ANNUAL REVIEWS
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HEALTH ISSUES FOR COLLEGE STUDENTS Kevin Patrick,1,2 Ted W. Grace / and Chris Y. Lovatol.3 lStudent Health Services, Division of Student Affairs; 2The University of California, San Diego-San Diego State University General Preventive Medicine Residency Pro gram; and 3Graduate School of Public Health, Division of Health Promotion, San Diego State University, San Diego, California 92182 KEY WORDS:
student health. adolescent health. school health. higher education
INTRODUCTION This paper addresses issues pertinent to the health of, and health care systems for, college students. We describe characteristics of the college student population, including important subgroups of students with unique health problems. After briefly reviewing the history and current practice of college health services, we address specific health problems and current and future issues for college student health. INSTITUTIONS OF HIGHER EDUCATION In 1990, there were more than 3500 colleges and universities in the United States (49), which range in size from the smallest technical and trade schools to comprehensive research universities with enrollments that exceed 50,000 students. Generalizations are difficult, because of the remarkable diversity of institutional morphology, which arises from variations in public or private governance and accountability; student population size, gender, ethnic char acteristics, and residential versus commuter status; number and type of gradu ate, professional, and/or research programs; and the overall financial resource base of the institution. 253
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From a public health standpoint, these institutions may be viewed as complex combinations of schools and workplaces in which social, environ mental, behavioral, political, economic, legal, philosophical, and cultural issues conspire to create unique and difficult challenges for health promotion, disease prevention, and medical care. In part, this is because of the tradi tionally open nature of college communities. Colleges and universities are unlike primary and secondary schools, in which the local school district and parents share authority. They are also distinct from traditional workplaces, in which employer-employee relationships, management structures, collective bargaining rules, and other hierarchical processes define issues of authority, accountability, and responsibility. Post-secondary students come and go. They commonly shift geopolitical jurisdictions because of their education. Although they often need them, students typically are ineligible for public social and human services, the eligibility for which is usually based upon complicated residence, income, and working status requirements. Universities vary tremendously with respect to how much, if at all, they attend to their students' nonacademic needs. Thus, college and university environments exist as extraordinarily complex social systems with nonuniform policies, unstable populations, and a wide range of relationships to the communities in which they are located. THE COLLEGE STUDENT POPULATION In the fall of 1988, 13,043,118 students attended colleges and universities in the US (50). Only 57% of these students were 24 years of age or younger, thus dispelling the common misperception that college students are 18-22 years old. Nearly 30% were aged 30 years or older. Overall, 54.6% were female. With regard to ethnicity, 81% were non-Hispanic whites, 9% were blacks, 5% were Hispanics, 4% were Asian/Pacific Islands, and 1% were American Indian; 20% lived in school-owned housing, 50% off-campus, and 30% with parents. Some 38% described themselves as independent. It is common for college health practitioners to define and characterize subpopulations of students (57). Grouping may be based upon preexisting health status or other shared characteristics on entry, or upon participation, while at the university, in environments associated with risk for health problems. Four important groups are as follows:
Disabled Students Of the 12.5 million college students enrolled in the fall of 1986, 1,319,229 (10.5%) had at least one disability (51). In 1988, 6% of full-time college freshmen were reported as having at least one disability, which more than doubles the figure for 1978 (47). Over half of these students have "hidden"
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disabilities, such as learning disorders (27). According to Section 504 of the Rehabilitation Act of 1973, a student qualifies as having a disability if he or she "has a physical or mental impairment which substantially limits one or more major life activity; has a record of such impairment; or is regarded as having such impairment. " Common disabilities seen among college students include visual handicaps; deafness and hearing impainnent; speech im pairment; neurologic and orthopedic handicaps; chronic diseases and con ditions, such as asthma, arthritis, lupus, diabetes, and cystic fibrosis; and chronic psychiatric disorders.
International Students In 1989-1990, there were more than 385,000 international college students (66). The majority came from Asian nations, with China, Taiwan, Japan, and Korea leading the list. Latin America, Europe, the Middle East, and Africa accounted for 11.9%, 9.7%, 6.4%, and 4.8%, respectively, of the in ternational student population. An estimated 35,000 additional students are enrolled in intensive English language programs, which are often attended before official enrollment in a college or university. Although most in ternational students come to the US alone, some bring spouses and children. International students, who have unique ethnic and culture-specific beliefs, present special health needs (6). It is common to have only a few fellow nationals on a given campus at any one time. The sense of isolation felt by such students contributes to, and is often made worse by, illness and its concomitant dependency.
Health Professions Students The health and health-related professions, such as medicine, nursing, den tistry, dental hygiene, physical therapy, and many of the biologic sciences, account for almost 450,000 students (26). Characterized by learning environ ments that require either direct patient contact or exposure to blood and patient tissue, such students are unique in their needs and demands for health services. Routine health problems found in this age group may be exaggerated in their incidence and importance because of heightened awareness brought about through study. The prevention and management of communicable diseases, such as tuberculosis, hepatitis B, and human immunodeficiency virus (HIV) infection present major challenges for student health practition ers.
Nontraditional Students "Nontraditional student" is a tenn used often and imprecisely, which general ly denotes older, part-time, and working students. On some campuses, partic ularly commuter campuses, they comprise more than half of all students.
