Health behaviour is a basis for human being’s health and health promotion is a global focus area of the health policy. The rising prevalence of lifestyle related diseases and aging population highlight the need to add knowledge of health behaviour and activities in health promotion. Nursing students are role models, health educators and they are going to motivate the clients and patients to healthy lifestyle and health behaviour. In this blog post, we focus on the comparison of health behaviour of nursing students in China, Japan, Sri Lanka and Finland. How do they feel about their own lifestyle choices?
Factors and barriers of healthy lifestyle
Students experience studying at university stressful and it can lead to unhealthy lifestyle. Also in nursing education the practical training in hospitals is experienced to be stressful. In the study of Thwaite et al (1) nursing students named the factors of healthy lifestyle to be
- eating well
- regular physical activity
- limiting alcohol, nicotine and caffeine use
- good sleep
- stress management
- social interaction and support.
They named the barriers of healthy lifestyle on individual level to be lack of motivation, exiting bad habits and lack of knowledge. The environmental barriers were identified to be lack of time, finances, limited access to healthy food and physical activities. On psychosocial level, the barriers were competing priorities, increasing study load, lack of social interaction and support, compassion fatigue and sift work. Students find it difficult to stick to healthy life style.
This blog post is based on the study, where the aim was to produce knowledge in health behavior and self-rated health of the nursing students. The study was part of the joint project: Health status, health behavior, health counselling and vocation among nursing students in Finland, China, Japan, and Sri Lanka – Comparison of nursing students in four countries. The results of the study related to motivation are described in blogpost (2).
Study about health behaviour of nursing students
Health promotion and health behaviour are the key content of nursing education (3, 4, 5 and 6). Healthy students have the strength to complete their studies and they will be healthy nurses, who have the strength to commit to the challenging nursing profession (7).
The purpose of the study was to describe nursing students´ health behavior and the differences between the participating countries (Finland, China, Japan and Sri Lanka). The study was implemented as a quantitative questionnaire study.
The themes of the questionnaire were
- Health and life situation
- Health services and counselling
- Social support
We also asked some background information, such as
- Country of home university
- Marital status
- Living with family
- Multicultural family background
- Basic education
- Semesters studied so far
Differences in nursing students` health behavior
On average, students’ health and life situation were good in all the four countries in this study. Statistically very significant differences were seen in physical health, economic situation, study success, and work situation. Statistically significant difference was in students’ experiences of social relations and almost statistically significant difference was in students’ experiences of mental health. Students’ motivation in nursing education was in general good; nevertheless, the differences between different countries were statistically very significant. In Finland, the students’ motivation was higher than in the other countries.
Not using alcohol, but spending time in social media
When inspecting the differences of the students’ from different countries, it can be seen that students from Finland used alcohol more often than students from other countries and they also smoked more often than others. Nutrition and dietary habits of Chinese students have changed to become healthier than in the other countries. In weight management, the biggest change had taken place in Sri Lanka. Students did physical exercise more often in China than in the other countries. All students used a lot of time in social media, but the students in Sri Lanka spent the most time in social media compared to others.
Good mental and physical health – but lack of support from professors
Health and life situation was evaluated by students´ own assessment of their physical and mental health, economic situation, study situation, work situation and relationship situation.
When inspecting the differences between four countries, the students from Japan assessed their physical health as best and the Chinese students assessed their mental health to be better than students in other countries. The economic situation was assessed to be the best by the students in Sri Lanka. The Finnish students assessed their study situation and work situation to be better than students from the other countries. In addition, the human relationships were assessed to be better in Finland than in other countries. In addition, Finnish students assessed their health and life situation a bit better than students from other countries.
Students experiences of the use of health services and councelling
Use of health services and counselling was investigated by asking the students’ experiences of the use of health services and health counselling.
When inspecting the differences between four countries, the following results were found. In Finland and Sri Lanka, students assess health services and counselling to be better than in China and Japan. Students’ experiences of use of the health services and health counselling were good on average but in Japan, students’ experiences were worse than in other countries.
