Introduction

Attitudes and health behaviors have been recognized as determinants of the health status and well-being of individuals ¹. For this reason, the absence of policies and actions towards health promotion can contribute to the increase in the global burden of disease around the world. Chronic diseases are consequences of the predominance of unhealthy lifestyles and behavior patterns in the population ¹.

College students comprise a significant share of the population and, since they are in a transition process between adolescence and adulthood, they are considered individuals in a situation of psychosocial vulnerability. The period of college life is considered a critical stage of the life cycle, even though it is recognized as transitory and dynamic, and may favor the adoption of risk behaviors that affect students' physical, mental, social, and economic health ². Therefore, the "current lifestyle" adopted by students, especially regarding eating habits and the practice of regular physical activity, could determine their health conditions ³.

The changes experienced in college life regarding academic routines and the practice of healthy behaviors are of special interest to public health. Therefore, studies that seek to examine the physical and mental health of students are necessary to support the development of public health policies, especially due to the high rates of health risk behaviors observed in the academic context, such as uncontrolled body weight, decreased physical activity, and increased use of psychoactive substances ².

In recent decades, works with different methodological approaches have been conducted in order to study college students' health, with a greater focus on the consumption of psychoactive substances. In Brazil, almost half of the university population (48.7%) has used psychoactive substances (excluding alcohol and tobacco products) at some point, with 86.2% reporting alcohol use and 46.7% tobacco use ⁴. Alcohol consumption is a frequent practice among college students in several regions around the world -often seen as a mediator of social relationships- that can cause serious consequences in the biopsychosocial sphere in the short and long term ⁵.

Among Brazilian nursing students, 84.4% have consumed psychoactive substances, 57.2% have consumed alcoholic beverages, and 26.7% have associated alcohol consumption with another illicit substance ⁶. A study conducted with 260 nursing students in Mexico showed that 64.6% had drunk at least once in their lifetime ⁷. In addition, a study that investigated past-year substance use among 4,033 student members of the United States National Student Nurses' Association (NSNA) showed that 61% of them reported binge drinking, 18% marijuana use, 5% illegal drugs use other than marijuana, and 10% reported the use of non-prescription drugs ⁸.

Health students, such as future nursing professionals, are considered a specific population group of strategic society development since they will produce and share systematized knowledge in the community ⁶. These are professionals responsible for applying their skills and competencies with emphasis on healthy attitudes and behaviors within the population ².

The easy access to psychoactive substances among college students and the attitudes adopted by this social segment often go in the opposite direction to the desired adoption of healthy behaviors, which makes the need to study these variables in different populations and regions imminent. Most studies available to date have assessed health behaviors in isolation ^2,4,6, with emphasis only on the prevalence of substance use. Therefore, no studies on health behaviors addressing the combination of nutritional factors, physical activity, sexual behaviors, self-care, depression, psychoactive substance use, and care for the environment among nursing students were identified.

With the above in mind, and considering the relevance of the topic and the need to provide consistent evidence, this study sought to evaluate the association between attitudes, health behaviors, and tobacco and alcohol use among nursing students.

Materials and methods

This is an exploratory, descriptive, and cross-sectional study conducted at a higher education institution in Vale do Ribeira, in the southern coast of the State of São Paulo (Brazil). The study was approved by the Research Ethics Committee of União das Instituições de Serviços, Ensino e Pesquisa LTDA (Protocol No. 1.589.998, CAAE: 56601316.4.0000.5490). All steps were conducted in accordance with the Resolution No. 466/2012 of the National Health Council of Brazil ⁹, responsible for regulating research on human beings. All the participants were informed about the research objectives and signed the informed consent form (ICF).

The sample size was calculated based on the number of students enrolled in all years of the undergraduate nursing course (N = 261). For the design, we considered 95% reliability and 2% precision. According to the sample calculation, the minimum estimated number was 156 students. To participate in the study, the eligibility criteria were defined as follows: being regularly enrolled in the course, of all genders, over 18 years, and present in class at the time of data collection. At the end of data collection, a total of 182 students participated in the study, representing 69.7% of the studied population.

Data collection occurred from August to November 2016, in the classroom, with the approval of the course coordinator. The methods used were submitted to comprehension evaluation through a pilot test with 10 students, who were not part of the final sample. The time required to complete the test was approximately 20 minutes.