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However, one must not assume that all students over a certain age, for example 28 or 35, fit into this category. Many older students are full-time students who have left a job, the military, or some other environment to pursue one or more years of study, or they are graduate students in extended length programs. We reserve the term nontraditional student for those stu dents whose primary sphere of activity is away from the campus environment. Depending upon their age and health status, nontraditional students may substantially broaden the range and complexity of health problems seen in a campus health center. HISTORICAL ASPECTS OF COLLEGE HEALTH The history of college health practice has been addressed in numerous pub lications over the past several decades (7, 8, 33, 34, 38, 40). Some historical aspects of college health are of particular relevance to the field of public health. For example, of the many early influences on college health, physical activity and health education were among the most important. This was represented in the early 1800s, through an effort to import the mens sana in corpore sano model of fitness from European higher education. Coupled with curricula in what was popularly called "hygiene, " at Williams College in 1851 and later in the same year at the City College of New York, students were educated on "the active duties of operative life, rather than those more particularly regarded as necessary for the pulpit, bar, or medical-profession" (41). During the latter half of the 1800s, several colleges and universities opened health centers based upon the sentiment expressed in 1856 by President Stearns of Amherst who noted that "the breaking down of health of students, especially in the spring of the year, which is exceedingly common, involving the necessity of leaving college in many instances, and crippling the energies and destroying the prospects of not a few who remain, is in my opinion wholly unnecessary if proper measures could be taken to prevent it" (22). In 1859, Amherst established a Department of Physical Education and Hygiene, generally regarded as the first college health service. Mount Holyoke and Vassar followed suit in 1861 and 1865, respectively. The health physician at each of these colleges had both clinical and teaching duties. The first "com prehensive" student health care services were probably offered at these two women's colleges. Combining medical services, infirmary care, nursing ser vices, and health promotion activities, these centers carried out almost all aspects of current-day student health services. The ascendency of public health knowledge and practice from the tum of the century through World War I contributed to college health practice. The federal government turned to Dr. Thomas Storey, Professor and Director of
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Hygiene at the City College of New York, to head an agency aimed at allocating federal resources for venereal disease control. Because of his view of the importance of university environments to the control of this problem, Dr. Storey ensured that some of these resources were spent to improve college health practice (7). After World War I, Dr. Storey's influence on college health continued with his 1927 publication, The Status of Hygiene Programs in Institutions ofHigher Education in the United States (44), which stimulated the development of the first set of recommended practices for college health centers. With an expanding economy and growth in size and number of institutions of higher education, almost 85% of colleges offered some sort of student health service by the early 1950s (34). COLLEGE HEALTH PRACTICE Approximately 1500 institutions of higher education, which enroll 80% of the nation's college students, provide some form of organized student health care (39). Student health centers (SHCs) range in size and scope of activity from small, nurse-directed facilities, which provide limited nursing and health educational services to comprehensive health facilities that resemble multi specialty group practices, some with their own Joint Commission on Accreditation of Healthcare Organizations-accredited hospitals. Three areas of emphasis predominate for SHCs: medical, psychological, and health pro motion. Medical services range from those that address acute problems only to full-spectrum care, including the management of chronic disease (15). Facilitating access to primary medical care is a central rationale for the existence of SHCs. High rates of uninsurance, unfamiliarity with the local community resources and/or how to get to them, and lack of understanding about whom to see if a medical problem develops are traits common to college students. Resource-poor SHCs often give only advice and assistance with access to community providers. On large campuses, the predominant model of SHC medical service is a primary care setting staffed by physicians, nurse practitioners, physician assistants, nurses, medical assistants, and various supporting laboratory, pharmacy and radiologic personnel. Immunization clinics and family planning clinics are common. Some campuses provide dental services, and a few provide optometric care. Psychological services are an important part of college health practice. These services range from small campuses, which might employ a masters level counselor for crisis intervention and minimal, short-term counseling duties, to large-scale operations staffed by psychologists, psychiatrists, and other mental health personnel. Services might include short-term, individual patient counseling, extended psychotherapy, crisis intervention, rape and
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sexual assault counseling, initiation and maintenance of psychopharmacolog ic agents, group therapy, and facilitation for such groups as Alcoholics Anonymous and Adult Children of Alcoholics (59). Health promotion and health educational services are the third "mainstay" of traditional college health practice. Zapka & Love (65) have stated that there is no arena in which health educational services plays a relatively greater role than in college health settings. Small SHCs usually dispense health education through the nursing staff. In larger SHCs, departments of health education or health promotion exist, staffed by masters or doctoral trained health promo tion or health education professionals. College students visit an SHC an average of two to three times during a school year (39). This level of utilization is somewhat lower than the 3. 5 medical visits per year for individuals aged 19-24 noted in the National Health Care Expenditures Survey (60). The lower average number of visits estimated for SHC utilization may result because students are only on campus part of the year, and many have conditions treated electively during the summer or other breaks from school. Although this paper concentrates on student health issues, it is important to recognize that some institutions extend campus health services to serve staff and/or faculty and occasionally student, staff, or faculty dependents. This becomes important when considering health education and health promotion programing. Smoking and alcohol policies, sexual harassment, and injury control are just a few areas in which comprehensive approaches aimed at the entire membership of the campus community are common. Student health centers are funded through a combination of fee-for-service, identified (prepaid) health fees, insurance reimbursement, and general univer sity support (39). Some SHCs augment these sources through creative arrangements with state or local health departments, research dollars, or other fund-raising activities. Private colleges are more likely than public institutions to require proof of health insurance before entry. This is also true of health professions schools. Health services, like most other components of universities, exist as a result of university policy. These policies are extremely important to the day to day operation of health centers, as they dictate everything from health center resource base to hiring policies. Policies and standards, which ultimately govern SHC activities, vary in proportion to the heterogeneity of colleges and universities themselves. Even in states with centrally managed, multisite university systems, such as the California State University or the State University of New York, the actual manifestations of uniform student health service policies may differ. The reasons for this difference include the prox imity of the campus to other medical or health resources, academic offerings of the campus (e.g. nursing or medical schools), local financial and
