The health of students in institutes of higher education: an important and neglected public health problem?

BACKGROUND

A survey of students in three UK higher education establishments was undertaken to obtain information about students' physical and emotional well-being, their attitudes to, and beliefs about health, and the prevalence of risk factors for future ill health.

METHODS

Health was measured by the prevalence of longstanding illness and by the SF-36 health status measurement tool. Survey results were compared with equivalent data for 18- to 34-year-olds in the local population. The prevalence of long-standing illness was also compared with two national surveys.

RESULTS

The survey achieved a 49 per cent response rate. More than one-third of respondents reported a long-standing illness, a higher prevalence than in all comparison surveys. Students scored significantly worse than their peers in the local population on all eight SF-36 dimensions. The greatest difference was for role limitations as a result of emotional problems. The main sources of emotional distress were study or work problems and money.

CONCLUSION

The poor response rate in this survey dictates the need for caution in interpretation of the results. However, they suggest that the health of students is poor relative to that of their peers, and that their emotional health is more of a problem than their physical health. Public health practitioners might want to pay more attention to the health of this important and relatively neglected group. Worries about studies and money appear to be affecting students' academic work, and this should be of concern to higher education establishments.

Do out-of-hours co-operatives improve general practitioners' health?

General practitioners (GPs) have been found to have a higher level of anxiety and depression then hospital managers and consultants. In 1995 and 1998, we surveyed GPs in Buckinghamshire. We found that the development of out-of-hours co-operatives was an important factor in the improvement in GPs' health status.

Behavior problems and group-based parent education programs

Behavior problems in children are an important social, educational, and health issue. The prevalence of these problems, their stability over time, their poor prognosis, and their costs to both individuals and the society, all point to the need for primary prevention and early effective interventions. A systematic review examined the effectiveness of group parent education programs that aimed to improve behavior problems in 3- to 10-year-old children. The phrase "parent education program" is used here to refer to group-based programs with a standardized format aimed at enhancing parenting skills. The term "behavior problems" is used to refer to children exhibiting externalizing problems such as temper tantrums, aggression, and noncompliance. It does not include children diagnosed as having attention-deficit hyperactivity disorder. This review focused explicitly on measures of child behavioral outcomes, which are only small, albeit important, outcomes of parent education programs. Reviews focusing on other clinically relevant outcomes are also needed, including parental well-being and attitudes towards parenting. Other reviews are also needed to collate evidence concerning the effectiveness of parent education programs with other age-groups, i.e., preschoolers and adolescents, and in improving other aspects of child well-being. The review included published studies only and as such may have been influenced by a "publication bias." Inclusion criteria comprised the use of a waiting list, a no-treatment or placebo control group, and at least one standardized measure assessing the child's behavior. Only studies published after 1970 that included at least one "group-based" parent education program were included. A total of 255 primary studies were identified, but only 16 of these and 2 follow-up studies met all of the specified inclusion criteria. Critical appraisal of these 16 studies revealed considerable heterogeneity in the interventions, the populations studied, and the outcome measures used. Nevertheless, these studies suggest that structured parent education programs can be effective in producing positive change in both parental perceptions and objective measures of children's behavior and that these changes are maintained over time. Because of the small number of controlled studies and their methodological variations, caution should be exercised before these findings are generalized broadly.

An epidemiological study of the relative importance of damp housing in relation to adult health

STUDY OBJECTIVE

To examine the association between damp housing and adult health, taking into account a wide range of other factors that may influence health and could confound this relation.

PARTICIPANTS AND SETTING

A general population sample of adults, aged 18-64, from Oxfordshire, Buckinghamshire, Berkshire and Northamptonshire.

DESIGN

Secondary analysis of responses to a postal questionnaire survey carried out in 1997 with a 64% response rate (8889 of 13 800). Housing dampness was assessed by self report. Health was measured by responses to a series of questions including presence of asthma and longstanding illness generally, use of health services and perceived health status (the SF-36). The effect of damp was examined using the chi(2) test and one way analysis of variance. Significant associations with the various health outcomes were further explored taking into account 35 other housing, demographic, psychosocial and lifestyle variables using stepwise logistic and linear regression.

MAIN RESULTS

Bivariate analyses indicated that damp was associated with the majority of health outcomes. Regression modelling however, found that being unable to keep the home warm enough in winter was a more important explanatory variable. Worry about pressure at work and to a lesser extent about money, showed an independent association with perceived health status equal to or greater than that of the housing environment, including cold housing, and that of health related lifestyles.

CONCLUSIONS

This study shows that being unable to keep the home warm enough in winter is more strongly associated with health outcomes than is damp housing. However, as cold and damp housing are closely related, it is likely that their combined effects are shown in these results. The importance of worry as an independent predictor of health status needs testing in other studies. Its prevalence and relative importance suggest that it may be a significant determinant of public health.

