the influence of a health education programme on healthy lifestyles and practices among university...

R E S E A R C H P A P E R

The influence of a health education programmeon healthy lifestyles and practices among

university studentsijn_1801 35..42

Fathieh A Abu-Moghli PhD RNAssociate Professor, Clinical Nursing Department, Director of Studies Department, University of Jordan, Amman, Jordan

Inaam A Khalaf PhD RNProfessor, Maternal Child Nursing Department, Director of Community Service Office, University of Jordan, Amman, Jordan

Farihan F Barghoti MDAssociate Professor, Family and Community Medicine Department, University of Jordan, Amman, Jordan

Accepted for publication May 2007

Abu-Moghli FA, Khalaf IA, Barghoti FF. International Journal of Nursing Practice 2010; 16: 35–42The influence of a health education programme on healthy lifestyles and practices among

university students

This study aimed at exploring the lifestyles of university students, the relationship between specific demographicalvariables and health practices and the role of training in improving these practices. An experimental and a comparisongroup were selected using the convenient sampling method. Two 5-day training programmes on healthy lifestyles wereconducted. Self-reported behaviours of both groups were assessed before and after the programme. The results reflectedslightly positive health practices related to the three behavioural categories with the type of diet being the highest andphysical activity being the lowest. No significant differences were reflected in relation to the selected variables. A positiveinfluence of training on improving health behaviours of university students related to the three behavioural categories wasobserved. Results suggest a similar course to be included as a university elective and students’ involvement in availableextra curricular activities be encouraged.

Key words: lifestyle, Jordan, nutritional habits, physical activity, university students.

INTRODUCTIONHealth is a dynamic process, which changes constantlythroughout life. Health denotes the quality of life involv-ing physical, social, emotional, intellectual and spiritualwell-being.1 One of the major potential challenges to

health is the rapid rise of non-communicable diseaseslinked by common preventable risk factors related tolifestyles.2

Health promotion continues to be sanctioned as thelong-term most cost-effective approach to the reductionof preventable health problems. Promoting healthy lif-estyles is a central element in attaining the goalsand objectives of Healthy People by the year 2010.3

Health-promoting lifestyles include many dimensionsCorrespondence: Fathieh A. Abu-Moghli, University of Jordan, Amman,Jordan. Email: [email protected]

International Journal of Nursing Practice 2010; 16: 35–42

doi:10.1111/j.1440-172X.2009.01801.x © 2010 Blackwell Publishing Asia Pty Ltd

such as physical activity, nutrition, stress manage-ment, health responsibility, interpersonal support andself-actualization.4

Improving physical activity and nutrition preventsdeadly chronic diseases and helps control their conse-quences in those who become ill. Nutrition and physicalactivity are key elements to reducing harm caused by heartdiseases, stroke and cancer, as well as diabetes. On theother hand, unhealthy behaviours are associated withcostly health consequences. Besides the detrimentalimpacts for individuals, families and communities is thefinancial burden of escalating health-care costs for chronicillnesses.5

Studies have indicated that health-related curriculahave led to significant changes in knowledge, attitudes andbehaviours of students in the middle and high school.6–10

At the university level, the importance of health courses inpromoting students’ health has been acknowledged,although the impact of such courses on students’ knowl-edge, attitudes and behaviours is still unclear.11–14 Conse-quently, the present study explores the healthy lifestylesof university students and the role of an educational pro-gramme in improving the students’ health practices. Theresults will provide information on how to best helpadults achieve and maintain healthy lifestyles and promotetheir health status.

ObjectivesThis study aims to:1. Assess university students’ current health practicesrelated to nutrition (type of diet, nutritional habits) andphysical activity.2. Identify the relationship between health practices andcertain demographic variables among university students.3. Evaluate the influence of an educational programme onimproving university students’ health practices.

Operational definitionsNutritional practices: the type of diet and nutritionalhabits indicated by the students as reflected by the scoresobtained on the study instrument.Physical activity: the physical practices reported bystudents as reflected by the scores obtained on the studyinstrument.

