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. 2025 Oct 28;17(21):3388.
doi: 10.3390/nu17213388.

Clustering of Unhealthy Lifestyle Behaviours and Its Contextual Determinants in Adolescents: A Multilevel Analysis of School-Based Surveys in 45 Countries

Yohannes Tekalegn Efa  1   2 , David Roder  1   2 , Zumin Shi  3 , Ming Li  1   4
Affiliations

Clustering of Unhealthy Lifestyle Behaviours and Its Contextual Determinants in Adolescents: A Multilevel Analysis of School-Based Surveys in 45 Countries

Yohannes Tekalegn Efa et al. Nutrients. .

Abstract

Background: This study examined the clustering of unhealthy lifestyle behaviours and their determinants among adolescents across Europe, Central Asia, and North America. Methods: The study included 210,713 adolescents aged 11 to 15 years from 45 countries who participated in the 2018 Health Behaviour in School-aged Children (HBSC) study. Lifestyle behaviours, including physical inactivity, inadequate fruit and vegetable consumption, frequent soft drink consumption, alcohol use, and smoking, were used to examine the clustering of unhealthy behaviours. Multilevel mixed-effects logistic regression was employed to assess the associations between unhealthy behaviour clustering (≥3 unhealthy behaviours) and contextual factors at the individual, family, and school levels. Results: A high prevalence of clustered unhealthy behaviours was observed among adolescents, with 51.5% engaging in three or more unhealthy lifestyle behaviours. The odds increased with age (AOR: 1.79, 95% CI: 1.75, 1.84 for those aged ≥ 15 years), among males (AOR: 1.26, 95% CI: 123, 1.28), and among those experiencing higher academic pressure (AOR: 1.13, 95% CI: 1.09, 1.17 for very high academic pressure). In contrast, the odds were lower among adolescents from a higher family affluence background (AOR: 0.62 95% CI: 0.60, 0.65 for high), among adolescents living with both parents (AOR: 0.83, 95 CI: 0.81, 0.85), those reporting higher family support (AOR: 0.62, 95% CI: 0.60, 0.63 for high), higher peer support at school (AOR: 0.87, 95% CI: 0.84, 0.89 for high), and those reporting higher school satisfaction (AOR: 0.50, 95% CI: 0.48, 0.52 for very high). Conclusions: The study reveals that one in two adolescents engages in three or more unhealthy lifestyle behaviours. It emphasises the need to tackle this public health challenge through multisectoral interventions targeting individual-level and contextual factors at the family and school levels.

Keywords: adolescents; alcohol drinking; clustering pattern; dietary habits; lifestyle; physical activity; smoking.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
The boxplot shows the prevalence of unhealthy lifestyle behaviours among adolescents in 45 countries. The box represents the interquartile range (IQR), which contains the middle 50% of the data. Whiskers extend from the box to the minimum and maximum values. The symbol “×” denotes the mean values, while “●” represents the lowest or highest observed prevalence.
Figure 2
Figure 2
Prevalence of three or more unhealthy lifestyle behaviours by country, HBSC 2018.
Figure 3
Figure 3
Prevalence of three or more unhealthy lifestyle behaviours by gender and country, HBSC 2018. Footnotes: ALB: Albania; ARM: Armenia; AUT: Austria; AZE: Azerbaijan; BEL1: Belgium (Flemish); BEL2: Belgium (French); BGR: Bulgaria; CAN: Canada; HRV: Croatia; CZE: Czech Republic; DNK: Denmark; ENG: England; EST: Estonia; FIN: Finland; FRA: France; GEO: Georgia; DEU: Germany; GRC: Greece; HUN: Hungary; ISL: Iceland; IRL: Ireland; ISR: Israel; ITA: Italy; KAZ: Kazakhstan; LVA: Latvia; LTU: Lithuania; LUX: Luxembourg; MKD: Macedonia; MLT: Malta; NLD: Netherlands; NOR: Norway; POL: Poland; PRT: Portugal; MDA: Republic of Moldova; ROU: Romania; RUS: Russia; SCO: Scotland; SRB: Serbia; SVK: Slovakia; SVN: Slovenia; ESP: Spain; SWE: Sweden; CHE: Switzerland; UKR: Ukraine; WAL: Wales.
Figure 4
Figure 4
Prevalence of three or more unhealthy lifestyle behaviours by age category and country, HBSC 2018. Footnotes: ALB: Albania; ARM: Armenia; AUT: Austria; AZE: Azerbaijan; BEL1: Belgium (Flemish); BEL2: Belgium (French); BGR: Bulgaria; CAN: Canada; HRV: Croatia; CZE: Czech Republic; DNK: Denmark; ENG: England; EST: Estonia; FIN: Finland; FRA: France; GEO: Georgia; DEU: Germany; GRC: Greece; HUN: Hungary; ISL: Iceland; IRL: Ireland; ISR: Israel; ITA: Italy; KAZ: Kazakhstan; LVA: Latvia; LTU: Lithuania; LUX: Luxembourg; MKD: Macedonia; MLT: Malta; NLD: Netherlands; NOR: Norway; POL: Poland; PRT: Portugal; MDA: Republic of Moldova; ROU: Romania; RUS: Russia; SCO: Scotland; SRB: Serbia; SVK: Slovakia; SVN: Slovenia; ESP: Spain; SWE: Sweden; CHE: Switzerland; UKR: Ukraine; WAL: Wales.
Figure 5
Figure 5
Prevalence of three or more unhealthy lifestyle behaviours by Family Affluence Scale (FAS) and country, HBSC 2018. Footnotes: ALB: Albania; ARM: Armenia; AUT: Austria; AZE: Azerbaijan; BEL1: Belgium (Flemish); BEL2: Belgium (French); BGR: Bulgaria; CAN: Canada; HRV: Croatia; CZE: Czech Republic; DNK: Denmark; ENG: England; EST: Estonia; FIN: Finland; FRA: France; GEO: Georgia; DEU: Germany; GRC: Greece; HUN: Hungary; ISL: Iceland; IRL: Ireland; ISR: Israel; ITA: Italy; KAZ: Kazakhstan; LVA: Latvia; LTU: Lithuania; LUX: Luxembourg; MKD: Macedonia; MLT: Malta; NLD: Netherlands; NOR: Norway; POL: Poland; PRT: Portugal; MDA: Republic of Moldova; ROU: Romania; RUS: Russia; SCO: Scotland; SRB: Serbia; SVK: Slovakia; SVN: Slovenia; ESP: Spain; SWE: Sweden; CHE: Switzerland; UKR: Ukraine; WAL: Wales.
Figure 6
Figure 6
Mixed-effects logistic regression analysis of factors associated with three or more unhealthy behaviours among adolescents using the 2018 HBSC data. The model is mutually adjusted for all reported covariates and the Human Development Index (HDI). AOR, adjusted odds ratio.
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