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programatic interpretation of central policy, administrative recognidon and support of student health needs, and advocacy on the part of students them selves for health care. Since 1964, the American College Health Association has offered recom mended standards for SHCs to use to develop externally valid and consistent programs. Revised on a periodic basis, most recently in 1991, these standards address clinical, mental health, health promotion, environmental health, and support services, as well as ethical and professional issues (2). HEALTH PROBLEMS OF COLLEGE STUDENTS Only one study in the recent medical or public health literature examines the types of problems encountered in student health centers (19), although some studies do address issues in specific subpopulations (18, 63). The lack of such data is an important public health problem, because its absence can lead medical and public health professionals to the conclusion that relatively few, and only minor, health needs occur among college students. Lack of informa tion can also lead to poor planning for health services delivery. A wide range of acute and chronic health problems, which represents a substantial burden of morbidity and mortality, does occur among college students. Acute health problems include genitourinary, respiratory, or gastrointestin al infections. Outbreaks of vaccine-preventable diseases, such as measles, mumps, and rubella, continue on college campuses (61, 62). Nearly two thirds of sexually transmitted disease cases occur among persons under 25 years of age (13), many among college students. Sexual assault of college students is common: One study suggests that one of six female college students were victimized by rape or attempted rape within the preceeding year (30). Dermatologic conditions, musculoskeletal problems, and minor trauma, including sprains, fractures, and lacerations, are commonly seen in student health centers. Injuries account for up to half of all deaths for those aged 10 to 24 years (53, 64), although with respect to college and university popUlations these statistics can be misleading. As stated earlier, only about 57% of the current college popUlation fall into the "typical" 18-24 age range. Also, certain causes of death, such as homicide, are clearly more common in nonstudent groups. Some chronic medical problems begin as a new event in the 18-24 age group, whereas others carry over from childhood. Seizure disorders, migraine headaches, bronchial asthma and other atopic disorders, type I insulin dependent diabetes, arthritis, inflammatory bowel disease, and peptic ulcer disease are just a few of the diseases encountered on a regular basis in student health facilities. Some cancers occur more frequently in college-age popu-
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lations. Acute leukemias, ,Hodgkin's disease, testicular neoplasms, and malignant bone tumors, such as osteogenic sarcomas, are more common in adolescents and young adults. More than 50% of all cases of acquired immunodeficiency syndrome (AIDS) are diagnosed in persons aged 25 to 39. A seroprevalence survey among university students reported one positive result per 500 students tested, or 0.2% (21). Student health centers serve a growing number of students with serious physical and psychological disabilities, such as patients with Down's syn drome, muscular dystrophy, cerebral palsy, trauma-induced neurologic def icits, and cystic fibrosis. Mental health problems, including stress and situational reactions, anxiety and panic disorders, sexual identity and dys functional problems, personality disorders, schizophrenia, and major de pressive disorders, often begin during the college years. HEALTH RISK BEHAVIORS A series of behavioral, developmental, and environmental issues, which recur throughout the above set of health problems and concerns for college stu dents, contribute to premature morbidity and mortality and reduced quality of life for college youth. From a public health and preventive medical perspec tive, these factors may be enumerated and addressed. Although they may be considered separately, it is essential to understand their interrelated nature.
Alcohol Use Alcohol use is the single most important public health problem for college students. Alcohol intoxication may be associated with up to 25% of all deaths in college-aged students (42). Heavy drinking episodes (five or more drinks) are more prevalent among college youth than their same age peers (54). Of injury-related deaths among persons aged 15-24, 75% are caused by motor vehicle accidents, and nearly half of all motor vehicle accidents involve alcohol (14). Besides motor vehicle accidents, alcohol abuse is closely related to other social and health problems of college students. On college campuses, alcohol consumption is related to two thirds of all violent behavior, almost half of all physical injuries, a third of all emotional difficulties, and 30% of all academic problems (25).
Tobacco and Other Drugs Although the rate of daily cigarette use among college students is lower than among the general population (13% versus 26%), nearly one in four college students smokes at least one cigarette per month (54), which suggests that they are experimenting with the substance and are at risk of addiction. Daily smoking rates are estimated at 9% for men and 15% for women (54). The
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concurrent use of tobacco and oral contraceptives among many women in this age group places them at higher risk of developing heart disease and cancer, in addition to the other negative health consequences of tobacco consumption. College students have an annual prevalence rate for marijuana use equal to their noncollege-age peers (35%), and a lower rate of daily marijuana use (1.8% versus 4.8%, respectively). Although other drug use among college students tends to be lower than among their same-age peers, the difference varies according to type of drug. Annual prevalence rates for any illicit drug other than marijuana is 19% for those enrolled in college versus 24% for high school graduates in the same age group (54).
Sexual Behavior Reportedly, 78% of adolescent girls and 86% of adolescent boys have en gaged in sexual intercourse by age 20 (52). The relationships of sexual behaviors to alcohol and drug use, stress, and developmental and cultural issues are a Gordian knot for researchers and practitioners in the field of college health. Sexually transmitted diseases, unintended pregnancy, and worry over these problems are the daily fare of college health centers. An assessment of the prevalence and risk factors for HIV among college students suggests that, although the overall prevalence of infection is low and confined to high-risk groups, the occurrence of behaviors that facilitate sexual transmission of HIV is high (31). Although college students appear to be knowledgeable about HIV infection, they have not adequately adopted pre ventive behaviors (28). One survey of college students found that only 25% of men and 16% of women always used a condom during sexual intercourse (32). However, condom use does appear to have increased minimally among college students in recent years (17). Unintended pregnancy continues to be a serious, and often life-changing, problem among college women, although a review of the recent medical and public health literature reveals no reports of pregnancy rates specific to college student populations. Cumulative evidence suggests that a substantial proportion of sexually active college students do not use contraceptives (17, 46). Alcohol and drug use has been associated with unprotected/unsafe sexual practices. A recent survey of freshman at 14 US colleges indicated that one of six students reported engaging in unplanned sexual activity after drinking alcoholic beverages (58).
Suicide and Stress Suicide is the third leading cause of death among youth aged 15-24, and the second leading cause of death among young white men in the same age group. Young women attempt suicide unsuccessfully approximately three times more often than their male counterparts (52). The causes of suicide are multiple and
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complex; however, substance abuse and severe stress in school or social life have been linked to suicide among youth (55). The college years represent a time of transition from adolescence to adulthood, and from more structured environments to independent living situations. Coping and adapting to this transition coincides with emotional and often psychologically traumatic ex periences, as well as life-style changes that can have lifetime consequences.
