Health-related barriers to learning among graduate students

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Health-related barriers to learning among graduate students

Health-related barriers

William Kernan Department of Public Health, William Paterson University, Wayne, New Jersey, USA and Department of Health and Behavior Studies, Columbia University Teachers College, New York, New York, USA

Jane Bogart

425 Received October 2009 Revised June 2010 Accepted July 2010

Department of Health and Behavior Studies, Columbia University Teachers College, New York, New York, USA and Student Health Service, Columbia University Medical Center, New York, New York, USA, and

Mary E. Wheat Student Health Service, Columbia University Medical Center, New York, New York, USA and Department of Internal Medicine, New York Presbyterian Hospital, New York, New York, USA Abstract Purpose – The purpose of this paper is to report the perceived impact of various health concerns on the academic performance of health sciences graduate students. Design/methodology/approach – The American College Health Association’s National College Health Assessment (ACHA-NCHA), a 58-item anonymous survey, was distributed to all graduate health science students during a five-week period in the spring semester. Findings – Students (n ¼ 1; 355) were most likely to report a negative perceived academic impact related to psychosocial concerns such as stress, depression/anxiety, and relationship problems. The students’ most pressing felt concerns were upper respiratory infections, stress, concerns about troubled loved ones and sleep difficulties. Clinical graduate students (n ¼ 712) were significantly more likely to report negative academic impacts related to upper respiratory infections (p ¼ 0:001), concern about a troubled friend or family member (p ¼ 0:001), sleep difficulties (p ¼ 0:005), relationship difficulties (p ¼ 0:030), and internet use/computer games (p ¼ 0:015) than non-clinical graduate students. However, the magnitude of those differences was small. Practical implications – This paper adds to one’s knowledge of student health concerns, which may help to address health-related barriers to learning. Originality/value – This paper presents findings that further explicate the reciprocal relationship between student health and learning by suggesting methodology to identify priority health issues among a graduate student population. Findings from this study of over 20 different health concerns indicate that the priority health concerns of graduate health science students are primarily psychological and psychosocial health issues. Keywords Students, Learning, Health, Mental health, Stress Paper type Research paper

Introduction Student health College students represent the future leaders of our society; therefore, identifying the health concerns and behaviors that impact their lives may result in approaches to

Health Education Vol. 111 No. 5, 2011 pp. 425-445 q Emerald Group Publishing Limited 0965-4283 DOI 10.1108/09654281111161248

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health education and prevention that have societal as well as individual impact. A number of significant health concerns have been identified among college students in the United States, including heavy episodic drinking (Perkins, 2002; Araujo and Wong, 2005; Wechsler et al., 1994; Sher and Rutledge, 2007, Schaus et al., 2009), recreational drug and tobacco use (Quintero, 2009, Clarkin et al., 2008), disordered eating behavior and obesity (Krahn et al., 2005; Berg et al., 2009; Pedersen and Ketchem, 2009; Desai et al., 2008), interpersonal violence (Fisher et al., 2000), sexually transmitted infections (Mark et al., 2008, Williams et al., 2008), and stress (Burris et al., 2009). Recent national surveys of the directors of US college counseling centers also indicate a growing concern about the increasing presence and severity of significant mental health issues on college campuses (Gallagher, 2009). In a recent report released by the American College Health Association (2009, p. 487), 63 percent of college students reported feelings of hopelessness on one or more occasions; 43 percent of students reported “feeling so depressed that it was difficult to function”, and 9 percent of students indicated they had seriously considered a suicide attempt in the past year. Learning-related issues are another escalating concern on college campuses. Sparks and Lovett (2009) report drastic growth in the number of individuals with learning disabilities pursing higher education while DuPaul et al. (2009) report that anywhere between 2-8 percent of college students suffer from Attention-Deficit Hyperactivity Disorder (ADHD). Indeed, approximately 25 percent of college students receiving accommodations for a documented disability are diagnosed with ADHD (Weyandt and DuPaul, 2006). In their systematic review of existing studies, Wilens et al. (2008) reported 5 to 35 percent lifetime misuse rates of prescription stimulant drugs among college students. Teter et al. (2006, p. 9) concluded that “the three most commonly reported motives for illicit use of prescription stimulants seemed related to a desire for enhanced academic performance”. The college environment itself may be a risk factor for several of these health concerns. College students engage in riskier drinking than their non-college attending peers ( Johnston et al., 2007; Substance Abuse and Mental Health Services Administration, SAMHSA, 2007). College women are also at higher risk for sexual assault when compared to their non-college attending peers (Karjane et al., 2005). Furthermore, research about the etiology of key health concerns indicates that they are interrelated. Dating violence is frequently associated with heavy drinking (Roudsari et al., 2009). Hingson et al. (2003) document an association between alcohol use and unprotected sexual activity. Depression emerges as a significant predisposing risk factor for eating disorders in college students ( Jacobi et al., 2004; Stice, 2002). Smoking behavior is linked to stress (Magid et al., 2009) and emotional and academic stresses are linked to disturbed sleeping patterns (Lund et al., 2009). Research on the health of college students often focuses on the study of a small number of health concerns. Often these studied health concerns are those deemed most relevant by those who work with college students but may not necessarily reflect the actual or perceived health concerns of the college students themselves. In 2000 the American College Health Association (ACHA) first administered the National College Health Assessment (NCHA) in an effort to collect data directly from college students about the health issues that most concern them. While self-report data has drawbacks, it is important to understand both the actual and perceived health needs expressed by college students. A recent data report summarized these findings, showing that the top

