Journal of Psychosomatic Research, Vol. 19, pp. 87 to 98. Pergamon Press, 1975. Printed in Great Britain
THE INFLUENCE OF RECENT LIFE EXPERIENCE ON THE HEALTH OF COLLEGE FRESHMEN MARTIN B. MARX,* THOMAS F. GARRITY~ and FRANK R. BOWERS$ (Received
29 July 1974)
INTRODUCTION DISEASE patterns among college students are commonly described by data which delineate the frequency of occurrence of physical and mental illness. Such data, usually categorized by diagnostic label, are obtained from interviews of students or from the records of a University’s Health Service [l-4]. When based on surveys, studies of the prevalence of disease among students may reveal interesting associations between reported illness and demographic or social characteristics of interest; and prevalence data obtained from health records may provide useful information for therapeutic or administrative purposes. However, the demographic or social characteristic of interest may be unrelated to the etiology of the illness and the limitations imposed by the selective recall of illnesses, selective attrition from a target population and selective entry into a health care system further restrict the value of all prevalence data for suggesting useful preventive measures. Preventive programs are logically directed toward populations which are at high risk of ill-health. Such populations are identifiable by documenting the differential occurrence of new events of illness during some time period, i.e., incidence. Among college students, effective intervention as a preventive measure may be directed most effectively toward a population showing an increased incidence of ill-health during their first year of college. Preventive programs would be aimed at altering factors found causally associated with an increased incidence. Since the mechanisms for continuous monitoring of students’ physical and mental health as well as their social and intellectual behavior already exist in most academic environments, evaluation of preventive programs is not difficult to conceptualize. Thus college campuses appear to be natural laboratories in which to develop incidence rates and identify potentially causal factors. Based on such data preventive programs may be developed and evaluated. BACKGROUND A factor of causal relevance in many disease processes is the stressful episode or life change event, i.e., an event, whether or not socially desirable, which requires some degree of adaptation by the person involved. It has been documented that an association exists between illness episodes and the frequency, pattern and magnitude of such life change events occurring in the recent past of affected persons [5,6]. The Schedule of Recent Experience (SRE) of Holmes and Rahe [7-101 has frequently served as the index of 43 selected events in studies assessing their association with somatic disease [ll-161. The occurrence of these events is expressed in “life change units” or L.C.U.‘s. These units *Requests for reprints should be sent to Dr. Marx at Associate Professor, Department of Community Medicine, University of Kentucky College of Medicine, Lexington, Kentucky 40506. TAssistant Professor, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, Kentucky 40506. JAssistant Professor, Department of Psychiatry, Director of Student Mental Health Service, University of Kentucky College of Medicine, Lexington, Kentucky 40506. 87
88
MARTIN B. MARX, THOMASF. GARRITYand FRANK R. BOWERS
are said to represent the amount of disruption in one’s life resulting from the occurrence of the particular event. Because the SRE considers several life events which are inappropriate for young adults. such as “son or daughter leaving home”. a College Schedule of Recent Exaerience (CSRE) was developed by Anderson 1171. Her questionnaire considers 47 life change events relevant for students. The selection of more relevant events for students, the ranking of the entire scale and the value of the L.C.U.‘s assigned to each event were obtained by concensus, after the fashion of Holmes and Rahe [18], utilizing the opinions of 284 college students at North Dakota State University, Fargo, North Dakota. The number of life change units assigned to each event ranges from 22 to 87. Anderson states [17], “The results of the Spearman rho coefficient of correlation show a very high agreement among all groups within the sample as to the amount of readjustment required for each of the 47 life change events. The highest degree of agreement was between the juniors and seniors, 0.970; and, the lowest correlation was between the freshmen and graduate students, 0.871.” Correlation between male and female students was 0.945. METHOD This study was designed to examine the association between scores obtained on Anderson’s instrument and subsequent health behavior among freshmen at the University of Kentucky. The following research hypothesis was posed for testing: Persons with high scores will have significantly more health problems than persons with low scores. Statistical significance has been assigned to differences of less than 5 per cent probability. For purposes of this study we have assumed that each of the 47 life change events constitutes a demand upon the body requiring adaptation [19], and that the magnitude of that demand is reliably quantified by the assigned L.C.U.‘s. The basic survey instrument consisted of 15 questions describing demographic and social characteristics and the 47 life change events of the CSRE (Appendix 1). It was administered on a voluntary basis to the members of all freshman English classes during the first week of school in September, 1972. The number of times each event occurred during the 12 months prior to the test date was recorded from “0” to “4 or more”. The L.C.U. value assigned to each event (Appendix 2) was multiplied by the number of times the event occurred to obtain a total life change value for each event. The values were then added to yield an overall change score for each individual. During the 1972.-1973 school year we obtained subjective information through personal interview and objective data by record review on the physical, emotional, social and academic well-being of nearly one-fifth (17 per cent) of the population completing the questionnaire. We first obtained the mean life change score for all completed questionnaires. We then classified as “high change” and “low change” those scores which fell more than one standard deviation above or below the mean and as “medium change”, those scores within one standard deviation of the mean. From each of the 3 categories a random sample of student’s names was drawn, without replacement, in November, February and May. These names were randomly assigned to 9 graduate students in Behavioral Science who had previously received special training to assure consistency in interview techniques. Neither the respondent nor the interviewer was aware of any individual’s life change score or category. Respondents were asked to report all health problems (Appendix 3) experienced during the previous 60 days. The interviewer then read, from a probe sheet, questions which facilitated the recall of recent health experience. From each respondent we obtained: (1) the number of different health problems, e.g. the number of health problems with different diagnostic labels in the previous 60 days; (2) the number of separate episodes of health problems with an episode defined as a continuous experience with a health problem beginning within the 60-day period; (3) the number of separate days upon which a health problem was experienced; (4) the number of days on which the respondent could not go about normal activities due to the health problem, i.e. disability; (5) whether or not the health problem was treated by a professional associated with the University and if so, when and by whom. When a respondent reported a time and place for professional treatment at the University this response was validated in June 1973 through the records at the University Student Health Service, the University Emergency Dental Service, the University Hospital Emergency Room and the University Student Counselling Service. In addition, a random sample of those students who reported “no health problem was professionally treated at the University” was drawn and that response was validated in a similar fashion. Since it was not possible to determine whether private non-University professional care was or was not obtained this question was not included in our interview schedule. In addition to problem-oriented information, the interviewers recorded responses to an index of current mental health, i.e. Langner’s 22 Item Psychiatric Impairment Scale [20, 211, which has a score range from O-22. Justification for inclusion of Langner’s scale in the interview schedule lay mainly in the belief that one’s current mental health is dependent upon life change events. Thus the
The influence of recent life experience on the health of college freshmen
89
average score for a life change group is considered here an outcome variable. A second reason for inclusion of the Langner Scale has to do with consideration of the score as an intervening variable between high life change and subsequent health behavior. In other words, we have examined whether or not the score on the Langner Scale is indicative of one’s capacity to cope with multiple life change events. Analysis of these data and discussion of the question shall be presented in a subsequent paper. The subjective health measures, called “reported stress”, were obtained in the areas of social, family and school life to provide additional evidence of mental health, morale, and happiness. In some sense these measures provide a type of validation for the Anderson Scale although the relationship between multiple life changes and perceived “stress” is not definitive. “Stress” perceived by the respondents in the three areas was quantified on a categorical scale ranging from 1 = “not stressful at all”, through 2 = “only slightly stressful” and 3 = “rather stressful” to 4 = “very stressful”. FINDINGS The target population for this study is the freshman class at the University of Kentucky who were residents on the Lexington campus during the fall semester of 1972. This consisted of 2,710 students who may be considered a time sample of convenience. The data describe 314 of these students who were interviewed regarding their physical and emotional health in the 60 days immediately preceding the interview. Based on the following considerations the interviewed sample is considered representative of the target population. Our questionnaire was administered during the freshman English classes held the first week of school, in September 1972. There were 2,224 students who received the questionnaire, e.g. 82 per cent of the freshman class. The 486 students not receiving the questionnaire had been excempted from the first semester of the college entrance examination (ACT) or excused for some other special reason. A careful examination of the characteristics of these 486 students showed that they did not differ from the 2,224 with regard to age, sex, ethnic group or marital status. All of the 2,224 questionnaires were returned but 384 were later disqualified from further analysis because of either incomplete or inconsistent answers. It was determined that these 384 students did not differ significantly from the 1,840 who satisfactorily completed the questionnaire with regard to sex, age, ethnic group, marital status or population of their hometown. An example of the comparability of the subpopulations to the target population is shown in Table 1 which describes the characteristic “ethnic group” as it was distributed in the target population and in each subpopulation. The 1,840 life change scores ranged from 42 to 3,890 with a mean of 891, a standard deviation of 544 and a median of 767. Our classification of these scores into high, medium and low categories as TABLE
I.-DISTRIBUTION OF 1972-1973 UNIVERSITY OF KENTUCKY FRESHMAN LEXINGTONCAMPUS,BYETHNICGROUPTOEACHSUBSAMPLE
Ethnic group
White
New enrollees on Lexington campus 1972 2601* (lOO)i (96.0)#
Not in freshEnglish classes 465 (17.9) (96.7)
Received Incomplete and or returned inconsistent questionnaire answers 2136 364 (82.1) (100) (17.0)s (96.0) (94.8)
Base sample 1772 (83.0) (96.3)
CLASS, RESIDENT ON
Drawn for interview Lost 405 (100) (96.4)
Interviewed
(zz.4) (93.4)
::!6) (975)
Black (1:) (3.3)
&) (3.9)
$9;
(1:) (0.7)
(&5) (0.4)
$5;
(100)
.
