Is self-esteem associated with self-rated health among French college students? A longitudinal epidemiological study: the i-Share cohort

The Associations between Depressive Symptoms and Self-Rated Health in Relation to Sense of Coherence among Adolescents: Cross-Sectional Study

BACKGROUND

We investigated the predictors of poor SRH in a representative sample of Lithuanian mainstream school students in grades 7-8. We also checked for gender differences in the associations between SRH and depressive symptoms and other predictors.

METHODS

A total of 2104 7th-8th-grade students participated (response rate 73.95%) and were asked about depressive symptoms, psychosomatic health complaints, negative acts at school, feeling at school, family stress and violence, sense of coherence, self-esteem, and lifestyle. We used a hierarchical regression analysis including a variety of self-rated health predictors.

RESULTS

Boys scored significantly higher on physical activity and smoking, whereas girls scored significantly higher on SRH, depressive symptoms, psychosomatic health complaints, and family stress and violence, though the significance was lost in the hierarchical regression. Depressive symptoms were the strongest predictor of poor SRH (standardized β = 0.309, p < 0.001), though other investigated predictors were also significant but had lower effect sizes. Strong evidence was found supporting the buffering role of sense of coherence in the relationship between depressive symptoms and SRH (standardized β = -0.266, p < 0.001).

CONCLUSIONS

We can conclude that the magnitude of the relationship between depressive symptoms and self-rated health is dependent on the levels of sense of coherence. We did not find gender differences in those associations. As poor SRH is easy to determine, especially with a one-item question, the cases of poorly rated health should be detected early and corrected by interventions in order to prevent poor health outcomes in the future.

Longitudinal trajectories of self-esteem, related predictors, and impact on depression among students over a four-year period at college in China

Self-esteem plays a crucial role in the psychological development of college students. Based on four-wave longitudinal data, this study empirically investigated the longitudinal trajectories of self-esteem, related predictors, and the impact on depression in a sample of Chinese college students. Piecewise growth mixture modeling was utilized to identify potential self-esteem trajectories. Furthermore, multinomial logistic regression models were employed along with the Kruskal‒Wallis test to analyze the factors that influence self-esteem development trajectories and assess variations in depression. The results showed that college students’ self-esteem trajectories can be divided into three categories: slowly decreasing (81.04%), rising then falling (16.94%), and falling then rising (2.02%). Various personal factors (e.g. ethnicity, family residence, self-reported health status, extroversion) and socioeconomic factors (e.g. closeness with classmates, family economic level, family social status, and the mother’s educational level) can influence the classification of students’ self-esteem development trajectories. Moreover, notable differences in depression were observed among students in different self-esteem trajectory groups. The results emphasize the imperative of implementing interventions to enhance self-esteem among college students.

Influencing factors of sense of responsibility among undergraduate nursing students: A cross-sectional study

BACKGROUND

Nursing students are critical in responding to public health emergencies like the COVID-19 pandemic. Their ability to fulfill their responsibilities is influenced by their sense of responsibility, which holds profound cultural significance, particularly in traditional Chinese culture. However, limited research has specifically explored the sense of responsibility among undergraduate nursing students in China and globally.

OBJECTIVES

This study aimed to determine the sense of responsibility among undergraduate nursing students and identify potential factors associated with it.

DESIGN, SETTING & PARTICIPANTS

We conducted a cross-sectional study and recruited 526 nursing students from June to July 2022 in Guizhou province in southwest China.

METHODS

Participants completed the General Information Questionnaire, Sense of Responsibility, and Self-esteem Scale. We analyzed the relationship between a sense of responsibility and self-esteem using Spearman correlation analysis. Then we determined factors that affect undergraduate nursing students' sense of responsibility using multiple linear stepwise regression.

RESULTS

Nursing students' total sense of responsibility scores were 96(84,106). The study found a positive association between self-esteem and a sense of responsibility (r = 0.433, P < 0.001) and its four dimensions: altruism (r = 0.381, P < 0.001), self-control (r = 0.378, P < 0.001), courage (r = 0.300, p < 0.001), and commitment (r = 0.361, P < 0.001). Self-esteem (β = 1.532, p < 0.001), personality (extroverted personality β = 7.263, P < 0.001; neutral personality β = 3.221, P = 0.029), and social practice experience (β = -3.156, P = 0.010) significantly influenced undergraduate nursing students' sense of responsibility (R2 = 0.268, F = 17.065, P < 0.001).

