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Are Health Behaviors Associated with Mental Health among Tertiary Education Students? A Systematic Review of Cohort Studies

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Title: Are Health Behaviors Associated with Mental Health among Tertiary Education Students? A Systematic Review of Cohort Studies
Language: English
Authors: Melinda Hutchesson (ORCID 0000-0002-1851-0661), Megan Whatnall, Sasha Fenton, Lee Ashton, Amanda Patterson, Jordan Smith (ORCID 0000-0003-4640-8645), Mitch J. Duncan, Frances Kay-Lambkin, Tracy Burrows
Source: Journal of American College Health. 2025 73(1):111-123.
Availability: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 13
Publication Date: 2025
Document Type: Journal Articles
Information Analyses
Reports - Research
Education Level: Higher Education
Postsecondary Education
Descriptors: College Students, Mental Health, Health Behavior, Eating Habits, Physical Activity Level, Life Style, Drinking, Sleep, Smoking, Drug Use, Intervention, Student Characteristics, Foreign Countries
Geographic Terms: United States, Canada, China, United Kingdom, Bangladesh, Finland, Brazil, India, Germany
DOI: 10.1080/07448481.2023.2201865
ISSN: 0744-8481
1940-3208
Abstract: Objective: To evaluate the association between health behaviors with mental health among tertiary education students. Methods: Six databases were searched until September 2021 for prospective cohort studies evaluating the association between health behavior(s) (dietary intake, physical activity, sedentary behavior, alcohol intake, sleep, smoking or illicit drug use) and mental health. Two independent reviewers screened records for inclusion, extracted data and completed risk of bias assessments. Results: 33 studies were included (14 assessed sleep, 14 alcohol intake, 13 physical activity, 8 smoking, 6 sedentary behavior, 4 diet, 1 illicit drug use). A consistent association between poor sleep, and physical inactivity with increased risk of poor psychological wellbeing, and between poor sleep and increased mental ill-health related outcomes was demonstrated. Conclusion: Findings suggest interventions to address poor sleep and physical inactivity among students may positively impact mental health. Further research of other health behaviors, and their association with mental health, is required.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1456873
Database: ERIC
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  Value: <anid>AN0182090937;acl01jan.25;2025Jan09.01:40;v2.2.500</anid> <title id="AN0182090937-1">Are health behaviors associated with mental health among tertiary education students? A systematic review of cohort studies </title> <p>Objective: To evaluate the association between health behaviors with mental health among tertiary education students. Methods: Six databases were searched until September 2021 for prospective cohort studies evaluating the association between health behavior(s) (dietary intake, physical activity, sedentary behavior, alcohol intake, sleep, smoking or illicit drug use) and mental health. Two independent reviewers screened records for inclusion, extracted data and completed risk of bias assessments. Results: 33 studies were included (14 assessed sleep, 14 alcohol intake, 13 physical activity, 8 smoking, 6 sedentary behavior, 4 diet, 1 illicit drug use). A consistent association between poor sleep, and physical inactivity with increased risk of poor psychological wellbeing, and between poor sleep and increased mental ill-health related outcomes was demonstrated. Conclusion: Findings suggest interventions to address poor sleep and physical inactivity among students may positively impact mental health. Further research of other health behaviors, and their association with mental health, is required.</p> <p>Keywords: Mental health; college student; health behavior; systematic review</p> <hd id="AN0182090937-2">Introduction</hd> <p>Mental ill-health has global impacts, with approximately 10% of individuals experiencing a mental health disorder.[<reflink idref="bib1" id="ref1">1</reflink>] The onset of mental health disorders occurs before age 25 for approximately two thirds (62.5%) of cases,[<reflink idref="bib2" id="ref2">2</reflink>] and young adults experience the highest rates of mental ill-health than any other adult life stage. Tertiary education students, including university students, are particularly vulnerable to mental ill-health. Global data demonstrates that approximately one-third of students in their first year of university study screened positive for at least one DSM-IV mental disorder,[<reflink idref="bib3" id="ref3">3</reflink>] and 94% of students report experiencing stress.[<reflink idref="bib4" id="ref4">4</reflink>]</p> <p>Evidence suggests that the health behaviors of tertiary education students, including physical activity, sedentary behavior, sleep, alcohol and drug use, tobacco smoking, and dietary intake are also often adversely impacted during this unique life stage.[<reflink idref="bib5" id="ref5">5</reflink>]<sups>,</sups>[<reflink idref="bib6" id="ref6">6</reflink>] For instance, data from the National College Health Assessment show high rates of health risk behaviors, e.g., 56% of students are not meeting physical activity guidelines and 44% are sleeping less than recommended.[<reflink idref="bib5" id="ref7">5</reflink>] Moreover, the literature shows that health risk behaviors often co-occur in tertiary education students[[<reflink idref="bib7" id="ref8">7</reflink>], [<reflink idref="bib9" id="ref9">9</reflink>]] with data from the National College Health Assessment indicating that 85% of students experience two or more health risk behaviors.[<reflink idref="bib6" id="ref10">6</reflink>]</p> <p>The higher rates of mental ill-health and poor health behaviors exhibited by university students may be linked to the unique transitions they experience during this time in their lives. For example, university students often experience changes to living arrangements, geographical separation from families, new financial responsibilities, the need to balance study with work, family, social and other commitments, and new academic expectations. Any of these lifestyle changes may adversely impact the students' stress/anxiety levels, financial status and their time availability and motivation to pursue and maintain healthy lifestyle behaviors such as regular physical activity, adequate sleep duration and a healthy diet.</p> <p>Previous research demonstrates that relationships exist between health behaviors and mental health in adults, or more specifically that engaging in higher risk lifestyle behaviors are associated with increased risk of mental ill-health.[[<reflink idref="bib7" id="ref11">7</reflink>], [<reflink idref="bib9" id="ref12">9</reflink>], [<reflink idref="bib11" id="ref13">11</reflink>], [<reflink idref="bib13" id="ref14">13</reflink>], [<reflink idref="bib15" id="ref15">15</reflink>], [<reflink idref="bib17" id="ref16">17</reflink>]] A 2020 systematic meta-review examined the impact of health behaviors, including physical activity, sleep, tobacco smoking and diet on the risk and treatment outcomes of multiple indicators of mental ill-health (e.g. depression, anxiety, schizophrenia and bipolar disorder).[<reflink idref="bib7" id="ref17">7</reflink>] The meta-review concluded that there is substantial evidence of the protective effect of physical activity in the prevention of mental ill-health, significant evidence that poor sleep increases the risk of mental ill-health, and increasingly strong evidence implicating tobacco smoking as a causal factor in the onset of mental ill-health. Although the findings for diet were less clear, overall, the review concluded that the evidence synthesis added further support for health behavior interventions being part of routine service delivery for the treatment and prevention of mental ill-health.[<reflink idref="bib7" id="ref18">7</reflink>]</p> <p>To-date, systematic reviews have explored associations between individual health risk behaviors and mental health among the general population and young adults.[[<reflink idref="bib7" id="ref19">7</reflink>], [<reflink idref="bib9" id="ref20">9</reflink>], [<reflink idref="bib11" id="ref21">11</reflink>], [<reflink idref="bib13" id="ref22">13</reflink>], [<reflink idref="bib15" id="ref23">15</reflink>], [<reflink idref="bib17" id="ref24">17</reflink>]] To the authors' knowledge, no previous systematic reviews have evaluated the association between multiple health behaviors and mental health among tertiary education students. Nor have previous systematic reviews focused on the longitudinal changes in health behaviors that occur during enrollment, and their associations with mental health, with many including predominantly cross-sectional studies. Therefore, the aim of this systematic review is to describe associations between health behaviors (i.e., dietary intake, physical activity, sedentary behavior, alcohol intake, sleep, smoking and illicit drug use) and mental health outcomes among tertiary education students, using evidence from prospective cohort studies. Evidence from the systematic review can inform the development of interventions tailored to tertiary education students. This is important given the unique life transitions that they face, the prevalence of health risk behaviors and the impact on their mental health.</p> <hd id="AN0182090937-3">Materials and methods</hd> <p></p> <hd id="AN0182090937-4">Protocol and registration</hd> <p>The protocol for the systematic review was registered with Open Science Framework (https://osf.io/wysju). The outcomes of the systematic review exploring associations between health behaviors and academic and/or mental health outcomes in tertiary education students have been divided across two papers. The findings related to academic performance have been previously published;[<reflink idref="bib18" id="ref25">18</reflink>] this paper focuses on the mental health outcomes. The conduct and reporting of the systematic review is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.