Assessment of suboptimal health status and their associated risks in university students: A cross-sectional study, UAE

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1 Research Article Assessment of suboptimal health status and their associated risks in university students: A cross-sectional study, UAE Saba Saleh Al-Hemyari 1 *, Ammar Abdulrahman Jairoun 2, Naseem Abdulla 2 ABSTRACT Objective: Suboptimal health status (SHS) is an intermediate stage between disease and health and is regarded as a subclinical characterized by a decline in vitality, in physiological function and the capacity for adaptation. The objectives of this study were to assess the SHS and to investigate a variety of factors associated with SHS in university students. Materials and Methods: A cross-sectional study was conducted over 3 months from January 2017 to March 2017 among Ajman University students. A random sample of medical students was recruited from both first and final study years. Results: The results of this study showed that half of the students (52.5%) gave higher SHS score and (47.5%) of them gave a lower score. Moreover, age between 15 and 19 and first years students was found to be significantly associated with higher SHS score (P = 0.002), (P = 0.000), respectively. Conclusion: The results of the study emphasized the importance of introducing a health promotion and counseling program that begin early in the medical colleges to screen early stage illness. KEY WORDS: Suboptimal health status, University students, Medical students INTRODUCTION The health status of university student is one of the major public health issues around the world. Medical colleges are considered as stressful and demanding environment. There has been a growth interest in the assessment of health status of the student. In one study among 381 Iranian students, 61.9% of students had healthy status. [1] In another study including 2103 college students from universities in Germany, Bulgaria, and Poland, 8.7% of the participants rated their health as excellent, 35.8% reported it as very good, 45.6% as good, 8.9% as fair, and 1% felt that their health was poor. [2] Further study among a random sample of 171 Venezuelan pharmacy students showed good overall health status of pharmacy students. [3] Suboptimal health status (SHS) can be defined as intermediate stage between the illness and the health and its considered as a subclinical, reversible stage of chronic disease. Prevention, prediction, and personalization of medicine are the aim of the any integrated preventive Access this article online Website: jprsolutions.info ISSN: treatment plan. SHS is similar to this concept by assessing the health status and providing effective strategies for improvement of health, prevention of disease and the treatment of early stage illness. In the recent years, the concept of SHS has been widely used in many other countries, including Japan, [4] Canada, [5] and Australia. [6] Acquiring and compiling knowledge about the health status of the medical students is an important step in creating health promotion program to meet the needs and concerns of university students and to provide counseling and interventions aimed to improve students health status in the future. To our knowledge, there was no study conducted in Arab countries as well as in Gulf Cooperation Council countries particularly in UAE assessing the health status of university students. The present study, therefore, aimed to assess SHS and to investigate a variety of factors associated with SHS in university students. MATERIALS AND METHODS Study Design and Study Setting This study was a cross-sectional descriptive-analytical research conducted in Ajman University (AU) from 1 Department of Clinical Pharmacy, Ajman University, Ajman, UAE, 2 Department of Public Health and Safety, Consumer Product Safety Section, Dubai Municipality, UAE *Corresponding author: Saba Saleh Al-Hemyari, Department of Clinical Pharmacy, Ajman University; Ajman, UAE. drsabasaleh@hotmail.com Received on: ; Revised on: ; Accepted on:

2 January to March 2017 among 505 first to fourth academic year students of medical colleges (Pharmacy and dentistry). Inclusion and Exclusion Criteria Participants had to meet the following inclusion criteria: (1) No history of somatic or psychiatric disease or any other chronic illness, (2) no history of medication consumption in the previous 2 weeks, (3) participants should belong to AU, (4) participants from medical sciences should range in between the first to the fourth year of study, and (5) willing to participate in the study. We excluded students who have a specific disease related to cardiovascular system, respiratory system, genitourinary system, digestive system, hematic system, and diabetes. It was ascertained that the participant s students do not suffer from any chronic diseases or have a history of somatic or psychiatric disease through their own medical files at the clinic university. In addition, before starting distribution of the study questionnaire, the students were asked if they suffer from any health problems or chronic diseases and if they consumed medication in the previous 2 weeks. The individuals who did not meet these criteria were excluded. Sample Size Estimation and Sampling Methods Simple random sample was used as the sampling method. According to Admission and Registration directory, the estimated total number of medical students was 1000 students distributed across pharmacy and dentistry colleges. We expect the prevalence rate to be around 35%. The alpha level is set to 5% so that we have a 95% confidence interval. The precision (D) of the 95% confidence interval is fixed to be 5% so that the width of the 95% CI will be at maximum 10%. According to the assumptions above, the minimum sample size required was n = 501 participants if we assume a non-response rate around 30%. The final chosen sample size was 505 students. Measurement Instruments A selfadministered questionnaire was used as a tool to collect the data from the participants. The questionnaire was comprised two main parts: Sociodemographic and lifestyle factors and SHSQ-25 questionnaire was used to assess the respondent SHS. The participants were asked to indicate how often they had experience any of various specific complaints in the last 3 months. The 25 items related to SHS were categorized into five subscales: Fatigue (9 items), cardiovascular system (3 items), digestive tract (3 items), immune system (3 items), and mental status (7 items). These items were rated on 5-points Likert scale (1= never or almost never, 2 = occasionally, 3 = often, 4 = very often, and 5 = always ). The raw scores of 1-5 on the questionnaire were recoded as 0-4. SHS scores were calculated for each respondent by summing the grading for the 25 items. Internal consistency of the subscales proved to be good. The Cronbach s alpha coefficients of SHSQ-25 were [7] Validation and Pre-testing of Questionnaire Before the study, the questionnaire was validated by subject experts for its content and relevance. Furthermore, it was field-tested several times on a pilot sample of 100 students to clarify any ambiguities and to determine the reliability of the questionnaire. Ethical Principles The study was approved by University Research Ethical Committees and approval letter was obtained to allow the researcher to distribute and collect the questionnaires among AUST students. The participation of the students in this study was entirely Table 1: Demographic characteristics of the students Demographic characteristics F, n=505 (%) Age (39.6) (56.4) (1.2) (2.6) >35 1 (0.2) Gender Male 145 (28.7) Female 360 (71.3) Study year First 61 (12.1) Second 203 (40.2) Third 61 (12.1) Fourth 127 (25.1) Fifth 53 (10.5) Marital status Married 33 (6.5) Single 472 (93.5) Total monthly income <5000 AED 91 (18.0) 5000 <10000 AED 83 (16.4) <20000 AED 252 (49.9) 20000>AED 79 (15.6) Nationality UAE national 24 (4.8) Non UAE national 481 (95.2) Health insurance coverage Yes 262 (51.9) No 243 (48.1) Physical activity/week 1 h 106 (21.0) 1 2 h 46 (9.1) 3 4 h 174 (34.5) 5 h 179 (35.4) Current smoking Yes 54 (10.7) No 451 (89.3) Height Mean±SD 165.3±9.43 Weight Mean±SD 65.4±15.56 BMI Mean±SD 23.85±5.21 Normal 302 (59.8) Overweight 98 (19.4) Obese 105 (20.8) SD: Standard deviation 933

