Health professional students at the University of Illinois Chicago (HOLISTIC) Cohort study: Prevalence of mental health and lifestyle behaviors effects among health professional students during the COVID-19 pandemic

Health professional students at the University of Illinois Chicago (HOLISTIC) Cohort study: Prevalence of mental health and lifestyle behaviors effects among health professional students during the COVID-19 pandemic | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Health professional students at the University of Illinois Chicago (HOLISTIC) Cohort study: Prevalence of mental health and lifestyle behaviors effects among health professional students during the COVID-19 pandemic Atithi Patel, Jun Lu, Jyotsna Bitra, Sunil Dommaraju, Daniel Loizzo, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4068047/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The COVID-19 pandemic adversely affected the mental health of healthcare workers. The World Health Organization estimates a 25% increase in anxiety prevalence during the pandemic. The mental health of students across the health professions during the pandemic is less well understood. Objectives To better understand the impact of the COVID-19 pandemic on health professional students, a cross-sectional analysis of data collected on enrollment in a cohort study was utilized to examine the prevalence of poor mental health days in association with lifestyle behaviors in seven health sciences colleges at a large public Midwestern university during the first two years of the COVID-19 pandemic. The study recruited 890 students enrolled full- or part-time across seven health sciences colleges in 2020 and/or 2021 using convenience sampling. Methods Participants completed questionnaires which included socio-demographic questions and items from the U.S. Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor and Surveillance System (BRFSS) 2019 survey. Results The participants reported a median of 7 days with poor mental health (IQR: 3-15 days) in the past 30 days. Female sex (OR 1.70, 95% CI [1.21, 2.38]), Asian race (OR 1.47, 95% CI [1.06, 2.06]), adverse childhood events (OR 2.01, 95 % CI [1.45-2.78]), and frequent cannabis use (OR = 2.03, 95 % CI [1.14-3.61]) were each associated with an increased risk of poor mental health during the COVID-19 pandemic. Exercise (OR 0.64, 95 % CI [0.42-0.97]) was found to be a protective factor, during COVID-19. Conclusions and Implications Results indicate the need to design, implement, and evaluate services to support mental health in health sciences students, particularly among certain subgroups. Students who are frequent cannabis users or have significant childhood trauma are more likely to have poor mental health and as such may benefit from additional mental health support. Health promotions around home-based exercise and intramural sports to health professional students along with longer open hours for the gym may be beneficial. health professional students mental health lifestyle behaviors Figures Figure 1 Figure 2 Background The COVID-19 pandemic adversely affected the mental health of healthcare workers due to several occupational factors such as extended work hours, concerns about occupational exposures to the SARS-CoV-2 virus for self and family, and limited access to personal protective equipment (at the start of the pandemic). 1 , 2 Health professional students also faced occupational limitations related to substantial disruptions in education, including a pivot from in-person to digital learning and training, virtual socialization, and uncertainty about the efficacy of their training. 1 , 3 , 4 Health professional students as a conglomerate population have not been extensively studied, especially within the United States (US), and few studies exist on this population, especially during the COVID-19 pandemic. Within nursing and medical students populations internationally, the pandemic was associated with higher rates of anxiety, depression, and distress. 1 , 5-8 There is further need for empirical information related to this large population within the health professional student body. The objective of this study was to address the gaps in the literature by studying the prevalence of poor mental health in students enrolled across seven health sciences colleges (applied health, dentistry, medicine, nursing, pharmacy, public health, social work) during the COVID-19 pandemic and lifestyle factors associated with increased or decreased risk of poor mental health in this population. Such information could help inform the need for support services that address mental health during the training of health professional students. Review of the literature related mental health and lifestyle behaviors among health professional students. This study mainly focuses on the association between various lifestyle and demographic factors such as adverse childhood events, substance use (alcohol and cannabis), racial identity, diet, and exercise on poor mental health days for health professional students. The studies on each variable are reviewed separately in the following sections. Adverse childhood events (ACEs) Adverse childhood experiences (ACEs) impact both early development and long-term health outcomes well into adulthood. 9 , 10 A higher number of ACEs, more than 4 out of 10, are correlated with increased prevalence of mental health problems later in life. 11 , 12 Past research has established that young adults, such as health professional students, are more dependent on their social networks to cope with the effects of negative emotional experiences such as ACEs. 13 During the COVID-19 pandemic, social networks were threatened by lockdowns, job loss, limits on social gatherings, and limited opportunities to initiate and foster long-term, intimate relationships. 13 Alradhi and colleagues found that young adults in Canada with significant ACEs were found to be more vulnerable to COVID-related mental health reductions. 13 Within the United States, health professional students have a significantly higher rates of ACEs. Approximately 16% of the general population in the United States have experiences 4 or more ACEs. 12 , 14 Within the United States, health professional students seem to have significantly higher rates of ACEs. Nursing and social work students 15 have a higher percentage of ACEs versus the national average with one study finding 42% of Master’s of Social Work students at a single institution were noted to have 4 or more ACEs. 16 Substance Use The substantial life changes and stressors of the COVID-19 pandemic led students and healthcare workers to resort to coping mechanisms such as alcohol consumption and cannabis use. 17 , 18 Alcohol Use. Individuals with pre-existing mental health issues are 10 times more likely to engage in alcohol consumption. 19 Healthcare workers reported increased levels of alcohol abuse due to increased stress levels during the frontline pandemic response 20 , which also led to increased mistakes on shifts 18 . Amongst nursing students in Israel, mental disengagement in the form of alcohol became more prominent near the end of lockdown. 5 Alcohol consumption in this population group was also observed to be associated with higher odds of moderate anxiety. 5 Cannabis Use. The relationship between cannabis use and mental health outcomes such as anxiety and depression has been investigated among undergraduate students, and Buckner et al. suggests an association between increased cannabis use and increased anxiety and depression. 21 Prior to COVID-19, over 30% of health professional students already used cannabis with a greater proportion of users being male. Exposure to diverse stressors, burnout, and relatively easy access to drugs increase health professional students’ vulnerability to substance use. Substance use may affect students’ current academic performance and mental health. 21-23 Among similarly aged college students, recent studies have found that cannabis use increased after the start of COVID-19, with an associated increase in depressive and anxiety symptoms. 24 , 25 Substance use data on college students provides valuable insights on the health professional student population given many undergraduate students are enrolled in health profession programs like those in the applied health sciences or undergraduate nursing programs, but also provides context for students who may eventually enter graduate health professional programs as well. Racial Identity. There is much evidence that the pandemic had harmful effects specifically on racial and ethnic minorities. 26 The discovery that the COVID-19 outbreak originated in Wuhan, China fueled xenophobic attitudes and actions against people of Asian complexions. 