Optimizing college health promotion in the digital age: Comparing perceived well-being, health behaviors, health education needs and preferences between college students enrolled in fully online versus campus-based programs

Sample

A volunteer sample of 961 college students enrolled in two large, accredited, fully online universities in the United States comprised the online student sample. At university number one, students were invited to participate through the school’s Participant Pool, a virtual bulletin board that connects researchers to participants. At university number two, students were recruited through the school’s “eCampus” portal, where students access their classrooms and support services. The announcement sent through communication listservs at both institutions invited students to take part in the research study and provided an explanation of the study aims. Participants were eligible to participate if they were currently enrolled in a fully online program and were 18 years of age or older. The study was hosted online in SurveyMonkey. The first page of the online survey was the consent form. It included background information, the voluntary nature of the study, risks and benefits, confidentiality, contacts and questions about rights as a participant, and the statement of consent via an electronic signature, regulated by the Uniform Electronic Transactions Act. Participants were informed that the maximum time commitment to complete the survey was 20 minutes, there was no monetary benefit, participation was optional and they could opt out at any time.

The NCHA archive and database in Spring 2015 included 91 497 completed college surveys and provided data for a comparison group. The comparison group completed the NCHA in the Spring of 2015 via an online surveying tool, Qualtrics. The comparison group received the survey link via a direct email from ACHA. The data was provided with permission by the ACHA.

Instrument

After electronically signing the consent form, participants completed a 36-item online survey comprised of subscales from the ACHA’s NCHA IIb. The NCHA is the most widely recognized survey used in college health in the United States.⁷ The original NCHA was developed by an interdisciplinary team of college health professionals and was pilot tested in 1998-1999 and has since undergone test for reliability and validity⁹ comparing common survey items with national surveys such as the National College Health Risk Behavior Survey (from the Centers for Disease Control) and the College Alcohol Study by the Harvard School of Public Health. The survey consists of 294 questions regarding physical and mental health, health education, and alcohol, tobacco, and drug use, as well as questions about impediments to academic performance and risk factors. Although the NCHA is not without limitations, a number of major studies has shown evidence that the ACHA-NCHA has “empirical value for representing the nation’s students.”⁷ The Spring 2015 data set included a sample of over 108 US colleges and universities and a total of 93 034 participants.

Permission was granted by ACHA to use select subscales of the NCHA IIb in order to create the 36-item online survey for online learners. The entire NCHA IIb was not utilized for this target population because some items, such as contraceptive use and frequency of “partying”, needed to be excluded due to a high rate of “not applicable” responses among the more “non-traditional” adult population. The researchers also wanted to keep the survey short and focused on issues that would be appropriate for addressing health promotion programming and services at the university level.

In order to better align with health risk factors and issues reported to be of influence to the well-being of non-traditional, online learners, the subscales included questions relating to: demographics (11 questions), health status and chronic health problems (CHP; 2 questions), alcohol and tobacco use (ATU; 2 questions), weight status, nutrition, exercise (WSNE; 7 questions), mental health (MH; 7 questions), academic impediments (AI; 1 question), and physical health (PH; 2 questions). Three additional questions were added about health education topic, modality and impact specifically “do you think your health and well-being impacts your academic standing?”, “are you interested in receiving information on the following topics”, and “if virtual services were offered, how would you like to receive this information?” Reliability analysis reported by the ACHA in 2013 demonstrated primarily moderate to strong scores for NCHA IIb sub scale items with reported standardized alphas as follows: 0.59 (CHP), 0.74 (ATU), 0.86 (WSNE), 0.84 (MH), 0.88 (AI), and 0.83 (PH).⁹

Statistical analyses

Descriptive and inferential statistical tests were used to analyze the data. The volunteer, online student sample was first screened for outliers, incomplete surveys, and participants that did not meet the study criteria. Forty-seven responses were excluded to arrive at the final total of 961. Frequencies on survey items were calculated and mean scores of subset measures for online students were compared against the NCHA IIb Spring 2015 data set using two-tailed z-test scores and independent sample t tests with alpha at 0.05. Online software Medcalc.com was used to calculate the t tests on the means and Social Science Statistics (online) was used for all z-calculations on the proportions.

