A large proportion of college students are insufficiently physically active, with approximately 30% to 50% not getting enough physical activity (PA) to accrue health benefits (1). Given the downward trend in the number of American students meeting aerobic PA requirements from 2008 and to most recently (American College Health Association [2,3]), it is unlikely that this situation has improved. It should be noted that student physical inactivity is not an issue exclusive to America (4).
The prevalence of student physical inactivity may be attributable to the significant reduction in PA observed after the transition from high school to college (5–10). Moreover, evidence suggests that the decline in PA does not stop after the transition but rather continues across one’s time at university (11,12).
Student PA is important as college is influential in the adoption of an active lifestyle that may continue throughout one’s life (13). PA potentially offers students protection from serious future health and well-being issues (6,14), as well as protection from more immediate anxiety, depression, and stress-related disorders, which appear to be increasing in prevalence among students (2,3). With more than 20 million postsecondary students in the United States (15), and more than 40% of 18–24 year-olds pursuing a postsecondary education (16), general practice would seem to be an ideal setting to identify sedentary students and deliver physical activity counseling (PAC).
PHYSICAL ACTIVITY COUNSELLING
Increasing the proportion of physician office visits that include counseling or education related to PA is a Healthy People 2020 (HP 2020) objective (17). Moreover, PA-11.2 seeks to increase the proportion of physician visits made by all child and adult patients that include counseling about exercise. In a call to action pertaining to PAC, Joy et al. (18) put forward several keys to effective PAC. First, linking patients to community resources, and specifically to health and fitness professionals, is a key strategy. Next was the need for more comprehensive physician education during medical school, residency and fellowship training, and beyond. Lastly, was the importance of being a positive PA role model, as physically active physicians are more likely to counsel patients to be active.
This call to action highlights some of the apparent barriers to physician PAC, which, in addition to insufficient training (19–21) and poor personal PA habits (19), also include patient safety (22) and the accompanying concern regarding liability, as well as the perception that PAC has little effect on patients’ behavior (23).
Little research has been conducted on PAC rates in college-aged individuals. Joffe et al. (24) found that 42% of freshman reported receiving PAC from their personal physician, and that both males (30.5%) and females (35.2%) frequently requested that the university health services provide additional information about PA. Data from the National Health Interview Survey indicate that the percentage of adults receiving PAC from physicians or other health professionals have increased from 22.6% in 2000 to 32.4% in 2010. However, college-age individuals (18–24 yr) demonstrated the smallest increase, from 10.4% to 16.1%, remaining by far the least likely to receive PAC. Moreover, PAC varies little by ethnicity, but those with chronic health conditions, in particular diabetes, tend to receive PAC at higher rates than the general population. PAC has also increased among those with overweight and obese but remains alarmingly low, with less than a third of those with overweight (30.5%) and less than half of those with obesity (46.9%) receiving PAC (25).
At present, it remains unknown whether PAC among college students varies based on demographic and/or physiological variables. The purpose of this investigation was to examine rates of PAC from health care practitioners to ascertain if the HP 2020 objective was being met in this population, and whether any demographic or physiological variables differentiated those who had received PAC and those who did not. A greater understanding of PAC rates among students and the identification of the presence of absence of differences based on demographic and/or physiological variables has the potential to inform interventions to enhance the provision of PAC to college students and their PA during this critical period in life.
A total of 522 college-age students enrolled at a large Northeastern University in the United States completed an objective fitness assessment as a part of a required class assignment, and then they were invited to voluntarily complete a survey. Twenty-two participants were excluded from analyses because of missing data, leaving a final sample of 500 participants. All students provided their informed consent, and trained technicians administered tests. The Pennsylvania State University Review Board approved this study.
Upon fitness assessment completion, participants completed an electronic survey (Qualtrics, Provo, UT) that linked with their fitness outcomes using an identification number.
Participants self-reported their age, sex, race/ethnicity, employment status, and residence location (on or off campus) and type (e.g., house, apartment building, etc.).
Height and weight were measured to calculate body mass index. Those with a body mass index in excess of 25 and 30 kg·m−2 were considered to have overweight or obesity. Body fat percentage was calculated via bioelectrical impedance analysis (Omron BF306; Omron Global, Lake Forest, IL).
