A latent class analysis of multiple health-risk behaviours among Portuguese college students

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Portada REIPE, volumen 11, número 1, 2024
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Published: Jul 1, 2024
DOI: https://doi.org/10.17979/reipe.2024.11.1.10028
Keywords:
university students, health behaviours, well-being

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Regina Alves
Universidade do Minho
https://orcid.org/0000-0001-7189-5487

Abstract

Traditionally, the prevalence of health-risk behaviours is high among university students. Although these behaviours are often analysed in isolation, there is likely evidence for the co-occurrence of multiple risk behaviours. In this study, a latent class analysis (LCA) was conducted with cross-sectional data from 840 Portuguese students (55.4% female) to explore patterns of multiple risk behaviours across seven behavioural dimensions (alcohol consumption, smoking, unhealthy eating, sedentary behaviour, risky sexual practices, illicit drug use, and self-medication). Additionally, a latent class regression was performed to explore predictors (perceived well-being and sociodemographic and academic characteristics) for each behavioural pattern. A three-class model emerged with different probabilities of risk: Low-risk behaviours (51.4%), Moderate-risk behaviors (14.9%), and High-risk behaviours (33.7%). Students with better perceptions of well-being and health were likelier to be in the healthier class. Students in the low- and moderate-risk classes were more likely to be in their first year of study, not in a romantic relationship and to be full-time students. Students who had not changed residence at the beginning of their studies and were female were more likely to be in the healthiest class. This study provides essential strategies for health promotion among university students, offering crucial insights for the design of effective health promotion interventions, especially targeted at specific groups of students with similar patterns of multiple risk behaviours.

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How to Cite
Alves, R. (2024). A latent class analysis of multiple health-risk behaviours among Portuguese college students. Revista de Estudios e Investigación en Psicología y Educación, 11(1). https://doi.org/10.17979/reipe.2024.11.1.10028
Issue
Vol. 11 No. 1 (2024)
Section
Articles
Author Biography

Regina Alves, Universidade do Minho

Research Centre on Child Studies (CIEC), Institute of Education, University of Minho: https://www.ie.uminho.pt
Braga – Portugal

Alves: A latent class analysis of multiple health-risk behaviours among Portuguese college students

Emerging adulthood is a critical period in the lives of young people when health-risk behaviours increase significantly. These behaviours correlate positively with the risk of developing chronic diseases (i.e. cardiovascular disease or cancer) that tend to last throughout life. Globally, more attention should be paid to university students, as empirical evidence shows that they are more likely to engage in health-risk behaviours than non-university young adults (). The most highly correlated health-risk behaviours include an unbalanced diet due to low consumption of fruits and vegetables (; ), the use of psychoactive substances such as tobacco, alcohol and illicit drugs () and lack of physical activity (). Many factors contribute to health-risk behaviours, especially distance from the family of origin ; ) and peer influence ().

Empirical studies typically analyse different health-risk behaviours as isolated measures, although the co-occurrence of multiple risk behaviours is more likely. In this sense, numerous cross-sectional and cohort studies among university students in several countries have relied on latent class analysis (LCA) to show the clustering of health-risk behaviours (; ; ; ; ; ; ; ; ; ), that is, the likelihood that an individual belongs to a particular class, depending on their response profile and the characteristics that distinguish them from others (). The first study to use LCA was developed in 2009 by Laska et al. with US college students to examine lifestyle patterns of health-risk behaviours. In 2014, a study using NCHA data (n = 39 colleges, n = 30,093 students) was published that identified four classes among the five behaviours examined (smoking, excessive alcohol consumption, unhealthy diet, sedentary lifestyle, and overweight or obesity), with clustering of risk behaviours (i.e. the high prevalence of two or more health-risk behaviours) in three of the classes (). Similarly, conducted an LCA of eight risk behaviours (fruit and vegetable consumption, alcohol use, drug use, smoking, marijuana use, sexual health, physical activity and sleep) among Canadian university students. This study found that most students (66%) fell into the ‘typical’ class (low likelihood of smoking and using illicit drugs and low likelihood of eating enough fruits and vegetables and being physically active), followed by the ‘high risk’ class (20%; a low likelihood of eating enough fruits and vegetables, getting enough sleep and being physically active and an increased likelihood of using illicit drugs, smoking and binge drinking).

