Institutional Characteristics and the Connection to College Student Health Sara B. Oswalt, PhD, MPH, CSE; Alyssa M. Lederer, MPH, CHES; Lisa T. Schrader, MPH, MCHES Objective: To examine whether 6 institutional characteristics were associated with health behavior and outcomes among college students. Methods: Chisquare statistics and ANOVAs were used to determine relationships between institutional characteristics and health issues among undergraduate participants (N = 81,242) for the spring 2011 American College Health Association-National College Health Assessment II. Results: Most institutional characteristics were significantly associated with all health issues. However, Cramer’s V and eta2 were frequently weak. Relationships be-
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merging adulthood has been identified as an important time period in which individuals establish health behaviors that they maintain into adulthood.1,2 Over two-thirds of high school graduates in the US immediately attend college,3 providing an access point to educate this population and potentially improve lifelong health habits. Unfortunately, much of the current literature shows patterns of poor health among college students, such as high risk substance use and problematic mental health.4 Understanding factors that can influence the health behaviors and attitudes of college students is critical to designing and implementing health interventions for college students and to positively impacting their future health. For health behavior in general, multiple theories have been proposed to explain the influences of both individual factors (eg, self-efficacy, perceived risk, and intention) and interpersonal factors (eg, peer influences, perceived social norms).5 However,
Sara B. Oswalt, Associate Professor, Department of Kinesiology, Health and Nutrition, University of Texas at San Antonio, San Antonio, TX. Alyssa M. Lederer, Doctoral Candidate and Associate Instructor, Department of Applied Health Science, Indiana University School of Public Health-Bloomington, Bloomington, IN. Lisa T. Schrader, Director of Health Promotion, Student Health Services, Middle Tennessee State University, Murfreesboro, TN. Correspondence Dr Oswalt; [email protected]
Am J Health Behav.™ 2015;39(4):475-486
tween institutional characteristics and health outcomes were complex with few clear patterns. Conclusions: This exploratory study provides insight into environmental influences specific to college health. Future research should consider individual student differences and campus offerings to improve understanding of how the environment affects college student health. Key words: institutional characteristics; university setting; between-college effects; health behavior Am J Health Behav. 2015;39(4):475-486 DOI: http://dx.doi.org/10.5993/AJHB.39.4.4
less is known about how environmental influences may affect the health status of college students. This exploratory study sought to examine institutional characteristics of colleges and universities and how these may play a role in the health and well-being of their respective students. The need to examine institutional characteristics is guided by health promotion principles and health behavior models. According to the American College Health Association’s Standards of Practice for Health Promotion in Higher Education,6 institutions of higher education are also communities; therefore, contextual systems and environmental designs should play a role in the types of targeted interventions offered at each location. Additionally, the Ottawa Charter for Health Promotion states: “To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment.”7(p.1) Both of these preeminent documents for college health professionals reflect concepts of the social-ecological model, which illustrates that individual, interpersonal, community, and societal factors interact to influence health and decision-making.8 Characteristics like institutional size or setting have the potential to shape the interpersonal and community elements of the model, and therefore, could play a role in the health of the students within these institutions.
