Filipino Nursing Students’ Health Promoting Behaviors during Pandemic

Background: Research on health promoting behaviors can assist nursing students in identifying, maintaining, and improving health behaviors. The notable impact and changes in lifestyle behaviors during the pandemic necessitate a closer look into students ’ health-promoting behaviors. However, there is a lacuna in the literature about health promoting activities of nursing students stuck at home and attending online learning during the pandemic. Purpose: This study assessed the level and predictors of health promoting behaviors of nursing students in a Philippine public university during a pandemic. Methods: This study used a cross-sectional design with 363 out of 531 undergraduate nursing students of a public university in the Philippines as study participants. Data were gathered using an online survey last March 2022 employing the Health Promoting Lifestyle Profile (HPLP) II. Significant predictors were identified using multiple linear regression analysis with the aid of SPSS version 26.0. Results: Results showed that nursing students had a high (M=2.80 out of 5) practice of health promoting behaviors. Physical activity ranked the lowest among the six dimensions of health promotion behaviors. The variables that predicted the health promoting behaviors of nursing students were self-reported academic performance (β=2 .110, p =.000), family income level (β=.055, p =.001), and academic year level (β=.057, p =.002). Conclusion: Nursing students should continue to maintain their good practice of health promoting behaviors. However, more attention should be given to engaging in physical activity to maintain holistic well-being.


Introduction
Healthy lifestyle promotion is an important factor of health status (Almutairi et al., 2018;Wei et al., 2012).Health promotion combines educational, social, and environmental efforts to promote healthy lifestyles and habits (Kim & Kim, 2018).It is designed to aid people in achieving their full potential in terms of physical, mental, social, and spiritual health (Kim & Kim, 2018;Shariferad et al., 2013).Moreover, health promoting behaviors involves a positive living approach and a way of boosting well-being and increasing self-actualization (Nassar & Shaheen, 2014;Wang et al., 2009).Health promoting behavior is an ever-present factor in the lives of university students, many of whom have varying lifestyles and practices (Al-Momani, 2021;Almutairi et al., 2018;Ashgar, 2021).Individuals can choose whether they want to improve their lifestyles and have several methods or means they can choose from (National Institute of Health, 2021).Health promoting behaviors, especially those of students, have been researched many times throughout the years, and studies found that those with good health promoting behaviors have better healthy lifestyles (Al-Momani, 2021;Hwang & Oh, 2020).
With the advent of the COVID-19 pandemic, restrictions, and quarantine practices were implemented to control and prevent the spread of the COVID-19 virus (Mattioli et al., 2020).The pandemic has impacted all sectors, including nursing education (Agu et al., 2021).As the crisis worsened, many governments shut down schools, colleges, and institutions to protect students, teachers, and their countries (Schleicher, 2020).As a means of maintaining and safeguarding the overall health of students and teachers, traditional in-person classes, skills laboratories, and student clinical or hospital placement were either suspended or restricted when the pandemic broke out and education shifted to online mode (Agu et al., 2021;Oducado & Soriano, 2021).
Meanwhile, multiple studies have already been conducted related to the health promoting behaviors of university students in pre-pandemic conditions (e.g., Al-Momani, 2021;Alzahrani et al., 2019;Ashgar, 2021;Fashafsheh et al., 2021;Hosseini et al., 2014;Hwang & Oh, 2020;Polat et al., 2016), particularly nursing students, and the factors affecting it.Mixed results were found with other studies reporting high (Hosseini et al., 2014), while others disclosing only moderate levels (Fashafsheh et al., 2021;Farokhzadian et al., 2018;Polat et al., 2016) of health promoting behaviors.However, to the researchers' best knowledge, there is a lacuna in published literature touching on the health promoting behaviors of nursing students in the pandemic setting.
COVID-19 dramatically impacted lifestyle behavior (Azzouzi et al., 2022).A closer look at the lifestyle of students is necessary as lifestyle is considered a key factor for the onset and course of diseases (Van der Werf et al., 2021).Results of studies among the general population and university students conducted elsewhere indicated changes in the lifestyle during the pandemic, such as physical inactivity, faulty eating patterns, and increased mental stress (Gadi et al., 2022;Li et al., 2021;Singh et al., 2021).Online classes and restrictions related to quarantine inhibited students from practicing self-care and good health habits during the worldwide health crisis (Cleofas, 2021).During this research, the students were still living within the pandemic context.Previous studies have not touched on health promoting activities of nursing students stuck at home and attending online learning during the pandemic.It must be noted that while the survey was done towards the end of the pandemic and there was already some relaxation with COVID-19-related restrictions in other parts of the world, the conditions in which the study was conducted have not returned to its pre-pandemic state.Also, students in this study have not yet returned to on-campus instruction.
Meanwhile, Walker et al. (1987) identified six lifestyle behaviors that promote health.These include health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, and stress management.The Health Promotion Model (Walker et al., 1987) assumes that demographic or personal characteristics may influence health promoting behaviors.Differentiation of behaviors that promote health by certain demographic constructs may help identify vulnerable student cohorts that may be targeted for health programs and interventions (Muller et al., 2022).It is argued that university life of students can be a crucial time in promoting the good and changing the unhealthy lifestyle behaviors of students (Cetinkaya & Sert, 2021).Given that the majority of lifelong good and ill lifestyle behaviors are formed throughout adolescence and continue to affect health even after early adulthood, it is critical to establish good health-related habits and disease prevention measures for teenagers and young adults (Fish & Nies, 1996;Musavian et al., 2014).Furthermore, the researchers recognized that it is vital to support students in developing and adopting behaviors that will maintain, improve and preserve their health and well-being and assist them in making sound health decisions (Ross et al., 2017).Nurses recognize the importance of a healthy balanced diet, stress management, adequate sleep, physical activity, and healthy relationships; this understanding, however, may not convert into self-care for nurses as they may not adhere to suggested physical activity and nutrition requirements (Ross et al., 2017).The same can be said about nursing students, especially if they are overburdened with assignments and classes (Chaabane et al., 2021).
As healthcare professionals in the future, nursing students have a vital role in public health for others and their own well-being and fitness (Hwang & Oh, 2020).Therefore, this study focused on how several factors involved in the lives of undergraduate nursing students affect their practice of health promoting behaviors, especially during the pandemic.The result of this study, based on student responses, could help inform university policymakers on ways to create healthier campuses, especially in nursing colleges.Hence this research was conducted to assess the level of practice and significant predictors of the health promoting behaviors among undergraduate nursing students during a pandemic.