This person-centred approach is more useful than a variable-centred approach as it allows the identification of multidimensional behavioural patterns () and the provision of personalised interventions after taking into account the characteristics of subgroups categorised on the basis of behavioural patterns (). Despite the importance of this type of study, there is a lack of research in Portugal aimed at classifying university students based on patterns of risk behaviours and analysing how perceptions of well-being may vary based on the grouping of health-risk behaviours. To advance the development of relevant intervention strategies for Portuguese university students, the aim of this study is to examine the patterns of multiple health-risk behaviours (physical activity, eating habits, tobacco use, alcohol use, illicit drug use, self-prescribed medication use and risky sexual behaviour) in a sample of Portuguese university students and to determine the predictors associated with each latent class.

Methods

Participants

This cross-sectional study involved 840 students enrolled at a university in northern Portugal during the 2018-2019 academic year. The participants’ ages ranged from 18 to 54 years (M = 20.8 ± 4.22), only 3% of students were 30 years or older. The majority of participants were female (55.4%), not in a romantic relationship (58.3%), had not changed residence upon entering higher education (64.9%), had a BMI corresponding to normal weight (73.1%) and were full-time students (88.8%). In addition, approximately one-third of the students surveyed were enrolled in engineering (36.0%) or social sciences and humanities (32.1%) programmes, and most of them were in their first year of study (55.2%) (Table 1).

Table 1Sample characteristics (N = 840) 
Characteristics n %
Year of study 1st year 464 55.2
3rd year 376 44.8
Scientific area Engineering sciences 302 36.0
Exact and natural sciences 136 16.2
Law and economic sciences 132 15.7
Human and social sciences 270 32.1
Sex Male 375 44.6
Female 465 55.4
Love relationship Yes 347 41.7
No 486 58.3
Current residence Displaced 291 35.1
Not displaced 537 64.9
BMI Low weight 58 7.1
Normal weight 599 73.1
Overweight 162 19.8
Professional situation Full time student 739 88.8
Worker/Student 93 11.2

Instruments

The students completed a self-report questionnaire consisting of three sections: sociodemographic questions, a health-risk behaviour questionnaire and the Well-Being and Health-Perception Scale (WbHPS).

Sociodemographic and academic questions

While maintaining the anonymity of the research instrument, it was essential to collect some sociodemographic data about the students, including gender, age, marital status, current residence, weight and height (to calculate BMI) and professional situation. In addition, the researcher recorded the year of attendance and the subject area of the course attended at the time of data collection.

Health-risk behaviour questionnaire

This section was divided into seven categories, each corresponding to the health-risk behaviours studied. This questionnaire was developed in three stages (scale construction, content validity, psychometric validity), following the procedures outlined by Bowling () and the Guide to Conducting Knowledge, Attitude, and Practice (KAP) Surveys (). A detailed description can be found in previous studies ().

Tobacco consumption was assessed with the question, ‘Do you currently smoke?’ For the purposes of this study, we dichotomised the ‘smoking’ responses into ‘yes’ (2) and ‘no’ (1).

The alcohol consumption category included the AUDIT-C (frequency of drinking in the past year, amount of alcohol consumed on a typical day and binge drinking) (). The AUDIT-C has a 5-point scale coded from 0 to 4 (range 0-12). A score above 4 points (≥5) for men or above 3 points (≥4) for women is classified as risk consumption: ‘yes’ (2) and ‘no’ (1). In addition, the following question on drunkenness was included: ‘In the last 12 months, how often did you get drunk?’ The response options were ‘never’, ‘once a month or less’, ‘2-4 times a month’, ‘2-3 times a week’ and ‘4 or more times a week’. The answer to the question ‘get drunk’ was also dichotomised into ‘yes’ (2) and ‘no’ (1).

