Associations between health promotion behaviors and multidimensional health among Chinese middle-school students—a study focusing on gender differences

1. Introduction

The World Health Organization (WHO) advocates for the support of lifestyle improvements through health promotion behaviors, identifying this approach as a key strategy for countries globally to address health challenges [1]. The adolescent period is crucial for establishing lifelong healthy behaviors and taking responsibility for healthcare, making a special time when risky may emerge. Good health promotion behavior is essential for an individual’s quality and is significant determinant of health and happiness [2]. Adolescent health promotion behaviors encompasses not just disease prevention, such as maintaining a balanced diet, ensuring proper nutrition, and forming dietary habits [3], but also involves responsibility, valuing life, managing stress, seeking social support and the ability to search for health information online. Influential factors on health promotion behavior include self-efficacy, self-esteem, perceived health status, levels of optimism and pessimism, eHealth literacy, the utilization of social media for health information, and health information—seeking behavior [4]. Importantly, gender is identified as a critical factor in adolescent health promotion, affecting health behaviors engagement in healthcare, and the quality of care received [5].

Currently, research participation is predominantly observed in the United States and European countries. Even in China, a significant portion of studies are performed on college students and chronic conditions in middle-aged and older populations, while research on middle school students is significantly lacking, which is seriously inconsistent with the current severe health of adolescents in China. The ongoing assessment of adolescent health promotion behaviors, encompassing nutrition, physical activity, social responsibility and stress management, is essential for the strategic planning and execution of appropriate care services tailored to adolescents across various stages. Research has identified that the school based physical education and health promotion interventions exhibit gender specific effects on the physical performance of sixth grade students, yielding positive short-term outcomes for both genders [6]. Therefore, we performed this study to investigate the relationships and gender differences in health promotion behavior and multidimensional health among rural middle-school students in China to provide theoretical framework for targeted health interventions within this demographic.

2. Literature review

Adolescence is a critical phase characterized by rapid physical growth and cognitive development encompassing, not only physical and cognitive changes but also emotional, moral and spiritual development [7]. During this period, many lifelong health habits are established, including imbalanced diets, insufficient physical activity, poor mental health, high psychological stress, and sometimes violent behavior [8]. These unhealthy behaviors signal a long-term risk of chronic diseases in adulthood, with lifestyle factors, such as depression, anxiety and poor health-related quality of life being closely linked to elevated health risks [9]. Nearly two-thirds of premature deaths in early adolescence and one-third of adult illnesses can be attributed to unhealthy lifestyle habits and risky behaviors initiated during adolescence. Thus, the assessment and improvement of health-promoting behaviors among adolescents is a pivotal area of international research.

In 1986, the WHO held the inaugural Global Health Promotion Conference in Ottawa, Canada, formally introducing the term of “health promotion”. This concept encompasses a range of social behaviors and strategies aimed at engaging various societal components—including members, departments, communities, families and individuals through administrative and organizational means, to share the responsibility of health maintenance and promotion. In 1987, Pender proposed the concept of health-promoting lifestyle, describing it as actions individuals undertake to maintain or enhance their health, achieve self-satisfaction, and realize their potential self-actualization [10]. Nola et al. [11] (1990) further distinguished that health promotion behavior from disease prevention, characterizing it as all individual actions aimed at sustaining and improving well-being, happiness, and health levels.

Research has identified gender disparities in health promotion behaviors among adolescents. An examination of college students’ life appreciation revealed its association with both physical activity and stress management, with the correlation being stronger in males compared to females [12]. The COVID-19 pandemic, which resulted in school closures, increased the risk of obesity among adolescents due to reduced physical activity, with females experiencing a more significant increase than males [13]. In Iran, risky health behaviors are observed more frequently among male adolescents than females [14]. A study focusing on health behavior in rural middle and high schools in Pennsylvania, USA, found that female students showed greater interest in weight loss and healthy eating or cooking practices, whereas male students were more inclined towards weightlifting [15]. Furthermore, the health promotion behavior of adolescents is influenced by the level of eHealth literacy. In Turkey, strong positive relationship between eHealth literacy and the health promotion behaviors of adolescents was found, including health responsibility, engagement in sports activities, nutrition, spiritual growth, interpersonal relationships, and stress management [16]. In China, the eHealth literacy has significant gender difference among university students, and those with high eHealth literacy have a higher ability to participate in health-related behaviors [17, 18]. Generally, female adolescents have more positive health promotion behaviors than male adolescents [19], but they often lag behind male adolescents in terms of sports and physical activity [20, 21].

Adolescence is a critical developmental period for individuals to establish lifelong healthy behaviors and take responsibility for their healthcare. To this end, the relationship between health promotion behaviors and multidimensional health was explored, providing theoretical reference for formulating intervention strategies for adolescent physical and mental health, so as to achieve precise intervention in adolescent health.

3. Materials and methods

4. Results

5. Discussions

This study investigated the relationships and gender differences in health promotion behaviors and multidimensional health among rural middle-school students in China to determine the multidimensional health of this population, identify predictive health-promoting behaviors for multidimensional health outcomes, and offer a theoretical foundation for future targeted interventions.