An evaluation of the effectiveness of the Injury Minimization Programme for Schools (IMPS)

OBJECTIVE

To evaluate the effect of an injury prevention programme (Injury Minimization Programme for Schools, IMPS) on children's primary and secondary prevention, and basic life support, knowledge, attitudes, skills, and behaviour.

DESIGN

Prospective non-randomised matched control.

SETTING

Radcliffe NHS Trust and primary and middle schools in Oxfordshire, UK.

SUBJECTS

1,200 year 6 children (10 and 11 years old); 600 received IMPS, a primary and secondary injury prevention programme taught in the school and hospital environments; 600 children in the control group received no planned intervention.

MAIN OUTCOME MEASURES

Safety knowledge, measured using a quiz. Resuscitation skills and behaviour observed and assessed using a simulated emergency scenario. Attitude and hypothetical behaviour towards safety assessed by the "draw and write" technique.

RESULTS

Before intervention, both groups had similar levels of knowledge. Five months after the intervention, significantly more IMPS trained children demonstrated a greater increase in knowledge in administering first aid and the correct procedure for making a call to the emergency services. They also demonstrated better basic life support techniques-for example, mouth-to-mouth and cardiac compressions. They identified more subtle dangers, were more likely to seek help, and tell others that their behaviour was dangerous.

CONCLUSION

The results demonstrate the benefits of the IMPS programme on injury prevention knowledge, attitudes, and behaviours.

Measuring the effectiveness of cataract surgery: the reliability and validity of a visual function outcomes instrument

AIMS

To assess test-retest reliability and validity of the "TyPE" patient self assessed visual function questionnaire, as part of a study in two hospitals measuring the effectiveness of cataract surgery. The American TyPE questionnaire had minor adaptations made for use in Britain.

METHODS

Test-retest reliability was assessed on 63 out of 378 adult cataract surgery patients in the study, using Spearman correlation coefficients and kappa coefficients of agreement. "Construct" validity was evaluated by comparing the association between changes in visual function questionnaire scores after surgery, with patients' perception of change in visual function obtained by independent interview of 24 patients.

RESULTS

The TyPE questionnaire items showed very good test-retest reliability. Average Spearman and kappa coefficients for 39 patients from hospital 1 were 0.93 and 0.84 respectively. Spearman and kappa coefficients of 0.9 and 0.81 were obtained for those nine patients in hospital 2 where both the test and retest questionnaires were filled in by the same people. However, for the 15 patients from hospital 2, where the questionnaire was filled in by different people in the retest, reliability was less good: the Spearman coefficients were still high, average 0.72, but the kappa coefficients were poor, 0.27. Good construct validity was exhibited, with a correlation of 0.79 between change in distance vision score from the questionnaires and the independent interview.

CONCLUSIONS

The adapted TyPE questionnaire is both very reliable and has good construct validity. The kappa coefficient should be used wherever possible to evaluate reliability. The test-retest reliability and validity and practicability of other visual function questionnaires have not been assessed adequately, and further development should be carried out of all such questionnaires, so that they may be introduced into routine clinical care.

Assessment of the SF-36 version 2 in the United Kingdom

OBJECTIVES

To introduce the UK SF36 Version II (SF36-II), and to (a) gain population norms for the UK SF36-II in a large community sample as well as to explore the instrument's internal consistency reliability and construct validity, and (b) to derive the Physical Component Summary (PCS) and Mental Component Summary (MCS) algorithms for the UK SF36-II.

DESIGN

Postal survey using a questionnaire booklet, containing the SF-36-II and questions on demographics and long term illness.

SETTING

The sample was drawn from General Practitioner Records held by the Health Authorities for Berkshire, Buckinghamshire, Northamptonshire, and Oxfordshire.

SAMPLE

The questionnaire was sent to 13,800 randomly selected subjects between the ages of 18-64 inclusive.

OUTCOME MEASURES

Scores for the eight dimensions of the UK SF36-II and the PCS and MCS summary scores.

RESULTS

The survey achieved a response rate of 64.4% (n = 8889). Internal consistency of the different dimensions of the questionnaire were found to be high. Normative data for the SF-36 are reported, broken down by age and sex, and social class. Factor analysis of the eight domains produced a two factor solution and provided weights for the UK SF36-II.

CONCLUSION

The SF36-II domains were shown to have improved reliability over the previous version of the UK SF36. Furthermore, enhancements to wording and response categories reduces the extent of floor and ceiling effects in the role performance dimensions. These advances are likely to lead to better precision as well as greater responsiveness in longitudinal studies.

Systematic review of the school entry medical examination

AIMS

To summarise and critically evaluate research conducted in the UK between 1962 and 1996, on the effectiveness and efficiency of the school entry medical (SEM) examination.