CONCLUSIONS

The study highlights the importance of nursing students' sense of responsibility and suggests room for improvement in its level. Higher self-esteem was associated with a stronger sense of responsibility. Additionally, self-esteem, personality, and social practice experience emerged as significant influencing factors. Nursing educators should prioritize students' sense of responsibility and explore targeted interventions, such as social practice activities, particularly for students with low self-esteem and introversion.

Does Subjective Well-Being Improve Self-Rated Health from Undergraduate Studies to Three Years after Graduation in China?

The health status of emerging adults is at risk. Although subjective well-being is one of the factors closely associated with health, their longitudinal relationship is not clear among emerging adults. The study aimed to investigate the prospective relationship between self-rated health and subjective well-being in emerging adults. The study collected longitudinal data from a total of 1021 Chinese college students (537 males and 484 females) for five years, including two years in college and three years after graduation. In the baseline survey, the average age of the sample was 21.57 years old. Descriptive statistics indicated that both self-rated health and subjective well-being significantly decreased from the senior year of college to the year after graduation. Correlation analysis revealed that self-rated health and subjective well-being had a significant positive relationship. In the five-wave random intercept cross-lagged panel model, subjective well-being unidirectionally predicted self-rated health. In other words, the subjective well-being in the previous year could positively predict self-rated health in the following year, but the previous self-rated health could not predict subsequent subjective well-being. Given the significance of emerging adulthood to individual development, more attention and care should be dedicated to improving subjective well-being so as to maintain good health and engagement in work.

Self-Esteem Trajectories After Occupational Injuries and Diseases and Their Relation to Changes in Subjective Health: Result From the Panel Study of Workers' Compensation Insurance (PSWCI)

BACKGROUND

Occupational injuries and diseases are life events that significantly impact an individuals' identity. In this study, we examined the trajectories of self-esteem among victims of occupational injury and disease and their relation to health.

METHODS

The Panel Study of Workers' Compensation Insurance conducted annual follow-ups on workers who had experienced occupational injury or disease. A total of 2,000 participants, who had completed medical care, were followed from 2013 to 2017. Growth mixture modeling was utilized to identify latent classes in the self-esteem trajectory. Additionally, logistic regressions were conducted to explore the association between trajectory membership, baseline predictors, and outcomes.

RESULTS

Three distinct trajectory classes were identified. Total 65.8% of the samples (n = 1,316) followed an increasing self-esteem trajectory, while 31.1% (n = 623) exhibited a constant trajectory, and 3.1% (n = 61) showed a decreasing trajectory. Individuals with an increasing trajectory were more likely to have a higher educational attainment (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.20-2.88), an absence of a moderate-to-severe disability rating (OR, 0.49; 95% CI, 0.25-0.96), no difficulty in daily living activities (OR, 0.81; 95% CI, 0.75-0.88), and were economically active (re-employed: OR, 2.46; 95% CI, 1.52-3.98; returned to original work: OR, 4.46; 9% CI, 2.65-7.50). Those with a decreasing self-esteem trajectory exhibited an increased risk of poor subjective health (OR, 1.89; 95% CI, 0.85-4.85 in 2013 to OR, 3.17; 95% CI, 1.04-13.81 in 2017), whereas individuals with an increasing trajectory showed a decreased risk (OR, 0.54; 95% CI, 0.43-0.68 in 2013 to OR, 0.44; 95% CI, 0.33-0.57 in 2017).

CONCLUSION

Our findings emphasize the diversity of psychological responses to occupational injury or disease. Policymakers should implement interventions to enhance the self-esteem of victims.