Adolescence is a pivotal period for the development of social and emotional habits, along with healthy practices that are essential for mental well-being. According to the WHO, half of all mental disorders in adults worldwide originate by the age of fourteen. Furthermore, about 14% of the global adolescent population aged 10–19 suffers from mental disorders [24]. Adolescents from experiencing, multidimensional poverty face a 50% higher risk of developing mental health problems compared to those from non-impoverished backgrounds [25]. Significant risk behaviors and health issues have been documented among rural youth, particularly those from impoverished and ethnic minorities [26]. Notably, approximately 33% of adolescents in the slums of Lucknow, India, face severe mental disorders [27]. Without timely intervention, mental health problems initiated in adolescence can persist into adulthood, impairing physical and mental health and diminishing the prospects for a fulfilling adult life.

Our analysis revealed that female participants displayed higher levels of health promotion behaviors than males, with significant gender differences observed in health responsibility behavior and interpersonal relationship behavior. The correlation between adolescent health promotion behavior, gender and health literacy is substantial [28]. Throughout adolescence, females typically exhibit a nuanced understanding of health, demonstrate a greater sense of health responsibility, and place a higher value on interpersonal relationships than males [29]. In contrast, males during this phase often show a tendency towards rebellion, preferring autonomy in their actions and exhibiting less concern for the perceptions of others [30]. Evidence from Chile corroborates that female adolescents engage in more proactive health promotion behaviors than males [31], indicating the necessity of acknowledging gender differences when developing and implementing health promotion strategies for adolescents. Customized approaches, such as the establishment of gender-specific educational settings, could be beneficial. It has been noted that many male adolescents resist participating in preventive health measures, are prone to risk-taking behaviors, and generally show a lack of health knowledge and awareness [11]. A study from Iran highlights these gender disparities, revealing that females and older adolescents are more susceptible to adopting unhealthy lifestyles [32], yet females consistently achieve higher overall scores in health promotion behavior than males [33].

Our findings also found that life appreciation behavior is the only factor that significantly influencing the multidimensional health outcomes of participants, including self-reported health, physical health and mental health. Notably, an elevated life appreciation score correlates with enhanced health across these dimensions. Life appreciation emerges as a critical element for cultivating a positive body image, interconnected with psychological factors such as self-reported health status, concerns about weight, familial influences and self-esteem [34]. Additionally, our findings reveal an inverse relationship between life appreciation and BMI, with young females exhibiting lower scores on life appreciation and being more prone to unhealthy BMI levels [35]. Investigations involving adolescents aged 12–19 from Denmark, Portugal and Sweden have demonstrated a positive link between life appreciation and key psychological outcomes, including self-esteem and mental health. Interestingly, male participants displayed superior physical appreciation abilities compared to girls [36], indicating a significant correlation between life appreciation and gender [37].

This study has several limitations. First, its cross-sectional design limits the ability to infer causality between the study variables examined. Second, this study was targeted at eighth-grade students from one rural middle school in Zhoukou (China), and thus the results may not be representative for other seventh and ninth-grade middle school students and urban middle school students and cannot also represent all ordinary middle school students in China. Third, the reliance on self-reported questionnaires for data collection may introduce response bias, potentially affecting the reliability of the findings. Despite these constraints, the voluntary, anonymous participation of 179 rural eighth-grade students from varied classes and family backgrounds provides a diverse sample that offers preliminary insights into the health promotion behaviors of this population.

6. Conclusions

This study found that among rural middle-school students, females had higher health promotion behavior levels than males, with significant gender differences observed in health responsibility and interpersonal relationship behaviors. However, no gender differences were identified in the multidimensional health outcomes measured. Life appreciation behavior was identified as the only factor that can simultaneously predict the multidimensional health of rural middle-school students, indicating that higher scores are associated with better overall health among these students. Despite 43.7% of middle-school teachers believing that rural middle-school students have good health promotion behaviors, the analysis of the student self-reported questionnaire showed that rural middle-school students’ physical health is worrying. These findings highlight the need for targeted intervention strategies to improve health outcomes among rural middle-school students. This research contributes valuable insights towards the formulation of such interventions.

Availability of data and materials

The data presented in this study are available on request from the corresponding author.

Author contributions

RPD—conducted the questionnaire survey and collect data. HT—performed the statistical analysis and prepared all tables. JC—drafted the manuscript. All authors revised and approved the final manuscript.

Ethics approval and consent to participate

This study was performed in compliance with the Declaration of Helsinki. All procedures relevant to study participants were approved by Xinyang Normal University ethics committee (XFEC-2023-030). Participation was voluntary. Participants were informed of the study objective and context and provided their parental written informed consent regarding privacy and information management policies.

Acknowledgment

The authors appreciate the help from middle-school students and teachers participated, as well Xinyang Normal University.

Funding

This research was funded by Nanhu Scholars Program for Young Scholars of XYNU (Xinyang Normal University, China), UGS Teaching Reform Research Project of Plan to Strengthen Basic Education Teacher Force of Xinyang Normal University (2022-GTTZD-01), and Graduate Education Reform and Quality Improvement Project in Henan Province in 2024 (YJS2024AL103).

Conflict of interest

The authors declare no conflict of interest.

Supplementary material

Supplementary material associated with this article can be found, in the online version, at https://oss.jomh.org/ files/article/1840320603378073600/attachment/ supplementary%20material.docx.