27 According to Tiwari and Zhang, Asian Americans already had higher rates of poor mental health pre-pandemic that xenophobia may have exacerbated. 26 Asian-Americans who were not personally subjected to acts of hate and violence still experienced mental exhaustion from being surrounded by the news of such incidents, in addition to the overall stress and anxiety caused by the COVID-19 pandemic. 27 Among Asian medical and biomedical graduate students, rates of anxiety and depression increased during the pandemic compared to the years prior. 7 Diet. The recommended guideline for fruit and vegetable intake for young people and adults is five portions per day. 28 The role of a properly balanced diet in the prevention and treatment of mental disorders has been suggested, as fruits and vegetables have a high content of nutrients are known to be protective against depression. 18 In general, any increased fruit and vegetable consumption results in the improvement of well-being, enhances happiness, and decreases depressive symptoms. 28 Dharmayani et al. concluded that the daily consumption of fruit by young people aged 18 to 29 years determined mental health stability and that the consumption of vegetables once a day among women revealed a lower risk of adult depression. 29 Disruption in education and financial burden during COVID-19, may have impacted health professional students’ diet. Among college students in the U.S. food insecurity increased by 59.6%. Less is known about food insecurity and decreased intake of fruits and vegetables within health professional students. 30 Exercise frequency and type. Physical activity is essential to improve and/or maintain physical and mental health and enhance quality of life. 31 Individuals who exercised had 43% fewer days of poor mental health in the past month than individuals who did not exercise. 32 This association was strongest for individuals who exercised between 30-60 min per session and a maximum of 90 min, 3 to 5 times per week. 32 During the pandemic, home based physical activities often became the safest way to exercise. Home based physical activities such as yoga and dancing were shown to alleviate anxiety, mood, and emotional health for medical students. 31 Exergames, exercises based on video games, provided a social outlet for users to engage with friends while participating in team physical activities. 31 Aims This study describes the association between lifestyle and demographic factors on the mental health and wellbeing of health professional students’ during the COVID-19 pandemic. Their behaviors can inform best practices for healthcare interventions and curriculum building in academic institutions. Methods Study Design The Health Professional Students at the University of Illinois Chicago (HOLISTIC) Cohort Study is a prospective cohort study to assess the well-being of health professional students. 33 The current report examines baseline data in participants who enrolled in 2021 (n=555) and 2022 (n=355). (Figure 1) Figure 1 Title: Recruitment Flowchart for HOLISTIC Cohort Study: Enrollment Trends from 2021 to 2022 -- Insert Figure 1 here-- Study Population The HOLISTIC Cohort Study enrolled students across seven health science colleges (applied health sciences, dentistry, medicine, nursing, pharmacy, public health, and social work) at the University of Illinois Chicago, a U.S. Department of Education designated minority-serving institution. 34 Students were eligible to enroll in the HOLISTIC Cohort Study if they were age 18 years or older and enrolled full- or part-time in a health science program that prepares its graduates to enter a healthcare profession. Questionnaire Participants filled out an online survey based on the validated U.S. Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor and Surveillance System (BRFSS) 2019 survey, which includes items about demographics, health status, and health-related behaviors. The health status domain includes items about Adverse Childhood Experiences (ACEs) 35 , potentially traumatic events that occur in childhood (0-17 years). Mental Health Mental health was assessed using the BRFSS self-reported question, “Now thinking about your mental health, which includes stress, depression, or difficulties with emotions, for how many days during the past 30 days was your mental health not good?” Statistical Analysis Mental health status was categorized into three groups based on the number of days with poor mental health in the past 30 days (at the time of survey response): good (less than 7 days), medium (7 to 13 days), and poor (more than 13 days). 36 Lifestyle and demographic factors were further operationalized and summarized based on the original survey responses.(Table 1) Descriptive statistics were utilized to characterize mental health status, demographic variables, and lifestyle behaviors of the study population across seven health science programs. For continuous variables, the median and interquartile range (IQR) were presented, while for categorical variables, counts and percentages were presented. The ordinal logistic regression was fitted to investigate the associations between multiple factors of interest and mental health. Multiple imputation was employed to address missing values while fitting the model. Additionally, a mixed graphical Gaussian model was fitted to visualize the conditional associations between the factors of interest. All statistical analyses were performed using R (version 4.1.3) software packages. A statistically significant association was defined as a two-sided p-value of less than 0.05, with a 95% confidence interval used for estimation. Results Participant Characteristics A total of 890 participants were included in the analyses in the current report (555 participants enrolled in 2021 and 335 participants enrolled in 2022). Participants were enrolled from the following colleges: the College of Medicine (n=234, 26.3%); College of Nursing (n=159, 17.9%), College of Pharmacy (n=146, 16.4%), College of Applied Health Sciences (n=123, 13.8%), School of Public Health (n=78, 8.8%), College of Dentistry (n=75, 8.4%), and Jane Addams College of Social Work (n=74, 8.3%). The median age of the participants was 25 years, with 79.0% identifying as female at birth and 53.6% identifying as non-white. Mental health Participants reported a median of 7 days with poor mental health (IQR: 3-15 days) in the past 30 days, with 48.6% indicating good mental health, 23.6% medium mental health, and 27.8% poor mental health. Demographic and Lifestyle factors associated with mental health The ordinal logistic regression analysis identified significant relationships between mental health and several demographic variables, such as age, assigned sex at birth, and race, with an odds ratio (OR) exceeding 1, indicating a higher chance of poor mental health days. Self-identified Asian (OR 1.47, 95% CI [1.06, 2.06]) and female students (OR 1.70, 95% CI [1.21, 2.38]) had higher odds of poor mental health, while younger students (OR 0.97, 95% CI [0.94, 0.99]) were more likely to report good mental health. Notably, more than 4 ACEs was strongly associated with mental health (OR 2.01, 95 % CI [1.45-2.78]). Lifestyle behaviors including cannabis use (OR = 2.03, 95 % CI [1.14-3.61]) and exercise behavior (OR 0.64, 95 % CI [0.42-0.97]) were found to be significantly associated with mental health. There were no significant associations between poor mental health days and the lifestyle behaviors of alcohol use and intake of fruits and vegetables. Furthermore, the network visualization presented in Figure 2 illustrates complex associations between various demographic and lifestyle variables. -- Insert Figure 2-- Figure 2 Footer: The edges between two nodes indicate the presence of an association between two factors. The width of the edge represents the strength of the association, with thicker edges indicating stronger associations. Red indicates a negative association, while green indicates a positive association. Grey is used when there is one or more nominal variables involved. Discussion We assessed health professional students’ mental health and wellbeing during the COVID-19 pandemic. In our sample, most students endorsed at least a week of poor mental health days in a month’s time. Students who identified as female and Asian had higher prevalence of poor mental health days in a month. Students who heavily used cannabis or experienced 4 or more ACEs were also more likely to experience increased number of poor mental health days during the pandemic. Students who exercised experienced fewer poor mental health days, indicating a likely better well-being. Regarding childhood trauma, we found 20.2% of students identified as having a significant number of ACEs, defined as 4 or more ACEs. This is slightly higher than the national average of 16%, which is consistent with comparable studies. 