Lifestyle Interventions for Multiple Behavioral Risk Factors Among Adolescents in Asia: A Systematic Review of Randomized Controlled Trials

Unhealthy lifestyle, such as alcohol use, and negative health outcomes have been associated with impairments in psychological well-being. The primary objective of the study was to test the efficacy of an intervention based on Well-Being Therapy to prevent or stem alcohol use, binge drinking and other unhealthy lifestyle among Italian adolescents in school settings. A three-arm cluster randomized controlled trial including three test periods (baseline, post-test, six-month follow-up) was implemented. Seven classes (144 students) were randomly assigned to receive well-being intervention (WBI), lifestyle intervention (LI), or no intervention (NI). Primary outcomes were alcohol use (AUDIT-C), binge drinking and other unhealthy lifestyle behaviors (i.e. unhealthy diet, physical inactivity, tobacco and cannabis smoking, poor sleep and Internet addiction). Linear mixed models and mixed-effects logistic regression were used to test the efficacy of WBI in comparison with LI and NI. At six-month follow-up, AUDIT-C total score increased more in NI in comparison with WBI (p = 0.044) and LI (p = 0.016), whereas the odds of being classified as at-risk drinker were lower in WBI (p = 0.038) and LI (p = 0.002), than NI. Only WBI showed a protective effect for cannabis use at post-test in comparison with NI (p = 0.003) and LI (p = 0.014). Sleep hours at night decreased more in NI than in LI (p = 0.027) at six months. Internet addiction decreased more in WBI (p = 0.002) and LI (p = 0.005) at post-test in comparison with NI. Although both interventions showed a positive impact on adolescent lifestyle, the positive effect of WBI on cannabis use underlines how this approach might be promising to stem adolescents’ substance use.

Adolescents worldwide are facing an alarming convergence of four lifestyle-related behavioural risks – physical inactivity, sedentary behaviour, poor sleep, and unhealthy diet – that threaten their current and future wellbeing. These behaviours frequently co-occur and are strongly associated with a range of adverse outcomes, including physical and mental health issues and compromised academic performance. Emerging evidence suggests these risks are particularly concerning in Southeast Asia, particularly Indonesia. In Indonesia, home to over 46 million adolescents (United Nations Population Fund [UNPF], 2024), national surveys highlight the rising prevalence trend. A significant proportion of adolescents do not meet recommended physical activity levels, nearly half engage in prolonged sedentary behaviour, many report sleep difficulties, and dietary quality remains poor (Global School-based Health Survey [GSHS], 2023; Kementerian Kesehatan Republik Indonesia [Kemenkes], 2018). These risks may be further compounded by systemic gaps in health promotion infrastructure and unequal access to services, which are frequently observed in low-resource settings across developing countries (Feigin et al., 2024). Despite the interconnected nature of these behaviours, most health interventions remain siloed, targeting single behaviours in isolation (Ahmed et al., 2021; Pushpa et al., 2024; Rizal et al., 2019). This fragmented approach may overlook the synergistic consequence of behavioural risks and misses critical opportunities for more holistic and efficient solutions. There is an urgent need for integrated interventions – characterised by addressing multiple behavioural risk factors simultaneously or sequentially – that are grounded in adolescents' lived experiences and tailored to the constraints of resource-limited environments. Considering this potential, it is encouraged to shift from isolated action to unified strategies, multi behaviour interventions. A focus on the big four behavioural risk factors is not only timely – it is essential to safeguard the health, development, and future potential of Indonesia’s young people and beyond.