Demographic characteristics of the samples

There were notable differences of demographic characteristics between the study sample (e.g. online students) and the comparison group (NCHA group) (Table 1). Of the 961 fully online students who completed the survey, the mean age was 40.2 years compared to 22.6 years for the NCHA group. The difference in the means of 17.6 years was highly statistically significant (P value < 0.0001). The student samples also differed in representation by racial/ethnic breakdown. More students identified as African American/Black in the online student sample (28.6%) compared to the NCHA group (5.5%) and more Hispanic/Latino students in the NCHA group than the online student sample (11.2% versus 5.2%). In the online student sample 2.6% identified as Asian/Pacific Islander compared to 13.7% in the NCHA sample and approximately 4% reported they were bi- or multi-racial in both samples.

The majority of students in the online and NCHA samples identified as female, 70.2% and 66.6% respectively. In terms of their sexual identity, the majority of students in both groups identified as heterosexual (90.0% for online students and 88.5% of non-online students), with the remainder identifying as LGBTQIA (9.1% online students vs. 11.5% non-online students).

More online students reported being married or partnered (53.9%) compared to students in the NCHA sample (9.3%), which is assumed to be based differences in age. The majority of online students worked 40 or more hours per week (61.8%) compared to the NCHA sample (6.5%), a highly statistically significant result (t-statistic = 92.93, P value < 0.0001). In addition, 92.0% students in the NCHA sample reported they were in school full-time versus 72.7% of students in fully online programs.

Health status and chronic health problems reported by online students vs. NCHA group

A higher percent of online students (15.7%) reported having been diagnosed with a chronic illness and/or disability (e.g. cancer, diabetes, autoimmune disorders) compared to 4.9% of the NCHA group (Table 2). Online college students were more likely to report a psychiatric condition (11.3%) compared to those in the NCHA sample (7.1%). The online sample also reported a higher percentage of a mobility disability (7.1%) versus the NCHA data set (0.9%). attention deficit/hyperactivity disorder (ADHD) was the highest reported health issue among the NCHA sample (7.4%) which is still lower than online student sample reporting ADHD (7.9%). More than double the percent of students in the online sample report deafness or problems with sight (10.1%) versus the NCHA sample (4.2%). The percent of students reporting a learning disability for both groups is around 4%. Test statistics for chronic illness (z = 14.90, Pvalue < 0.0001), deafness/hearing loss (z = 8.16, Pvalue < 0.0001), psychiatric condition (z = 4.98, Pvalue < 0.0001), and speech or language disorder (z = 3.79, Pvalue < 0.0001) were all statistically significant. The tests for learning disability (z = 0.55, Pvalue = 0.58) and attention deficit disorder (z = 0.56, Pvalue = 0.58) were not significant and we failed to reject that the null hypothesis was true.

Alcohol and tobacco use

The NCHA sample had statistically significantly higher percentages of students binge drinking (e.g. consuming 5 or more drinks in one sitting) over the previous 2 weeks compared to the online college students.

Although a greater percentage of online students in the sample (8.1%) reported smoking daily versus the NCHA sample (2.5%) (z = 10.57, Pvalue < 0.0001), cigarette use in the 30 days prior to completing the survey is higher in the NCHA sample at 8.0% compared to 4.7% of the online students (Table 3). Daily use of cigars, little cigars, clove cigarettes, and smokeless tobacco were similar for both groups.

Weight status, nutrition and exercise

There were statistically significant differences between the two groups on weight status (Table 4). Over 66% of online students classified themselves as overweight (z = 8.73, Pvalue < 0.0001) to very overweight (z = 22.67, Pvalue < 0.0001) with 69.4% currently trying to lose weight (z = 10.47, Pvalue < 0.0001), compared to the NCHA sample with 36.4% classifying themselves as overweight to very overweight and 52% trying to lose weight. The percentage of online students who consumed three or more servings of fruits and vegetables per day was higher (40.2%) compared to the NCHA sample (33.1%), although more than half in both samples reported consuming two or fewer servings per day. Regarding exercise, online students had a higher percent of zero days per week of: moderate-intensity cardio (30.5%), vigorous intensity (53.5%) and strength training (56.5%). Only 15.5% reported engaging in five or more days each week. A greater percentage of online students (53.5%) reported no days of vigorous-intensity cardio per week, compared to 41.1% of the NCHA sample. Only 8.6% of online students reported engaging in five or more days each week of vigorous cardio. Additionally, 56.6% of online students reported no (0 days) of strength training per week. Finally, 61.3% of online students reported sitting more than 6 hours each day.

