRH and the HPLP-IICR subscales. Moderate positive correlations were found between such subscales of the HPLP-IICR as ‘Health Management’ and ‘Spiritual Growth’ (r = 0.58, p < 0.001), and ‘Nutrition’ and ‘Physical Activities’ (r = 0.41, p < 0.001).

Because only a very small percentage of students (6.4%) rated their health as ‘Poor’ or ‘Very Good’, the items in original 5-point Likert scale of ‘Poor’ and ‘Not so good’, and ‘Good’ and ‘Very good’ were merged. The new categories for SRH were re-grouped into ‘Not so good’, ‘Average’, and ‘Good’ as the three ordered categories for the dependent variable in an ordinal logistic regression for ease of analysis. Table 4 showed that students who had a higher health management score (OR: 1.12, 95% CI: 1.04–1.21) and who had experienced no family conflicts in the recent month (OR: 1.64, 95% CI: 1.01–2.66) were more likely to have higher self-rated health. It was marginally significant for students who are religious to have higher self-rated health (OR 1.67, 95% CI: 0.98–2.85).

Our study is the first of its kind to compare the self-rated health and health-promoting lifestyles of junior and senior year nursing students, as well as the relationship between SRH and health-promoting lifestyles, and to examine the predictors of SRH among nursing students in a tertiary institution.

In our study, all Year 5 students had completed the required clinical practicum before graduation, while the Year 2 students had not commenced their clinical practice. It was presumed that the final year nursing students would demonstrate significantly better health-promoting behaviours than their junior counterparts. Contrary to our expectations, there were no significant differences between the two groups in the subscale scores of the HPLP-IICR, with the exception of ‘Health Responsibility’. The specific items for ‘Health Responsibility’ included discussing one’s own health concerns with healthcare professionals, inquiring about self-care methods from healthcare professionals, seeking a second opinion from physicians, and taking the initiative to report symptoms of abnormalities in their body to a physician. Differences in education increased over time. The significant difference in ‘Health Responsibility’ suggests that the effects of nursing education and clinical practice are linked to greater health consciousness and proactiveness on the part of the senior nursing students. Furthermore, the experiences gained from the clinical practicum cannot be underestimated, as the clinical practicum provides students with opportunities to deliver health promotion information to clients. Under the guidance of their clinical teachers, students can engage in reflections during the process of giving care and apply the knowledge that they have acquired to improving their own health. Furthermore, nurses have been encouraging patients to monitor their symptoms and promptly report them to healthcare professionals to promote early detection and treatment. The above evidence supports the notion that senior nursing students are better able to maintain their health responsibilities and to respond appropriately to health concerns than junior nursing students. Our findings are similar to previous studies conducted in Hong Kong and Turkey [14, 26], and partially consistent with a study in Thailand [27], revealing that freshmen reported being worse than more senior students at health responsibility, nutrition, and stress management.

There were insignificant differences between the two groups of students in other subscales of the HPLP-IICR. With regard to the demographic data, there were significant differences between the junior and senior students in engagement in a part-time job and having religious beliefs. Most of the senior students held part-time jobs and were not religious. Although these students should be more health conscious about managing their lifestyle because of their nursing education, they considered it a luxury to engage in daily physical exercise and enjoy leisure activities, as they were juggling a heavy study load, participating in clinical practices, and a part-time job. According to Sossah [28], nursing students face various stressors, with fear over their clinical performance tending to be their greatest source of stress. Apart from this, the effort to maintain meaningful interpersonal relationships, the uncertainty over future career choices, and having an inadequate support network further aggravated their stress levels. Although there was conflicting evidence on the association between religious beliefs and stress, a systematic review showed that religion and spirituality can help people to deal with the aftermath of trauma and to nurture relationships with others [29]. Another previous study also identified a significant negative correlation between perceived stress and spiritual well-being in a group of community dwelling adults after a six-week spiritual intervention [30]. The above studies explain some of the connections between spirituality and stress relief. If the majority of the senior students hold a part-time job and are not religious, this could explain the high levels of stress associated with their relatively low scores on ‘Health Management’ and ‘Physical Activities’. As for the junior students, they face enormous challenges, such as the need to adapt to new teaching and learning methods in tertiary education and to develop effective and meaningful relationships with peers, which may contribute to negative health-promoting lifestyles. Mirghafourvand et al.’s study [31] supported the view that social support, self-efficacy and mother’s occupation are predictors of a health-promoting lifestyle among adolescent girls. Apart from providing support to nursing students to determine their study and career goals and to find a purpose in life, nurse educators should teach students about how to expand their social networks and about various stress management techniques to increase their self-efficacies. These techniques include mindfulness-based stress reduction, progressive muscle relaxation, cognitive behavioural therapy, and so on [32]. It is only through using multiple strategies that nursing students can be empowered to manage their lifestyle and make a fair appraisal of their well-being.