37 Social work, public health, and nursing students had a 43.2%, 28.2%, and 25.2% higher likelihood of significant ACEs compared to our general student population, respectively. 12 , 16 In our sample, students with significant ACEs were almost twice (2.01) as likely to have worse mental health in comparison to all participants. Given the increased prevalence of ACEs within social work students and direct training exposure to patients undergoing ACEs, this group may require additional health promotion and therapy resources as their work may trigger emotions from their past. ACEs have been associated with emotional dysregulation and low coping skills. Added stressors from the pandemic and exposure to patient suffering during their education may explain the worse mental health of health professional students with significant ACEs. 12 Though we found no significant association found between light, moderate, or heavy drinkers and their number of poor mental health days, in previous studies, it has been found that alcohol consumption changes depending on the scenario. 17 During the lockdown, social drinking was no longer a common option. As such, the lack of significant association between drinking and poor mental health in our study may be due to the change in circumstances associated with alcohol consumption during the pandemic. Furthermore, our survey questionnaire did not include questions about the social situations surrounding drinking. When examining cannabis use among health professional students, we found an association between the frequency of cannabis use and mental health. Health professional students that were frequent cannabis users had twice the odds of poor mental health compared to those that never used cannabis. Previous studies of undergraduates found a similar association between frequent cannabis use and poor mental health. 24 , 25 We continue to see this trend in health professional students, even though they may be more informed about the risks of substance use. This could be due to cannabis being more accepted to use without social interaction compared to other substances, and the pandemic increasing time spent alone due to online learning and social distancing. Primary care providers should consider including screening about cannabis use during substance use and mental health conversations with health professional students due to the association between these factors and the increasing prevalence of cannabis use. Further research is still necessary to establish a causal relationship between cannabis use and mental health. Within our study, only Asian identity was associated with a significantly higher number of poor mental health days compared to other races. Our study demonstrated that Asian students had a 47% increase in the odds of poor mental health compared to white students (p<0.05) (Table 4). Other race categories were also compared; however, there was not a statistically significant difference (Table 4). Tiwari and Zhang noted a sevenfold increase in the prevalence of depression and anxiety symptoms amongst Asian Americans post-pandemic. 26 Experiencing or witnessing xenophobia towards Asian Americans due to the pandemic could have further exacerbated the pandemic’s already negative impact on Asian students’ mental health. 27 In times of extreme xenophobia, university officials should be prompt in providing additional mental health resources to target groups. The majority of our participants (72%) reported consuming less than the recommended daily five portions of fruits and vegetables. Our findings demonstrated marginal significance (p = 0.07) between fruit and vegetable intake and mental health (Table 3), which reflects the conflicting conclusions present in the literature. 28 , 29 Students who consumed more than the recommended daily five portions of fruits and vegetables reported having 75% fewer poor mental health days per month (i.e., less than seven days out of the month). However, students consuming the recommended amount of fruits and vegetables still experienced more than seven poor mental health days per month. This study did not investigate food insecurities — a significant predictor of poor mental health days for females and males found in other studies. 38 Future versions of this study will need to consider a food insecurity variable to determine whether it impacts health professional students’ mental health in relation to their diet. Lastly, students who exercise more than the recommended level were 46% less likely to experience poor mental health than students who do not exercise. Any amount and type of physical activity has been shown to have mental health benefits, though no particular type was more significantly beneficial than others in previous studies. 31 In our study, the greatest decrease in poor mental health days was found to be associated with moderate exercise types, which includes bicycling, yoga, and dancing, aligning with previous studies. 31 83.7% of health professional students engage in moderate exercise.(Table 2) As such, institutions providing intramural sports and moderate/vigorous exercise programs in convenient locations for health professions students is important to continue these beneficial health habits. Limitations Limitations of this study included the lack of precision and specificity in the assessment of lifestyle factors for quantity of substance use and intake of fruits and vegetables. Study designs that employ measures to evaluate serving size for substance use and intake of fruits and vegetables could address this limitation. Another limitation is the use of self-reporting for all measures; future studies can address this by evaluating electronic health records and governmental contact tracing databases in addition to self-reporting for lifestyle factors such as food insecurity, specific mental health diagnoses, COVID symptom presentation and vaccination status, patient exposure, and adherence to social distancing measures. This data was collected with study participants from a single, Midwestern minority-serving public university; it is not known if findings from the HOLISTIC Cohort Study would apply to health professional students elsewhere. Multi-center studies that employ the protocol 33 of this study across multiple public and private universities in the U.S. and internationally could be used to address the potential for limited generalizability from the HOLISTIC Cohort Study. Conclusion The HOLISTIC Cohort Study has established a platform for assessing the health of health professional students educated during a unique time in history––the COVID-19 pandemic. To our knowledge, no other cohort study has evaluated a comprehensive set of health indicators, including mental health and occupational trajectories as students trained during the COVID-19 pandemic enter the health professional workforce. Health professional students’ mental health status during COVID-19 can be correlated with sex and racial Asian identity. Asian students experienced especially increased stressors during the COVID-19 pandemic due to the xenophobia they experienced or witnessed. Students who are frequent cannabis users or have significant childhood trauma are more susceptible to poor mental health and as such may benefit from additional mental health support. Despite decreased access to gyms during lockdown, home based (yoga) or singular exercise (biking) was a protective health behavior in our study population. Health promotions around home-based exercise and intramural sports to health professional students along with longer open hours for the gym may be beneficial. Abbreviations ACEs (Adverse Childhood Events), COVID-19 (Coronavirus Disease 2019), US (United States), HOLISTIC (Health Professional Students at the University of Illinois Chicago Cohort Study), CDC (Center for Disease Control), BRFSS (Behavioral Risk Factor and Surveillance System) Declarations Ethics approval and consent to participate: Approved by University of Illinois (UIC) IRB Consent for publication: N/A Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: Research reported in this publication was supported by the George H. Miller Memorial Fund. The content is solely the responsibility of the authors and does not necessarily represent the official views of the University of Illinois Chicago or the George H. Miller Memorial Fund. Authors' contributions: AP conceptualized the research question, led the manuscript team, and was the primary contributor to writing the manuscript. JL performed the data analysis and wrote the results section. JB and IH wrote the exercise sections and helped stitch together others’ paragraphs. SD conceptualized the study. SD and DL carried out the study and coordinated recruitment efforts for multiple years. BG and NG wrote the section on ACEs NK wrote the section on substance use DW and JLG wrote the section on nutrition. JKF was the primary faculty mentor for this manuscript. MK, RA, and JAK were primary faculty mentors for the conduction of the study. All authors read and approved the final manuscript. JAK co-led the study design and acquisition of data in the parent study; reviewed and provided edits for the work; and, helped to secure funding for the parent study. Acknowledgements: Authors' information (optional): References Collaborative TMS. The perceived impact of the Covid-19 pandemic on medical student education and training - an international survey. BMC Med Educ . Nov 9 2021;21(1):566. doi:10.1186/s12909-021-02983-3 Biber J, Ranes B, Lawrence S, et al. Mental health impact on healthcare workers due to the COVID-19 pandemic: a U.S. cross-sectional survey study. J Patient Rep Outcomes . Jun 13 2022;6(1):63. doi:10.1186/s41687-022-00467-6 Plakhotnik MS, Volkova NV, Jiang C, et al. The Perceived Impact of COVID-19 on Student Well-Being and the Mediating Role of the University Support: Evidence From France, Germany, Russia, and the UK. 