Illicit drug consumption included three questions on the use of cannabis, cocaine and hallucinogens (‘In the last 12 months, how often have you used...?’). Users of illicit drugs were categorised as ‘yes’ (2) and ‘no’ (1).

The prevalence of self-medication was analysed using the question, ‘In the past 12 months, how often have you taken antidepressants, sedatives, relaxants or tranquillisers (without a medical prescription); painkillers or anti-inflammatories (without a medical prescription) or vitamins or food supplements (without a medical prescription)?’ Consumers of antidepressants, painkillers and vitamins for self-medication were categorised as ‘yes’ (2) and ‘no’ (1).

Sexual risk behaviours were divided into four ‘yes’ (2) and ‘no’ (1) response categories: early age (first sexual intercourse at age 16 or younger); multiple partners (two or more sexual partners in the past 12 months); inconsistent condom use (did not use a condom for all sexual intercourse in the past 12 months); and sex, alcohol and drugs (sexual intercourse after alcohol or drug use in the past 12 months).

Healthy eating habits were assessed by the consumption of fruit, vegetables, foods with added sugar and fast food in the last seven days (e.g. ‘In the last seven days, how often did you eat fruit (other than natural fruit juices or drinks)?’ on a scale from 0 = ‘never’ to 5 = ‘3 or more times a day’). In addition, two questions were asked about skipping meals (breakfast, lunch and/or dinner) in the last seven days. For the analyses, the questions were categorised as 1 using a binary method according to the healthy eating guidelines (), taking into account the following: skipping meals (skipping breakfast and skipping lunch and/or dinner at least once a week); low fruit consumption (two or fewer times a day); low vegetable consumption (two or fewer times a day); higher consumption of sweets (four or more times a week) and higher consumption of fast food (four or more times a week).

The Godin Leisure-Time Exercise Questionnaire () assessed physical activity, including total time (in minutes) spent walking and doing moderate or vigorous activity in the previous week. The scores followed the information provided by the authors of the questionnaire. Subsequently, ‘being sedentary’ was classified into ‘yes’ (2) and ‘no’ (1) using a binary method. The following question on sedentariness was also included: ‘On a normal day, how many hours do you spend sitting?’ Again, sitting for more than eight hours per day was classified as high.

Well-being and Health Perception Scale (WbHPS)

Well-being was assessed using the Well-being and Health Perception Scale (WbHPS) (). The WbHPS was answered on a 5-point Likert scale and included the following dimensions: satisfaction with life, satisfaction with oneself, felt happiness, perceived health and satisfaction with physical fitness. The scores for each item were summed, with the highest scores representing a higher level of well-being. The psychometric properties of this scale have been described in detail in previous studies ().

Procedures

The target population consisted of students from a university in northern Portugal enrolled in the first and third years of the undergraduate and integrated master's programmes during the 2018-2019 academic year. The criteria for exclusion were defined as follows: classes from master's or postgraduate programs, as well as classes held in post-working hours, were excluded to limit the population to traditional students; courses without classes in the first and third years were excluded to ensure representation from students across all years of study within the same courses; and classes related to health sciences were excluded due to potential biases, especially concerning their knowledge about health ().

To create a stratified sample based on the year of study and the scientific area, were considered 5447 university students enrolled in the first- and third-year courses, distributed across 47 courses and four subject areas (as defined by the Foundation for Science and Technology): Engineering, Exact and Natural Sciences, Judicial and Economic Sciences, Social Sciences and Humanities. Considering the number of students in each subject area, 16 courses were identified by simple random selection, resulting in 32 first- and third-year classes.

Using G*Power 3.1.9.2 analysis software, the minimum sample size required for this study was 592 students (margin of error = 5%, confidence level = 99% and distribution of responses = 50%). A total of 873 questionnaires were distributed, reflecting the total number of students who were present in the classroom and had agreed to participate in the study. However, 33 questionnaires were considered invalid due to missing or incongruent responses that could call into question the validity of the information collected. The response rate was 96.2% (95% CI: 94.8-97.6).

