Factors Associated with Healthy Behavior for Preventing Non-Communicable Diseases

Introduction

The morbidity and mortality rates of Non-Communicable Diseases (NCDs) continue to increase in both low and high-income countries in ASEAN. NCDs are the biggest cause of death in ASEAN countries, affecting global industries. The increase in morbidity and mortality rates across all age groups is attributed to factors like lifestyle changes, urbanization, and inadequate healthcare systems.¹ WHO (2019) revealed that 17 million or about 62% of people died at the age of less than 70 years old.² The Lancet Commission on Adolescent Health and Wellbeing reported that the greatest burden of disease among people aged 10–24 years was from NCDs, which accounted for 56% of global disability-adjusted life-years (DALYs) in 2016.^3,4 From 1990 to 2019, DALYs attributable to NCDs also increased by 13.1%.³ Countries with limited health resources tend to have difficulties in effectively managing NCD cases. This rise is significant, indicating a pressing public health crisis that demands urgent interventions to reduce premature deaths and alleviate healthcare burdens. Interventions to prevent non-communicable diseases are very important because they can reduce 82% of premature deaths and save lives and reduce the burden of health financing.

Despite the fact that NCDs pose a global problem, University students’ knowledge and prevention are still lacking. A report indicates that the prevalence of non-communicable disease (NCDs) continues to rise among university students, with more than half of the students having intermediate and high risk for type 2 Diabetes Mellitus.⁴ Furthermore, research in Bangladesh has reported that adolescent participants’ physical inactivity is linked to university students who have unhealthy lifestyles, such as missing breakfast or lacking social support.^5,6 This demonstrates how lifestyle plays a significant impact on students’ cognitive and emotional development. If neglected, it can raise the risk of unhealthy behaviors, mental issues, and non-communicable diseases. Therefore, preventing non-communicable diseases (NCDs), such as implementing effective health promotion strategies, within universities is an essential investment to encourage healthier lifestyle choices and mitigate the potential burden of NCDs in the future.

Another study involving university students from 24 countries, including some in the ASEAN region, found that 15.9% of university students had three or more NCD-related behavioral risk factors, such as lack of physical activity, poor diet, and tobacco use.⁷ This finding indicates that the majority of university students may not be fully aware of the behaviors that can increase the risk of NCDs. The low percentage highlights a gap in knowledge and awareness about health and the importance of prevention among University Students. University students often change their eating habits, experience increased stress levels, and reduce physical activity due to academic pressures. Along with a limited awareness of the importance of health, these changes can lead students to adopt unhealthy behaviors that may raise their risk of Non-Communicable Diseases (NCDs).

The transition into university life presents unique challenges for students, including lifestyle changes that can significantly influence their health and increase the risk of NCDs. These include academic, financial, social, and future-oriented pressures.⁸ This period of transition at the university level necessitates that students reorganize their time to identify available periods of free time, activities, social relationships, and dietary patterns.⁹ Students who are highly occupied and experiencing elevated stress levels tend to gravitate towards fast food establishments or purchase fast food items in the vicinity of their campus or residence, as it is a more cost-effective and convenient alternative to cooking.¹⁰

College students often experience increased stress due to academic load which impacts lifestyle changes. Stress experienced by students plays an important role in the health behaviors adopted. Studies show that there is a positive correlation between smoking behavior and stress levels.¹¹ Sedentary behavior in university students is also at a very alarming level worldwide and student activities also often increase sedentary time in the form of sitting.¹² Studies reveal that 65% of university students spend 9.75 hours on sedentary behavior.¹³

Unhealthy lifestyle behaviors such as following unhealthy dietary patterns, lack of exercise, alcohol consumption, and insufficient quantity and/or quality of sleep increase the risk of Metabolic syndrome.¹⁴ The innovative Care for Chronic Conditions (ICCC) framework has been adopted by the WHO for health system transformation towards better care for chronic diseases. These guidelines are encouraging and supporting, but the situation within ASEAN countries greatly affects the ability to control Non-Communicable Diseases (NCDs).

