Research Article
A Longitudinal Examination of the Interrelationship of Multiple Health Behaviors

https://doi.org/10.1016/j.amepre.2014.04.019Get rights and content

Background

Evaluating the interrelationship of health behaviors could assist in the development of effective public health interventions. Furthermore, the ability to identify cognitive mediators that may influence multiple behavioral changes requires evaluation.

Purpose

To evaluate covariation among health behaviors, specifically alcohol consumption, leisure-time physical activity, and smoking, and examine whether mastery acts as a mediating social-cognitive mechanism that facilitates multiple health behavior change in a longitudinal analysis.

Methods

In 2010, secondary data analysis was conducted on the first seven cycles of the Canadian National Population Health Survey. Data collection began in 1994–1995 and has continued biennially. At the time of this analysis, only seven cycles of data (2006–2007) were available. Parallel process growth curve models were used to analyze covariation between health behaviors and the potential mediating effects of perceived mastery.

Results

Increases in leisure-time physical activity were associated with reductions in tobacco use, whereas declines in alcohol consumption were associated with decreases in tobacco use. Covariation between alcohol consumption and leisure-time physical activity did not reach statistical significance. For the most part, mastery was unsuccessful in mediating the interrelationship of multiple behavioral changes.

Conclusions

Health behaviors are not independent but rather interrelated. In order to optimize limited prevention resources, these results suggest that population-level intervention efforts targeting multiple modifiable behavioral risk factors may not need to occur simultaneously.

Introduction

It has been estimated that a substantial proportion of the American1, 2, 3 and Canadian4 general population participate in multiple unhealthy behaviors, with physical inactivity, smoking, and excessive alcohol consumption being among the most prevalent.2, 3, 4 Notwithstanding the challenges associated with implementing multiple health behavior change strategies, health professionals have acknowledged that such interventions are advantageous.5

Their benefits include a greater impact on the occurrence and severity of morbidity and mortality,5, 6 the opportunity for a choice-based approach in changing health behaviors,7 conservation of the health professional’s time and resources while minimizing healthcare expenditures,5, 8 and a greater relevance to real-world circumstances.5 Therefore, multiple health behavior research has garnered increased attention in relation to planning future public health interventions.9, 10

Although multiple health behavior change may represent the future of public health strategies and policies,11, 12 several unanswered questions remain. As unhealthy behaviors tend to cluster,10, 13, 14 evaluating the interrelationship of health behaviors could assist in the development of effective and cost-efficient public health interventions.6, 12, 15 Although evaluated for some time, the concept of covariation requires further examination, as much remains unknown.16

Furthermore, although the literature has identified social-cognitive mechanisms (e.g., self-efficacy) that may influence single behavioral change,15, 17 the potential mediating role that these mechanisms may have on multiple behavioral changes is not known.15 For instance, mastery refers to the perception that individuals have the ability to control important events that occur throughout their life.18 Although mastery has been shown to be associated with smoking,19, 20 alcohol dependence,21 and physical activity,22 the impact of mastery on the covariation of health behaviors has yet to be examined.

The current study will attempt to provide greater insight into the interrelationship of multiple health behaviors by (1) evaluating covariation among health behaviors, alcohol consumption, leisure-time physical activity, and smoking and (2) examining whether mastery acts as a mediating social-cognitive mechanism that facilitates changes among multiple health behaviors.

Previous observational studies have incorporated several methodologic limitations that may have compromised their findings. Although cross-sectional studies23, 24, 25, 26, 27 provide valuable insight into the concept of covariation, they are unable to account for behavioral changes. Longitudinal studies are necessary to evaluate covariation.

Additional limitations of previous research include small or unrepresentative samples of the general population,23, 24, 25, 26, 28, 29, 30, 31, 32 the use of dichotomous or categorical outcome variables,28, 29, 31, 32, 33 and the inability to assess social-cognitive mechanisms that may mediate the adoption and maintenance of multiple health behaviors.23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 The current study addresses these concerns by using a large, nationally representative sample of Canadians to assess the longitudinal trajectories of multiple behavioral changes and the potential mediating effects of mastery.

Section snippets

Methods

A detailed description of the Canadian longitudinal National Population Health Survey (NPHS) study design is presented elsewhere.34 Briefly, data collection for the first cycle began in 1994–1995 and has continued biennially for subsequent cycles. At the time of this analysis, only seven cycles of data (2006–2007) were available. The NPHS target population included Canadians residing in households throughout all ten provinces.

Excluded from the sampling frame were Canadians residing on Indian

Results

Weighted demographic characteristics for this Canadian sample are illustrated in Table 1. In 1994–1995, women comprised a slight majority of this sample. The average age of this sample was 41 years and the majority of Canadians (58.9%) were married or common law. Most Canadians (51.8%) had acquired at least some post-secondary school, and 15% of this Canadian sample was categorized as having high income adequacy. Over time, individuals had attained higher levels of education. Income adequacy

Discussion

Canadians demonstrate the capability to adopt or maintain significant favorable behavioral changes in leisure-time physical activity and tobacco use. Comparable longitudinal trends have been reported by others.41, 42, 43, 44 Alcohol consumption increased biennially by 0.03 beverages per day. Although each of these three behavioral trajectories reached statistical significance, one could argue that the estimated magnitudes of such behavioral changes were small. However, even small and attainable

Acknowledgments

The authors would like to thank Dr. Kristopher Preacher for his assistance in the interpretation of the findings of this analysis.

Dr. Cairney is supported through an endowed professorship provided by the Department of Family Medicine at McMaster University.

No financial disclosures were reported by the authors of this paper.

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