[<reflink idref="bib19" id="ref26">19</reflink>]</p> <hd id="AN0182090937-5">Eligibility criteria</hd> <p>Studies included in the systematic review had to meet eligibility criteria for the type of participants, exposures, outcomes, and study design, that were established a priori (Table 1).</p> <p>Table 1. Eligibility criteria for the systematic review.</p> <p> <ephtml> <table><tbody valign="top"><tr><td>Participants</td><td>Tertiary education students (i.e., those enrolled in academic education as well as advanced vocational or professional education as per the UNESCO International Standard Classification of Education 2011)<xref ref-type="table-fn" rid="tfn1">a</xref></td></tr><tr><td>Exposure</td><td>One or more health behaviors must have been self-reported or objectively measured during the student's tertiary education enrollment. The health behaviors were included based on the following definitions: <italic>Dietary intake:</italic> energy, macro/micronutrients, or food group intake, as well as diet quality, or dietary or eating patterns. <italic>Physical activity</italic>: total energy expenditure, frequency or duration of physical activity in total or at different intensities or modes (e.g. aerobic, resistance). <italic>Sedentary behavior</italic>: frequency and duration of sitting time or screen time. <italic>Alcohol intake:</italic> frequency or quantity of alcohol intake, as well as alcohol dependence. <italic>Sleep: sleep</italic> duration, quality, timing or alertness. <italic>Smoking</italic> included tobacco smoking or e-cigarettes. <italic>Illicit drug use:</italic> frequency or quantity of use of illegal drugs, misuse or non-medical use of pharmaceutical drugs, or inappropriate use of other substances (such as inhalants), as well as drug dependence. Cannabis was included in this category.</td></tr><tr><td>Outcomes</td><td>One or more mental health outcome must have been measured, and the association between a health behavior and mental health outcome reported. Mental health outcomes included psychological well-being, or the absence or occurrence of mental illness/mental health disorders. Mental illness/mental health disorders including depression, anxiety, schizophrenia, bipolar mood disorder, personality disorders and eating disorders. Psychological well-being including hedonic (e.g. happiness, positive emotions) and eudemonic (e.g. self-acceptance, autonomy) domains.</td></tr><tr><td>Study design</td><td>Only prospective cohort studies were considered for inclusion in the review. Retrospective or cross-sectional analyses were excluded.</td></tr></tbody></table> </ephtml> </p> <p>1 <sups>a</sups>United Nations Educational Scientific and Cultural Organization (UNESCO). International Standard Classification of Education (ISCED) 2011. Montreal, Canada; 2012.</p> <hd id="AN0182090937-6">Information sources and search strategy</hd> <p>Six electronic databases (MEDLINE, EMBASE, PsycINFO, Web of Science, CINAHL and CENTRAL) were searched from the date of inception to 4 September 2021, with searches limited to studies published in English and involving human subjects. A senior medical librarian developed the search strategy in consultation with the review team (Supplementary Table 1). The reference lists of all included studies were also searched for relevant articles, and relevant articles from a previous systematic review were included.[<reflink idref="bib20" id="ref27">20</reflink>]</p> <hd id="AN0182090937-7">Study selection</hd> <p>Study selection was managed in Covidence systematic review software (Veritas Health</p> <p>Innovation, Melbourne, Australia). All records from the search, with duplicates removed, were uploaded to Covidence. Two independent reviewers screened the title, abstracts and keywords of all identified records (M.H. and M.W., L.A., or T.B.) against the eligibility criteria. Records that appeared to meet the eligibility criteria or where it was uncertain, proceeded to full text review. The full articles were retrieved and reviewed by two independent reviewers (M.H. and M.W.) against the eligibility criteria, with a third reviewer used in the case of any disagreements (A.P.). Reasons for exclusion were recorded consistent with the eligibility criteria.</p> <hd id="AN0182090937-8">Data extraction</hd> <p>Data were extracted by one reviewer (K.S or S.F.), and checked by a second reviewer (S.F or M.H.). The data collection form was developed for the purposes of the review, and pilot-tested prior to implementation. Data extracted included study characteristics (e.g. country, year), participants (e.g. number, age, and gender), exposure (type and measurement method of health behavior), outcomes (type and measurement method for mental health outcomes) and study results (i.e. the association between health behaviors and mental health outcomes).</p> <hd id="AN0182090937-9">Risk of bias in individual studies</hd> <p>Risk of bias was assessed using the 11-item Joanna Briggs Institute Critical Appraisal tool (Checklist for Cohort Studies).[<reflink idref="bib21" id="ref28">21</reflink>] The tool was completed at the study level by two independent reviewers (KS and MW, TB or SF.), with a third reviewer consulted on any disagreements (M.H.). Questions were assessed as yes, no, unclear or not applicable. The overall risk of bias for each study was classed as high if three or more criteria were 'no' or 'unclear', or otherwise low risk.</p> <hd id="AN0182090937-10">Data synthesis</hd> <p>Data were analyzed using the vote counting method of Sallis et al.,[<reflink idref="bib22" id="ref29">22</reflink>] where the following categorizations apply: if 0 to 33% of studies reported a significant association, the results were classified as "no association"; if 34 to 59% of studies reported a significant association, the results were classified as "inconsistent"; and if 60% or more of studies reported a significant association, the result was classified as "positive" or "negative" based on the direction of the association. If fewer than four studies reported on that outcome the results were classified as "uncertain". Associations were classified as "positive" if the presence of the health risk behavior (e.g. smoking, illicit drug use, physical inactivity) was associated with an increased risk of a poor mental health outcome. For example, if one study reported a positive association between physical inactivity and higher risk of incident depression and another study reported a negative association between physical activity and lower risk of incident depression these results were both coded as positive. The vote counting method was applied for each health behavior individually, and psychological well-being, and mental ill-health related outcomes were reported separately.</p> <hd id="AN0182090937-11">Results</hd> <p></p> <hd id="AN0182090937-12">Description of included studies</hd> <p>A total of 9438 unique articles were identified. From this, 33 studies were included (Figure 1). A summary of study characteristics is provided in Table 2, and detailed characteristics are presented in Supplementary Table 2. The majority of the studies were published since 2016 (n = 24; 73%), and fifty-four percent of the cohorts were from tertiary education institutions in North America (n = 18). All studies were in a university/college setting. While all studies were prospective cohort studies, the number of follow-up points and study duration were variable. The median number of follow-up points was two but ranged from one to 17. The duration of follow-up was most commonly (n = 21 studies, 63%) less than one year (or academic year), with many (n = 11, 33%) one semester or less.</p> <p>DIAGRAM: Figure 1. Flow diagram of included studies.</p> <p>Table 2. Summary of study characteristics in 33 studies exploring associations between health behaviors and mental health in tertiary education students.</p> <p> <ephtml> <table><thead><tr><td /><td>n</td><td>%</td></tr></thead><tbody valign="top"><tr><td>Publication year</td><td><2000</td><td char=".">0</td><td char=".">0</td></tr><tr><td>2000–2005</td><td char=".">2</td><td char=".">6</td></tr><tr><td>2006–2010</td><td char=".">1</td><td char=".">3</td></tr><tr><td>2011–2015</td><td char=".">6</td><td char=".">18</td></tr><tr><td>2016–2020</td><td char=".">24</td><td char=".">73</td></tr><tr><td>Country</td><td>USA</td><td char=".">12</td><td char=".">36</td></tr><tr><td>Canada</td><td char=".">6</td><td char=".">18</td></tr><tr><td>China</td><td char=".">5</td><td char=".">15</td></tr><tr><td>UK</td><td char=".">4</td><td char=".">12</td></tr><tr><td>Bangladesh</td><td char=".">2</td><td char=".">6</td></tr><tr><td>Brazil</td><td char=".">1</td><td char=".">3</td></tr><tr><td>Finland</td><td char=".">1</td><td char=".">3</td></tr><tr><td>India</td><td char=".">1</td><td char=".">3</td></tr><tr><td>China & Germany (multi-country study)</td><td char=".">1</td><td char=".">3</td></tr><tr><td>Number of participants at baseline</td><td>Total</td><td char=".">63,374</td></tr><tr><td>Median</td><td char=".">1057</td></tr><tr><td>Range</td><td char=".">28–15,396</td></tr><tr><td>Sex/Gender</td><td>Average proportion of females</td><td char=".">65.2</td></tr><tr><td>Average proportion of males</td><td char=".">34.8</td></tr><tr><td>Age (years)</td><td>Mean (SD)</td><td char=".">19.9 (1.2)</td></tr><tr><td>Young adults (16–31 years)</td><td char=".">14</td><td char=".">42</td></tr><tr><td>Adults (18 years and over)</td><td char=".">2</td><td char=".">6</td></tr><tr><td>Age range not reported/unclear</td><td char=".">17</td><td char=".">52</td></tr><tr><td>Ethnicity</td><td>Predominantly white</td><td char=".">14</td><td char=".">42</td></tr><tr><td>Predominantly nonwhite</td><td char=".">6</td><td char=".">18</td></tr><tr><td>Not reported</td><td char=".">13</td><td char=".">39</td></tr><tr><td>Type of student enrollment</td><td>Undergraduate students</td><td char=".">28</td><td char=".">85</td></tr><tr><td>Undergraduate and postgraduate students</td><td char=".">0</td><td char=".">0</td></tr><tr><td>Unclear/Not reported</td><td char=".">5</td><td char=".">15</td></tr><tr><td>Type of student