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SYSTEMATIC REVIEW article

Front. Public Health, 28 April 2020 | https://doi.org/10.3389/fpubh.2020.00137

A Systematic Umbrella Review on the Epidemiology of Modifiable Health Influencing Factors and on Health Promoting Interventions Among University Students

  • 1Institute of Occupational, Social and Environmental Medicine, University Medical Centre of the University of Mainz, Mainz, Germany
  • 2Department Sport Medicine, Rehabilitation and Disease Prevention, Institute of Sport Science, Johannes Gutenberg University, Mainz, Germany
  • 3Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
  • 4Department of Communication, Johannes Gutenberg University, Mainz, Germany

Background: Universities represent an important setting for health promotion. The unique collective of university students is of particular relevance since they are the leaders, decision-makers, and parents of tomorrow. In this context, modifiable health influencing factors as well as interventions to prevent these, play a crucial role. Therefore, the present umbrella review aims to (i) provide an overview of review articles addressing epidemiological issues (prevalence and determinants) of modifiable health influencing factors in university students and (ii) to provide an overview of review articles addressing the evidence of interventions to promote/enhance modifiable health influencing factors in university students.

Methods: A systematic literature search was performed in the databases PubMed, Cochrane Reviews Library und Web of Science according to the PRISMA guidelines. Only systematic reviews and meta-analyses were included. The AMSTAR-2-Tool was used for the quality assessment.

Result: The initial search resulted in 10,726 records of which 81 fulfilled the inclusion criteria, with a further distinction in articles with an epidemiological focus (n = 39) and in articles with interventional approaches (n = 42). Topics of the different review articles ranged from physical activity over mental health, substance use, sleep, diet and nutrition, and media consumption. Many review articles had a specific focus on medical and nursing students and originated from the U.S.A., U.K., or China.

Discussion: This umbrella review provides an overview of review articles on the epidemiology of modifiable health influencing factors and on the evidence of interventions targeting these factors among university students. Thereby, experts as well as stakeholders in the field could gain insights into crucial target points for health promotion. It identifies research gaps in terms of study region and groups of students.

Introduction

According to the World Health Organization (WHO) health is more than just the current condition of a person, but rather “a resource for everyday life” (1). It is created and lived by people within the settings of their everyday life: where they learn, work, play, and love (1), emphasizing the interconnectedness between individuals and their environments. In 2015, an international expert group formulated the Okanagan Charter and pointed out that universities are an important setting of everyday life for health promotion (2). They further stated that from a public health point of view, the unique collective of university students would be of particular relevance (2) since they are the leaders, decision-makers, and parents of tomorrow. Therefore, health promotion in students could be sustainable and beneficial for the general society. Additionally, the students' entrance into a new living environment, called university, causes changes in the home environment, work environment, and recreational environment (3). Furthermore, in the critical period of young adulthood (18–25 years), students are potentially vulnerable for risky health behavior such as drinking or physical inactivity (4).

In the context of health promotion in university students, modifiable health influencing factors play a crucial role. These factors encompass, for instance, physical activity, nutrition, substance, and media use (5). What they all have in a common is that they can be modified instantly and may have immediate or long-term effects on an individual's health (6). In contrast, other relevant health influencing factors like age, gender, or genetics cannot be changed instantly. Given the fact that the time being enrolled at a university as a student is relatively short (regularly 3–4 years for bachelors and 2 years additional years for masters), modifiable health influencing factors play a significant role for health promotion among university students. Taking the great potential of these factors for health promotion and prevention into account, it is important to provide an evidence base on (i) the epidemiology of modifiable health influencing factors (prevalence and determinants) and (ii) interventions to promote/enhance modifiable health influencing factors in university students. On the one hand, information on the epidemiology will be relevant to identify these factors and potential risk groups among university students, which might be of particular interest for health promotion. On the other hand, the information will be important in order to identify potential scientific knowledge gaps regarding specific health factors, student collectives or countries. In addition, from a public health point of view, knowledge regarding interventions to promote modifiable health influencing factors will be of significant relevance to develop and implement evidence-based student health interventions in a more personalized way and tailored to specific risk groups.