&5)$ (4.2)
$5) (3.0)
(1:) (2.9)
($3,1
(6i.7) (2.5)
(2Z.5)8
di.5) (0.7)
(12) (0.7)
(1;) (2.8)
;!.a
420 (100) (100)
106 (25.2) (100)
314 (74.8) (100)
.
Non-white
Totals
2710
486 (17.9) (100)
(100)
. 2224 (82.1) (100) (100)
* n. t Row per cent. $ Column per cent. 8 Per cent based on previous column to left.
(1.0) 384 (1’;;)”
1840 (82.7) (100)
.
90
MARTINB. MARX, THOMASF. GARRITYand FRANK R. BOWERS
previously described resulted in 15 per cent (276) of the population being classed as high, 75 per cent (1,380) as medium and 10 per cent (184) as low life change. The distribution of the 1,840 students according to each of the demographic characteristics was examined in relation to membership in each of the categories in order to determine if our statistical trichotomy had coincidentally distributed the population in a biased fashion. Statistical significance of any observed differences from the expected was estimated by the Chi Square statistic based on assumptions under the goodness of fit model. The expected distribution under this model was defined by those percentages of the total sample of 1,840 students classified as high (15 per cent), medium (75 per cent) and low (10 per cent). With the exception of ethnic group, the distribution among the 3 categories was not significantly different from the expected. A significantly greater proportion of non whites and blacks than expected appeared in the high life change category (x2 = 7.29, 2 df, p = < 0.05). Our interview sample contained 140 names drawn at random from each of the 3 categories representing 51 per cent (140/276) of the students with high life change scores, 10 per cent (140/1,380) of the students with medium scores and 78 per cent (140/184) of the students with low scores. Oversampling of the high and low categories was deliberate in order to assure large enough numbers for meaningful analysis in the comparison of the 2 extreme groups. Attrition from this sample of 420 individuals amounted to 106 persons. A greater proportion was lost to interview from the low and high life change categories than from the medium category. The final sample actually interviewed from the high life change category constituted 70 per cent (98/140), 79 per cent (111/140) of the medium sample chosen and 75 per cent (105/140) of the low group chosen. A careful follow-up was conducted on those lost to interview. This showed that they did not differ signiticantly from those interviewed with regard to age, sex, marital status or population of their hometown. However a signXcantly greater proportion of non-whites and blacks was lost to interview than expected, x2 = 924,2 &, p = < 0.01. Since our low and medium change categories contained fewer non-whites and blacks than expected under the goodness of fit model and because a greater than expected number of non-whites and blacks were lost to interview from our randomly drawn sample, our interviewed sample contained no non-whites and only 8 blacks, 7 in the high change category and 1 in the medium category. Because of the small number of blacks in the final sample it is inappropriate to discuss potential ethnic group differences with regard to our dependent measures of health outcome, The association between life change category and the magnitude of the mean value for each of the physical and emotional measures of health was examined by the l-way analysis of variance. The mean value for each of the health outcome variables was determined by dividing the total number of events, e.g. different health problems, separate health problem episodes, days of illness, days of disability and total scores on the Langner scale, by the total number of persons represented in the life change category. There was a significant difference in the means of the physical and emotional health outcome variables such that the high category had the highest mean, the medium the next highest mean and the low life change category the lowest mean value, Table 2. In order to determine if the relationship was dependent upon the presence of the 7 blacks in the high life change category further analysis was conducted with the 7 blacks in the high category and the 1 in the medium category eliminated. The nature of the relationship and the statistical significance of the difference in the means were maintained as illustrated on lines labelled (B) in Table 2.
TABLE 2.--&sOcIA~ON BETWEEN CATEGORY OF LIFE CHANGE AND HEALTH OUTCOME VARIABLES FOR INTERVIEWED SAMPLE.(A)ENTIRE SAMPLEAND(B)SAMPLEWITH 8 BLACKSEXCLUDED
Health outcome and range Mean no. different health problems (O-13) Mean no. health problem episodes (O-110) Mean no. days health problem experienced (O-254)* Mean no. disability days (O-60) Mean Langner score (O-22)
(A) (Bj
(A) (B) (A) (B) (A) (B) (A) (B)
Life change category Low Medium High 2.23 (105) 2.88 (111) 3.62 (98) 2.23 (105) 2.87 (110) 3.59 (91) 4.85 (105) 8.81 (111) 12.54 (98) 4.85 (105) 8.81 (110) 12.57 (91) 20.98 (105) 30.36 (111) 47.83 (98) 20.98 (105) 30.28 (110) 47.17 (91) 1.98 (105) 2.14 (111) 6.21 (98) 1.98 (105) 2.14 (110) 6.34 (91) 2.72 (105) 344 (111) 5.27 (98) 7.72 (105) 344 (110) 5.28 (91)
F
Ratio 15.21 14.38 7.56 7.72 14.30 13.32 8.17 8.31 26.69 27.05
Prob. 0~001 O+IOl 0.001 0.001 0~001 O+t)l 0.001 0.001 0.001 0~001
*While the maximum number of separate days-at-risk of a problem is 60, if more than one problem existed on any one day, for example a broken arm and a cold, the day was counted twice.
The influence of recent life experience on the health of college freshmen
91
The mean values for each of the more subjective measures of health, i.e. “reported relation to social life, family life and school work, were calculated in a similar fashion and for the 3 life change categories by the l-way analysis of variance. A statistically significant was found between the means in the 3 categories for “reported stress” associated with and school work, Table 3.
stress” in compared difference family life
STRESS”
VARIABLES
TABLE %-~ssoc~~~~o~
BETWEEN
CATEGORY
OF LIFE CHANGE
AND TWO“REPORTED
Life change category Medium (111) Low (105) 1.36 149
“Reported stress” and range Mean reported in family life (l-4) Mean reported with school work (l-4)
2.34
2.33
F
High (98)
Prob.
1.78
Ratio 7.06
0.001
2.61
4.52
0.01
We next considered the relationship between each of the demographic variables and our health outcome variables. The variables concerned with population of hometown and marital status plus the variable “social class” obtained on the interviewed sample using the Hollingshead 2 factor index of social position 1221,showed no association with any of the health outcome variables and no clear pattern was discernible. A single statistically significant association was demonstrated between age and one of the more subjective health variables. Freshman students over 30 yr of age reported a significantly greater amount of stress associated with school work than those students under 30 yr of age, F = 2.37, p = < 0.05. When a comparison was made between males and females only one category of health outcome, i.e. average number of illness days, showed a significant difference with females having the greater mean number. When this association was examined by life change category a similar relationship existed at each level although the significance of the difference was lost, perhaps as a function of the smaller numbers upon which the means were based. There was, however, an increasingly higher mean for both males and females from low to high life change category and the magnitude of the differences in the means increased in a like manner, Table 4. TABLE
&+~~SOCIATION BETWEEN CATEGORY OF LIFE CHANGE MEANNUMBEROFILLNESSDAYSINMALESANDFEMALES
Life change category All (314) High (98) Medium (111) Low (105) *Fratio
= 5.02; Fprob.
AND
Mean number of illness days A Males Females 27.80 37.25 9.45* 40.96 55.14 14.18 24.60 34.22 9.62 19.10 23.39 4.29 = 0.02.
A comparison of the overall severity of illness was made between the 3 life change categories on the basis of 2 measures of severity defined as: (a) the average duration (in days) of an illness episode, i.e. the total number of days of illness for an entire group divided by the total number of illness episodes for that life change group, (b) the average duration of a disabling illness episode, i.e. the total number of days lost from normal activity for an entire group divided by the total number of illness episodes for that life change group. The average duration of an illness episode was found to be 4 days for both the high and low life change groups. The average duration of a disabling episode was 0.3 day for both the high and low life change groups. The total number of health problems reported by the interviewed sample was examined to determine the overall percentage of those problems which was dealt with by a professional from one of the University facilities. This overall utilization rate was then taken as the “expected” and the comparable rate of utilization was examined for each life change category in order to determine if there had been differential utilization. There were 909 health problems reported by the 314 students. Ten per cent of these problems were dealt with by a professional associated with one of the University health facilities. There was not a significant difference in the utilization for persons in the 3 life change categories although the number of health problems per person increased from the life change category labelled low to the high life change category, Table 5.
MARTINB. MARX, THOMASF. GARRITYand FRANK F. BOWERS
92
TABLE 5.-UTILIZATION OF UNIVERSITYASSOCIATEDPROFESSIONAL SERVICES PROBLEMS
Life change category and number All (314) High (98) Medium (111) Low (105)
BY LIFE CHANGE
FOR
HEALTH
RELATED
CATEGORY
Number of health problems Total Per person 2.9 909 3.6 356 2.9 319 2.2 234
Number treated percentage by university 91 10 32 9 38 12 21 9
Finally, we questioned whether the nature of the associations found between life change category and our health outcome variables was influenced by seasonal variation in disease incidence. It is recognized that the reported incidence of many infectious and allergic conditions shows seasonal variation. Our samples, drawn in November, February and May, reflect the occurrence of ill health during three separate 60-day periods, i.e., mid-September to mid-November, mid-December to mid-February and early March to early May. It is conceivable that the magnitude of the differences between mean values for the 3 life change categories might be altered if an increase in incidence were reflected mainly among persons with high life change, perhaps due to increased susceptibility [23]. In such a situation the magnitude of differences between the mean values at each level of life change for the various dependent measures would become greater during a peak incidence period. Such a peak period cannot be identified by the occurrence of a greater difference in our observed means but rather must be defined by an external reporting system unrelated to our data. Further, one must ascertain that any disease showing an increased incidence in the University undergraduate population is, in fact, the same disease responsible for a reported increased incidence in the high life change group. We were unable to detect any external evidence of a peak period for any disease during the 1972-1973 school year in the University community. When the data were examined for each interview period according to life change category the nature of previously described relationships between mean values remained for each of our main health outcome variables and the differences between mean values for the high versus the low life change categories appear relatively constant, Table 6.