Methods of quantifying change in multiple risk factor interventions

Physician screening for multiple behavioral health risk factors

Background: Prevention of non-communicable diseases (NCDs) and their behavioral risk factors (tobacco use, unhealthy diet, physical inactivity, harmful use of alcohol) among children and adolescents have garnered paramount importance under the Sustainable Development Goals. Methods: Project PaThWay is a school-based, two years, multi-component intervention to prevent key behavioral NCD risk factors among school-going children (classes 6-8th; 10-14 years) from private and public schools across two Indian cities (Pune and Bengaluru). We assessed the baseline knowledge, attitude, and behavior related to NCD risk factors (unhealthy diet, physical inactivity, and tobacco use) of the participating students through a survey. The intervention was developed and designed for implementation by the trained teachers and similar-age peers, as facilitators. The teachers and peer leaders were trained through organising school-level orientation workshops for implementation of intervention activities, after baseline assessment. Year 1 of the intervention focuses on the knowledge and learnings and year 2 on enhancing the life-skills (leadership, communication, refusal, health advocacy, etc.). Regular monitoring visits by the project team to ensure intervention activities are being carried out as planned and providing continuous support. The end line evaluation will be done after the completion of two years’ intervention to evaluate the effectiveness of the Project PaThWay intervention. Outcome measures will include improved knowledge, positive attitude, improve behaviors related to diet, physical activity, and tobacco use, and enhanced skills in handling NCD risk factors. A process evaluation will explore several aspects of Project PaTHWay intervention (fidelity, dosage, reach, adaptations), social validity (acceptability, feasibility, utility). Conclusion: Project PaTHWay, having a multiple-component intervention, may offer the best chance for success, as it addresses multiple risk factors using multi-pronged strategies. The agents of intervention implementation are trained teachers and similar-age student peer leaders (as facilitators), one of the successful and effective approaches in school-based interventions globally and in India.

BackgroundRisk behaviours, such as smoking and physical inactivity account for up to two-thirds of all cardiovascular deaths, and are associated with substantial increased mortality in many conditions including cancer and diabetes. As risk behaviours are thought to co-occur in individuals we conducted a systematic review of studies addressing clustering or co-occurrence of risk behaviours and their predictors. As the main aim of the review was to inform public health policy in England we limited inclusion to studies conducted in the UK.MethodsKey databases were searched from 1990 to 2016. We included UK based cross-sectional and longitudinal studies that investigated risk behaviours such as smoking, physical inactivity, unhealthy diet. High heterogeneity precluded meta-analyses.ResultsThirty-seven studies were included in the review (32 cross-sectional and five longitudinal). Most studies investigated unhealthy diet, physical inactivity, alcohol misuse, and smoking. In general adult populations, there was relatively strong evidence of clustering between alcohol misuse and smoking; and unhealthy diet and smoking. For young adults, there was evidence of clustering between sexual risk behaviour and smoking, sexual risk behaviour and illicit drug use, and sexual risk behaviour and alcohol misuse.The strongest associations with co-occurrence and clustering of multiple risk behaviours were occupation (up to 4-fold increased odds in lower SES groups) and education (up to 5-fold increased odds in those with no qualifications).ConclusionsAmong general adult populations, alcohol misuse and smoking was the most commonly identified risk behaviour cluster. Among young adults, there was consistent evidence of clustering found between sexual risk behaviour and substance misuse. Socio-economic status was the strongest predictor of engaging in multiple risk behaviours.This suggests the potential for interventions targeting multiple risk behaviours either sequentially or concurrently particularly where there is evidence of clustering. In addition, there is potential for intervening at the social or environmental level due to the strong association with socio-economic status.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3373-6) contains supplementary material, which is available to authorized users.

The study assessed the prevalence and associated factors of behavioural risk factors of non-communicable diseases (NCDs) among adolescents in four Caribbean countries. In all 9,143 adolescents (15 years=median age) participated in the cross-sectional "2016 Dominican Republic, 2016 Suriname, 2017 Jamaica, and 2017 Trinidad and Tobago Global School-Based Student Health Survey (GSHS)". Eight behavioural risk factors of NCDs were assessed by a self-administered questionnaire. Prevalence of each behavioural NCD risk factor was physical inactivity (84.2%), inadequate fruit and vegetable intake (82.2%), leisure-time sedentary behaviour (49.6%), daily≥2 soft drinks intake (46.8%), ever drunk (28.6%), twice or more days a week fast food consumption (27.6%), having overweight/obesity (27.4%), and current tobacco use (13.8%). Students had on average 3.6 (SD=1.4), and 79.0% had 3-8 behavioural NCD risk factors. In multivariable linear regression, psychological distress and older age increased the odds, and attending school and parental support decreased the odds of multiple behavioural NCD risk factors. A high prevalence and co-occurrence of behavioural risk factors of NCDs was discovered and several factors independently contributing to multiple behavioural NCD risk factors were identified.

