Stress and health risk behaviors among university students

Rev Bras Enferm. 2020;73(1): e20180035 http://dx.doi.org/10.1590/0034-7167-2018-0035 8 of ABSTRACT Objective: To analyze the level of stress and its relationship with health risk behaviors among university students. Method: Cross-sectional analytical study carried out at a higher education institution in Picos-PI. A total of 377 students were evaluated for sociodemographic and academic variables, stress profile, sleep quality, alcohol use, smoking habits and level of physical activity. The Statistical Package for the Social Sciences (SPSS), version 20.0 was used for data processing and analysis. Results: Sleep quality was poor for 65.3% of the subjects, and sleep disturbances were found in 17.0%. Stress was observed in 68.7% of the sample. Stress was associated with the following variables: gender, time in the institution, poor sleep quality. Conclusion: Most of the students evaluated present some level of stress associated with poor sleep quality, which is a risk to the quality of life of these individuals. Descriptors: Stress; Psychological; Universities; Students; Sleep; Quality of Life.


INTRODUCTION
The university is a moment of intense changes in students' lives. It can be a source of stress and influence the student's adaptation, or lead to the acquisition of behavior patterns that will have repercussions throughout their lives (1)(2) . These facts are concerning, since, according to Souza et al. (3) and Faria, Gandolfi, Moura (4) , the adoption of health risk behaviors is associated with a low level of psychological well-being among university students, due to the stress experienced in the university environment.
Studies have identified an association between high frequency of stress and health risk behaviors among university students (5) , with emphasis on the use of psychoactive substances (6)(7) , sedentary behavior (8) , inadequate sleep patterns (9) and unhealthy eating habits (10) .
The university is an environment that produces knowledge in the most varied areas; however, being in the university does not always mean presenting a healthy lifestyle, a fact that is confirmed among students of several Higher Education Institutions (HEI) in Brazil (11)(12)(13)(14)(15)(16) .
Therefore, student's health is a current issue that needs to be understood based on the interaction between the demands of Higher Education and the social, economic and personal factors, taking into consideration the vulnerability and psychic suffering of a significant number of university students (17) .
It is necessary to study the level of stress and the health risk behaviors among university students, since, as described by Moreira, Santiago and Alencar (18) , the early detection of risk factors can allow planning and implementing intervention programs.

OBJECTIVE
To analyze the level of stress and its relationship with health risk behaviors among university students.

Ethical aspects
The present study was performed after obtaining approval from the Research Ethics Committee of the Federal University of Piauí (CEP/UFPI), according to Resolution 466/2012 of the National Health Council (CNS).

Design, area and period
Analytical, cross-sectional, quantitative study carried out from April to November 2016, in a higher education institution in the city of Picos-PI.

Inclusion and exclusion criteria and sample
The study participants were students of both genders between 18 and 30 years old. Students in long-distance learning or postgraduate education, those in a different academic calendar and exchange students were excluded.
A total of 377 undergraduate students from the areas of health, biological sciences, humanities, and exact sciences were selected proportionally among all the periods in each course.