enrollment</td><td>Students enrolled in health or medical degrees/courses</td><td char=".">6</td><td char=".">18</td></tr><tr><td>Student's degree/course not specified</td><td char=".">27</td><td char=".">82</td></tr><tr><td>Health behavior/s assessed</td><td>Alcohol intake</td><td char=".">14</td><td char=".">42</td></tr><tr><td>Sleep</td><td char=".">14</td><td char=".">42</td></tr><tr><td>Physical activity</td><td char=".">13</td><td char=".">39</td></tr><tr><td>Smoking</td><td char=".">8</td><td char=".">24</td></tr><tr><td>Sedentary behavior</td><td char=".">6</td><td char=".">18</td></tr><tr><td>Dietary intake</td><td char=".">4</td><td char=".">12</td></tr><tr><td>Illicit drug use</td><td char=".">1</td><td char=".">3</td></tr><tr><td>Assessed 1 health behavior</td><td char=".">21</td><td char=".">64</td></tr><tr><td>Assessed 2 health behaviors</td><td char=".">6</td><td char=".">18</td></tr><tr><td>Assessed >2 health behaviors</td><td char=".">6</td><td char=".">18</td></tr><tr><td>Number of times health behavior/s were measured</td><td>1</td><td char=".">8</td><td char=".">24</td></tr><tr><td>>1</td><td char=".">25</td><td char=".">76</td></tr><tr><td>Type of mental health outcome/s assessed</td><td>Mental illness/mental health disorders</td><td char=".">20</td><td char=".">61</td></tr><tr><td>Psychological well being</td><td char=".">18</td><td char=".">55</td></tr><tr><td>Mental health composite measure</td><td char=".">2</td><td char=".">6</td></tr><tr><td>Length of follow up</td><td>≤ one academic semester</td><td char=".">11</td><td char=".">33</td></tr><tr><td>> one academic semester to one year/academic year</td><td char=".">10</td><td char=".">30</td></tr><tr><td>> one to 4 years/academic years</td><td char=".">11</td><td char=".">33</td></tr><tr><td>Not reported/Unclear</td><td char=".">1</td><td char=".">3</td></tr><tr><td>Number of follow up time points</td><td>Median</td><td char=".">2</td></tr><tr><td>Range</td><td char=".">1–17</td></tr><tr><td>Mean retention rate<xref ref-type="table-fn" rid="tfn2">a</xref></td><td>Mean (SD)</td><td char=".">74 (23)</td></tr></tbody></table> </ephtml> </p> <p>2 <sups>a</sups>Based on 29 studies as n = 4 studies did not clearly report retention rate.</p> <hd id="AN0182090937-13">Description of study designs and participant characteristics</hd> <p>There was a total of 63,374 participants across the included cohorts, ranging from 28 to 15,396 participants per cohort. All participants were university or college students, with no studies set in other tertiary education institutions. Eighty-eight percent of cohorts (n = 29) included both males and females, with an average of 65% female participants. The mean age of participants was 19.9 years. Sixty-one percent of the cohorts (n = 20) reported ethnicity; within these cohorts' participants were predominantly white. Most cohorts (n = 28, 85%) reported the type of student enrollment, and of these all studies recruited undergraduate students.</p> <hd id="AN0182090937-14">Description of exposure measures</hd> <p>The number of health behaviors measured ranged from one to six per study, with 21 studies (64%) measuring one health behavior, 6 studies (18%) two health behaviors, and the remaining six studies (18%) measuring three to six health behaviors. The most measured health behaviors were alcohol intake and sleep (n = 14 studies each, 42%), followed by physical activity (n = 13 studies, 39%), and the least commonly measured behavior was illicit drug use (n = 1 study, 3%). Despite 12 studies measuring more than one type of health behavior, only two studies of these considered the combined exposure to the health behaviors (i.e. concomitant smoking and alcohol intake,[<reflink idref="bib23" id="ref30">23</reflink>] and sedentary behavior and physical activity).[<reflink idref="bib24" id="ref31">24</reflink>] In 25 (76%) of the studies health behavior/s were measured at multiple time points (i.e. measuring change in the health behavior).</p> <hd id="AN0182090937-15">Alcohol intake</hd> <p>Fourteen studies measured alcohol intake as an exposure measure.[<reflink idref="bib23" id="ref32">23</reflink>]<sups>,</sups>[[<reflink idref="bib25" id="ref33">25</reflink>], [<reflink idref="bib27" id="ref34">27</reflink>], [<reflink idref="bib29" id="ref35">29</reflink>], [<reflink idref="bib31" id="ref36">31</reflink>], [<reflink idref="bib33" id="ref37">33</reflink>], [<reflink idref="bib35" id="ref38">35</reflink>], [<reflink idref="bib37" id="ref39">37</reflink>]] All 14 studies measured alcohol intake via self-report surveys, and 12 (86%) measured alcohol intake at multiple time points.[[<reflink idref="bib26" id="ref40">26</reflink>], [<reflink idref="bib28" id="ref41">28</reflink>], [<reflink idref="bib30" id="ref42">30</reflink>], [<reflink idref="bib32" id="ref43">32</reflink>], [<reflink idref="bib34" id="ref44">34</reflink>], [<reflink idref="bib36" id="ref45">36</reflink>]] Ten studies (71%) assessed one component of alcohol intake, and four studies (29%) included more than one (e.g. frequency and quantity). The most common components of alcohol intake assessed were frequency of alcohol consumption and quantity of alcohol consumed (Figure 2).</p> <p>PHOTO (COLOR): Figure 2. Measures of alcohol intake in 14 included studies.</p> <hd id="AN0182090937-16">Sleep</hd> <p>Fourteen studies measured sleep as an exposure measure, and all of these studies measured sleep via self-report.[<reflink idref="bib23" id="ref46">23</reflink>]<sups>,</sups>[<reflink idref="bib25" id="ref47">25</reflink>]<sups>,</sups>[<reflink idref="bib27" id="ref48">27</reflink>]<sups>,</sups>[<reflink idref="bib34" id="ref49">34</reflink>]<sups>,</sups>[<reflink idref="bib35" id="ref50">35</reflink>]<sups>,</sups>[[<reflink idref="bib37" id="ref51">37</reflink>], [<reflink idref="bib39" id="ref52">39</reflink>], [<reflink idref="bib41" id="ref53">41</reflink>], [<reflink idref="bib43" id="ref54">43</reflink>], [<reflink idref="bib45" id="ref55">45</reflink>]] Of these studies, sleep was measured only at baseline in five studies (36%), and at multiple time points in nine studies (64%). Eight studies (57%) measured one component of sleep, and six studies (43%) more than one. The most common components of sleep assessed were overall sleep quality, followed by sleep duration and daytime sleepiness/dysfunction (Figure 3).</p> <p>PHOTO (COLOR): Figure 3. Measures of sleep in 14 included studies.</p> <hd id="AN0182090937-17">Physical activity</hd> <p>Thirteen studies measured physical activity as an exposure measure, all using self-report surveys.[[<reflink idref="bib23" id="ref56">23</reflink>], [<reflink idref="bib25" id="ref57">25</reflink>]]<sups>,</sups>[[<reflink idref="bib27" id="ref58">27</reflink>], [<reflink idref="bib29" id="ref59">29</reflink>]]<sups>,</sups>[<reflink idref="bib36" id="ref60">36</reflink>]<sups>,</sups>[[<reflink idref="bib46" id="ref61">46</reflink>], [<reflink idref="bib48" id="ref62">48</reflink>], [<reflink idref="bib50" id="ref63">50</reflink>]] Eight studies (62%) assessed one component of physical activity, while five studies (38%) assessed more than one. The most common components of physical activity that were assessed were frequency and duration (Figure 4). Physical activity was measured only at baseline in two studies (15%), and at multiple time points in eleven studies (85%).</p> <p>PHOTO (COLOR): Figure 4. Measures of physical activity in 13 included studies.</p> <hd id="AN0182090937-18">Smoking</hd> <p>Eight studies measured smoking as an exposure, all via self-report survey.[<reflink idref="bib23" id="ref64">23</reflink>]<sups>,</sups>[[<reflink idref="bib27" id="ref65">27</reflink>], [<reflink idref="bib29" id="ref66">29</reflink>]]<sups>,</sups>[<reflink idref="bib36" id="ref67">36</reflink>]<sups>,</sups>[[<reflink idref="bib51" id="ref68">51</reflink>], [<reflink idref="bib53" id="ref69">53</reflink>]] Seven studies (88%) measured one component of smoking exposure, and one study (12%) more than one. Current smoking status was the most common component assessed (Figure 5). One study measured smoking only at baseline (12%) and seven studies assessed smoking at multiple time points (88%).</p> <p>PHOTO (COLOR): Figure 5. Measures of smoking in 8 included studies.</p> <hd id="AN0182090937-19">Sedentary behavior</hd> <p>Six studies measured sedentary behavior as an exposure measure, all using self-report surveys.[<reflink idref="bib23" id="ref70">23</reflink>]<sups>,</sups>[<reflink idref="bib24" id="ref71">24</reflink>]<sups>,</sups>[<reflink idref="bib27" id="ref72">27</reflink>]<sups>,</sups>[<reflink idref="bib29" id="ref73">29</reflink>]<sups>,</sups>[<reflink idref="bib47" id="ref74">47</reflink>]<sups>,</sups>[<reflink idref="bib48" id="ref75">48</reflink>] All studies assessed one component of sedentary behavior, with four studies (67%) assessing total daily time spent being sedentary, one study (17%) daily hours spent in recreational screen time, and one (17%) total daily screen time. All assessed sedentary behavior at multiple time points.</p> <hd id="AN0182090937-20">Dietary intake</hd> <p>Four studies measured dietary intake as an exposure measure, all via self-report survey.[<reflink idref="bib27" id="ref76">27</reflink>]<sups>,</sups>[<reflink idref="bib29" id="ref77">29</reflink>]<sups>,</sups>[<reflink idref="bib36" id="ref78">36</reflink>]<sups>,</sups>[<reflink idref="bib54" id="ref79">54</reflink>] The four studies each measured one component of dietary intake, with each assessing a different component (frequency of meal consumption; breakfast consumption; vegetarian diet status; and the degree of healthy eating practices). In three studies (75%) dietary intake was assessed at multiple time points, and in one study (25%) it was assessed at a single time point.</p> <hd id="AN0182090937-21">Illicit drug use</hd> <p>One study measured illicit drug use, via self-report survey.[<reflink idref="bib25" id="ref80">25</reflink>] In this study substance misuse was measured at a single time point.