It has long been believed by educators that health and learning are inextricably linked and a recent growing body of literature clearly illustrates the strong reciprocal nature of this linkage (1, 2). An environment for academic success can best be achieved when barriers to optimal health are low and strategies exist to remove health-related concerns that impede the learning process. Support systems within medical education that address health-related barriers to academic success can best foster such an environment when the specific health concerns that have the greatest degree of negative impact on student learning and success are known.
Because the medical education literature suggests that medical students suffer from a variety of health problems (3–8), this pilot study was designed with two specific objectives: 1) to determine the most prevalent health concerns experienced by medical students at a single institution, and 2) to establish which of these health concerns were perceived as most harmful to student learning. Results from this study will inform the development of an instrument that measures the impact of health on learning in the context of medical education, as well as guide the development of health-promoting interventions.
The National College Health Assessment (NCHA) is a 58-item questionnaire developed by the American College Health Association (ACHA) to broadly assess habits, perceptions, and behaviors related to the most prevalent health topics among college students. This instrument is widely used among college health professionals and has been administered over 400 times at U.S. institutions of higher education (9).
The NCHA was administered at Columbia University’s College of Physicians and Surgeons during the spring term of 2005 under a protocol approved by the University’s Institutional Review Board. In order to ensure confidentiality, student responses were collected through a web-based survey contract with ACHA, who then compiled the data into summary reports. Students were notified that all personal identifying information would be separated from their responses before the summary reports and raw data were sent to University study personnel for further analyses.
The current study focuses on the results from a single question about health-related impediments to academic performance. Respondents were presented a list of 24 health concerns (Table 1
) and the following three categories of response for each concern: 1) I did not experience this; 2) I experienced this, but it did not impact my academics; 3) I experienced this and it negatively impacted my academics. In the current study, this scale has good internal consistency, with a Cronbach alpha coefficient of 0.76.
As there are no established models for analyzing responses to this specific question, we conducted two frequency analyses to determine the prevalence of each health concern and the prevalence of perceived negative academic impact of each concern. Based on these analyses, a model was constructed to evaluate the relative threat posed by each of the health concerns.
Full results are summarized in Table 1
. All 651 medical students enrolled were sampled, with 315 students (48.4%) returning complete surveys. Respondents were proportionally similar to the sampled population on a variety of demographic characteristics, including sex, ethnicity, age, and status as an international student.
We first determined the frequency with which each of the listed health concerns was reported. A number of the health concerns were infrequently experienced by medical students, with fewer than 5% of students reporting a learning disability (n=4), pregnancy (n=9), or sexually transmitted disease (n=10), and less than 1% of students reporting a sexual assault (n=2), physical assault (n=2), or mononucleosis (n=3). No students reported being HIV infected.
As shown in Table 2
, students were most likely to report upper respiratory infections (cold/flu/sore throat), interpersonal concerns (concerns about troubled friends or family members, death of a friend or family member, and relationship difficulty), and mental health concerns (depression/anxiety/seasonal affective disorder and stress). Other frequently reported health issues included allergies, alcohol use, Internet use/computer games, and sleep difficulties.
A second frequency analysis was conducted to answer the following question: “For each health concern, what percentage of students experiencing the concern reported a perceived negative academic impact?” As shown in Table 2
, learning-related health issues (learning disability and attention deficit disorder) were reported as having the greatest negative academic impact (threat). Mental health issues and interpersonal concerns were also perceived by medical students to contribute significantly to negative academic consequences.
At our institution, we have a robust student support network, encompassing career advising, professional counseling, primary medical care, health promotion services, peer education, and academic support. This particular instrument, which systematically measures student knowledge, behaviors, and beliefs related to a wide array of health concerns, was selected to assist these support systems in prioritizing needs, improving services, and allocating resources for student support.
Students experiencing attention deficit disorder (6.8%, n=21), learning disabilities (1.3%, n=4), and mononucleosis (0.09%, n=3) reported the greatest degree of academic impact relative to the health concern. However, the frequency of these concerns within the population was very low. On the other hand, upper respiratory infections were commonly experienced by medical students but were not perceived as contributing significantly to negative academic outcomes. Thus, when analyzing these data, it is important not only to assess the frequency of each health concern, but also the relative threat posed by each concern (in this case, the student’s perception of negative academic impact).
When using this Frequency X Threat model, we see that of the 10 most frequent health concerns experienced by medical students, five also appear among the top 10 with the greatest perceived academic threat (shown in bold in Table 2
). These include two categorical mental health concerns (depression/anxiety/seasonal affective disorder and stress) and three specific interpersonal concerns (concerns about a troubled friend or family member, death of a friend or family member, and relationship difficulty). Based on prior reports in the medical education literature (3–5, 8), it is not surprising that mental health issues and interpersonal concerns are among the most prevalent health concerns experienced by medical students. Our results indicate that these concerns are also responsible for a substantial amount of the negative health-related academic consequences reported by students.
As this was a pilot study utilizing an existing item embedded in a much larger survey, several limitations deserve mention. The measure was developed for use primarily with undergraduate college students and, as part of a much lengthier questionnaire, posed a moderate degree of respondent burden (about 30 minutes, which we suspect was the main factor in the resultant response rate).
Further challenges were posed by the structure and wording of the question. Despite representing different diagnoses and constructs, several mental health concerns were measured as one global concern (depression/anxiety/seasonal affective disorder). Additionally, the question does not differentiate between students with a true diagnosis and those without. It is important to know, for example, if a student has a medical diagnosis of attention deficit disorder or, because he has trouble paying attention now and then, simply thinks he suffers from the disorder. Further, in this study “stress” was a health concern that was found to be both frequently experienced and threatening to learning. However, because it was not further defined, future research should define this construct more clearly.
In this study, academic impact was assessed by the medical students’ self-appraisal of impact for each of the health concerns. This appraisal process is complex, requiring both recall and insight. It is reasonable to assume that some students might underestimate both the frequency and the impact of some health concerns (e.g., alcohol use). A more objective measure of academic impact should be identified.
In attempting to create an environment that supports medical student learning, we propose adding one final dimension to the Frequency X Threat model: potential for intervention. With such a model as a guide, our efforts and resources would be targeted to those health concerns that are most frequent, most threatening to academic success, and have the greatest potential for intervention. The mental health issues and interpersonal concerns reported in this pilot study are common, cause substantial reported negative impact, and would likely be amenable to intervention.
To test the usefulness of this model, future research must measure the potential positive impact on learning related to students’ engagement in selected health promoting behaviors, such as exercise, social support, and effective use of coping skills. We believe that partnerships between academic and student service resources may enhance benefit and create opportunities for the development of effective coping skills. For example, Mindfulness Based Stress Reduction courses, offered as a second year elective at our institution, have been shown to reduce stress and enhance hardiness (10–12), thus enabling students to cope more effectively with stress.
Our future research will focus on 1) expanding and clarifying some of the constructs addressed in this single question (e.g., stress, mental health diagnoses); 2) developing a more systematic assessment of negative academic impact; and 3) exploring and testing potential interventions.