Our results revealed no significant difference in SRH among the two groups of students. The previous literature review showed that suboptimal self-rated health is associated with unhealthy lifestyle behaviours, such as inadequate physical exercise and poor stress management, in young population groups. Since both groups of students showed no significant differences in health-promoting lifestyle, the findings lend further support for the view that a healthy lifestyle can influence a person’s perception of their own health. This concurs with the findings of Molarius et al. [33] to support the notion that poor self-rated health is independently related to both psychosocial as well as lifestyle factors among men and women.

Regarding the correlations in the subscale scores of the HPLP-IICR, our results showed a moderate positive relationship between ‘Health Management’ and ‘Spiritual Growth’ among the nursing students. The items for ‘Health Management’ include interpersonal relationships and stress management, while the items for ‘Spiritual Growth’ include holding out hope for the future, having opportunities to face new challenges, and receiving support from a group of people who care. The above are subjective evaluations of the degree to which an individual feels fulfilled in terms of needs, goals, and life satisfaction. There is evidence showing that adolescents are facing a great deal of anxiety, and that having someone, such as a friend or adult, to consult would alleviate their depression and increase their level of satisfaction with their life at school [34]. Hui concluded that having an increased ability to cope with stress and adversity will result in higher life satisfaction and better academic performance [35]. As ‘Health Management’ implies interpersonal relationships and stress management, if students are able to manage their time well, maintain fulfilling relationships with other people, and find the time to relax daily, this will tend to lead to better self-care and to better self-rated health. According to Saravia and Chau [36], manageability is a description of whether a person is capable of coping with demanding situations and has the resources to do so. Being able to relax and manage good interpersonal relationships has emotional meaning that leads to a subjective appraisal of health. Comprehensive and well-coordinated stress management programmes that include ways to identify coping strategies and cultivate resilience should be included in the undergraduate nursing programme to avoid threats to mental well-being and to enhance the students’ determination to face new challenges. Likewise, time management programmes, including the assignment of leisure time, would not only provide students with opportunities to relax and get along with others but also help them to participate in enjoyable activities that would promote well-being and fulfilment in their lives [37].

The finding of a moderate positive correlation between nutrition and physical activities is supported by earlier studies indicating that adolescents with an optimal Body Mass Index and good nutritional status are more active and spend less time on sedentary activities. Their healthy life habits include the regular consumption of fruit and dairy products and regular engagement in physical activities [38, 39]. Most tertiary institutions in Hong Kong do not require nursing students to participate in mandatory sports programmes as extra-curricular activities. Perhaps because of this, changes in attitude regarding the importance of physical exercise have not occurred among the nursing students, despite the instillation of theoretical knowledge on the subject during their studies. It is therefore necessary for educators to develop comprehensive, continuous, and inclusive physical education sessions despite their busy teaching schedule. The use of rewards or incentives for nursing students who demonstrate the initiative to participate in sports activities should be considered to promote lifestyle changes in tertiary institutions.

To further examine the predictors of SRH, the final model showed that the two variables with a significant direct effect on SRH were having a higher score in ‘Health Management’ and experiencing no recent family conflicts. Our results agreed with those of two recent studies conducted in Japan and Egypt on the relationship between work-family conflict and poor SRH [40, 41]. These studies revealed that men and women who experienced high work-family conflict tended to perceive their health status as poor. Another study, which examined the role played by the family environment of university students, indicated that non-cohesion, conflict, and control play crucial roles in the occurrence of depressive symptoms [42]. Strong and harmonious family ties are crucial factors in a student’s well-being. According to recent statistics [43], the number of divorces has increased continuously in Hong Kong, with the figure for 2016 being more than double that in 1991. Cross-border marriages between individuals from Hong Kong and mainland China made up 34.7% of registered marriages in Hong Kong in 2016, and have become a significant component of Hong Kong marriages [44]. Divorce, single and separate parenting, remarriage, and the formation of step-families are having pervasive effects on family relationships, resulting in temporary or permanent disruptions and leading to an increase in conflicts among family members [45]. These family conflicts and misunderstandings can be particularly painful and often affect the health of family members, particularly their emotional and psychological health. One study showed that family dinners play a significant role in adolescent development and emotional well-being. The frequency with which an individual has dinner with family members is positively related to life satisfaction and mental health [46]. When there is good bonding in the family, family meals can contribute to the development of fewer symptoms of depression in adolescents [47]. In working with adolescents with emotional problems, other than to provide the usual counselling services, adolescents could be encouraged to have family meals, as these are associated with psychological well-being and considered an effective approach to enhancing self-rated health. However, family dinners are of little benefit if parent-child relationships are not strong.

Despite its limitations, the present study provided information on the health-promoting behaviours and self-rated health of junior and senior year nursing students, and identified the predictors of self-rated health from demographic factors and subscales of the HPLP-IICR. Nursing education and clinical practice can undoubtedly increase the necessary health knowledge of nursing students, but may not change their attitudes and actual health-promoting behaviours. The correlations were determined between various dimensions of a health-promoting lifestyle, such as self-management and spiritual growth, nutrition, and physical activities. Students with a higher health management score and no family conflicts were more likely to give a positive appraisal of their health status. It is recommended that, through the use of multiple strategies, nursing students be empowered to manage their lifestyle and make a fair appraisal of their well-being.