Data collection from Japan, China, Sri Lanka and Finland
Data were collected through an e-form in 2018 in Japan (N=193), China (N=200), Sri Lanka (N=200) and Finland (N=202), in total N=795 (668 female and 127 male students answered the questionnaire). The age of the students were between
- 18-22 years (64%, n=508)
- 23-27 years (27%, n=215)
- 28-32 years (5%, n=38)
- 33 years or more 4 % of the students (n=35)
E-form was modified from the questionnaire based on Dr Anita Näslindh-Ylispangar doctoral dissertation (8) to focus on health behaviour and self-rated health status, and it was modified in co-operation with all participating four countries representatives responding to the differences in cultural issues. The study was conducted in accordance with ethical principles of research (9). All participants were informed about all aspects of the study and confidentiality of data before the data collection. Answering to the questionnaire was voluntary and the data was collected without identification of person. (10)
Comparison of background of the nursing students and reflections by experts in each country are described in more detailed in the edited research blog of Metropolia University of Applied Sciences “Tikissä” (11).
Lessons learned from this study
According to study results, there were significant differences between the countries. In Finland, nursing students were older than in the other three countries and many of them worked during the studies. Also in Japan, many Japanese nursing college students worked part-time because of their economic conditions.
The partners from four countries designed the questionnaire together. However, there might be cultural differences in what way the students answered to the different questions. It is not sure, if the students answered honestly to the questions related to the use of alcohol and smoking. In some countries, it is not considered culturally appropriate to drink or smoke as a nursing student. In Finland, the students were significantly older than the students in other countries were and the use of alcohol is culturally more acceptable.
Some of the differences may be related to cultural issues. In the questions related to life style of students, the following differences were noted: The students in Finland used alcohol more often than the students in other countries. For example, in Japan, under-aged (persons under the age of 20) drinking and smoking is prohibited by law. In China, the students had better dietary habits and they did more physical exercises than the students in Finland, Japan and Sri Lanka. However, the students in Sri Lanka spent the most time in social media and they had the most changes in weight management. An open question remains, what is the correlation between the time spent in social media and lack of physical exercise. In addition, what is the correlation between online studies and physical exercise and time used in social media? According to the study, the use of internet and social media was huge.
Nutrition and exercise plays a significant role in China and Japan
According to the Chinese partner, confidence in Traditional Chinese Medicine (TCM) has been boosted in China. Theories in health preserving are also an important part of TCM, as they are more comprehensible to ordinary Chinese people than modern nutrition theories. Nursing students, who are deeply influenced by TCM health practices from childhood, learn modern health science theories and are encouraged to compare them to their daily practice. As a result, students actively adjust their dietary habits and therefore feel more satisfied with them.
In Japan, 42,5 % of Japanese nursing students lived with their childhood family, and because of that many of them have the same good eating habits as their families. College students in China are required to earn college credits in physical education. They choose a sport they prefer and attend weekly training. The credit requirement guarantees time and motivation for physical exercise. Also, online fitness mobile applications (apps) have become popular in China during recently years. So-called ‘mind and body practices’ like Yoga and Tai Chi compensate for not being able to hit gyms during busy days. Some Japanese nursing students are in the college circles or club activities (such as tennis, badminton, basketball and volleyball). The students practice 1-3 times a week.
Mental health and good economic situation supports the well-being of the students
In the questions about health and life situation, the Chinese students assessed their mental health to be better than students in other countries. Sri Lankan students assessed their economic situation to be better than in the other countries. The Finnish students assessed their study and work situation and human relations being better than in China, Japan and Sri Lanka. However, according to this study, most of the students were in good mental health. In addition, their financial situation was good.
In Sri Lanka, students studying in government sector nurses’ training schools are provided with monthly allowances during the entire period of their studies. This has led to the stable economic status of Sri Lankan student nurses. Students enrolled in to private sector nursing schools are mainly the one who have an idea of moving to the western world through pathway programs. Students with this type of intention mainly are from middle or upper class family background. Hence, it is obvious that the students in the private sector also have good economic status.
