Changes in physical activity, diet, sleep, and mental well-being when starting university: A qualitative exploration of Australian student experiences

Abstract

Objective: To explore young adult’s experiences of how starting university influenced their physical activity, diet, sleep, and mental well-being, and barriers and enablers to health behavior change. Participants: University students aged 18–25 years. Methods: Three focus groups were conducted in November 2019. Inductive thematic approach was utilized to identify themes. Results: Students (female: n = 13, male: n = 2, other gender identity: n = 1, 21.2 (1.6) years) reported mental well-being, physical activity levels, diet quality and sleep health were negatively affected. Stress, study demands, university timetabling, not prioritizing physical activity, cost and availability of healthy foods, and difficulty falling asleep were key barriers. Health behavior change interventions aiming to support mental well-being need to include both information and support features. Conclusions: There is a significant opportunity to improve the transition to university for young adults. Findings highlight areas to target in future interventions to improve physical activity, diet, and sleep of university students.

Keywords:

• Diet quality
• exercise
• mental health
• sleep health
• young adult

Introduction

Young adult university students have been identified as a population at-risk of mental health disorders, due to higher rates of psychological distress than the general population and their non-studying peers.^1,2 The rates of reporting very high levels of psychological distress are higher among university students (19%) compared to the general population (3%).² This is a concern, as the period from 18 to 25 years, which often coincides with commencing university studies, is a particularly susceptible time for developing mental illness.³ It is therefore a critical time to intervene to alter mental health trajectories. Evidence suggests that physical activity, a high-quality diet, and good quality sleep can reduce the risk of developing poor mental health and play an important role in the management of mental health problems.^4–13 However, the majority (75%) of young Australians aged 18–25 years do not meet Australian physical activity guidelines of at least 150 minutes of moderate-to-vigorous physical activity over five sessions and at least 2 sessions of strength-based activity per week.¹⁴ They also have the poorest diet quality of all adult age groups,¹⁵ with only 3.6% meeting the recommended daily intake of two serves of fruits and five serves of vegetables.¹⁶ Young adults also have the highest self-reported prevalence of difficulties falling asleep (41%), inadequate sleep duration (60%) and waking feeling unrefreshed (65%) of all age groups.¹⁷ Similar statistics have been found in the Australian, Canadian and US university student population.^18–20 Multiple studies demonstrate that insufficient physical activity, poor diet quality and poor sleep tend to cluster,^21–24 and reporting a greater number of health-risk behaviors has been associated with poorer mental health.^24,25

Although several studies highlight the importance of physical activity, and good quality diet and sleep for promoting mental health among university students, little is known about how commencing university affects these behaviors.^26–30 Time and convenience, the availability and cost of healthy food, lack of social support and self-discipline and taste preferences have been identified as key influencing factors for food choices, whereas lack of motivation, enjoyment and social support, time and budget constraints and negative experiences with gym facilities were found to be key barriers to participating in physical activity.^26–30 However, these focus groups investigated food choices and physical activity in the context of weight management rather than mental health. In terms of sleep, one study of first year university students found that women and those living away from home and experiencing more financial stress reported more sleep disturbances, and that periods of more negative affect and stress coincided with times of poorer sleep, whereas socializing and spending time with friends were associated with better sleep.³¹ A qualitative study has also identified moving out of home to shared housing (e.g., noise, socializing), an unstructured academic schedule including studying late at night, as well as difficulties winding down to sleep in first year students, to be associated with poor sleep.³² A greater understanding of how physical activity, diet and sleep change when starting university, how it is associated with mental well-being, and barriers to improving these behaviors, is needed to aid the development of preventative initiatives for those commencing university studies.

The aim of this study was therefore to explore young adult’s (18–25 years) experiences of how starting university influenced their physical activity, diet, sleep, and mental well-being. The secondary aim of this study was to identify perceived barriers and facilitators to health behavior change.