Health outcome variable
Mean no. of different health problems Mean no. of health problem episodes Mean no. of days health problem experienced Mean no. of disability days Mean Langner score
Life change
category 0’)
High (98) Medium (111) LOW (losj High Medium Low High Medium Low High Medium Low High Medium Low
Interview period
Sept.-Nov. (N = 103) 3.54 3.11 2.46 12.31 6.50 6.12 50 82 36.97 23.34 4.60 2.05 3.34 5.26 4.03 2.72
Dec.-Feb. Mar.-May (N = 83) (N = 128) AHvsL* AHvsL AHvsL (35) 3.76 (26) 3.59 (37) (36) 1.08 3.23 (30) 1.47 2.47 (35) 1.57 (32) 2.29 (27) 2.02 (46) 12.80 11.46 6.19 15.70 8.43 6.20 7.22 4.37 4.24 47.76 44.30 25.48 34.50 26.39 22.67 26.58 21.37 17.72 4.76 8.89 1.26 2.00 3.65 2.33 7.35 1.11 1.54 4.64 5.70 5.43 3.37 1.97 3.04 2.94 2.67 2.76
*Difference between mean value for high and mean value for low life change. DISCUSSION
AND SUMMARY
This study has concentrated on examining the relationship between life change and subsequent illness experience in a population of college freshmen. The character of adaptive or adjustment mechanisms brought into play by the occurrence of a major
The influenceof recent life experience on the health of collegefreshmen
93
life change event has not been labelled. Furthermore, no attempt is made to explain what physiologic changes result from such adaptive efforts nor why or how such life ‘changes may influence health behavior. A statistically significant association between high levels of life change, as determined by the College schedule of recent experience, and increased illness measured by 5 health outcome variables is described by the data. The 5 measures considered as dependent variables in this study are: (1) the average number of different health problems during a prior 60-day period, (2) the average number of health problem episodes during the 60-day period, (3) the average number of days on which a health problem was experienced in the 60-day period prior to the interview, (4) the average number of disability days in the prior 60-day period and (5) the average score for the group on the Langner 22 item psychiatric impairment scale. The data were collected in a “blind” fashion by trained interviewers from a representative and random sample of freshman students. Every effort has been made to determine if selective attrition occurred at any point. With the exception of ethnic group, subpopulation distributions based on our selected demographic variables have remained within expected proportions. Because the proportions of non-whites and blacks in our final interview sample were different from expected based on the proportions found in the freshman class, i.e. no non-whites and only 8 blacks in the final sample with 7 blacks in the high life change category and 1 in the medium category, we have presented our analyses concerning the 5 dependent variables with the blacks included in the sample and excluded from the sample. The nature of the relationship between life change category and our dependent measures of health outcome was unchanged by the exclusion. In order to determine if the relationships described could be explained by high life change individuals complaining more or remembering more of their health problems than the low life change individuals we calculated two measures of severity of illness and found that the two extreme groups did not differ in either the average duration of illness episodes or the average duration of disabling illness episodes. In addition none of the 3 life change groups differed significantly from the expected utilization rate of University health service facilities, Table 5. The positive association between magnitude of life change and “reported stress” was not unexpected. Such associations, though not definitive validation of the Anderson Scale, are at least consistent with the notion that individuals undergoing multiple life changes perceive greater stress than those with fewer life change episodes. The relationship between age (over 30 yr) and “reported stress” relating to school work is consistent with the impression and experience of many professional counsellors
[241. An alternative explanation for the findings, i.e. the differential distribution of a potentially relevant demographic characteristic among the life change categories, has been examined and found unsupported as an explanation. The prospective design of the study permits characterization of the associations described as “potentially causal”. Our conclusions are that the link between major life change and illness which has been well documented in adults is equally evident in our college population. Further, the utility of Anderson’s instrument as an index of those life change events relevant to illness is clearly demonstrated. The use of this
94
MARTINB. MARX, THOMASF. GA~RITYand FRANK R. BOWERS
instrument in the identification of that segment of an entering college class which is at greatest risk of illness is suggested by these findings. REFERENCES 1. THOMPSONJ. R., BENTZW. K. and LIPTZIN M. B. The prevalence of psychiatric disorder in an undergraduate population. J. Am. Coil. Hlth. Ass. 13, 532 (1964). 2. FARNSWORTHD. L. (Ed.) College Health Administra&on. Appleton-Century-Crofts, New York (1964). 3. MACMILLINA. M. The Health Opinion Survey: Technique for estimating prevalence of psychoneurotic and related types of disorder in communities. Psychol. Res. 2, 325 (1957). 4. LANCERT. S. and MICHAELS. T. Life Stress and Mental Health. The Free Press, Glencoe, Ill. (1963). 5. LEVI L. (Ed.) Society, Stress and Disease, Vol. 1, The Psychosocial Environment and Psychosomatic Disease. Oxford University Press, London (1971). 6. WOLFF H. C., WOLFF S. and HARE C. C. (Eds.) Life Stress and Bodily Disease. Res. Publ. Ass. _ Res. Nerv. Ment. Dis. 29, Williams & Wilkins,.Baliimore (1950). 7. HOLMEST. H. and RAHE R. H. The social readiustment rating scale. J. Psvchosom. Res. 11. 213 (1967). 8. MASUDA M. and HOLMEST. H. Magnitude
estimations of social readjustments. J. Psychosom. Res. 11,219 (1967). 9. MASUDA M. and HOLMEST. H. The social readjustment rating scale: a cross cultural study of Japanese and Americans. J. Psychosom. Res. 11, 227 (1967). 10. WYLER A. R., MASUDA M. and HOLMEST. H. The seriousness of illness rating scale: reproducibility. J. Psychosom. Res. 14, 59 (1970). 11. RAHE R. H., MEYERM., SMITHM., KJAER G. and HOLMEST. H. Social stress and illness onset. J. Psychosom. Res. 8, 35 (1964). 12. RAHE R. H., MAHAN J. L. and ARTHUR R. J. Prediction of near-future health change from subject’s preceding life changes. J. Psychosom. Res. 14,401 (1970). 13. RAHE R. H. Life change measurement as a predictor of illness. Proc. R. Sot. Med. 61., 1124. 44 (1968). 14. RUBIN R. T., GUNDERSONE. K. E. and ARTHUR R. J. Life stress and illness pattern in the U.S. navy-V. Prior life change and illness onset in a battleshio crew. J. Psvchosom. Res. 15.89 (19711. 15. P&H W. M., GUNDERS~NE. K., ERICKSONJ., RAHE R. h. and RUB& R. T. Variations of‘illnegs incidence in the navy population. Milit. Med. 224, (June 1972). 16. BRAMWELLS. T., WAGNERN. M., MASUDAM. and HOLMEST. H. Prediction of illness in college athletes. In preparation. 17. ANDERSONG. E. College Schedule of Recent Experience. Masters Thesis, North Dakota State University, unpublished (1972). Illness Reports. Review 18. RAHE R. H. Subjects’ Recent Life Changes and Their Near-Future Article Ann. Clin. Res. 4, 250 (1972). 19. SELYEH. The evolution of the stress concept. Am. Sci. 61, 692 (1973). 20. LANGNERT. S. A twenty-two item screening score of psychiatric symptoms indicating impairment. J. Hlrh. Sot. Behav. 3,269 (1962). 21. SHADERR. I., EBERTM. H. and HARMATSJ. S. Langner’s psychiatric impairment scale: A short _ screening device. Am. J. Psychiut. 128, 596 (1971). _ 22. HOLLINGSHEAD A. B. Two factor index of social uosition. Printed nrivatelv. New Haven. Conn. (1957). 23. RAHE R. H., GUNDERSONE. K. and ARTHUR R. J. Demographic
and psychological factors in acute illness reporting. J. Chron. Dis. 23, 245 (1970). 24. ROSE H. A., Director, Student Characteristics Unit, University Counselling and Testing Center. University of Kentucky, Lexington, Kentucky, personal communication (1974). APPENDIX 1 COLLEGE SCHEDULE OF RECENT EXPERIENCE (modified)* There is mounting evidence to suggest that one’s life experiences correlate with health and illness patterns. To further examine the correlation this questionnaire is being offered to all freshmen on a voluntary basis. We hope you will complete the instructions and at least the first 15 questions. *M. B. Marx/F. R. Bowers (UKMC-1972) U-1972) CSRE.
modification
of G. Anderson/R.