At the time of data collection, the students who were present in the classroom were oriented as to the objectives of the study and the completion of the questionnaire after their acceptance by signing the ICF. The data collection instrument was made up of five parts:

Results

Of the 182 participants, 137 (75.3%) were female, without a partner (105; 60.9%), with a mean age of 26.7 (SD = 8.0) years and a range of 17 to 54 years. More than half of the participants worked during the day (126; 69.2%), 86 (47.3%) considered their health status at that time as stable, and 82 (45.1%) indicated improvement needs. Among participants, 175 (96.2%) believed that the care for their health could be reflected in the assistance given to the patient. Regarding the use of psychoactive substances, almost half of the students (90; 49.5%) used alcoholic beverages. As for the experimental use of illicit drugs, 19 (10.4%) reported this situation at some point in their lives and 10 (5.5%) had consumed tobacco products.

More than half of the students were classified with a stable level regarding health habits and behaviors, 97 (53.3%) practiced physical activities, 99 (54.9%) took care of nutritional aspects, 103 (57.1%) were attentive to self-care with health, 101 (55.5%) with the environment, 95 (52.7%) with sexual behaviors, 97 (53.8%) with safe transportation, and 95 (52.7%) with psychoactive substance use.

These behaviors were distinct among students based on gender, age, marital status, and work, with statistically significant values (Table 1). There were no statistical differences in the association analyses between sociodemographic characteristics with the health self-care category, as well as with the transportation, environment, and substance use categories (AHBO).

Table 1 Sociodemographic characteristics, attitudes, and health behaviors among nursing students, Registro, São Paulo, Brazil, 2016 (N = 182) 

Note: a: Fisher's exact test; b: Chi-square test. *p ≤ 0.05. HA: healthy; PR: precarious. One student did not answer the questionnaire completely, so there are variables with 181 answered cases.

Source: authors.

Male students differed in frequent practice and care regarding physical activities (men 66.7% suitable versus women 51.1% precarious) when compared to women. However, for sexual-related care behaviors (men 61.4% precarious versus women 57.7% suitable, p = 0.028) and the use of drugs and similar (men 60.0% precarious versus women 56.9% suitable, p = 0.048), men showed higher percentages of precarious behaviors when compared to women, with statistically significant values.

The age group was associated with physical activity practice and nutritional care, in which 78.8% of younger students (17-19 years) were classified with proper physical activity practices and 57.4% of the participants aged 30-39 and 60% aged > 40 were more sedentary (p = 0.008). As for nutritional care behaviors, 69.7% of the youngest students had poor care, while all 15 students aged over 40 years were properly nourished (p ≤ 0.001).

Marital status was associated with physical activity (single 67.6% suitable versus with partner 69% precarious, p < 0.001), nutrition (with partner 73.2% suitable versus single 56.8% precarious, p < 0.001), and sexual behavior (with partner 63.4% suitable versus single 53.86% precarious, p = 0.025), with statistically significant differences.

Finally, being currently working was associated only with the practice of physical activities, that is, students who did not work (66.1%) practiced properly physical activities when compared to 52.4% who worked and were sedentary (p = 0.021).

Traffic safety behavior (AHBO) was not associated with substance use in this study. Almost all smoking (active) students had poor nutrition care (90.9%). One-third of students who drank at a high-risk level (AUDIT-C) showed precarious health care (30.9%) and almost all individuals with a moderate or very high level of nicotine dependence (FTND) (83.3%) also showed this trend. Environmental care was more precarious among students who drank at high risk levels (AUDIT-C) (56.7%, p = 0.009), binge-drank (56.8%, p < 0.001), and had consumed alcoholic beverages in the past year (54.9%, %, p < 0.001), with statistically significant differences. Sexual behaviors were associated only among students who experimented with illicit drug use (p < 0.001) (Table 2).

Table 2 Use of alcohol, tobacco, illicit drugs, attitudes and health behaviors, Registro, São Paulo, Brazil, 2016 (N = 182) 

Note: Fisher's Exact Test. *p ≤ 0.05. HA: healthy; PR: precarious. One student did not answer the questionnaire completely, so there are variables with 181 answered cases.

Source: authors.

The behaviors related to physical activities, self-care with health, sexual behaviors, and use of drugs and similar (AHBO) were not associated with health perceptions and symptoms suggestive of depression (PHQ-2). Students who viewed their current health as precarious (85.7%) or in need of improvement (48.8%) showed poor nutritional care. Less than half of the students with precarious sexual behaviors considered that health care is reflected in the care provided. Approximately one-third of those with symptoms suggestive of depression (n = 52) showed appropriate traffic safety behaviors (32.7%, p = 0.021) (AHBO) (Table 3).