Chinese students typically live on campus and share a room with other people and with that they will get social support. Also the family support in China is strong, as being the only child in the family, children are deeply attached to their families. In addition, healthy lifestyle choices are related to improvements in mental health. It should be noted that in this study, the sample data of Chinese students shows good physical activity, as well as low frequency of alcohol assumption and smoking. These are in line with better mental health results. There were differences in answers related to health services and counselling. The study showed that Finnish and Sri Lankan nursing students assessed this question in the same way, versus the answers from Japan and China. What is the reason for this? Are the Japanese and Chinese nursing students shy to ask help when needed? Or are there limited health services and counselling available at the university? In this study, we did not get answers to these questions.
Support services available in Japan, China and Sri Lanka
In Japan, students’ experiences were worse than in other countries. Tokushima University has the Tokushima University Campus Life Health Support Center. There is a health management department for physical and mental health, and a general counseling department for student counseling. In addition, faculty members in charge of each grade and faculty members in charge of graduation research are also assigned, and the grade teacher holds interviews at least once a year. Despite there are resources for the student’s support, the student’s evaluation were poor. Possible causes include insufficient information provision in those resources, lack of resources that can be easily consulted, and the characteristics of Japanese university students who have problems on their own and they do not seek help from themselves. Further investigation is needed in the future.
Nurses training schools in Sri Lanka have well established protocols in handling students’ concerns related to their health. Individual records on students’ health status being maintained at the school. In addition, one staff member has been appointed as the in charge for students’ medical concerns and the respective staff member take necessary actions by liaising with the hospital/hospitals to handle any medical condition. This has led to the easy access to the health services in Sri Lankan setting.
In China, students may feel uncomfortable with visiting professional consultants especially when it comes to psychiatric illness. They may prefer to get support from people they know, such as parents or friends first, rather than strangers even if they could be more professional. Besides, self-treat and self-care may be another option for nursing students, which could be explored in future studies.
The need to support nursing students during their studies
Most of the students did well. However, there was always a small group of students, who would have needed more support. It was quite surprising, that students reported they had only limited support from their professors or lecturers. The question is how to recognize these students and how to help them to get support. We would need a simple questionnaire by e.g. smart telephone application, and with it regularly follow up students´ wellbeing and health. This would help finding them and advising different options in receiving support in studies and personal life.
In many Asian countries, students start university studies straight after the high school. At that phase of life, it might not yet be possible to know, what they would like to become and which profession to choose. Maybe that is the reason, why Finnish students were most satisfied with their studies and work, as they were already older and had more experiences in working life.
This study shows that there is a need to investigate regularly the health and wellbeing of students. Even though, most of the students were doing well, we cannot afford losing any students. When students feel well, they are able to complete their studies in time and they are able to graduate to become competent professionals to help other people. Lack of number of nursing professional is a global challenge. During the nursing studies, it is important to support the future graduates to build their resilience to face multiple challenges in their working life, as nursing profession is a demanding profession in many ways. If we were to repeat this study now, the results might be different because of the current pandemic. Especially during the COVID-19, many institutions have moved to online teaching, and students are studying at home without social contacts.
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- Aija Ahokas, Senior Lecturer, Metropolia University of Applied Sciences, Helsinki, Finland
- Eila-Sisko Korhonen, Metropolia University of Applied Sciences, Helsinki, Finland (Free Researcher)
- Anita Näslindh-Ylispangar, Freelance writer, Helsinki, Finland
- Wu Xue, School of Nursing, Peking University, China
- Shaomei Shang, School of Nursing, Peking University, China
- Kithsiri Edirisinghe, International Institute of Health Sciences, Sri Lanka
- Reiko Okahisa, Department of Community Health Nursing, Tokushima University, Japan
- Leena Rekola, Principal lecturer, School of Health care, Metropolia University of Applied Sciences, Helsinki, Finland