Health-Promoting Lifestyle and Associated Factors among Medical Sciences Students in Kermanshah, Iran: A Cross-Sectional Study

Background Lifestyle includes routine and daily living activities affecting an individual's health. The present study aimed at evaluating the health-promoting lifestyle profile (HPLP) of medical sciences students of Kermanshah, Iran. Methods In this cross-sectional study, 343 medical sciences students were enrolled by the stratified random sampling method. The data collection tools were demographic information form and the HPLP-II questionnaire. Data were analyzed using descriptive and analytical statistics. Results The mean overall HPLP-II score of the subjects was 2.25 ± 0.44 out of 4. Of the six HPLP-II dimensions, the highest and lowest scores belonged to interpersonal relations and physical activity, respectively. The mean overall HPLP-II score was statistically different in terms of gender, marital status, smoking habits, and economic status (P ≤ 0.05). Conclusion HPLP-II level was moderate in most of the students, and health-promoting behaviors, in the physical activity dimension, were in a low state. The results emphasized the need for interventions to improve students' lifestyles.


Introduction
Lifestyle includes daily routines that become habitual and affect physical and mental health [1]. Measures such as a healthy diet, adequate sleep and activity, weight control, and lack of smoking and alcohol consumption constitute lifestyle [2,3]. An unhealthy lifestyle is one of the main risk factors for chronic diseases and premature death [4,5]. According to the US Department of Health and Human Services, unhealthy behavior and lifestyle is one of the leading causes of death [6]. Improvement of lifestyle leads to satisfaction, success at work, and physical health, called the healthpromoting lifestyle profile (HPLP). It consists of six dimensions as follows: physical activity, nutrition, health responsibility, spiritual growth, interpersonal relations, and stress management [2,7,8]. Students often neglect to maintain a healthy lifestyle, which puts them at risk of old age diseases [9]. Likewise, an unhealthy diet and low physical activity are reported as one of the dimensions of an unhealthy lifestyle in students [10][11][12]. Excessive consumption of fast foods, low physical activity, an irregular sleep pattern, and smoking are among the unhealthy behaviors that negatively affect students' health [13,14]. In 2016, a study in the United States showed that 40% of students were overweight, and 19% had high serum cholesterol levels due to an unhealthy lifestyle [15]. Likewise, a study in the UK (2017) reported that a small number of students followed five healthy lifestyle behaviors, including a healthy diet, regular physical activity, maintaining a healthy weight, and not smoking [16]. erefore, it is essential to observe HPLP to prevent chronic diseases [14,17]. Concerning the importance of the issue and the lack of information about the HPLP of students of Kermanshah University of Medical Sciences (KUMS), the current study was designed. In this study, we sought to answer the following questions: what are the mean scores of HPLP-II and its dimensions and what is the relationship between the mean HPLP-II and the personal characteristics of students?

Study Design.
is descriptive-analytic cross-sectional study was conducted in six faculties of Kermanshah University of Medical Sciences.
e study was performed according to STROBE instructions.

Study Questions.
In this study, we sought to answer the following questions: (1) What are the mean scores of HPLP-II and its dimensions? (2) What is the relationship between the mean HPLP-II and the personal characteristics of students?

Sample and Sampling
Method. e study population included all the students studying in the affiliated faculties of Kermanshah University of Medical Sciences (n � 3725), including medicine, nursing and midwifery, health, paramedical, pharmacy, and dentistry. e sample size was calculated based on the results of the study of Rezaei-Adaryani and Rezaei-Adaryani [18], and using the formula n � ((σ) 2 * Z 2 (α/2) )/d 2 equal to 312 people (d � 0.04, σ � 0.36, α � 1.96). To cover the missing data, 31 people (10%) were added to the sample size (343 people in total). e sample size was proportional to the total number of students in each faculty. e number of students in each faculty was as follows: medicine, 95 people; nursing and midwifery, 52 people; paramedical, 88 people; health, 57 people; dentistry, 18 people; pharmacy, 33 people.
Inclusion criteria were as follows: willingness to participate in the study and lack of lifestyle-affecting diseases (i.e., diabetes, multiple sclerosis, and musculoskeletal disorders). e stratified random sampling method was used to select the subjects, and each faculty formed a stratum. e simple random sampling method using a table of random numbers was employed to select the subjects in each stratum.