Nutrition and Physical Activity During the college years, adolescents and young adults develop health habits that put them at greater risk for the development of many chronic diseases, including cardiovascular disease, cancer, and osteoporosis. Dietary habits and physical activity are primary risk factor areas subject to change during the college years. Stephens et al (43) have suggested that the most dramatic reduction in physical activity levels occurs between the ages of 18 and 24. There is increasing epidemiologic evidence to support a positive relationship between physical activity and physical health, and a similar relationship apparently exists between physical activity and mental health (9). Diet is linked to heart disease and cancer, yet American eating habits do not reflect our current level of knowledge ( 16). The college years represent a time during which there are likely to be unique barriers (e.g. resources, skills, and facilities) that limit college students' ability to maintain healthful eating habits. The intense academic and social pressures of campus life may increase the risk for development of an eating disorder, such as binge-eating, purging, and dieting (45). UNIQUE ISSUES FOR THE FIELD OF COLLEGE HEALTH To complete the picture of college health in this country, we address some final issues.
Nonstandard Age Definitions for Adolescence and Youth One of the most important barriers to the development of coherent health programs for college-age youth is that of differing definitions of "adoles cence" and "youth. " Without commonly agreed upon standards for these terms, it is virtually impossible to collect meaningful morbidity and mortality data; develop, compare, and evaluate programs aimed at addressing health issues of adolescents and youth; or even create appropriate policies aimed at health promotion, disease prevention, and medical care. Age grouping per meates everything in medicine and public health, from medical practice arrangements to research agendas to journal publications. Some age group ings for adolescence end at 17 or 18 years (48). Others extend to 24 years. For
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example, the United Nations' definition of "youth" or "young people" encom passes the age limits 15 to 24 years (4). Similarly, the World Health Orga nization's definition of adolescence has raised the upper age limit to 24 years, or about the time of total socioeconomic independence (4). Three recent reports on adolescent health have avoided addressing the health issues of college-age youth. The Congressional Office of Technology Assessment's April 1991 report on adolescents limited its scope to those aged 10 through 18 years (48). The American Medical Association acknowledged the importance of barriers to health care access faced by those aged 19 to 24, but excluded them from its report (20). Finally, preliminary data from the National Center for Health Statistics on the health care utilization patterns of adolescents covers only those aged 11 to 20 years (35). It is difficult not to conjecture that the reason young adults were ignored in these reports is that unique data for them is sparse and confusing. In an environment in which information on adolescents and young adults is either not collected at all, or collected in nonstandard ways, it can easily appear that few problems exist.
Responsibility, Accountability, and Perceptual Issues One of the largest "cracks" in the way our society handles health problems is that confronted by adolescents and young adults as they transit from the sphere of authority and responsibility of their family-of-origin and move into that of their own family and workplace. Who is responsible for the health of the 22-year-old emancipated college student with a part-time job in the service industry: the student, his/her parents, the college, the student's employer, the community in which the student lives, or some combination of these? The "structure" of our health care system does not yield an answer to this question. Our discipline-bound perspectives in public health and medicine only confound the issue. Organized medicine has overlooked the college student population in the past, probably because of the limited economic incentives in such a traditionally "healthy" group. This has contributed to the rising concern over the competency of health care professionals to meet the health needs of young people (5). School health, a traditional area of public health practice, is almost always considered to address only those issues relevant to preschool through 12th grade students. Public health practice, on the other hand, tends to focus upon defined disadvantaged and underserved populations in governmental jurisdictions. College students are not included when planning these services, even in the face of profound shifts in their social and demographic characteristics. Students covered by their parents' insurance policies are usually only eligible through age 22 or 23, and many lack insurance (37). A recent survey in California found that up to 30% of students had no medical insurance (10). Experience on our campus suggests that another 30% have only partial health
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insurance coverage. Temporary status in low-skilled labor positions does not provide insurance for self-supporting students. Also, even though most adolescents and young adults do not incur great expenses for health care during any given year, average expenditure data can be misleading. One study found that 10% of adolescents with the highest expenses accounted for 65% of all out-of-pocket expenses (36). Given that college is now commonly a five to seven-year undertaking, with variable amounts of time "off' to either join the temporary workplace or to pursue individual interests, questions of responsibility are very complicated indeed. DIRECTIONS FOR THE FUTURE OF COLLEGE HEALTH Several current, anticipated, and necessary developments are likely to shape the future of college health theory and practice.