[<reflink idref="bib25" id="ref81">25</reflink>]</p> <hd id="AN0182090937-22">Description of outcome measures</hd> <p>Twenty studies (61%) examined mental ill-health related outcomes, with five different outcomes assessed: depression (n = 18 studies), anxiety (n = 5), stress (n = 5), suicide ideation and attempts (n = 3), and internalizing symptoms (n = 1). Eighteen studies (55%) examined psychological wellbeing related outcomes, with 13 different outcomes assessed: feelings of happiness, sadness, stress and anxiety (n = 2 studies), psychological impairment/stress (n = 2), mental wellbeing (n = 2), stressors (n = 1), sense of coherence (n = 1), self-concept (n = 1), subjective wellbeing (n = 1), affect (n = 1), psychological flexibility/inflexibility (n = 1), emotional dysregulation (n = 1), repetitive negative thoughts (n = 1), positive mental health (n = 1), and self-esteem (n = 1). Two studies examined a composite mental health measure, which was intrapersonal adjustment.</p> <hd id="AN0182090937-23">Risk of bias</hd> <p>Just over half of the included studies (n = 18, 55%) were assessed as low risk of bias,[<reflink idref="bib23" id="ref82">23</reflink>]<sups>,</sups>[<reflink idref="bib25" id="ref83">25</reflink>]<sups>,</sups>[[<reflink idref="bib32" id="ref84">32</reflink>], [<reflink idref="bib34" id="ref85">34</reflink>]]<sups>,</sups>[<reflink idref="bib37" id="ref86">37</reflink>]<sups>,</sups>[[<reflink idref="bib39" id="ref87">39</reflink>], [<reflink idref="bib41" id="ref88">41</reflink>], [<reflink idref="bib43" id="ref89">43</reflink>], [<reflink idref="bib45" id="ref90">45</reflink>]]<sups>,</sups>[<reflink idref="bib47" id="ref91">47</reflink>]<sups>,</sups>[<reflink idref="bib48" id="ref92">48</reflink>]<sups>,</sups>[<reflink idref="bib50" id="ref93">50</reflink>]<sups>,</sups>[<reflink idref="bib54" id="ref94">54</reflink>] and fifteen studies (45%) were assessed as high risk of bias (Table 3).[<reflink idref="bib24" id="ref95">24</reflink>]<sups>,</sups>[[<reflink idref="bib26" id="ref96">26</reflink>], [<reflink idref="bib28" id="ref97">28</reflink>], [<reflink idref="bib30" id="ref98">30</reflink>]]<sups>,</sups>[<reflink idref="bib36" id="ref99">36</reflink>]<sups>,</sups>[<reflink idref="bib38" id="ref100">38</reflink>]<sups>,</sups>[<reflink idref="bib45" id="ref101">45</reflink>]<sups>,</sups>[<reflink idref="bib46" id="ref102">46</reflink>]<sups>,</sups>[[<reflink idref="bib51" id="ref103">51</reflink>], [<reflink idref="bib53" id="ref104">53</reflink>]] All studies had a low risk of bias in terms of the groups within studies being similar and recruited from the same population, and with the follow-up time being reported and sufficient. Most studies also had a low risk of bias for the exposures being measured similarly to assign people to both exposed and unexposed groups (n = 32, 97%), for the use of valid and reliable measures of exposures (n = 19, 58%), for the use of strategies to deal with confounding factors (n = 30, 91%), for the use of valid and reliable measures of outcomes (n = 29, 88%), whether follow-up was complete or loss to follow-up described (n = 18, 55%), and for appropriate statistical analyses (n = 32, 97%). High risk of bias was determined in most studies where the participants were free of the outcome at the start of the study (n = 25, 76%).</p> <p>Table 3. Critical appraisal of 33 studies exploring associations between health behaviors and mental health in tertiary education students.</p> <p> <ephtml> <table><thead><tr><td>Study</td><td>Health behavior/s assessed</td><td>Critical appraisal item</td><td>Overall risk</td></tr><tr><td char=".">1</td><td char=".">2</td><td char=".">3</td><td char=".">4</td><td char=".">5</td><td char=".">6</td><td char=".">7</td><td char=".">8</td><td char=".">9</td><td char=".">10</td><td char=".">11</td></tr></thead><tbody valign="top"><tr><td>Dinis and Bragança<xref ref-type="bibr" rid="bibr55">55</xref></td><td>Smoking</td><td>Y</td><td>Y</td><td>U</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>N</td><td>U</td><td>Y</td><td>High</td></tr><tr><td>Kwak et al.<xref ref-type="bibr" rid="bibr9">9</xref></td><td>Physical activity; alcohol intake; sleep; illicit drug use</td><td>Y</td><td>Y</td><td>U</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>NA</td><td>NA</td><td>Y</td><td>Low</td></tr><tr><td>Tavernier and Willoughby<xref ref-type="bibr" rid="bibr41">41</xref></td><td>Alcohol intake; sleep</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Low</td></tr><tr><td>Hossain et al.<xref ref-type="bibr" rid="bibr27">27</xref></td><td>Physical activity; sedentary behavior; alcohol intake; sleep; smoking</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>Low</td></tr><tr><td>Wong et al.<xref ref-type="bibr" rid="bibr42">42</xref></td><td>Sleep</td><td>Y</td><td>Y</td><td>N</td><td>N</td><td>NA</td><td>N</td><td>N</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>High</td></tr><tr><td>Mohammed et al.<xref ref-type="bibr" rid="bibr30">30</xref></td><td>Alcohol intake</td><td>Y</td><td>Y</td><td>Y</td><td>U</td><td>U</td><td>N</td><td>Y</td><td>Y</td><td>U</td><td>Y</td><td>Y</td><td>High</td></tr><tr><td>Molnar et al.<xref ref-type="bibr" rid="bibr31">31</xref></td><td>Dietary intake; physical activity; sedentary behavior; alcohol intake; sleep; smoking</td><td>Y</td><td>Y</td><td>U</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>N</td><td>N</td><td>Y</td><td>High</td></tr><tr><td>Rosenthal et al.<xref ref-type="bibr" rid="bibr33">33</xref></td><td>Dietary intake; physical activity; sedentary behavior; alcohol intake; smoking</td><td>Y</td><td>Y</td><td>U</td><td>Y</td><td>Y</td><td>U</td><td>U</td><td>Y</td><td>Y</td><td>NA</td><td>Y</td><td>High</td></tr><tr><td>Zhang et al.<xref ref-type="bibr" rid="bibr50">50</xref></td><td>Physical activity</td><td>Y</td><td>Y</td><td>U</td><td>Y</td><td>Y</td><td>U</td><td>U</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>High</td></tr><tr><td>Zhang et al.<xref ref-type="bibr" rid="bibr50">50</xref></td><td>Physical activity</td><td>Y</td><td>Y</td><td>U</td><td>Y</td><td>Y</td><td>U</td><td>U</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>High</td></tr><tr><td>Mushquash et al.<xref ref-type="bibr" rid="bibr32">32</xref></td><td>Physical activity; alcohol intake; smoking</td><td>Y</td><td>Y</td><td>U</td><td>U</td><td>NA</td><td>N</td><td>Y</td><td>Y</td><td>N</td><td>N</td><td>N</td><td>High</td></tr><tr><td>Zou et al.<xref ref-type="bibr" rid="bibr43">43</xref></td><td>Sleep</td><td>Y</td><td>Y</td><td>U</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Low</td></tr><tr><td>Gardani et al.<xref ref-type="bibr" rid="bibr56">56</xref></td><td>Smoking</td><td>Y</td><td>Y</td><td>U</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>High</td></tr><tr><td>Semplonius and Willoughby<xref ref-type="bibr" rid="bibr34">34</xref></td><td>Alcohol intake</td><td>Y</td><td>U</td><td>U</td><td>U</td><td>NA</td><td>N</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>High</td></tr><tr><td>Tavernier and Willoughby<xref ref-type="bibr" rid="bibr35">35</xref></td><td>Alcohol intake</td><td>Y</td><td>Y</td><td>Y</td><td>U</td><td>NA</td><td>N</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>High</td></tr><tr><td>Velten et al.<xref ref-type="bibr" rid="bibr36">36</xref></td><td>Alcohol intake</td><td>Y</td><td>Y</td><td>Y</td><td>U</td><td>NA</td><td>N</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Low</td></tr><tr><td>Shi et al.<xref ref-type="bibr" rid="bibr44">44</xref></td><td>Sleep</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>Low</td></tr><tr><td>Marquez et al.<xref ref-type="bibr" rid="bibr57">57</xref></td><td>Dietary intake</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Low</td></tr><tr><td>Evans et al.<xref ref-type="bibr" rid="bibr37">37</xref></td><td>Alcohol intake</td><td>Y</td><td>Y</td><td>U</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Low</td></tr><tr><td>Buysse<xref ref-type="bibr" rid="bibr58">58</xref></td><td>Smoking</td><td>Y</td><td>Y</td><td>Y</td><td>U</td><td>NA</td><td>N</td><td>Y</td><td>Y</td><td>N</td><td>N</td><td>Y</td><td>High</td></tr><tr><td>Bandiera et al.<xref ref-type="bibr" rid="bibr51">51</xref></td><td>Physical activity; sedentary behavior</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>Low</td></tr><tr><td>Marsden et al.<xref ref-type="bibr" rid="bibr52">52</xref></td><td>Physical activity; sedentary behavior</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>Low</td></tr><tr><td>Garett et al.<xref ref-type="bibr" rid="bibr38">38</xref></td><td>Alcohol intake; sleep</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>Low</td></tr><tr><td>Savage et al.<xref ref-type="bibr" rid="bibr48">48</xref></td><td>Sleep</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Low</td></tr><tr><td>Wilson et al.<xref ref-type="bibr" rid="bibr49">49</xref></td><td>Sleep</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>U</td><td>N</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>High</td></tr><tr><td>Langberg et al.<xref ref-type="bibr" rid="bibr39">39</xref></td><td>Sleep</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Low</td></tr><tr><td>Langberg et al.<xref ref-type="bibr" rid="bibr39">39</xref></td><td>Sleep</td><td>Y</td><td>Y</td><td>U</td><td>Y</td><td>U</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Low</td></tr><tr><td>Kuuppelomaki and Utriainen<xref ref-type="bibr" rid="bibr28">28</xref></td><td>Physical activity; sedentary behavior</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>U</td><td>Y</td><td>Y</td><td>N</td><td>U</td><td>Y</td><td>High</td></tr><tr><td>Peltz et al.<xref ref-type="bibr" rid="bibr40">40</xref></td><td>Dietary intake; physical activity; alcohol intake; smoking</td><td>Y</td><td>Y</td><td>N</td><td>U</td><td>NA</td><td>N</td><td>Y</td><td>Y</td><td>U</td><td>U</td><td>Y</td><td>High</td></tr><tr><td>Saules et al.<xref ref-type="bibr" rid="bibr53">53</xref></td><td>Physical activity</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>Y</td><td>NA</td><td>Y</td><td>Low</td></tr><tr><td>Kroencke et al.<xref ref-type="bibr" rid="bibr46">46</xref></td><td>Sleep</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Low</td></tr><tr><td>Ren et al.