Research design
This study was completed through the use of a descriptive cross-sectional research design.

Setting and samples
A complete or total enumeration was utilized in the study, wherein the acceptable response rate is 60% and above (Bennett et al., 2011;Fincham, 2008).All 531 undergraduate students from levels one to four of a public College of Nursing in the Philippines were invited to participate in the study.The college offers a four-year baccalaureate degree program and is the only public university within the Province of Iloilo.Out of 531 students, 363 responses (68.36%) responded.A-priori sample size using G*Power (Kang, 2021) for multiple regression with eight and nine predictors, .80desired statistical power, and .15anticipated effect size only requires a minimum sample of 108 and 113, respectively.The subjects included in this study were officially enrolled students of the college in the second semester of 2022 and were willing to participate in the study.The five students who were part of the research team of this present investigation were excluded.

Measurement and data collection
Data collection was done through a two-section questionnaire.The instrument was administered in the English language as the medium of instruction in Philippine Nursing schools is English.The first part included six socio-demographic questions (gender, academic year level, family income level, presence of medical condition, location of residence, and the number of people in the household) as well as the perceived academic performance of the student, COVID-19 infection history, and COVID-19 vaccination status.The second part consisted of the Health Promoting Lifestyle Profile (HPLP) II questionnaire (Walker et al., 1987).The researchers had permission to download and use the HPLP II for non-commercial data collection purposes.The HPLP II tool consists of 52 items categorized into six subscales: health responsibility (9 items), physical activity (8 items), nutrition (9 items), spiritual growth (9 items), interpersonal relations (9 items), and stress management (8 items).A Likert-type scale was used to measure each behavior, with ranges of never (1), sometimes (2), often (3), and routinely (4).The following scale of means based on the work of Beliran and Legaspi (2014) was followed for the interpretation of this study: Very Low (1.00-1.50),Low (1.51-2.50),High (2.51-3.50),and Very High (3.51 -4.00).HPLP II had a Content Validity Index of 1.00 and a Cronbach's alpha result of .83(Tejada, 2019).In addition, the researchers have also tested the internal consistency of the instrument based on the actual data and revealed that the results of Cronbach's alpha were the following: .81 for health responsibility, .85 for physical activity, .71for nutrition, .86 for spiritual growth, .80 for interpersonal relations, .78 for stress management and .94for the entire scale.
To gather data, the researchers secured permission and approval from the Office of the Dean and the respective Division Chairpersons per year level to conduct the study last March 2022.Afterwards, the chairpersons of the student curriculum of each level were asked to contact the class chairpersons of each section through messenger or email.They were requested to post the link in their respective class Facebook group chats or group pages.The students were encouraged to forward the link to their classmates through messaging or emailing apps to maximize the response rate.To ensure that only the study participants were given access to the survey link, the Google Forms were restricted to university users and were only distributed to college students included in the study.The link included the electronic informed consent.The participants had to click on the box that stated their voluntary participation.Then they had to click "next" to be directed to the research survey questionnaire.When the expected response rate was reached, the participants' responses were monitored, consolidated, and organized using Google Sheets.The data was then classified, tallied, interpreted, and processed.

Data analysis
Statistical computations were calculated using IBM SPSS version 26.Data were described using descriptive statistics.A test for normality of data distribution using the Kolmogorov -Smirnov Test was done.The t-test for Independent Samples and one-way ANOVA were used to test the difference between categories of the independent variable.Multiple regression analysis (step-wise) was employed to identify significant predictors.The significance level was set at .05 alpha.

Ethical considerations
The researchers submitted this study to the West Visayas State University Unified Research Ethics Review Committee (URERC), and it was approved with URERC Protocol Number Nurse Media Journal of Nursing, 13(1), 2023, 4 Copyright © 2023, NMJN, e-ISSN 2406-8799, p-ISSN 2087-7811 WVSU.URERC-2022.CONS_001.Electronic informed consent was used, and the participants were allowed to withdraw from the study without feeling obligated to continue.Moreover, there were no repercussions for those who did not participate since this was not a mandatory survey.The consolidated data were only made accessible to the researchers.

Profile of participants
A total of 363 responses were included in this analysis.It can be gleaned from Table 1 that the majority of the participants were female (71.6%), from the lower middle-income class (28.4%), had four (4) or less number of family members in the household (49.0%), residing in towns (52.9%), have average academic performance (81.0%), reported no medical condition (77.7%), and have not been infected with .Almost all (99.2%) are fully vaccinated.There were nearly an equal number of students per year except for Level IV (20.4%).

Differences in health promoting behaviors
Table 3 shows the differences in health promoting behaviors of nursing students using t-test for Independent Samples and ANOVA.Results of statistical analysis revealed that there was a significant difference in the overall health promoting behaviors of nursing students when grouped according to academic year level (F=3.817,p=.010), family income level (F=2.773,p=.027), and self-reported academic performance (F=12.473,p=.000).

Predictors of health promoting behaviors
Table 4 shows that multiple regression analysis using step-wise method revealed that selfreported academic performance (β=2.110,p=.000), family income level (β=.055, p=.001), and academic year level (β=.057, p=.002) were significant predictors of nursing students' health promoting behaviors accounting for 11.4% of the variance.