Literature reviewIn one of the reviewed studies, the lifestyles were assessedamong culturally varied students.15 The East European

students’ lifestyles were found to be less healthy thanWestern Europeans. East European students were lesslikely to be aware of the relationship between lifestylepractices and risk of developing cardiovascular diseases. Inanother study, gender differences in students’ healthhabits and motivation for a healthy lifestyle were investi-gated.16 The study results showed that female students hadhealthier habits related to alcohol consumption and nutri-tion but were more stressed. Male students showed a highlevel of overweight and obesity and were less interested innutrition advice and health-enhancing activities.However, a study conducted in Hong Kong indicated thathealth-promoting behaviours and psychosocial well-beingof university students did not differ significantly bygender, but male students scored better than female stu-dents on the physical exercise subscale.17

A study of the association between health-relatedbehaviours, social relationship and health status in latechildhood and adolescence indicated that in both genders,smoking, irregular breakfast eating and poor perceivedcurrent health were associated with persistent inactivity.18

The association between the practice of regular physicalexercise, the anthropometrical and physiological charac-teristics, and the dietary habits and the type of study(nursing vs. other disciplines) was also investigated.19

Regular physical exercise in nursing students was found tobe positively correlated with higher absolute and relativemaximal volume of oxygen and with lower diastolic bloodpressure. However, statistically significant differencesbetween the two groups in anthropometric indices werenot observed. Similarly, a descriptive cross-sectionalstudy was conducted to assess current awareness and prac-tice of health risk behaviours among Egyptian universitystudents.20 The main determinants of risky behaviourreported were being a male, of older age, having a highallowance and having no attention to danger.

The effect of health education on health-related behav-iours has been studied worldwide. At the school level, astudy was conducted to investigate the effect of a healtheducation programme on healthy lifestyles on promotingchild health in schools.21 A significant increase in students’knowledge of nutrition and healthy lifestyles as deter-mined by the scores obtained on a pre–post-test wasreported. At the university, the results of a pilot study toevaluate the effects of a healthy-lifestyle-promoting pro-gramme, taught as part of an undergraduate communityhealth nursing course, indicated a positive change in physi-cal fitness, exercise and nutrition among students.22

36 FA Abu-Moghli et al.

© 2010 Blackwell Publishing Asia Pty Ltd

Similarly, a study conducted in Taiwan indicated that acourse on health promotion for nursing students signi-ficantly increased students’ intent to adopt healthylifestyles.23 In Lebanon, a positive impact of a university-level ‘Health Awareness’ course on attitudes and behav-iours of undergraduates enrolled in the course wasreported. In addition, movement in a health promotiondirection along the stages of change was evident forsmoking, type of diet and exercise.24

The literature reviewed has confirmed the relationshipbetween the lifestyles and the health status of individuals.Moreover, it reflected that nurse educators are in an idealposition to develop and provide health promotion andillness prevention programmes, both for their ownnursing students and for a broader campus-wide studentpopulation. Yet, the degree of the impact of health edu-cation on university students’ knowledge, attitudes andbehaviours still needs to be clarified.

METHODDesign

This quasi-experimental study is designed to evaluatethe extent to which the participation in a health edu-cation programme influences students’ health-relatedbehaviours.

Setting and sampleThe target population of the study was undergraduatestudents enrolled in the various faculties at the Universityof Jordan. The University of Jordan is the oldest institu-tion of higher education in Jordan. The university popu-lation is mainly youth as the students’ age ranges from 18to 25 years.

The convenient sampling method was used to select thesample. An experimental group was formed throughposting announcements in all 18 faculties inviting studentsto participate in a workshop on healthy lifestyles. Regis-tration of students was performed at the CommunityService Office at the university. Students’ consent forparticipation in the study was solicited during registrationtime. The number of students who registered, attendedthe workshop and accepted to participate in the study was60 students. However, 46 of them (76.6%) completedthe questionnaire before and 2 months after the work-shop. For the comparison group, the students attendinganother educational programme offered by the Commu-nity Service Office (civic education) were approached(n = 100), of whom only 84 (84%) accepted to partici-

pate and completed the questionnaire before and 2months after the programme.

InstrumentA self-administered questionnaire to assess the attitudeand self-reported behaviours of students was developedby the researchers based on an extensive review of theliterature and an items pool prepared by the six healthprofessionals who conducted the programme. The ques-tionnaire is composed of two parts; part one includesselected demographic information and questions relatedto smoking habits, illnesses, regular medications takenand habits related to sports. Part two includes 25 descrip-tive statements of behaviours related to lifestyles groupedunder three categories: type of diet (nine items), nutri-tional habits (eight items) and physical activity (eightitems). A four-point scale—always, most of the time,rarely and never with values 4, 3, 2 and 1, respectively, isused to assess students’ responses to the statements ineach behavioural category.

The questionnaire was submitted to a jury of threenurse educators and two family physicians to assess valid-ity. A pilot study was conducted on a sample of students(n = 20), who were not included in the study; accordinglymodifications of the instrument and method were done.Internal consistency reliability (Cronbach alpha) estimateswere 0.71 for the type of diet, 0.70 for nutritional habitsand 0.79 for physical activity. The overall internal consis-tency reliability was 0.77.