Healthy People 2000 2000: National Health Promotion and Disease Prevention 2000 specifically addresses college student health as follows: "Increase to at least 50% the proportion of postsecondary institutions with institution-wide health promotion programs for students, faculty, and staff' (52). Postsecondary institutions, including two- and four-year commu nity colleges, private colleges, universities, and trade and technical schools, have been identified as settings in which many 18- to 24-year-olds can be reached. Currently, there are no reliable national estimates of the proportion of postsecondary schools that offer institution-wide health promotion pro grams. A survey of 3000 postsecondary institutions conducted by the Amer ican College Health Association in 1989- 1990 suggests that at least 20% of the institutions surveyed offered health promotion activities for students ( 1). It is encouraging that Healthy People 2000 recognizes young people as a special population that, in many cases, experiences higher rates of morbidity, disabil ity, and mortality than the general population (3). Healthy People
Objectives for the Year
Comprehensive College Health and the Integration of School Health, College Health, Worksite Health, and Public Health Promotion A comprehensive approach to college health requires the integration of pro grams and services similar to that which is now advocated for school health. College communities share many characteristics with K-12 schools. Tradi tional school health, including only health instruction and clinical health services, is expanding to incorporate five additional areas: integrated school and community health promotion efforts, physical education, food service, counseling, and health promotion programs for faculty and staff (29). College
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health practice is likely to expand similarly. A framework for the develop ment of campus-based health programs would include environmental, bio medical, behavioral, and organizational interventions (23). However, as we noted earlier, the unique, independent, and often balkanized nature of college campuses will make such logical and coherent approaches difficult. The first step should be measurable success in community health pro motion--
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Annu. Rev. Publ. Health 1992. 13:253-68 Copyright © 1992 by Annual Reviews Inc. All rights reserved
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HEALTH ISSUES FOR COLLEGE STUDENTS Kevin Patrick,1,2 Ted W. Grace / and Chris Y. Lovatol.3 lStudent Health Services, Division of Student Affairs; 2The University of California, San Diego-San Diego State University General Preventive Medicine Residency Pro gram; and 3Graduate School of Public Health, Division of Health Promotion, San Diego State University, San Diego, California 92182 KEY WORDS:
student health. adolescent health. school health. higher education
INTRODUCTION This paper addresses issues pertinent to the health of, and health care systems for, college students. We describe characteristics of the college student population, including important subgroups of students with unique health problems. After briefly reviewing the history and current practice of college health services, we address specific health problems and current and future issues for college student health. INSTITUTIONS OF HIGHER EDUCATION In 1990, there were more than 3500 colleges and universities in the United States (49), which range in size from the smallest technical and trade schools to comprehensive research universities with enrollments that exceed 50,000 students. Generalizations are difficult, because of the remarkable diversity of institutional morphology, which arises from variations in public or private governance and accountability; student population size, gender, ethnic char acteristics, and residential versus commuter status; number and type of gradu ate, professional, and/or research programs; and the overall financial resource base of the institution. 253
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From a public health standpoint, these institutions may be viewed as complex combinations of schools and workplaces in which social, environ mental, behavioral, political, economic, legal, philosophical, and cultural issues conspire to create unique and difficult challenges for health promotion, disease prevention, and medical care. In part, this is because of the tradi tionally open nature of college communities. Colleges and universities are unlike primary and secondary schools, in which the local school district and parents share authority. They are also distinct from traditional workplaces, in which employer-employee relationships, management structures, collective bargaining rules, and other hierarchical processes define issues of authority, accountability, and responsibility. Post-secondary students come and go. They commonly shift geopolitical jurisdictions because of their education. Although they often need them, students typically are ineligible for public social and human services, the eligibility for which is usually based upon complicated residence, income, and working status requirements. Universities vary tremendously with respect to how much, if at all, they attend to their students' nonacademic needs. Thus, college and university environments exist as extraordinarily complex social systems with nonuniform policies, unstable populations, and a wide range of relationships to the communities in which they are located. THE COLLEGE STUDENT POPULATION In the fall of 1988, 13,043,118 students attended colleges and universities in the US (50). Only 57% of these students were 24 years of age or younger, thus dispelling the common misperception that college students are 18-22 years old. Nearly 30% were aged 30 years or older. Overall, 54.6% were female. With regard to ethnicity, 81% were non-Hispanic whites, 9% were blacks, 5% were Hispanics, 4% were Asian/Pacific Islands, and 1% were American Indian; 20% lived in school-owned housing, 50% off-campus, and 30% with parents. Some 38% described themselves as independent. It is common for college health practitioners to define and characterize subpopulations of students (57). Grouping may be based upon preexisting health status or other shared characteristics on entry, or upon participation, while at the university, in environments associated with risk for health problems. Four important groups are as follows:
Disabled Students Of the 12.5 million college students enrolled in the fall of 1986, 1,319,229 (10.5%) had at least one disability (51). In 1988, 6% of full-time college freshmen were reported as having at least one disability, which more than doubles the figure for 1978 (47). Over half of these students have "hidden"
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disabilities, such as learning disorders (27). According to Section 504 of the Rehabilitation Act of 1973, a student qualifies as having a disability if he or she "has a physical or mental impairment which substantially limits one or more major life activity; has a record of such impairment; or is regarded as having such impairment. " Common disabilities seen among college students include visual handicaps; deafness and hearing impainnent; speech im pairment; neurologic and orthopedic handicaps; chronic diseases and con ditions, such as asthma, arthritis, lupus, diabetes, and cystic fibrosis; and chronic psychiatric disorders.
International Students In 1989-1990, there were more than 385,000 international college students (66). The majority came from Asian nations, with China, Taiwan, Japan, and Korea leading the list. Latin America, Europe, the Middle East, and Africa accounted for 11.9%, 9.7%, 6.4%, and 4.8%, respectively, of the in ternational student population. An estimated 35,000 additional students are enrolled in intensive English language programs, which are often attended before official enrollment in a college or university. Although most in ternational students come to the US alone, some bring spouses and children. International students, who have unique ethnic and culture-specific beliefs, present special health needs (6). It is common to have only a few fellow nationals on a given campus at any one time. The sense of isolation felt by such students contributes to, and is often made worse by, illness and its concomitant dependency.
Health Professions Students The health and health-related professions, such as medicine, nursing, den tistry, dental hygiene, physical therapy, and many of the biologic sciences, account for almost 450,000 students (26). Characterized by learning environ ments that require either direct patient contact or exposure to blood and patient tissue, such students are unique in their needs and demands for health services. Routine health problems found in this age group may be exaggerated in their incidence and importance because of heightened awareness brought about through study. The prevention and management of communicable diseases, such as tuberculosis, hepatitis B, and human immunodeficiency virus (HIV) infection present major challenges for student health practition ers.
Nontraditional Students "Nontraditional student" is a tenn used often and imprecisely, which general ly denotes older, part-time, and working students. On some campuses, partic ularly commuter campuses, they comprise more than half of all students.