self-reported health concerns experienced by college students included allergies, back pain, sinus infections, depression, strep throat, and anxiety disorders (American College Health Association, 2009). Graduate student health To date, most college student health research has focused on undergraduates. Data on graduate student health is fragmented and sparse in comparison to that available for undergraduate college students – in fact, of the over 80,000 students comprising the 2008 NCHA data set, only 8,435 (11 percent) were graduate students (American College Health Association, 2009) Because of this, it is not fully clear to what extent the health concerns of undergraduate students are also priority health concerns of graduate students. This lack of existing data hampers health educators’ attempts to prioritize graduate students’ health concerns and develop effective intervention programs and support services. Graduate and professional students currently represent about 15 percent of all students enrolled in the degree-granting institutions of higher education in the United States (American College Health Association, 2009). According to the US Department of Education, enrollment in US graduate schools has doubled since the mid-1970s, from 1.3 million students in 1976 to 2.6 million graduate students enrolled in 2007 (the latest year for which data are available). Further, it is estimated that by the year 2018 there will be over 3.1 million students enrolled in US graduate institutions (Planty et al., 2009). In their discussion of the extant literature on graduate student mental health, Hyun et al. (2006) note the relative absence of graduate student data and the failure of many studies to distinguish between undergraduate and graduate students. Although few in number, research studies that document the health concerns of diverse groups of graduate students do exist (e.g. Schulte et al., 2008; Heins et al., 1984; Hyun et al., 2006). Common throughout these studies is the characterization of graduate students as a vulnerable population at risk for the adverse physical and mental health effects that accompany high levels of distress (Schwartz-Mette, 2009; Nelson et al., 2001; Hyun et al., 2006). This distress has been linked to the graduate school environment, which is described as a time when students face unique challenges of family and financial obligations (Hyun et al., 2006), as well as heightened academic demand and increased academic expectations (Toews et al., 1993). Given this significant distress, it is worth investigating the intersection between student-reported health concerns and related impacts on academic achievement in a graduate student population. The relationship between graduate student health and academic achievement It has long been believed by educators that learning and health are inextricably linked and a growing body of literature clearly illustrates the strong reciprocal nature of this linkage (Mitchell, 2000; Symons et al., 1997; Eisenberg et al., 2009). A study of 1,027 US medical students found that personal illness, including substance abuse and mental health issues, was significantly associated with student’s perceived academic vulnerability (Roberts et al., 2001). Among a group of 321 students in the UK, it was found that both depression and financial stress predicted adverse academic performance as measured by performance on exams (Andrews and Wilding, 2004). Further in a study of 747 US undergraduate and graduate students, Eisenberg et al. (2009) report that symptoms of eating disorders and co-occurring depression and anxiety are associated with lower grade point average (GPA).


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The implication in the existing literature that graduate students suffer from significant health problems that adversely affect student achievement is worthy of further inquiry. What is not clear from the literature is the range of health issues experienced by graduate students, nor are the adverse effects of these various concerns on graduate student learning fully documented among a diverse group of graduate students. Additionally, it is not known whether some sub-populations of graduate students are more likely to experience certain health concerns and/or subsequently experience related academic impacts as a result. Hyun et al. (2006) point out that much of the existing research on graduate student health tends to focus on specific selected sub-samples. For example, the health problems experienced by medical students, including stress (Vitaliano et al., 1989; Mosely et al., 1994; Stecker, 2004), depression (Givens and Tjia, 2002), anxiety (Dyrbye et al., 2006), and substance abuse (Newbury-Birch et al., 2001; Croen et al., 1997; Mangus et al., 1998) are well-documented. Similar health concerns have been reported among graduate dental students, post-baccalaureate nursing students, and master’s and doctoral-level psychology students (Murphy et al., 2009; Laurence et al., 2009; Maville et al., 2004; Schwartz-Mette, 2009; Nelson et al., 2001). Aims of this study Utilizing a diverse group of students enrolled in eight distinct programs, we explored the intersection between health and self-reported academic impacts by comparing those involved in clinical and non-clinical graduate training. The major purpose of this study was to identify a process that would assist college health professionals in the recognition of the most pressing health concerns experienced by graduate students for program planning purposes. Once these health concerns are identified, appropriate and targeted interventions can be developed to ameliorate the impact of these health concerns on student learning. Therefore, we address four key research questions in this paper: (1) What are the most prevalent health concerns experienced by graduate students at an academic medical center? (2) What are the differences, if any, in the relative rates of these health concerns between clinical graduate students and non-clinical graduate students? (3) Which of these health concerns are perceived by students as most deleterious to their learning? (4) What are the differences, if any, in the perceived negative impact of these health concerns between clinical and non-clinical students? This study contributes to a literature on graduate student health that is relatively sparse and differs from previously published research in several important ways. First, whereas much of the extant literature on graduate student health examines one or two specific sub-samples of students (medical students or psychology students, for example), we examine the health concerns graduate students enrolled in eight different academic programs and explore the differences among these groups. Second, whereas many existing studies simply describe the presence of health concerns among graduate students, this study explores the perceived impact that experiencing various health concerns has on student learning.