Data collection methodAn official permission to conduct the study was obtainedfrom the university administration. Ethical approval wasobtained from two ethical committees: the ResearchCommittee at the Faculty of Nursing and the ResearchEthical Committee at the Deanship of Academic Researchat the University of Jordan. Both committees confirm tothe provisions of the Declaration of Helsinki in 1995 (asrevised in Edinburgh 2000).

Two 5-day educational programmes on healthy lif-estyles were planned and coordinated by the researchersand conducted by a group of faculty members (four nurseeducators and one community and one family physician).The daily sessions extended over an 8 h period each. Theprogramme was designed to help students make self-directed and autonomous health decisions. The contentwas related to the students’ daily life practices (i.e. eatingbreakfast, water intake per day, exercise and relaxation).

Healthy lifestyles 37


An interactive approach was used and students were ledthrough group discussions and role play to reflect on therelationship between health behaviour and health status.Various active teaching strategies and learning resourceswere used to enhance students’ understanding. A manualincluding all presented material was prepared by the edu-cators and distributed to all students in the experimentalgroup.

The questionnaire was distributed to students whoagreed to participate in the study before the beginning ofthe first session for both the experimental and comparisongroups. It was re-administered to the students in bothgroups during a meeting that was held 2 months after theend of the educational programme.

Data analysisStatistical analyses were performed using the statisticalsoftware package spss version 13 (SPSS Inc., Chicago, IL,USA). Scores of items within the same health style wereadded and mean score calculated for each respondent andthen for all respondents in the sample to create one vari-able measuring each style. Descriptive statistics (frequen-cies and percentages and SD) and t-test were used tomeasure significant differences between the mean scoresfor each of the three health styles according to students’gender and faculty type. The pretest and post-test scoresrelated to the type of diet and nutritional habits passed theKolmogorov–Smirnov normality test (P > 0.05), whereaspretest and post-test scores related to physical activity didnot pass the Kolmogorov–Smirnov normality test exceptafter logarithmic transformation.

Body mass index (BMI) was calculated by determiningthe relationship between weight and height. A BMI lessthan 20 is considered to be low, a BMI of 20–25 is con-sidered to be normal and a BMI of greater than 25 isconsidered to be high.

Analysis of variance (anova) was used to test significantdifferences in the pretest mean scores of students in thethree BMI categories followed by Student–Newman–Keuls test for multiple comparisons. Analysis of covari-ance (ancova) was used to test for differences in post-testscores between the two groups (comparison, experimen-tal) and the pretest scores were used as covariate in thecomparison between the two groups. Paired analysis formeans was conducted for pretest scores as compared withpost-test scores to indicate significant improvement inbehaviours of the experimental group related to the threecategories (type of diet, nutritional habits and physicalactivity). In all of the statistical tests, the null hypothesiswas rejected (P � 0.05).

RESULTSTable 1 shows the characteristics of both the experimentaland comparison groups. It shows that 23.8% of the stu-dents were male and 76.2% were female. Out of the totalsample, 34.1% were enrolled at humanity faculties and64.9% were in science faculties. The majority of the stu-dents (70.7%) have a normal BMI whereas 11.2% haveless than the normal BMI and 18.1% have a BMI abovethan the normal.

Other background information indicates that the twogroups were very similar. No significant differences were

Table 1 Characteristic of the sample illustrated by frequencies and percentages

Variable Group Total (n = 8130)

N (%)

Comparison (n = 84)

N (%)

Experimental (n = 846)

N (%)

Gender Male 18 (21.4) 13 (28.3) 31 (23.8)

Female 66 (78.6) 33 (71.7) 99 (76.2)

Faculty Humanity 21 (25.3) 24 (52.2) 45 (34.1)

Science 62 (74.7) 22 (47.8) 84 (64.9)

Body mass index Lower 10 (13.7) 3 (07.0) 13 (11.2)

Normal 47 (64.4) 35 (81.4) 82 (70.7)

Upper 16 (21.9) 5 (11.6) 21 (18.1)



indicated except for the smoking behaviour as 4.8% of thecomparison group and 15.2% of the experimental groupwere smokers (c2 = 4.19). Almost all the study partici-pants (98.8% and 97.5% of the comparison and experi-mental groups, respectively) believe that practising sportsis healthy. However, 4.8% of the comparison and 8.7% ofthe experimental group are members in a sport club. Only9.5% and 10.9% of the comparison and experimentalgroups, respectively, indicated that they complain ofhealth problems and 11.9% and 6.7% of the comparisonand experimental groups, respectively, take prescribedmedications.

