All studies published in Clinical Gastroenterology and Hepatology are embargoed until 3PM ET of the day they are published as corrected proofs on-line. Studies cannot be publicized as accepted manuscripts or uncorrected proofs.
Clinical Gastroenterology and Hepatology 2014;-:-–-
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58
Effects of Inflammatory Bowel Disease on Students’ Adjustment to College Q13
S. Bashar Almadani,*,a Jeremy Adler,‡,a Jeff Browning,§ Elan H. Green,jj Karla Helvie,jj Raf Rizk,jj and Ellen M. Zimmermannjj *Department of Internal Medicine, Division of Gastroenterology, Rush University Medical Center, Chicago, Illinois; ‡ Department of Pediatrics and Communicable Diseases, Division of Pediatric Gastroenterology, jjDepartment of Internal Medicine, Division of Gastroenterology, University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan; § Virginia Commonwealth University, Richmond, Virginia BACKGROUND & AIMS:
Successful adjustment to college is required for academic success. We investigated whether inflammatory bowel disease (IBD) activity affects this adjustment process.
METHODS:
We created an online survey that included a standardized adjustment to college questionnaire (SACQ), a general quality of life survey (SF-12), a disease-specific short IBD quality of life survey (SIBDQ), and disease activity indices. Undergraduate students across the United States were recruited via social media.
RESULTS:
Surveys were completed by 65 students with Crohn’s disease (CD), 28 with ulcerative colitis, and 214 healthy students (controls). Disease-specific quality of life (SIBDQ results) correlated with IBD disease activity (rho [ –0.79; P < .0001). High college adjustment scores (SACQ results) were associated with high SIBDQ scores. Students with IBD had lower mean SACQ scores than controls (307 vs 290; P < .0001). There was a modest inverse correlation between CD activity and SACQ (rho [ –0.24; P < .04). Disease activity in students with CD was associated strongly with their self-reported ability to keep up with academic work (P < .0089) and confidence in their ability to meet future academic challenges (P < .0015). Students with active IBD reported feeling as if they were not doing well for the amount of work they were doing (P < .018), and students with ulcerative colitis reported irregular class attendance (P < .043).
CONCLUSIONS:
Students with IBD do not adjust to college as well as healthy students. Disease activity affects their adjustment and attitudes about academics—especially among students with CD. Successful adjustment is important for academic success, affecting graduation rates and future economic success. Strategies to increase disease control and provide social and emotional support during college could improve adjustment to college and academic performance, and increase patients’ potential.
Q8
Q9
Keywords: Transition; Age; Teen; Young Adult; UC. Q10 Q11
he formative years of college are critical to a successful career after graduation. Students who do not adjust well to college achieve lower grades and have higher drop-out rates, both of which have lifelong implications regarding career opportunities, earning potential, and the availability of high-quality health insurance. Little is known about how students with chronic illnesses adapt to the challenges and demands of college life. Even less is known about how students with inflammatory bowel disease (IBD) adjust to college. Students with IBD are known to experience greater perceived stress than their classmates without IBD.1 Perceived stress has a detrimental impact on a student’s ability to adjust to college.2,3 The relationship between IBD disease activity and stress is complex. It is
T
not clear how disease activity or the stress of coping with active IBD is related to college adjustment. In a pilot study assessing college adjustment in University of Michigan students with IBD, we found that students with
a
Authors share co-first authorship.
Abbreviations used in this paper: CD, Crohn’s disease; HBI, Harvey– Bradshaw Index; IBD, inflammatory bowel disease; SACQ, student adjustment to college; SCCAI, simple clinical colitis activity index; SF-12, general quality of life survey the short-form 12; SIBDQ, disease-specific short inflammatory bowel disease quality of life survey; UC, ulcerative colitis. © 2014 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.03.032
FLA 5.2.0 DTD YJCGH53779_proof 6 May 2014 7:26 pm ce
Q7
59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116
2
117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
Almadani et al
Clinical Gastroenterology and Hepatology Vol.