<xref ref-type="bibr" rid="bibr54">54</xref></td><td>Physical activity</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>Y</td><td>NA</td><td>Y</td><td>Low</td></tr><tr><td>Savage et al.<xref ref-type="bibr" rid="bibr47">47</xref></td><td>Sleep</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>N</td><td>Y</td><td>Y</td><td>Y</td><td>U</td><td>Y</td><td>Low</td></tr></tbody></table> </ephtml> </p> <p>3 Item descriptions; 1) Were the two groups similar and recruited from the same population?, 2) Were the exposures measured similarly to assign people to both exposed and unexposed groups?, 3) Was the exposure measured in a valid and reliable way?, 4) Were confounding factors identified?, 5) Were strategies to deal with confounding factors stated?, 6) Were the groups/participants free of the outcome at the start of the study (or at the moment of exposure)?, 7) Were the outcomes measured in a valid and reliable way?, 8) Was the follow up time reported and sufficient to be long enough for outcomes to occur?, 9) Was follow up complete, and if not, were reasons to loss to follow up described and explored?, 10) Were strategies to address incomplete follow up utilized?, 11) Was appropriate statistical analysis used?.</p> <hd id="AN0182090937-24">Description of associations between health behaviors and mental health outcomes</hd> <p>Table 4 summarizes the associations between health behaviors and mental health outcomes using the vote counting system. Hereafter, use of the term 'significant' is used to indicate an association that was statistically significant.</p> <p>Table 4. Summary of 33 retrospective cohort studies exploring the associations between health risk behaviors and mental health outcomes among tertiary education students.</p> <p> <ephtml> <table><thead><tr><td>Health risk behaviors</td><td>Summary of studies with psychological well-being related outcomes</td><td>Summary of students with mental ill-health related outcomes</td></tr></thead><tbody valign="top"><tr><td /><td>n/N</td><td>Association</td><td>n/N</td><td>Association</td></tr><tr><td>Alcohol use</td><td char=".">1/5 (20%)</td><td>No association</td><td char=".">6/10 (60%)</td><td>Inconsistent*</td></tr><tr><td>Poor sleep<sup>a</sup></td><td char=".">5/6 (83%)</td><td>Positive</td><td char=".">8/9 (100%)</td><td>Positive</td></tr><tr><td>Physical inactivity</td><td char=".">6/8 (75%)</td><td>Positive</td><td char=".">3/7 (43%)</td><td>Inconsistent</td></tr><tr><td>Smoking</td><td char=".">0/3 (0%)</td><td>Uncertain</td><td char=".">3/6 (50%)</td><td>Inconsistent</td></tr><tr><td>Poor dietary intake</td><td char=".">0/2 (50%)</td><td>Uncertain</td><td char=".">2/3 (67%)</td><td>Uncertain</td></tr><tr><td>Sedentary behavior</td><td char=".">2/ 4 (50%)</td><td>Inconsistent</td><td char=".">2/3 (67%)</td><td>Uncertain</td></tr><tr><td>Illicit drug use</td><td char=".">0</td><td>Uncertain</td><td char=".">0/1 (0%)</td><td>Uncertain</td></tr></tbody></table> </ephtml> </p> <p>4 n/N (%) = number of studies reporting a significant association/Number of studies which explored the association, and the % that demonstrated a significant association. Association with mental health outcome: No association if 0 to 33% of studies report a significant association; Inconsistent if 34 to 59% of studies report a significant association, Positive or Negative if 60% or more of studies report a significant association, based on the direction of the association. Uncertain if less than four studies reported on the exposure/outcome.* Inconsistent as 5 studies positive association and 1 study negative association</p> <hd id="AN0182090937-25">Alcohol intake:14 studies. 23 , 25–37</hd> <p>The overall association between alcohol intake and psychological wellbeing was graded as "no association" with four out of five studies reporting no significant association. [<reflink idref="bib25" id="ref105">25</reflink>]<sups>,</sups>[<reflink idref="bib28" id="ref106">28</reflink>]<sups>,</sups>[<reflink idref="bib29" id="ref107">29</reflink>]<sups>,</sups>[<reflink idref="bib35" id="ref108">35</reflink>] One study in undergraduate students (n = 627 at baseline) with a three-year follow-up reported an association between greater alcohol intake and higher subjective wellbeing, and an association between greater adverse alcohol consequences and lower subjective wellbeing.[<reflink idref="bib31" id="ref109">31</reflink>]</p> <p>Ten studies explored the association between alcohol intake with mental ill-health.[<reflink idref="bib23" id="ref110">23</reflink>]<sups>,</sups>[[<reflink idref="bib25" id="ref111">25</reflink>], [<reflink idref="bib27" id="ref112">27</reflink>]]<sups>,</sups>[<reflink idref="bib30" id="ref113">30</reflink>]<sups>,</sups>[[<reflink idref="bib32" id="ref114">32</reflink>], [<reflink idref="bib34" id="ref115">34</reflink>]]<sups>,</sups>[<reflink idref="bib36" id="ref116">36</reflink>]<sups>,</sups>[<reflink idref="bib37" id="ref117">37</reflink>] Six studies reported a significant association,[<reflink idref="bib26" id="ref118">26</reflink>]<sups>,</sups>[<reflink idref="bib27" id="ref119">27</reflink>]<sups>,</sups>[<reflink idref="bib30" id="ref120">30</reflink>]<sups>,</sups>[<reflink idref="bib33" id="ref121">33</reflink>]<sups>,</sups>[<reflink idref="bib34" id="ref122">34</reflink>] of these, five a positive association, and one a negative association. Therefore, the association was graded as "inconsistent". Two studies (n = 1140, n = 325 at baseline) reported significant positive associations between alcohol use and depression,[<reflink idref="bib27" id="ref123">27</reflink>]<sups>,</sups>[<reflink idref="bib30" id="ref124">30</reflink>] and one study in undergraduate students reported an association between additional alcohol consequences and increased risk of onset depression.[<reflink idref="bib33" id="ref125">33</reflink>] One study (n = 1140 at baseline) reported a positive association between alcohol intake and anxiety at 15-months,[<reflink idref="bib27" id="ref126">27</reflink>] and one study in 2607 undergraduate students found that alcohol problems were associated with increased internalizing symptoms.[<reflink idref="bib26" id="ref127">26</reflink>] One study which recruited first year undergraduate male and female students reported a positive association between concomitant alcohol use and smoking, and risk of depression in the female participants.[<reflink idref="bib23" id="ref128">23</reflink>] One study found that alcohol use was associated with lower depressive symptoms.[<reflink idref="bib34" id="ref129">34</reflink>]</p> <hd id="AN0182090937-26">Sleep: 14 studies. 23 , 25 , 27 , 34 , 35 , 37–45</hd> <p>The overall association between sleep and psychological wellbeing was graded as "positive" (i.e. poor sleep was consistently associated with poorer psychological wellbeing) with five of six studies reporting a significant association. [<reflink idref="bib34" id="ref130">34</reflink>]<sups>,</sups>[[<reflink idref="bib38" id="ref131">38</reflink>], [<reflink idref="bib40" id="ref132">40</reflink>]]<sups>,</sups>[<reflink idref="bib45" id="ref133">45</reflink>] Of these five studies, poorer sleep quality was associated with higher stress in one 10-week study in undergraduate students,[<reflink idref="bib38" id="ref134">38</reflink>] increased psychological inflexibility in an 8-week study (n = 792 at baseline),[<reflink idref="bib40" id="ref135">40</reflink>] and greater emotional dysregulation in another study in undergraduate students.[<reflink idref="bib34" id="ref136">34</reflink>] One study which measured sleep in undergraduate students daily for 18 days over a three week period reported an association between shorter sleep duration and later bedtime, and increased repetitive negative thoughts.[<reflink idref="bib45" id="ref137">45</reflink>] One study in 62 undergraduate students diagnosed with Attention Deficit Hyperactivity Disorder found that daytime sleepiness was associated with greater overall psychological impairment.[<reflink idref="bib39" id="ref138">39</reflink>]</p> <p>The overall association between sleep with mental ill-health was graded as "positive" (i.e. poor sleep was consistently associated with greater mental ill-health.) with eight of nine studies reporting a significant association. [<reflink idref="bib25" id="ref139">25</reflink>]<sups>,</sups>[<reflink idref="bib27" id="ref140">27</reflink>]<sups>,</sups>[<reflink idref="bib34" id="ref141">34</reflink>]<sups>,</sups>[<reflink idref="bib37" id="ref142">37</reflink>]<sups>,</sups>[<reflink idref="bib40" id="ref143">40</reflink>]<sups>,</sups>[[<reflink idref="bib42" id="ref144">42</reflink>], [<reflink idref="bib44" id="ref145">44</reflink>]] Of these eight studies, four studies in undergraduate students with follow-ups ranging from two to twelve months reported that poorer sleep quality was associated with increased depression,[<reflink idref="bib34" id="ref146">34</reflink>]<sups>,</sups>[<reflink idref="bib37" id="ref147">37</reflink>]<sups>,</sups>[<reflink idref="bib40" id="ref148">40</reflink>]<sups>,</sups>[<reflink idref="bib43" id="ref149">43</reflink>] and one 12 month study (n = 686 at baseline) found an association between poorer sleep quality and increased anxiety.[<reflink idref="bib43" id="ref150">43</reflink>] One study (n = 3029) in first year undergraduate students that assessed sleep at baseline only, reported an association between poorer sleep quality and increased risk of depressive symptoms, and anxiety, at follow-up.[<reflink idref="bib25" id="ref151">25</reflink>] Increased dissatisfaction with sleep was also associated with depression and anxiety,[<reflink idref="bib27" id="ref152">27</reflink>] as was short sleep and long sleep time frequency in one study conducted over 15 months.[<reflink idref="bib27" id="ref153">27</reflink>] Poorer sleep quality was associated with increased suicidal ideation in one, two month study,[<reflink idref="bib40" id="ref154">40</reflink>] and sleep disturbances were also associated with increased risk of suicidal ideation and attempts in another study (n = 11740), which measured sleep disturbances at baseline only.