Ethnic Discrimination and Self-rated Health among Hispanic Emerging Adults: Examining the Moderating Effects of Self-esteem and Resilience

Exposure to ethnic discrimination has been conceptualized as a sociocultural stressor that is associated with lower self-rated health. However, this association remains understudied among Hispanics and less is known about constructs that may mitigate the effects of ethnic discrimination on self-rated health. Accordingly, this study aimed to (a) examine the association between ethnic discrimination and self-rated health among Hispanic emerging adults (ages 18-25), and (b) examine the extent to which self-esteem and resilience may moderate this association. A convenience sample of 200 Hispanic emerging adults from Arizona (n=99) and Florida (n=101) was recruited to complete a cross-sectional survey. Data were analyzed using hierarchical multiple regression and moderation analyses. Results indicate that higher ethnic discrimination was associated with lower self-rated health. Moderation analyses indicated that self-esteem functioned as a moderator that weakened the association between ethnic discrimination and self-rated health; however, resilience did not function similarly as a moderator. This study adds to the limited literature on ethnic discrimination and self-rated health among Hispanics and highlights that psychological factors, such as enhancing self-esteem, may help buffer the adverse effects of ethnic discrimination on health outcomes.

Major depressive disorder in post-secondary students attending foodbanks in France

Introduction

Poor mental health among youth is a major public health issue that has risen to the forefront since the COVID-19 crisis, especially among post-secondary students and precarious populations. The objectives of this work were to evaluate the rate of major depressive disorder (MDD) among precarious post-secondary students in the greater Paris region, to describe its risk factors, and to identify determinants for not seeking care.

Methods

We conducted a multi-site, cross-sectional survey of post-secondary students attending a selection of 13 student foodbanks in the greater Paris region (France) between 30 November 2021 and 27 January 2022. This study had two complementary epidemiological and sociological components: a quantitative description of MDD through completion of a questionnaire performed through face-to-face or telephone interviews, and a qualitative assessment of the factors underlying MDD through in-depth follow-up interviews conducted among a sub-selection of students who participated in the first phase.

Results

Among 456 students who participated in our survey, 35.7% presented with MDD. The risk of suffering from MDD was higher among women, students housed by third-parties, students reporting moderately to severely hungry and/or poor physical health. Students receiving material and/or social support were less likely to present with MDD. Among students who reported needing health care in the last year or since their arrival in France, 51.4% did not seek care.

Conclusion

To address poor mental health among precarious students, policy action must jointly consider financial precarity, administrative barriers, housing, food security, physical health, and access to health services, especially mental health.

Childhood parental companionship, self-esteem and prosocial behavior in college students: A correlation analysis

BACKGROUND

We aimed to evaluate the correlation of Childhood parental companionship, self-esteem and prosocial behavior in college students.

METHODS

We conducted a survey to assess the childhood parental companionship, self-esteem and prosocial behavior in our college from November 1, 2021 to December 15, 2021. The parental companionship status questionnaire, Self-Esteem Scale (SES) and prosocial behavior questionnaire were used for survey. Pearson linear correlation analysis was used for evaluating the correlation of childhood parental companionship, self-esteem and prosocial behavior in college students. The Bootstrap method was used to test the potentially mediating effect.

RESULTS

A total of 2186 college students were included. The average total companionship score was (60.52 ± 5.17), the average self-esteem scale score was (27.15 ± 8.56), the prosocial behavior questionnaire score was (61.19 ± 15.04). Pearson correlation analysis indicated that childhood parental companionship was positively correlated with self-esteem (r = 0.679) and prosocial behavior(r = 0.679) in included college students (all P < 0.05). Self-esteem had mediating effect on parental companionship and prosocial behavior of included college students, its mediating effect was -0.445, accounting for 77.92 % of the total effect.

CONCLUSIONS

Childhood parental companionship is positively correlated with self-esteem and prosocial behavior, and self-esteem play a mediating role in the parental companionship and prosocial behavior of college students.

The association between substance use and subsequent employment among students: prospective findings from the CONSTANCES cohort

PURPOSE

To examine prospectively associations between substance use and subsequent employment among young students.

METHODS

From the French population-based CONSTANCES cohort, 1427 students who never worked were included between 2012 and 2018 and followed up for 2.1 years on average. Generalized estimating equations computed the odds of being unemployed versus employed according to substance use at baseline controlling for sociodemographic factors and depressive state. Tobacco use (smoking status and number of cigarettes), cannabis use frequency, and at-risk alcohol use according to the Alcohol Use Disorder Identification Test (total score > 7) were introduced separately in the models.

RESULTS

Tobacco use was not significantly associated with employment. Cannabis use at least weekly was associated with increased odds of being unemployed OR 1.73 (1.16-2.57). At-risk alcohol use was no longer significantly associated with employment after adjustment for depressive state, while analyses on sub-scores of alcohol use suggested that alcohol dependence was associated with increased odds of being unemployed OR 1.65 (1.16-2.34).