Management of Non-Communicable Diseases (NCDs) includes massive education by health workers on healthy living practices.¹⁵ Part of this education is the topic of smoke prevention, smoking cessation, and prevention of second-hand smoke. Proper nutrition and daily activity education are also essential topics. The involvement of multidisciplinary health workers greatly influences the effectiveness of interventions to prevent and manage Non-Communicable Diseases (NCDs).¹⁶ If health workers and financing are not evenly distributed throughout the region including rural and remote areas, then the challenge of disparities must still be faced.¹⁷

Reviewing strategies and implementing Non-Communicable Disease (NCD) prevention in various Indonesian regions is beneficial for implementation in other areas. However, a review with ASEAN coverage would provide greater insight into regional and country policies. The implementation of strategies in ASEAN countries that share close geographical and cultural characteristics allows for the repetition and modification of programs and policies to prevent non-communicable diseases (NCDs) in a manner that is accurate, effective, and efficient.

The purpose of this study is to map the existing literature on the factors associated with healthy behavior in the context of the prevention and management of non-communicable diseases (NCDs) among university students in ASEAN countries.

Materials and Methods

Design

The design of this article was written in the scoping review with a PCC framework. We created a data extraction form to help collect and organize important data from the selected articles. The purpose of the mapping procedure or scoping mapping using the draft table that the authors conducted was to produce a descriptive overview of the findings that answered the research questions. Prisma Extension for Scoping Review (PRISMA-ScR) was also used to present methods to optimize the reporting of the review results. The PRISMA-ScR was established to improve the reporting quality of scoping reviews. It includes a checklist of 20 essential items and 2 optional items that guide researchers in clearly articulating their review processes and findings.¹⁸ By adhering to these guidelines, researchers can ensure that their scoping reviews are comprehensive, transparent, and reproducible, which is crucial for advancing knowledge in a given field.

Search Methods

The keywords used included “Adult” AND “Healthy lifestyle” AND “Intervention” AND “University” OR “College” AND “ASEAN countries” in several databases, namely EBSCOhost, PubMed, ScienceDirect, Scopus, and Sage Journal. All keywords of databases are written in Table 1 below.

Table 1 Keywords of Databases

This article uses the PCC (Population, Concept, and Context) framework and is presented in Table 2.

Table 2 PCC Framework

Eligibility Criteria

To determine the articles reviewed, the authors determined the inclusion and exclusion criteria based on the PCC format. This article reviews both qualitative and quantitative studies. The search is restricted to full-text articles in English and Bahasa Indonesia published from 2020 to 2024. Restricting the scope of data from the past 5 years may be more advantageous as it can capture the latest trends, research developments, and current health policies, ensuring that the findings are highly relevant and practical to address the current factors related to healthy behavior for preventing NCD in Southeast Asia. Given the diversity of languages in the region, including studies in both English and Bahasa Indonesia guarantees a wider representation of research relevant to the ASEAN context. Review, study protocols papers, articles published in other languages except English and Bahasa, and Non-Communicable diseases that do not focus on the University student population were not included. It is because this study focuses on university students as they represent a vulnerable group during a critical phase in life, high frequency of sedentary behavior or inactivity, high stress, and poor diet in students can endanger their health and put students have a high risk at NCDs.¹⁹ The articles were reviewed by the four reviewers based on the Prisma Extension for Scoping Review (PRISMA-ScR) (see Figure 1).

Figure 1 PRISMA-ScR. Notes: This figure depicts the PRISMA-ScR flow diagram used to illustrate the process of article identification, screening, and inclusion in the review.

Data Extraction and Analysis

The data analysis is conducted in accordance with the most recent Arksey & O’Malley guidelines on scoping reviews. The stages of this process are as follows: 1) determining the research question, 2) identifying appropriate literature relevant to the research question, and 3) selecting the results of literature studies that are appropriate to the research context, 4) conducting data mapping based on the literature that has been collected, 5) synthesizing, compiling, summarizing, and reporting the results, and 6) consulting with experts.²⁰ This framework provides a foundational approach that outlines essential steps for conducting scoping reviews, such as identifying research questions and mapping existing literature, which is particularly beneficial for complex topics where the evidence base is broad and varied.²¹

All articles were identified using the Mendeley software reference manager to determine suitability and eliminate duplicate articles. Further elimination was done by reviewing the title and abstract of each article. The authors then reviewed the full-text of all reviewed articles based on the specified criteria. Data were extracted to include important information, encompassing the study site, study design, aim, sample, instrument, and main findings. After collecting the data, all authors analyzed and interpreted each finding based on the research objectives and framework. Lastly, the authors conducted a thorough review of the included studies to ensure accuracy and minimize any errors during the data extraction process.