Methods Population The study population included all graduate health sciences students (n ¼ 2; 508) enrolled in the campus health service of a large academic medical center in New York, NY, USA, during the spring term of 2005. The sampled population included students enrolled in the following programs: medicine, dentistry and oral surgery, post-baccalaureate nursing, occupational therapy, physical therapy, and masters/doctoral programs in human nutrition, biomedical sciences and public health. Study design This investigation was descriptive and quantitative in nature, using a cross-sectional design. The study utilized the American College Health Association-National College Health Assessment (ACHA-NCHA), a 58-item questionnaire developed broadly to assess habits, perceptions, and behaviors related to the most prevalent health topics among college students. This instrument is widely used among college health professionals and has been administered at over 400 institutions of higher education in the USA and Canada (American College Health Association, 2009). The ACHA-NCHA was administered under a protocol approved by the medical center’s Institutional Review Board. In order to ensure confidentiality, student responses were collected through a web-based survey contract with ACHA, who then compiled the data into summary reports. Two weeks before the start of the study, students were contacted via email by study personnel to inform them of the purpose of the upcoming survey. Students were given the opportunity to ask questions and were also notified at that time that all personal identifying information would be separated from their responses before the summary reports and raw data were sent to study personnel for further analyses. This paper focuses on the results from a multi-item question about health-related impediments to academic performance. The question reads: “Within the last school year, have any of the following affected your academic performance? (Please select the most serious outcome for each of the items below).” Respondents were presented with a list of 24 health concerns (see Table I for a complete listing) and the following five responses for each concern: (1) This did not happen to me/not applicable. (2) I have experienced this issue but my academics have not been affected. (3) I experienced this and received a lower grade on an exam or important project. (4) I experienced this and received a lower grade in a course. (5) I experienced this and received an incomplete in a course or dropped the course. In the current study, this scale had good internal consistency, with a Cronbach alpha coefficient of 0.76. Data analysis As there are no established models for analyzing responses to this specific item for needs assessment or program planning purposes, we conducted two frequency analyses using SPSS, version 13 to determine the prevalence of each health concern and the prevalence of perceived negative academic impact of each concern. We then


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Table I. All graduate students (n ¼ 1,355), clinical students (n ¼ 712) and non-clinical students (n ¼ 643) experiencing various health concerns in the past year

Cold/flu/sore throat Stress Concern for a troubled friend or family membera Sleep difficulties Alcohol use Relationship difficulty Internet use/computer games Allergies Depression/anxiety/seasonal affective disorder Death of a friend or family member Sinus or ear infection/strep throat/bronchitis Injury Chronic pain Chronic illness (diabetes, asthma, etc. . . .)b Attention deficit disorderc Drug used Eating disorder/problem Pregnancy (yours or your partner’s) Sexually transmitted disease Learning disability Assault (sexual) Assault (physical) Mononucleosis HIV infection

All graduate Clinical students students (n ¼ 1,355) (n ¼ 712) % % 78.9 75.4 63.5 51.7 47.4 43.4 41.6 31.1 28.4 26.0 23.5 12.0 11.1 10.7 8.6 8.6 5.4 5.4 3.2 2.8 1.7 1.5 1.3 0.1

78.8 76.8 66.4 52.2 47.5 45.8 42.1 28.8 27.8 26.4 22.1 11.0 9.6 9.0 7.0 6.7 5.8 4.4 2.8 2.5 1.1 1.1 1.3 0.0

Non-clinical students (n ¼ 643) % 79.0 73.9 60.2 51.0 47.3 40.7 41.1 33.7 29.1 25.5 24.9 13.1 12.9 12.6 10.4 10.7 5.0 6.5 3.6 3.1 2.3 1.9 1.4 0.3

Notes: aSignificant between group difference ( p ¼ 0.020); bsignificant between group difference ( p ¼ 0.040); csignificant between group difference ( p ¼ 0.033); dsignificant between group difference ( p ¼ 0.012)

conducted additional statistical analyses using Chi-square analysis and independent-samples t-tests to identify any between group differences based on the health concerns measured. The data meet the assumptions for both of these statistical techniques; however Fisher’s Exact test was used in several instances where the expected frequency was less than 5. Based on these analyses a model was constructed to evaluate the relative threat posed by each of the health concerns. Results The respondents All graduate health sciences students enrolled in the campus health service (n ¼ 2; 508) during the spring 2005 semester were sampled, with 1,355 students (54 percent) returning complete surveys. Demographic characteristics of respondents are shown in Table II. Respondents were proportionally similar to the entire sampled population on all measured demographic characteristics. Respondents were divided into two subgroups for further analytic purposes. The first subgroup was composed of all students enrolled in medical, dental, nursing,