Methods

Study design

This qualitative study included three semi-structured focus groups conducted in November 2019. The study was approved by the University of Newcastle Ethics Committee [ref: H-2019-0329] and participants provided written informed consent. The manuscript adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) framework for reporting focus groups.³³

Participants and recruitment

Students from the University of Newcastle (UON), Australia who had participated in the UON Student Healthy Lifestyle Survey (SHLS) in 2019 were invited to participate in focus groups via email if they had given consent for re-contacting.¹⁹ The SHLS is an online, cross-sectional survey aiming to identify the prevalence of health risk factors in UON students and was conducted through Survey Monkey between 9 September and 5 October 2019.^19,24 The SHLS survey was open to all students, regardless of age or primary study campus. The inclusion criteria for the current study were that they had to be a current UON student aged 18–25 years and able to attend the focus groups on Callaghan campus. The recruitment email contained a short description (“Help us understand how starting university has affected your well-being, physical activity, eating and sleeping habits”) and a link to the study information statement where students were informed of the study aims, an online eligibility screening questionnaire and a consent form. Recruitment emails were sent one week apart in October/November 2019.

The online recruitment email was sent to 1,260 students, however as there was no way of filtering out those who were ineligible due to age, or were located at other campuses, not everyone receiving the email would have been able to participate. The recruitment survey was accessed 83 times, of which 27 were not eligible for inclusion (n = 25 aged ≥25 years, n = 1 aged <18 years, and n = 1 was not an UON student), and eight exited the survey prior to the eligibility questions. Of the 49 eligible participants, 42 individuals completed the whole survey, and 27 provided contact details and completed consent forms. Out of the 27 who consented and were invited, 16 attended the focus groups. Those who did not attend were either uncontactable, failed to attend or were not able to attend the available time slots due to study or work commitments.

Semi-structured focus groups

The focus group topic guide was developed by members of the research team. Interview questions aimed to explore the students’ experiences around how starting university had influenced their physical activity, diet, sleep and mental health and well-being (Table 1). Probing techniques to facilitate elaboration on responses were also used. The focus groups were conducted in-person on campus and lasted approximately 60 minutes. They were facilitated by two members of the research team acting as a moderator (SF) and assistant moderator (SO). Both facilitators were female dietitians with prior experience in qualitative research. The assistant moderator took notes during the discussions, made sure all key topics were included and provided a summary to the participants at the end of the group. The focus group discussions were recorded using a mobile phone application. Drinks and snacks were provided during the focus group. Moderators were unknown to participants.

Table 1. Focus group questions.

Opening and warm-up questions
Presentation of the research topic Let’s just quickly start with participants telling us their favorite food?
Introduction/ projective techniques
As mentioned earlier, we are interested how starting university has influenced your well-being. 1. What comes to mind when you think of starting university and mental health and well-being?
Transition question
2. In your experience, how might health behaviors such as eating, physical activity and sleep influence your mental health and well-being?
Main key questions
3. What comes to mind when you think of eating habits since starting university? 4. What comes to mind when you think of physical activity habits since starting university? 5. What comes to mind when you think of sleep habits since starting university? 6. If you were to use an online tool to assess your mental well-being, physical activity, eating and sleeping habits, what kinds of resources or support would you like to try and help you improve (if indicated)?
Summary/ additional comments
All things considered [moderator to provide overall summary] is this an adequate summary? Did I correctly describe what was said? And is there anything you want to say that you didn’t get the chance to say?

Data analysis

A qualitative analysis was conducted by author VH who is an experienced qualitative researcher who was not involved in study design or data collection. An inductive thematic approach based on that outlined in Braun & Clarke was chosen due to the importance in this exploratory study of allowing participants experiences to shape the thematic structure.³⁴ NVivo 11 (QSR International) was used to assist with the organizational aspects of the analysis. An initial hierarchical coding scheme was developed based on in vivo coding of the transcripts. This was an iterative process with the final coding scheme subsequently being applied to the complete data set. This coding formed the basis for development of a thematic structure. All data falling under each theme and sub-theme were reviewed prompting minor changes to ensure that the thematic structure captured the entirety of the dataset. Thematic narratives were developed which were supported by integration of representative participant quotes, which were reviewed by author SO.