Data collection was conducted in the classroom in May 2019. Before the paper questionnaires and the informed consent forms were distributed, the research objectives were presented, confidentiality and anonymity of responses were ensured, the voluntary nature of participation was guaranteed, and the right to decline participation or withdraw at any time was explained. All participants gave their consent before completing the questionnaire, which took about 15 minutes to complete.

This study was approved by the Ethics Committee for Research in the Social Sciences and Humanities of the UMinho Ethics Council under protocol CEICSH 009/2019.

Statistical analyses

In the first step, descriptive analysis was conducted for the different variables by analysing frequencies, means and standard deviations using the Statistical Package for the Social Sciences (SPSS) version 28.0 for Windows. In the second step, LCA was conducted with seven categorical observable variables (risky drinking, smoking, unhealthy diet, sedentarism, risky sexual practices, illicit drugs and self-medication practices) to identify patterns of health-risk behaviour. A range of LCA models with two to five classes was explored to determine the number of classes that best represented patterns of health-risk behaviour (). The Akaike Information Criterion (AIC) and the Bayesian Information Criterion (BIC) were considered to determine the optimal number of conceptually significant classes (). In addition, the G2 and log-likelihood (LLIK) values of the estimated model were calculated to select the best-fitting model. Thus, the lowest G2, AIC and BIC values and the highest LLIK value indicated the best-fitting model ().

Entropy was used as an additional criterion to determine the final model. Entropy is a quality criterion for classification, with higher values between 0 and 1 indicating a better fit (). However, as these indices are not uniformly indicative of a single model specification (and may overestimate or underestimate the number of latent classes), model-specific estimates for two-, three- and four-class models were examined to select a final model specification based on the interpretability of the results as well as theory and previous results in the literature, as suggested by . Based on these criteria, we determined that the three-class model was the best fit for the data. All LCA analyses were performed using the GLCA R package in Jamovi software, version 2.3.2. After finalising the model, we performed multinomial logistic regression estimated by odds ratio and the corresponding 95% confidence intervals to analyse the analyses of the predictors (well-being and demographic characteristics) of the classes of health-risk behaviours.

Results

Multiple health-risk behaviours

Table 2 shows the prevalence of the 14 health-risk behaviours in the seven behavioural dimensions under analysis. The prevalence of these behaviours ranged from 7.4% (high consumption of fast food) to 90.4% (insufficient consumption of vegetables), indicating that the prevalence of some risk behaviours (e.g. poor diet and alcohol consumption) was much higher than others. Statistically significant differences were found in the prevalence of certain risk behaviours between male and female students. Drunkenness, use of illicit drugs, early sexual initiation, sexual activity after alcohol and drug use and consumption of sugar products are more common among male students. Conversely, the self-medication with analgesics and sedentary behaviour are more common among female students.

Table 2Multiple health-risk behaviours by sex (N = 840) 
Total Male Female χ 2
n % n % n %
Smoking 168 20.0 85 22.7 83 17.8 3.01
Risky alcohol consumption 337 40.1 152 40.5 185 39.8 .05
Getting drunk 368 43.8 186 49.6 182 39.1 9.23**
Use of illegal drugs 178 22.2 114 31.7 64 14.5 33.75***
Self-medication with antidepressants 111 13.9 27 7.5 84 19.0 3.01
Self-medication with analgesics 326 40.8 116 32.2 210 47.7 19.72***
Self-medication with vitamins 211 26.4 92 25.6 119 27.0 .21
Early age 213 25.4 110 29.3 103 22.2 5.66*
Multiple partners 103 12.3 52 13.9 51 11.0 1.62
Inconsistent condom use 329 39.2 148 39.5 181 38.9 .03
Sex, alcohol and drugs 177 21.1 94 25.1 83 17.8 6.50*
Skipping meals 428 51.0 188 50.3 240 51.6 .15
Insufficient fruit consumption 753 89.9 344 92.0 409 88.1 3.34
Insufficient vegetable consumption 784 94.0 354 95.7 430 92.7 3.30
Higher consumption of fast food 62 7.4 29 7.7 33 7.1 .11
Higher consumption of sweets 465 55.5 222 59.4 243 52.4 4.09*
Sedentariness 298 35.7 106 28.3 192 41.7 16.11***
High sitting time 436 51.9 204 54.4 232 49.9 1.69