Characteristic

%

Ethnicity White – not Hispanic (includes Middle Eastern) Black – not Hispanic Hispanic or Latino Asian or Pacific Islander American Indian or Alaskan Native Other

61.3 6.9 5.6 22.4 0.4 3.4

Sex Male Female

31.2 68.8

International student Yes No

9.5 90.5

Registration status Full-time Part-time

81.0 19.0

Age (years) Mean Standard deviation

28.4 6.535


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Note: n ¼ 1,355

Table II. Demographic characteristics of respondents

occupational therapy and physical therapy programs, henceforth referred to as “clinical students.” Of the 2,508 graduate students sampled, 1,273 (51 percent) were clinical students. Responses were collected from 712 clinical students, which accounted for 53 percent of the total responses received. “Non-clinical students,” those enrolled in masters/doctoral-level programs in public health, human nutrition, and biomedical sciences (n ¼ 1; 235, 49 percent of the sampled population) comprised the second subgroup.,”Completed surveys were received from 47 percent (n ¼ 643) of the non-clinical students. The relative proportions of students in these two sub-groups in both the sampled population and the final group of respondents were remarkably similar (see Table III). When comparing the mean age of clinical students and non-clinical students, an independent-samples t-test revealed a significant difference between clinical students (M ¼ 27:47, SD ¼ 6:09) and non-clinical students (M ¼ 29:40, SD ¼ 6:85; tð1; 331Þ ¼ 5:40, p ¼ 0:000, d ¼ 0:29), with non-clinical students likely to be older than clinical students. Chi-square analyses revealed further significant between-group differences, with non-clinical students more likely to be part-time (x 2 [1, Population (n ¼ 2,508) n % Clinical students Non-clinical students

1,273 1,235

51 49

Sample (n ¼ 1,355) n % 712 643

53 47

Table III. Response rates

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N ¼ 1; 355 ¼ 50:22, p ¼ 0:000, d ¼ 0:39), international (x 2[1, n ¼ 1; 355 ¼ 41:04, p ¼ 0:000, d ¼ 0:35), and Hispanic (x 2 [1, n ¼ 1; 355 ¼ 3:97, p ¼ 0:035, d ¼ 0:11). No other significant between-group differences were found. Health concerns among graduate health sciences students Our first objective, to determine the most prevalent health concerns experienced by the graduate students in our sample, was accomplished by establishing the frequency with which each of the listed health concerns was reported. While all twenty-four health concerns were experienced by at least one student in the sampled population, fewer than 5 percent of students reported a sexually transmitted disease or learning disability and less than 2 percent of students reported a sexual assault, physical assault, mononucleosis, or HIV infection. As shown in Table I, students were most likely to report experiencing upper respiratory infections (cold/flu/sore throat, 78.9 percent), interpersonal concerns (concern for a troubled friend or family member, 63.5 percent; relationship difficulty, 43.4 percent; death of a friend or family member, 26 percent), and mental health concerns (stress, 75.4 percent; depression/anxiety/seasonal affective disorder, 28.4 percent). Other commonly reported health issues included sleep difficulties (51.7 percent), alcohol use (47.4 percent), internet use/computer games (41.6 percent), and allergies (31.1 percent). A second frequency analysis was conducted to determine the most prevalent health concerns among clinical students and non-clinical students. Results (displayed in Table I) indicate that the rank order of health concerns experienced by the clinical students was identical to the rank order of the health concerns experienced by the entire sample of graduate students. Similarly, the rank order of the health concerns experienced by the non-clinical students was nearly identical to those experienced by the entire sample, with the exception of internet use/computer games and pregnancy, which were only one ranking out of order. Our second objective was to determine if there were any differences in the relative rates that clinical graduate students and non-clinical graduate students reported experiencing the various health concerns measured. Chi-square analyses were conducted on twenty-three of the twenty-four health variables to determine if there were any significant differences between the two groups. No analysis was done for HIV infection given that no clinical students reported that health concern. Significant between-group differences were noted, with clinical students more likely to experience a concern with a troubled friend or family member (x 2 [1, n ¼ 1; 355 ¼ 5:42, p ¼ 0:020, d ¼ 0:13) and non-clinical students more likely to report drug use (x 2 [1, n ¼ 1; 355 ¼ 6:32, p ¼ 0:012, d ¼ 0:14), attention deficit disorder (x 2 [1, n ¼ 1; 355 ¼ 4:52, p ¼ 0:033, d ¼ 0:12), and chronic illness (x 2 [1, n ¼ 1; 355 ¼ 4:23, p ¼ 0:040, d ¼ 0:11). There were no other significant differences among any of the remaining health concerns suggesting that both clinical and non-clinical students experience the majority of the health concerns measured in this study at relatively equal rates. Perceived academic impact of health concerns The third objective was to establish which of the measured health concerns were perceived by students as most harmful to their learning. For each health concern, all students reporting that health concern were grouped as:

.

.

those who experienced the health concern, but did not perceive a related negative academic impact; or those who experienced the health concern and reported experiencing a related negative academic impact (see Table IV).