CONCLUSION

Public health campaigns targeting youth should include lower chances of getting employed among the detrimental roles of regular cannabis use and at-risk alcohol use.

No moderating effect of coping skills on the association between bullying experience and self-esteem: Results from K-CHILD study

Introduction

Few studies have investigated the moderating effect of coping skills on the association between bullying experience and low self-esteem. The aim of this study was to examine whether coping skills have a moderating effect on the association between bullying experience and self-esteem among Japanese students.

Methods

Data from the population-based Kochi Child Health Impact of Living Difficulty (K-CHILD) study conducted in 2016 were analyzed. Participants included fifth-and eighth-grade students living in Kochi Prefecture, Japan. A questionnaire for the students (n = 5,991) assessed the bullying experience, self-esteem (the Japanese Edition of the Harter's Perceived Competence Scale for Children), and coping skills that comprised six types (The shortened version of coping skills for elementary school children). Multivariate linear regression analyses were conducted to examine the association between bullying experience and self-esteem and then the moderating effects of six types of coping as interaction terms on the association were considered.

Results

Bullying experience was inversely associated with self-esteem. All six types of coping did not moderate the relationship between bullying experience and low self-esteem even after adjusting for cofounders (all P for interaction > 0.15).

Conclusion

Coping skills did not moderate the association between bullying experience and self-esteem, suggesting that intervention to boost coping skills to mitigate the adverse effect of bullying experience may not be promising.

Cross-Sectional Analysis of Mental Health among University Students: Do Sex and Academic Level Matter?

University students' mental health and well-being is a growing public health concern. There is a lack of studies assessing a broad range of mental health domains by sex and academic level of study. This cross-sectional online survey of BSc, MSc, and PhD students (n = 3353, 67% female) enrolled at one university in Germany assessed a wide scope of mental health domains, covering positive (i.e., self-rated health, self-esteem, student engagement) and negative aspects (i.e., perceived stress, irritation, and screening positive for depression, anxiety, comorbidity, and psychological distress). We evaluated differences in mental health by sex and academic level. Overall, although self-rated health did not differ by sex and academic level, females and lower academic level were associated with less favorable mental health. Males reported higher prevalence of high self-esteem, and higher engagement (all p ≤ 0.04). Conversely, mean perceived stress and cognitive/emotional irritation were higher among females, as were rates for positive screenings for anxiety, anxiety and depression comorbidity, and psychological distress (p < 0.001 for all). Likewise, lower academic level (BSc) was associated with lower rates of high self-esteem (p ≤ 0.001), increased perceived stress (p < 0.001), and higher prevalence of positive screening for depression, anxiety, comorbidity, and psychological distress (p ≤ 0.002 for all), while higher academic level (PhD) was linked to increased student engagement (p < 0.001 for all). Although the effect sizes of sex and academic level on student mental health were modest, these findings support a need for action to establish and expand early detection and prevention programs, on-campus advisory services, and peer counseling that focus on the sex-specific and academic-study-level-specific factors, as well as mental health and career development resources for students. Academics and policy makers need to consider multipronged intervention strategies to boost confidence of students and their academic career.

It gets better with age: Resilience, stigma, and mental health among lesbian, gay, bisexual, transgender and queer persons from Poland

Lesbian, gay, bisexual, transgender, and queer populations are disproportionately affected by chronic stress associated with stigma which contributes to health adversities including depression. Negative impact of stigma on health can be alleviated by factors such as resilience. Little is known however on how exposure to stigma, protective factors and mental health change with age among gender and sexually diverse persons. Our study aimed at investigating this issue. Our sample consisted of (i) 245 sexually diverse cisgender women, (ii) 175 sexually diverse cisgender men, and (iii) 98 transgender and gender diverse persons. We collected data through a web-based survey. Linear regression models were performed to investigate the interactions of age and each group of participants for resilience, stigma exposure, and mental health indicators (depression and self-esteem). We hypothesized that resilience and mental health indicators will be positively associated with age in all distinguished groups despite the continued exposure to minority stress. The analysis yielded no significant relationships between stigma exposure and age among study participants. However, we observed significant interaction effects of distinguished groups of participants and age in case of self-esteem, depression, and resilience. Self-esteem and resilience were related positively, and depression was negatively associated with age in all study groups. Additionally, we observed that sexually diverse cisgender men demonstrated significantly increased resilience, reduced depression and higher self-esteem compared to other groups. Although the exposure to stigma did not decrease with age, resilience and self-esteem increased, suggesting that LGBTQ persons manage to thrive despite adversities.