Study protocol
The students' socio-demographic and academic characteristics were assessed through a semi structured form, with questions related to the year of admission to university, course, current period, gender, age, among others. The Brazilian Economic Classification Criteria (CCEB) were used to determine the socioeconomic level of the university students (19) .
The Lipp's Stress Symptoms Inventory (LSSI) was used to evaluate stress among university students. It is based on a quadriphasic model described by Lipp (alert, resistance, near exhaustion and exhaustion). In this stage, a specific professional from the area of psychology was assigned to evaluate the inventories.
The LSSI is divided in three phases or parts. The first one consists of 15 symptoms, divided into F1 (physical symptoms) and P1 (psychological symptoms). Symptoms that were experienced in the last 24 hours should be marked with an x. The cut-off score in this part is six. The second phase also consists of 15 symptoms, equally divided into F2 (physical symptoms) and P2 (psychological symptoms). In this phase, the symptoms experienced in the last week should be marked and the cut-off score is three. The third phase is composed of 23 symptoms, also divided into F3 (physical symptoms) and P3 (psychological symptoms). The symptoms experienced in the last month should be marked and the cut-off score is eight. The correction tables present in the ISSL Handbook (20) were used to identify the phase of stress that the individual was experiencing.
Sleep quality was analyzed trough the Pittsburgh Sleep Quality Index (PSQI), in the version validated, translated and adapted to the Brazilian standards. The sum of the scores in this index (zero to three points for each component) produces a global score, which ranges from 0 to 21, with highest score indicating the worst quality of sleep. University students who present scores above five points will be classified as poor sleepers (21) .
The Alcohol Use Disorder Identification Test was used to identify individuals at risk and with probable alcohol dependence. It is a self-administered, low-cost test that evaluates alcohol consumption in the last twelve months. The total score ranges from 0 to 40 points. Thus, four categories of alcohol consumption are defined: low risk (0 to 7 points), risk (8 to 15 points), harmful drinking (16 to 19 points) and probable alcohol dependence (≥20 points) (22) .
Regarding smoking habits, the students were asked about the frequency of cigarette smoking, and were classified into four categories: daily smokers, occasional smokers, ex-smokers and non-smokers. The students considered as daily smokers were those who smoked at least one cigarette per day on the month prior to application of the questionnaire; occasional smokers were those who did not smoke everyday; ex-smokers were those who had quit smoking for at least one month; and non-smokers were those who had never smoked or had been smoking for less than one month (23) .
The International Physical Activity Questionnaire version 8 (IPAQ-8), a short form validated in Brazil (24) , was used to assess the level of physical activity. It assesses the number of days and minutes of physical activities performed as leisure, work, transportation and housework in the week prior to completing the questionnaire. With these data, the IPAQ classifies the individual into the categories: Sedentary, Insufficiently active A, Insufficiently active B, Active and very active.
of Stress and health risk behaviors among university students Oliveira ES, Silva AFR, Silva KCB, Moura TVC, Araújo AL, Silva ARV.

Analysis of results and statistics
The Statistical Package for the Social Sciences (SPSS), version 20.0 was used for data processing and analysis.

RESULTS
Most of the participants were female (61.5%), between 18 and 21 years old (61.5%), with a median of 21 years (interquartile range: 19-22.5 years), self-identified as brown (54.6%) and were single (92.8%). In addition, the majority had family incomes in the range of 1 to 3 minimum wages (68.4%), belonged to the socioeconomic classes C1 and C2 (53.6%), lived with relatives (57.0%) and were from other cities of Piauí (53.3%) ( Table 1). classified as low risk. Regarding the level of physical activity, 47.5% were active, while 30.8% were insufficiently active. The analysis of sleep quality showed that 65.3% of the participants were poor sleepers and 17.0% had sleep disturbances (Table 2).  The levels of stress were compared with the socioeconomic and demographic data. The phases of stress were associated with gender (p=0.000) and time in the teaching institution (p=0.031) ( Table 3).
Among the health risk behaviors studied, the sleep quality was the only one that presented a moderate association with the stress phases (p = 0.000), indicating that most university students with stress have poor sleep quality or sleep disturbances (Table 4).