Dubord (N.D. State
The influence of recent life experience
on the health of college freshmen
95
We earnestly solicit your responses to questions 16 through 62. All information will be treated with the strict confidentiality afforded all medical records. The entire study should be completed in approximately 2 years and the results will be made known at that time. The answer sheet for this questionnaire is marked off in sections. Section I provides space for answering questions 1 through 40. Section II provides space for answering questions 41 through 62. Read each item and the choice of answers carefully, judge the answer as it applies to you and mark it on the answer sheet. After you have finished look over the answer sheet and make sure that all questions have been answered. Mark your answers black and heavy and use PENCIL ONLY. Make corrections if necessary, but erase clearly. Do not mark in the booklet. Place the answer sheet inside the booklet and turn it in when completed. UNIVERSITY
OF
COLLEGE DEPARTMENT
OF
OF
KENTUCKY MEDICINE
COMMUNITY
MEDICINE
AND STUDENT
HEALTH
LEXINGTON,
SERVICE
KENTUCKY
INSTRUCTIONS Please turn the answer sheet sideways and print your name in the empty boxes provided on the right-hand side of the page. Blacken the appropriate lettered box in the column below each letter of your name. If the number of spaces for your first name is insufficient, use only your first initial. Mark the appropriate box for the current semester. Mark the aoorooriate grade in the column provided. F = freshman; S = sophomore; 3 = junior; 4 = senior and 5 = graduate student. _ Mark the aoorooriate boxes in the columns titled Birth date for month and for year. Mark the appropriate box in the column titled Sex. B = male; G = female. Fill your student number in the empty boxes and then black in the proper number in each CO~XXI under the student number. Now turn the paper longways and begin marking your answers to the questions. You may wish to use a sheet of blank paper to guide your answers so that you are sure the marks are in the proper blanks. SECTION I Mark the appropriate letter for: (1) your marital status. (A) married (B) divorced (C) separated (D) widowed (E) single (2) your ethinic group. (A) White (B) Black (C) Oriental (D) Am. Indian (E) Other (3) the years you have lived at your present Home address. (A) 1 year or less (B) more than 1 year and less than 5 years (C) more than 5 years and less than 10 years (D) 10 years or + (4) the number of times you have moved in the last 5 years. If you moved to Lexington to attend college, count that as 1 move. (A) 0 (B) 1 (C) 2 (D) 3 (E) 4 or more times (5) the population of your place of birth at the time of your birth. (A) rural or farm (B) 5OOO-- (C) 5000+ (D) 50,000+ (E) 5OO,~i(6) where most of your life has been spent. (A) rural or farm (B) 5000- (C) 5000+ (D) 50,000+ (E) 500,000+ (7) your number of brothers. (A) 0 (B) 1 (C) 2 (D) 3 (E) 4 or more (8) your number of sisters. (A) 0 (B) 1 (C) 2 (D) 3 (E) 4 or more (9) your birth order in the family. (A) oldest (B) youngest (C) middle (D) only child (10) if you have seen someone to aid you with mental health in the last 3 months. (A) yes (B) no
96
MARTINB. MARX, THOMAS F. GARRIT~ and FRANK R. BOWERS (11) if you have seen someone to aid you with physical health in the last 3 months. (A) yes CB) no (12) your age when mother died. (A) mother living (B) &5 years (C) 6-10 years (D) 11-15 years (E) 16+ years (13) your age when father died. (A) father living (B) O-5 years (C) 610 years (D) 11-15 years (E) 161. years (14) your age when mother and father were divorced or separated. (A) parents not divorced or separated (B) O-5 years (C) 6-10 years (D) 11-15 years (E) 16+ years (15) your age when either of your parents remarried. (A) neither parent remarried (B) O-5 years (C) 610 years (D) 11-15 years (E) 16+ years
Each of the following questions may be answered by one of these letters: (A) 0 (B) 1 (C) 2 (D) 3 (E) 4 or higher Mark the appropriate letter that corresponds to the Number of times during the Iast year (12 months period) that you: entered. college. married. had either a lot more or a lot less trouble with your boss. held a job while attending school. experienced the death of a spouse. experienced a major change in sleeping habits (sleeping a lot more or a lot less, or a change in part of the day when asleep). experienced the death of a close family member. experienced a major change in eating habits (a lot more or a lot less food intake, or very different meal hours or surroundings). (24) made a change in or choice of a major field of study. (25) had a revision of your personal habits (friends, dress, manners, associations). (26) experienced the death of a close friend. (27) have been found guilty of minor violations of the law (tratlic tickets, jay walking, etc.). (28) have had an outstanding personal achievement. (29) experienced pregnancy, or fathered a pregnancy. (30) had a major change in the health or behavior of a family member. (31) had sexual difficulties. (32) had trouble with in-laws. had a major change in the number of family get-togethers (a lot more or a lot less). g:; had a major change in financial state (a lot worse off or a lot better off than usual). (35) gained a new family member (through birth, adoption, older person moving in, etc.). (36) changed your residence or living conditions. (37) had a major conflict in or change in values. (35) had a major change in church activities (a lot more or a lot less than usual). had a marital reconciliation with your mate. were fired from work. g; Now move to Section II of the Answer Sheet. (41) were divorced. (42) changed to a different line of work. (43) had a major change in the number of arguments with spouse (either a lot more or a lot less than usual). (44) had a major change in responsibilities at work (promotion, demotion, lateral transfer). (45) had your spouse begin or cease work outside the home. (46) had a major change in working hours or conditions. (47) had a marital separation from your mate. (48) had a maior change in usual type and/or amount of recreation. (49) had a major change in the use of drugs (a lot more or a lot less). (50) took a mortaae or loan less than $10,000 (such as purchase of a car, TV, school loan, etc.). (51) had a major personal injury or illness. (52) had a major change in the use of alcohol (a lot more or a lot less). (53) had a major change in social activities. (54) had a major change in the amount of participation in school activities. (55) . , had a maior change in the amount of independence and responsibility (for example: for budgeting-time). (56) took a trip or a vacation. (57) were engaged to be married.
The influence of recent life experience on the health of college freshmen
97
The number of times during the lust year that you: Code: (A) 0 (B) 1 (C) 2 (D) 3 (E) 4 or higher. (58) changed to a new school. (59) changed dating habits. (60) had trouble with school administration (instructors, advisors, class scheduling, etc.). (61) broke or had broken a marital engagement or a steady relationship. (62) had a major change in self-concept or self-awareness. APPENDIX
2
L.C.U. SCORES FOR EACH OF LIFE CHANGE
EVENTS ON CSRE 50 17 38 43 87 34 77 30 41 45 68 22 40 68 56 58 42 26 53 50 42 50 36 58 62 76 50 50 47 41 42 74 37 52 52 65 46 43 38 49 33 54 50 41 44 60 57
(1) Entered college (2) Married (3) Trouble with your boss (4 Held a job while attending school (5) Experienced the death of a spouse Major change in sleeping habits Experienced the death of a close family member (8) Major change in eating habits (9) Change in or choice of major field of study (IO) Revision of personal habits (II) Exoerienced the death of a close friend (12) Found guilty of minor violations of the law (13) Had an outstanding persona1 achievement *(l4) Experienced pregnancy, or fathered a pregnancy (15) Major change in health or behavior of family member (16) Had sexual difficulties (17) Had trouble with in-laws (18) Major change in number of family get-togethers (19) Major change in financial state (20) Gained a new family member (21) Change in residence or living conditions (22) Major conflict or change in values Major change in church activities ii:; Marital reconciliation with your mate (25) Fired from work Were divorced :;; Changed to a different line of work Major change in number of arguments with spouse I;; Major change in responsibilities at work Had your spouse begin or cease work outside the home ‘::Y; Major change in working hours or conditions (32) Marital separation from mate Major change in type and/or amount of recreation :z; Major change in use of drugs (35) Took on a mortage or loan of less than $10,000 (36) Major persona1 injury or illness Major change in use of alcohol ;::; Major change in social activities $(39) Major change in amount of participation in school activities (40) Major change in amount of independence and responsibility (41) Took a trip or a vacation (42) Engaged to be married (43) Changed to a new school (44) Changed dating habits (45) Trouble with school administration §(46) Broke or had broken a marital engagement or a steady relationship (47) Major change in self-concept or self-awareness
I;;
*Underlined phrase added; iWife changed lined phrase added.
to spouse; JCo-curricula
changed
to school;
OUnder-
98
MARTINB. MARX, THOMASF. GARRITYand FRANK R. BOWERS APPENDIX
3
PROBES ON NEW HEALTH
PROBLEMS
(1) Injuries and accidents (with or without subsequent infection) sustained from any cause: vehicular, athletic, occupational, and other. For example: Skin cuts, bruises, punctures; Muscle strains, pulls, including back; Bone or joint sprain, breaks; Face or Mouth-tooth break, nose break, black eye, etc. (2) Infection (bacteria1 or viral) of any system except respiratory andgastrointestinal. For example: Skin infections, poison ivy, warts, boils, rash, acne flair-ups; Blood infections, mononucleosis; Organ infections, e.g. liver-hepatitis; Genito-urinary, venereal disease, urinary tract infection. (3) Respiratory infection. For example: infections of ear, nose, throat, or lungs; coughs, colds, sinus, middle ear infections; bronchitis, sore throat, laryngitis, pneumonia, asthma flair-up, hay fever flair-up; running nose, pleurisy. (4) Gastro-intestinal infection. For example: vomiting, nausea, diarrhea; change in bowel habits; other pains in gastro-intestinal area. (5) Neurological and emotional. For example: seizures or fits, depression or apathy, anxiety or nervousness, insomnia, loss of appetite, headaches or migraine, difficulty concentrating, irritable, speech or memory problems. (6) Other and problems not classifiable above. For example: change in menstrual flow, sudden weight change, anemia, flair-up of any existing (chronic) condition (e.g., diabetic flair-up) problems of sexual functioning; change in blood pressure, heart problem, blood vessel problems; swelling ankles; eye problems.