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Association between Fruit and Vegetable Consumption and Depression Symptoms in Young People and Adults Aged 15-45: A Systematic Review of Cohort Studies. Int J Environ Res Public Health . Jan 18 2021;18(2)doi:10.3390/ijerph18020780 Kopels MC, Roulette CJ. Food insecurity, diet and mental distress among resource insecure students during COVID-19. Evol Med Public Health . 2023;11(1):18-29. doi:10.1093/emph/eoad001 Ai X, Yang J, Lin Z, Wan X. Mental Health and the Role of Physical Activity During the COVID-19 Pandemic. Front Psychol . 2021;12:759987. doi:10.3389/fpsyg.2021.759987 Chekroud SR, Gueorguieva R, Zheutlin AB, et al. Association between physical exercise and mental health in 1.2 million individuals in the USA between 2011 and 2015: a cross-sectional study. Lancet Psychiatry . Sep 2018;5(9):739-746. doi:10.1016/S2215-0366(18)30227-X Dommaraju SR, Rivera SG, Rocha EG, et al. Health professional students at the University of Illinois Chicago (HOLISTIC) Cohort Study: A protocol. PLoS One . 2022;17(8):e0269964. doi:10.1371/journal.pone.0269964 Loizzo DD, Datta A, Dommaraju SR, et al. COVID-19 Vaccine Hesitancy among Health Professional Students: Cross-Sectional Data from the First Wave of the HOLISTIC Cohort Study. Vaccines (Basel) . Sep 19 2022;10(9)doi:10.3390/vaccines10091566 U.S. Department of Health and Human Services CfDCaP. Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System Survey Questionnaire. Accessed 4 June, 2023. Kapp JM, Micheas L, Holmes S, Stormont M, Reinke WM. Prevalence of Poor Mental Health Days and Adverse Childhood Experience Reporting in U.S. Adults Before and After COVID-19. Community Ment Health J . Feb 2023;59(2):233-242. doi:10.1007/s10597-022-01001-0 Legislatures NCoS. Report adverse childhood experiences. https://www.ncsl.org/health/adverse-childhood-experiences#:~:text=Nearly%2016%20percent%20of%20adults,a%20higher%20number%20of%20ACEs Wattick RA, Hagedorn RL, Olfert MD. Relationship between Diet and Mental Health in a Young Adult Appalachian College Population. Nutrients . Jul 25 2018;10(8)doi:10.3390/nu10080957 Tables Tables 1 to 4 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Table11.pdf Table 1: Operationalization of Survey Questions for Lifestyle Factors Information Table21.pdf Table 2: Participants’ Demographical Information of Study Population across Seven Health Science Colleges Table31.pdf Table 3: Participants’ Mental Health Lifestyle Factors Across Seven Health Science Colleges Table41.pdf Table 4: Ordinal Logistic Regression Analysis Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4068047","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":280207472,"identity":"3c159559-830a-4119-b9b6-ed3a0322485c","order_by":0,"name":"Atithi Patel","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYLACxj81cvwMjA1AJjNxGhoYG44ZSzaQqIU5ccMBMIcILfyzm58/+LiDjXHzjeTGDwwV1okNhLRI3Dlm2DjzjAyz2Y3EZgmGM+mEtTDcSDBs5mFjYwNqaWNgbDtMWIv8jfSPzX/YmHmMZ4C0/CNCi8GNHMNmxjZmCQMJkJYGIrQY3jlTOLPnzDEDiTMPmyUSjqUbE9Qid7t9w4cfFTX1/e3pDz98qLGWJaiFQQKZk0BQOYaWUTAKRsEoGAXYAACLXUO/YNrgrQAAAABJRU5ErkJggg==","orcid":"","institution":"University of Illinois Chicago","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Atithi","middleName":"","lastName":"Patel","suffix":""},{"id":280207473,"identity":"90025cbe-9050-4674-9199-35ae699c088a","order_by":1,"name":"Jun Lu","email":"","orcid":"","institution":"University of Illinois Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Lu","suffix":""},{"id":280207474,"identity":"07ddbb89-a8d5-4484-9a35-9a8537404bc9","order_by":2,"name":"Jyotsna Bitra","email":"","orcid":"","institution":"University of Illinois Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jyotsna","middleName":"","lastName":"Bitra","suffix":""},{"id":280207475,"identity":"043260bd-1bec-42d0-89c8-c0f7228d9162","order_by":3,"name":"Sunil Dommaraju","email":"","orcid":"","institution":"University of Illinois Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sunil","middleName":"","lastName":"Dommaraju","suffix":""},{"id":280207476,"identity":"c725177b-ca0d-4ca4-8e32-b7241dd3fd45","order_by":4,"name":"Daniel Loizzo","email":"","orcid":"","institution":"University of Illinois Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Loizzo","suffix":""},{"id":280207477,"identity":"3d4ee216-ebc2-43b3-93f3-d5ff3715a949","order_by":5,"name":"Brenda Guillen","email":"","orcid":"","institution":"University of Illinois Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Brenda","middleName":"","lastName":"Guillen","suffix":""},{"id":280207478,"identity":"253cb89f-01b7-46f8-9a65-f0f5f91844b6","order_by":6,"name":"Niamh Kane","email":"","orcid":"","institution":"University of Illinois Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Niamh","middleName":"","lastName":"Kane","suffix":""},{"id":280207479,"identity":"378d21e7-e52a-4e21-a9c7-586d83ef26ef","order_by":7,"name":"Danielle Westnedge","email":"","orcid":"","institution":"University of Illinois Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Danielle","middleName":"","lastName":"Westnedge","suffix":""},{"id":280207480,"identity":"7ab907e4-81b6-4949-bc7f-2af0d59a98a7","order_by":8,"name":"Jessica Lopez Guzman","email":"","orcid":"","institution":"University of Illinois Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jessica","middleName":"Lopez","lastName":"Guzman","suffix":""},{"id":280207481,"identity":"d33fc81b-f89b-46fe-9f6f-8d7272646fa0","order_by":9,"name":"Nancy Giang","email":"","orcid":"","institution":"University of Illinois Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nancy","middleName":"","lastName":"Giang","suffix":""},{"id":280207482,"identity":"27700493-55c2-437c-868a-c4014d96fbdd","order_by":10,"name":"Isabella Hartnett","email":"","orcid":"","institution":"University of Illinois Chicago","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Isabella","middleName":"","lastName":"Hartnett","suffix":""},{"id":280207483,"identity":"27a60dc4-45a2-4f00-9905-b428c12827ed","order_by":11,"name":"Mary T. 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The width of the edge represents the strength of the association, with thicker edges indicating stronger associations. Red indicates a negative association, while green indicates a positive association. Grey is used when there is one or more nominal variables involved.\u003c/p\u003e","description":"","filename":"Figure21.png","url":"https://assets-eu.researchsquare.com/files/rs-4068047/v1/12f8c50bfb6cceb84badc252.png"},{"id":54024500,"identity":"ebb8dba1-36fd-4793-ad42-33e778e3e253","added_by":"auto","created_at":"2024-04-03 14:30:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":776664,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4068047/v1/1b47feaa-04f2-45d7-9ba0-e9532fa47135.pdf"},{"id":53009849,"identity":"fb52e318-cbd0-4381-85b6-27df1c7ba05f","added_by":"auto","created_at":"2024-03-19 15:24:32","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":28675,"visible":true,"origin":"","legend":"\u003cp\u003eTable 1: Operationalization of Survey Questions for Lifestyle Factors Information\u003c/p\u003e","description":"","filename":"Table11.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4068047/v1/1b93ede07a3bda0cad626a34.pdf"},{"id":53009854,"identity":"a7831d6a-0e7d-4f94-bf6a-84872e2eb5a3","added_by":"auto","created_at":"2024-03-19 15:24:32","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":22280,"visible":true,"origin":"","legend":"\u003cp\u003eTable 2: Participants’ Demographical Information of Study Population across Seven Health Science Colleges\u003c/p\u003e","description":"","filename":"Table21.