Although rarely experienced, the graduate students in this sample reported the greatest negative academic impacts related to their experience with learning disabilities (60.5 percent) and attention deficit disorder (58.1 percent). Psychosocial issues were also commonly reported, with students indicating adverse effects on learning related to depression/anxiety/seasonal affective disorder (43.6 percent), relationship difficulty (28.7 percent), stress (26.9 percent), death of a friend or family member (19.9 percent) and concern about a troubled friend or family member (19.4 percent). Other health concerns frequently reported to have a negative impact on learning included mononucleosis (38.9 percent), pregnancy (30.1 percent), sleep

Health concern Learning disability Attention deficit disorder Depression/anxiety/seasonal affective disorder Mononucleosisa Pregnancy (yours or your partner’s) Relationship difficultyb Stress Sleep difficultiesc Chronic illness (diabetes, asthma, etc. . . .) Assault (sexual)a Death of a friend or family member Cold/flu/sore throatd Concern for a troubled friend or family memberd Chronic pain Eating disorder/problem Sinus or ear infection/strep throat/bronchitis Internet use/computer gamese Sexually transmitted diseasea Assault (physical) a Injury Drug usea Allergies Alcohol use HIV infection


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% experiencing a related negative academic consequence Clinical Non-clinical All students students students % % % 60.5 58.1 43.6 38.9 30.1 28.7 26.9 22.9 22.8 21.7 19.9 19.4 19.4 19.2 16.4 16.4 15.1 11.6 10.0 9.3 8.5 5.2 4.5 0.0

61.1 64.0 44.4 33.3 35.5 32.5 28.7 27.2 23.4 12.5 21.3 23.4 23.7 16.2 14.6 16.6 18.7 10.0 25.0 10.3 8.3 6.8 4.7 0.0

60.0 53.7 42.8 44.4 26.2 24.0 24.8 18.0 22.2 26.7 18.3 15.0 14.2 21.7 18.8 16.1 11.0 13.0 0.0 8.3 8.7 3.7 4.3 0.0

Notes: aFisher’s Exact Test used in place of Chi-Square due to small cell size; no significant associations found; bSignificant between group difference ( p ¼ 0.030); cSignificant between group difference ( p ¼ 0.005); dSignificant between group difference ( p ¼ 0.001); eSignificant between group difference ( p ¼ 0.015)

Table IV. Percentage of graduate students reporting a negative academic consequence among those who experienced various health concerns in the past year

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difficulties (22.9 percent), chronic illness (22.8 percent), sexual assault (21.7 percent), and cold/flu/sore throat (19.4 percent). Health concerns that were perceived as having very little influence on learning included injuries (9.3 percent), drug use (8.5 percent), allergies (5.2 percent), and alcohol use (4.5 percent). HIV infection was not reported by any student as having a related negative academic impact. Using Chi-Square analysis, we then examined differences in the relative rates that clinical students and non-clinical students reported these health concerns as negatively influential on their learning. Findings indicate that when compared to non-clinical students, clinical students were significantly more likely to report a negative academic consequence related to experiencing an upper respiratory infection, (x 2 [1, n ¼ 1,355] ¼ 11.48, p ¼ 0:001, d ¼ 0:18), concern about a troubled friend or family member (x 2 [1, n ¼ 1; 355 ¼ 11:59, p ¼ 0:001, d ¼ 0:19), sleep difficulty (x 2 [1, n ¼ 1; 355 ¼ 7:78, p ¼ 0:005, d ¼ 0:15), excessive internet use/computer game playing (x 2 [1, n ¼ 1; 355 ¼ 5:88, p ¼ 0:015, d ¼ 0:13), and relationship difficulty (x 2 [1, n ¼ 1; 355 ¼ 4:68, p ¼ 0:030, d ¼ 0:12). No other significant between-group differences were found. Discussion The purpose of this section is to summarize the key findings, discuss the inadequacy of using prevalence data or between-group differences to guide program planning efforts, and suggest a methodology for graduate institutions to effectively identify the most “pressing” health concerns. Health concerns of graduate health sciences students Findings from this study clearly indicate which health concerns are experienced frequently by health sciences graduate students. Of the twenty-four health concerns measured, four were reported by more than half of the students surveyed: cold/flu/sore throat, stress, concern for a troubled friend or family member, and sleep difficulties. It is not surprising that upper respiratory tract infections (URIs) were reported as the most prevalent health concern in this study, as URIs were identified as common health concerns among college students in other studies (Nichol et al., 2005; American College Health Association, 2009). Similarly, many studies have identified stress as a primary health concern experienced by graduate students (Dyrbye et al., 2006; Laurence et al., 2009; Maville et al., 2004; Mosely et al., 1994; Nelson et al., 2001). Alcohol use, relationship difficulty, and problematic internet use/computer game playing were all reported by more than 40 percent of the students, therefore making them highly prevalent health concerns within our study population. Conversely, ten health concerns were experienced by fewer than 10 percent of the sampled students, indicating some noteworthy differences from the common health concerns identified in undergraduate populations (American College Health Association, 2009). Existing research suggests that students studying the clinical health sciences are often subjected to harsh learning environments which consequently result in adverse health outcomes. Long work hours, weak social support systems, intense peer competition, and abuse from faculty and patients are elements of the environment within which clinical graduate students often work and learn (Silver and Glicken, 1990; Clark and Zeldow, 1988; Ferns and Meerabeau, 2007). Medical education has even been called a