Results

Participants

In total, three focus groups were conducted, consisting of five to six participants each (n = 16 in total). The average age of participants was 21.2 (SD 1.6) years, they were predominantly female (81.3%), and born in Australia (87.5%), and 44% lived at home with their parents. Almost half (44%) of the sample were first-year students, 31% were second- or third-year students and 25% were fourth- or fifth-year students. The majority were undergraduate students (69%) (Table 2).

Table 2. Study participant characteristics.

Measure	Range/Categories	Mean (SD)
Age	18–24 years	21.2 (1.6)
Hours of paid work if in employment (n = 11/16, 68.8%)	2–25 hours per week	9.2 (9.0)
		Count (%)
Gender	Female	13 (81.3)
	Male	2 (12.5)
	Other gender identity	1 (6.3)
Aboriginal and/or Torres Strait Islander origin	Aboriginal	1 (6.3)
	Torres Strait Islander	0 (0)
	Neither	15 (93.7)
Birth country	Australia	14 (87.5)
	Southeast Asia	2 (12.5)
Domestic or International student	Domestic	15 (93.8)
	International	1 (6.2)
Living situation	Parent’s home	7 (43.8)
	Renting	7 (43.8)
	Own home	1 (6.3)
	On campus	1 (6.3)
Financial support	No	5 (31.3)
	Yes	11 (68.7)
Study type	Undergraduate	11 (68.8)
	Postgraduate	2 (12.5)
	English language and Foundation studies	3 (18.8)
Year of study	1st year	7 (43.8)
	2nd year	4 (25.0)
	3rd year	1 (6.2)
	4th year	3 (18.8)
	5th year or later	1 (6.2)
Faculty	Business and Law	2 (12.5)
	Education and Arts	5 (31.2)
	Health and Medicine	3 (18.8)
	Science	3 (18.8)
	English language and Foundation studies	3 (18.8)

Qualitative analysis of focus groups

Commencing university studies influences physical activity

Lack of routine

Most students reported a reduction in physical activity after commencing university. Some students alluded to routine being the reason for their higher rates of participation in physical activity and sports while at high school.

I was going four times a week for almost an hour each time [at the start of the semester] and then all the breaks started happening and I lost my routine and everything. Now I don’t want to go. (Student A, Group 1)

Access to facilities

Those who were successful in maintaining activity levels reported taking advantage of facilities on or near campus.

The Forum [the university gym] is virtually across the road, so if I had a two-hour gap between lectures or something, I could easily just walk down and smash out a workout, then come back. (Student A, Group 3)

Yet another student had found an innovative way to couple sport and exercise with socialization and doing so for no financial outlay through volunteering.

I volunteer weekly at The Forum [the university gym] for the language center students… you’re doing something for good and plus, you’re exercising and you’re meeting new friends. So, to me, that’s worth it. (Student B, Group 3)

Mental health impact of physical activity

Many participants noted they were time poor due to often working part-time in addition to studying, and physical activity was perceived as an additional chore that could not be justified.

To me it’s like to be doing more physical activity would be adding more mental health issues and stress over not doing Uni. (Student B, Group 1)

When you start at 11 at night and don’t finish ‘til 7 in the morning you don’t want to go outside and exercise…Trying to work enough to pay bills is not as easy as I thought it was going to be. I have two jobs at the moment, study full-time, it’s rough. (Student C, Group 2)

However, the discussion among the students who prioritized physical activity was grounded in their acknowledgement and experience of its benefits on focus, performance, and wellbeing.

I feel like exercise is the biggest one that makes me feel good… I feel like I get like a high after going for a run. (Student C, Group 1)

Going to my social sporting games and things, I find that I get a lot of energy from that, and I feel really motivated after going for a run and talking to them, to go then home and do work kind of thing. (Student B, Group 1)

Commencing university influences student’s diet quality

Lack of routine

Students reported eating less healthy since starting university. Classes and timetables changing every semester made it difficult to establish the type of routine which had been present during high school, often leading to skipping meals and increased consumption of convenience foods.