Crohn’s disease had more difficulty adjusting to college than their healthy classmates and that the students with more active disease had greater difficulty adjusting to college than those with less active disease.4 To enlarge the study population and increase the power to detect subtle differences, we designed a nationwide, Internetbased study to examine the relationship between IBD disease activity and college adjustment. Our national study confirmed observations that students with IBD adjusted less well to college than their peers. This was particularly true of social and emotional adjustment. Further, worsening disease activity negatively impacted college adjustment and had alarming affects on selfreported academic attitudes. Our findings could provide important information for students, parents, and caregivers, as well as college faculty and administration, which could help students be more successful in college and later in life.
Materials and Methods
Q12
Q13
We performed an Internet-based case-control study that was administered nationwide from May 2008 through September 2011. We intended to recruit a 2:1 ratio of healthy students to students with IBD. We recruited students through multiple modalities to maximize the number of students reached. This included pamphlets, fliers, newspaper advertisements, e-mails sent out by local university student health services (Table 2 shows the states that were represented), as well as e-mails to student support or interest groups. We also implemented an e-marketing campaign using social media websites such as www.facebook.com and www. myspace.com, as well as various IBD-related websites including the Crohn’s and Colitis Foundation of America’s website (www.ccfa.org). Recruitment of students as
-,
No.
-
healthy controls was accomplished by asking each student with IBD to provide the link to the survey to 2 friends who do not have IBD, but are approximately the same age, have a similar major of study, and who have similar study habits as determined by the student with IBD. To do so, they were prompted to submit their friends’ e-mail addresses. An automatic e-mail generator then sent an automatic e-mail invitation. The healthy friends of each IBD student formed the matched control group. This study was approved by the University of Michigan institutional review board, including waiver of parental consent for 17-year-old students.
Survey Instruments We created a web-based informed consent with subsequent links to surveys created with SurveyMonkey (www.surveymonkey.com). The surveys included both disease-independent and disease-specific questionnaires. The disease-independent surveys were administered to all study participants and included the Student Adjustment to College Questionnaire (SACQ) and the short-form 12 (SF-12). The SACQ (Table 1) is a wellvalidated, self-reported, adjustment to college survey, using 67 questions on 4 different subscales: academic, social, emotional, and school attachment.5,6 Questions address how well a student perceives that they are adapting to the demands of college life.6 The SF-12 is a well-validated, general quality of life survey containing questions on physical and mental subscales.7 The disease-specific surveys were administered to subjects with IBD. We used the Short Inflammatory Bowel Disease Questionnaire (SIBDQ) to assess IBDrelated quality of life. This validated questionnaire consists of 10 questions that measure the impact of IBD on social and emotional domains as well as physical
Table 1. Demographics
Age (mean SEM)a Duration of disease, y Sex, female/totalb Class standingb Freshman Sophomore Junior Senior Hospitalized in past 2 years Surgery for IBD Part-time student for health reasons Live at college
Q14 Q15
Q16
Q34
UC vs CD P value
Control vs IBD P value
Control
UC
CD P value
19.9 1.3 – 136/214
20.3 1.7 3.8 0.6 20/28
20.2 1.6 4.8 0.5 46/65
.07 .2 .5c
.6 – .1c
40 52 58 64 – – 1/214
3 6 8 11 12/28 3/28 1/28
14 10 18 23 29/65 10/65 4/65
.6c
.5c
.9c .6c .6c
– – .05c
.198/214
25/28
60/65
.6c
.7c
a
Ten students failed to report their age (2 with UC, 6 with CD, and 2 controls). One student failed to report their class standing and sex. c Pearson chi square. b
FLA 5.2.0 DTD YJCGH53779_proof 6 May 2014 7:26 pm ce
175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232
-
233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290
2014
College Students with IBD
symptoms.8,9 The Harvey–Bradshaw Index (HBI) is a widely used Crohn’s disease activity index consisting of symptom questions, physical examination findings, and hematocrit level.10 Sandler et al11 developed a modified HBI questionnaire that does not include physical examination or laboratory tests and was shown to correlate well with the original HBI. We used this modified HBI to assess disease activity in students with Crohn’s disease (CD). Students with ulcerative colitis (UC) completed the Simple Clinical Colitis Activity Index (SCCAI), a validated 16-question survey, to assess disease activity.12 For aggregate analysis of disease activity among students with both CD and UC we used the percentage of maximum score for each activity index as described previously.4 We additionally queried academic information including whether the student is enrolled full time or part time, the geographic location of their college, the frequency with which they visit home, whether the students with IBD believe that their disease has influenced their schedule or course load, and whether they have had to drop out because of their disease, among others (Table 2).