[<reflink idref="bib44" id="ref155">44</reflink>] One 15 month study (n = 1195 at baseline) found associations between daytime dysfunction and depression, daytime dysfunction and anxiety, and sleep disturbance and anxiety.[<reflink idref="bib42" id="ref156">42</reflink>]</p> <hd id="AN0182090937-27">Physical activity: 13 studies. 23–25 , 27–29 , 36 , 46–50</hd> <p>The overall association between physical activity with psychological wellbeing was graded as "positive" (i.e. physical inactivity was consistently associated with poorer psychological wellbeing) with six of eight studies reporting a significant association.[<reflink idref="bib24" id="ref157">24</reflink>]<sups>,</sups>[<reflink idref="bib28" id="ref158">28</reflink>]<sups>,</sups>[<reflink idref="bib29" id="ref159">29</reflink>]<sups>,</sups>[<reflink idref="bib36" id="ref160">36</reflink>]<sups>,</sups>[<reflink idref="bib46" id="ref161">46</reflink>] Increased physical activity frequency was associated with decreased anxiety and increased feelings of happiness in two studies in undergraduate psychology students conducted over 13 and 15 weeks,[<reflink idref="bib46" id="ref162">46</reflink>] increased sense of coherence in one study conducted over three academic semesters,[<reflink idref="bib28" id="ref163">28</reflink>] and positive mental health in one study (n = 15396 at baseline) with a one year follow-up.[<reflink idref="bib36" id="ref164">36</reflink>] One study in 28 undergraduate students found that greater time spent doing physical activity was associated with higher self-concept.[<reflink idref="bib29" id="ref165">29</reflink>] The remaining study (n = 573 at baseline) reported that insufficient physical activity (combined with high or low sedentary behavior) was associated with higher psychological distress in the cohort of undergraduate students.[<reflink idref="bib24" id="ref166">24</reflink>]</p> <p>Seven studies explored the association between physical activity and mental ill-health, [<reflink idref="bib23" id="ref167">23</reflink>]<sups>,</sups>[<reflink idref="bib25" id="ref168">25</reflink>]<sups>,</sups>[<reflink idref="bib27" id="ref169">27</reflink>]<sups>,</sups>[<reflink idref="bib36" id="ref170">36</reflink>]<sups>,</sups>[[<reflink idref="bib48" id="ref171">48</reflink>], [<reflink idref="bib50" id="ref172">50</reflink>]] with three studies reporting a significant "positive" association.[<reflink idref="bib25" id="ref173">25</reflink>]<sups>,</sups>[<reflink idref="bib27" id="ref174">27</reflink>] Therefore, the evidence was graded as "inconsistent'. One study in 1140 undergraduate students reported that high physical inactivity was associated with depression and anxiety,[<reflink idref="bib27" id="ref175">27</reflink>] and one study (n = 3029) which assessed physical activity at baseline only found that less frequent physical activity was associated with increased risk of depressive symptoms at the six month follow-up.[<reflink idref="bib25" id="ref176">25</reflink>] One study in 1163 undergraduate students conducted over one year reported that high leisure-time physical activity was associated with lower levels of depressive symptoms.[<reflink idref="bib50" id="ref177">50</reflink>]</p> <hd id="AN0182090937-28">Smoking: 8 studies. 23 , 27–29 , 36 , 51–53</hd> <p>Three studies investigated the association between smoking status, and poor psychological well-being, with no significant associations reported.[<reflink idref="bib28" id="ref178">28</reflink>]<sups>,</sups>[<reflink idref="bib29" id="ref179">29</reflink>]<sups>,</sups>[<reflink idref="bib36" id="ref180">36</reflink>] The evidence was classified as "uncertain" due to the low number of studies exploring this association.</p> <p>Six studies investigated the association between smoking status and mental ill-health.[<reflink idref="bib23" id="ref181">23</reflink>]<sups>,</sups>[<reflink idref="bib27" id="ref182">27</reflink>]<sups>,</sups>[<reflink idref="bib36" id="ref183">36</reflink>]<sups>,</sups>[[<reflink idref="bib51" id="ref184">51</reflink>], [<reflink idref="bib53" id="ref185">53</reflink>]] Three of the six studies reported a significant "positive" association,[<reflink idref="bib23" id="ref186">23</reflink>]<sups>,</sups>[<reflink idref="bib36" id="ref187">36</reflink>]<sups>,</sups>[<reflink idref="bib52" id="ref188">52</reflink>] therefore, the evidence was categorized as "inconsistent". Of the three positive associations, one study (n = 15396 at baseline) reported an association between current smoking and increased mental health problems at the one year follow-up,[<reflink idref="bib36" id="ref189">36</reflink>] and one study in undergraduate students (n = 5236) found that increased frequency of use of cigarettes, e-cigarettes and hookah was associated with increased depressive symptoms.[<reflink idref="bib52" id="ref190">52</reflink>] The other study in undergraduate male and female students reported a positive association between concomitant smoking and alcohol use, and risk of depression in the female participants.[<reflink idref="bib23" id="ref191">23</reflink>]</p> <hd id="AN0182090937-29">Sedentary behavior: 6 studies. 23 , 24 , 27 , 29 , 47 , 48</hd> <p>Four studies explored the association between sedentary behavior and poor psychological well-being,[<reflink idref="bib24" id="ref192">24</reflink>]<sups>,</sups>[<reflink idref="bib29" id="ref193">29</reflink>]<sups>,</sups>[<reflink idref="bib47" id="ref194">47</reflink>]<sups>,</sups>[<reflink idref="bib48" id="ref195">48</reflink>] with two reporting a significant "positive" association,[<reflink idref="bib24" id="ref196">24</reflink>] therefore, the evidence was categorized as "inconsistent". One study reported that increased time spent in sedentary behavior was associated with decreased mental wellbeing at the one-year follow-up.[<reflink idref="bib47" id="ref197">47</reflink>] Another study in undergraduate students reported that high or low sedentary behavior (combined with insufficient physical activity) was associated with higher psychological distress.[<reflink idref="bib24" id="ref198">24</reflink>]</p> <p>Three studies investigated the association between sedentary behavior and mental ill-health,[<reflink idref="bib23" id="ref199">23</reflink>]<sups>,</sups>[<reflink idref="bib27" id="ref200">27</reflink>]<sups>,</sups>[<reflink idref="bib48" id="ref201">48</reflink>] with two reporting a significant "positive" association.[<reflink idref="bib27" id="ref202">27</reflink>]<sups>,</sups>[<reflink idref="bib48" id="ref203">48</reflink>] One study conducted over 15 months in undergraduate students (n = 1140 at baseline), reported an association between high and excessive screen time and depression and anxiety.[<reflink idref="bib27" id="ref204">27</reflink>] The other study, conducted over six months, found that increased time spent in sedentary behavior was associated with an increase in perceived stress.[<reflink idref="bib48" id="ref205">48</reflink>] The evidence was classified as "uncertain" given that only two studies were identified.</p> <hd id="AN0182090937-30">Dietary intake: 4 studies. 27 , 29 , 36 , 54</hd> <p>Two studies explored the association between dietary intake with poor psychological wellbeing,[<reflink idref="bib29" id="ref206">29</reflink>]<sups>,</sups>[<reflink idref="bib36" id="ref207">36</reflink>] and no significant associations were reported. Given there were only two studies exploring this association, the evidence was classified as "uncertain".</p> <p>Three studies explored the association between dietary intake and mental ill-health,[<reflink idref="bib27" id="ref208">27</reflink>]<sups>,</sups>[<reflink idref="bib36" id="ref209">36</reflink>]<sups>,</sups>[<reflink idref="bib54" id="ref210">54</reflink>] with two reporting a positive significant association.[<reflink idref="bib27" id="ref211">27</reflink>]<sups>,</sups>[<reflink idref="bib54" id="ref212">54</reflink>] The evidence was categorized as "uncertain". One study reported an association between low and high daily meal consumption frequency and depression and anxiety,[<reflink idref="bib27" id="ref213">27</reflink>] and the other study found that higher breakfast consumption frequency was associated with decreased depressive symptoms.[<reflink idref="bib54" id="ref214">54</reflink>]</p> <hd id="AN0182090937-31">Drug use: 1 study. 25</hd> <p>One study explored the association between illicit drug use with mental ill-health.[<reflink idref="bib25" id="ref215">25</reflink>] No significant association was reported and therefore the evidence is "uncertain".</p> <hd id="AN0182090937-32">Discussion</hd> <p>The aim of this systematic review was to describe prospective associations between health behaviors and mental health among tertiary education students. We found consistent evidence for an association between poor sleep, and physical inactivity with increased risk of poor psychological wellbeing, and between poor sleep and increased mental ill-health related outcomes. Inconsistent evidence was found for the association between alcohol use and sedentary behavior with psychological wellbeing, and also between alcohol use, physical inactivity and smoking with mental ill-health. Due to a low number of included studies, the evidence for the association between illicit drug use and dietary intake with psychological wellbeing, and dietary intake, sedentary behavior, and illicit drug use with mental ill-health remains uncertain.