3 voluntary and without compensation. Before data collection, the purpose of the survey was explained, and they were also informed that the completion and submission of the questioner would be taken on their consent and all students signed the informed consents. Statistical Analysis On the receipt of survey forms, data were checked for completeness and consistency then coded data were entered and analyzed using the Statistical Package for Social Sciences version 23. Data were summarized using mean and standard deviation values for sub optimal health scores, number and percentage for categorical variables. Comparison between the groups was done using independent t-test and oneway ANOVA tests for scores. The level of statistical significance was defined as P < RESULTS Sociodemographic Characteristics of the Participants This cross-sectional study was conducted among medical student (Dentistry and pharmacy) of AU to determine: The prevalence of self-perceived stress, SHS and their risk factors among medical students also, to examine the relationship between the stress and SHS of medical students. The survey was conducted from January to March A total of 505 students participated in this study. Table 1 summarizes the frequency and percentage of students in different groups with respect to age, gender, study year, marital status, total monthly income, nationality, health insurance coverage, physical activity, smoking status, height, and weight. Assessment of SHS Among Study Participants SHSQ-25 was our tool to assess the SHS of the students. It is a 25-item instrument that includes five dimensions: Fatigue (9 items), mental health (7 items), immune system (3 items), cardiovascular system (3 items), and digestive system (3 items). The participants were asked to rate their behaviors on a five-point Likert type scale (1 = never or almost never, 2 = occasionally, 3 = often, 4 = very often, and 5 = always ). The raw scores of 1-5 on the questionnaire were recoded as 0-4. SHS scores were calculated for each respondent by summing the grading for the 25 items. The participants were divided into two groups by the median SHS score of 31, high SHS score group (SHS score 31) and low SHS score group (SHS <31). The mean SHS score among the SHS group was 33.3 ± 14.4 overall, 265 (52.5%) respondents gave higher SHS score and 240 (47.5%) gave lower score. Table 2 summarizes the frequency (%) of each of the questions related to SHS questionnaire. Factors Associated with Student SHS Table 3 summarizes the bivariate analysis in which SHSQ-25 score dependent variable is tabulated against Table 2: Student Suboptimal health status (SHSQ 25) How often is it, that you (your) n (%) Never or almost never Occasionally Often Very often Always Exhausted without greatly increasing your physical 73 (14.5) 276 (54.7) 76 (15.0) 63 (12.5) 17 (3.4) activity Your fatigue could not be substantially alleviated 78 (15.4) 207 (41.0) 99 (19.6) 93 (18.4) 28 (5.5) by rest You were lethargic when working 29 (5.7) 169 (33.5) 152 (30.1) 122 (24.2) 33 (6.5) You suffered from headaches 49 (9.7) 203 (40.2) 96 (19.0) 120 (23.8) 37 (7.3) You suffered from dizziness 129 (25.5) 223 (44.2) 81 (16.0) 60 (11.9) 12 (2.4) Your eyes ached or were tired 125 (24.8) 215 (42.6) 85 (16.8) 51 (10.1) 29 (5.7) You suffered from a sore throat 114 (22.6) 231 (45.7) 107 (21.2) 46 (9.1) 7 (1.4) Your muscles or joints felt stiff 109 (21.6) 204 (40.4) 103 (20.4) 69 (13.7) 20 (4.0) You have pain in your shoulder/neck/waist 83 (16.4) 189 (37.4) 118 (23.4) 77 (15.2) 38 (7.5) You have a heavy feeling in your legs when 197 (39.0) 187 (37.0) 76 (15.0) 39 (7.7) 6 (1.2) walking You feel out of breath while sitting still 253 (50.1) 151 (29.9) 64 (12.7) 27 (5.3) 10 (2.0) You suffered from chest congestion 249 (49.3) 169 (33.5) 6 (12.1) 22 (4.4) 4 (0.8) You were bothered by heart palpitations 164 (32.5) 182 (32.0) 78 (15.4) 61 (12.1) 20 (4.0) Your appetite is poor 154 (30.5) 194 (38.4) 83 (16.4) 56 (11.1) 18 (3.6) You suffered from heartburn 217 (43.0) 183 (36.2) 50 (9.9) 39 (7.7) 16 (3.2) You suffered from nausea 162 (32.1) 219 (43.4) 80 (15.8) 26 (5.1) 18 (3.6) You could not tolerate the cold 118 (23.4) 177 (35.0) 88 (17.4) 69 (13.7) 53 (10.5) You had difficulty falling asleep 83 (16.4) 187 (37.0) 102 (20.2) 75 (14.9) 58 (11.5) You had trouble with waking up during night 115 (22.8) 175 (34.7) 107 (21.2) 65 (12.9) 43 (8.5) You had trouble with your short term memory 98 (19.4) 176 (34.9) 121 (24.0) 71 (14.1) 39 (7.7) You could not respond quickly 174 (34.5) 196 (38.8) 81 (16.0) 35 (6.9) 19 (3.8) You had difficulty concentrating 70 (13.9) 232 (45.9) 110 (21.8) 62 (12.3) 31 (6.1) You were distracted for no reason 106 (21.0) 201 (39.8) 92 (18.2) 67 (13.3) 39 (7.7) You felt nervous or jittery 63 (12.5) 169 (33.5) 124 (24.6) 97 (19.2) 52 (10.3) You caught a cold in the past 3 months 161 (31.9) 220 (43.6) 71 (14.1) 42 (8.3) 11 (2.2) 934