Currently, hundreds of review articles regarding the epidemiology of modifiable health influencing factors of university students and according interventions can be found in the literature. To name a few, Keating et al. focused on physical activity behavior in college students (7), Castro et al. on sedentary behavior in university students (8), Elani et al. on stress among dental students (9), McKenna et al. on psychological wellbeing of international students in the health professions (10), Bennett et al. on smoking behavior of college students (11), Davoren et al. on alcohol consumption of university students in Ireland and the UK (12), Candido et al. on drug consumption of medical students (13), or Cassidy et al. on sexual behavior (14) of university students. Most of these reviews have in common, that they only address one specific modifiable health influencing factor in either one specific collective of students (e.g., dental students, medical students, college students), or in university students per se, in a specific region or worldwide. The large amount of studies in this field, however, makes it difficult to gain an overview about existing literature, to generate a synthesis of the evidence as well as to identify a potential lack of knowledge or research gaps (e.g., regarding rarely explored modifiable health influencing factors, specific student collectives or regions) respectively. Therefore, the present umbrella review aims to (i) provide an overview of review articles addressing epidemiological issues (prevalence and determinants) of modifiable health influencing factors in university students, (ii) to provide an overview of review articles addressing the evidence of interventions to promote/enhance modifiable health influencing factors in university students, enabling us to, (iii) detect potential health-related risk groups in the student population regarding, for example, field of study or region, and to (iv) identify health-related knowledge gaps in the student population, for example, regarding field of study or region.

Materials and Methods

The decision to perform an umbrella review was based on the large amount of single studies and review articles dealing with health of university students. The present review was performed according to the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) Guidelines (15).

Search Strategy

A systematic literature search was carried out in the electronic databases PubMed, Cochrane Reviews Library, and Web of Science. For the data base PubMed, the following three-level search term (collective, institution, and topic) was created using Boolean operators: (student OR students) AND (university OR college OR “higher education” OR academy OR “tertiary education” OR school) AND (health* OR wellbeing OR disease OR disorder OR illness OR sickness OR “physical activ*” OR “physical inactiv*” OR exercise OR fitness OR sedentary OR sedentariness OR nutrition OR diet OR “substance use” OR “substance abuse” OR “substance consumption” OR “substance misuse” OR “drug use” OR “drug abuse” OR “drug consumption” OR “drug misuse” OR doping OR “pharmacological neuroenhancement” OR “pharmacological cognitive enhancement” OR alcohol OR smoking OR tobacco OR marijuana OR cannabis OR addiction OR “media use” OR “media consumption” OR “media usage” OR “internet use” OR “internet consumption” OR “mobile phone use” OR “mobile phone consumption” OR “smart phone use” OR “smart phone consumption” OR “cell phone use” OR “cell phone consumption” OR stress OR anxiety OR mobbing OR bullying OR mindfulness OR satisfaction OR “quality of life” OR self-concept OR “risk behavio*” OR “risk attitude” OR resilience OR vaccination OR vaccines OR “hand-wash*” OR “sexual behavio*” OR “sun protection” OR “sun burn”). Since we searched for [All Fields] in PubMed, MeSH terms were generated automatically. For the other databases, this search term was adapted following the individual Cochrane Reviews Library and Web of Science search guidelines. If possible, limits for article type (review) and language (German and English) were activated. No time limits were set. The search was completed on February 28th, 2019.

Inclusion Criteria

In this systematic umbrella review, all review articles had to fulfill the following inclusion criteria: (1) being a systematic review or meta-analysis. To be classified as systematic, at least points 6 to 9 of the PRISMA checklist had to be fulfilled; (2) focusing exclusively on students from universities, colleges and universities of applied sciences. Studies investigating mixed student collectives (e.g., pupils, medical residents) were excluded (3) addressing the prevalence or/and determinants of at least one modifiable health influencing factor; or/and (4) addressing the effects of at least one intervention to promote at least one modifiable health influencing factor; (5) being published in a peer-reviewed journal in (6) English or German language. All kinds of study designs (observational, cross-sectional, longitudinal, randomized, non-randomized, and uncontrolled) were included.

Selection Process and Data Extraction

The flow chart in Figure 1 provides a transparent documentation of article elimination. Two reviewers independently screened title and abstract of all potentially relevant articles. Then, two independent reviewers evaluated full texts and removed duplicates. Specific reasons for exclusion are presented in the flow chart. Uncertainties were discussed in the researcher team in order to achieve consensus. The data extraction was also performed according to the dual control principle. Relevant data of the included articles were summarized in tables and checked for accuracy by another researcher. Uncertainties were discussed in the reviewer team in order to achieve consensus.

FIGURE 1
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Figure 1. PRISMA flow diagram.

The following data were extracted: (1) authors; (2) year of review; (3) number of included single studies (4) subject characteristics (e.g., field of study, age, gender, and race) (5) data on modifiable health influencing factors (6) important findings were highlighted (7) result of the quality assessment (if carried out). Furthermore, the number of participants per review article was calculated. Based on the descriptive distribution of the number of original articles per country in each included review article, a color scheme was created to graphically depict countries with high scientific output on modifiable health influencing factors among students and countries with less scientific output. If the study countries of the original article were not provided in the included articles (e.g., only information about the continent), the study country was extracted from the original article.