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Institutional Characteristics and the Connection to College Student Health Few published articles have examined institutional characteristics and how they relate to overall health. Primack et al9,10 found that institutional characteristics have some significance regarding substance use behaviors of students. They found that waterpipe smoking was most strongly correlated to non-religion-affiliated institutions located in large cities in the western region of the United States.9 Similarly, tobacco, marijuana, and alcohol use were most highly correlated to geographic region compared to other campus characteristics.10 Although not health-related in nature, there is evidence that institutional characteristics may influence other aspects of the student experience. Wald et al11 reported that attendance at a private institution was associated with a higher grade point average than attendance at a public institution. Another study found that students attending private, religion-affiliated institutions were more likely to engage in community service than students attending public, non-religion-affiliated institutions.12 Research also has shown that students who dropped out of higher education were more likely to come from public, low-selectivity institutions or institutions with a higher percentage of minority students.13 Given the limited published research on the relationship between institutional characteristics and student health outcomes, paired with the potential importance of this relationship, further study of this novel area is warranted. As such, the research question for this exploratory study was: Are there associations between college students’ health outcomes and institutional characteristics? We explored the research question using a large national dataset. To examine the research question comprehensively, several health issues were analyzed: obesity-related behaviors and outcomes, substance use, mental health, sexual health, sleep, and health impediments to academic success. These health outcomes were selected because they are considered priority issues for college health professionals to address in Healthy Campus 2020, the guiding framework for improving college students’ health nationwide.14 Ultimately this information should be helpful to practitioners as they consider individual and environmental strategies to enhance the health of college students. METHODS This study involved a secondary data analysis of the American College Health Association-National College Health Assessment (ACHA-NCHA) II spring 2011 dataset.15 Individual universities conduct the ACHA-NCHA II on their campuses in accordance with their institutional policies. Data can be collected in-person through classroom sampling or online; for the spring 2011 survey, the response rate was 81% for surveys administered in the classroom and 21% for surveys administered online, for a 29% response rate overall.16 Only colleges and universities that randomly select students
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or that survey students from randomly selected classrooms are included in the ACHA-NCHA II national database.17 Participants The spring 2011 ACHA-NCHA II data set contains information collected from 105,781 undergraduate and graduate students enrolled at 129 2-year and 4-year universities. Because of known differences between populations at 2-year and 4-year schools,18-21 and differences between graduate and undergraduate students,22-24 only undergraduate students at 4-year schools were included. Additionally, 2 of the 4-year institutions were eliminated because over 90% of their participants were graduate students. The final sample consisted of 81,242 students from 118 different universities. Seven universities identified as a minority serving institution, a historically black college or university, or a Hispanic-serving institution. Other university and student demographics are presented in Table 1. Measures The ACHA-NCHA II consists of 66 items related to health behaviors and outcomes. For the purpose of this study, 15 items were examined. Because survey questions are single-items asking about behavior (there are no scales or no latent variables being measured), no psychometric properties (eg, reliability) can be determined; however, the overall survey provides similar results to nationally representative surveys.17 The dependent variables addressed 6 main areas: obesity-related behaviors and outcomes, substance use, mental health, sexual health, sleep, and health impediments to academic success. Obesity-related behaviors and outcomes. Four items were included in the obesity-related behaviors and outcomes category: fruit/vegetable consumption; meeting physical activity (PA) guidelines; body mass index (BMI); and overweight/ obese weight status. For fruit and vegetable consumption, participants were asked how many servings they usually consume per