Table 3 Perceptions about health, suggestive symptoms of depression, and health habits and behaviors, Registro, São Paulo, Brazil, 2016 (N = 182) 

Note: Fisher's Exact Test. *p ≤ 0.05. HA: healthy; PR: Precarious. One student did not answer the questionnaire completely, so there are variables with 181 answered cases.

Source: authors.

Discussion

In the present study, the use of alcoholic beverages, illicit drugs and tobacco was associated with poor health behavior among nursing students. Working was associated with sedentary behaviors and single students showed poorer nutritional and sexual health behaviors when compared to those living with a partner. Furthermore, in male individuals, there was also greater precariousness in sexual health behaviors and in the consumption of drugs and similar when compared to women.

These results corroborate the evidence available in the international literature stating that socio-demographic factors such as age, income, gender, and/or working conditions tend to influence people's lifestyle ^16,17. Although, students know the importance of a "healthy lifestyle," the adoption of these behaviors represents a challenge in higher education as students are not always encouraged or have the conditions to promote self-care ³.

The precarious lifestyle adopted can increase the risks for the emergence of chronic non-communicable diseases, which can often be preventable ¹. Moreover, the lasting behavior of an unhealthy lifestyle may endure in future generations ¹⁸. Studies looking at lifestyle among college students have seen a slight increase in recent decades ^16,17. However, strategies to analyze the numerous behaviors that cause health risks using standardized tools are still limited, which inhibits the potential for discussion and generalization of the results. In Brazil, few studies have evaluated the behavior and health habits adopted by nursing students ⁶.

In this research, although male students practice more physical activities than female students, the results show that in other areas, such as sexual behavior and use of drugs and the like, this care becomes precarious. Gender is one of the most important factors associated with health risk behaviors ¹⁹. Evidence suggests that women practice less physical activity than men (¹⁶, 17), which may be linked to the overload of other daily activities, resulting from the double workday and excessive personal attributions.

The insufficient level of physical activity reported by women increases the chances of being overweight ²⁰ and represents a potential risk for physical and mental health problems ²¹. Since nursing is a profession with a predominant female presence, it is essential to seek strategies and intervention programs that favor the regular practice of physical activity.

As for male individuals, there is evidence that men are at greater risk than women regarding health behaviors ¹⁹ due to greater exposure to health risk situations linked to substance abuse, involvement in fights, and firearm use ¹⁹. Men are also more exposed to frequent sexual partner switching and unprotected sex ²². In the younger population, such behaviors are even more frequent. Therefore, the context surrounding behavior and inappropriate health habits should be analyzed considering the differences between genders. This can be explained by the multiple working hours of women (working outside home and assuming the role of mother, wife and performing household activities) as a contributing factor to reducing the time spent on physical activity ²³, and by the male-related risk behaviors mentioned above.

It is noteworthy that the age group was also a determining factor for the type of behavior and health habits. Although younger students were more physically active, the same trend was not identified regarding nutritional aspects. On the other hand, the opposite is also true, that is, the older the students are, the better they care for their nutrition and the less they practice physical activity. Regardless of age, regular physical activity and the adoption of healthy eating habits should undoubtedly be permanent behaviors in the lives of men. It is significant that the adoption of these practices represents a protective factor against numerous non-communicable chronic diseases and premature death ¹⁶. However, a growing pattern of physical inactivity and poor diet since childhood is observed in the contemporary world, factors that represent a serious public health problem ²¹.

Single students and those who did not work showed greater adequacy in physical activity practice. On the other hand, those who lived with a partner showed more appropriate nutritional and sexual behavior. Entering higher education allows contact with new experiences and often the adoption of unhealthy routines. Although the practice of physical activity is common among young adults, this behavior tends to decline over the years ²⁴.

Still related to the precariousness of health behaviors, the sexual experiences among college students stand out in our findings. Despite being inserted in a high level education environment, the behaviors and habits associated with avoiding the exchange of partners and the use of condoms in sexual relations are often unsatisfactory ²⁵. These behaviors increase a student's vulnerability to sexually transmitted infections (STIS). Therefore, being in a stable relationship and having the support of a partner can increase protection against unfavorable health outcomes ¹⁷.

Another finding of this study refers to the consumption of psychoactive substances and the domains of the AHBO. For alcohol consumption in different patterns and levels (last year, at-risk level, and binge drinking) the most affected domains were: physical activity, self-care for health, and the environment. We further noted that approximately half of the students had a low commitment to self-care, which therefore supports the hypothesis that alcohol consumption in different patterns tends toward poor impairment in several health behaviors, with a progressive evolution between frequency/dose and poor self-care ^26,17. Improvement in health outcomes depends not only on changing one or two lifestyle habits but on changing multiple health behaviors simultaneously ²⁷.