Results

In this scoping review, seven articles that focused on factors associated with healthy lifestyle among university students in Southeast Asia were identified and examined. These findings underscore the factors that influence a healthy lifestyle in reducing the risk of non-communicable diseases (NCDs) and improving overall well-being. The origin of articles from several countries in Southeast Asia are included in this study, except Cambodia and Timor Leste. All included articles are cross-sectional studies with total respondents of 71.923 university students. These included articles reported that the influence factors of healthy behavior exist. Five of the reviewed articles collected data online while two of them collected data offline. It was found that no interventions were used from the seven reviewed articles. Information extracted from the selected studies consists of standard data: title, author, year of publication, country of origin, study design, and research sample. Characteristic data of included articles is shown in Table 3.

Table 3 Characteristic Data of Included Articles

Moreover, data extraction was carried out carefully related to the seven articles, such as the tools utilized in the studies and the health outcomes that were observed as a result. This systematic process is outlined in Table 4. By synthesizing these results, this review aims to contribute to a deeper understanding of how to foster healthier lifestyles among university students in Southeast Asia and to inform future research directions in this critical area of public health. Almost all included articles used physical activity, social support, food consumption, and mental well-being instruments. However, only a limited study reported that instrument related to perceptions of university support is useful (see Table 4).

Table 4 Data Extraction

Factor Related to Healthy Lifestyle Among University Students for Non-Communicable Disease Prevention

The crucial intervention is to conduct regular surveys to monitor behavioral changes in specific population groups, thereby providing more accurate information for making appropriate health promotion decisions. Research suggests that first-year students tend to exhibit lower levels of activity than their second-year counterparts. Moreover, the Healthy University Framework (HUF) of the ASEAN University Network – Health Promotion Network (AUN–HPN) has been demonstrated to influence physical activity among university students in Thailand.^25,29,30

This present study revealed that there are three risk factors associated with an unhealthy lifestyle including sugar consumption, mental health challenges, and smoking. High consumption of sugary beverages was reported by over half of the respondents (n=8482; 55.2%); over 10% of respondents (n=2009; 13.1%) experienced poor mental well-being; and almost 10% of respondents (n=1364; 8.9%) were smokers.²⁴ Moreover, the dissemination of knowledge, particularly regarding the benefits and adoption of a positive perception of cardiovascular health, will enhance students’ awareness of this critical area. The perceived benefits and acquired knowledge represent an indirect impact of health-enhancing behaviors.²²

Furthermore, the consumption of fruits and vegetables has been identified as a contributing factor. This study expands upon previous findings regarding the relationship between inadequate fruit and vegetable consumption and shorter sleep duration. This scoping revealed the inverse relationship between fruit and vegetable consumption and poor sleep quality and restlessness.^26,28,31 An increase in fruit and vegetable consumption has been linked to a reduction in both poor sleep quality and sleep disturbances.

Among the seven articles included in this study, four articles emphasize that adopting a healthy lifestyle is crucial for university students in Southeast Asia. This lifestyle encompasses various internal factors such as dietary habits, academic performance (GPA), gender, sleep quality, and body mass index (BMI).^22–24,27 Each of these factors significantly contributes to overall health and well-being. These factors are essential for fostering habits that not only enhance students’ daily lives but also lower the risk of developing non-communicable diseases (NCDs) in the long term.

Conversely, three other articles reveal that although internal factors are crucial, external factors including social environments and available resources, also play a role in shaping students’ health behaviors.^25,29,30 However, it is evident that students who actively engage in a healthy lifestyle, characterized by balanced nutrition, regular physical activity, and adequate sleep, are more likely to experience improved health outcomes. Importantly, no articles were found that attribute health outcomes solely to external factors without considering the impact of individual lifestyle choices. This observation underscores the premise that while external influences can impact individual health, it is primarily the commitment to a healthy lifestyle that serves as a foundation for reducing the risk of NCDs among university students.

Discussions

An understanding of the benefits derived from disease prevention has a positive effect on cognition and perception. This study’s results align with the theoretical principles of the health behavior model and other empirical research findings on physical activity, weight management, and nutritional behaviors among young adults. The study revealed that demographic variables (specifically, age) significantly influenced health beliefs (ie, perceptions of vulnerability and severity). Age is a factor that contributes to people’s perception of disease prevention. Increasing age is associated with an increased risk of disease occurrence and thus increased vigilance in disease prevention.^32,33 This is in accordance with the study findings that first-year students have low levels of physical activity when compared to second-year students.