THE INFLUENCE OF RECENT LIFE EXPERIENCE ON THE HEALTH OF COLLEGE FRESHMEN MARTIN B. MARX,* THOMAS F. GARRITY~ and FRANK R. BOWERS$ (Received
29 July 1974)
INTRODUCTION DISEASE patterns among college students are commonly described by data which delineate the frequency of occurrence of physical and mental illness. Such data, usually categorized by diagnostic label, are obtained from interviews of students or from the records of a University’s Health Service [l-4]. When based on surveys, studies of the prevalence of disease among students may reveal interesting associations between reported illness and demographic or social characteristics of interest; and prevalence data obtained from health records may provide useful information for therapeutic or administrative purposes. However, the demographic or social characteristic of interest may be unrelated to the etiology of the illness and the limitations imposed by the selective recall of illnesses, selective attrition from a target population and selective entry into a health care system further restrict the value of all prevalence data for suggesting useful preventive measures. Preventive programs are logically directed toward populations which are at high risk of ill-health. Such populations are identifiable by documenting the differential occurrence of new events of illness during some time period, i.e., incidence. Among college students, effective intervention as a preventive measure may be directed most effectively toward a population showing an increased incidence of ill-health during their first year of college. Preventive programs would be aimed at altering factors found causally associated with an increased incidence. Since the mechanisms for continuous monitoring of students’ physical and mental health as well as their social and intellectual behavior already exist in most academic environments, evaluation of preventive programs is not difficult to conceptualize. Thus college campuses appear to be natural laboratories in which to develop incidence rates and identify potentially causal factors. Based on such data preventive programs may be developed and evaluated. BACKGROUND A factor of causal relevance in many disease processes is the stressful episode or life change event, i.e., an event, whether or not socially desirable, which requires some degree of adaptation by the person involved. It has been documented that an association exists between illness episodes and the frequency, pattern and magnitude of such life change events occurring in the recent past of affected persons [5,6]. The Schedule of Recent Experience (SRE) of Holmes and Rahe [7-101 has frequently served as the index of 43 selected events in studies assessing their association with somatic disease [ll-161. The occurrence of these events is expressed in “life change units” or L.C.U.‘s. These units *Requests for reprints should be sent to Dr. Marx at Associate Professor, Department of Community Medicine, University of Kentucky College of Medicine, Lexington, Kentucky 40506. TAssistant Professor, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, Kentucky 40506. JAssistant Professor, Department of Psychiatry, Director of Student Mental Health Service, University of Kentucky College of Medicine, Lexington, Kentucky 40506. 87
88
MARTIN B. MARX, THOMASF. GARRITYand FRANK R. BOWERS
are said to represent the amount of disruption in one’s life resulting from the occurrence of the particular event. Because the SRE considers several life events which are inappropriate for young adults. such as “son or daughter leaving home”. a College Schedule of Recent Exaerience (CSRE) was developed by Anderson 1171. Her questionnaire considers 47 life change events relevant for students. The selection of more relevant events for students, the ranking of the entire scale and the value of the L.C.U.‘s assigned to each event were obtained by concensus, after the fashion of Holmes and Rahe [18], utilizing the opinions of 284 college students at North Dakota State University, Fargo, North Dakota. The number of life change units assigned to each event ranges from 22 to 87. Anderson states [17], “The results of the Spearman rho coefficient of correlation show a very high agreement among all groups within the sample as to the amount of readjustment required for each of the 47 life change events. The highest degree of agreement was between the juniors and seniors, 0.970; and, the lowest correlation was between the freshmen and graduate students, 0.871.” Correlation between male and female students was 0.945. METHOD This study was designed to examine the association between scores obtained on Anderson’s instrument and subsequent health behavior among freshmen at the University of Kentucky. The following research hypothesis was posed for testing: Persons with high scores will have significantly more health problems than persons with low scores. Statistical significance has been assigned to differences of less than 5 per cent probability. For purposes of this study we have assumed that each of the 47 life change events constitutes a demand upon the body requiring adaptation [19], and that the magnitude of that demand is reliably quantified by the assigned L.C.U.‘s. The basic survey instrument consisted of 15 questions describing demographic and social characteristics and the 47 life change events of the CSRE (Appendix 1). It was administered on a voluntary basis to the members of all freshman English classes during the first week of school in September, 1972. The number of times each event occurred during the 12 months prior to the test date was recorded from “0” to “4 or more”. The L.C.U. value assigned to each event (Appendix 2) was multiplied by the number of times the event occurred to obtain a total life change value for each event. The values were then added to yield an overall change score for each individual. During the 1972.-1973 school year we obtained subjective information through personal interview and objective data by record review on the physical, emotional, social and academic well-being of nearly one-fifth (17 per cent) of the population completing the questionnaire. We first obtained the mean life change score for all completed questionnaires. We then classified as “high change” and “low change” those scores which fell more than one standard deviation above or below the mean and as “medium change”, those scores within one standard deviation of the mean. From each of the 3 categories a random sample of student’s names was drawn, without replacement, in November, February and May. These names were randomly assigned to 9 graduate students in Behavioral Science who had previously received special training to assure consistency in interview techniques. Neither the respondent nor the interviewer was aware of any individual’s life change score or category. Respondents were asked to report all health problems (Appendix 3) experienced during the previous 60 days. The interviewer then read, from a probe sheet, questions which facilitated the recall of recent health experience. From each respondent we obtained: (1) the number of different health problems, e.g. the number of health problems with different diagnostic labels in the previous 60 days; (2) the number of separate episodes of health problems with an episode defined as a continuous experience with a health problem beginning within the 60-day period; (3) the number of separate days upon which a health problem was experienced; (4) the number of days on which the respondent could not go about normal activities due to the health problem, i.e. disability; (5) whether or not the health problem was treated by a professional associated with the University and if so, when and by whom. When a respondent reported a time and place for professional treatment at the University this response was validated in June 1973 through the records at the University Student Health Service, the University Emergency Dental Service, the University Hospital Emergency Room and the University Student Counselling Service. In addition, a random sample of those students who reported “no health problem was professionally treated at the University” was drawn and that response was validated in a similar fashion. Since it was not possible to determine whether private non-University professional care was or was not obtained this question was not included in our interview schedule. In addition to problem-oriented information, the interviewers recorded responses to an index of current mental health, i.e. Langner’s 22 Item Psychiatric Impairment Scale [20, 211, which has a score range from O-22. Justification for inclusion of Langner’s scale in the interview schedule lay mainly in the belief that one’s current mental health is dependent upon life change events. Thus the
The influence of recent life experience on the health of college freshmen
89
average score for a life change group is considered here an outcome variable. A second reason for inclusion of the Langner Scale has to do with consideration of the score as an intervening variable between high life change and subsequent health behavior. In other words, we have examined whether or not the score on the Langner Scale is indicative of one’s capacity to cope with multiple life change events. Analysis of these data and discussion of the question shall be presented in a subsequent paper. The subjective health measures, called “reported stress”, were obtained in the areas of social, family and school life to provide additional evidence of mental health, morale, and happiness. In some sense these measures provide a type of validation for the Anderson Scale although the relationship between multiple life changes and perceived “stress” is not definitive. “Stress” perceived by the respondents in the three areas was quantified on a categorical scale ranging from 1 = “not stressful at all”, through 2 = “only slightly stressful” and 3 = “rather stressful” to 4 = “very stressful”. FINDINGS The target population for this study is the freshman class at the University of Kentucky who were residents on the Lexington campus during the fall semester of 1972. This consisted of 2,710 students who may be considered a time sample of convenience. The data describe 314 of these students who were interviewed regarding their physical and emotional health in the 60 days immediately preceding the interview. Based on the following considerations the interviewed sample is considered representative of the target population. Our questionnaire was administered during the freshman English classes held the first week of school, in September 1972. There were 2,224 students who received the questionnaire, e.g. 82 per cent of the freshman class. The 486 students not receiving the questionnaire had been excempted from the first semester of the college entrance examination (ACT) or excused for some other special reason. A careful examination of the characteristics of these 486 students showed that they did not differ from the 2,224 with regard to age, sex, ethnic group or marital status. All of the 2,224 questionnaires were returned but 384 were later disqualified from further analysis because of either incomplete or inconsistent answers. It was determined that these 384 students did not differ significantly from the 1,840 who satisfactorily completed the questionnaire with regard to sex, age, ethnic group, marital status or population of their hometown. An example of the comparability of the subpopulations to the target population is shown in Table 1 which describes the characteristic “ethnic group” as it was distributed in the target population and in each subpopulation. The 1,840 life change scores ranged from 42 to 3,890 with a mean of 891, a standard deviation of 544 and a median of 767. Our classification of these scores into high, medium and low categories as TABLE
I.-DISTRIBUTION OF 1972-1973 UNIVERSITY OF KENTUCKY FRESHMAN LEXINGTONCAMPUS,BYETHNICGROUPTOEACHSUBSAMPLE
Ethnic group
White
New enrollees on Lexington campus 1972 2601* (lOO)i (96.0)#
Not in freshEnglish classes 465 (17.9) (96.7)
Received Incomplete and or returned inconsistent questionnaire answers 2136 364 (82.1) (100) (17.0)s (96.0) (94.8)
Base sample 1772 (83.0) (96.3)
CLASS, RESIDENT ON
Drawn for interview Lost 405 (100) (96.4)
Interviewed
(zz.4) (93.4)
::!6) (975)
Black (1:) (3.3)
&) (3.9)
$9;
(1:) (0.7)
(&5) (0.4)
$5;
(100)
.