Instead of doing lunch or dinner I’ll just snack a lot in-between. It’s always really bad snacks, it’s chocolate and ice cream and chips and stuff, so stuff that’s really easy, open, devour it and then move on just get rid of the hunger pain and just keep going. Rather than in high school I used to just eat my classic three meals, eat them when I’m meant to eat them. (Student A, Group 2)

Many barriers to healthy eating

Important barriers to healthy eating discussed within the groups were lack of affordable healthy foods on campus, a limited budget for groceries, limited cooking skills and not feeling motivated to cook proper meals for themselves.

I probably even prefer to wait ‘til I go home rather than spend $6, $7 on salad which I can’t afford. Other than that, it’s a lot of bread, a lot of fried stuff. (Student B, Group 2)

It’s moving out of home and just the knowledge of what to cook, how to cook. (Student D, Group 1)

These issues were further compounded by the difficulties associated with living in shared or campus accommodation where kitchen/cooking facilities were limited, and other students often stole their food if they stored them in shared kitchens.

Mental health impact of poor diet

Students spoke about the negative impact of missing meals or irregular meals on focus and mental alertness, and a few students talked of the negative influences an unhealthy diet had in terms of a ubiquitous feeling of guilt over a deviation away from the ‘ideal diet’, especially for those studying health-related courses.

I think I put a lot of pressure on myself, so [it’s] not even the diet that’s affecting me but it’s the knowledge about what I’m eating that’s affecting me. (Student C, Group 1)

While students had awareness of the importance of a healthy diet and the health concerns relating to poor diets, for some, it also contributed to feelings of shame, guilt and judgment around diet and weight.

But I also struggle to kind of – as I touched on earlier, that stigma around eating habits – struggle to distinguish whether I’m feeling bad because of guilt around diet and diet culture. I know for a fact that at times I maybe in second year really struggled with thoughts around my weight and around my body image. (Student E, Group 1)

Commencing university influences student’s sleep habits

Difficulties falling asleep

Most students talked of getting much less sleep compared to their pre-university life.

[I’m now getting] so much less [sleep]. I was probably getting at least nine, 10 hours every night while I was in high school, now I’m here, five [hours]. (Student C, Group 2)

Many talked of the demands of studying as being a direct cause of their poor sleep hygiene and acknowledged an impact on mental health stemming from a lack of sufficient good quality sleep. Mainly the discussions around sleep centered around difficulties unwinding or “shutting down” after studying or working late into the evening which then affected their resilience and ability to perform the following day.

I’m not actually entirely sure. I get back from Uni late some nights and then because I’ve been at Uni learning my brain doesn’t want to shut down. I stay up most of the night just watching movies and stuff like that, just trying to get my brain to shut down but just going over everything I learn or everything I’ve learned runs round and can’t shut down. (Student D, Group 2)

External factors

For some, the impact of a noisy environment in student and campus accommodation was a significant factor negatively impacting sleep.

I don’t have a choice, but I’m living out of home, living in a shared house with people that are having parties, socializing around me. It’s not the most friendly environment to have peaceful sleep in. (Student C, Group 3)

Mental health implications of poor sleep

Several students talked of having grown very conscious of the need for sufficient sleep since starting University, but most still found it difficult to achieve.

I think I feel like I have actually become more conscious about my sleeping, because if I don’t then things go to shit. (Student E, Group 1)

For those who being satisfied with their sleep, one of the main factors was a university timetable which didn’t involve either early morning classes (before 9am), evening classes, or placements which necessitated an early start. A few students also commented on the positive effect online courses had on their sleep patterns due to not having to do early morning commutes to campus classes.

I’ve found that particularly easier this year…our course is online in the last year and so I’ve found that I can work ‘til midnight and then sleep ‘til 8:30am and that’s fine. I’m able to do that fairly consistently and yeah, generally getting an amount of sleep that is good for me. (Student D, Group 3)

Commencing university influences student’s mental health

A complex interaction between mental health and health behaviors

A host of elements associated with life as a university student interacted with health behaviors to negatively impact the mental health and well-being of students. Those who had a history of mental health complaints had experienced an exacerbation of symptoms and problems in response to the stress of university studies and, for some, moving away from the security of the family home adversely impacted their mental health.