Gender also plays a crucial role in influencing students’ healthy lifestyles. Studies have shown that women are more likely than men to take steps to prevent disease. However, female students have lower activity levels and poorer diets. Based on research conducted in Singapore, female students have low levels of physical activity compared to men, with most of these women (73%) exercising less than three times per week.³⁴ Female students tend to consume salty foods such as chips and fatty foods compared to male students. This is influenced by fear of judgment, stereotypes, environment and feelings of inadequacy that women tend to have.³⁵ The student’s country of origin is also related to healthy lifestyles. This is influenced by urbanization, gross domestic product per capita, human development index, culture related to eating behavior, health promotion policies, and advocacy in a country that contributes to the lifestyle of people in it.³⁶

Other factors found in this present study are the mental well-being and sleep patterns of the university students. These factors are important to avoid stress and depression. A similar study conducted outside the ASEAN region at a university in the United Arab Emirates that employed the Systematic Assessment of Resilience (SAR) tool, which proved to be highly beneficial. The implementation of the Systematic Assessment of Resilience (SAR) has been demonstrated to enhance resilience and mitigate the incidence of depression. The SAR framework provides comprehensive guidance for fostering resilience and enhancing four key interventions: (1) self-regulation, which entails the ability to regulate one’s behavior and cope with challenges; (2) Management, which describes the capacity of students to utilize available resources in an efficacious manner to overcome obstacles. (3) Engagement, which highlights the capacity of students to engage and commit to pursuing challenges with persistence; and (4) Growth, which reflects the sustained development of students to meet future challenges. Training sessions were conducted to familiarise participants with the utilization and implementation of the SAR framework. These sessions were completed before the commencement of the rotation as a pre-requisite for the online workshop, which lasted five hours.³⁷

Despite these positive outcomes from specific interventions like SAR, a significant limitation in this review is the absence of interventions altogether. This is a significant limitation that warrants careful consideration. This gap may stem from several underlying factors, including the nature of the research designs employed and the prevailing focus within the academic community. Many studies tend to prioritize descriptive or correlational research methods, which are essential for understanding phenomena but do not involve direct interventions. For instance, non-experimental designs, such as qualitative and descriptive studies, are often utilized to explore relationships among variables rather than to test specific interventions. However, this present study indicated that modelling knowledge, health beliefs, and health-promoting based on university policy implementation will benefit non communicable prevention among university students.

HUF AUN-HPN

The framework within the university environment about health is the Healthy University Framework (HUF). HUF represents a collaborative framework for promoting health within the university environment across the ASEAN region. HUF is divided into three principal categories of framework. Firstly, the systems and infrastructure are designed to create a healthy university. There are suggested elements for establish a healthy university framework, including: 1) University policies to promote health; 2) A healthy working environment, clean, and green environment; 3) Health promotion services, counselling, and advisory support; 4) Equal opportunities including disability friendly; 5) Health promotion curriculum and co-curriculum; 6) Capacity building on health promotion; 7) Health promotion research; 8) University Volunteerism; 9) Budgetary support for healthy university programs.³⁸

Building upon this foundation, the second category encompasses thematic areas that include a zero-tolerance policy to address behaviors that detrimental to health. This thematic focus serves as a strategy to fulfill the criteria of a healthy university by promoting various health activities across universities in the ASEAN region.³⁸ The HUF employs a comprehensive approach encouraging all stakeholders within the university environment to share knowledge and expertise while ensuring equal rights in developing innovative solutions to regional health issues.

In addition to HUF, the ASEAN University Network (AUN) plays a critical role in facilitating knowledge sharing and collaboration among academic institutions in Southeast Asia. Higher Education Institutions (HEIs) will enable in creation of a place health promotion program that will help develop and build effectiveness and efficiency in three interrelated functions, namely education, research, and public service. Through AUN, University staff can review and maintain the condition of all individuals in university settings, including Pre-Recruitment Health Screening, Outreach Program, Fitness Program, NCD Monitoring and Risk Reduction, Promoting Non-Smoking, and Health/Social Counselling.³⁸ Campus health promotion initiatives are essential to building healthy universities with members who are effective in finding, sharing, and applying knowledge and skills for the benefit of people and society.

Moreover, the Health Promotion Network (HPN) is an integral component of AUN that focuses specifically on networking for health promotion in Southeast Asia. Consequently, the AUN-HPN represents a collaborative policy initiative between academic institutions and healthcare professionals to promote health and well-being to enhance the quality of life in the ASEAN region. This policy encompasses a range of activities, including research, health programs, health promotion strategies, and regional meetings that address the specific health needs and challenges within the region.