&5)$ (4.2)
$5) (3.0)
(1:) (2.9)
($3,1
(6i.7) (2.5)
(2Z.5)8
di.5) (0.7)
(12) (0.7)
(1;) (2.8)
;!.a
420 (100) (100)
106 (25.2) (100)
314 (74.8) (100)
.
Non-white
Totals
2710
486 (17.9) (100)
(100)
. 2224 (82.1) (100) (100)
* n. t Row per cent. $ Column per cent. 8 Per cent based on previous column to left.
(1.0) 384 (1’;;)”
1840 (82.7) (100)
.
90
MARTINB. MARX, THOMASF. GARRITYand FRANK R. BOWERS
previously described resulted in 15 per cent (276) of the population being classed as high, 75 per cent (1,380) as medium and 10 per cent (184) as low life change. The distribution of the 1,840 students according to each of the demographic characteristics was examined in relation to membership in each of the categories in order to determine if our statistical trichotomy had coincidentally distributed the population in a biased fashion. Statistical significance of any observed differences from the expected was estimated by the Chi Square statistic based on assumptions under the goodness of fit model. The expected distribution under this model was defined by those percentages of the total sample of 1,840 students classified as high (15 per cent), medium (75 per cent) and low (10 per cent). With the exception of ethnic group, the distribution among the 3 categories was not significantly different from the expected. A significantly greater proportion of non whites and blacks than expected appeared in the high life change category (x2 = 7.29, 2 df, p = < 0.05). Our interview sample contained 140 names drawn at random from each of the 3 categories representing 51 per cent (140/276) of the students with high life change scores, 10 per cent (140/1,380) of the students with medium scores and 78 per cent (140/184) of the students with low scores. Oversampling of the high and low categories was deliberate in order to assure large enough numbers for meaningful analysis in the comparison of the 2 extreme groups. Attrition from this sample of 420 individuals amounted to 106 persons. A greater proportion was lost to interview from the low and high life change categories than from the medium category. The final sample actually interviewed from the high life change category constituted 70 per cent (98/140), 79 per cent (111/140) of the medium sample chosen and 75 per cent (105/140) of the low group chosen. A careful follow-up was conducted on those lost to interview. This showed that they did not differ signiticantly from those interviewed with regard to age, sex, marital status or population of their hometown. However a signXcantly greater proportion of non-whites and blacks was lost to interview than expected, x2 = 924,2 &, p = < 0.01. Since our low and medium change categories contained fewer non-whites and blacks than expected under the goodness of fit model and because a greater than expected number of non-whites and blacks were lost to interview from our randomly drawn sample, our interviewed sample contained no non-whites and only 8 blacks, 7 in the high change category and 1 in the medium category. Because of the small number of blacks in the final sample it is inappropriate to discuss potential ethnic group differences with regard to our dependent measures of health outcome, The association between life change category and the magnitude of the mean value for each of the physical and emotional measures of health was examined by the l-way analysis of variance. The mean value for each of the health outcome variables was determined by dividing the total number of events, e.g. different health problems, separate health problem episodes, days of illness, days of disability and total scores on the Langner scale, by the total number of persons represented in the life change category. There was a significant difference in the means of the physical and emotional health outcome variables such that the high category had the highest mean, the medium the next highest mean and the low life change category the lowest mean value, Table 2. In order to determine if the relationship was dependent upon the presence of the 7 blacks in the high life change category further analysis was conducted with the 7 blacks in the high category and the 1 in the medium category eliminated. The nature of the relationship and the statistical significance of the difference in the means were maintained as illustrated on lines labelled (B) in Table 2.
TABLE 2.--&sOcIA~ON BETWEEN CATEGORY OF LIFE CHANGE AND HEALTH OUTCOME VARIABLES FOR INTERVIEWED SAMPLE.(A)ENTIRE SAMPLEAND(B)SAMPLEWITH 8 BLACKSEXCLUDED
Health outcome and range Mean no. different health problems (O-13) Mean no. health problem episodes (O-110) Mean no. days health problem experienced (O-254)* Mean no. disability days (O-60) Mean Langner score (O-22)
(A) (Bj
(A) (B) (A) (B) (A) (B) (A) (B)
Life change category Low Medium High 2.23 (105) 2.88 (111) 3.62 (98) 2.23 (105) 2.87 (110) 3.59 (91) 4.85 (105) 8.81 (111) 12.54 (98) 4.85 (105) 8.81 (110) 12.57 (91) 20.98 (105) 30.36 (111) 47.83 (98) 20.98 (105) 30.28 (110) 47.17 (91) 1.98 (105) 2.14 (111) 6.21 (98) 1.98 (105) 2.14 (110) 6.34 (91) 2.72 (105) 344 (111) 5.27 (98) 7.72 (105) 344 (110) 5.28 (91)
F
Ratio 15.21 14.38 7.56 7.72 14.30 13.32 8.17 8.31 26.69 27.05
Prob. 0~001 O+IOl 0.001 0.001 0~001 O+t)l 0.001 0.001 0.001 0~001
*While the maximum number of separate days-at-risk of a problem is 60, if more than one problem existed on any one day, for example a broken arm and a cold, the day was counted twice.
The influence of recent life experience on the health of college freshmen
91
The mean values for each of the more subjective measures of health, i.e. “reported relation to social life, family life and school work, were calculated in a similar fashion and for the 3 life change categories by the l-way analysis of variance. A statistically significant was found between the means in the 3 categories for “reported stress” associated with and school work, Table 3.
stress” in compared difference family life
STRESS”
VARIABLES
TABLE %-~ssoc~~~~o~
BETWEEN
CATEGORY
OF LIFE CHANGE
AND TWO“REPORTED
Life change category Medium (111) Low (105) 1.36 149
“Reported stress” and range Mean reported in family life (l-4) Mean reported with school work (l-4)
2.34
2.33
F
High (98)
Prob.
1.78
Ratio 7.06
0.001
2.61
4.52
0.01
We next considered the relationship between each of the demographic variables and our health outcome variables. The variables concerned with population of hometown and marital status plus the variable “social class” obtained on the interviewed sample using the Hollingshead 2 factor index of social position 1221,showed no association with any of the health outcome variables and no clear pattern was discernible. A single statistically significant association was demonstrated between age and one of the more subjective health variables. Freshman students over 30 yr of age reported a significantly greater amount of stress associated with school work than those students under 30 yr of age, F = 2.37, p = < 0.05. When a comparison was made between males and females only one category of health outcome, i.e. average number of illness days, showed a significant difference with females having the greater mean number. When this association was examined by life change category a similar relationship existed at each level although the significance of the difference was lost, perhaps as a function of the smaller numbers upon which the means were based. There was, however, an increasingly higher mean for both males and females from low to high life change category and the magnitude of the differences in the means increased in a like manner, Table 4. TABLE
&+~~SOCIATION BETWEEN CATEGORY OF LIFE CHANGE MEANNUMBEROFILLNESSDAYSINMALESANDFEMALES
Life change category All (314) High (98) Medium (111) Low (105) *Fratio
= 5.02; Fprob.
AND
Mean number of illness days A Males Females 27.80 37.25 9.45* 40.96 55.14 14.18 24.60 34.22 9.62 19.10 23.39 4.29 = 0.02.
A comparison of the overall severity of illness was made between the 3 life change categories on the basis of 2 measures of severity defined as: (a) the average duration (in days) of an illness episode, i.e. the total number of days of illness for an entire group divided by the total number of illness episodes for that life change group, (b) the average duration of a disabling illness episode, i.e. the total number of days lost from normal activity for an entire group divided by the total number of illness episodes for that life change group. The average duration of an illness episode was found to be 4 days for both the high and low life change groups. The average duration of a disabling episode was 0.3 day for both the high and low life change groups. The total number of health problems reported by the interviewed sample was examined to determine the overall percentage of those problems which was dealt with by a professional from one of the University facilities. This overall utilization rate was then taken as the “expected” and the comparable rate of utilization was examined for each life change category in order to determine if there had been differential utilization. There were 909 health problems reported by the 314 students. Ten per cent of these problems were dealt with by a professional associated with one of the University health facilities. There was not a significant difference in the utilization for persons in the 3 life change categories although the number of health problems per person increased from the life change category labelled low to the high life change category, Table 5.
MARTINB. MARX, THOMASF. GARRITYand FRANK F. BOWERS
92
TABLE 5.-UTILIZATION OF UNIVERSITYASSOCIATEDPROFESSIONAL SERVICES PROBLEMS
Life change category and number All (314) High (98) Medium (111) Low (105)
BY LIFE CHANGE
FOR
HEALTH
RELATED
CATEGORY
Number of health problems Total Per person 2.9 909 3.6 356 2.9 319 2.2 234
Number treated percentage by university 91 10 32 9 38 12 21 9
Finally, we questioned whether the nature of the associations found between life change category and our health outcome variables was influenced by seasonal variation in disease incidence. It is recognized that the reported incidence of many infectious and allergic conditions shows seasonal variation. Our samples, drawn in November, February and May, reflect the occurrence of ill health during three separate 60-day periods, i.e., mid-September to mid-November, mid-December to mid-February and early March to early May. It is conceivable that the magnitude of the differences between mean values for the 3 life change categories might be altered if an increase in incidence were reflected mainly among persons with high life change, perhaps due to increased susceptibility [23]. In such a situation the magnitude of differences between the mean values at each level of life change for the various dependent measures would become greater during a peak incidence period. Such a peak period cannot be identified by the occurrence of a greater difference in our observed means but rather must be defined by an external reporting system unrelated to our data. Further, one must ascertain that any disease showing an increased incidence in the University undergraduate population is, in fact, the same disease responsible for a reported increased incidence in the high life change group. We were unable to detect any external evidence of a peak period for any disease during the 1972-1973 school year in the University community. When the data were examined for each interview period according to life change category the nature of previously described relationships between mean values remained for each of our main health outcome variables and the differences between mean values for the high versus the low life change categories appear relatively constant, Table 6.