Study Instruments.
e demographic information form and HPLP-II questionnaire were used as data collection instruments. e demographic information form included nine items on age, gender, field of study, place of residence, marital status, economic status, weight, height, and smoking habits.
e HPLP-II questionnaire was used to evaluate HPLP. Studies by Savarese et al. and Petrash & Murtazina evaluated the internal consistency of the questionnaire and reported its Cronbach's alpha as 0.94 and 0.88, respectively [7,19]. e Persian version of HPLP-II was psychometrically assessed in studies by Soleimani Moghadam et al. and Tanjani et al., reporting Cronbach alpha of 0.80 and 0.78, respectively [20,21]. e HPLP-II includes 52 items scored based on a fourpoint Likert scale as never [1], sometimes [2], most often [3], and regularly [4]. It measures HPLP-II in six dimensions of nutrition (nine items), physical activity (eight items), health responsibility (nine items), stress management (eight items), interpersonal relations (nine items), and self-realization (nine items). e mean score earned by each person was calculated out of four and a mean score of ≥2.5 was considered a positive response [18]. e economic status of the family was categorized in the present study based on the monthly income as high (≥$ 201), middle ($101-$ 200), and low (≤$100).

Data Collection Method.
After obtaining approval from the Ethics Committee of KUMS, the researcher referred to the Education Department of the affiliated faculties to enroll the eligible students. Accordingly, the study objectives were explained to students, and their consent for participation in the study was obtained. en, the questionnaires were distributed among the subjects and collected after completion.

Statistical
Analysis. Data were analyzed using SPSS software version 16. Descriptive statistics (mean, standard deviation, and frequency tables) and analytical statistics (Mann-Whitney U test, Kruskal-Wallis H test, and Kolmogorov-Smirnov test) were used to analyze the data. Kolmogorov-Smirnov test was used to evaluate the normality of the HPLP-II variable and its subset, and the results showed an abnormal distribution of these variables.
e Mann-Whitney U test was utilized to compare the mean HPLP-II scores in terms of the two-state qualitative variables, including gender, marital status, place of residence, and smoking habits. e Kruskal-Wallis H test was used to compare the mean HPLP-II scores in terms of the multistate qualitative variables, including the field of study, BMI, and family economic status. e level of significance for all tests was less than 0.05.

Ethical Consideration.
e ethics committee of Kermanshah University of Medical Sciences approved the study with the code KUMS.REC.1399.167 (approval date 2020-05-11). Written and informed consent was obtained from all participants. Emphasis was placed on the confidentiality of participants' information.

Results
In the current study, the response rate was 100%. According to the results, 173 subjects (50.4%) were females, 323 (94.2%) single, 306 (89.2%) dormitory residents, and 95 (27.7%) medical students, and 218 (63.6%) had a medium family income (Table 1). e mean overall HPLP-II score was 2.25 out of 4. Among the six HPLP-II dimensions, the highest and lowest mean scores belonged to interpersonal relations (2.60 ± 0.52) and physical activity (1.97 ± 0.62), respectively ( Table 2). e results showed that the mean HPLP-II score of the married subjects was significantly higher than that of single ones (2.47 ± 0.38 vs. 2.24 ± 0.43), and the difference was statistically significant. In the present study, the mean HPLP score of male subjects was significantly higher than that of females (2.34 ± 0.40 vs. 2.16 ± 0.45). Students who lived with their families had a higher mean HPLP-II score than those living in dormitories (2.23 ± 0.43 vs. 2.40 ± 0.47), and the difference was statistically insignificant. e results showed that the mean HPLP-II score of nonsmoking students was significantly higher than that of smoking ones (2.30 ± 0.43 vs. 2.00 ± 0.42). In the present study, subjects with high economic status (≥$ 201) had a higher mean HPLP-II score than those with middle or low status ($ 101-$ 200, and ≤$ 100, respectively). No significant relationship was found between the mean HPLP-II score and age and BMI variables (Table 3).