For me when I started Uni I wasn’t on medication. Probably three months into starting Uni, I started on an antidepressant… I’m on double the antidepressant that I was when I started. (Student B, Group 2)

Students expressed that it was the relentless stress associated with the need to perform and complete large volumes of work which had the largest reciprocal effect on the adoption of a healthy lifestyle.

When I’m stressed, I will want to eat more sugar. When I’m stressed, I want to sleep more. Then I couldn’t sleep at night but only sleep at the day and then I couldn’t get up. When I get up, it’s half of the day already passed and I feel like I waste half of my life doing nothing, just sleeping. Then I was so tired. I think of all my assignments and then I feel stressed more. (Student E, Group 2)

While not explored explicitly as part of the focus groups, there was an indication of mental health influences being more pronounced for students who had moved away from home to study, and one international student specifically elaborated on the influence of social isolation in this context.

Since starting Uni it would come up to exams and I would just cry for a whole day. Then I’d need to sleep for a whole day because I would have a headache. This went on for the first year at Uni. It wasn’t ‘til halfway through this year I was like “right, I’m going to go and see my doctor.” She said that I had really high anxiety. Now I’m taking medicine which… I didn’t have this problem in high school because I had a connection with all my fellow peers and teachers, everyone was there for you. In university you’re sort of just a little boat in a whole sea of boats. (Student F, Group 2)

Student’s thoughts around useful resources to support behavior change

Information provision generally seen as unhelpful, with some caveats

In discussions of the types of information and services that students felt would assist them to adopt healthier behaviors, most agreed that information provision had limited efficacy.

Information without support is completely useless. (Student E, Group 1)

Feedback about their own diet in relation to an ‘ideal’ was viewed as ineffective and potentially damaging and expressed that knowledge of a problem does not change the barriers they face when attempting to change their behavior.

For me, personally, with diet and all of that, I don’t find it very productive for somebody to tell me that my diet sucks because I already know that. I’m like yeah, cool, so what am I going to do about it? (Student B, Group 2)

“That doesn’t change whether you’ve got the time to plan meals. It doesn’t change whether you’ve got money to plan meals and for me reading that sort of stuff just further makes me feel inadequate.” (Student C, group 1)

It was perceived as important that advice addressed and acknowledged the multi-faceted barriers to adopting a healthy lifestyle.

I think it’s important not to have this one big goal… it should just be looking at how to just improve, it doesn’t have to specifically be you’re super-fit and you’ve got the perfect balance of vegetables and meat and fruit all the time for every single meal of the day, and you don’t have to be sleeping perfectly every day. It just needs to be realistic; it just needs to be better than what you’re doing. (Student D, Group 2)

The type of information which in all groups was raised as potentially helpful was information which also assisted students in establishing new behaviors, e.g., information about resources and services available, recipes, meal plans, free fruit, and vegetable boxes on campus and similar.

I think a resource that would be helpful if… like, oh, here are some activities going on this week. There’s a group of people organizing it, a free soccer game that you could take part in, or someone’s doing a nature walk around a couple of the campuses, or something, that would be cool. (Student D, Group 3)

Discussion

This study contributes important insights into young adult’s experiences of how starting university has influenced their physical activity, diet, and sleep in the context of mental well-being. An overarching theme of the discussions was that while most students acknowledged the positive benefit of physical activity, a healthy diet, and getting enough sleep on their mental well-being, stress associated with study demands, university timetabling and often part-time work, made it difficult to prioritize health behaviors. Collectively, the findings of this study indicate that starting university has a significant negative effect on health behaviors and mental well-being.

The results of the thematic analysis have been summarized in Tables 3–5. These tables also provides a summary of potential strategies to address themes, and it is important to note that while these were based on what students reported as helpful or perceived may be helpful, these are also crafted based on evidence from behavior change theory and other research, as presented throughout the discussion.

Table 3. Links to mental well-being for physical activity, major themes, and potential strategies to address themes.