Mental health

Regarding mental health, the survey inquired about students’ feelings in the previous two weeks. The NCHA sample had statistically significant higher proportions for: “Overwhelmed by all I have to do” (z = -9.12, Pvalue < 0.0001); “felt very lonely” (z = -7.98, Pvalue < 0.0001); “felt very sad” (z = -6.53, Pvalue < 0.0001); “felt so depressed it was difficult to function” (z = -3.27, Pvalue < 0.0001); and “felt overwhelming anxiety” (z = -2.51, Pvalue < 0.0001) (Table 5). However, a higher percentage of online students (29.3%) reported having been diagnosed with depression (z = 7.85, Pvalue < 0.0001) compared to the NCHA sample (19.1%). For both samples, more than half reported experiencing “more than average” to “tremendous levels” of stress over the previous 12 months (online= 51.9%, NCHA= 53.2%). Regarding sleep, the NCHA sample had a statistically significant higher percent of students who reported not getting enough rest to feel sleepy during the day (41.5%) for “more than a little problem” to a “very big problem” (z = -6.39, Pvalue < 0.0001) compared to 31.1% of the online student sample.

Academic impediments

The top five health impediments to academic performance reported by online students were: 1) stress; 2) chronic health problem; 3) work; 4) anxiety; and 5) death of a family/friend (Table 6). The top five health education topics of interest reported by online college students were: 1) stress; 2) nutrition; 3) physical activity; 4) sleep difficulties; 5) how to help others in distress.Stress, anxiety, and work ranked as top academic impediments for both groups, but chronic health problems and death of a family/friend were specific to online students. The majority (71%) of online students believed that health and well-being impacted their academic standing, and 70.1% indicated “yes” they would participate in virtual health services and use electronic health promotion resources or programs if they were offered at their university.

Limitations

This study, like all research, was not without limitations. The first was that participants in the online group were selected through convenience sampling of two fully online universities and did not reflect all online students in the United States. This may have limited variation in responses and thereby inhibits generalizability of findings. In addition, the NCHA IIb subscales used to collect the data only provide a snapshot of a college student’s health and well-being, as defined by the limitations of the scale and self-reported data. Although it is the most widely used college health instrument, the NCHA has a number of limitations such as item sensitivity, not defining health behaviors, and absence of theory, as recently outlined by researchers Rahn, Pruitt and Goodson.²²Ideally, future iterations of the NCHA would account for the shifting demographics in higher education and the fact that more full-time students are enrolling in fully online academic programs.

Also, future research on fully online students’ health issues should take into consideration the following variables: age, identified gender (to include non-binary), work status, timing of survey, type of campus, and major life events that may influence answers. Additionally, to improve generalizability, future studies should use a national sample of online students and compare this to a sample of non-online students of similar age and work profiles. Although similar differences could be found between two groups within the general population with such different demographics, this study highlights the changes colleges and universities have to promote health and well-being of their online students.

Implications for Practice

Assessing community capacity and needs, developing tailored health education and promotion programs and services, and delivering health education in formats most likely to reach the intended audience are primary responsibilities of health education specialists.²³ Although wellness data is collected yearly across college campuses in the United States, there has previously been little known about online students’ health needs and behaviors, or how college health services are evolving, to address the needs of this population.

The study findings underscored the need for US colleges and universities to increase digital health promotion resources, programs, and strategies tailored for the growing number of online, place-bound, and commuter students. The demand is there; the large majority (70.1%) of online students (n = 961) in this study indicated they would use health promotion resources and services if they were offered at their institution. However, few universities are doing more than providing written material online.²¹ In order to achieve social change and become a bigger part of the healthcare solution, university health services should positivity impact their online community’s behaviors and well-being, which requires interaction with each other, participation, leadership, and the uptake of interventions.¹³

Most of the health issues reported by students in this study are addressed by Healthy Campus (e.g. mental health issues such as stress, nutrition, sleep, physical activity). Stress, anxiety, and work were ranked as top academic impediments for both groups, but chronic health programs and death of a family/friend were specific to online students. These findings suggest that online students may benefit from stress, time management, and physical activity programs aimed at working adults-especially those prone to long periods of sitting.

Leveraging technology to improve college health promotion will not only cater to the preferences of more digital savvy Millennial and post-Millennial students, but will also address a resource gap, especially for those enrolled in fully online programs. Furthermore, as the results of the student survey confirmed, health and well-being are connected to academic success. By providing services and programs that address some of the most pressing health challenges, universities may simultaneously strengthen students’ academic performance and persistence.