4 Table 3: Factors associated with Student SHS SHS score Variables n (%) Mean±SD P value Age (39.6) 35.6± * (56.4) 32.3± year 20 (4.0) 25.7±14.8 Gender Male 145 (28.7) 31.5± Female 360 (71.3) 34.1±13.9 Study year First years 264 (52.3) 35.5± * Final years 241 (47.7) 30.9±13.7 Marital status Married 33 (6.5) 35.4± Single 472 (93.5) 33.2±14.3 Total monthly income <5000 AED 91 (18.0) 31.8± < (16.4) 36.3±12.9 AED < (49.9) 33.4±14.0 AED 20000> AED 79 (15.6) 31.7±14.2 Nationality UAE national 24 (4.8) 39.0± Non UAE national 481 (95.2) 33.1±14.2 Health insurance Yes 262 (51.9) 33.4± No 243 (48.1) 33.2±14.3 Physical activity/ week <1 h 106 (21.0) 31.7± h 46 (9.1) 32.7± h 174 (34.5) 32.6± h 179 (35.4) 35.1±15.4 Current smoking Yes 54 (10.7) 34.3± No 451 (89.3) 33.2±14.2 BMI Normal (<25 kg/m 2 ) the independent variables. There was an effect shown of age on SHS (P = 0.002). Students aged between 15 and 19 were more likely to have SHS compared to those aged between 20 and 24 and 25 years old (P = 0.040), (P = 0.013), respectively. There was an effect seen of study year on SHS (P = 0.000). First year students were more likely to have SHS compared to final year students. However, gender, marital status, total monthly income, insurance coverage, physical activity, and smoking were not associated with SHS. DISCUSSION 302 (59.8) 33.3± Overweight 109 (21.6) 35.2±15.9 ( kg/m 2 ) Obese ( 30 kg/m 2 ) 94 (18.6) 33.3±13.5 *P<0.05 is considered significant, SD: Standard deviation Taking into the account that medical students face several challenges such as academic demands, financial limitations, physiological stress, mental tension and tend to be socially isolated, a better understanding of students health status and associated risk factors is imperative in development of health promotion plan to meet the needs, and concerns of university students. In this regard, several studies using different measures have reported the health status among medical students. Some studies assessed students health and associated physical, psychological, studying, and sociodemographic factors using selfrated health status. [8-11] Another study assessed the general health status of Iranian students using General Health Questionnaire-28. [1] However, in this study, we assessed the SHS of the medical students using the SHSQ-25 self-reported questionnaire. SHS can be defined as an intermediate stage between disease and health, and it is regarded as a subclinical, reversible stage of chronic disease. The present study assessed the SHS of the medical students by dividing the participants into two groups by the median SHS score of 31, high SHS score group (SHS score 31), and low SHS score group (SHS <31). About half of the respondents (52.5%) reported higher SHS score and (47.5%) reported lower score. A similar finding was reported among Chinese students where prevalence rate of SHS was 55.9%. [12] Previous studies have likewise obtained results consistent with this view. [13,14] The present study examined a variety of factors associated with SHS among medical students. Students aged between 15 and 19 exhibited higher SHS score than those aged between 20 and 24 and 25 years old (P = 0.040), (P = 0.013), respectively. Moreover, SHS score decreased as the students class level in the university increased (P = 0.000). The implications of this higher SHS score suggested that the studied students had a negative perception about health complaints, had general weakness and decline in vitality, physiological function and in the capacity for adaptation. Therefore, early signs of SHS among medical students should be addressed hence an effective approach to the improvement of health, the prevention of disease and the treatment of early stage illness can be implemented in the medical universities. CONCLUSION The results of the study emphasized the importance of introducing a health promotion and counseling program that begin early in the medical colleges to screen early stage illness and adjust to different learning environment during the first years of medical education. REFERENCES 1. Hashemian A, Direkvand-Moghadam A, Delpisheh A, Direkvand-Moghadam A, Fathollahi E, Barmalzan R, et al. General health status among high school students in Ilam: A cross-sectional study. Int J Epidemiol Res. 2015;2(1): Mikolajczyk RT, Brzoska P, Maier C, Ottova V, Meier S, Dudziak U, et al. Factors associated with self-rated health 935

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