Discussion
This study assessed the level of practice and significant predictors of health promoting behaviors among undergraduate nursing students during a pandemic.This study demonstrated that self-reported academic performance, family income level, and academic year level significantly predicted nursing students' health promoting behaviors.
In this study, the majority of nursing students have not been diagnosed or experienced being infected with COVID-19.This may be due to the students and community members' strict implementation of safety precautions (Tuppal et al., 2021).A study by Rabacal et al. (2022) indicated that higher education students from Western Visayas region of the Philippines generally had a high practice of COVID-19 preventive measures.Nursing students were concerned about their well-being and their families during the pandemic (Barrett, 2022) and thus practiced COVID-19 preventive measures to reduce the chances of acquiring the disease.The suspension of face-to-face teaching and learning and clinical experiences may also have benefited nursing students, reducing the chances of COVID-19 transmission (Agu et al., 2021;Oducado & Soriano, 2021).
It is also to note that nursing students in this study had very high COVID-19 vaccination rates.Based on their background in nursing, nursing students could understand the necessity, effectiveness, and safety of the COVID-19 vaccine, as evidenced by their willingness to get the vaccination (Jiang et al., 2021).Furthermore, the study of Oducado et al. (2022) disclosed that nursing students highly intend to attend face-to-face classes.During data collection, only vaccinated students of higher education institutions were allowed to join limited face-to-face classes.
In this study, while very high practice was deemed most desirable, the health promoting behaviors of student nurses were still found to be high.This result is similar to the study of Hosseini et al. (2014), which showed that Tehran-based nursing students' health promoting behaviors scored high.On the contrary, studies conducted by Fashafsheh et al. (2021) in Palestine, Polat et al. (2016) in Turkey, and Farokhzadian et al. (2018) in Iran showed that nursing students had a moderate degree of health promotion.The variation with other related studies and this research may be due to how the mean was interpreted as the interpretation of a "moderate" corresponds to "high" in terms of this study's scale of means.Nevertheless, it is noteworthy that nursing students practice health promoting behaviors to a moderate to a great extent, although improvements can also still be made.
Moreover, in this study, the overall mean score was highest in the subscale of interpersonal relations.This could be due to the students spending most of their time with their classmates, who are also their friends, even on the online platform.Also, the school and the college provide a range of extracurricular activities that could strengthen student camaraderie despite the virtual setup.The relationships among nursing students are recognized by them as being crucial to their learning in clinical practice, as a forum for their feelings of safety and decreased anxiety while learning together.Peer learning has shown positive experiences when the students support each other in knowledge development (Holst et al., 2017;Stenberg & Carlson, 2015).
In addition, spiritual growth was also rated high by the respondents.This could be attributed to the educational institution, which offers a wide range of spiritual formation activities such as regular masses and recollections, including the various religious organizations open to nursing students.This result is similar to the study by Tejada (2019) in the Philippines, which showed that among 118 regular nursing students, the highest means were spiritual growth and interpersonal relations.Moreover, other studies by Alzahrani et al. (2019) among medical students in Saudi Arabia, Fashafsheh et al. (2021) among nursing students in Palestine, Polat et al. (2016) among nursing students in Turkey, Farokhzadian et al. (2018) among nursing and midwifery school in Iran, Hosseini et al. (2014) among nursing students in Tehran, Shaheen et al. (2015) among university students in Jordan, and Al-Momani (2021) among medical students in Saudi Arabia revealed that the greatest mean in the spiritual growth dimension.