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However, one must not assume that all students over a certain age, for example 28 or 35, fit into this category. Many older students are full-time students who have left a job, the military, or some other environment to pursue one or more years of study, or they are graduate students in extended length programs. We reserve the term nontraditional student for those stu dents whose primary sphere of activity is away from the campus environment. Depending upon their age and health status, nontraditional students may substantially broaden the range and complexity of health problems seen in a campus health center. HISTORICAL ASPECTS OF COLLEGE HEALTH The history of college health practice has been addressed in numerous pub lications over the past several decades (7, 8, 33, 34, 38, 40). Some historical aspects of college health are of particular relevance to the field of public health. For example, of the many early influences on college health, physical activity and health education were among the most important. This was represented in the early 1800s, through an effort to import the mens sana in corpore sano model of fitness from European higher education. Coupled with curricula in what was popularly called "hygiene, " at Williams College in 1851 and later in the same year at the City College of New York, students were educated on "the active duties of operative life, rather than those more particularly regarded as necessary for the pulpit, bar, or medical-profession" (41). During the latter half of the 1800s, several colleges and universities opened health centers based upon the sentiment expressed in 1856 by President Stearns of Amherst who noted that "the breaking down of health of students, especially in the spring of the year, which is exceedingly common, involving the necessity of leaving college in many instances, and crippling the energies and destroying the prospects of not a few who remain, is in my opinion wholly unnecessary if proper measures could be taken to prevent it" (22). In 1859, Amherst established a Department of Physical Education and Hygiene, generally regarded as the first college health service. Mount Holyoke and Vassar followed suit in 1861 and 1865, respectively. The health physician at each of these colleges had both clinical and teaching duties. The first "com prehensive" student health care services were probably offered at these two women's colleges. Combining medical services, infirmary care, nursing ser vices, and health promotion activities, these centers carried out almost all aspects of current-day student health services. The ascendency of public health knowledge and practice from the tum of the century through World War I contributed to college health practice. The federal government turned to Dr. Thomas Storey, Professor and Director of
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Hygiene at the City College of New York, to head an agency aimed at allocating federal resources for venereal disease control. Because of his view of the importance of university environments to the control of this problem, Dr. Storey ensured that some of these resources were spent to improve college health practice (7). After World War I, Dr. Storey's influence on college health continued with his 1927 publication, The Status of Hygiene Programs in Institutions ofHigher Education in the United States (44), which stimulated the development of the first set of recommended practices for college health centers. With an expanding economy and growth in size and number of institutions of higher education, almost 85% of colleges offered some sort of student health service by the early 1950s (34). COLLEGE HEALTH PRACTICE Approximately 1500 institutions of higher education, which enroll 80% of the nation's college students, provide some form of organized student health care (39). Student health centers (SHCs) range in size and scope of activity from small, nurse-directed facilities, which provide limited nursing and health educational services to comprehensive health facilities that resemble multi specialty group practices, some with their own Joint Commission on Accreditation of Healthcare Organizations-accredited hospitals. Three areas of emphasis predominate for SHCs: medical, psychological, and health pro motion. Medical services range from those that address acute problems only to full-spectrum care, including the management of chronic disease (15). Facilitating access to primary medical care is a central rationale for the existence of SHCs. High rates of uninsurance, unfamiliarity with the local community resources and/or how to get to them, and lack of understanding about whom to see if a medical problem develops are traits common to college students. Resource-poor SHCs often give only advice and assistance with access to community providers. On large campuses, the predominant model of SHC medical service is a primary care setting staffed by physicians, nurse practitioners, physician assistants, nurses, medical assistants, and various supporting laboratory, pharmacy and radiologic personnel. Immunization clinics and family planning clinics are common. Some campuses provide dental services, and a few provide optometric care. Psychological services are an important part of college health practice. These services range from small campuses, which might employ a masters level counselor for crisis intervention and minimal, short-term counseling duties, to large-scale operations staffed by psychologists, psychiatrists, and other mental health personnel. Services might include short-term, individual patient counseling, extended psychotherapy, crisis intervention, rape and
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sexual assault counseling, initiation and maintenance of psychopharmacolog ic agents, group therapy, and facilitation for such groups as Alcoholics Anonymous and Adult Children of Alcoholics (59). Health promotion and health educational services are the third "mainstay" of traditional college health practice. Zapka & Love (65) have stated that there is no arena in which health educational services plays a relatively greater role than in college health settings. Small SHCs usually dispense health education through the nursing staff. In larger SHCs, departments of health education or health promotion exist, staffed by masters or doctoral trained health promo tion or health education professionals. College students visit an SHC an average of two to three times during a school year (39). This level of utilization is somewhat lower than the 3. 5 medical visits per year for individuals aged 19-24 noted in the National Health Care Expenditures Survey (60). The lower average number of visits estimated for SHC utilization may result because students are only on campus part of the year, and many have conditions treated electively during the summer or other breaks from school. Although this paper concentrates on student health issues, it is important to recognize that some institutions extend campus health services to serve staff and/or faculty and occasionally student, staff, or faculty dependents. This becomes important when considering health education and health promotion programing. Smoking and alcohol policies, sexual harassment, and injury control are just a few areas in which comprehensive approaches aimed at the entire membership of the campus community are common. Student health centers are funded through a combination of fee-for-service, identified (prepaid) health fees, insurance reimbursement, and general univer sity support (39). Some SHCs augment these sources through creative arrangements with state or local health departments, research dollars, or other fund-raising activities. Private colleges are more likely than public institutions to require proof of health insurance before entry. This is also true of health professions schools. Health services, like most other components of universities, exist as a result of university policy. These policies are extremely important to the day to day operation of health centers, as they dictate everything from health center resource base to hiring policies. Policies and standards, which ultimately govern SHC activities, vary in proportion to the heterogeneity of colleges and universities themselves. Even in states with centrally managed, multisite university systems, such as the California State University or the State University of New York, the actual manifestations of uniform student health service policies may differ. The reasons for this difference include the prox imity of the campus to other medical or health resources, academic offerings of the campus (e.g. nursing or medical schools), local financial and