Statistical Analysis
Q17
Q18
Descriptive statistics were used to evaluate demographics. The Wilcoxon rank-sum test was used to compare ordinal variables such as college adjustment (SACQ), and the Student t test was used as appropriate for continuous variables such as the general quality of life (SF-12) between subjects with IBD and subjects in the control group. To investigate the impacts of disease activity (HBI and SCCAI) on college adjustment (SACQ) and disease-specific quality of life (SIBDQ), the Spearman rank correlation was calculated from subjects with IBD. The Spearman rank correlation was used because both the SACQ and SIBDQ provide ordinal results and thus require nonparametric statistics. All tests were 2-tailed with a threshold for significance set at a P value of .05 or less. To assess the relationship between disease activity and scoring of individual questions, we used the Cochran–Mantel–Haenszel chi-squared test. Analysis was performed using Stata for Mac version 12.1 statistical software (College Station, TX).
Results Q19
The survey was initiated by 465 undergraduate students, 307 (66%) of whom completed the survey. The students attended schools in 27 states throughout the United States, with the majority (39%) being from Michigan. A total of 94.4% of students were enrolled full time. Of the 5.9% who were enrolled part time, 33.3% indicated that this was owing to health problems (Table 2). Respondents included 65 students with Crohn’s disease, 28 students with ulcerative colitis, and
3
Q1
214 students without IBD as nondiseased controls (Table 3). The class rank of the respondents included 57 freshmen (19%), 68 sophomores (22%), 84 juniors (27%), and 98 seniors (32%). The distribution of classes was similar between controls and students with IBD.
Adjustment to College Students with IBD had an overall poorer adjustment to college (mean SACQ, 290.3 3.5) than their healthy peers (mean, 307.3 2.3; P < .0001; Figure 1). There was no difference in college adjustment between students with CD and UC (293.1 4.3 vs 283.9 5.7; P < .22). There were also no differences between how well women adjusted to college compared with men for either those with IBD (287.8 4.1 vs 296.4 6.6; P ¼ .16) or healthy students (304.9922 2.944 vs 311.0 3.6; P ¼ .14). When CD and UC were considered separately, students with both CD and UC had lower college adjustment scores than controls (CD, 293.1 4.3, P ¼ .0021; and UC, 283.9 5.7, P ¼ .0002; vs controls, 307.3 2.3).
Q20
Q21
Disease Activity and Adjustment to College There was a significant, although modest, inverse relationship between Crohn’s disease activity (as determined by the HBI) and college adjustment scores (SACQ, rho ¼ -0.24, P ¼ .04; Figure 2A), indicating that more severe disease activity is associated with poorer college adjustment. There was no such association between SACQ and SCCAI in students with UC (rho ¼ 0.14; P ¼ .48), however, it was noted that few students with UC had severe disease activity, limiting the scope of this assessment (Figure 2B). Students with Crohn’s disease who lived at home with their parents had significantly poorer college adjustment than students with Crohn’s disease who lived at school (258.2 16.2 vs 296.0 4.3; P ¼ .029), whether in a dormitory or an apartment. There were no significant differences in college adjustment between students who lived at home or lived at school for students with UC (271.7 21.1 vs 285.4 6.0; P ¼ .46) or in healthy control students (315.9 9.1 vs 306.6 2.3; P ¼ .41).
Adjustment to College and Quality of Life The college adjustment measure (SACQ) correlated with disease-specific quality of life (SIBDQ, rho ¼ 0.28; P ¼ .0063; Figure 3A). The SACQ contains questions in several domains. When considered separately, the personal-emotional domain of the SACQ correlated best with the SIBDQ (rho ¼ 0.43; P < .0001), indicating a significant impact on emotional adjustment relating to college adjustment for IBD students. The SIBDQ in students with Crohn’s disease was not different from that of students with UC (43.6 vs 45.4; P ¼ .44), however, the personal-emotional SACQ correlated more strongly with
FLA 5.2.0 DTD YJCGH53779_proof 6 May 2014 7:26 pm ce
Q22
291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348
4
349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406
Almadani et al
Clinical Gastroenterology and Hepatology Vol.