The association between social capital indicators and psychological distress in Catalan adolescents

According to the WHO, globally, one in seven adolescents experiences a mental disorder, being in a detrimental situation toward educational achievement, social cohesion, future health and life chances. Calls to identify risk and resilience factors to develop effective preventive actions have been made. Following a systemic approach, we conducted a cross-sectional study on the relationship between social capital and psychological distress in a sample of Catalan adolescents in Barcelona, taking into account a range of other relevant aspects at different levels influencing mental health, including gender, age, migrant status, family background, lifestyle factors, body mass index, and self-rated health. Data were collected through validated questionnaires in December 2016 from 646 of 14- to 18-year-old adolescents from three public and private high schools in Barcelona (Spain). Data analysis included descriptive analysis, a correlational study and logistic regression to obtain the odds ratio for social capital indicators to be associated with psychological distress. Our results suggest that reporting higher levels of family support and higher levels of teacher-student trust reduce the likelihood of suffering psychological distress. Higher levels of neighborhood informal control were associated with mental health, but a possible detrimental effect cannot be ruled out. Being a girl, reporting low self-rated health or higher media use was also associated with higher likelihood of psychological distress. Current results may encourage interventions that focus on social capital as a means to reduce psychological distress and foster well-being in youth.

Mental health condition of college students compared to non-students during COVID-19 lockdown: the CONFINS study

OBJECTIVES

To estimate the effect of student status on mental health condition during COVID-19 general lockdown in France.

DESIGN

Cross-sectional analysis comparing students and non-students recruited in the same study.

SETTING

Participants of the web-based CONFINS study implemented during the general lockdown in France in spring 2020.

PARTICIPANTS

2260 participants (78% women) including 1335 students (59%).

PRIMARY AND SECONDARY OUTCOME MEASURES

Through an online questionnaire, participants declared if they have experienced suicidal thoughts, coded their perceived stress on a 10-points scale and completed validated mental health scales (Patient Health Questionnaire-9 for depressive symptoms, Generalised Anxiety Disorder-7 for anxiety symptoms) during the last 7 days. The effect of college student status on each mental health condition was estimated using multivariate logistic regression analyses. Stratified models for students and non-students were performed to identify population-specific factors.

RESULTS

Student status was associated with a higher frequency of depressive symptoms (adjusted OR (aOR)=1.58; 95% CI 1.17 to 2.14), anxiety symptoms (aOR=1.51; 95% CI 1.10 to 2.07), perceived stress (n=1919, aOR=1.70, 95% CI 1.26 to 2.29) and suicidal thoughts (n=1919, aOR=1.57, 95% CI 0.97 to 2.53). Lockdown conditions that could be potentially aggravating on mental health like isolation had a higher impact on students than on non-students.

CONCLUSIONS

College students were at higher risk of mental health disturbances during lockdown than non-students, even after taking into account several potential confounding factors. A close follow-up and monitoring of students' mental health status is warranted during lockdown periods in this vulnerable population.

A machine learning approach for predicting suicidal thoughts and behaviours among college students

Suicidal thoughts and behaviours are prevalent among college students. Yet little is known about screening tools to identify students at higher risk. We aimed to develop a risk algorithm to identify the main predictors of suicidal thoughts and behaviours among college students within one-year of baseline assessment. We used data collected in 2013–2019 from the French i-Share cohort, a longitudinal population-based study including 5066 volunteer students. To predict suicidal thoughts and behaviours at follow-up, we used random forests models with 70 potential predictors measured at baseline, including sociodemographic and familial characteristics, mental health and substance use. Model performance was measured using the area under the receiver operating curve (AUC), sensitivity, and positive predictive value. At follow-up, 17.4% of girls and 16.8% of boys reported suicidal thoughts and behaviours. The models achieved good predictive performance: AUC, 0.8; sensitivity, 79% for girls, 81% for boys; and positive predictive value, 40% for girls and 36% for boys. Among the 70 potential predictors, four showed the highest predictive power: 12-month suicidal thoughts, trait anxiety, depression symptoms, and self-esteem. We identified a parsimonious set of mental health indicators that accurately predicted one-year suicidal thoughts and behaviours in a community sample of college students.