The period prevalence of risk behavior co-occurrence among Canadians

Introduction: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality globally accounting for 30% of total deaths worldwide with 82% of these deaths occurring in low/middle income countries (LMIC). WHO targeted 4 behavioral risk factors (physical inactivity, unhealthy diet, tobacco use, harmful use of alcohol) as the foundation of the WHO framework on prevention and control of CVD in LMIC. The purpose of this study was to examine the prevalence, distribution and association of these 4 risk factors in selected countries of Sub-Saharan Africa (SSA). Methods: Secondary analysis was conducted on data from the population-based WHO World Health Survey using data from 4 countries in SSA to reflect low (Senegal), middle (Ghana, Kenya), and high (South Africa) GDP. The data was weighted to account for country-specific sample sizes and pooled to provide regional prevalence estimates. The analysis controlled for age, gender, living location (rural/urban) and education. Analysis included Chi-square and logistic regression. Results: The pooled data among 13,850 subjects revealed high prevalence of unhealthy diet (67%), with lower prevalence of physical inactivity, tobacco use and harmful alcohol (12%, 14%, 6%, respectively). Country-specific analysis revealed that prevalence of behavioral CVD risk factors varied by socio-demographic variables within the countries of interest. Physical inactivity and unhealthy diet was higher among older individuals (p<.05) and female (p<.05). Tobacco use and harmful use of alcohol was higher in middle age men (p<.001) with a trend for higher use in rural locations. Among the selected countries significant differences include: Kenya had the highest prevalence of unhealthy diet (OR=12.5, 95%CI=11.1-14.3). South Africa had the highest prevalence of physical inactivity (OR=7.8, 95%CI=6.8-9.1) and tobacco use (OR=2.8, 95%CI=2.4-3.3). Ghana had the highest prevalence of harmful use of alcohol (OR=3.8, 95%CI=3.1-4.6). Conclusions: This study demonstrates within and between-country differences in the prevalence and distribution of the 4 CVD behavioral risk factors. These results highlight the necessity of local and region-specific data to tailor policy, resource allocation and prevention measures.

Clustering patterns of behavioural risk factors for cardiovascular diseases in Bangladeshi adolescents: A population-based study

Smoking in combination with other behavioral risk factors is known to have a negative influence on health, and individuals who smoke typically engage in multiple risk behaviors. However, little is known about the clustering of risk behaviors among smokers of varying race/ethnicity. The purpose of this study was to examine patterns of cancer risk behaviors and to identify predictors of multiple risk behaviors in a racially/ethnically diverse sample of individuals seeking smoking cessation treatment. Overweight/obesity, at-risk alcohol consumption, and insufficient physical activity were measured in 424 smokers (African American, n = 144; Latino, n = 141; and Caucasian, n = 139). Results indicated that 90% of participants reported behavioral cancer risk factors in addition to smoking. Approximately 70% of participants were overweight or obese, 48% engaged in at-risk drinking, and 27% were insufficiently physically active. Univariate analyses indicated that race/ethnicity (P < 0.001), smoking level (P = 0.03), and marital status (P = 0.04) were significant predictors of multiple risk behaviors, although only race/ethnicity remained a significant predictor (P < 0.001), when gender, smoking level, age, education, household income, marital status, and health insurance status were included in a multivariate model. Multivariate analysis indicated that the odds of engaging in multiple risk behaviors were significantly higher among Latinos (odds ratio = 2.85) and African Americans (odds ratio = 1.86) than Caucasians. Our findings highlight the need for research aimed at identifying determinants of racial/ethnic differences in multiple risk behaviors and indicate the importance of developing culturally sensitive interventions that target multiple risk behaviors.

BackgroundHealth risk behaviours often co-occur in adolescence. This may be partially explained by a set of common risk and protective factors. The current study examines the association between risk behaviours throughout adolescence and identifies common risk factors for multiple risk behaviour in late adolescence.MethodsWe use data from the Longitudinal Study of Young People in England. We examined the association between risk behaviours at age 14 (n = 15,588), age 16 (n = 12,416) and age 19 (n = 9,548). The associations between age 19 risk behaviour and earlier risk behaviours and risk and protective factors were assessed longitudinally. Health risk behaviours included smoking, alcohol use, illicit drug use, delinquency and unsafe sexual behaviour.ResultsAll risk behaviours were found to be associated with other risk behaviours with associations weakening through adolescence. A number of sociodemographic, interpersonal, school and family factors at age 14 predicted risk behaviour and multiple risk behaviour at 19, though predictors for heavy alcohol use often differed from other health risk behaviours. Past risk behaviour was a strong predictor of age 19 risk behaviour though many involved in only one form of risk behaviour in mid-adolescence do not progress to multiple risk behaviour.ConclusionsOur findings reaffirm the links between health risk behaviours, but these diminish throughout adolescence with multiple risk behaviour usually initiated in mid-adolescence. Multiple risk behaviour is initiated in early or mid adolescence with a number of common risk factors explaining the co-occurrence of risk behaviours.