-,
No.
-
Table 2. Additional Survey Questions Questions Full-time Part-time Currently enrolled Highest level of education attained by parents/primary caregiver
In which state do you attend college?
How often do you visit home?
What is your current living situation?
Q35
Has having IBD affected you in the following ways? (respondents with IBD only)
Have you ever let your teachers know of your diagnosis? (respondents with IBD only) Have you ever used the following (respondents with IBD only)
Did you delay starting college because of your IBD? (respondents with IBD only) Have you ever had to drop out because of your IBD? (respondents with IBD only)
Q23
SIBDQ in students with Crohn’s disease than in students with UC (rho ¼ 0.51 vs 0.24). Not surprisingly, the overall assessment of disease-specific quality of life (SIBDQ) correlated closely with disease activity (rho ¼ -0.79; P < .0001), indicating that more severe disease activity is associated with a lower quality of life (Figure 3B). Students with poor college adjustment (IBD and control), defined by Baker et al,6 the authors of the SACQ, as a t-score corresponding to the lowest quartile, were more likely to report feeling unable to keep up to date with their academic work (c2 ¼ 6.84; P ¼ .0089), reported being unsatisfied with their academic performance (c2 ¼ 8.07; P ¼ .0045), had more difficulty concentrating (c2 ¼ 6.0, P ¼ .014), reported more inefficient use of their study time (c2 ¼ 12.55, P ¼ .0004),
Number (percentage of all respondents unless otherwise noted) 290 (94.4%) 18 (5.9%); because of work, 12 (3.9%); because of health problems, 6 (2%) Yes, 263 (85.7%); no, 44 (14.3%) Junior high/middle school, 3 (1.0%); high school, 22 (7.2%); some college, 39 (12.7%); college graduate, 89 (29.0%); master’s degree, 80 (26.1%); professional degree, 95 (30.9%) Michigan, 120 (39.1%); Virginia, 37 (12.1%); Pennsylvania, 34 (11.1%); North Carolina, 21 (6.8%); Maryland, 14 (4.6%); Illinois, 13 (4.2%); New York, 13 (4.2%); Minnesota, 12 (3.9%); Massachusetts, 8 (2.6%); Ohio, 6 (2%);
Clinical Gastroenterology and Hepatology 2014;-:-–-
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58
Effects of Inflammatory Bowel Disease on Students’ Adjustment to College Q13
S. Bashar Almadani,*,a Jeremy Adler,‡,a Jeff Browning,§ Elan H. Green,jj Karla Helvie,jj Raf Rizk,jj and Ellen M. Zimmermannjj *Department of Internal Medicine, Division of Gastroenterology, Rush University Medical Center, Chicago, Illinois; ‡ Department of Pediatrics and Communicable Diseases, Division of Pediatric Gastroenterology, jjDepartment of Internal Medicine, Division of Gastroenterology, University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan; § Virginia Commonwealth University, Richmond, Virginia BACKGROUND & AIMS:
Successful adjustment to college is required for academic success. We investigated whether inflammatory bowel disease (IBD) activity affects this adjustment process.
METHODS:
We created an online survey that included a standardized adjustment to college questionnaire (SACQ), a general quality of life survey (SF-12), a disease-specific short IBD quality of life survey (SIBDQ), and disease activity indices. Undergraduate students across the United States were recruited via social media.
RESULTS:
Surveys were completed by 65 students with Crohn’s disease (CD), 28 with ulcerative colitis, and 214 healthy students (controls). Disease-specific quality of life (SIBDQ results) correlated with IBD disease activity (rho [ –0.79; P < .0001). High college adjustment scores (SACQ results) were associated with high SIBDQ scores. Students with IBD had lower mean SACQ scores than controls (307 vs 290; P < .0001). There was a modest inverse correlation between CD activity and SACQ (rho [ –0.24; P < .04). Disease activity in students with CD was associated strongly with their self-reported ability to keep up with academic work (P < .0089) and confidence in their ability to meet future academic challenges (P < .0015). Students with active IBD reported feeling as if they were not doing well for the amount of work they were doing (P < .018), and students with ulcerative colitis reported irregular class attendance (P < .043).