Table 2 shows that the mean scores of the two groupson the pretest reflect slightly positive health practicesrelated to the three behavioural categories (Mean = 2.42,SD = 0.35). The highest score was related to the type ofdiet (Mean = 2.61, SD = 0.43) followed by nutritionalhabits (Mean = 2.60, SD = 0.47) and the lowest was forthe physical activity (Mean = 2.04, SD = 0.59).

In regard to the relationship between practices in thethree categories (type of diet, nutritional habits and physi-cal activity) and gender and type of faculty (humanities or

scientific), the results of t-test show no significant differ-ences at P = 0.05 level or less for any of the health prac-tices (t-test values ranged between 0.01 and 3.92).

anova test results reflected significant differencesbetween BMI (low, normal and high) and health practicesrelated to the type of diet (F = 3.92, P = 0.02). TheStudent–Newman–Keuls test shows that students whohave a low BMI have a higher mean scores for practicesrelated to the type of diet (Mean = 2.93, SD = 0.35)compared with students who have a normal BMI(Mean = 2.58, SD = 0.43), and students who have ahigher than normal BMI (Mean = 2.61, SD = 0.4)(Table 2). Students with low BMI scored higher on nutri-tional habits than those who have normal and high BMI(2.64, 2.59, 2.48, respectively); these differences were,however, not significant. On the other hand, students’BMI did not seem to be related to physical activity asstudents with high BMI scored higher on physical activityfollowed by students with normal and finally those withlow BMI.

To evaluate the influence of the educational pro-gramme on improving health behaviours of university

Table 2 Pretest mean scores, standard deviation (SD) and t-test for both the experimental and comparison groups

Variable Lifestyle

Physical activity Type of diet Nutritional habit Total

Mean SD 95% CI Mean SD 95% CI Mean SD 95% CI Mean SD 95% CI

Gender Male (n = 31) 2.12 0.68 1.87–2.37 2.65 0.38 2.51–2.79 2.51 0.45 2.34–2.68 2.44 0.39 2.29–2.58

Female (n = 99) 2.02 0.55 1.91–2.13 2.59 0.44 2.50–2.68 2.62 0.48 2.52–2.72 2.41 0.34 2.35–2.48

t-test 0.70 0.67 1.08 0.29

P-value 0.48 0.5 0.28 0.77

Faculty Humanities

(n = 45)

1.95 0.51 1.80–2.11 2.53 0.42 2.41–2.66 2.61 0.49 2.46–2.76 2.37 0.36 2.26–2.48

Science (n = 84) 2.09 0.62 1.96–2.23 2.64 0.43 2.55–2.74 2.58 0.46 2.48–2.68 2.45 0.34 2.37–2.52

t-test 1.14 1.36 0.36 1.17

P value 0.25 0.17 0.72 0.25

Body

mass

index

Lower (n = 13) 2.03 0.6 1.67–2.40 2.93 0.35 2.71–3.14 2.64 0.62 2.26–3.02 2.55 0.37 2.33–2.77

Normal (n = 82) 2.05 0.55 1.93–2.17 2.58 0.43 2.48–2.67 2.59 0.45 2.49–2.69 2.41 0.34 2.34–2.49

Upper (n = 21) 2.08 0.72 1.75–2.42 2.61 0.4 2.43–2.79 2.48 0.48 2.26–2.70 2.4 0.4 2.22–2.58

F-test 0.01 3.92 0.59 0.9

P-value 0.98 0.02 0.55 0.41

CI, confidence interval.



students related to the three categories, and to test thedifferences between the comparison and experimentalgroups, ancova test was applied taking into considerationthe value of pretests results. The results as reflected inTable 3 show a significant difference in relation to type ofdiet (F = 11.52, P = 0.00) as the experimental group hadhigher mean score (2.82) than the comparison group(2.65). A significant difference between the experimentaland the comparison groups was also reflected in relationto nutritional habits (F = 22.56, P = 0.00) where theexperimental group scored higher (Mean = 2.81) thanthe comparison group (Mean = 2.57). No significant dif-ferences in health behaviours related to physical activitywere recorded at P = 0.05 level (F = 0.0).

DISCUSSIONThis research explores the healthy lifestyles of universitystudents and the role of education in improving theirhealth practices. The percentages of male and female stu-dents in the sample selected reflect the percentage of bothmale and female students enrolled at the university at thetime of the study. Moreover, although the non-probability sampling procedure was used for selecting thesample, yet, no significant differences in the backgroundinformation (smoking behaviour, beliefs about exercisesand health status) of the two groups were noted, whichindicates that the sample is representative of the universitystudents.