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4068047/v1/c5b46068b5b0cdf3e72cabf5.pdf"},{"id":53009850,"identity":"2db59757-bde8-458e-b4f3-57500c90f653","added_by":"auto","created_at":"2024-03-19 15:24:32","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":29108,"visible":true,"origin":"","legend":"\u003cp\u003eTable 3: Participants’ Mental Health Lifestyle Factors Across Seven Health Science Colleges\u003c/p\u003e","description":"","filename":"Table31.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4068047/v1/a8ce4b1f9b47360c2ed15cfc.pdf"},{"id":53009852,"identity":"9084f9e5-3116-4213-b06b-3f0f4f825dd3","added_by":"auto","created_at":"2024-03-19 15:24:32","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":26063,"visible":true,"origin":"","legend":"\u003cp\u003eTable 4: Ordinal Logistic Regression Analysis\u003c/p\u003e","description":"","filename":"Table41.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4068047/v1/76f8c5cffab40f983b3b4979.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Health professional students at the University of Illinois Chicago (HOLISTIC) Cohort study: Prevalence of mental health and lifestyle behaviors effects among health professional students during the COVID-19 pandemic","fulltext":[{"header":"Background","content":"\u003cp\u003eThe COVID-19 pandemic adversely affected the mental health of healthcare workers due to several occupational factors such as extended work hours, concerns about occupational exposures to the SARS-CoV-2 virus for self and family, and limited access to personal protective equipment (at the start of the pandemic).\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e2\u003c/sup\u003e Health professional students also faced occupational limitations related to substantial disruptions in education, including a pivot from in-person to digital learning and training, virtual socialization, and uncertainty about the efficacy of their training.\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e3\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e4\u003c/sup\u003e Health professional students as a conglomerate population have not been extensively studied, especially within the United States (US), and few studies exist on this population, especially during the COVID-19 pandemic. Within nursing and medical students populations internationally, the pandemic was associated with higher rates of anxiety, depression, and distress.\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e5-8\u003c/sup\u003e There is further need for empirical information related to this large population within the health professional student body. \u003c/p\u003e\n\u003cp\u003eThe objective of this study was to address the gaps in the literature by studying the prevalence of poor mental health in students enrolled across seven health sciences colleges (applied health, dentistry, medicine, nursing, pharmacy, public health, social work) during the COVID-19 pandemic and lifestyle factors associated with increased or decreased risk of poor mental health in this population. Such information could help inform the need for support services that address mental health during the training of health professional students. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReview of the literature related mental health and lifestyle behaviors among health professional students. \u003c/strong\u003eThis study mainly focuses on the association between various lifestyle and demographic factors such as adverse childhood events, substance use (alcohol and cannabis), racial identity, diet, and exercise on poor mental health days for health professional students. The studies on each variable are reviewed separately in the following sections.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdverse childhood events (ACEs) \u003c/strong\u003eAdverse childhood experiences (ACEs) impact both early development and long-term health outcomes well into adulthood.\u003csup\u003e9\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e10\u003c/sup\u003e A higher number of ACEs, more than 4 out of 10, are correlated with increased prevalence of mental health problems later in life.\u003csup\u003e11\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e12\u003c/sup\u003e Past research has established that young adults, such as health professional students, are more dependent on their social networks to cope with the effects of negative emotional experiences such as ACEs.\u003csup\u003e13\u003c/sup\u003e During the COVID-19 pandemic, social networks were threatened by lockdowns, job loss, limits on social gatherings, and limited opportunities to initiate and foster long-term, intimate relationships.\u003csup\u003e13\u003c/sup\u003e Alradhi and colleagues found that young adults in Canada with significant ACEs were found to be more vulnerable to COVID-related mental health reductions.\u003csup\u003e13\u003c/sup\u003e Within the United States, health professional students have a significantly higher rates of ACEs. Approximately 16% of the general population in the United States have experiences 4 or more ACEs.\u003csup\u003e12\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e14\u003c/sup\u003e Within the United States, health professional students seem to have significantly higher rates of ACEs. Nursing and social work students\u003csup\u003e15\u003c/sup\u003e have a higher percentage of ACEs versus the national average with one study finding 42% of Master’s of Social Work students at a single institution were noted to have 4 or more ACEs.\u003csup\u003e16\u003c/sup\u003e \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubstance Use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe substantial life changes and stressors of the COVID-19 pandemic led students and healthcare workers to resort to coping mechanisms such as alcohol consumption and cannabis use.\u003csup\u003e17\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e18\u003c/sup\u003e \u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAlcohol Use. \u003c/em\u003eIndividuals with pre-existing mental health issues are 10 times more likely to engage in alcohol consumption.\u003csup\u003e19\u003c/sup\u003e Healthcare workers reported increased levels of alcohol abuse due to increased stress levels during the frontline pandemic response\u003csup\u003e20\u003c/sup\u003e, which also led to increased mistakes on shifts\u003csup\u003e18\u003c/sup\u003e. Amongst nursing students in Israel, mental disengagement in the form of alcohol became more prominent near the end of lockdown.\u003csup\u003e5\u003c/sup\u003e Alcohol consumption in this population group was also observed to be associated with higher odds of moderate anxiety.\u003csup\u003e5\u003c/sup\u003e \u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCannabis Use. \u003c/em\u003eThe relationship between cannabis use and mental health outcomes such as anxiety and depression has been investigated among undergraduate students, and Buckner et al. suggests an association between increased cannabis use and increased anxiety and depression.\u003csup\u003e21\u003c/sup\u003e Prior to COVID-19, over 30% of health professional students already used cannabis with a greater proportion of users being male. Exposure to diverse stressors, burnout, and relatively easy access to drugs increase health professional students’ vulnerability to substance use. Substance use may affect students’ current academic performance and mental health.\u003csup\u003e21-23\u003c/sup\u003e Among similarly aged college students, recent studies have found that cannabis use increased after the start of COVID-19, with an associated increase in depressive and anxiety symptoms.\u003csup\u003e24\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e25\u003c/sup\u003e Substance use data on college students provides valuable insights on the health professional student population given many undergraduate students are enrolled in health profession programs like those in the applied health sciences or undergraduate nursing programs, but also provides context for students who may eventually enter graduate health professional programs as well. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRacial Identity. \u003c/strong\u003eThere is much evidence that the pandemic had harmful effects specifically on racial and ethnic minorities.\u003csup\u003e26\u003c/sup\u003e The discovery that the COVID-19 outbreak originated in Wuhan, China fueled xenophobic attitudes and actions against people of Asian complexions.\u003csup\u003e27\u003c/sup\u003e According to Tiwari and Zhang, Asian Americans already had higher rates of poor mental health pre-pandemic that xenophobia may have exacerbated.\u003csup\u003e26\u003c/sup\u003e Asian-Americans who were not personally subjected to acts of hate and violence still experienced mental exhaustion from being surrounded by the news of such incidents, in addition to the overall stress and anxiety caused by the COVID-19 pandemic.