A randomized control study method was used. Nursing students were invited to join the study on a voluntary basis by signing a consent form with detailed information concerning the current study. They were randomly divided into two groups by using block randomization: control group and experimental group. Students in both the experimental and control groups were asked to fill in an online pre-test questionnaire, which included demographic information, and the measurement (i.e. HPLP-II, ESTEEM and GSES) to determine their health promoting lifestyle, self-esteem, and self-efficacy, respectively. In addition, only the students in the experimental group had to participate in a 6-session program of holistic health practice, introducing physical health (enhancing physical activity, nutrition, and sleep), mental health (managing stress), social health (interpersonal relationship), and spiritual health (pursuing meaning of life) to them. Participants must meet the 80% attendance criterion of the program in order to take part in the post-test of this survey. Furthermore, after 6 sessions, all participants in both groups were invited to complete an online post-test questionnaire, which had the same content as the online pre-test questionnaire.

The inclusion criteria of the participants of this study were those who have not acquired knowledge related to health, hence only “freshmen” who are the new students in the first-year nursing program could be recruited. A total of 64 first-year nursing students of a nursing school in the publicly-funded higher educational institute were invited to join, and 56 out of 64 students were willing to participate in the study. They were randomly assigned with 27 participants in experimental group and 29 participants in control group. A flow chart of the sampling process is presented in Fig. (1).

Ethical approval was obtained from the nursing school before carrying out the study. Participation in the study was voluntary and anonymous, and all participants were invited after they were informed about the purpose and procedure of the study. They had the right to withdraw at any time during the study. Participants signed an informed consent form before completing the online questionnaire. Confidentiality was guaranteed.

Data collection was done in the public nursing school. All participants had signed an informed consent after a briefing of the details of the study by the principal investigator. Then, the participants were asked to complete the online pre-test questionnaires by themselves within the date from 30/8/2019 to 7/9/2019. After the 3-month intervention, all participants from the experimental and control groups were again requested to fill in the online post-test questionnaire by themselves within the period from 9/11/2019 to 19/11/2019.

The online questionnaires for the pre-test and post-test were the same in content, which included demographic information and the measurements tools (i.e. HPLP-II, ESTEEM & GSES) to determine the health promoting behaviors, self-esteem, and self-efficacy of the participants, respectively.

52 out of 56 participants (93% response rate) completed the online pre-test questionnaire in this study, including 13 male nursing students and 39 female nursing students, aged 17 years old or above. Almost 80% of participants reported they had no religion; whereas 14% declared they were Buddhist, 2% were Christian, 2% were Catholic, and 2% others. Demographic data of the participants is shown in Table 2. Chi-square test was performed with the demographic data of experimental and control group, and no statistical difference was detected. Details of the Chi-square test of demographic data are presented in Table 3.

The Chinese version of HLPL-II was used to explore the 6 domains of the holistic health of the participants: health responsibility, physical activity, nutritional habits, spiritual growth, interpersonal relations, and stress management of participants. Results found that the mean of physical activity was the lowest score (mean=17.15) among the 6 domains, followed by health responsibility (mean=18.6), stress management (mean=20.19), nutritional habits (mean=21.23), interpersonal relationship (mean=23.13), and spiritual growth (mean=23.25). The mean score of total HPLP-II was 123.58. Details of each mean, standard deviation, minimum, and maximum scores of the 6 domains of HPLP-II are presented in Table 4.

38 out of 52 participants (73% response rate), who had filled the pre-test questionnaire, completed the post-test questionnaire in this study. Seventeen participants were from the experimental group and 21 participants were from the control group. There was a significantly positive increase in all 6 domains of HPLP-II (P<0.005), as well as self-esteem (P<0.01) and self-efficacy (P<0.01) in the experimental participants when comparing their pre-test and post-test results. In contrast, there was no significant difference in comparing the pre-test and post-test results of the control group, except for self-esteem, which showed a significant difference (P<0.05). Details of paired t-test of scores of the 6 domains of HPLP-II, ESTEEM, and GSES of the two groups are presented in Tables 5 and 6.

Fig. (1). Flow chart showing the sampling process.

This study has added new information on the holistic health status in terms of health promoting behaviors of the first-year nursing students in a Macao public educational institute. Chi-square test showed that there was no difference in their demographic background, which may affect the intervention of the program. Physical activity was found to be the lowest mean score among the 6 domains. This finding was similar to the study of Luk et al. 2014, which investigated the healthy lifestyle of enrolled nursing students in Hong Kong using the Chinese version of HPLP-II. In this study, the subjects’ physical activity was also the lowest, whereas spiritual growth was ranked the highest among the 6 domains in HPLP-II [21]. One possible reason is that the lecture classes of first-year nursing students were mostly scheduled in the morning, as a result, students could get part-time jobs after school for financial reasons [26] and this may affect how much free time they had for physical activity. Secondly, previous studies showed that nursing students had too many presentations and assignments as part of their study requirement [27, 28], which could be a reason why they seldom have time for physical activity. Moreover, studies found that peer groups influenced students' preference to undertake physical activity [29, 30]. However, first-year nursing students may not yet start to establish strong peer relationships in class, and as a result, they lack peer support and company to carry out physical activity. Encouragement to take part in physical activity should be provided to first-year nursing students. Further studies such as focus groups or in-depth interviews can be performed to further explore this phenomenon among nursing students.

In addition, health responsibility was ranked the second-lowest among the 6 domains in the study. This may be due to their lack of health knowledge in improving their personal health since they were only freshmen in their first year of nursing study. Supports from school teachers and peers in sharing health knowledge could be an advantage to these first-year nursing students in improving their health responsibility. On the other hand, spiritual growth was ranked the highest among the 6 domains in this study. One possible reason is that nursing students enjoy the process of helping and respecting others, as well as bringing hope to support significant others. These behaviors may help nursing students enhance their own spiritual growth [31, 32] at the same time.

However, there was no significant difference found when comparing the mean scores of the 6 domains between gender, age, and religion. The reason may be due to the small sample size in certain groups (i.e. male: n=13; age <18 years old: n=4; with religion: n=10). Therefore, no significant relationship was found with the demographic data in this study.

This Holistic Health Practice Program, including the essential components of physical, psychosocial, and spiritual aspects of holistic health, is found to be effective in promoting healthy lifestyles. This result is consistent with other studies for the promotion of health in different health aspects. Previous studies emphasized that encouraging nursing students to promote and enhance their healthy lifestyles was essential to nursing students [4, 33], and interpersonal communication course could significantly help first-year nursing students to improve their self-efficacy [10]. Wills & Kelly (2017) found 3 types of interventions which could encourage nursing students to promote healthy lifestyles: (1) education and training sessions, (2) pulse accelerometer, and (3) online personal wellness goal-setting tool. These interventions should be embedded in the nursing curriculum and delivered within the course of the nursing program [33]. The focus of this program not only helps participants assess and reflect on their holistic health, but also encourages them to develop a health promotion plan to achieve better health. The findings of this study showed that the intervention could significantly enhance the health promoting lifestyle, self-esteem, and self-efficacy of the experimental participants who had undergone a 3-month holistic health practice. Nursing schools should consider integrating the program in the formal nursing curriculum for the promotion of holistic health of first-year nursing students. Or as an alternative, it can be tailor-made as an extracurricular course to enhance the holistic health of the students.