Factors associated with self-rated health status in university students: a cross-sectional study in three European countries.(Research article)(Survey)

Authors: Rafael T Mikolajczyk [1]; Patrick Brzoska [2]; Claudia Maier [2]; Veronika Ottova [3]; Sabine Meier [1]; Urszula Dudziak [4]; Snezhana Ilieva [5]; Walid El Ansari (corresponding author) [6]

Background

Asking for a self-rating of health is a legitimate technique for assessing the health of individuals [1]. While self-rating of health is a good measure of objective and subjective health [2], it is also a feasible way to measure health in large-scale surveys [3, 4]. Self-rating of health has been shown to have high reliability, validity and predictive power for a variety of illnesses and conditions [5]. Self-rated health has been extensively studied in older adult population groups, where a range of factors associated with self-rated health has been identified [6, 7, 8]. Much less is known about the self-rated health of younger populations. An exception is the international "Health Behaviour in School-Aged Children" study which contributed to the understanding of factors associated with self-rated health in school-aged children [9, 10]. However, for young adults (e.g. university students) the available information remains limited in scope. On the one hand, university students have concerns, burdens and worries which are different from other population groups. On the other hand, these students face the dual stress of having academic challenges and achievements often within the face of financial limitations [11, 12]. Hence unsurprisingly, in Sweden students were found to have lower perceived quality of life when compared with their working peers [13], and similar observations have been reported in the UK [14]. The published literature also suggests that young people preferentially employ psychological or behavioural factors as a rating frame for their health [3, 15, 16]. In contrast, for older people, physical well-being plays a more crucial role in assessing their health [3, 8]. Given the observation that young adults differ from older people in their perception of health, a better understanding and a separate analysis of the factors associated with self-rated health status (SRHS) is needed for this younger age group. This is particularly true for university students, who represent an important and broad subpopulation of young adults.

Some studies of self-rated health exist for student populations in selected countries: e.g. USA [15], Canada [17], Hungary [16, 18], and the UK [14]. Recent reports on the health of student populations in the USA have employed only crude analysis [19, 20, 21]. These studies cannot be directly compared with each other in terms of sample selection, measures and methods of analysis, thus they do not provide sufficient information regarding possible differences in self-rated health and the factors associated with it across countries. Conversely, some comparative cross-country studies of health in student populations do exist [22, 23], however they have not assessed or reported findings in regard to the factors associated with SRHS. Thus there is a gap in the research concerning the SRHS in students across countries.

A recent review of inquiries which employed SRHS as an outcome variable found that such studies often omitted important variables or alternatively, did not provide adequate systematic analyses [24]. Most of these studies dealt with other age groups. Interestingly, the studies related to student populations were more complete in respect to the considered variables [14, 15, 16, 17, 18]. However, apart from lacking international comparisons, some issues remain unresolved. For example, the literature that addresses differences in SRHS for males and females has shown conflicting results: some studies found no significant differences between genders in bivariate analysis [18] or when controlling for other variables [15]. In contrast, other investigations have reported significant differences between genders in bivariate or stratified analyses. Yet these studies fell short of assessing the effect of gender using multivariable models [16, 20, 25, 26]. Collectively, these concerns have formed the basis of the study described in this paper.

The present study had three specific aims: first, to investigate a wide range of variables potentially associated with SRHS in student populations, employing a cross-country comparison of students from three countries in Western (Germany), Central (Poland) and South Eastern (Bulgaria) Europe, second, to test whether these associations differed by gender and/or across participating countries, and third, to assess the comparative contributions of psychological, physical and other variables to the SRHS of student populations.

Methods

Study design and sample

The data analysed in this paper is from the Cross National Student Health Study (CNSHS). The CNSHS is a health survey that was conducted in 7 European countries between 1998 to 2005 [27]. This paper uses data collected in the survey conducted in 2005 at three universities; participants include 2103 first-year students at the University of Bielefeld, Germany; the Catholic University of Lublin, Poland; and Sofia University, Bulgaria. Ethical approvals for the study were obtained through the participating faculties. Participation in the survey was voluntary via a self-administered questionnaire distributed during lectures. The questionnaire employed was compiled and developed from different published sources, including validated instruments used in various populations [28, 29, 30, 31], as well as questions developed specifically for this survey. The original version of the questionnaire was written in German and then translated into Bulgarian and Polish using two separate translations and expert consultation. Response rates were over 95% for both the Bulgarian and Polish samples, but varied from 60%-100% for the German sample depending on the surveyed groups, 85% on average (response rates were lower in large lecture rooms than in smaller seminars). Because each of the universities had unique academic structures composed of different faculties of various sizes, the surveys were implemented only in certain classes in an effort to achieve comparability between and representativeness for each of the participating universities. Collectively, the sample was comprised of students from 5 disciplines: natural sciences, humanities, social sciences, law, and economy, each contributing to about 20% of the sample.

Measures

SPHS was assessed by the single item used in the 1998 German Federal Health Survey [32] (similar wording …