CONCLUSIONS:
Students with IBD do not adjust to college as well as healthy students. Disease activity affects their adjustment and attitudes about academics—especially among students with CD. Successful adjustment is important for academic success, affecting graduation rates and future economic success. Strategies to increase disease control and provide social and emotional support during college could improve adjustment to college and academic performance, and increase patients’ potential.
Q8
Q9
Keywords: Transition; Age; Teen; Young Adult; UC. Q10 Q11
he formative years of college are critical to a successful career after graduation. Students who do not adjust well to college achieve lower grades and have higher drop-out rates, both of which have lifelong implications regarding career opportunities, earning potential, and the availability of high-quality health insurance. Little is known about how students with chronic illnesses adapt to the challenges and demands of college life. Even less is known about how students with inflammatory bowel disease (IBD) adjust to college. Students with IBD are known to experience greater perceived stress than their classmates without IBD.1 Perceived stress has a detrimental impact on a student’s ability to adjust to college.2,3 The relationship between IBD disease activity and stress is complex. It is
T
not clear how disease activity or the stress of coping with active IBD is related to college adjustment. In a pilot study assessing college adjustment in University of Michigan students with IBD, we found that students with
a
Authors share co-first authorship.
Abbreviations used in this paper: CD, Crohn’s disease; HBI, Harvey– Bradshaw Index; IBD, inflammatory bowel disease; SACQ, student adjustment to college; SCCAI, simple clinical colitis activity index; SF-12, general quality of life survey the short-form 12; SIBDQ, disease-specific short inflammatory bowel disease quality of life survey; UC, ulcerative colitis. © 2014 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.03.032
FLA 5.2.0 DTD YJCGH53779_proof 6 May 2014 7:26 pm ce
Q7
59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116
2
117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
Almadani et al
Clinical Gastroenterology and Hepatology Vol.
Crohn’s disease had more difficulty adjusting to college than their healthy classmates and that the students with more active disease had greater difficulty adjusting to college than those with less active disease.4 To enlarge the study population and increase the power to detect subtle differences, we designed a nationwide, Internetbased study to examine the relationship between IBD disease activity and college adjustment. Our national study confirmed observations that students with IBD adjusted less well to college than their peers. This was particularly true of social and emotional adjustment. Further, worsening disease activity negatively impacted college adjustment and had alarming affects on selfreported academic attitudes. Our findings could provide important information for students, parents, and caregivers, as well as college faculty and administration, which could help students be more successful in college and later in life.
Materials and Methods
Q12
Q13
We performed an Internet-based case-control study that was administered nationwide from May 2008 through September 2011. We intended to recruit a 2:1 ratio of healthy students to students with IBD. We recruited students through multiple modalities to maximize the number of students reached. This included pamphlets, fliers, newspaper advertisements, e-mails sent out by local university student health services (Table 2 shows the states that were represented), as well as e-mails to student support or interest groups. We also implemented an e-marketing campaign using social media websites such as www.facebook.com and www. myspace.com, as well as various IBD-related websites including the Crohn’s and Colitis Foundation of America’s website (www.ccfa.org). Recruitment of students as
-,
No.
-
healthy controls was accomplished by asking each student with IBD to provide the link to the survey to 2 friends who do not have IBD, but are approximately the same age, have a similar major of study, and who have similar study habits as determined by the student with IBD. To do so, they were prompted to submit their friends’ e-mail addresses. An automatic e-mail generator then sent an automatic e-mail invitation. The healthy friends of each IBD student formed the matched control group. This study was approved by the University of Michigan institutional review board, including waiver of parental consent for 17-year-old students.