</p> <p>The included studies explored a wide variety of outcomes pertaining to mental ill-health and psychological wellbeing. For mental ill-heath indicators, five different groupings of outcomes were assessed and for psychological wellbeing 13 different outcomes. Across these groupings of outcomes a variety of measurement tools were also used. For example, for the five studies considering anxiety, three different tools were utilized. Similarly, for the assessment of the health behavior exposure, a variety of different components of the individual health behaviors were assessed within each construct. For example, across the 14 studies measuring sleep, there were 11 different sleep variables assessed. Therefore, although the systematic review located consistent evidence (positive and no association) for the association between some health behaviors and a range of mental health outcomes, it is important to consider the diversity in health behavior variables, as well as the mental health outcomes across the included studies. There is currently insufficient evidence to confirm associations between specific components of individual health behaviors (e.g. frequency of alcohol consumption vs. quantity of alcohol consumption) with specific psychological wellbeing outcomes, or indicators of mental ill-health. Therefore, while this systematic review provides guidance as to what health behaviors are important for treatment and prevention of mental ill-health among tertiary education students, it cannot provide evidence of what specific changes to health behaviors to target within interventions. Furthermore, the diversity in exposure and outcome measurements across the included studies may explain some of the findings in the current review that are inconsistent with previous research. The heterogeneity within the measurement of both the exposure and outcomes also precluded meta-analyses to be conducted in this review.</p> <p>The current systematic review found consistent evidence that poor sleep was associated with poorer psychological wellbeing and greater mental ill-health. The results from the current review are comparable with previous systematic reviews demonstrating an association between sleep and mental health outcomes in adults, including reviews focusing on university students. [<reflink idref="bib7" id="ref216">7</reflink>]<sups>,</sups>[<reflink idref="bib14" id="ref217">14</reflink>]<sups>,</sups>[<reflink idref="bib55" id="ref218">55</reflink>]<sups>,</sups>[<reflink idref="bib56" id="ref219">56</reflink>] For example, Firth et al.[<reflink idref="bib7" id="ref220">7</reflink>] demonstrated from 25 observational studies a weighted pooled effect size of 0.39 for the association between sleep quality and stress among undergraduate university students. Similar to this review, the authors highlighted the heterogeneity in measurement of both sleep quality and stress within the studies included in the meta-analysis. Therefore, future research is required to consider the multiple components of sleep (i.e., quality, duration, timing, satisfaction) that comprise overall sleep health,[<reflink idref="bib58" id="ref221">58</reflink>] to clarify the association between sleep and mental health among university students.</p> <p>The current systematic review found consistent evidence that low levels of physical activity was associated with poorer psychological wellbeing, but inconsistent evidence for the association between physical activity and mental ill-health. Our findings are consistent with the growing evidence of the positive impact of increased physical activity on wellbeing among adults.[<reflink idref="bib57" id="ref222">57</reflink>] However, they are contradictory to a recent meta-review of evidence examining health behaviors impact on the risk and treatment of mental ill-health, which concluded there is 'substantial evidence' that physical inactivity is a risk factor for mental ill-health.[<reflink idref="bib7" id="ref223">7</reflink>] The current systematic review also demonstrated no association between alcohol use and psychological wellbeing, and inconsistent evidence for the association between alcohol use and mental ill-health. Previous research exploring the association between alcohol use and mental health outcomes has also produced variable findings.[<reflink idref="bib10" id="ref224">10</reflink>]<sups>,</sups>[<reflink idref="bib15" id="ref225">15</reflink>]<sups>,</sups>[<reflink idref="bib59" id="ref226">59</reflink>] For example, a 2018 meta-analysis examining the association between substance use and mental health disorders among adolescents and young adults demonstrated a positive association between alcohol use with depression (OR: 1.50, 95% CI: 1.24-1.83) and anxiety (OR: 1.54, 95% CI: 1.19–2.00),[<reflink idref="bib15" id="ref227">15</reflink>] whereas other reviews reported a lack of consistency in findings.[<reflink idref="bib10" id="ref228">10</reflink>]<sups>,</sups>[<reflink idref="bib59" id="ref229">59</reflink>] This inconsistency in findings for alcohol and physical activity may be due to the variability of measurement of exposure/outcome previously discussed, short duration of follow-up across the included studies, or the quality of the studies included in this review.</p> <p>The current systematic review cannot draw conclusions regarding the association between smoking and mental-ill-health, or the association between sedentary behaviors with psychological well-being, due to inconsistent evidence. Our results for smoking are inconsistent with a recent meta-review of evidence examining health behaviors impact on the risk and treatment of mental ill-health, which concluded there is 'increasingly strong' evidence that smoking is a risk factor for mental ill-health.[<reflink idref="bib7" id="ref230">7</reflink>] Whereas, our finding for the association between sedentary behavior and psychological wellbeing is consistent with previous research. For example, Teychenne et al systematically reviewed observational studies (n = 26) exploring associations between time in sedentary behavior and stress and concluded the poor-quality evidence provided inconsistent or null evidence of an association.[<reflink idref="bib12" id="ref231">12</reflink>] Due to the low number of studies exploring some health behaviors, the current review also cannot draw conclusions regarding the association between illicit drug use and dietary intake with psychological wellbeing, and dietary intake, sedentary behavior, and illicit drug use with mental ill-health, further highlighting the need for further research in this area. Research of these health behaviors among tertiary education students is especially important, given the known changes to these behaviors that may occur during the transition to university or college.</p> <p>A major gap in the existing evidence for the association between health behaviors and mental health of tertiary education students is the lack of studies that consider the co-occurrence of health risk behaviors, given strong evidence of co-occurrence in this population.[<reflink idref="bib6" id="ref232">6</reflink>]<sups>,</sups>[[<reflink idref="bib60" id="ref233">60</reflink>], [<reflink idref="bib62" id="ref234">62</reflink>]] However, despite several included cohort studies assessing more than one health behavior, only two explored the cumulative impact of more than one health behavior. Notably, these two studies both focused on two health behaviors only. Further, included studies also failed to consider co-occurring mental ill-health outcomes. Another limitation of the included cohort studies was the short follow-up periods (i.e. 63% of studies were one year or less), which limited the ability of the studies to understand changes in health behaviors and mental health throughout enrollment in tertiary education, or their changing associations over time. This is particularly important given the nature of both the exposure and outcomes of interest, which often take time to change, and therefore may have limited the ability to detect associations. Future prospective cohort studies in this setting should therefore address these gaps, by considering how multiple health behaviors change and interact throughout the entire duration of a student's enrollment. Finally, despite the reviews focus on tertiary education, the included studies recruited only college/university students, with a specific focus on undergraduate students and therefore highlights the need for research including those enrolled in vocational courses, and higher university degrees.</p> <p>Future studies should also address the methodological limitations of the studies included in this review, with almost half of the included studies (n = 15, 45%) assessed as having a high risk of bias. Overall, more transparent and clear reporting of cohort methodology may improve overall risk of bias. Most important is transparent reporting of identification of confounding factors, and strategies used to account for confounding factors, and incomplete follow-up. A consistent limitation of the included studies was in the reporting of health risk behaviors measurement, and therefore uncertainty over the validity and reliability. Notably, most studies (n = 21) did not exclude participants based on the occurrence of the mental health outcome of interest at cohort commencement. While this is understandable, given the nature of the outcome measure, it is an important consideration in the interpretation of the findings, and associations reported between health behaviors and mental health outcomes.</p> <hd id="AN0182090937-33">Strengths and limitations of the systematic review</hd> <p>This systematic review has several methodological strengths. It was undertaken in accordance with the PRISMA guidelines, six databases were searched for relevant studies, and studies were included that were established a priori. The review also used a vote counting method to synthesize the data that has been used previously,[<reflink idref="bib64" id="ref235">64</reflink>]<sups>,</sups>[<reflink idref="bib65" id="ref236">65</reflink>] and is therefore reproducible. However, this method only considers the statistical significance of the findings in terms of the number of studies finding a positive, negative or no association. The results therefore do not consider the magnitude of the association. Further, due to the evidence synthesis approach, along with the nature of the studies included in the systematic review, it was not possible to explore other factors that may influence the association between health behaviors and mental health, such as country the study was undertaken in or key student characteristics (e.g., 1st year students, program of study). In addition, for the purposes of this review health behaviors were considered as the exposure, and mental health as the outcome. The potential bi-directional association between some health behaviors and mental health was not explored, and is therefore an area for future research. Finally, the review was also limited to studies published in English, which may have resulted in relevant studies being excluded.