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programatic interpretation of central policy, administrative recognidon and support of student health needs, and advocacy on the part of students them selves for health care. Since 1964, the American College Health Association has offered recom mended standards for SHCs to use to develop externally valid and consistent programs. Revised on a periodic basis, most recently in 1991, these standards address clinical, mental health, health promotion, environmental health, and support services, as well as ethical and professional issues (2). HEALTH PROBLEMS OF COLLEGE STUDENTS Only one study in the recent medical or public health literature examines the types of problems encountered in student health centers (19), although some studies do address issues in specific subpopulations (18, 63). The lack of such data is an important public health problem, because its absence can lead medical and public health professionals to the conclusion that relatively few, and only minor, health needs occur among college students. Lack of informa tion can also lead to poor planning for health services delivery. A wide range of acute and chronic health problems, which represents a substantial burden of morbidity and mortality, does occur among college students. Acute health problems include genitourinary, respiratory, or gastrointestin al infections. Outbreaks of vaccine-preventable diseases, such as measles, mumps, and rubella, continue on college campuses (61, 62). Nearly two thirds of sexually transmitted disease cases occur among persons under 25 years of age (13), many among college students. Sexual assault of college students is common: One study suggests that one of six female college students were victimized by rape or attempted rape within the preceeding year (30). Dermatologic conditions, musculoskeletal problems, and minor trauma, including sprains, fractures, and lacerations, are commonly seen in student health centers. Injuries account for up to half of all deaths for those aged 10 to 24 years (53, 64), although with respect to college and university popUlations these statistics can be misleading. As stated earlier, only about 57% of the current college popUlation fall into the "typical" 18-24 age range. Also, certain causes of death, such as homicide, are clearly more common in nonstudent groups. Some chronic medical problems begin as a new event in the 18-24 age group, whereas others carry over from childhood. Seizure disorders, migraine headaches, bronchial asthma and other atopic disorders, type I insulin dependent diabetes, arthritis, inflammatory bowel disease, and peptic ulcer disease are just a few of the diseases encountered on a regular basis in student health facilities. Some cancers occur more frequently in college-age popu-
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lations. Acute leukemias, ,Hodgkin's disease, testicular neoplasms, and malignant bone tumors, such as osteogenic sarcomas, are more common in adolescents and young adults. More than 50% of all cases of acquired immunodeficiency syndrome (AIDS) are diagnosed in persons aged 25 to 39. A seroprevalence survey among university students reported one positive result per 500 students tested, or 0.2% (21). Student health centers serve a growing number of students with serious physical and psychological disabilities, such as patients with Down's syn drome, muscular dystrophy, cerebral palsy, trauma-induced neurologic def icits, and cystic fibrosis. Mental health problems, including stress and situational reactions, anxiety and panic disorders, sexual identity and dys functional problems, personality disorders, schizophrenia, and major de pressive disorders, often begin during the college years. HEALTH RISK BEHAVIORS A series of behavioral, developmental, and environmental issues, which recur throughout the above set of health problems and concerns for college stu dents, contribute to premature morbidity and mortality and reduced quality of life for college youth. From a public health and preventive medical perspec tive, these factors may be enumerated and addressed. Although they may be considered separately, it is essential to understand their interrelated nature.
Alcohol Use Alcohol use is the single most important public health problem for college students. Alcohol intoxication may be associated with up to 25% of all deaths in college-aged students (42). Heavy drinking episodes (five or more drinks) are more prevalent among college youth than their same age peers (54). Of injury-related deaths among persons aged 15-24, 75% are caused by motor vehicle accidents, and nearly half of all motor vehicle accidents involve alcohol (14). Besides motor vehicle accidents, alcohol abuse is closely related to other social and health problems of college students. On college campuses, alcohol consumption is related to two thirds of all violent behavior, almost half of all physical injuries, a third of all emotional difficulties, and 30% of all academic problems (25).
Tobacco and Other Drugs Although the rate of daily cigarette use among college students is lower than among the general population (13% versus 26%), nearly one in four college students smokes at least one cigarette per month (54), which suggests that they are experimenting with the substance and are at risk of addiction. Daily smoking rates are estimated at 9% for men and 15% for women (54). The
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concurrent use of tobacco and oral contraceptives among many women in this age group places them at higher risk of developing heart disease and cancer, in addition to the other negative health consequences of tobacco consumption. College students have an annual prevalence rate for marijuana use equal to their noncollege-age peers (35%), and a lower rate of daily marijuana use (1.8% versus 4.8%, respectively). Although other drug use among college students tends to be lower than among their same-age peers, the difference varies according to type of drug. Annual prevalence rates for any illicit drug other than marijuana is 19% for those enrolled in college versus 24% for high school graduates in the same age group (54).
Sexual Behavior Reportedly, 78% of adolescent girls and 86% of adolescent boys have en gaged in sexual intercourse by age 20 (52). The relationships of sexual behaviors to alcohol and drug use, stress, and developmental and cultural issues are a Gordian knot for researchers and practitioners in the field of college health. Sexually transmitted diseases, unintended pregnancy, and worry over these problems are the daily fare of college health centers. An assessment of the prevalence and risk factors for HIV among college students suggests that, although the overall prevalence of infection is low and confined to high-risk groups, the occurrence of behaviors that facilitate sexual transmission of HIV is high (31). Although college students appear to be knowledgeable about HIV infection, they have not adequately adopted pre ventive behaviors (28). One survey of college students found that only 25% of men and 16% of women always used a condom during sexual intercourse (32). However, condom use does appear to have increased minimally among college students in recent years (17). Unintended pregnancy continues to be a serious, and often life-changing, problem among college women, although a review of the recent medical and public health literature reveals no reports of pregnancy rates specific to college student populations. Cumulative evidence suggests that a substantial proportion of sexually active college students do not use contraceptives (17, 46). Alcohol and drug use has been associated with unprotected/unsafe sexual practices. A recent survey of freshman at 14 US colleges indicated that one of six students reported engaging in unplanned sexual activity after drinking alcoholic beverages (58).
Suicide and Stress Suicide is the third leading cause of death among youth aged 15-24, and the second leading cause of death among young white men in the same age group. Young women attempt suicide unsuccessfully approximately three times more often than their male counterparts (52). The causes of suicide are multiple and
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complex; however, substance abuse and severe stress in school or social life have been linked to suicide among youth (55). The college years represent a time of transition from adolescence to adulthood, and from more structured environments to independent living situations. Coping and adapting to this transition coincides with emotional and often psychologically traumatic ex periences, as well as life-style changes that can have lifetime consequences.