Predicted Aerobic Fitness
Maximal oxygen uptake (V˙O2max) was predicted using the YMCA Submaximal Cycle Ergometer test (26) while wearing a heart rate monitor. The direct heart rate plotting method, work rate, and heart rate were used to produce a V˙O2max estimate.
Cholesterol, Lipid, and Glucose Testing
Total cholesterol and fasting plasma glucose were assessed with a commercially available analyzer (Cholestech LDX, Alere, Waltham, MA). Forty microliters of blood were collected via finger stick and injected into a Cholestech LDX lipid profile with glucose cassette. The normative value for total cholesterol is below 200 mg·dL−1, whereas the normative value for fasting plasma glucose is below 100 mg·dL−1.
Two tests, a 1-min maximum repetition push-up test and a modified curl-up test (max. 75 curl-ups), provided measures of muscular endurance (26).
Moderate PA and vigorous PA were assessed using the Global Physical Activity Questionnaire (27). Moderate forms of PA included any activities that cause a small increase in breathing or heart rate, such as brisk walking, cycling, swimming, and playing volleyball. Vigorous forms of PA included any activities that cause a large increase in breathing or heart rate, such as running and playing football. The Global Physical Activity Questionnaire was also used to assess sedentary behavior separately on weekdays and weekends (h·d−1).
Participants were asked whether they had visited the on-campus health clinic, or a clinic other than the on-campus clinic in the past 24 months. PAC was assessed by asking those who indicted whether they had visited a clinic whether the associated health care provider had talked about them being physical active or what they were doing for exercise. Participants who visited a clinic were categorized based on whether they did or did not receive PAC and where they received counseling (on-campus clinic, off-campus clinic, either).
Physical Activity Information Sources
Participants were asked to indicate whether they had sought information (yes/no) from the following sources: online, friends, family, fitness professional, professor, health care provider, peer, magazines, apps, and television.
Participants responded to the four items based on the Perceived Stress Scale 4 (28) about the frequency with which participants had experienced stress/depressive feelings and thoughts on a 5-point Likert scale (0 = never; 4 = very often). A scale score was calculated using the four items, with a higher score indicating poorer mental health. The scale demonstrated acceptable reliability (α = 0.731).
Descriptive statistics were computed to characterize the sample. Physiological variables were categorized according the criteria outlined by the American College of Sports Medicine (26). Analyses examined differences between those who did and did not receive PAC and by location of counseling. Analyses also examined differences between those who did and did not report depressive symptoms. Differences in continuous and categorical variables were examined using independent samples t-tests and chi-square tests for independence, respectively. All analyses were run using SPSS 24.0 (IBM, Armonk, NY), with significance levels set at P < 0.05. Effect sizes, or eta-squared (η2), were calculated using the formula (t2/(t2 + (N − 1)).
Participant (n = 500) characteristics are displayed in Table 1. The majority of participants (79.9%) of participants met the American College of Sports Medicine’s PA recommendations (29).
Clinic Visit and PAC Prevalence
A total of 384 participants (76.8%) reported visiting a health care clinic within the previous 24 months. A breakdown of which type of health care clinic participants visited (on vs off campus) and whether they received PAC is shown in Table 2. Of those who visited a health clinic, 56.8% reported receiving PAC, with an independent chi-square test showing that those who visited off-campus clinic were significantly more likely to received PAC than those who visited an on-camp clinic, χ2(6, n = 384) = 230, P < 0.001, φ = 0.744.
Differences Based on PAC
The groups displayed in Table 2 were used to differences in a range of variables between those who did and did not receive PAC. No differences were found based on PA or anthropometric variables between those who did and did not receive PAC. Those who received PAC regardless of location were found to have significantly higher total cholesterol (Table 3) and to be less likely to seek PA advice from a health care provider (Table 4). The results analyses of other variables did not approach statistical significance (Tables 3 and 4). The differences in cholesterol appear to be largely attributable to those who received PAC off campus, who were found to have significantly higher total cholesterol (P = 0.042, η2 = 0.017). Chi-square tests for the maximum repetition push-up test showed that those who received PAC off campus and PAC regardless of location had significantly greater muscular endurance, although, by contrast, parametric analyses indicated that the difference was not statistically significant. Physiological, muscular endurance, and PA information variables did not differ between who did and did not receive PAC on campus.
