{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,11]],"date-time":"2026-07-11T06:33:02Z","timestamp":1783751582200,"version":"3.55.0"},"reference-count":46,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2021,1,13]],"date-time":"2021-01-13T00:00:00Z","timestamp":1610496000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000925","name":"National Health and Medical Research Council","doi-asserted-by":"publisher","award":["APP1143269"],"award-info":[{"award-number":["APP1143269"]}],"id":[{"id":"10.13039\/501100000925","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Health risk factors such as tobacco smoking, inadequate fruit intake, inadequate vegetable intake, risky alcohol consumption, physical inactivity, obesity, anxiety and depression often commence during adolescence and young adulthood. Vocational education institutions enrol many students in these age groups making them an important setting for addressing multiple health risk factors. This systematic review examined (i) co-occurrence of health risk factors, (ii) clustering of health risk factors, and (iii) socio-demographic characteristics associated with co-occurrence and\/or clusters of health risks among vocational education students. MEDLINE, PsycINFO, EMBASE, CINAHL and Scopus were searched to identify eligible studies published by 30 June 2020. Two reviewers independently extracted data and assessed methodological quality using the National Heart, Lung and Blood Institute Quality Assessment Tool. Five studies assessed co-occurrence and three studies clustering of health risks. Co-occurrence of health risk factors ranged from 29\u201398% and clustering of alcohol use and tobacco smoking was commonly reported. The findings were mixed about whether gender and age were associated with co-occurrence or clustering of health risks. There is limited evidence examining co-occurrence and clustering of health risk factors in vocational education students. Comprehensive assessment of how all these health risks co-occur or cluster in vocational education students is required.<\/jats:p>","DOI":"10.3390\/ijerph18020637","type":"journal-article","created":{"date-parts":[[2021,1,13]],"date-time":"2021-01-13T11:52:32Z","timestamp":1610538752000},"page":"637","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":32,"title":["Multiple Health Risk Factors in Vocational Education Students: A Systematic Review"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9665-1139","authenticated-orcid":false,"given":"Prince","family":"Atorkey","sequence":"first","affiliation":[{"name":"School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia"},{"name":"Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW 2287, Australia"},{"name":"Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia"},{"name":"Priority Research Centre for Health Behaviour, Faculty of Health & Medicine, University of Newcastle, Callaghan, NSW 2308, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0382-1552","authenticated-orcid":false,"given":"Judith","family":"Byaruhanga","sequence":"additional","affiliation":[{"name":"School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia"},{"name":"Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW 2287, Australia"},{"name":"Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia"},{"name":"Priority Research Centre for Health Behaviour, Faculty of Health & Medicine, University of Newcastle, Callaghan, NSW 2308, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christine","family":"Paul","sequence":"additional","affiliation":[{"name":"School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia"},{"name":"Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia"},{"name":"Priority Research Centre for Health Behaviour, Faculty of Health & Medicine, University of Newcastle, Callaghan, NSW 2308, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John","family":"Wiggers","sequence":"additional","affiliation":[{"name":"School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia"},{"name":"Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW 2287, Australia"},{"name":"Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia"},{"name":"Priority Research Centre for Health Behaviour, Faculty of Health & Medicine, University of Newcastle, Callaghan, NSW 2308, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Billie","family":"Bonevski","sequence":"additional","affiliation":[{"name":"School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia"},{"name":"Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9914-2732","authenticated-orcid":false,"given":"Flora","family":"Tzelepis","sequence":"additional","affiliation":[{"name":"School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia"},{"name":"Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW 2287, Australia"},{"name":"Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia"},{"name":"Priority Research Centre for Health Behaviour, Faculty of Health & Medicine, University of Newcastle, Callaghan, NSW 2308, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,1,13]]},"reference":[{"key":"ref_1","unstructured":"World Health Organization (2020, October 01). Noncommunicable Diseases Country Profiles 2018. Available online: https:\/\/www.who.int\/nmh\/publications\/ncd-profiles-2018\/en\/."