* p < .05 ; **p < .01 ; ***p < .001

Latent classes of risk behaviours

Based on the 14 health-risk behaviours analysed, a three-latent-class model was selected after comparing the fit, parsimony and interpretability indices between models with two to five latent classes, as described in the section on statistical analyses and presented in Table 3.

Table 3Summary of information for selecting number of latent classes of multiple health-risk behaviours (N = 840) 
Number of Latent Classes LLIK AIC BIC Entropy G2 df G2 p
2 -7583 15239 15451 .77 4683 802 .08
3 SM -7516 15144 15409 .84 4549 783 .14
4 -7458 15066 15421 .76 4434 764 .10
5 -7416 15020 15464 .79 4349 745 .16
6 -7385 14996 15531 .77 4258 726 .34

Note: SM = Selected model; LLIK = Log-likelihood; AIC = Akaike Information Criterion; BIC = Bayesian information criterion; G2 = Likelihood ratio test statistic.

The probabilities of a 'yes' response for each of the 14 risk behaviours are shown in Table 4 for each latent class. The likelihood of a 'no' response can be calculated by subtracting the item response probabilities from 1. These probabilities indicate the possibility that a student in a particular class will engage in a specific risk behaviour and can be used to characterise the three latent classes in the model.

Table 4Item-response probabilities from the three-latent-class model of multiple health-risk behaviours (N = 840) 
Label 1 Low-risk behaviours 2 Moderate-risk behaviours 3 High-risk behaviours
Latent class prevalences .51 .15 .34
Item-response probabilities Corresponding to a ‘yes’ response
Smoking .05 .15 .45
Risky alcohol consumption .09 .62 .77
Getting drunk .03 1.00 .81
Use of illegal drugs .04 .18 .51
Self-medication with antidepressants .12 .15 .16
Self-medication with analgesics .38 .38 .46
Self-medication with vitamins .23 .13 .36
Early age .17 .06 .46
Multiple partners .29 .00 .32
Inconsistent condom use .29 .17 .65
Sex, alcohol and drugs .02 .00 .59
Skipping meals .44 .43 .66
Insufficient fruit consumption .89 .96 .89
Insufficient vegetable consumption .93 .99 .94
Higher consumption of fast food .05 .48 .13
Higher consumption of sweets .55 .52 .58
Sedentariness .38 .42 .29
High sitting time .58 .48 .44

Note: Major probabilities are in bold to highlight the overall pattern.

Class 1 (labelled ‘low-risk behaviours’) represents the majority of students in the sample (51.4%) and is considered the healthiest class. These students were more likely to be physically active (61.7%), although they were more likely to sit for more than eight hours a day (58.2%) and more likely not to smoke (94.7%), not have risky alcohol consumption (90.0%) and/or not use illicit drugs (96.1%). However, students in this class were not likely to consume the recommended amounts of fruit (88.7%) and vegetables (92.7%).

Class 2 (labelled 'moderate risk behaviours’) represents the students (14.9%) at moderate risk of engaging in health-risk behaviours. Students in this class were more likely to have been drunk in the past year (100%), to have consumed too few fruits (96.4%) and vegetables (98.9%), and to have eaten fast food several times a week (48.3%). In addition, students with a high probability of alcohol consumption classified as risky belonged to this class (62.4%). Notwithstanding this, and similar to the ‘low-risk behaviour’ class, the moderately healthy students were less likely to smoke (14.8%), use illicit drugs (17.6%) and take non-prescribed medications such as antidepressants (14.9%), painkillers (37.7%) and vitamins (13.0%). Of the three classes identified, these students were least likely to engage in the following risky sexual behaviours: early age (6.3%), multiple partners (0.16%), inconsistent condom use (16.6%), sex, alcohol and drugs (< .001%).