“neglectful and abusive family system” (McKegney, 1989, p. 452) which “promotes cynicism, callousness, and self-doubt” (Novack et al., 1999, p. 516). Therefore, this study sought to identify any meaningful differences in the prevalence of health concerns reported by clinical graduate students and non-clinical graduate students. In their review of the existing literature, Dutta et al. (2005) reported that high levels of stress were found among diverse groups of clinical graduate health-professions students. Rates of depression and suicide were shown to be higher among medical students when compared to the general population (Mosely et al., 1994). Similarly, when compared to traditional students, stress levels were higher among accelerated graduate nursing students (Youssef and Goodrich, 1996). Not all studies, however, found significant differences between clinical and non-clinical graduate students and the health concerns they experience. In a comparison of graduate students studying medicine, law, chemistry, and psychology, there were no between-group differences in perceived stress levels (Heins et al., 1984). In a comparison of a diverse group of clinical and non-clinical graduate students, clinical students “were found to have the same spectrum of perceived problems as the other students” (Bjorksten et al., 1983, p. 759). In our study, significant between-group differences were found among four of the twenty-three health concerns analyzed. However, when comparing the magnitude of these differences to Cohen’s classification for effect size (Cohen, 1992), these differences, ranging from 0.11 to 0.14, were quite small, indicating that clinical and non-clinical students are likely to be much more similar than they are different regarding their experience with various health concerns. Perceived academic impact of health concerns among graduate health sciences students Learning-related health concerns and psychosocial issues were perceived as chief academic threats by the students in our study. Based on previous reports (see Ruban et al., 2003), it is no surprise that students experiencing learning disabilities and attention deficit disorder reported a negative impact on learning related to those health concerns. Also consistent with previous research indicating a high degree of perceived academic vulnerability related to depression, anxiety, and relationship trouble among medical students (Roberts et al., 2001), graduate students in our study likewise reported negative academic consequences related to their experience with various psychosocial concerns, including depression, stress, and troubled relationships. We found several significant between-group differences related to student’s perceptions of the academic impact of various health concerns, with clinical students more likely to report negative academic consequences related to five of the twenty-three measured health variables. This is similar to results presented by Bjorksten et al. (1983) who found that although medical students reported similar problems as other graduate students, they tended to complain more often about those problems. Moreover, Heins et al. (1984) found that medical students reported higher levels of stress related to academics than graduate students in psychology and chemistry. Our initial findings suggest that while most health concerns were experienced at similar rates by both subgroups, clinical students may perceive a greater academic impact related to certain health concerns. However, the magnitude of these differences, with effect sizes ranging from 0.12 to 0.19, were relatively small, preventing us from concluding that the clinical students and non-clinical students in pour study are different from one another in any meaningful way.


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Identifying a program planning prioritization methodology As previously stated, the overarching aim of this study was to identify a process that would assist college health professionals in the recognition of the most “pressing” health concerns experienced by graduate students for program planning purposes. One potential methodology to use to identify the most pressing health concerns could be to compare distinct groups of graduate students. Several statistically significant differences were found between the two sub-groups of students in our study. However, selecting priority health concerns based on significant between-group differences may not yield the best results when the magnitude of these differences is small, as is the case in this study. Moreover, even in the presence of significant differences with greater magnitude, this methodology may not be helpful in identifying the most pressing concerns. For example, despite the significant difference between the two subgroups related to concerns about a troubled friend or family member, it was the third most prevalent concern for both clinical and non-clinical students, and therefore a potentially pressing concern for both. Likewise, when compared to clinical students, non-clinical students were significantly more likely to report chronic illness attention deficit disorder, and drug use as impediments to their academic performance; however each of these concerns was infrequently experienced by both groups, calling into question the utility of this method in identifying the most pressing health concerns experienced by graduate students. Another potential method to identify the most pressing health concerns would be to simply select those that are most prevalent among all graduate students. However, this methodology may overestimate the importance of some health concerns while undervaluing the significance of others. For example, we found that learning disabilities and ADHD were experienced infrequently by graduate students (2.8 percent and 8.6 percent respectively). However, numerous studies assert that it is paramount to student success that these concerns be addressed (Sparks and Lovett, 2009; Weyandt and DuPaul, 2006). Conversely, upper respiratory infections were commonly experienced by graduate students but were much less threatening to learning; only 19.4 percent of students reported a related negative academic outcome. Further, both physical assault and sexual assault were reported infrequently by students (1.5 percent and 1.7 percent respectively), but often result in serious consequences (both academic and otherwise) for the students involved (Carr, 2007). This raises some interesting questions. Are personal safety issues to be appraised as less important than concerns that are experienced more frequently by students, such as a cold, seasonal allergies or a sore throat? How does one quantify and compare the impact of a mild cold versus that of a violent sexual assault? Therefore, to determine which health concerns are truly most “pressing” involves more than identifying between-group differences or examining the prevalence of each health concern. The magnitude of the negative impact of the concern must be also be considered. Perceived academic threat of various health concerns A more functional methodology to identify the most “pressing” health concerns among a graduate student population is to examine both prevalence of the concern and any related perceived negative impact on learning, which we define as “threat” to learning.