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"b349","DOI":"10.1136\/bmj.b349","article-title":"Combined effect of health behaviours and risk of first ever stroke in 20,040 men and women over 11 years\u2019 follow-up in Norfolk cohort of European Prospective Investigation of Cancer (EPIC Norfolk): Prospective population study","volume":"338","author":"Myint","year":"2009","journal-title":"BMJ"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"711","DOI":"10.1001\/archinternmed.2010.76","article-title":"Influence of individual and combined health behaviors on total and cause-specific mortality in men and women: The United Kingdom health and lifestyle survey","volume":"170","author":"Kvaavik","year":"2010","journal-title":"Arch. Internet Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e004787","DOI":"10.1136\/bmjopen-2014-004787","article-title":"The future burden of obesity-related diseases in the 53 WHO European-Region countries and the impact of effective interventions: A modelling study","volume":"4","author":"Webber","year":"2014","journal-title":"BMJ Open"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Webber, L., Kilpi, F., Marsh, T., Rtveladze, K., Brown, M., and McPherson, K. (2012). High rates of obesity and non-communicable diseases predicted across Latin America. PLoS ONE, 7.","DOI":"10.1371\/journal.pone.0039589"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"135","DOI":"10.3389\/fpubh.2018.00135","article-title":"Clustering of Multiple Risk Behaviors Among a Sample of 18-Year-Old Australians and Associations with Mental Health Outcomes: A Latent Class Analysis","volume":"6","author":"Champion","year":"2018","journal-title":"Front. Public Health"},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Bennasar-Veny, M., Yanez, A.M., Pericas, J., Ballester, L., Fernandez-Dominguez, J.C., Tauler, P., and Aguilo, A. (2020). Cluster Analysis of Health-Related Lifestyles in University Students. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17051776"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Thomas, K., Nilsson, E., Festin, K., Henriksson, P., Lowen, M., Lof, M., and Kristenson, M. (2020). Associations of Psychosocial Factors with Multiple Health Behaviors: A Population-Based Study of Middle-Aged Men and Women. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17041239"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Gardner, L.A., Champion, K.E., Parmenter, B., Grummitt, L., Chapman, C., Sunderland, M., Thornton, L., McBride, N., The Health Life, T., and Newton, N.C. (2020). Clustering of Six Key Risk Behaviors for Chronic Disease among Adolescent Females. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17197211"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"365","DOI":"10.1016\/j.ypmed.2013.03.002","article-title":"A scoping review of statistical approaches to the analysis of multiple health-related behaviours","volume":"56","author":"McAloney","year":"2013","journal-title":"Prev. Med."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Khaw, K.T., Wareham, N., Bingham, S., Welch, A., Luben, R., and Day, N. (2008). Combined impact of health behaviours and mortality in men and women: The EPIC-Norfolk prospective population study. PLoS Med., 5.","DOI":"10.1371\/journal.pmed.0050070"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1016\/j.ypmed.2009.11.009","article-title":"The benefits and challenges of multiple health behavior change in research and in practice","volume":"50","author":"Prochaska","year":"2010","journal-title":"Prev. Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1016\/j.ypmed.2008.02.001","article-title":"Multiple health behavior change research: An introduction and overview","volume":"46","author":"Prochaska","year":"2008","journal-title":"Prev. Med."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"276","DOI":"10.1089\/pop.2011.0060","article-title":"Enhancing multiple domains of well-being by decreasing multiple health risk behaviors: A randomized clinical trial","volume":"15","author":"Prochaska","year":"2012","journal-title":"Popul. Health Manag."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1016\/j.amepre.2011.08.026","article-title":"Physical activity and other health-risk behaviors during the transition into early adulthood: A longitudinal cohort study","volume":"42","author":"Kwan","year":"2012","journal-title":"Am. J. Prev. Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"i11","DOI":"10.1093\/pubmed\/fdr112","article-title":"Policy responses to multiple risk behaviours in adolescents","volume":"34","author":"Hale","year":"2012","journal-title":"J. Public Health"},{"key":"ref_17","unstructured":"Organisation for Economic Co-Operation and Development (2018). Education at a Glance 2018: OECD Indicatiors, OECD Publishing."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Suciati, P. (2018). Why Do Students Choose Vocational School? Lesson Learned from Indonesian Vocational Education. KnE Soc. Sci., 3.","DOI":"10.18502\/kss.v3i11.2802"},{"key":"ref_19","first-page":"163","article-title":"Patterns of multiple health risk\u2013behaviours in university students and their association with mental health: Application of latent class analysis","volume":"36","author":"Kwan","year":"2016","journal-title":"Health Promot. Chronic Dis. Prev. Can. Res. Policy Pract."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1404","DOI":"10.1016\/S0140-6736(13)62116-9","article-title":"The prognosis of common mental disorders in adolescents: A 14-year prospective cohort study","volume":"383","author":"Patton","year":"2014","journal-title":"Lancet"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"S36","DOI":"10.1016\/j.jadohealth.2012.04.016","article-title":"Reducing the burden of depression in youth: What are the implications of neuroscience and genetics on policies and programs?","volume":"52","author":"Patel","year":"2013","journal-title":"J. Adolesc. Health"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1186\/s12966-015-0257-6","article-title":"Young adult males\u2019 motivators and perceived barriers towards eating healthily and being active: A qualitative study","volume":"12","author":"Ashton","year":"2015","journal-title":"Int. J. Behav. Nutr. Phys. Act."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1177\/1757913916666875","article-title":"Determinants of health-related lifestyles among university students","volume":"137","author":"Aceijas","year":"2017","journal-title":"Perspect. Public Health"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Janssen, M.M., Mathijssen, J.J., van Bon-Martens, M.J., Van Oers, H.A., and Garretsen, H.F. (2014). A qualitative exploration of attitudes towards alcohol, and the role of parents and peers of two alcohol-attitude-based segments of the adolescent population. Subst. Abus. Treat. Prev. Policy, 9.","DOI":"10.1186\/1747-597X-9-20"},{"key":"ref_25","first-page":"793","article-title":"A 2-year young adult obesity prevention trial in the US: Process evaluation results","volume":"31","author":"Laska","year":"2016","journal-title":"Health Promot. Int."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1216","DOI":"10.2105\/AJPH.2008.147454","article-title":"Disparities in dietary intake, meal patterning, and home food environments among young adult nonstudents and 2- and 4-year college students","volume":"99","author":"Nelson","year":"2009","journal-title":"Am. J. Public Health"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"222","DOI":"10.3109\/10673229.2012.712839","article-title":"Help seeking for mental health on college campuses: Review of evidence and next steps for research and practice","volume":"20","author":"Eisenberg","year":"2012","journal-title":"Harv. Rev. Psychiatry"},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Vankim, N.A., Ehlinger, E., Lust, K., Story, M., and Laska, M.N. (2010). Understanding young adult physical activity, alcohol and tobacco use in community colleges and 4-year post-secondary institutions: A cross-sectional analysis of epidemiological surveillance data. BMC Public Health, 10.","DOI":"10.1186\/1471-2458-10-208"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1016\/j.ypmed.2015.07.003","article-title":"Which modifiable health risk behaviours are related? A systematic review of the clustering of Smoking, Nutrition, Alcohol and Physical activity (\u2018SNAP\u2019) health risk factors","volume":"81","author":"Noble","year":"2015","journal-title":"Prev. Med."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Meader, N., King, K., Moe-Byrne, T., Wright, K., Graham, H., Petticrew, M., Power, C., White, M., and Sowden, A.J. (2016). A systematic review on the clustering and co-occurrence of multiple risk behaviours. BMC Public Health, 16.","DOI":"10.1186\/s12889-016-3373-6"},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Moher, D., Liberati, A., Tetzlaff, J., and Altman, D.G. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med., 6.","DOI":"10.1371\/journal.pmed.1000097"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"159","DOI":"10.2307\/2529310","article-title":"The measurement of observer agreement for categorical data","volume":"33","author":"Landis","year":"1977","journal-title":"Biometrics"},{"key":"ref_33","unstructured":"National Heart Lung and Blood Institute (2018, February 01). Background: Development and Use of Study Quality Assessment Tools, Available online: http:\/\/www.nhlbi.nih.gov\/health-pro\/guidelines\/in-develop\/cardiovascular-risk-reduction\/tools\/background."},{"key":"ref_34","first-page":"b92","article-title":"Guidance on the conduct of narrative synthesis in systematic reviews","volume":"1","author":"Popay","year":"2006","journal-title":"Prod. ESRC Methods Programme Version"},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Bannink, R., Broeren, S., Heydelberg, J., van\u2019t Klooster, E., and Raat, H. (2015). Depressive symptoms and clustering of risk behaviours among adolescents and young adults attending vocational education: A cross-sectional study. BMC Public Health, 15.","DOI":"10.1186\/s12889-015-1692-7"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"185","DOI":"10.1071\/HE13047","article-title":"The vocational education setting for health promotion: A survey of students\u2019 health risk behaviours and preferences for help","volume":"24","author":"Bonevski","year":"2013","journal-title":"Health Promot. J. Austr."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"585","DOI":"10.1080\/10668926.2018.1520659","article-title":"Identifying Barriers to Mental Health Service Utilization Among Heavy Drinking Community College Students","volume":"43","author":"Cadigan","year":"2019","journal-title":"Community Coll. J. Res. Pract."},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Chyderiotis, S., Benmarhnia, T., Spilka, S., Beck, F., Andler, R., Legleye, S., and Menvielle, G. (2020). Why do apprentices smoke much more than high school students? Understanding educational disparities in smoking with a Oaxaca-blinder decomposition analysis. BMC Public Health, 20.","DOI":"10.1186\/s12889-020-09050-4"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"71","DOI":"10.5993\/AJHB.42.2.7","article-title":"Chronic Disease Risk Typologies among Young Adults in Community College","volume":"42","author":"Jeffries","year":"2018","journal-title":"Am. J. Health Behav."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"136","DOI":"10.1016\/j.addbeh.2016.02.027","article-title":"Polysubstance use patterns and trajectories in vocational students--a latent transition analysis","volume":"58","author":"Tomczyk","year":"2016","journal-title":"Addict. Behav."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"701","DOI":"10.1038\/bdj.2007.1112","article-title":"Smoking, alcohol and drug use among vocational dental practitioners in 2000 and 2005","volume":"203","author":"Underwood","year":"2007","journal-title":"Br. Dent. J."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Haug, S., Schaub, M.P., Salis Gross, C., John, U., and Meyer, C. (2013). Predictors of hazardous drinking, tobacco smoking and physical inactivity in vocational school students. BMC Public Health, 13.","DOI":"10.1186\/1471-2458-13-475"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"376","DOI":"10.1007\/s11121-009-0140-2","article-title":"Latent class analysis of lifestyle characteristics and health risk behaviors among college youth","volume":"10","author":"Laska","year":"2009","journal-title":"Prev. Sci."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"134","DOI":"10.1016\/j.pec.2009.08.007","article-title":"Multiple health behavior clusters among female college students","volume":"79","author":"Quintiliani","year":"2010","journal-title":"Patient Educ. Couns."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1016\/j.ypmed.2010.04.005","article-title":"Lifestyle risk factors of students: A cluster analytical approach","volume":"51","author":"Dodd","year":"2010","journal-title":"Prev. Med."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1186\/s12966-015-0203-7","article-title":"Effectiveness of interventions targeting physical activity, nutrition and healthy weight for university and college students: A systematic review and meta-analysis","volume":"12","author":"Plotnikoff","year":"2015","journal-title":"Int. J. Behav. Nutr. Phys. Act."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/2\/637\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T05:10:48Z","timestamp":1760159448000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/2\/637"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,1,13]]},"references-count":46,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2021,1]]}},"alternative-id":["ijerph18020637"],"URL":"https:\/\/doi.org\/10.3390\/ijerph18020637","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,1,13]]}}}