Survey Instruments We created a web-based informed consent with subsequent links to surveys created with SurveyMonkey (www.surveymonkey.com). The surveys included both disease-independent and disease-specific questionnaires. The disease-independent surveys were administered to all study participants and included the Student Adjustment to College Questionnaire (SACQ) and the short-form 12 (SF-12). The SACQ (Table 1) is a wellvalidated, self-reported, adjustment to college survey, using 67 questions on 4 different subscales: academic, social, emotional, and school attachment.5,6 Questions address how well a student perceives that they are adapting to the demands of college life.6 The SF-12 is a well-validated, general quality of life survey containing questions on physical and mental subscales.7 The disease-specific surveys were administered to subjects with IBD. We used the Short Inflammatory Bowel Disease Questionnaire (SIBDQ) to assess IBDrelated quality of life. This validated questionnaire consists of 10 questions that measure the impact of IBD on social and emotional domains as well as physical
Table 1. Demographics
Age (mean SEM)a Duration of disease, y Sex, female/totalb Class standingb Freshman Sophomore Junior Senior Hospitalized in past 2 years Surgery for IBD Part-time student for health reasons Live at college
Q14 Q15
Q16
Q34
UC vs CD P value
Control vs IBD P value
Control
UC
CD P value
19.9 1.3 – 136/214
20.3 1.7 3.8 0.6 20/28
20.2 1.6 4.8 0.5 46/65
.07 .2 .5c
.6 – .1c
40 52 58 64 – – 1/214
3 6 8 11 12/28 3/28 1/28
14 10 18 23 29/65 10/65 4/65
.6c
.5c
.9c .6c .6c
– – .05c
.198/214
25/28
60/65
.6c
.7c
a
Ten students failed to report their age (2 with UC, 6 with CD, and 2 controls). One student failed to report their class standing and sex. c Pearson chi square. b
FLA 5.2.0 DTD YJCGH53779_proof 6 May 2014 7:26 pm ce
175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232
-
233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290
2014
College Students with IBD
symptoms.8,9 The Harvey–Bradshaw Index (HBI) is a widely used Crohn’s disease activity index consisting of symptom questions, physical examination findings, and hematocrit level.10 Sandler et al11 developed a modified HBI questionnaire that does not include physical examination or laboratory tests and was shown to correlate well with the original HBI. We used this modified HBI to assess disease activity in students with Crohn’s disease (CD). Students with ulcerative colitis (UC) completed the Simple Clinical Colitis Activity Index (SCCAI), a validated 16-question survey, to assess disease activity.12 For aggregate analysis of disease activity among students with both CD and UC we used the percentage of maximum score for each activity index as described previously.4 We additionally queried academic information including whether the student is enrolled full time or part time, the geographic location of their college, the frequency with which they visit home, whether the students with IBD believe that their disease has influenced their schedule or course load, and whether they have had to drop out because of their disease, among others (Table 2).
Statistical Analysis
Q17
Q18
Descriptive statistics were used to evaluate demographics. The Wilcoxon rank-sum test was used to compare ordinal variables such as college adjustment (SACQ), and the Student t test was used as appropriate for continuous variables such as the general quality of life (SF-12) between subjects with IBD and subjects in the control group. To investigate the impacts of disease activity (HBI and SCCAI) on college adjustment (SACQ) and disease-specific quality of life (SIBDQ), the Spearman rank correlation was calculated from subjects with IBD. The Spearman rank correlation was used because both the SACQ and SIBDQ provide ordinal results and thus require nonparametric statistics. All tests were 2-tailed with a threshold for significance set at a P value of .05 or less. To assess the relationship between disease activity and scoring of individual questions, we used the Cochran–Mantel–Haenszel chi-squared test. Analysis was performed using Stata for Mac version 12.1 statistical software (College Station, TX).
Results Q19
The survey was initiated by 465 undergraduate students, 307 (66%) of whom completed the survey. The students attended schools in 27 states throughout the United States, with the majority (39%) being from Michigan. A total of 94.4% of students were enrolled full time. Of the 5.9% who were enrolled part time, 33.3% indicated that this was owing to health problems (Table 2). Respondents included 65 students with Crohn’s disease, 28 students with ulcerative colitis, and
3
Q1
214 students without IBD as nondiseased controls (Table 3). The class rank of the respondents included 57 freshmen (19%), 68 sophomores (22%), 84 juniors (27%), and 98 seniors (32%). The distribution of classes was similar between controls and students with IBD.
Adjustment to College Students with IBD had an overall poorer adjustment to college (mean SACQ, 290.3 3.5) than their healthy peers (mean, 307.3 2.3; P < .0001; Figure 1). There was no difference in college adjustment between students with CD and UC (293.1 4.3 vs 283.9 5.7; P < .22). There were also no differences between how well women adjusted to college compared with men for either those with IBD (287.8 4.1 vs 296.4 6.6; P ¼ .16) or healthy students (304.9922 2.944 vs 311.0 3.6; P ¼ .14). When CD and UC were considered separately, students with both CD and UC had lower college adjustment scores than controls (CD, 293.1 4.3, P ¼ .0021; and UC, 283.9 5.7, P ¼ .0002; vs controls, 307.3 2.3).