Health outcome variable
Mean no. of different health problems Mean no. of health problem episodes Mean no. of days health problem experienced Mean no. of disability days Mean Langner score
Life change
category 0’)
High (98) Medium (111) LOW (losj High Medium Low High Medium Low High Medium Low High Medium Low
Interview period
Sept.-Nov. (N = 103) 3.54 3.11 2.46 12.31 6.50 6.12 50 82 36.97 23.34 4.60 2.05 3.34 5.26 4.03 2.72
Dec.-Feb. Mar.-May (N = 83) (N = 128) AHvsL* AHvsL AHvsL (35) 3.76 (26) 3.59 (37) (36) 1.08 3.23 (30) 1.47 2.47 (35) 1.57 (32) 2.29 (27) 2.02 (46) 12.80 11.46 6.19 15.70 8.43 6.20 7.22 4.37 4.24 47.76 44.30 25.48 34.50 26.39 22.67 26.58 21.37 17.72 4.76 8.89 1.26 2.00 3.65 2.33 7.35 1.11 1.54 4.64 5.70 5.43 3.37 1.97 3.04 2.94 2.67 2.76
*Difference between mean value for high and mean value for low life change. DISCUSSION
AND SUMMARY
This study has concentrated on examining the relationship between life change and subsequent illness experience in a population of college freshmen. The character of adaptive or adjustment mechanisms brought into play by the occurrence of a major
The influenceof recent life experience on the health of collegefreshmen
93
life change event has not been labelled. Furthermore, no attempt is made to explain what physiologic changes result from such adaptive efforts nor why or how such life ‘changes may influence health behavior. A statistically significant association between high levels of life change, as determined by the College schedule of recent experience, and increased illness measured by 5 health outcome variables is described by the data. The 5 measures considered as dependent variables in this study are: (1) the average number of different health problems during a prior 60-day period, (2) the average number of health problem episodes during the 60-day period, (3) the average number of days on which a health problem was experienced in the 60-day period prior to the interview, (4) the average number of disability days in the prior 60-day period and (5) the average score for the group on the Langner 22 item psychiatric impairment scale. The data were collected in a “blind” fashion by trained interviewers from a representative and random sample of freshman students. Every effort has been made to determine if selective attrition occurred at any point. With the exception of ethnic group, subpopulation distributions based on our selected demographic variables have remained within expected proportions. Because the proportions of non-whites and blacks in our final interview sample were different from expected based on the proportions found in the freshman class, i.e. no non-whites and only 8 blacks in the final sample with 7 blacks in the high life change category and 1 in the medium category, we have presented our analyses concerning the 5 dependent variables with the blacks included in the sample and excluded from the sample. The nature of the relationship between life change category and our dependent measures of health outcome was unchanged by the exclusion. In order to determine if the relationships described could be explained by high life change individuals complaining more or remembering more of their health problems than the low life change individuals we calculated two measures of severity of illness and found that the two extreme groups did not differ in either the average duration of illness episodes or the average duration of disabling illness episodes. In addition none of the 3 life change groups differed significantly from the expected utilization rate of University health service facilities, Table 5. The positive association between magnitude of life change and “reported stress” was not unexpected. Such associations, though not definitive validation of the Anderson Scale, are at least consistent with the notion that individuals undergoing multiple life changes perceive greater stress than those with fewer life change episodes. The relationship between age (over 30 yr) and “reported stress” relating to school work is consistent with the impression and experience of many professional counsellors
[241. An alternative explanation for the findings, i.e. the differential distribution of a potentially relevant demographic characteristic among the life change categories, has been examined and found unsupported as an explanation. The prospective design of the study permits characterization of the associations described as “potentially causal”. Our conclusions are that the link between major life change and illness which has been well documented in adults is equally evident in our college population. Further, the utility of Anderson’s instrument as an index of those life change events relevant to illness is clearly demonstrated. The use of this
94
MARTINB. MARX, THOMASF. GA~RITYand FRANK R. BOWERS
instrument in the identification of that segment of an entering college class which is at greatest risk of illness is suggested by these findings. REFERENCES 1. THOMPSONJ. R., BENTZW. K. and LIPTZIN M. B. The prevalence of psychiatric disorder in an undergraduate population. J. Am. Coil. Hlth. Ass. 13, 532 (1964). 2. FARNSWORTHD. L. (Ed.) College Health Administra&on. Appleton-Century-Crofts, New York (1964). 3. MACMILLINA. M. The Health Opinion Survey: Technique for estimating prevalence of psychoneurotic and related types of disorder in communities. Psychol. Res. 2, 325 (1957). 4. LANCERT. S. and MICHAELS. T. Life Stress and Mental Health. The Free Press, Glencoe, Ill. (1963). 5. LEVI L. (Ed.) Society, Stress and Disease, Vol. 1, The Psychosocial Environment and Psychosomatic Disease. Oxford University Press, London (1971). 6. WOLFF H. C., WOLFF S. and HARE C. C. (Eds.) Life Stress and Bodily Disease. Res. Publ. Ass. _ Res. Nerv. Ment. Dis. 29, Williams & Wilkins,.Baliimore (1950). 7. HOLMEST. H. and RAHE R. H. The social readiustment rating scale. J. Psvchosom. Res. 11. 213 (1967). 8. MASUDA M. and HOLMEST. H. Magnitude
estimations of social readjustments. J. Psychosom. Res. 11,219 (1967). 9. MASUDA M. and HOLMEST. H. The social readjustment rating scale: a cross cultural study of Japanese and Americans. J. Psychosom. Res. 11, 227 (1967). 10. WYLER A. R., MASUDA M. and HOLMEST. H. The seriousness of illness rating scale: reproducibility. J. Psychosom. Res. 14, 59 (1970). 11. RAHE R. H., MEYERM., SMITHM., KJAER G. and HOLMEST. H. Social stress and illness onset. J. Psychosom. Res. 8, 35 (1964). 12. RAHE R. H., MAHAN J. L. and ARTHUR R. J. Prediction of near-future health change from subject’s preceding life changes. J. Psychosom. Res. 14,401 (1970). 13. RAHE R. H. Life change measurement as a predictor of illness. Proc. R. Sot. Med. 61., 1124. 44 (1968). 14. RUBIN R. T., GUNDERSONE. K. E. and ARTHUR R. J. Life stress and illness pattern in the U.S. navy-V. Prior life change and illness onset in a battleshio crew. J. Psvchosom. Res. 15.89 (19711. 15. P&H W. M., GUNDERS~NE. K., ERICKSONJ., RAHE R. h. and RUB& R. T. Variations of‘illnegs incidence in the navy population. Milit. Med. 224, (June 1972). 16. BRAMWELLS. T., WAGNERN. M., MASUDAM. and HOLMEST. H. Prediction of illness in college athletes. In preparation. 17. ANDERSONG. E. College Schedule of Recent Experience. Masters Thesis, North Dakota State University, unpublished (1972). Illness Reports. Review 18. RAHE R. H. Subjects’ Recent Life Changes and Their Near-Future Article Ann. Clin. Res. 4, 250 (1972). 19. SELYEH. The evolution of the stress concept. Am. Sci. 61, 692 (1973). 20. LANGNERT. S. A twenty-two item screening score of psychiatric symptoms indicating impairment. J. Hlrh. Sot. Behav. 3,269 (1962). 21. SHADERR. I., EBERTM. H. and HARMATSJ. S. Langner’s psychiatric impairment scale: A short _ screening device. Am. J. Psychiut. 128, 596 (1971). _ 22. HOLLINGSHEAD A. B. Two factor index of social uosition. Printed nrivatelv. New Haven. Conn. (1957). 23. RAHE R. H., GUNDERSONE. K. and ARTHUR R. J. Demographic
and psychological factors in acute illness reporting. J. Chron. Dis. 23, 245 (1970). 24. ROSE H. A., Director, Student Characteristics Unit, University Counselling and Testing Center. University of Kentucky, Lexington, Kentucky, personal communication (1974). APPENDIX 1 COLLEGE SCHEDULE OF RECENT EXPERIENCE (modified)* There is mounting evidence to suggest that one’s life experiences correlate with health and illness patterns. To further examine the correlation this questionnaire is being offered to all freshmen on a voluntary basis. We hope you will complete the instructions and at least the first 15 questions. *M. B. Marx/F. R. Bowers (UKMC-1972) U-1972) CSRE.
modification
of G. Anderson/R.