[Impact of the pandemic on students]

French society has become aware of the distress of students, to the point of setting up systems dedicated to their mental health. To avoid confusion, it is important to qualify the mental health of students and to suggest ways to understand why this is a vulnerable population facing the health crisis.

Chubby, Hairy and Fearless. Subcultural Identities and Predictors of Self-Esteem in a Sample of Polish Members of Bear Community

Bear subculture exists within a larger gay community, which has been recognized by public health experts as disproportionately burdened with stigma and related health adversities. Bears are distinguished by a particular body look—body hirsuteness and heavy-set physique. Previous research documented the various health risks, and the exposure to both sexual minority and weight stigma, of this population. In this study we focused on the determinants of self-esteem in Bears. We explored the significance of such predictors as: perceived sexual minority and weight stigma, age, resilience, and physique as reflected by the BMI. Our sample consisted of 60 men from the Polish Bear community (i.e., Bears, Cubs, Otters, Wolves). Linear regression models were performed for the entire sample (N = 60) and for Bear-identified men (N = 31). Perceived sexual minority stigma negatively, and resilience positively, predicted self-esteem. In the case of Bear-identified men, age, perceived exposure to weight discrimination, and BMI were also significant predictors of self-esteem. Higher BMI in the case of Bear-identified men predicted higher self-esteem. Our results suggest that although Bear-identified men are characterized by their similarities to other gay men, subcultural identities create unique social contexts that are important for health and health interventions in this population.

The Association between Health Literacy and Self-Rated Health Amongst Australian University Students

Health literacy is the capacity to understand, access, and effectively utilize health information and healthcare to make informed health decisions. This cross-sectional study uses the multi-dimensional Health Literacy Questionnaire (HLQ) to investigate associations between demographic characteristics, self-rated health and health literacy among students (n = 932) in two Australian universities. We used Pearson's chi-square to determine differences in self-rated health between demographic groups, Cohen's defect Sizeto measure differences in HLQ scale scores between demographic groups, and logistic regression to determine associations between HLQ scores and self-rated health. A clear association was found between self-rated health and health literacy: as health literacy increased, so did self-rated health. Findings also demonstrate lower health literacy for culturally and linguistically diverse students, and those studying Arts compared to Health degrees. Lower self-rated health was correlated with HLQ scales including being less active in managing one's own health, having less social support for one's health, possessing insufficient health information and lower confidence in navigating the healthcare system. This study provides a comprehensive picture of potentially vulnerable students and identifies strategies for supporting their health endeavors while studying at university.

Cluster Analysis of Health-Related Lifestyles in University Students

Health-related lifestyles in young adults are a public health concern because they affect the risk for developing noncommunicable diseases. Although unhealthy lifestyles tend to cluster together, most studies have analyzed their effects as independent factors. This study assessed the prevalence, association, and clustering of health-related lifestyles (smoking, alcohol consumption, physical activity, and quality of diet) among university students. This cross-sectional study examined a sample of student participants from the University of the Balearic Islands (n = 444; 67.8% females; mean age: 23.1 years). A self-reported questionnaire was used to assess health-related lifestyles. Men that consumed more alcohol, had less healthy diets, were more likely to be overweight, and performed more physical activity. Women had a higher prevalence of low weight and performed less physical activity. Physical activity had a negative association with time using a computer (OR: 0.85; 95% CI: 0.76, 0.95) and a positive association with adherence to the Mediterranean diet (OR: 1.16; 95% CI: 1.02, 1.32). Adherence to the Mediterranean diet had a negative association with tobacco consumption (OR: 0.52; 95% CI: 0.30, 0.91), and positive associations with having breakfast every day (OR: 1.70; 95% CI: 1.05, 2.76) and consuming more daily meals (OR: 1.43; 95% CI: 1.10, 1.87). Cluster analysis indicated the presence of three distinct groups: Unhealthy lifestyles with moderate risk; unhealthy lifestyles with high risk; and healthy lifestyles with low risk. Health promotion interventions in the university environment that focus on multiple lifestyles could have a greater effect than interventions that target any single lifestyle.