</p> <hd id="AN0182090937-34">Conclusion</hd> <p>This systematic review describing prospective associations between health behaviors and mental health among tertiary education students found consistent evidence for an association between poor sleep, and physical inactivity with increased risk of poor psychological wellbeing, and between poor sleep and increased mental ill-health related outcomes. Inconsistent or uncertain evidence was found for all other health behaviors of interest.</p> <hd id="AN0182090937-35">Implications for practice</hd> <p>The review provides further support for the implementation of interventions to address poor sleep and physical inactivity for the treatment and prevention of mental ill-health in the tertiary education setting. The findings can be used to advocate for investment in such strategies.</p> <hd id="AN0182090937-36">Implications for future research</hd> <p>The systematic review highlighted there is currently no evidence evaluating the impact of multiple health risk behaviors on mental health of tertiary education students, as well as a lack of evidence for some individual health behaviors (dietary intake, sedentary behavior, illicit drug use and smoking). Furthermore, most studies focused on only one semester or academic year, and therefore did not explore the likely transitions in health behaviors and mental health that occur throughout enrollment. The available evidence does not consider what facets of each health behaviors are associated with mental health outcomes (e.g. what components of dietary intake). This knowledge is vital to our understanding of how to intervene most effectively to improve health behavior for treatment and prevention of mental ill-health for tertiary education students, and therefore should be the focus of future research.</p> <hd id="AN0182090937-37">Acknowledgments</hd> <p>Debbie Booth, Senior Librarian, University of Newcastle for applying the search strategy. Kaylee Slater for assistance with data extraction.</p> <hd id="AN0182090937-38">Conflict of interest disclosure</hd> <p>The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of Australia. 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  Data: Are Health Behaviors Associated with Mental Health among Tertiary Education Students? A Systematic Review of Cohort Studies
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  Label: Language
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  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Melinda+Hutchesson%22">Melinda Hutchesson</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-1851-0661">0000-0002-1851-0661</externalLink>)<br /><searchLink fieldCode="AR" term="%22Megan+Whatnall%22">Megan Whatnall</searchLink><br /><searchLink fieldCode="AR" term="%22Sasha+Fenton%22">Sasha Fenton</searchLink><br /><searchLink fieldCode="AR" term="%22Lee+Ashton%22">Lee Ashton</searchLink><br /><searchLink fieldCode="AR" term="%22Amanda+Patterson%22">Amanda Patterson</searchLink><br /><searchLink fieldCode="AR" term="%22Jordan+Smith%22">Jordan Smith</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-4640-8645">0000-0003-4640-8645</externalLink>)<br /><searchLink fieldCode="AR" term="%22Mitch+J%2E+Duncan%22">Mitch J. Duncan</searchLink><br /><searchLink fieldCode="AR" term="%22Frances+Kay-Lambkin%22">Frances Kay-Lambkin</searchLink><br /><searchLink fieldCode="AR" term="%22Tracy+Burrows%22">Tracy Burrows</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+American+College+Health%22"><i>Journal of American College Health</i></searchLink>. 2025 73(1):111-123.
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  Data: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
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  Data: Y
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  Label: Page Count
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  Data: 13
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  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Information Analyses<br />Reports - Research
– Name: Audience
  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink><br /><searchLink fieldCode="EL" term="%22Postsecondary+Education%22">Postsecondary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22College+Students%22">College Students</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Behavior%22">Health Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Eating+Habits%22">Eating Habits</searchLink><br /><searchLink fieldCode="DE" term="%22Physical+Activity+Level%22">Physical Activity Level</searchLink><br /><searchLink fieldCode="DE" term="%22Life+Style%22">Life Style</searchLink><br /><searchLink fieldCode="DE" term="%22Drinking%22">Drinking</searchLink><br /><searchLink fieldCode="DE" term="%22Sleep%22">Sleep</searchLink><br /><searchLink fieldCode="DE" term="%22Smoking%22">Smoking</searchLink><br /><searchLink fieldCode="DE" term="%22Drug+Use%22">Drug Use</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Characteristics%22">Student Characteristics</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22United+States%22">United States</searchLink><br /><searchLink fieldCode="DE" term="%22Canada%22">Canada</searchLink><br /><searchLink fieldCode="DE" term="%22China%22">China</searchLink><br /><searchLink fieldCode="DE" term="%22United+Kingdom%22">United Kingdom</searchLink><br /><searchLink fieldCode="DE" term="%22Bangladesh%22">Bangladesh</searchLink><br /><searchLink fieldCode="DE" term="%22Finland%22">Finland</searchLink><br /><searchLink fieldCode="DE" term="%22Brazil%22">Brazil</searchLink><br /><searchLink fieldCode="DE" term="%22India%22">India</searchLink><br /><searchLink fieldCode="DE" term="%22Germany%22">Germany</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/07448481.2023.2201865
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0744-8481<br />1940-3208
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Objective: To evaluate the association between health behaviors with mental health among tertiary education students. Methods: Six databases were searched until September 2021 for prospective cohort studies evaluating the association between health behavior(s) (dietary intake, physical activity, sedentary behavior, alcohol intake, sleep, smoking or illicit drug use) and mental health. Two independent reviewers screened records for inclusion, extracted data and completed risk of bias assessments. Results: 33 studies were included (14 assessed sleep, 14 alcohol intake, 13 physical activity, 8 smoking, 6 sedentary behavior, 4 diet, 1 illicit drug use). A consistent association between poor sleep, and physical inactivity with increased risk of poor psychological wellbeing, and between poor sleep and increased mental ill-health related outcomes was demonstrated. Conclusion: Findings suggest interventions to address poor sleep and physical inactivity among students may positively impact mental health. Further research of other health behaviors, and their association with mental health, is required.
– Name: AbstractInfo
  Label: Abstractor
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  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1456873
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        Value: 10.1080/07448481.2023.2201865
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      – Text: English
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      Pagination:
        PageCount: 13
        StartPage: 111
    Subjects:
      – SubjectFull: College Students
        Type: general
      – SubjectFull: Mental Health
        Type: general
      – SubjectFull: Health Behavior
        Type: general
      – SubjectFull: Eating Habits
        Type: general
      – SubjectFull: Physical Activity Level
        Type: general
      – SubjectFull: Life Style
        Type: general
      – SubjectFull: Drinking
        Type: general
      – SubjectFull: Sleep
        Type: general
      – SubjectFull: Smoking
        Type: general
      – SubjectFull: Drug Use
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Student Characteristics
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: United States
        Type: general
      – SubjectFull: Canada
        Type: general
      – SubjectFull: China
        Type: general
      – SubjectFull: United Kingdom
        Type: general
      – SubjectFull: Bangladesh
        Type: general
      – SubjectFull: Finland
        Type: general
      – SubjectFull: Brazil
        Type: general
      – SubjectFull: India
        Type: general
      – SubjectFull: Germany
        Type: general
    Titles:
      – TitleFull: Are Health Behaviors Associated with Mental Health among Tertiary Education Students? A Systematic Review of Cohort Studies
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Melinda Hutchesson
      – PersonEntity:
          Name:
            NameFull: Megan Whatnall
      – PersonEntity:
          Name:
            NameFull: Sasha Fenton
      – PersonEntity:
          Name:
            NameFull: Lee Ashton
      – PersonEntity:
          Name:
            NameFull: Amanda Patterson
      – PersonEntity:
          Name:
            NameFull: Jordan Smith
      – PersonEntity:
          Name:
            NameFull: Mitch J. Duncan
      – PersonEntity:
          Name:
            NameFull: Frances Kay-Lambkin
      – PersonEntity:
          Name:
            NameFull: Tracy Burrows
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 0744-8481
            – Type: issn-electronic
              Value: 1940-3208
          Numbering:
            – Type: volume
              Value: 73
            – Type: issue
              Value: 1
          Titles:
            – TitleFull: Journal of American College Health
              Type: main
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