	Links to mental well-being	Themes	Potential strategies to address themes
Physical activity	Perception that adding in physical activity would add stress (take time away from study) vs. others who recognize that they feel more focused and motivated after physical activity sessions.	Difficulty maintaining routine^35	Goal setting support—set goals for how many active minutes/ steps/ physical activity sessions they will participate in during the week and plan out when/ where.
			Habit formation support—building in cues/prompts to help support behavior change (i.e., I put on active wear each morning to go for a walk between lectures)
			Problem solving support—identify triggers for not following through with plans to do physical activity (i.e., I get too stressed doing assignments) and identify strategies for avoiding these (i.e., I need to remind myself I feel refreshed after taking a movement break in my studies) and awareness around the fact that lapses in habits occur and mental scripts to motivate them to return to positive habits.
		Information about benefits^35,^36	Increase awareness around the benefits of physical activity on mental health, sleep, and cognition/ academic achievement.
			Promote benefits of small bouts of activity/ breaks in sitting throughout study sessions.
		Lack of awareness of physical activity options	Electronic resource on what is available in terms of formal and informal physical activity opportunities locally, kept easily visible and accessible through frequently visited online learning portals.

Table 4. Links to mental well-being for diet quality, major themes, and potential strategies to address themes.

	Links to mental well-being	Themes	Potential strategies to address themes
Diet quality	Negative impact on focus and mental alertness from missing meals, having irregular meals, or relying on convenience food. Guilt about not eating ‘healthy enough’ intertwined with body image concerns.	Logistics (time, budget, skills, cooking facilities and equipment)^26,^37	Provide recipe resources with easy recipes (in terms of steps involved and equipment needed) and affordable ingredients.
			Advocate for initiatives such as microwaves in common areas on campus to heat lunches and more affordable healthy options in the university food outlets.
			Electronic resource with information related to healthy eating on campus (free fruit and vegetable boxes, microwaves, cooking demonstrations, healthy food specials on campus, etc.) kept easily visible and accessible through frequently visited online learning portals.
		Difficulty maintaining routine^38	Goal setting support—set an achievable goal for improving diet quality and plan when/ where (i.e., ‘I’ll put a piece of fruit in my bag to snack on between lectures’).
			Habit formation support-building in cues/prompts to help support behavior change (i.e., ‘I pack my lunch while making breakfast/ dinner’)
			Problem solving support—identify triggers for not following through with plans to be more organized with healthy food (i.e., too rushed in the morning to prepare lunch) and identify strategies for avoiding these (i.e., pack the night before), and increase awareness around the fact that lapses in habits occur and mental scripts to motivate them to return to positive habits.
		Information about benefits^39	Increase awareness of short- and long-term benefits of healthy eating (physical and mental health, focus and mental clarity). Do this without attaching it to physical appearance or weight status in resources to limit negative impact on body image and disordered eating.
			Promote benefit of incremental, positive improvements in diet quality in educational resources to avoid an ‘all-or-nothing’ mentality.

Table 5. Links to mental well-being for sleep health, major themes, and potential strategies to address themes.

	Links to mental well-being	Themes	Potential strategies to address themes
Sleep health	Stress and late-night studying affected their asleep. Poor sleep significantly influenced their ability to cope with the stress of university studies and life in general, including participating in physical activity and making healthy food choices.	Difficulties winding down to sleep^40	Employ good sleep hygiene practices: consistent bed- and wake-times; find a pre-bedtime routine to wind down; keep the bed for sleep (avoid studying/ watching tv, etc.); low lighting/ limit screen use prior to bed; do some physical activity in the day; avoid late/ long naps, only consume caffeine early in the day; no smoking; do not drink alcohol close to bedtime; create a calm and comfortable sleeping environment.
			Use relaxation/ mindfulness techniques to calm the body and mind prior to bed.
		Noisy shared housing	Use ear plugs and white noise machines to soften the noise.
			Advocate for a set time where noise is kept to a minimum if possible.
		Difficulty maintaining routine^41	Try to pick lectures/ tutorials that are held when it will not interfere with sleep as best as possible, get to know what works best for them (are they an early bird or night owl?)
			Work out a routine for the semester where wake- and bedtimes can be as consistent as possible (i.e., if they must be up at 7am to make it to their earliest lecture, try waking up close to 7 most days, and pick an appropriate corresponding bedtime so they get enough sleep). Self-monitor sleep timing to keep on track.