On the other hand, physical activity had the lowest mean that was reported in this study.It is significant to note that 48.5% had low and 8.0% had very low physical activity.Other studies conducted pre-pandemic by Alzahrani et al. (2019), Cetinkaya and Sert (2021), Farokhzadian et al. (2018), Fashafsheh et al. (2021), Hosseini et al. (2014), Polat et al. (2016), andShaheen et al. (2015) showed that physical activity similarly had the lowest mean.Fashafsheh et al. (2021) explained that regular exercise routines still need to be fully absorbed into daily life as leisure activities.During the pandemic, accessing sports equipment and facilities was challenging due to lockdowns and restrictions on physical mobility.Also, with the advent of the pandemic and online classes, students spend most of their time in front of their computers and gadgets (Oducado et al., 2021), further limiting their physical activity.Other variables that may hinder physical activity include poor time management and a disregard for the negative effects of immobility (Thivel et al., 2018).
This study demonstrated that year level predicted the overall level of practice of health promoting of nursing students.Post-hoc analysis revealed that level IV or senior students had significantly higher overall health promoting behaviors than level 1 or first-year (p=.008) and level 2 or second-year (p=.040) students.Similarly, the study of Polat et al. (2016) found that the mean total score of fourth-year students was significantly higher than the other year levels.A significant difference in health promoting behaviors based on the academic level was also noted in other studies conducted elsewhere (Cetinkaya & Sert, 2021;Muller et al., 2022).And while some scholars pointed out that sedentary lifestyle tends to increase with age especially after early adolescence (Tamanal & Kim (2020), it may also be that students in higher academic year levels have acquired more valuable information about the importance of practicing healthy lifestyle and deleterious health outcome of sedentary behavior.College students' drive to modify their lifestyle by gaining additional health knowledge while studying health-related courses may be one factor (Mašina et al., 2017).These may help explain why higher academic levels have better health behaviors than those in the lower academic years.
Also, this study found that the practice of health promoting behaviors of nursing students was influenced by family income.Post-hoc analysis revealed that the upper middle-income class had significantly higher overall health promoting behaviors than the poor to low-income class (p=.046).This finding is supported by the study of Shaheen et al. (2015), whose findings indicated a statistically significant positive association between monthly family income and the average score on all subscales of health promoting behaviors among university students in Jordan.Socioeconomic variation in healthy lifestyle was also noted among university students in Europe (Cicchella et al., 2022).In addition, Ashgar (2021) also found that among adults in Saudi Arabia, those with stable income were more likely to adopt one or more of the health promoting behaviors.The study of Nacar et al. (2014) also noted that health promoting behaviors were higher for those with better economic situations among medical students in Turkey.Money directly influences health through the services and goods people purchase, either helping or harming their health.
Finally, this study demonstrated that perceived academic performance predicted the overall level of practice of health promoting behaviors of nursing students.Results reveal that those with above-average academic performance (p=.000) and average academic performance (p=.000) had significantly higher overall health promoting behaviors than those with failing to below-average academic performance.This finding is supported by the studies of Heidari et al. (2017) and Tamanal & Kim (2020), wherein academic performance was positively related to a healthier lifestyle: the higher the academic achievement, the more the student practices a health promoting lifestyle.Students with high academic performance have lifestyle habits that positively affect their health, including lessening their screen time, regular eating and sleeping schedules, and decreased social media use (Dubuc et al., 2019).Habits that promote the students' academic performance could also promote their well-being.High academically performing students know how to plan effectively, pay attention to their schedules, set attainable goals, and know when they need activity and rest.