Nutrition and Physical Activity During the college years, adolescents and young adults develop health habits that put them at greater risk for the development of many chronic diseases, including cardiovascular disease, cancer, and osteoporosis. Dietary habits and physical activity are primary risk factor areas subject to change during the college years. Stephens et al (43) have suggested that the most dramatic reduction in physical activity levels occurs between the ages of 18 and 24. There is increasing epidemiologic evidence to support a positive relationship between physical activity and physical health, and a similar relationship apparently exists between physical activity and mental health (9). Diet is linked to heart disease and cancer, yet American eating habits do not reflect our current level of knowledge ( 16). The college years represent a time during which there are likely to be unique barriers (e.g. resources, skills, and facilities) that limit college students' ability to maintain healthful eating habits. The intense academic and social pressures of campus life may increase the risk for development of an eating disorder, such as binge-eating, purging, and dieting (45). UNIQUE ISSUES FOR THE FIELD OF COLLEGE HEALTH To complete the picture of college health in this country, we address some final issues.
Nonstandard Age Definitions for Adolescence and Youth One of the most important barriers to the development of coherent health programs for college-age youth is that of differing definitions of "adoles cence" and "youth. " Without commonly agreed upon standards for these terms, it is virtually impossible to collect meaningful morbidity and mortality data; develop, compare, and evaluate programs aimed at addressing health issues of adolescents and youth; or even create appropriate policies aimed at health promotion, disease prevention, and medical care. Age grouping per meates everything in medicine and public health, from medical practice arrangements to research agendas to journal publications. Some age group ings for adolescence end at 17 or 18 years (48). Others extend to 24 years. For
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example, the United Nations' definition of "youth" or "young people" encom passes the age limits 15 to 24 years (4). Similarly, the World Health Orga nization's definition of adolescence has raised the upper age limit to 24 years, or about the time of total socioeconomic independence (4). Three recent reports on adolescent health have avoided addressing the health issues of college-age youth. The Congressional Office of Technology Assessment's April 1991 report on adolescents limited its scope to those aged 10 through 18 years (48). The American Medical Association acknowledged the importance of barriers to health care access faced by those aged 19 to 24, but excluded them from its report (20). Finally, preliminary data from the National Center for Health Statistics on the health care utilization patterns of adolescents covers only those aged 11 to 20 years (35). It is difficult not to conjecture that the reason young adults were ignored in these reports is that unique data for them is sparse and confusing. In an environment in which information on adolescents and young adults is either not collected at all, or collected in nonstandard ways, it can easily appear that few problems exist.
Responsibility, Accountability, and Perceptual Issues One of the largest "cracks" in the way our society handles health problems is that confronted by adolescents and young adults as they transit from the sphere of authority and responsibility of their family-of-origin and move into that of their own family and workplace. Who is responsible for the health of the 22-year-old emancipated college student with a part-time job in the service industry: the student, his/her parents, the college, the student's employer, the community in which the student lives, or some combination of these? The "structure" of our health care system does not yield an answer to this question. Our discipline-bound perspectives in public health and medicine only confound the issue. Organized medicine has overlooked the college student population in the past, probably because of the limited economic incentives in such a traditionally "healthy" group. This has contributed to the rising concern over the competency of health care professionals to meet the health needs of young people (5). School health, a traditional area of public health practice, is almost always considered to address only those issues relevant to preschool through 12th grade students. Public health practice, on the other hand, tends to focus upon defined disadvantaged and underserved populations in governmental jurisdictions. College students are not included when planning these services, even in the face of profound shifts in their social and demographic characteristics. Students covered by their parents' insurance policies are usually only eligible through age 22 or 23, and many lack insurance (37). A recent survey in California found that up to 30% of students had no medical insurance (10). Experience on our campus suggests that another 30% have only partial health
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insurance coverage. Temporary status in low-skilled labor positions does not provide insurance for self-supporting students. Also, even though most adolescents and young adults do not incur great expenses for health care during any given year, average expenditure data can be misleading. One study found that 10% of adolescents with the highest expenses accounted for 65% of all out-of-pocket expenses (36). Given that college is now commonly a five to seven-year undertaking, with variable amounts of time "off' to either join the temporary workplace or to pursue individual interests, questions of responsibility are very complicated indeed. DIRECTIONS FOR THE FUTURE OF COLLEGE HEALTH Several current, anticipated, and necessary developments are likely to shape the future of college health theory and practice.
Healthy People 2000 2000: National Health Promotion and Disease Prevention 2000 specifically addresses college student health as follows: "Increase to at least 50% the proportion of postsecondary institutions with institution-wide health promotion programs for students, faculty, and staff' (52). Postsecondary institutions, including two- and four-year commu nity colleges, private colleges, universities, and trade and technical schools, have been identified as settings in which many 18- to 24-year-olds can be reached. Currently, there are no reliable national estimates of the proportion of postsecondary schools that offer institution-wide health promotion pro grams. A survey of 3000 postsecondary institutions conducted by the Amer ican College Health Association in 1989- 1990 suggests that at least 20% of the institutions surveyed offered health promotion activities for students ( 1). It is encouraging that Healthy People 2000 recognizes young people as a special population that, in many cases, experiences higher rates of morbidity, disabil ity, and mortality than the general population (3). Healthy People
Objectives for the Year
Comprehensive College Health and the Integration of School Health, College Health, Worksite Health, and Public Health Promotion A comprehensive approach to college health requires the integration of pro grams and services similar to that which is now advocated for school health. College communities share many characteristics with K-12 schools. Tradi tional school health, including only health instruction and clinical health services, is expanding to incorporate five additional areas: integrated school and community health promotion efforts, physical education, food service, counseling, and health promotion programs for faculty and staff (29). College
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health practice is likely to expand similarly. A framework for the develop ment of campus-based health programs would include environmental, bio medical, behavioral, and organizational interventions (23). However, as we noted earlier, the unique, independent, and often balkanized nature of college campuses will make such logical and coherent approaches difficult. The first step should be measurable success in community health pro motion--