day, with response options of 0, 1-2, 3-4 or 5 or more. Responses were dichotomized by 5 or more servings per day versus less than 5 servings per day.25 Exercise was based on reported moderate- and vigorous-PA. ACHA dichotomized this variable as “met” versus “did not meet” national PA guidelines.26 BMI was calculated by ACHA based on reported height/weight and treated as a continuous variable. Using BMI, ACHA categorized weight status by underweight, desired weight, overweight, Class I obesity, Class II obesity, and Class III obesity. For the current study, overweight and the 3 obesity classifications were collapsed as all of these weight statuses have been found to increase the likelihood of numerous problematic health conditions.27 All individuals who responded were included in the analyses for these items. If height or weight was not provided,
Oswalt et al
Table 1 Institutional Characteristics (N = 118 Universities and N = 81,242 Students) Universities % (N)
Students % (N)
Northeast
26.3% (31)
32.4% (26,334)
Midwest
20.3% (24)
19.4% (15,774)
South
29.7% (35)
24.7% (20,069)
West
23.7% (28)
23.5% (19,065)
>500,000
11.9% (14)
19.6% (15,913)
Institutional Characteristic Region
Community Size
Campus Size
Carnegie Classification
Public or Private Religion-affiliated
250,000-499,999
7.6% (9)
6.8% (5,485)
50,000-249,999
39.8% (47)
38.1% (30,918)
10,000-49,999
28.8% (34)
24.3% (19,760)
20,000
23.7% (28)
32.1% (26,111)
10,000-19,999
24.6% (29)
26.1% (21,228)
5000-9999
23.7% (28)
23.4% (19,016)
2500-4999
12.7% (15)
10.3% (8,378)
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merging adulthood has been identified as an important time period in which individuals establish health behaviors that they maintain into adulthood.1,2 Over two-thirds of high school graduates in the US immediately attend college,3 providing an access point to educate this population and potentially improve lifelong health habits. Unfortunately, much of the current literature shows patterns of poor health among college students, such as high risk substance use and problematic mental health.4 Understanding factors that can influence the health behaviors and attitudes of college students is critical to designing and implementing health interventions for college students and to positively impacting their future health. For health behavior in general, multiple theories have been proposed to explain the influences of both individual factors (eg, self-efficacy, perceived risk, and intention) and interpersonal factors (eg, peer influences, perceived social norms).5 However,
Sara B. Oswalt, Associate Professor, Department of Kinesiology, Health and Nutrition, University of Texas at San Antonio, San Antonio, TX. Alyssa M. Lederer, Doctoral Candidate and Associate Instructor, Department of Applied Health Science, Indiana University School of Public Health-Bloomington, Bloomington, IN. Lisa T. Schrader, Director of Health Promotion, Student Health Services, Middle Tennessee State University, Murfreesboro, TN. Correspondence Dr Oswalt; [email protected]
Am J Health Behav.™ 2015;39(4):475-486
tween institutional characteristics and health outcomes were complex with few clear patterns. Conclusions: This exploratory study provides insight into environmental influences specific to college health. Future research should consider individual student differences and campus offerings to improve understanding of how the environment affects college student health. Key words: institutional characteristics; university setting; between-college effects; health behavior Am J Health Behav. 2015;39(4):475-486 DOI: http://dx.doi.org/10.5993/AJHB.39.4.4
less is known about how environmental influences may affect the health status of college students. This exploratory study sought to examine institutional characteristics of colleges and universities and how these may play a role in the health and well-being of their respective students. The need to examine institutional characteristics is guided by health promotion principles and health behavior models. According to the American College Health Association’s Standards of Practice for Health Promotion in Higher Education,6 institutions of higher education are also communities; therefore, contextual systems and environmental designs should play a role in the types of targeted interventions offered at each location. Additionally, the Ottawa Charter for Health Promotion states: “To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment.”7(p.1) Both of these preeminent documents for college health professionals reflect concepts of the social-ecological model, which illustrates that individual, interpersonal, community, and societal factors interact to influence health and decision-making.8 Characteristics like institutional size or setting have the potential to shape the interpersonal and community elements of the model, and therefore, could play a role in the health of the students within these institutions.