Implications and limitations
The study results provide several important implications concerning the practice of health promoting behaviors of nursing students.Since health-related habits continue to affect health after early adulthood, establishing positive health behaviors among college-age students is crucial since altering behavioral patterns in early adulthood is easier.It is vital to identify the level and factors influencing health promoting behaviors to improve and encourage health promoting behaviors among college students.Future healthcare practitioners, such as nursing students, will be crucial in educating patients on good lifestyle choices and serving as role models for healthy living.Nursing students must maintain and promote their personal and professional health.The study findings will also be instrumental in designing and implementing strategies and programs to promote students' health and exploring modification of school policies and environments to help students maintain and encourage their practice of health behaviors.
This study has limitations.The study only focused on the practices of health promoting behaviors reported by nursing students with respect to the six subscales of the HPLP II.The study was limited to undergraduate nursing students in one nursing college in the Philippines.The conclusions drawn from this study cannot be extended to other nursing students who are not included in the sample.Furthermore, because this study utilized a descriptive cross-sectional design, it could not infer causality between variables or follow changes over time.Given the use of online survey questionnaires, self-report bias, subjectivity, and social desirability were also limitations of this study.This study only included selected predictors, and there may also be other factors that may influence health promoting behaviors not included in this study.

Conclusion
This study highlights that while nursing students frequently incorporate health promoting behaviors into their lifestyle, they still seldom engage in physical activities, and regular exercise routines are still not fully integrated into daily activities.Also, this study underscores that certain personal characteristics, such as perceived academic performance, academic year level, and family income influence nursing students' health-promoting behaviors.Nursing students should continue to maintain their health-promoting behavior, and focus should be given to incorporating any form of physical activity into their daily schedule to keep active and maintain holistic wellbeing.

Table 2 .
Level of health promoting behaviors of nursing students (n=363)

Table 4 .
Regression analysis of health promoting behaviors (n=363)