Class 3 (labelled ‘high-risk behaviours’; 33.7%) exhibited high-risk behaviours in all dimensions except for sedentariness. For example, students in this class were more likely to smoke (44.7%), have risky alcohol consumption (77.4%), get drunk (81.2%) and use illicit drugs (50.8%) but less likely to be physically inactive (29.4%) and sit too long during the day (44.1%). In addition, this class was the most likely to take without prescription medications such as antidepressants (16.4%), painkillers (46.2) and vitamins (36.3%) and engage in the following risky sexual behaviours: early age (46.2%), multiple partners (31.9%), inconsistent condom use (65.2%) and sex, alcohol and drugs (59.1%). In addition, the members of this group reported unhealthy eating habits, such as a high likelihood of skipping meals (65.8%), consuming sugary products (58.1%), and eating too little fruit (88.7%) and vegetables (93.8%).

Sociodemographic and well-being predictors as a function of latent classes of health-risk behaviours

Based on the class with the higher probability of risk behaviours, the probability of belonging to the healthiest class ('low-risk behaviours’) increased by 1.06 times for each additional point in the WbHPS. Similarly, being female increased the likelihood of belonging to Class 1 by 24.1% compared to Class 3 and by 10.3% compared to Class 2. Students who had not changed their residence when beginning their university studies were 1.98 and 1.83 times more likely to be in Class 1 than Class 3 and 2, respectively. Being in the first year of study, not being in a romantic relationship and being a full-time student increased the likelihood of being in the healthiest and moderately healthy classes compared to Class 3 (‘high-risk behaviours’) (Appendix).

Discussion

This study revealed distinct patterns of multiple health-risk behaviours among Portuguese university students, namely the existence of three recognisable classes. These classes included students prone to engaging in health-risk behaviours (33.7%) and students with low (51.4%) and moderate (14.9%) risks of engaging in risky behaviours. These classes were similar to previous studies with university students regarding class division (; ; ; ; ; ). However, this study shows a higher proportion of students in the high-risk class, whereas previous studies showed a higher proportion of students with moderate-risk behaviour patterns.

Of concern is that the vast majority of students, regardless of class, were very likely to consume too few fruits and vegetables and too many sugary products. Similarly, in the study conducted by , nursing students were found to be the most likely to have unhealthy diets across all latent classes. These results demonstrate that while public health has traditionally focused on reducing certain risk behaviours, such as tobacco, alcohol and illicit drugs (; ), other risk behaviours associated with non-communicable diseases, such as dietary habits, also deserve attention. These behavioural patterns may reflect difficulties such as the cost and accessibility of fruit and vegetables or the difficulty of preparing healthy meals.

Sedentary lifestyles and the amount of time students spend sitting during the week may be related to the number of consecutive lessons and their duration. Therefore, teachers should encourage students to get up and move around after a prolonged sitting period (). As this is a new phase of life where students have to balance their personal lives with academic, family and social commitments, it is not surprising that students may place less emphasis on physical activity during this stage (; ).

Regarding alcohol consumption, both ‘moderate risk behaviours’ and ‘higher risk behaviours’ were highly likely to involve binge drinking and drunkenness. Other studies have also found that binge drinking is among the highest health-risk classes (). Thus, alcohol consumption should also be discouraged through university health promotion programmes.

The multinomial regression analysis indicated that students in the healthiest class were more likely to be female, in their first year of study, to be full-time students, not to be in a romantic relationship, and not to have moved when they began their studies. Similarly, previous research has shown that male and younger students were likelier to be in unhealthy or moderate lifestyle classes than the healthier ones (; ). With this in mind, it is critical to intervene with students in their first year of university study when new experiences significantly influence behavioural choices.