Key barriers to physical activity (Table 3) were difficulties maintaining a routine, and a lack of awareness of what is available on campus in terms of social clubs and sports to help find an activity they enjoy. This indicated that habit formation and learning strategies to reestablish disrupted routines may be helpful components of an intervention, as well as an easily accessible overview of opportunities for physical activity on campus. There was also a clear divide between those who actively used physical activity as a stress reliever and a means to improve motivation to focus on study, and those who perceived that spending time on physical activity would add stress to their life by taking away from available study time. This latter finding is in line with other studies which report university students who have a personality more vulnerable to stress have lower levels of physical activity.⁴² These findings indicate that increasing student awareness around positive benefits of physical activity not only on physical health but also on mental health,^7,43,44 sleep health,⁴⁵ and possibly academic performance,^46–48 may be important for those who do not prioritize time for physical activity. Promoting the benefits of small movement breaks to reduce sedentary time may also be feasible and beneficial for this group of students.^49–51 These findings are supported by a recent systematic review which identified ‘habit formation’ and ‘information about emotional consequences’, as well as ‘material reward’ and ‘valued self-identity’ as promising behavior change techniques for increasing physical activity in young adults,³⁵ and the findings of this study can be used to tailor interventions to university students specifically.

Barriers to healthy eating at university (Table 4) included difficulties maintaining a routine, a limited budget, and few affordable healthy food options to purchase on campus, a lack of cooking equipment and/or facilities, and limited cooking skills, which is in line with other studies.^26,37 This led to skipping meals, or getting by on cheaper convenience food, which they found to negatively influence their focus and mental alertness. These findings suggest resources to help students improve diet quality need to be sensitive to the budget, time, skill, and cooking equipment limitations faced by students. Furthermore, focusing on short term benefits to making the effort of being more organized with for example packing lunch, such as improved concentration and being more productive with their time may be beneficial. As with physical activity, strategies to assist them getting back on track when they find it difficult to maintain a routine that supports healthy eating may be helpful. These findings are supported by a systematic review which identified ‘habit formation’, ‘salience of consequences’, ‘adding objects to the environment’ (i.e., free fruit and vegetable boxes), and ‘prompts/cues’ to be promising behavior-change techniques for improving diet quality in young adults.³⁸ An additional finding of the current study was how eating habits were reported to contribute to poorer mental well-being through feelings of guilt and shame around not eating “healthy enough,” as well as eating habits being intertwined with body image concerns. This is an important point to consider in the development of resources aimed at improving diet quality. Young adulthood also coincides with the median age of onset for eating disorders and disordered eating behaviors, significantly influencing mental and physical well-being.⁵² It may therefore be judicious to use weight-neutral resources which highlight the short and long-term benefits of healthy eating irrespective of weight status in this at-risk population.³⁹

Barriers to good sleep at university (Table 5) included early morning or late-night lectures or tutorials and studying, difficulties winding down to sleep, and noisy shared housing environments, in line with other studies.^31,32 For those who experienced difficulties with sleep it was reported to negatively influence every other area of their life, including their mental well-being and motivation to be physically active and eat well. This aligns with a study which investigated the differential associations between sleep, physical activity, and dietary factors as predictors of mental health and well-being in young adults, which found sleep quality to be the strongest predictor of depressive symptoms and poor well-being, followed by sleep duration, physical activity, and raw fruit and vegetable consumption.⁵³ A large Australian population-based cohort study has also found that insomnia increased the odds of poor mental health regardless of activity level.⁵⁴ Furthermore, a latent class analysis of health behavior patterns in the overall Student Healthy Lifestyle Survey sample also found that students with an ‘unhealthy lifestyle’ pattern with the lowest likelihood of meeting sleep duration guidelines had the highest odds of high or very high psychological distress.²⁴ Evidence of efficacious sleep interventions in young adult university students is scarce,^55,56 but Internet-delivered cognitive behavior therapy is efficacious and accessible in the treatment of insomnia for the general population and could be tailored to this population.^57,58 While many external factors such as timetabling and shared housing may be difficult to avoid as a student, employing relaxation techniques and good sleep hygiene habits could be key targets for interventions aiming to improve student well-being.⁴⁰ In terms of behavior change techniques, self-monitoring (e.g., tracking bed and wake times) and implementation intention (e.g., “I will avoid drinking caffeine 6 hours before bedtime”) have both been effective in improving sleep in university students.⁴¹ The latter technique also showed an interaction with improving the ability to avoid stress/anxiety provoking activities at bedtime, which was reported as a significant concern in the current study.