Discussion
According to the results, the mean overall HPLP-II score was at a moderate level, in line with the results of studies by Mehri [2,26]. It indicates that marital status can influence the promotion of health.
In the present study, the mean overall HPLP-II score of the male subjects was significantly higher than that of females, consistent with the results of studies by Mehri [2,12,14,28,29]. Given that the HPLP-II has six domains, males and females can gain different scores in each due to physical, mental, and psychological differences. e results showed that students who lived with their families had a higher mean overall HPLP-II score than the ones living in dormitories. is result was consistent with that of Mehri et al. in Iran and inconsistent with that of Alzahrani et al. in Saudi Arabia [2,12]. Students who live in dormitories benefit from fewer facilities and less family support compared to the ones living with their families, which can affect their HPLP-II scores.
In the current study, the mean overall HPLP-II score of nonsmoking students was significantly higher than that of smoking ones, consistent with the results of Alzahrani et al. in Saudi Arabia, Lolokote et al. in China, and Aynaci and Akdemir in Turkey [12,26,30]. Smoking is an unhealthy behavior with negative impacts on lifestyle.
In the present study, students with a high economic level had a significantly higher mean HPLP-II score than the ones with middle to low levels.  [1,12,26,28]. Financial concerns significantly affect HPLP and, therefore, financial support of students from both the family and university seems essential.
In the present study, the mean HPLP-II score was at a moderate level in all the age groups, and no significant difference was observed among them.
is finding was consistent with the result of Alzahrani et al. in Saudi Arabia [12] and inconsistent with those of Al-Qahtani and Al-Qahtani in Saudi Arabia, Lolokote [2,26,32]. Although no significant relationship was found in the present study between the mean HPLP-II score and BMI, it can be used as an index of HPLP-II.
In the present study, the mean HPLP-II score was at a moderate level in students of all KUMS faculties, and no significant difference was found among them. In the study by Pakseresht et al. in Iran, among medicine, dentistry, health, Journal of Environmental and Public Health 3 nursing, and paramedical faculties, the paramedical faculty had the highest mean score in interpersonal relations and spiritual growth dimensions [1]. e study by Almutairi et al. in Saudi Arabia showed a significant difference between the schools of medicine and sciences in terms of health responsibility [14]. e authors of the present study believe that medical students are role models and should have good HPLP-II, considering the nature of their chosen profession.
In the present study, among the six HPLP-II domains, the highest and lowest scores belonged to interpersonal relations and physical activity, respectively, consistent with the study by Mak et al. in China [33], although some studies reported that the highest mean scores are related to interpersonal relations [2,29,34] and spiritual growth [12,28,29,34], and the lowest to physical activity [2,12,29,34], nutrition [2], and health responsibility dimensions [28,29]. Different results may be due to cultural and educational differences among universities. ese differences highlight the importance of conducting further research and applying the results to plan macro-educational and health policies. is study faced several limitations. One limitation was the possibility of social desirability bias. In this type of bias, instead of giving correct answers to questions, respondents give answers that are more acceptable to others and society. Considering the possibility of social desirability bias, the questionnaires were anonymous to minimize the impact. e main limitation of the cross-sectional study is that the temporal relationship between the exposure and outcome variables cannot be determined because the exposure and outcome variables are measured simultaneously. erefore, due to the nature of cross-sectional studies, it is not possible to determine the causal relationship between the variables of this study. Considering the effect of personal and cultural variables on HPLP-II, caution should be exercised in generalizing the results.

Conclusion
Most students had moderate HPLP-II. e highest and lowest scores of HPLP-II dimensions belonged to interpersonal relations and physical activity, respectively. ere was a significant relationship between the mean HPLP-II score and the variables of gender, marital status, economic status, and smoking habits; however, it was insignificant in terms of BMI and age groups. It is suggested to evaluate the effect of interventions on students' HPLP-II in future studies.
Data Availability e identified datasets analyzed during the current study are available from the corresponding author upon reasonable request.

Disclosure
is study was drawn from a research project (No. 990225) sponsored by Kermanshah University of Medical Sciences.

Conflicts of Interest
e authors declare there are no conflicts of interest.