This study also analysed how perceptions of health and well-being were related to patterns of multiple risk behaviours. Overall, the results showed that students with a higher level of well-being were less likely to belong to a class with a high number of risk behaviours. This finding is consistent with other studies showing that higher risk patterns in multiple behaviours are associated with poorer mental health outcomes, namely psychological distress and stress (; ; ), with the inverse relationship also demonstrated. In other words, there is a bidirectional effect between health-risk behaviours and mental health indicators (e.g. happiness, life satisfaction and depression) (; ; ).

Strengths and limitations of the study

To our knowledge, this is the first study to analyse complex patterns of health-risk behaviours among Portuguese university students across a wide range of behaviours, focusing on their relationship with perceived well-being and health. Not only do the results provide critical information about students' behavioural patterns and help in the development of health promotion strategies, but this study also demonstrates the usefulness of sophisticated analytical tools such as LCA to understand complex behaviours that would not be possible with statistical approaches such as linear regression.

Although a relatively new statistical analysis was used to analyse the clustering of multiple health-risk behaviours among university students and, because it is a model-based approach, to estimate the actual probability of an outcome as a function of latent class membership (), this study has some limitations that should be considered when interpreting the results. First, it should be noted that this is a cross-sectional study whose data were only collected at one Portuguese public university. Therefore, it is not possible to generalise the results to students from other universities or young people in the same age group or to establish causal relationships. Secondly, a self-report questionnaire was used, which might have led to a bias in the responses due to social desirability. However, validated tools were used to minimise this, and confidentiality and anonymity were guaranteed.

Note that health-risk behaviours were assessed on different time scales (e.g. last seven days, last 30 days, last 12 months), and seasonal effects were not captured. Although measures with more extended time scales were intended to capture the less prevalent health-risk behaviours (e.g. illicit drug use), consistency across all behaviours would be ideal. Furthermore, even though data collection was carried out during an academic period that excluded festivities, the described behaviors may not accurately reflect the pattern of behaviors, especially concerning dietary habits in the past seven days. Similarly, specific periods of self-medication were not considered, such as during study and exam preparation. It is noteworthy that the use of electronic cigarettes or heated tobacco products was not considered, as the use of these tobacco products was minimal among university students (). Another limitation worth mentioning is the exclusion of students from health science courses. This decision was made considering the potential bias that could be introduced (). It is essential to emphasize that this methodological choice by no means implies a disregard for the importance of investigating the behaviours of students in these fields in future studies. Additionally, it is crucial to acknowledge that a meta-analysis conducted by identified a significantly higher prevalence of self-medication practices with antibiotics among medical students compared to students in other scientific disciplines.

Even though dichotomising risk variables is common in LCA and contributes to the interpretability and communication of findings, categorising data in this way may lead to some loss of meaning. Finally, while we included several sociodemographic and academic factors in the analysis, others may be relevant to the analysis of health-risk behaviours, such as students' socioeconomic status. Therefore, future studies should include other variables and conduct longitudinal analyses to assess the same students over time.

Practical implications and future studies

This study highlights the need for a reorientation of health services and higher education institutions to ensure that efforts are focused on promoting healthy behaviours that are already commonly targeted, such as smoking and drug use, but also dietary eating habits. In addition, the Healthy Campus 2020 guidelines () advocate for a greater focus on nutrition and physical activity among young adults. However, higher education institutions need more initiatives to promote healthy, active lifestyles to achieve these goals.

Furthermore, there is a need for continued research on this topic to better understand the patterns of health-risk behaviours and their relationship to well-being among university students. Future research should therefore include longitudinal studies to analyse the behavioural changes in students' profiles and their mental health status throughout their time at university. This further investigation can be used to determine the timing of interventions to support student health and well-being and to target interventions at specific classes of students.

Current strategies for health promotion for university students are generally most effective for the majority of the university population, such as integrating health promotion activities into curricula. However, the results of this study suggest that at-risk groups need a tailored intervention. This intervention can be health promotion materials that target the different health-risk behaviours together rather than addressing them individually. By simultaneously addressing several target health-risk behaviours, people can transfer their knowledge and experience from one behaviour to another. Although it is not clear which approach is most effective (single behaviour or multi-behaviour) (), it must always be taken into account that, on the one hand, risk behaviours are interrelated and co-occur, and, on the other hand, separate approaches may be needed for certain risk behaviours, especially in the case of illicit drug use. Finally, any strategies developed to promote health and well-being in higher education should be consistent with the International Charter for Health-Promoting Universities and Colleges guidelines () and focus on both the academic environment and support for individual students.