Quality Assessment

For all studies with scope on interventions, an additional quality assessment was performed using the “assessing the methodological quality of systematic reviews (AMSTAR) 2” tool (16). The AMSTAR 2 contains 16 items for a critical appraisal of systematic reviews. It rates the overall confidence of a review article in four categories (from high to critically low) through spotting critical and non-critical weaknesses. Therefore, the results of the quality assessment should not be used to obtain an overall score, but to identify critical domains (15).

Results

The initial search resulted in 10,726 records through database searching (n = 7,178 from PubMed; n = 3,378 from Web of Science; n = 28 from Cochrane Library), and from an additional side search on sleep hygiene among students (n = 142). Of these, 10,362 records were excluded after title and abstract screening according to the selection criteria, resulting in a number of 364 potentially appropriate articles. After removal of duplicates, 261 full texts were available for detailed assessment. One hundred and eighty articles were excluded for specific reasons, see flow chart (Figure 1). Thus, 81 articles, comprising 2,703 original articles, met the eligibility criteria and were included in this umbrella review. They were further distinguished in articles with an epidemiological focus (n = 39; comprising 1,525 original articles) and in articles with interventional approaches (n = 42; comprising 1,178 original articles).

Table 1 provides a summary of the main characteristics of the identified articles, including: collective, region, number of original articles included, and quality assessment. The identified articles (n = 81) were published between 2007 and 2018 and fall into one of seven broad categories, namely “substance use” (n = 36), “mental health / wellbeing” (n = 26), “diet and nutrition” (n = 6), “physical activity” (n = 4), “sleep hygiene” (n = 3), “media consumption” (n = 2), “others” (n = 4); Figure 2. The different categories display the variety of health topics throughout the review articles. The quality assessment for the interventional articles indicated mainly a critically low (n = 23) and low (n = 13) quality, demonstrating a potential risk for bias and only few articles were identified with moderate quality (n = 6). The investigated collective was not further classified in most of the review articles, with only a few exceptions (e.g., nursing students, medical students, or dental students). Mainly university/college students as a general population were under investigation.

TABLE 1
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Table 1. Main characteristics of the articles included in the systematic umbrella review.

FIGURE 2
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Figure 2. Number of included review articles sorted by topic and whether they have focus on epidemiology or intervention aspects.

As shown in Table 1, the included original studies among the eligible review articles were performed in various countries. However, some of the included review articles concentrated exclusively on students' health in particular countries. Figure 3 gives a visual impression of the worldwide spreading of the included original articles showing a strong research focus in USA, UK, and China and a low scientific research interest, for example, in other European countries like Portugal, Poland, Germany, and Italy.

FIGURE 3
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Figure 3. Visual impression of the worldwide distribution of the included original articles.

Substance Use

A total of 36 review articles, comprising 1,312 original articles including ~1,269,602 students, focused on substance use in students. This category was subdivided into the subcategories alcohol (n = 18), drugs (licit and illicit; n = 9), smoking (n = 6), alcohol and drugs (n = 2), and smoking and drugs (n = 1). These categories, the research question, and the main outcomes of the review articles are sorted by epidemiological review articles and interventional review articles in Table 2. Alcohol consumption was of primary interest in four epidemiological review articles, whereas 14 review articles investigated the effectiveness of strategies to reduce alcohol use in the student collective. The large number of published review articles concerning alcohol consumption shows that especially drinking is a big issue in the student collective. Both, face-to-face programs and internet-based approaches show promising results in reducing drinking behavior. However, few review articles show limited effects and research for long-term impact is lacking. Nine review articles assessed the prevalence of the use of drugs. Further, motives for drug misuse and the role of demographic and psychosocial circumstances are of importance. No interventional review articles met the inclusion criteria. Smoking was of primary interest in six review articles. Five review articles evaluated the smoking behavior among students and one SR/MA focused on the success of anti-smoking policy approaches. In three review articles, a combination of substances [alcohol and drugs (n = 2) and smoking and drugs (n = 1)] was the object of investigation.

TABLE 2
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Table 2. Main outcomes of the articles included in the systematic umbrella review focusing on “substance use” (n = 36).