Q20
Q21
Disease Activity and Adjustment to College There was a significant, although modest, inverse relationship between Crohn’s disease activity (as determined by the HBI) and college adjustment scores (SACQ, rho ¼ -0.24, P ¼ .04; Figure 2A), indicating that more severe disease activity is associated with poorer college adjustment. There was no such association between SACQ and SCCAI in students with UC (rho ¼ 0.14; P ¼ .48), however, it was noted that few students with UC had severe disease activity, limiting the scope of this assessment (Figure 2B). Students with Crohn’s disease who lived at home with their parents had significantly poorer college adjustment than students with Crohn’s disease who lived at school (258.2 16.2 vs 296.0 4.3; P ¼ .029), whether in a dormitory or an apartment. There were no significant differences in college adjustment between students who lived at home or lived at school for students with UC (271.7 21.1 vs 285.4 6.0; P ¼ .46) or in healthy control students (315.9 9.1 vs 306.6 2.3; P ¼ .41).
Adjustment to College and Quality of Life The college adjustment measure (SACQ) correlated with disease-specific quality of life (SIBDQ, rho ¼ 0.28; P ¼ .0063; Figure 3A). The SACQ contains questions in several domains. When considered separately, the personal-emotional domain of the SACQ correlated best with the SIBDQ (rho ¼ 0.43; P < .0001), indicating a significant impact on emotional adjustment relating to college adjustment for IBD students. The SIBDQ in students with Crohn’s disease was not different from that of students with UC (43.6 vs 45.4; P ¼ .44), however, the personal-emotional SACQ correlated more strongly with
FLA 5.2.0 DTD YJCGH53779_proof 6 May 2014 7:26 pm ce
Q22
291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348
4
349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406
Almadani et al
Clinical Gastroenterology and Hepatology Vol.
-,
No.
-
Table 2. Additional Survey Questions Questions Full-time Part-time Currently enrolled Highest level of education attained by parents/primary caregiver
In which state do you attend college?
How often do you visit home?
What is your current living situation?
Q35
Has having IBD affected you in the following ways? (respondents with IBD only)
Have you ever let your teachers know of your diagnosis? (respondents with IBD only) Have you ever used the following (respondents with IBD only)
Did you delay starting college because of your IBD? (respondents with IBD only) Have you ever had to drop out because of your IBD? (respondents with IBD only)
Q23
SIBDQ in students with Crohn’s disease than in students with UC (rho ¼ 0.51 vs 0.24). Not surprisingly, the overall assessment of disease-specific quality of life (SIBDQ) correlated closely with disease activity (rho ¼ -0.79; P < .0001), indicating that more severe disease activity is associated with a lower quality of life (Figure 3B). Students with poor college adjustment (IBD and control), defined by Baker et al,6 the authors of the SACQ, as a t-score corresponding to the lowest quartile, were more likely to report feeling unable to keep up to date with their academic work (c2 ¼ 6.84; P ¼ .0089), reported being unsatisfied with their academic performance (c2 ¼ 8.07; P ¼ .0045), had more difficulty concentrating (c2 ¼ 6.0, P ¼ .014), reported more inefficient use of their study time (c2 ¼ 12.55, P ¼ .0004),
Number (percentage of all respondents unless otherwise noted) 290 (94.4%) 18 (5.9%); because of work, 12 (3.9%); because of health problems, 6 (2%) Yes, 263 (85.7%); no, 44 (14.3%) Junior high/middle school, 3 (1.0%); high school, 22 (7.2%); some college, 39 (12.7%); college graduate, 89 (29.0%); master’s degree, 80 (26.1%); professional degree, 95 (30.9%) Michigan, 120 (39.1%); Virginia, 37 (12.1%); Pennsylvania, 34 (11.1%); North Carolina, 21 (6.8%); Maryland, 14 (4.6%); Illinois, 13 (4.2%); New York, 13 (4.2%); Minnesota, 12 (3.9%); Massachusetts, 8 (2.6%); Ohio, 6 (2%);