Implementing the Healthy University Framework involves several strategic steps that aim to create a healthy campus environment and support the well-being of students and staff. First, policy creation is an important first step, where commitment from university leaders is needed to agree and integrate health policies into the organizational culture. Once the policy is in place, various programs and activities can be launched, such as anti-smoking programs, alcohol-free initiatives, and health promotion that includes mental health education and physical activity.³⁸ The active involvement of students and staff in the planning and implementation of these programs is highly recommended to increase their effectiveness.

Finally, it is important to ensure that all such activities are outcome-based and regularly evaluated to achieve the key performance indicators set. The operational structure consists of several groups, including the Secretariat, Advisory Group, and Working Groups, each of which has a specific role in the implementation of this framework.³⁸ The Advisory Group serves to provide strategic direction, while the Working Groups are responsible for the implementation of particular programs in the health sector. This structured approach is expected to create a healthier campus environment that supports the well-being of the entire academic community (see Figure 2).

Figure 2 The framework of factors associated with NCDs in Southeast Asia Nation countries. Notes: This figure presents the conceptual framework of factors influencing non-communicable diseases in Southeast Asian nations, including internal and external factors.

Strengths and Limitations

The article offers insights that may be pertinent to the Southeast Asian student population, which may exhibit distinctive characteristics compared to other regional student populations. By focusing on Southeast Asia, this article can examine the distinctive social, cultural, and economic factors present in each ASEAN member state. The findings of this study can be utilized by policymakers, educational institutions, and local organizations to develop policies that are more aligned with the needs of students in Southeast Asia.

However, it should be noted that the article is not without limitations. One significant limitation identified in this review is the absence of interventions across the studies analyzed. This lack of intervention-focused research restricts the understanding of practical applications and the potential effectiveness of various strategies in addressing the issues at hand. The absence of interventions means that while existing literature can be assessed for trends and outcomes, conclusions about actionable steps or best practices cannot be drawn based on this evidence. This gap highlights a critical area for future research, where studies incorporating specific interventions could provide valuable insights and contribute to a more comprehensive understanding of the topic.

As the review is limited to the Asian Southeast Asian region, the findings may not be applicable to other student populations in other regions. Readers from outside the region may therefore perceive the findings as less relevant. Moreover, the article does not examine studies that employ intervention, which may limit its ability to offer compelling evidence in support of proposed solutions.

Conclusions

This review examines the internal and external factors that influence healthy behavior among university students in ASEAN countries. A total 7 studies were included, highlighting key factors namely dietary habits, duration and quality of sleep, Body Mass Index (BMI), students’ knowledge and perceptions, and the implementation of health frameworks within university environments. This illustrates the complexity of determinants of health behaviors. Four of the seven articles indicate that internal factors related to students’ daily behavior significantly influence the risk of NCDs among university students. In contrast, three articles report that the risk of NCDs is influenced by a combination of internal and external factors. Moreover, this review revealed a significant correlation between healthy lifestyle practices and psychological well-being among students, as well as their susceptibility to cardiovascular disease. Notably, one study identified three risk factors associated with an unhealthy lifestyle, which are sugar consumption, mental health challenges, and smoking. Specifically, 8482 respondents had high consumption of sugary beverages.

To effectively tackle these internal and external influences, it is imperative to implement efficacious interventions for the prevention and management of Non-communicable Diseases (NCDs) among university students. Universities should prioritize the integration of health education into their curricula, promote physical activity through campus initiatives, and enhance access to nutritious food options on campus. The implementation of a holistic health promotion strategy and the creation of a supportive environment at the university level hinges on the effective implementation of the HUF AUN-HPN. This framework also plays an important role in reducing the burden of noncommunicable diseases (NCDs) among young adults.

Building on the findings of this review, future studies could explore the combining interventions between increasing fruit and vegetable consumption with improving physical activity as part of an integrated NCD prevention program. Additionally, future studies might examine the feasibility, cultural adaptability, and long-term sustainability of such combination interventions, considering the diverse socio-economic and cultural settings in the region. In conclusion, ASEAN universities should take practical steps such as establishing partnerships with local health organizations, conducting regular health assessments for students, and fostering student-led health initiatives to effectively implement HUF and promote healthier lifestyle among students.