METHODS

An electronic search of a large number of databases, in conjunction with a search of reference lists, and sources in the grey literature produced a total of 64 studies.

RESULTS

Only one overview and 16 primary studies met the review's broad inclusion criteria. The results showed significant differences in the identification and referral of new and ongoing problems not only between the routine and selective SEM but also within the two types of SEM examination. There were also large differences in the numbers of children selected for SEM examination. No study included in the review defined either the methods or the criteria used to identify children as screen positive. No study provided follow up of children after referral to estimate the positive predictive value or yield of the screening, or follow up of the whole cohort to identify false negative cases.

CONCLUSION

Data on the effectiveness and efficiency of both the routine and selective SEM examination in accurately identifying children with new or ongoing health problems are not available at the present time. The studies reviewed here demonstrate the fragility of the evidence on which the school entry medical is based, and call into question the ethical basis of this programme.

The value of preschool vision screening

This paper summarises the findings of a systematic review of research on preschool vision screening. The review concludes that the provision of such screening programmes should be reconsidered, if not abandoned.

Screening in child health

Screening programmes in child health have evolved on the basis of individual enthusiasm and professional consensus, rather than being based on objective evidence of benefit. Three reviews have been carried out in the UK over the past 10 years. The only programmes which show robust evidence of effectiveness are those for PKU and hypothyroidism. The value of screening for hearing loss and vision defects is widely accepted, but there are many unresolved issues. Programmes for detection of congenital dislocation of the hip, congenital heart disease and growth disturbances are of doubtful value. Early identification of developmental problems is stressed by parents, but screening may not be the best way to achieve this. The UK programme of well-child care places increasing emphasis on promotion of physical and emotional health; screening tests should either be subjected to quality monitoring, or removed from the programme if they cannot fulfil the classic criteria of Wilson and Jungner.

Effectiveness of preschool vision screening

The ninth systematic review (Snowdon and Stewart-Brown 1997) from the NHS Centre for Reviews and Dissemination concludes that the lack of good evidence about the effectiveness of preschool vision screening justifies the withdrawal of the programme. The authors are concerned about the ethical correctness of inviting very young children to an implicitly beneficial examination when there is little to justify the intervention. The following article discusses the issues associated with vision screening of children aged three and four years old.

Emotional health problems are the most important cause of disability in adults of working age: a study in the four counties of the old Oxford region

OBJECTIVE

To assess the contribution of emotional health problems to the burden of disability affecting people of working age.

DESIGN

Analysis of data collected in a postal questionnaire survey of a random sample of people aged 18-64 years.

SETTING

The four counties of the old Oxford region in 1991.

SUBJECTS

9332 people who responded to a questionnaire survey mailed to 14,000 people randomly selected from the Family Health Service Authority registers of the four counties of Berkshire, Buckinghamshire, Oxfordshire, and Northamptonshire.

OUTCOMES MEASURES

Interference with work or other regular daily activity as reported in questions 4 and 5 of the health status measure SF-36.

RESULTS

In this population the prevalence of disability attributable to emotional health problems was greater than that attributable to all physical health problems combined. People reporting that their work or other regular daily activity was affected by their emotional health were much less likely to report a long-standing illness, consultation with a GP or consultation with a hospital doctor than people reporting a physical health problem.

CONCLUSIONS

Emotional health problems are a more important cause of disability in adults of working age than all physical health problems put together. Their importance is underestimated in health needs assessment exercises, which are based on NHS consultation rates or reporting of chronic illness. Research into the causes, prevention, and management of emotional health problems should be a national priority for the health service.

The effects of fundholding in general practice on prescribing habits three years after introduction of the scheme

OBJECTIVES

To observe changes in prescribing practice that occurred after the introduction of fundholding in first wave practices and to contrast these with changes occurring in similar non-fundholding practices.

DESIGN

Prospective observational study.

SETTING

Oxford region fundholding study.

SUBJECTS

Eight first wave fundholding practices and five practices that were not interested in fundholding in 1990-1, which were similar in terms of practice size, training status, locality, and urban rural mix. Three of the fundholding and none of the non-fundholding practices were dispensing practices.

MAIN OUTCOME MEASURES

Changes in prescribing practice as measured by net cost per prescribing unit, cost per item, number of items prescribed, and substitution rates for generic drugs three years after the introduction of fundholding. Data for fundholding practices were analysed separately according to whether they were dispensing or non-dispensing practices.

RESULTS

Prescribing costs rose by a third or more in all types of practice. The patterns of change observed in this cohort after one year of fundholding were reversed. No evidence existed that fundholding had controlled prescribing costs among non-dispensing fundholders; costs among dispensing fundholders rose least, but the differences were small compared with the overall increase in costs.

CONCLUSIONS

Early reports of the effectiveness of fundholding in curbing prescribing costs have not been confirmed in this longer term study.