Dubord (N.D. State
The influence of recent life experience
on the health of college freshmen
95
We earnestly solicit your responses to questions 16 through 62. All information will be treated with the strict confidentiality afforded all medical records. The entire study should be completed in approximately 2 years and the results will be made known at that time. The answer sheet for this questionnaire is marked off in sections. Section I provides space for answering questions 1 through 40. Section II provides space for answering questions 41 through 62. Read each item and the choice of answers carefully, judge the answer as it applies to you and mark it on the answer sheet. After you have finished look over the answer sheet and make sure that all questions have been answered. Mark your answers black and heavy and use PENCIL ONLY. Make corrections if necessary, but erase clearly. Do not mark in the booklet. Place the answer sheet inside the booklet and turn it in when completed. UNIVERSITY
OF
COLLEGE DEPARTMENT
OF
OF
KENTUCKY MEDICINE
COMMUNITY
MEDICINE
AND STUDENT
HEALTH
LEXINGTON,
SERVICE
KENTUCKY
INSTRUCTIONS Please turn the answer sheet sideways and print your name in the empty boxes provided on the right-hand side of the page. Blacken the appropriate lettered box in the column below each letter of your name. If the number of spaces for your first name is insufficient, use only your first initial. Mark the appropriate box for the current semester. Mark the aoorooriate grade in the column provided. F = freshman; S = sophomore; 3 = junior; 4 = senior and 5 = graduate student. _ Mark the aoorooriate boxes in the columns titled Birth date for month and for year. Mark the appropriate box in the column titled Sex. B = male; G = female. Fill your student number in the empty boxes and then black in the proper number in each CO~XXI under the student number. Now turn the paper longways and begin marking your answers to the questions. You may wish to use a sheet of blank paper to guide your answers so that you are sure the marks are in the proper blanks. SECTION I Mark the appropriate letter for: (1) your marital status. (A) married (B) divorced (C) separated (D) widowed (E) single (2) your ethinic group. (A) White (B) Black (C) Oriental (D) Am. Indian (E) Other (3) the years you have lived at your present Home address. (A) 1 year or less (B) more than 1 year and less than 5 years (C) more than 5 years and less than 10 years (D) 10 years or + (4) the number of times you have moved in the last 5 years. If you moved to Lexington to attend college, count that as 1 move. (A) 0 (B) 1 (C) 2 (D) 3 (E) 4 or more times (5) the population of your place of birth at the time of your birth. (A) rural or farm (B) 5OOO-- (C) 5000+ (D) 50,000+ (E) 5OO,~i(6) where most of your life has been spent. (A) rural or farm (B) 5000- (C) 5000+ (D) 50,000+ (E) 500,000+ (7) your number of brothers. (A) 0 (B) 1 (C) 2 (D) 3 (E) 4 or more (8) your number of sisters. (A) 0 (B) 1 (C) 2 (D) 3 (E) 4 or more (9) your birth order in the family. (A) oldest (B) youngest (C) middle (D) only child (10) if you have seen someone to aid you with mental health in the last 3 months. (A) yes (B) no
96
MARTINB. MARX, THOMAS F. GARRIT~ and FRANK R. BOWERS (11) if you have seen someone to aid you with physical health in the last 3 months. (A) yes CB) no (12) your age when mother died. (A) mother living (B) &5 years (C) 6-10 years (D) 11-15 years (E) 16+ years (13) your age when father died. (A) father living (B) O-5 years (C) 610 years (D) 11-15 years (E) 161. years (14) your age when mother and father were divorced or separated. (A) parents not divorced or separated (B) O-5 years (C) 6-10 years (D) 11-15 years (E) 16+ years (15) your age when either of your parents remarried. (A) neither parent remarried (B) O-5 years (C) 610 years (D) 11-15 years (E) 16+ years
Each of the following questions may be answered by one of these letters: (A) 0 (B) 1 (C) 2 (D) 3 (E) 4 or higher Mark the appropriate letter that corresponds to the Number of times during the Iast year (12 months period) that you: entered. college. married. had either a lot more or a lot less trouble with your boss. held a job while attending school. experienced the death of a spouse. experienced a major change in sleeping habits (sleeping a lot more or a lot less, or a change in part of the day when asleep). experienced the death of a close family member. experienced a major change in eating habits (a lot more or a lot less food intake, or very different meal hours or surroundings). (24) made a change in or choice of a major field of study. (25) had a revision of your personal habits (friends, dress, manners, associations). (26) experienced the death of a close friend. (27) have been found guilty of minor violations of the law (tratlic tickets, jay walking, etc.). (28) have had an outstanding personal achievement. (29) experienced pregnancy, or fathered a pregnancy. (30) had a major change in the health or behavior of a family member. (31) had sexual difficulties. (32) had trouble with in-laws. had a major change in the number of family get-togethers (a lot more or a lot less). g:; had a major change in financial state (a lot worse off or a lot better off than usual). (35) gained a new family member (through birth, adoption, older person moving in, etc.). (36) changed your residence or living conditions. (37) had a major conflict in or change in values. (35) had a major change in church activities (a lot more or a lot less than usual). had a marital reconciliation with your mate. were fired from work. g; Now move to Section II of the Answer Sheet. (41) were divorced. (42) changed to a different line of work. (43) had a major change in the number of arguments with spouse (either a lot more or a lot less than usual). (44) had a major change in responsibilities at work (promotion, demotion, lateral transfer). (45) had your spouse begin or cease work outside the home. (46) had a major change in working hours or conditions. (47) had a marital separation from your mate. (48) had a maior change in usual type and/or amount of recreation. (49) had a major change in the use of drugs (a lot more or a lot less). (50) took a mortaae or loan less than $10,000 (such as purchase of a car, TV, school loan, etc.). (51) had a major personal injury or illness. (52) had a major change in the use of alcohol (a lot more or a lot less). (53) had a major change in social activities. (54) had a major change in the amount of participation in school activities. (55) . , had a maior change in the amount of independence and responsibility (for example: for budgeting-time). (56) took a trip or a vacation. (57) were engaged to be married.
The influence of recent life experience on the health of college freshmen
97
The number of times during the lust year that you: Code: (A) 0 (B) 1 (C) 2 (D) 3 (E) 4 or higher. (58) changed to a new school. (59) changed dating habits. (60) had trouble with school administration (instructors, advisors, class scheduling, etc.). (61) broke or had broken a marital engagement or a steady relationship. (62) had a major change in self-concept or self-awareness. APPENDIX
2
L.C.U. SCORES FOR EACH OF LIFE CHANGE
EVENTS ON CSRE 50 17 38 43 87 34 77 30 41 45 68 22 40 68 56 58 42 26 53 50 42 50 36 58 62 76 50 50 47 41 42 74 37 52 52 65 46 43 38 49 33 54 50 41 44 60 57
(1) Entered college (2) Married (3) Trouble with your boss (4 Held a job while attending school (5) Experienced the death of a spouse Major change in sleeping habits Experienced the death of a close family member (8) Major change in eating habits (9) Change in or choice of major field of study (IO) Revision of personal habits (II) Exoerienced the death of a close friend (12) Found guilty of minor violations of the law (13) Had an outstanding persona1 achievement *(l4) Experienced pregnancy, or fathered a pregnancy (15) Major change in health or behavior of family member (16) Had sexual difficulties (17) Had trouble with in-laws (18) Major change in number of family get-togethers (19) Major change in financial state (20) Gained a new family member (21) Change in residence or living conditions (22) Major conflict or change in values Major change in church activities ii:; Marital reconciliation with your mate (25) Fired from work Were divorced :;; Changed to a different line of work Major change in number of arguments with spouse I;; Major change in responsibilities at work Had your spouse begin or cease work outside the home ‘::Y; Major change in working hours or conditions (32) Marital separation from mate Major change in type and/or amount of recreation :z; Major change in use of drugs (35) Took on a mortage or loan of less than $10,000 (36) Major persona1 injury or illness Major change in use of alcohol ;::; Major change in social activities $(39) Major change in amount of participation in school activities (40) Major change in amount of independence and responsibility (41) Took a trip or a vacation (42) Engaged to be married (43) Changed to a new school (44) Changed dating habits (45) Trouble with school administration §(46) Broke or had broken a marital engagement or a steady relationship (47) Major change in self-concept or self-awareness
I;;
*Underlined phrase added; iWife changed lined phrase added.
to spouse; JCo-curricula
changed
to school;
OUnder-
98
MARTINB. MARX, THOMASF. GARRITYand FRANK R. BOWERS APPENDIX
3
PROBES ON NEW HEALTH
PROBLEMS
(1) Injuries and accidents (with or without subsequent infection) sustained from any cause: vehicular, athletic, occupational, and other. For example: Skin cuts, bruises, punctures; Muscle strains, pulls, including back; Bone or joint sprain, breaks; Face or Mouth-tooth break, nose break, black eye, etc. (2) Infection (bacteria1 or viral) of any system except respiratory andgastrointestinal. For example: Skin infections, poison ivy, warts, boils, rash, acne flair-ups; Blood infections, mononucleosis; Organ infections, e.g. liver-hepatitis; Genito-urinary, venereal disease, urinary tract infection. (3) Respiratory infection. For example: infections of ear, nose, throat, or lungs; coughs, colds, sinus, middle ear infections; bronchitis, sore throat, laryngitis, pneumonia, asthma flair-up, hay fever flair-up; running nose, pleurisy. (4) Gastro-intestinal infection. For example: vomiting, nausea, diarrhea; change in bowel habits; other pains in gastro-intestinal area. (5) Neurological and emotional. For example: seizures or fits, depression or apathy, anxiety or nervousness, insomnia, loss of appetite, headaches or migraine, difficulty concentrating, irritable, speech or memory problems. (6) Other and problems not classifiable above. For example: change in menstrual flow, sudden weight change, anemia, flair-up of any existing (chronic) condition (e.g., diabetic flair-up) problems of sexual functioning; change in blood pressure, heart problem, blood vessel problems; swelling ankles; eye problems.