Mental Health/Wellbeing

A total of 26 review articles, comprising 762 original articles including ~806,389 students, focused on mental health and wellbeing in students. The research question and the main outcomes of the review articles are sorted by epidemiological review articles and interventional review articles in Table 3. Mental health was of primary interest in nine epidemiological review articles, whereas 17 review articles investigated the effectiveness of strategies to improve the mental health state in the student collective. The topic “stress” in nursing students is primarily studied in the category “mental health.” The identification of stressors, the estimation of prevalence, and the effectiveness of coping strategies to decrease stress or anxiety, were paramount. However, topics like “suicidal thoughts” and “mental health prevention programs” in other student collectives were also evaluated.

TABLE 3
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Table 3. Main outcomes of the articles included in the systematic umbrella review focusing on “mental health/wellbeing” (n = 26).

Diet and Nutrition

A total of 6 review articles, comprising 148 original articles including ~50,698 students, focused on diet and nutrition in students. The research question and the main outcomes of the review articles are sorted by epidemiological review articles and interventional review articles in Table 4. Diet and nutrition were of primary interest in two epidemiological review articles whereas four review articles investigated the effectiveness of strategies to improve the dietary intake in the student collective. One of ten medical students is at risk for an eating disorder. Further, students age, color, having children, and being financially independent, are related to higher rates of food insecurity. Various strategies, like in-person interventions, media approaches, and nutrition labeling, are promising in improving the dietary habits among university students.

TABLE 4
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Table 4. Main outcomes of the articles included in the systematic umbrella review focusing on “diet and nutrition” (n = 6).

Physical Activity

A total of 4 review articles, comprising 282 original articles including ~220,100 students, focused on the physical activity level in students. The research question and the main outcomes of the review articles are sorted by epidemiological review articles and interventional review articles in Table 5. Physical activity was of primary interest in two epidemiological review articles, whereas two review articles investigated the effectiveness of strategies to influence activity behaviors in the student collective. The length of study is positively associated with an increase in weight and body fat, and the self-reported sedentary behavior or screen time is associated with gender, physical activity behavior, and obesity markers (e.g., BMI and fat percentage). Modifiable factors should be addressed by physical activity promotion approaches with promising personalized interventions.

TABLE 5
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Table 5. Main outcomes of the articles included in the systematic umbrella review focusing on “physical health” (n = 4).

Sleep

A total of 3 review articles, comprising 107 original articles including ~117,432 students focused on sleep in students. The research question and the main outcomes of the review articles are sorted by epidemiological review articles and interventional review articles in Table 6. Sleep disturbance was of primary interest in one epidemiological review article among Chinese students, whereas two review articles investigated the effectiveness of strategies to improve sleep. There is insufficient evidence on educational approaches for sleep hygiene, whereas cognitive behavioral therapies confirm large effects for improved sleep.

TABLE 6
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Table 6. Main outcomes of the articles included in the systematic umbrella review focusing on “sleep” (n = 3).

Media Consumption

A total of 2 review articles, comprising 36 original articles including ~41,896 students, focused on media consumption in students. The research question and the main outcomes of the included systematic reviews and meta-analysis are presented in Table 7. Media consumption was of primary interest in two epidemiological systematic reviews and meta-analysis. The prevalence of internet addiction is high among Chinese students and a crucial issue among medical students.

TABLE 7
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Table 7. Main outcomes of the articles included in the systematic umbrella review focusing on “media consumption” (n = 2).

Others

A total of 4 review articles, comprising 56 original articles including ~21,612 students focused on “other” topics in students. The research question and the main outcomes of the included systematic reviews and meta-analysis are presented in Table 8.

TABLE 8
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Table 8. Main outcomes of the articles included in the systematic umbrella review focusing on “others” (n = 4).

Discussion

The aim of this study was to provide an overview of review articles on the epidemiology of modifiable health influencing factors and on the evidence of interventions targeting these factors among university students. Thereby, experts as well as stakeholders in the field could gain insights into crucial target points for health promotion and receive guidance about which intervention approaches have shown to be effective and hence, are advisable to implement in practice.

An almost equal amount of review articles with focus on epidemiology and intervention was found. Topics included in the different review articles ranged from physical activity over mental health, substance use, sleep, diet and nutrition, and media consumption. Most frequently targeted was the topic of substance use, particularly alcohol consumption. Also, in the field of mental health, many studies have been conducted—numerous of them dealing with stress. The fields of media consumption, sleep, nutrition, and physical (in)activity are still understudied and more attention needs to be paid to these factors.

For alcohol use and mental health, more intervention studies as compared to epidemiology studies exist. Conversely, in the remaining categories (sleep, diet and nutrition, physical activity, media consumption) the number of epidemiology and intervention studies is not as discrepant. This might be due to the fact, that the overall number of review articles in the area of mental health and alcohol use is higher than in the other categories. Studies that intervene on the setting/environment level as opposed to the individual level are underrepresented. A reason for this might be that environmental strategies could be more difficult to implement and evaluate (92). This is a finding that calls for action since already in the Okanagan Charter the need for a setting-based approach was highlighted (2).