Conclusion

This study makes an important contribution to the literature on health-risk behaviours in higher education by identifying three classes of behaviours in a sample of Portuguese university students. Common to all latent classes were unhealthy eating habits and sedentary behaviour. In addition, students who belonged to the classes most likely to engage in risky behaviours were found to experience lower levels of well-being. These findings underscore the need for higher education institutions to implement socio-educational programmes aimed at preventing the adoption of unhealthy habits upon entering higher education. Such programmes would enable students to make informed and responsible choices. There is also a call for psychosocial interventions that facilitate students' reflection on their well-being and happiness, thereby contributing to their holistic development. Furthermore, these findings highlight the need to support and target the development of activities for the classes of students most likely to engage in risky behaviours.

References

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Appendix

Adjusted odds ratios (OR) and 95% confidence intervals (CI) from multinomial logistic regression model about class on sociodemographic variables and well-being 
Class Predictor OR 95% CI
1 - 3 Predictor 0.0852 0.0222 0.328
Intercept 1.0600* 1.0067* 1.116*
WbHPS 1.5313* 1.0988* 2.134*
Year study: 1st year - 3rd year
Scientific area: 0.9734 0.5831 1.625
Exact and natural sciences - Engineering sciences 0.7829 0.4657 1.316
Law and economic sciences - Engineering sciences 0.9370 0.6054 1.450
Human and social sciences - Engineering sciences 1.8026* 1.2414* 2.618*
Sex: Female - Male 1.5356* 1.0972* 2.149*
Love relationship: No - Yes 2.8107* 1.9788* 3.992*
Current residence: Not displaced - Displaced 1.7270* 1.0491* 2.843*
Professional Situation: Full time student - Worker/Student
BMI: 0.8723 0.4448 1.711
Normal weight - Low weight 1.0876 0.5125 2.308
2 - 3 Overweight - Low weight 0.1076 0.0182 0.636
Intercept 1.0129 0.9474 1.083
WbHPS 2.1099* 1.3436* 3.313*
Year study: 1st year - 3rd year
Scientific area: 1.3818 0.7362 2.593
Exact and natural sciences - Engineering sciences 0.9212 0.4651 1.824
Law and economic sciences - Engineering sciences 0.7707 0.4270 1.391
Human and social sciences - Engineering sciences 1.0283 0.6321 1.673
Sex: Female - Male 2.0832* 1.3086* 3.316*
Love relationship: No - Yes 1.0033 0.6454 1.560
Current residence: Not displaced - Displaced 2.5167* 1.0657* 5.943*
Professional Situation: Full time student - Worker/Student
BMI: 0.6866 0.3005 1.569
Normal weight - Low weight 0.5007 0.1899 1.320
1 - 2 Overweight - Low weight 0.792 0.142 4.420
Intercept 1.047 0.981 1.117
WbHPS 0.726 0.471 1.118
Year study: 1st year - 3rd year
Scientific area: 0.704 0.392 1.265
Exact and natural sciences - Engineering sciences 0.850 0.441 1.638
Law and economic sciences - Engineering sciences 1.216 0.694 2.131
Human and social sciences - Engineering sciences 1.753* 1.103* 2.786*
Sex: Female - Male 0.737 0.472 1.151
Love relationship: No - Yes 2.801* 1.828* 4.293*
Current residence: Not displaced - Displaced 0.686 0.292 1.613
Professional Situation: Full time student - Worker/Student
BMI: 1.271 0.605 2.670
Normal weight - Low weight 2.173 0.895 5.275

Note: OR: odds ratio; 95% CI: 95% confidence intervals; AIC = 1533; χ 2 (22) = 109, p < .001 ; *p < .05