\u003csup\u003e27\u003c/sup\u003e Among Asian medical and biomedical graduate students, rates of anxiety and depression increased during the pandemic compared to the years prior.\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiet. \u003c/strong\u003eThe recommended guideline for fruit and vegetable intake for young people and adults is five portions per day.\u003csup\u003e28\u003c/sup\u003e The role of a properly balanced diet in the prevention and treatment of mental disorders has been suggested, as fruits and vegetables have a high content of nutrients are known to be protective against depression.\u003csup\u003e18\u003c/sup\u003e In general, any increased fruit and vegetable consumption results in the improvement of well-being, enhances happiness, and decreases depressive symptoms.\u003csup\u003e28\u003c/sup\u003e Dharmayani et al. concluded that the daily consumption of fruit by young people aged 18 to 29 years determined mental health stability and that the consumption of vegetables once a day among women revealed a lower risk of adult depression.\u003csup\u003e29\u003c/sup\u003e Disruption in education and financial burden during COVID-19, may have impacted health professional students’ diet. Among college students in the U.S. food insecurity increased by 59.6%. Less is known about food insecurity and decreased intake of fruits and vegetables within health professional students.\u003csup\u003e30\u003c/sup\u003e \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExercise frequency and type.\u003c/strong\u003e Physical activity is essential to improve and/or maintain physical and mental health and enhance quality of life.\u003csup\u003e31\u003c/sup\u003e Individuals who exercised had 43% fewer days of poor mental health in the past month than individuals who did not exercise.\u003csup\u003e32\u003c/sup\u003e This association was strongest for individuals who exercised between 30-60 min per session and a maximum of 90 min, 3 to 5 times per week.\u003csup\u003e32\u003c/sup\u003e During the pandemic, home based physical activities often became the safest way to exercise. Home based physical activities such as yoga and dancing were shown to alleviate anxiety, mood, and emotional health for medical students.\u003csup\u003e31\u003c/sup\u003e Exergames, exercises based on video games, provided a social outlet for users to engage with friends while participating in team physical activities.\u003csup\u003e31\u003c/sup\u003e \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims \u003c/strong\u003eThis study describes the association between lifestyle and demographic factors on the mental health and wellbeing of health professional students’ during the COVID-19 pandemic. Their behaviors can inform best practices for healthcare interventions and curriculum building in academic institutions. \u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eStudy Design\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Health Professional Students at the University of Illinois Chicago (HOLISTIC) Cohort Study is a prospective cohort study to assess the well-being of health professional students.\u003csup\u003e33\u003c/sup\u003e The current report examines baseline data in participants who enrolled in 2021 (n=555) and 2022 (n=355). (Figure 1) \u003c/p\u003e\n\u003cp\u003eFigure 1 Title: Recruitment Flowchart for HOLISTIC Cohort Study: Enrollment Trends from 2021 to 2022\u003c/p\u003e\n\u003cp\u003e-- Insert Figure 1 here--\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudy Population\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe HOLISTIC Cohort Study enrolled students across seven health science colleges (applied health sciences, dentistry, medicine, nursing, pharmacy, public health, and social work) at the University of Illinois Chicago, a U.S. Department of Education designated minority-serving institution.\u003csup\u003e34\u003c/sup\u003e Students were eligible to enroll in the HOLISTIC Cohort Study if they were age 18 years or older and enrolled full- or part-time in a health science program that prepares its graduates to enter a healthcare profession. \u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQuestionnaire\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants filled out an online survey based on the validated U.S. Centers for Disease Control and Prevention\u0026rsquo;s (CDC) Behavioral Risk Factor and Surveillance System (BRFSS) 2019 survey, which includes items about demographics, health status, and health-related behaviors. The health status domain includes items about Adverse Childhood Experiences (ACEs)\u003csup\u003e35\u003c/sup\u003e, potentially traumatic events that occur in childhood (0-17 years). \u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMental Health\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMental health was assessed using the BRFSS self-reported question, \u0026ldquo;Now thinking about your mental health, which includes stress, depression, or difficulties with emotions, for how many days during the past 30 days was your mental health not good?\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMental health status was categorized into three groups based on the number of days with poor mental health in the past 30 days (at the time of survey response): good (less than 7 days), medium (7 to 13 days), and poor (more than 13 days).\u003csup\u003e36\u003c/sup\u003e Lifestyle and demographic factors were further operationalized and summarized based on the original survey responses.(Table 1) Descriptive statistics were utilized to characterize mental health status, demographic variables, and lifestyle behaviors of the study population across seven health science programs. For continuous variables, the median and interquartile range (IQR) were presented, while for categorical variables, counts and percentages were presented. The ordinal logistic regression was fitted to investigate the associations between multiple factors of interest and mental health. Multiple imputation was employed to address missing values while fitting the model. Additionally, a mixed graphical Gaussian model was fitted to visualize the conditional associations between the factors of interest. All statistical analyses were performed using R (version 4.1.3) software packages. A statistically significant association was defined as a two-sided p-value of less than 0.05, with a 95% confidence interval used for estimation.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eParticipant Characteristics\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA total of 890 participants were included in the analyses in the current report (555 participants enrolled in 2021 and 335 participants enrolled in 2022). \u0026nbsp;Participants were enrolled from the following colleges: the College of Medicine (n=234, 26.3%); College of Nursing (n=159, 17.9%), College of Pharmacy (n=146, 16.4%), College of Applied Health Sciences (n=123, 13.8%), School of Public Health (n=78, 8.8%), College of Dentistry (n=75, 8.4%), and Jane Addams College of Social Work (n=74, 8.3%). The median age of the participants was 25 years, with 79.0% identifying as female at birth and 53.6% identifying as non-white.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMental health\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported a median of 7 days with poor mental health (IQR: 3-15 days) in the past 30 days, with 48.6% indicating good mental health, 23.6% medium mental health, and 27.8% poor mental health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDemographic and Lifestyle factors associated with mental health\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe ordinal logistic regression analysis identified significant relationships between mental health and several demographic variables, such as age, assigned sex at birth, and race, with an odds ratio (OR) exceeding 1, indicating a higher chance of poor mental health days.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSelf-identified Asian (OR 1.47, 95% CI [1.06, 2.06]) and female students (OR 1.70, 95% CI [1.21, 2.38]) had higher odds of poor mental health, while younger students (OR 0.97, 95% CI [0.94, 0.99]) were more likely to report good mental health. Notably, more than 4 ACEs was strongly associated with mental health (OR 2.01, 95 % CI [1.45-2.78]).\u0026nbsp;Lifestyle behaviors including cannabis use (OR = 2.03, 95 % CI [1.14-3.61])\u0026nbsp;and exercise behavior\u0026nbsp;(OR \u0026nbsp;0.64, 95 % CI [0.42-0.97])\u0026nbsp;were found to be significantly associated with mental health.