DISCUSSION
The characterization of higher education students presented here is similar to other national and international studies, which show majority of female students, single, with family income between 1 and 3 minimum wages, belonging to socioeconomic levels C1 and C2, and between 18 and 21 years old (1,5,(25)(26)(27)(28) .
Corroborating the findings of this study in relation to the risk behaviors among university students, the literature has reported low levels of smoking among Brazilian youth (7,(29)(30) and among the general population (31) . The low prevalence of smoking can be a reflection of anti-smoking policies implemented in the country. This is a positive aspect, since smoking is one of the most important risk factors for the occurrence of chronic noncommunicable diseases (32) .
Regarding alcohol, most of the young students evaluated were classified as low risk; however, the fact that some university students experienced harmful drinking or characteristics of probable alcohol dependence in the prior month is alarming. According to Soares and Oliveira (7) , alcohol use tends to persist throughout the university years, and may even remain long enough to harm Regarding health risk behaviors, 93.1% of college students reported being non-smokers. As for alcohol use, 78.5% were of Stress and health risk behaviors among university students Oliveira ES, Silva AFR, Silva KCB, Moura TVC, Araújo AL, Silva ARV.  of Stress and health risk behaviors among university students Oliveira ES, Silva AFR, Silva KCB, Moura TVC, Araújo AL, Silva ARV. the students' health, since alcohol is an important preventable risk factor for cardiovascular diseases (CVD) and it can contribute to the adoption of other health risk behaviors (33) .
The evaluation of sedentarism among the students showed a satisfactory level of physical activity in more than half of the sample. These findings differ from other studies involving university students, which found percentages of sedentarism ranging from 70.2% to 78.4% (1,14,26,29) . These results can be explained by the widespread dissemination of the importance of taking care of the body and the negative effects of lack of physical exercise. However, the insufficient level of physical activity identified in part of the sample suggests that there is still resistance to physical exercise in the daily life of many university students, who, in general, claim they have excessive activities, fatigue, lack of time or lack of motivation (34) .
The results related to sleep quality reveal a critical scenario, since sleep has an important role in the physical, psychological and mental health of individuals, and poor sleep can lead to serious cognitive problems (9,25,30,(35)(36)(37)(38)(39)(40) . Despite the different socioeconomic and cultural characteristics, studies from different parts of the world also found poor sleep quality among undergraduate students, which is explained by short sleep duration and later bedtimes on weekdays due to their high demand of activities, associated with changes in sleep patterns on weekends (41)(42) .
Among other possible explanations for the high number of individuals with poor sleep quality, it is worth mentioning that the daily life in the HEI is characterized by numerous academic activities that may lead to the reduction of hours of sleep. It is also worth noting that many students end up having an unbalanced lifestyle, replacing hours of sleep with social interaction, sometimes associated with alcohol and tobacco use (37,40) .
For decades, the literature has been demonstrating the importance of assessing the vulnerability to stress among young adults. The transitions experienced in this phase lead to confrontation of new situations, such as searches for careers, autonomy, stability, affective relationship, identities and for the role that this young person will have in society, increasing their susceptibility to stressors (43) .
In this aspect, stress was present in the majority of the university students investigated, which is in consonance with other investigations (44)(45) . The most frequent phase among the students was resistance, a finding similar to those of Lameu, Salazar and Souza (46) and Bonifácio et al. (17) . Although few students reached more severe phases of stress, the detection of these less severe stages also require attention (44) , since less intense but recurrent stress events are potentially pathogenic (20) .
Female students did not only present a higher percentage of stress, but also showed a higher prevalence in all phases, results also verified in other studies (45)(46) . Considering that the stress factors faced in the university are the same for men and women, a possible explanation for this result may be that women have less difficulty to express their fears, discomforts and difficulties.
The time in the institution was another variable significantly associated with stress levels. According to Soares and Oliveira (7) after admission to the university comes a phase of adaptation to the daily life of higher education and the new teaching methodologies. It is known that every process in which the subject is exposed to new situations and needs to develop or acquire skills can lead to some intensity of stress. Therefore, the relationship between these variables in the university context was predictable.
Sleep quality moderately influenced the stress profile of university students (p=0.000), as the majority of individuals with poor sleep quality were in the most severe stages of stress. In this sense, Sateia (47) explains that the association between psychological illness and distress and sleep disorders is bidirectional, that is, mental disorders lead to the occurrence of sleep disorders and vice-versa.

Limitations of the study
The quantitative evaluation is highlighted as a limitation of this study, as the predictors of stress and the occurrence of risk behaviors were not evaluated. These data could favor a clearer profile about the main demands and stressors for university students.

Contributions to nursing, health, or public policy
Despite the limitations, the results reached the objective proposed and contribute to the health of university students by providing important information for the development of other studies in the same perspective and for the construction of educational strategies focused on the ways of coping with stress and choosing healthier life behaviors, which can have positive impacts on quality of life and health in general.

CONCLUSION
This study demonstrated that most university students present some level of stress which is associated with the variables: gender, time in the institution and sleep quality.
Therefore, the presence of stress is a risk to the physical and mental health of university students and can directly interfere with their growth and personal and professional development, producing negative effects that influence their daily living habits and their health.
It is emphasized that this subject needs to be further debated in the university environment, since stress is a current public health problem that affects the entire academic community, and the university cannot remain silent in this scenario. Thus, it is necessary to develop integrated actions that help students to face stressful experiences in a conscious and healthy way.