When juxtaposing these two distinct criteria (prevalence and threat) we see that of the ten most prevalent health concerns experienced by all graduate students, four also appear among the top ten with the greatest perceived academic threat (shown in bold in Table V). These include two categorical mental health concerns (depression/anxiety/seasonal affective disorder and stress), one interpersonal concern (relationship difficulty), and sleep difficulties. Based on prior reports in the graduate education literature (Roberts et al., 2001; Hyun et al., 2006; Schulte et al., 2008; Andrews and Wilding, 2004), it is not surprising that mental health issues and interpersonal concerns are among the most prevalent health concerns experienced by graduate students. Our results indicate that these concerns also contribute to negative academic consequences as perceived by students. Therefore, assessing both “threat” to learning and prevalence serves as a better method to identify the most pressing health concerns compared to only using one or the other. When comparing the ten most prevalent and ten most threatening health concerns among clinical graduate students, a slightly different picture emerges (see Table V). In addition to the four most pressing health concerns experienced by all graduate students, one additional health concern arises among clinical students – concern for a troubled friend or family member. This is not surprising as clinical students were significantly more likely to report experiencing this concern (p ¼ 0:020) and perceive a related negative academic impact (p ¼ 0:001) relative to non-clinical students. This suggests that this concern may be a particularly important issue to address with the clinical graduate student population, even though the magnitude of these differences was found to be small. A repeat analysis of the top concerns reported by non-clinical students yields only three health concerns that emerge as most pressing – stress, relationship difficulties and depression/anxiety/season affective disorder (see Table V). Each of these concerns was also listed as most pressing among all graduate students. Sleep difficulties, the fourth health issue that appears on the most pressing list for all students, does not appear on the list for non-clinical graduate students. Although there was a statistically significant difference (p ¼ 0:005) found between clinical and non-clinical student’s perception of sleep difficulties as negatively influential on learning, the magnitude of this difference was small (d ¼ 0:15). Potential for intervention While it is helpful to know both the prevalence of health concerns and the potential threat posed by these health concerns, it is also important to consider which health concerns are most amenable to intervention. Pickett and Hanlon (1990) developed a four component process by which to rank health concerns within a population. This Basic Priority Rating (BPR) is useful in quantifying this complex and often subjective prioritization process. The BPR requires that each need (in our case, each health concern) be ranked in terms of the size of the problem, the level of seriousness of the problem, the effectiveness of potential interventions, and the likelihood that an intervention could actually be implemented given available resources. In attempting to create an environment that supports student learning on college campuses specific to the data collected on the ACHA-NCHA, Kenzig and Kernan (2007) proposed a modification of the BPR which includes three primary dimensions of interest:


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1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10

Clinical graduate students 1 78.8 Cold/flu/sore throat 2 76.8 Stressa 3 66.4 Concern for troubled friend or familya 4 52.2 Sleep difficultiesa 5 47.5 Alcohol use 6 45.8 Relationship difficultya 7 42.1 Internet use/computer games 8 28.8 Allergies 9 27.8 Depression/anxiety/SADa 10 26.4 Death of a friend/family member

Non-clinical graduate students 1 79.0 Cold/flu/sore throat 2 73.9 Stressa 3 60.2 Concern for troubled friend/family 4 51.0 Sleep difficulties 5 47.3 Alcohol use 6 41.1 Internet use/computer games 7 40.7 Relationship difficultya 8 33.7 Allergies 9 29.1 Depression/anxiety/SADa 10 25.5 Death of a friend/family member

Learning disability Attention deficit disorder Mononucleosis Depression/anxiety/SADa Assault (sexual) Pregnancy Stressa Relationship difficultya Chronic illness Chronic pain

Notes: aHealth concerns are those appearing on both ranked lists, denoting the most “pressing” health concerns among graduate students; data include only those graduate students who reported experiencing the health concern in the past year

60.0 53.7 44.4 42.8 26.7 26.2 24.8 24.0 22.2 21.7

Attention deficit disorder Learning disability Depression/anxiety/SADa Pregnancy Mononucleosis Relationship difficultya Stressa Sleep difficulties Assault (physical) Concern for troubled friend/familya

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64.0 61.1 44.4 35.5 33.3 32.5 28.7 27.2 25.0 23.7

Learning disability Attention deficit disorder Depression/anxiety/SADa Mononucleosis Pregnancy Relationship difficultya Stressa Sleep difficultiesa Chronic illness Assault (sexual)

1 2 3 4 5 6 7 8 9 10

All graduate students 1 78.9 Cold/flu/sore throat 2 75.4 Stressa 3 63.5 Concern for troubled friend/family 4 51.7 Sleep difficultiesa 5 47.4 Alcohol use 6 43.4 Relationship difficultya 7 41.6 Internet use/computer games 8 31.1 Allergies 9 28.4 Depression/anxiety/SADa 10 26.0 Death of a friend/family member 60.5 58.1 43.6 38.9 30.1 28.7 26.9 22.9 22.8 21.7