475
Institutional Characteristics and the Connection to College Student Health Few published articles have examined institutional characteristics and how they relate to overall health. Primack et al9,10 found that institutional characteristics have some significance regarding substance use behaviors of students. They found that waterpipe smoking was most strongly correlated to non-religion-affiliated institutions located in large cities in the western region of the United States.9 Similarly, tobacco, marijuana, and alcohol use were most highly correlated to geographic region compared to other campus characteristics.10 Although not health-related in nature, there is evidence that institutional characteristics may influence other aspects of the student experience. Wald et al11 reported that attendance at a private institution was associated with a higher grade point average than attendance at a public institution. Another study found that students attending private, religion-affiliated institutions were more likely to engage in community service than students attending public, non-religion-affiliated institutions.12 Research also has shown that students who dropped out of higher education were more likely to come from public, low-selectivity institutions or institutions with a higher percentage of minority students.13 Given the limited published research on the relationship between institutional characteristics and student health outcomes, paired with the potential importance of this relationship, further study of this novel area is warranted. As such, the research question for this exploratory study was: Are there associations between college students’ health outcomes and institutional characteristics? We explored the research question using a large national dataset. To examine the research question comprehensively, several health issues were analyzed: obesity-related behaviors and outcomes, substance use, mental health, sexual health, sleep, and health impediments to academic success. These health outcomes were selected because they are considered priority issues for college health professionals to address in Healthy Campus 2020, the guiding framework for improving college students’ health nationwide.14 Ultimately this information should be helpful to practitioners as they consider individual and environmental strategies to enhance the health of college students. METHODS This study involved a secondary data analysis of the American College Health Association-National College Health Assessment (ACHA-NCHA) II spring 2011 dataset.15 Individual universities conduct the ACHA-NCHA II on their campuses in accordance with their institutional policies. Data can be collected in-person through classroom sampling or online; for the spring 2011 survey, the response rate was 81% for surveys administered in the classroom and 21% for surveys administered online, for a 29% response rate overall.16 Only colleges and universities that randomly select students
476
or that survey students from randomly selected classrooms are included in the ACHA-NCHA II national database.17 Participants The spring 2011 ACHA-NCHA II data set contains information collected from 105,781 undergraduate and graduate students enrolled at 129 2-year and 4-year universities. Because of known differences between populations at 2-year and 4-year schools,18-21 and differences between graduate and undergraduate students,22-24 only undergraduate students at 4-year schools were included. Additionally, 2 of the 4-year institutions were eliminated because over 90% of their participants were graduate students. The final sample consisted of 81,242 students from 118 different universities. Seven universities identified as a minority serving institution, a historically black college or university, or a Hispanic-serving institution. Other university and student demographics are presented in Table 1. Measures The ACHA-NCHA II consists of 66 items related to health behaviors and outcomes. For the purpose of this study, 15 items were examined. Because survey questions are single-items asking about behavior (there are no scales or no latent variables being measured), no psychometric properties (eg, reliability) can be determined; however, the overall survey provides similar results to nationally representative surveys.17 The dependent variables addressed 6 main areas: obesity-related behaviors and outcomes, substance use, mental health, sexual health, sleep, and health impediments to academic success. Obesity-related behaviors and outcomes. Four items were included in the obesity-related behaviors and outcomes category: fruit/vegetable consumption; meeting physical activity (PA) guidelines; body mass index (BMI); and overweight/ obese weight status. For fruit and vegetable consumption, participants were asked how many servings they usually consume per day, with response options of 0, 1-2, 3-4 or 5 or more. Responses were dichotomized by 5 or more servings per day versus less than 5 servings per day.25 Exercise was based on reported moderate- and vigorous-PA. ACHA dichotomized this variable as “met” versus “did not meet” national PA guidelines.26 BMI was calculated by ACHA based on reported height/weight and treated as a continuous variable. Using BMI, ACHA categorized weight status by underweight, desired weight, overweight, Class I obesity, Class II obesity, and Class III obesity. For the current study, overweight and the 3 obesity classifications were collapsed as all of these weight statuses have been found to increase the likelihood of numerous problematic health conditions.27 All individuals who responded were included in the analyses for these items. If height or weight was not provided,
Oswalt et al
Table 1 Institutional Characteristics (N = 118 Universities and N = 81,242 Students) Universities % (N)
Students % (N)
Northeast
26.3% (31)
32.4% (26,334)
Midwest
20.3% (24)
19.4% (15,774)
South
29.7% (35)
24.7% (20,069)
West
23.7% (28)
23.5% (19,065)
>500,000
11.9% (14)
19.6% (15,913)
Institutional Characteristic Region
Community Size
Campus Size
Carnegie Classification
Public or Private Religion-affiliated
250,000-499,999
7.6% (9)
6.8% (5,485)
50,000-249,999
39.8% (47)
38.1% (30,918)
10,000-49,999
28.8% (34)
24.3% (19,760)
20,000
23.7% (28)
32.1% (26,111)
10,000-19,999
24.6% (29)
26.1% (21,228)
5000-9999
23.7% (28)
23.4% (19,016)
2500-4999
12.7% (15)
10.3% (8,378)