Cross-sectional associations of gender identity and sexual orientation, with co-occurrence and clustering of health-related behaviours among British adolescents: Millennium cohort study

The authors assessed individual, social, and school correlates of multiple chronic disease behavioral risk factors (physical inactivity, sedentary behavior, tobacco smoking, alcohol drinking, and high body mass index) in a representative sample of Canadian youth aged 10-15 years (mean = 12.5 years) attending public schools. Cross-sectional data (n = 1,747) from cycle 4 (2000-2001) of the National Longitudinal Survey of Children and Youth were used. Ordinal regression models were constructed to investigate associations between selected covariates and multiple behavioral risk-factor levels (0/1, 2, 3, or 4/5 risk factors). Older age (odds ratio (OR) = 1.95, 95% confidence interval (CI): 1.21, 3.13), caregiver smoking (OR = 1.49, 95% CI: 1.09, 2.03), reporting that most/all of one's peers smoked (OR = 7.31, 95% CI: 4.00, 13.35) or drank alcohol (OR = 3.77, 95% CI: 2.18, 6.53), and living in a lone-parent family (OR = 1.94, 95% CI: 1.31, 2.88) increased the likelihood of having multiple behavioral risk factors. Youth with high self-esteem (OR = 0.92, 95% CI: 0.85, 0.99) and youth from families with postsecondary education (OR = 0.58, 95% CI: 0.41, 0.82) were less likely to have a higher number of risk factors. Although several individual and social characteristics were associated with multiple behavioral risk factors, no school-related correlates emerged. These variables should be considered when planning prevention programs.

Background We aimed to undertake a Cochrane systematic review to quantify the effect of multiple risk behaviour interventions on prevention of substance use, antisocial behaviour, sexual risk, vehicle risk, self-harm, gambling, physical inactivity and unhealthy diet among individuals aged 8–25 years as little is known about their effectiveness (CD009927). Methods Eleven databases were searched to 14 November 2016. Randomised controlled trials were included that addressed two or more risk behaviours in individuals aged 0–18 years. Data were pooled in a random-effects meta-analysis in Revman 5.3. For each outcome, we included subgroups relating to study type (individual, family or school-level and universal or targeted in approach). The quality of evidence was assessed using the GRADE approach. Results We identified 34 680 titles, screened 27 691 articles and included seventy studies. We found moderate quality evidence indicating that universal school-level interventions were beneficial in relation to tobacco use (odds ratio [OR] 0.77, 95% confidence interval [CI] 0.60–0.97, n=15 354, I2 57%), alcohol use (OR 0.72, 95% CI 0.56 to 0.92, n=8,751, I2 58%), and physical activity (OR 1.32, 95% CI 1.16 to 1.50, n=6 441, I2 0%) compared to a comparator. Lower quality evidence indicated possible benefit for drug use (OR 0.74, 95% CI 0.55 to 1.00, n=11 058, I2 69%) and antisocial behaviour (OR 0.81, 95% CI 0.66 to 0.98, n=20 756, I2 66%), while findings were less certain for sexual risk behaviour (OR 0.80, 95% CI 0.60 to 1.08, n=13 351, I2 80%; low quality evidence) and unhealthy diet (OR 0.82, 95% CI 0.64 to 1.06, n=6441, I2 49%, moderate quality evidence). Analyses indicated that family- and individual-level interventions probably have little or no effect on these outcomes, although fewer such studies were identified. The quality of studies was judged to be of moderate or low quality for most outcomes, primarily owing to concerns around selection, performance and detection bias, and heterogeneity between studies. Conclusion Available evidence is strongest for universal school-level interventions that target multiple risk behaviours demonstrating that they may be effective in preventing certain risk behaviours. However, concerns around poor reporting and study quality highlight the need to strengthen the evidence base in this field. This abstract is based on preliminary findings from a Cochrane review currently underway. Upon completion and approval, the final version is expected to be published in the Cochrane Database of Systematic Reviews.