No differences in mental health based on whether students had visit a health clinic or had received PAC. However, the scale scores of those who failed to meet moderate PA (P = 0.019, η2 = 0.011) and vigorous PA (P = 0.002, η2 = 0.020) recommendations were significantly higher, indicating poorer mental health.
In the current study, 56.8% of students visiting campus health services received PAC, far higher than that reported in previous investigations in students (24) and national data on college-age individuals (25), and dramatically exceeds the HP 2020 objective (17). At present, there is no national data on the rates of PAC among college students, although inclusion of items relation PAC in the American College Health Association’s NCHA represents an ideal opportunity to procure such data.
There were few differences between those who did and did not receive PAC, with total cholesterol being the only variable of note to differ significantly between groups. Study design prevented the determination of whether students or health care providers initiated PAC. That PAC status did not differ based on any PA measures suggests a lack of targeted PAC among the least active, least fit, or most overweight/obese, which is in contrast to national data pertaining to the general population (25). In other words, there appears to be no priority in providing treatment to those arguably in the greatest need. Furthermore, results indicate that those who received PAC were less likely to have sought it from their health care provider, which raises questions about the rationale used by physicians on deciding to whom PAC should be given.
Study design also prohibited determination as to what form PAC was provided. PAC was just as likely to be provided on campus (60.3%) as off campus (62.6%), but far more people saw off-campus providers than on-campus providers. However, this may be attributable to many students maintaining coverage under their parent’s health insurance as a result of the Affordable Care Act (30), which would likely see them use external health care providers. As such, the same pattern of behavior may not be observed at universities more isolated from alternative health care providers, or among graduate students who are typically covered by their university’s health insurance, who were excluded from this study. Regardless, given campus health services primarily focus on acute medical conditions (31), the utility of the PA vital sign (PAVS) and focus on PAC in this population is questionable. In particular, in light of the fact that young adults are less likely to use health care in general compared with any age-group, which raises questions regarding the clinical utility of the PAVS in a college setting.
Findings indicate a negative relationship between physical inactivity and mental health among college students, consistent meta-analyses that have found exercise to be beneficial with respect to improving mental health through reducing stress (32) and depressive symptoms (33–36). In addition, exercise compares favorably to pharmaceutical alternatives as a first-line treatment for nonclinical depression and can alleviate depressive symptoms when used as an supplement to medications (37). As such, PAC has the potential to address both physical and mental health problems.
EIM initiatives in non-campus-based clinical settings have shown clinical utility, however (38,39), the requirement for the PAVS in EIM-OC initiatives needs further discussion to determine how college students perceive and use and campus health services and how colleges are delivering such services. Although this study yielded several interesting findings, there were some limitations, including the following: using self-report PA measures, a small sample size, and limited generalizability. Perhaps the most significant limitation of this study was the absence of any measures of the quality of effectiveness of the PAC received by students.
In future studies, researchers should consider examining how the PAVS is integrated into university health care systems, who initiates PAC (patient vs physician), and the effectiveness of PAC and any support provided by physical fitness professionals that students may be referred to in both the short and long term. The barriers to physicians practicing in student health care centers providing PAC to students also warrant further investigation as such barriers may be unique to the patient and/or context.
Although further research is required, practical implications do arise from the findings of this study. For one, the apparent lack of targeted PAC demonstrates an opportunity to better and more efficiently address the needs of college students with respect to PAC. Efficient systems facilitating the identification of those who do and do not stand to benefit from PAC have the potential to ensure that those in need receive PAC, and that those not in need to not receive PAC allowing physicians to focus on other aspects of such patients’ health or reduce the consultation time. Such a system would also hold physicians accountable to provide PAC and follow-up with patients as to the effectiveness of PAC in subsequent consultations.
Although students were receiving PAC at a higher rate than recommended in HP 2020, further investigation is warranted on the use of PAC at campus health services, in particular the initiation of PAC, the PAC techniques/strategies used by physicians, and the short- and long-term effectiveness of PAC on PA and associated health outcomes.
No funding was received for this study. The authors thank the students who volunteered to participate in this study as well as Pennsylvania State University Center for Fitness and Wellness, in particular Alison Bruner, for their assistance with data collection.
None of the authors have a conflict of interest related to the present study. The results of the present study do not constitute endorsement by the American College of Sports Medicine.
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