\u0026nbsp;There were no significant associations between poor mental health days and the lifestyle behaviors of alcohol use and intake of fruits and vegetables. Furthermore, the network visualization presented in Figure 2 illustrates complex associations between various demographic and lifestyle variables.\u003c/p\u003e\n\u003cp\u003e-- Insert Figure 2--\u003c/p\u003e\n\u003cp\u003eFigure 2 Footer: The edges between two nodes indicate the presence of an association between two factors. The width of the edge represents the strength of the association, with thicker edges indicating stronger associations. Red indicates a negative association, while green indicates a positive association. Grey is used when there is one or more nominal variables involved.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe assessed health professional students’ mental health and wellbeing during the COVID-19 pandemic. In our sample, most students endorsed at least a week of poor mental health days in a month’s time. Students who identified as female and Asian had higher prevalence of poor mental health days in a month. Students who heavily used cannabis or experienced 4 or more ACEs were also more likely to experience increased number of poor mental health days during the pandemic. Students who exercised experienced fewer poor mental health days, indicating a likely better well-being. \u003c/p\u003e\n\u003cp\u003eRegarding childhood trauma, we found 20.2% of students identified as having a significant number of ACEs, defined as 4 or more ACEs. This is slightly higher than the national average of 16%, which is consistent with comparable studies.\u003csup\u003e37\u003c/sup\u003e Social work, public health, and nursing students had a 43.2%, 28.2%, and 25.2% higher likelihood of significant ACEs compared to our general student population, respectively.\u003csup\u003e12\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e16\u003c/sup\u003e In our sample, students with significant ACEs were almost twice (2.01) as likely to have worse mental health in comparison to all participants. Given the increased prevalence of ACEs within social work students and direct training exposure to patients undergoing ACEs, this group may require additional health promotion and therapy resources as their work may trigger emotions from their past. ACEs have been associated with emotional dysregulation and low coping skills. Added stressors from the pandemic and exposure to patient suffering during their education may explain the worse mental health of health professional students with significant ACEs.\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThough we found no significant association found between light, moderate, or heavy drinkers and their number of poor mental health days, in previous studies, it has been found that alcohol consumption changes depending on the scenario.\u003csup\u003e17\u003c/sup\u003e During the lockdown, social drinking was no longer a common option. As such, the lack of significant association between drinking and poor mental health in our study may be due to the change in circumstances associated with alcohol consumption during the pandemic. Furthermore, our survey questionnaire did not include questions about the social situations surrounding drinking.\u003c/p\u003e\n\u003cp\u003eWhen examining cannabis use among health professional students, we found an association between the frequency of cannabis use and mental health. Health professional students that were frequent cannabis users had twice the odds of poor mental health compared to those that never used cannabis. Previous studies of undergraduates found a similar association between frequent cannabis use and poor mental health.\u003csup\u003e24\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e25\u003c/sup\u003e We continue to see this trend in health professional students, even though they may be more informed about the risks of substance use. This could be due to cannabis being more accepted to use without social interaction compared to other substances, and the pandemic increasing time spent alone due to online learning and social distancing. Primary care providers should consider including screening about cannabis use during substance use and mental health conversations with health professional students due to the association between these factors and the increasing prevalence of cannabis use. Further research is still necessary to establish a causal relationship between cannabis use and mental health.\u003c/p\u003e\n\u003cp\u003eWithin our study, only Asian identity was associated with a significantly higher number of poor mental health days compared to other races. Our study demonstrated that Asian students had a 47% increase in the odds of poor mental health compared to white students (p\u0026lt;0.05) (Table 4). Other race categories were also compared; however, there was not a statistically significant difference (Table 4). Tiwari and Zhang noted a sevenfold increase in the prevalence of depression and anxiety symptoms amongst Asian Americans post-pandemic.\u003csup\u003e26\u003c/sup\u003e Experiencing or witnessing xenophobia towards Asian Americans due to the pandemic could have further exacerbated the pandemic’s already negative impact on Asian students’ mental health.\u003csup\u003e27\u003c/sup\u003e In times of extreme xenophobia, university officials should be prompt in providing additional mental health resources to target groups. \u003c/p\u003e\n\u003cp\u003eThe majority of our participants (72%) reported consuming less than the recommended daily five portions of fruits and vegetables. Our findings demonstrated marginal significance (p = 0.07) between fruit and vegetable intake and mental health (Table 3), which reflects the conflicting conclusions present in the literature.\u003csup\u003e28\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e29\u003c/sup\u003e Students who consumed more than the recommended daily five portions of fruits and vegetables reported having 75% fewer poor mental health days per month (i.e., less than seven days out of the month). However, students consuming the recommended amount of fruits and vegetables still experienced more than seven poor mental health days per month. This study did not investigate food insecurities — a significant predictor of poor mental health days for females and males found in other studies.\u003csup\u003e38\u003c/sup\u003e Future versions of this study will need to consider a food insecurity variable to determine whether it impacts health professional students’ mental health in relation to their diet. \u003c/p\u003e\n\u003cp\u003eLastly, students who exercise more than the recommended level were 46% less likely to experience poor mental health than students who do not exercise. Any amount and type of physical activity has been shown to have mental health benefits, though no particular type was more significantly beneficial than others in previous studies.\u003csup\u003e31\u003c/sup\u003e In our study, the greatest decrease in poor mental health days was found to be associated with moderate exercise types, which includes bicycling, yoga, and dancing, aligning with previous studies.\u003csup\u003e31\u003c/sup\u003e 83.7% of health professional students engage in moderate exercise.(Table 2) As such, institutions providing intramural sports and moderate/vigorous exercise programs in convenient locations for health professions students is important to continue these beneficial health habits. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLimitations of this study included the lack of precision and specificity in the assessment of lifestyle factors for quantity of substance use and intake of fruits and vegetables. Study designs that employ measures to evaluate serving size for substance use and intake of fruits and vegetables could address this limitation. Another limitation is the use of self-reporting for all measures; future studies can address this by evaluating electronic health records and governmental contact tracing databases in addition to self-reporting for lifestyle factors such as food insecurity, specific mental health diagnoses, COVID symptom presentation and vaccination status, patient exposure, and adherence to social distancing measures. This data was collected with study participants from a single, Midwestern minority-serving public university; it is not known if findings from the HOLISTIC Cohort Study would apply to health professional students elsewhere. Multi-center studies that employ the protocol\u003csup\u003e33\u003c/sup\u003e of this study across multiple public and private universities in the U.S. and internationally could be used to address the potential for limited generalizability from the HOLISTIC Cohort Study. \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe HOLISTIC Cohort Study has established a platform for assessing the health of health professional students educated during a unique time in history\u0026ndash;\u0026ndash;the COVID-19 pandemic. To our knowledge, no other cohort study has evaluated a comprehensive set of health indicators, including mental health and occupational trajectories as students trained during the COVID-19 pandemic enter the health professional workforce. Health professional students\u0026rsquo; mental health status during COVID-19 can be correlated with sex and racial Asian identity. Asian students experienced especially increased stressors during the COVID-19 pandemic due to the xenophobia they experienced or witnessed. Students who are frequent cannabis users or have significant childhood trauma are more susceptible to poor mental health and as such may benefit from additional mental health support. Despite decreased access to gyms during lockdown, home based (yoga) or singular exercise (biking) was a protective health behavior in our study population. Health promotions around home-based exercise and intramural sports to health professional students along with longer open hours for the gym may be beneficial.