Additionally, it was identified that students who were active smokers or had a moderate or very high level of nicotine dependence (FTND) showed inferior performance in nutrition and self-care. It is estimated that low rates of fruit and vegetable consumption and low levels of engagement in physical activity, along with high levels of tobacco consumption, have been responsible for two-thirds of cardiovascular disease, cancer, and the mortality associated with other causes ²⁸. Although knowledge about what constitutes a balanced diet is widespread in the nursing course ²⁷, the difficulty of following a routine for healthy cooking and eating practices -associated with exposure to academic stress- and the growing trend of consuming quick snacks represent challenges to be overcome ²⁹.

Students who had used illicit drugs experimentally showed impaired sexual behaviors. This finding, in particular, reinforces data available in the literature that point to the low commitment to health care by individuals using psychoactive substances ³⁰. Furthermore, STIS and unintended pregnancy often result from the use of psychoactive substances, especially illicit ones ^30,31, as they interfere with judgment and decision-making. The association of both behaviors can result in damage to the student's health and undermine the efficient performance in the academic routine in the nursing course.

In addition to physical health, mental health also represents a key factor in the behaviors and health habits that will be adopted by students. In this work, negative perceptions about self-care and mental health were associated with poor health behaviors linked to the nutrition and traffic safety domains (AHBO). The perception of current health status can be characterized as negative or positive. In this sense, factors such as stress, insufficient sleep, sedentary lifestyle, and unfavorable social environments can result in a negative perception toward health. On the other hand, the positive perception is associated with increased quality of life and general well-being of the individual ³². In the present study, more than half of the nursing students worked during the day, which can be seen as a risk factor for increased activity overload, reduced sleep, reduced physical activity, and, consequently, a negative health perception.

Although universities know that the academic calendar produces peaks in students' anguish and afflictions, no counterbalancing measures are systematically implemented to promote mental health care ¹⁶, especially in private institutions, for financial reasons. Therefore, it is necessary to rethink the assistance offered to students during the academic trajectory, since performing activities that promote physical and mental well-being can result in better academic and professional performance ³³.

Brazilian universities house a large number of students, especially as a result of the huge expansion of the student body that has occurred in recent decades. Hence, public health monitoring systems and interventions should be part of the structure and services offered to students. With more than eight million students entering higher education in Brazil ³⁴, universities should be healthy environments and spaces for the expansion of health promotion activities.

In this scenario, it is essential to rethink how students receive academic assistance during graduation since, as provided in the Nursing Curriculum Guidelines, one of the specific skills to be developed during training involves "caring for one's own physical and mental health and seeking their well-being as a citizen and as a nurse" (³⁵, p. 3). Planning activities aimed at promoting healthy lifestyles in nursing students is essential to reduce behavioral patterns that are unfavorable to quality of life and stimulate biopsychosocial well-being.

Considering this is cross-sectional research, the results of this study do not allow us to state a causal relationship. Therefore, future studies with different methodological designs, including prospective ones, are necessary. The use of different methodologies will enable the analysis of the relationship between healthy habits and behaviors and the use of psychoactive substances. In addition, our findings should be evaluated with caution because they involve a peculiar sample of nursing students from a Brazilian region, which may not reflect the reality of other students.

The strengths of this study include the use of a robust methodology and the analysis of the relationship between health behaviors and the use of psychoactive substances through the use of standardized tools (AUDIT-C, FTND, AHBO, and PHQ-2) to measure the studied variables, which enables comparisons with other works. In the field of nursing science, the main contribution of the evidence produced by this study is the unprecedented detailing of the behavior and health habits of a previously unexplored population. Thus, the data may be useful in planning monitoring actions and interventions directed at the development of healthy lifestyles among nursing students, which contributes to the panoramic view involving different locations.

Conclusions

Nursing students reported appropriate health habits and behaviors for physical activity, nutrition, self-care, environment, sexual behavior, and safe transportation. However, the use of alcoholic beverages, illicit drugs and tobacco were also identified in the studied population, being associated with poor health habits.

The evidence from this study provides subsidies for planning interventions aimed at preventing the use of psychoactive substances and promoting a healthy lifestyle, which can be useful for reducing health problems in nursing students and future nursing professionals.