Overall, students expressed that any resources or interventions aimed at helping them improve health behaviors needed to be realistic and consider the barriers they face. They emphasized the desire for goal setting which did not require them to meet a specific universal standard to succeed, but instead focus on incremental improvements. This is in line with evidence that suggests that goals that are too challenging may be counter-productive in the early stages of learning complex tasks such as improving physical activity, healthy eating and sleep health.³⁶ Believing certain targets must be met to gain benefits, i.e., “eat 5 serves of vegetables a day” may be daunting, when evidence suggests any incremental improvement is likely advantageous.³⁶ Focus group participants also expressed that information without added support elements would not be useful, indicating that a multi-component intervention combining information with other tools to support behavior-change (e.g., assistance with goal setting, self-monitoring, etc.) may be more efficacious. This is supported by a systematic review of physical activity interventions in young adults.³⁵ Sleep health was reported to significantly influence other health behaviors, and there is evidence of a bidirectional association between sleep and physical activity,^59,60 as well as evidence that short sleep duration (≤5.5 hours per night) increases energy consumption.⁶¹ Therefore, interventions which target multiple health behaviors concurrently may be more efficacious than single behavior interventions.⁶² While further research is needed in this area, there is evidence that jointly improving physical activity levels and sleep health can improve mental health outcomes.⁶³

The findings of this study must be viewed in context of its limitations. Participants were recruited from the SHLS respondents, which may have introduced selection bias as those with an interest in health may have been more likely to respond to the survey. Students who had experienced challenges when commencing university may also have been more likely to participate in the current study. The focus of the current study was the experience of “commencing university,” but the sample included four (25%) students in their 3rd year of study which means they are reflecting a few years back in time and this could introduce bias. However, they still fit the criteria for “young adult,” and it was decided their insights and reflections would still be valuable. While the sample was primarily female, there was a good distribution of characteristics such as living situation, financial support, and faculty within the sample. Furthermore, while three focus groups have been shown to achieve 80% saturation,⁶⁴ additional groups may have uncovered additional themes. The focus groups were also part of a pilot study to guide the development of an online tool to assist students in improving their health behaviors, which may have influenced findings for the secondary aim. Additionally, this study took place just prior to the Covid-19 pandemic changed the way tertiary education was delivered for a considerable amount of time. As universities are welcoming students back on campus, a considerable opportunity exists in addressing the external barriers students face in participating in health promoting behaviors and supporting their mental well-being through policy and practice. This could include a more flexible delivery of programs to allow students to choose if they attend in-person or online, a more visible and accessible social and sport events calendar to re-build campus atmosphere and support student well-being, and establishing a healthier food environment through implementing standards and guidelines for campus food outlets and vending machines and the provision of suitable eating areas on campus with microwaves and water access, similar to those found for workplaces and school canteens.^65,66

Conclusion

There is a significant opportunity to support student mental well-being when they start university by providing support to encourage participation in health behaviors such as physical activity, healthy eating, and good sleep health. Interventions to improve health behaviors and mental well-being may want to focus on habit formation and strategies to maintaining each health behavior in a phase of life characterized by frequent change, while taking into consideration the specific barriers to each behavior. Universities also have an opportunity to facilitate health promotion through policy and practice change.

Conflict of interest disclosure

The authors report there are no competing interests to declare. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of Australia and received approval from the Institutional Review Board of University of Newcastle.

Additional information

Funding

Professor Duncan was supported by a Career Development Fellowship (APP1141606) from the National Health and Medical Research Council.