The results gave insights into what interventions seem to be successful. For instance, promising results of interventions in order to reduce drinking behavior could be found in face-to-face programs and internet-based approaches. However, there is a need for future research that can identify approaches with long-term effects. In the field of improving dietary habits of university students in-person interventions, media approaches and nutrition labeling seem to be good strategies. In the area of physical activity promotion interventions future studies should consider personalized interventions. Yet, it is difficult to make conclusions about many of the interventions due to biased studies. In order to improve sleep among university students behavioral cognitive therapy showed larger effects compared to sleep hygiene interventions.

This umbrella review points out a focus of the identified review articles on specific groups like medical or nursing students in the current research landscape that are disproportionately often assessed. This might be explained by the fact that these groups are highly vulnerable, for instance, in terms of mental health problems, as was shown in previous studies (9396). Future research should aim to incorporate diverse study disciplines and not only target specific groups. Furthermore, the review articles are predominantly conducted in the US, China, and UK. Studies from European countries, like Germany, are underrepresented (97). A large amount of studies included international studies. Yet, the majority of studies still was conducted in the US and UK. It is possible, however, that a search in different languages would have resulted in more studies. Comparisons across different countries and cultures are limited due to differences in school systems. Similarly, the transfer of results and recommendations to other countries needs to be considered with caution as findings might not be generalizable or appropriate for other cultures (98). Therefore, other countries need to take up research in order to identify similarities or differences between countries/cultures.

The quality assessment revealed a low quality for most studies. Therefore, conclusions based on the results need to be drawn carefully and should be investigated in more detail to maintain confidence in the findings. This demonstrates a critical finding and the need for further studies to improve their methodology by adhering to guidelines of how to perform review articles ideally. However, it must be stated that the AMSTAR tool seems very strict. The use of the tool itself is challenging as it requires some experience in order to rate the quality of other studies.

A possible limitation of this umbrella review is that it does not describe the current state of research sufficiently, since there might have been single studies published by now that have not been included into review articles, yet. Furthermore, this umbrella review combined review articles with very different methodologies, which makes it more difficult to compare and interpret results. This point is particularly critical for intervention studies. Another aspect to consider is that only studies in English and German language were included. Moreover, gray literature was not included (99).

The current umbrella review only includes review articles with data of epidemiological and interventional studies on student level. This might seem to contradict the setting-based approach of including everyone in interventions, such as staff/faculty members. This decision had to be made, however, in order to make studies more comparable to each other. Practical implications for health promotion at universities also need to consider research findings incorporating interventions for different groups beyond students as stated, for instance, in the SR by Fernandez et al. (92).

Conclusion

This umbrella review provides a large overview of the research landscape with regard to modifiable health influencing factors and according interventions. Counting to the methodological strengths is the extensive amount of studies reviewed in duplicate as part of the general conduct according to the PRISMA guidelines (15). Further making this umbrella review exceptional is that it combines a wide spectrum of health topics that were displayed in the different categories: from physical activity to diet and nutrition, mental health, substance use and media consumption, a diverse set of topics is covered. In addition, a salutogenic approach was focused. This umbrella review is not disease oriented but rather oriented toward positive health and modifiable factors (health determinants and health behaviors). It provides a great overview for those who quickly need to gain information about the current evidence of modifiable health influencing factors in the context of health promotion among university students.

Author Contributions

All authors contributed to the conception, analysis, and interpretation of the manuscript. All authors read and approved the final document.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: university students, modifiable health influencing factors, epidemiology, intervention, health promotion

Citation: Dietz P, Reichel JL, Edelmann D, Werner AM, Tibubos AN, Schäfer M, Simon P, Letzel S and Pfirrmann D (2020) A Systematic Umbrella Review on the Epidemiology of Modifiable Health Influencing Factors and on Health Promoting Interventions Among University Students. Front. Public Health 8:137. doi: 10.3389/fpubh.2020.00137

Received: 09 January 2020; Accepted: 03 April 2020;
Published: 28 April 2020.

Edited by:

Harshad Thakur, Tata Institute of Social Sciences, India

Reviewed by:

Iffat Elbarazi, Abu Dhabi University, United Arab Emirates
Melissa Bopp, Pennsylvania State University (PSU), United States

Copyright © 2020 Dietz, Reichel, Edelmann, Werner, Tibubos, Schäfer, Simon, Letzel and Pfirrmann. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Daniel Pfirrmann, pfirrma@uni-mainz.de

These authors share first authorship