Most threatening health concerns (%)

Table V. Most “pressing” health concerns reported by graduate students: prevalence X threat

Most prevalent health concerns (%)

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(1) prevalence of the health problem; (2) threat posed by the health problem, measured by student’s perceptions of negative academic impact; and (3) potential for intervention, a combination of the final two components of Pickett and Hanlon’s (1990) BPR, effectiveness and efficacy of potential interventions in the campus community. With such a model as a guide, our efforts and resources would be targeted to those health concerns that are most prevalent, most threatening to academic success, and have the greatest potential for intervention. The mental health and interpersonal concerns reported in this study are common and cause substantial reported negative academic impact. Furthermore, they are likely to be very amenable to intervention in the milieu of graduate education (Benton and Benton, 2006). Limitations Because this study reported the results from an existing item embedded in a much larger survey, several limitations deserve mention. The measure was developed for use primarily with undergraduate college students and posed a moderate degree of respondent burden (about 30 minutes, which we suspect was a main factor in the resultant response rate). Nonetheless, the response rate in the current study (54 percent) falls well with Baruch’s (1999, p. 429), “norm response rate” for academic studies in the behavioral sciences. Further challenges were posed by the structure and wording of the item. Several mental health diagnoses and constructs were inappropriately measured as one global concern (depression/anxiety/seasonal affective disorder) and because the survey collected self-reported data, there is no way to accurately know how many students had been diagnosed with a mental health disorder It is important to know, for example, if a student has a medical diagnosis of depression or, because he feels down at times, simply thinks he suffers from the condition. Furthermore, academic impact was assessed by the student’s self appraisal of impact related to each health concern. Many published studies measuring the health concerns of graduate students use self-report measures designed to capture “perceived impact” – the student’s own judgment of the degree to which a given health concern results in or contributes to a given outcome (Roberts et al., 2001; Heins et al., 1984; Maville et al., 2004). We recognize that this appraisal process is complex, requiring both recall and insight and it is therefore reasonable to assume that students might underestimate the impact of some health concerns on their learning. Although we feel strongly that student’s perceptions of their own academic experience deserve attention, we do recognize the limitations of using self-report as the sole measure of impact on learning. Implications for future research Our findings suggest that additional future research on the subject is warranted. Mental health concerns, including depression and anxiety, are common health concerns reported by graduate students (Hyun et al., 2006; Givens and Tjia, 2002). Our results indicate that these concerns are both common and perceived as threatening to student’s academic achievement. However, since our study did not ask students if they


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had ever received a medical diagnosis of any of the measured mental health concerns, future research should incorporate validated mental health scales to discern which students have a true diagnosis and which students do not. In this study “stress” was a health concern that was found to be both frequently experienced and threatening to learning. However, we cannot know for certain how students defined stress when responding to this item. Findings from other studies have operationalized graduate student stress based on stress-domains (e.g. academic stress, financial stress) and academic program-specific stressors (Heins et al., 1984; Andrews and Wilding, 2004). Future research should define this construct more clearly and assist students differentiate between stress and anxiety. While it is interesting and helpful to know which health concerns graduate students perceive as detrimental to their learning, future research should include an objective measure of academic impact, such as grade point average (GPA), in addition to the self-report measure. Other potential, less subjective measures of academic impact for use among graduate students could include scores on national licensing exams, grades in individual classes, or grades on important projects or exams. Finally, when attempting to identify the most pressing health concerns among a graduate student population, the potential for students to inaccurately assess the actual academic impact of certain health issues must not be overlooked as this could impact the accuracy of the priority ranking methodology. For example, previous research clearly shows that alcohol contributes to many significant negative consequences among graduate students (Kriegler et al., 1994; Schwartz-Mette, 2009; Bemak et al., 1999). When asked about their perceptions of academic vulnerability associated with various personal health concerns, medical students reported the greatest degree of concern about alcohol and drug use (Roberts et al., 2001). Although the students in our study reported frequently engaging in alcohol use, very few students (4.5 percent) associated alcohol use with a negative academic impact. This is inconsistent with previously published data about the serious academic consequences related to use ( Jennison, 2004), suggesting that students may underestimate the negative impact of their alcohol use on their academic performance. The reasons for this should be explored in future research. Furthermore, this brings into question the utility of assessing alcohol use with a single item and future research should assess the frequency of use and amount of alcohol consumed by students in order to identify patterns of consumption that are most deleterious to learning. Conclusion This is a study of graduate students’ health concerns and student’s perceptions of the impact of these health concerns on their learning. Consistent with reports from other studies (e.g. Hyun et al., 2006; Eisenberg et al., 2009), our findings indicate that graduate students, regardless of status as a clinical or non-clinical student, widely perceive psychosocial concerns as negatively influential to their learning. Therefore, interventions directed at identifying and treating student depression, stress, anxiety, and interpersonal concerns are warranted. Further, in contrast to findings by other investigators (e.g. Roberts et al., 2001), students in our study did not perceive a connection between their alcohol use and adverse academic consequences. Interventions aimed at correcting misperceptions and educating graduate students about the impact of alcohol on learning may also be helpful.

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