The results of the present study reflected slightly posi-tive health practices related to the three behavioural cat-

egories with the type of diet being the highest and physicalactivity being the lowest. These results are congruentwith those of a study conducted by Lee and Loke17 whoreported that less than half of the university students atefruits and vegetables every day and only a few wereengaged in some form of physical activity or exercisedregularly.

Inconsistency regarding the relationship betweengender and nutritional habits and physical activity wasreflected in the literature. Although, in some studies,female students were reported to have healthier habitsrelated to nutrition, male students were found to be morelikely to exercise regularly.16,25 Yet, other studiesreflected that students’ scores on nutritional habits did notdiffer significantly by gender, and that male studentsscored better than female students on physical exercise.18

The results of the present study, however, indicated nosignificant relationship between students’ gender or typeof school (sciences or humanities) and the students’ habitsrelated to either nutrition or physical activity.

The results of the present study reflected significantdifferences between BMI and health practices related tothe type of diet. Students who have low BMI have highermean scores for practices related to the type of diet com-pared with the students who have a normal BMI andstudents who have high BMI. Students with lower BMIscored higher on nutritional habits followed by the normaland the high BMI. These differences were however notsignificant. On the other hand, students’ BMI did notseem to be related to physical activity as students with

Table 3 Means and standard deviation (SD) for pretest and post-test and ancova test between groups

Variable Comparison Experimental ancova Observed

power

Mean SD 95% CI Mean SD 95% CI F-test P-value

Physical activity Pretest 2.02 0.64 1.88–2.16 2.08 0.48 1.94–2.23 0.00 0.99 0.05

Post-test 2.02 0.63 1.88–2.50 2.30 0.59 2.12–2.48

Type of diet Pretest 2.65 0.42 2.56–2.74 2.51 0.43 2.38–2.64 11.52 0.00 0.92

Post-test 2.65 0.42 2.56–2.74 2.82 0.46 2.69–2.96

Nutritional habits Pretest 2.57 0.49 2.47–2.68 2.63 0.44 2.50–2.76 22.56 0.00 0.99

Post-test 2.57 0.49 2.46–2.68 2.81 0.43 2.68–2.94

Total Pretest 2.42 0.37 2.35–2.50 2.41 0.32 2.31–2.51 1.70 0.19 0.25

Post-test 2.42 0.36 2.34–2.50 2.65 0.38 2.44–2.57

CI, confidence interval.



high BMI scored higher on physical activity followed bystudents with normal BMI and finally students with lowBMI. Steptoe et al. indicated that, in their study, nosimple association between BMI and physical exercise wasobserved.15 Among women, BMI was not related to physi-cal exercise. Among men, a curvilinear associationemerged with higher levels of engagement among indi-viduals with a BMI in the average range.

The results of the present study indicated a positiveinfluence of education on improving health behaviours ofuniversity students related to the three behavioural cat-egories. The difference in the scores of the experimentaland control groups was significant in relation to type ofdiet and nutritional habits but was not significant in rela-tion to physical activity. This result supports the results ofmany of the reviewed studies21–24 and might be attributedto that it is easier to note the direct influence on behav-iours that do not require much effort such as nutrition vs.behaviours related to physical activity. However, theresults of a study conducted in Beijing reflected contra-dictory results.26 Interestingly, the Beijing study indicateda significant decrease in the participation in physical exer-cise and a significantly greater intake of high-salt foods.

In conclusion, this study provides preliminary supportfor the impact of the programme on students’ knowledgeand behaviour. One of the main factors considered ascontributing to the success of the programme is that stu-dents participated voluntarily. However, several factorslimit the generalization of the results. Self-selection toparticipate in the programme might indicate that respon-dents in the experimental group are already sensitized andinterested and might be more receptive to health messagestransmitted than other university students. Moreover, acausal interpretation of the association between educationand physical activity cannot be made from this studybecause of the relatively short period between the pre-and post-tests. Consequently, a follow up on studentsmight better predict changes in physical exercise over a12-month period. Moreover, to confirm the real effect ofhealth education, it is recommended that a similar course,taught by health-care professionals specifically nurse edu-cators, be included as a university elective that is subjectto pre- and post-testing of knowledge and self-reportedbehaviours. In addition, students should be encouraged tojoin the extra curricular activities such as sports and healthawareness campaigns, which are already available at theuniversity campus on continuous basis to enhance theirattitudes and practices of healthy lifestyles.

ACKNOWLEDGEMENTSWe are grateful to the Deanship for ScientificResearch—University of Jordan—and the UnitedNations Population Fund (UNFPA) for funding this study.Our gratitude extends to the university students, whoseparticipation made this study possible, and to many otherswho contributed to this study.

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