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACEs (Adverse Childhood Events), COVID-19 (Coronavirus Disease 2019), US (United States), HOLISTIC (Health Professional Students at the University of Illinois Chicago Cohort Study), CDC (Center for Disease Control), BRFSS (Behavioral Risk Factor and Surveillance System)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: Approved by University of Illinois (UIC) IRB\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication: N/A\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding: Research reported in this publication was supported by the George H. Miller Memorial Fund. \u0026nbsp;The content is solely the responsibility of the authors and does not necessarily represent the official views of the University of Illinois Chicago or the George H. Miller Memorial Fund.\u003c/p\u003e\n\u003cp\u003eAuthors' contributions: AP conceptualized the research question, led the manuscript team, and was the primary contributor to writing the manuscript. JL performed the data analysis and wrote the results section. JB and IH wrote the exercise sections and helped stitch together others’ paragraphs. SD conceptualized the study. SD and DL carried out the study and coordinated recruitment efforts for multiple years. BG and NG wrote the section on ACEs NK wrote the section on substance use DW and JLG wrote the section on nutrition. JKF was the primary faculty mentor for this manuscript. MK, RA, and JAK were primary faculty mentors for the conduction of the study. All authors read and approved the final manuscript. JAK co-led the study design and acquisition of data in the parent study; reviewed and provided edits for the work; and, helped to secure funding for the parent study.\u003c/p\u003e\n\u003cp\u003eAcknowledgements:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors' information (optional):\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eCollaborative TMS. The perceived impact of the Covid-19 pandemic on medical student education and training - an international survey. \u003cem\u003eBMC Med Educ\u003c/em\u003e. Nov 9 2021;21(1):566. doi:10.1186/s12909-021-02983-3\u003c/li\u003e\n \u003cli\u003eBiber J, Ranes B, Lawrence S, et al. Mental health impact on healthcare workers due to the COVID-19 pandemic: a U.S. cross-sectional survey study. \u003cem\u003eJ Patient Rep Outcomes\u003c/em\u003e. Jun 13 2022;6(1):63. doi:10.1186/s41687-022-00467-6\u003c/li\u003e\n \u003cli\u003ePlakhotnik MS, Volkova NV, Jiang C, et al. 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Association between physical exercise and mental health in 1.2 million individuals in the USA between 2011 and 2015: a cross-sectional study. \u003cem\u003eLancet Psychiatry\u003c/em\u003e. Sep 2018;5(9):739-746. doi:10.1016/S2215-0366(18)30227-X\u003c/li\u003e\n \u003cli\u003eDommaraju SR, Rivera SG, Rocha EG, et al. Health professional students at the University of Illinois Chicago (HOLISTIC) Cohort Study: A protocol. \u003cem\u003ePLoS One\u003c/em\u003e. 2022;17(8):e0269964. doi:10.1371/journal.pone.0269964\u003c/li\u003e\n \u003cli\u003eLoizzo DD, Datta A, Dommaraju SR, et al. COVID-19 Vaccine Hesitancy among Health Professional Students: Cross-Sectional Data from the First Wave of the HOLISTIC Cohort Study. \u003cem\u003eVaccines (Basel)\u003c/em\u003e. Sep 19 2022;10(9)doi:10.3390/vaccines10091566\u003c/li\u003e\n \u003cli\u003eU.S. Department of Health and Human Services CfDCaP. Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System Survey Questionnaire. Accessed 4 June, 2023.\u003c/li\u003e\n \u003cli\u003eKapp JM, Micheas L, Holmes S, Stormont M, Reinke WM. Prevalence of Poor Mental Health Days and Adverse Childhood Experience Reporting in U.S. Adults Before and After COVID-19. \u003cem\u003eCommunity Ment Health J\u003c/em\u003e. Feb 2023;59(2):233-242. doi:10.1007/s10597-022-01001-0\u003c/li\u003e\n \u003cli\u003eLegislatures NCoS. Report adverse childhood experiences. https://www.ncsl.org/health/adverse-childhood-experiences#:~:text=Nearly%2016%20percent%20of%20adults,a%20higher%20number%20of%20ACEs\u003c/li\u003e\n \u003cli\u003eWattick RA, Hagedorn RL, Olfert MD. Relationship between Diet and Mental Health in a Young Adult Appalachian College Population. \u003cem\u003eNutrients\u003c/em\u003e. Jul 25 2018;10(8)doi:10.3390/nu10080957\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"health professional students, mental health, lifestyle behaviors","lastPublishedDoi":"10.21203/rs.3.rs-4068047/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4068047/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe COVID-19 pandemic adversely affected the mental health of healthcare workers. The World Health Organization estimates a 25% increase in anxiety prevalence during the pandemic. The mental health of students across the health professions during the pandemic is less well understood.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo better understand the impact of the COVID-19 pandemic on health professional students, a cross-sectional analysis of data collected on enrollment in a cohort study was utilized to examine the prevalence of poor mental health days in association with lifestyle behaviors in seven health sciences colleges at a large public Midwestern university during the first two years of the COVID-19 pandemic. The study recruited 890 students enrolled full- or part-time across seven health sciences colleges in 2020 and/or 2021 using convenience sampling.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants completed questionnaires which included socio-demographic questions and items from the U.S. Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor and Surveillance System (BRFSS) 2019 survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants reported a median of 7 days with poor mental health (IQR: 3-15 days) in the\u003c/p\u003e\n\u003cp\u003epast 30 days. Female sex (OR 1.70, 95% CI [1.21, 2.38]), Asian race (OR 1.47, 95% CI [1.06, 2.06]), adverse childhood events (OR 2.01, 95 % CI [1.45-2.78]), and frequent cannabis use (OR = 2.03, 95 % CI [1.14-3.61]) were each associated with an increased risk of poor mental health during the COVID-19 pandemic. Exercise (OR 0.64, 95 % CI [0.42-0.97]) was found to be a protective factor, during COVID-19.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions and Implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResults indicate the need to design, implement, and evaluate services to support mental health in health sciences students, particularly among certain subgroups. Students who are frequent cannabis users or have significant childhood trauma are more likely to have poor mental health and as such may benefit from additional mental health support. Health promotions around home-based exercise and intramural sports to health professional students along with longer open hours for the gym may be beneficial.\u003c/p\u003e","manuscriptTitle":"Health professional students at the University of Illinois Chicago (HOLISTIC) Cohort study: Prevalence of mental health and lifestyle behaviors effects among health professional students during the COVID-19 pandemic","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-19 15:24:27","doi":"10.21203/rs.3.rs-4068047/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"03df327c-6494-42d8-9ae1-171594dc9fc9","owner":[],"postedDate":"March 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-03T14:21:57+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-19 15:24:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4068047","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4068047","identity":"rs-4068047","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}