How has the health of college students changed in the last 50 years?

The American College Health Association (ACHA) is marking the completion of its 100^th year this month. The challenges faced, opportunities seized and advances made in the last 50 years are well described in the article by Huey, Crihfield and Jopp¹—ACHA has accomplished a great deal, and college health professionals have much to be proud of. (The accomplishments of the first fifty years of ACHA were documented in an article by Ruth Boynton, published in this journal in 1971²).

Over the last five decades, tens of millions of (mostly) young adults have passed through the higher education system in this country. Their health and wellness, both on an individual and a population basis, have been influenced significantly by the thousands of college health professionals who have been and are working on campuses across the USA. In this editorial, I will attempt to review how the health of college students has changed in the last 50 years.

To begin, we need to look at how the college student population has changed since 1970. In that year, approximately 2,758,000 students graduated from high school in this country.³ Just under 52% of that cohort enrolled in college, 48% of whom were female. Total college enrollment in 1970 was 7.4 million (6.3 million undergraduate and 1.1 million graduate students).⁴ By 2017 (the latest year for which data are available), 2,870,000 students graduated from American high schools, and nearly 67% of them enrolled in college. The percentage of women in the matriculating class had risen to 57. Total enrollment in higher education was 18.9 million, more than a 2.5 fold increase (14.8 million undergraduates and 4.1 million graduates). The percentage of 18-21 year olds who were attending college rose from the mid-30’s in 1970 to the lower 50’s in 2018.

Enrollment among racial/ethnic minorities has changed in the last fifty years as well. While white enrollment increased from just under 9.1 million in 1976 to more than 10.3 million in 2018, Black enrollment more than doubled (from just over 1 million to nearly 2.5 million) and Hispanic enrollment jumped from just under 400,000 to over 3.6 million.⁵ The other group with large gains in enrollment numbers since 1970 has been international students: about 1.6% of all college students in the USA that year were foreign nationals (roughly 150,000). In 2018, almost 1.1 million international students were attending American colleges and universities, comprising 5.3% of the total student population.⁶

Clearly, the number of college students has increased substantially in the last fifty years, and college students have become a more diverse population, now predominantly female with larger numbers of students from a variety of racial and ethnic backgrounds. While it is relatively easy to “count heads”, collecting information on the health status of a population over a number of decades is more difficult. In the remainder of this editorial, I am reporting the data that I could find. A more rigorous approach to each of these health categories would be ideal, but that will have to wait for a better day. While there are any number of health indicators that could be chosen, I started with the Centers for Disease Control and Prevention (CDC)’s Adolescent Health indicators⁷ and added a few categories that are important in college health.

While death is a relatively rare event in a college student population, each occurrence affects the entire campus community. However, there is surprisingly little published research on college student deaths. We simply don’t have data on the number of student deaths annually for the last five decades. One study (done by ACHA members and staff) reports the number of deaths among 18-24 year old undergraduates reported by 157 schools that responded to a survey in 2010.⁸ The total death rate was 22.4/100,000 students, which is far lower than the roughly 70 deaths/100,000 rate for the entire 15-24 year old population.⁹ However, I could not find any reports of college student death rates for any other years, so we don’t know how this has changed over time.

The picture is clearer for life expectancy. College students who were born in 1950 (and typically attending college in 1970) had a life expectancy at birth of 68.2 years, whereas those born in 2000 (and in college now) had a life expectancy at birth of 76.8 years. Women have a somewhat greater life expectancy than men (by about 5 years), and whites have a greater life expectancy than Blacks (although the gap is narrower now than it was 50 years ago).¹⁰

One factor in how long one lives is whether one has access to health care. In this country, that requires having health insurance (or being independently wealthy). No data are available for the college student population in the 1970s or 80’s. In 1984, the earliest year for which I could find age-specific data for the general population, about 25% of 18-24 year olds were uninsured.¹¹ Again, there were significant discrepancies among racial ethnic groups: 13% for whites, 20% for Blacks and almost 30% for Hispanics. By 2017, the uninsured rate among that age group had fallen to 14%, with almost no difference between whites and Blacks; however, the rate for Hispanics remained twice that of whites. According to the Fall 2019 NCHA survey, 95% of respondents reported having health insurance.¹²

An important dimension of health for college students is smoking status. While data on college student smoking in the 1970s are not available, surveys on high school students and 18-19 year olds have been published.¹³ In 1974, 35% of 18-19 year olds reported smoking tobacco, and in 1976, the smoking rate for high school seniors was 38%. By 1981, those figures had fallen to 29-30%, and the smoking rate for 18-19 year olds continued to decline into the 1990s. The first NCHA survey in 2000 showed a 25% 30-day smoking rate.¹⁴ The 2019 NCHA III survey showed that the 90-day tobacco cigarette smoking rate was down to 8.5%, but over 15% of respondents reported using e-cigarettes.¹²

Much has been written about alcohol consumption by college students, but how much has really changed in the last 50 years? The American Council on Education surveyed first year college students in 1970.¹⁵ 56% of respondents (67% of men and 43% of women) reported drinking beer in the last year. In 1985, the overall rate rose to 66%, but in 2006 it was down to 42%. The NCHA survey in 2000 reported that 68% of respondents consumed alcohol on one or more days in the last month. The wording of the questions was different on the 2019 NCHA III survey: 93.4% reported consuming alcohol in the last 90 days with 40% reporting at least weekly drinking. The binge drinking rate in the last two weeks was over 38%, but binge drinking data were not collected on college campuses in the 1970s and 80’s, so we don’t know if that has changed.

Obesity rates have increased significantly in all age groups over the last 50 years, and we have some indications that college students are not exempt from this trend.¹⁶ While no data from the 1970s are available on college students specifically, the obesity rate among 12-19 year olds in the general population was around 6%. The 2000 NCHA survey found it to be 8%, and by 2019 over 37% reported being overweight by body mass index (BMI) with another 16% being obese by BMI. This is consistent with the results of the 2017-18 NHANES survey, which yielded a 40% overweight/obese figure for 20-39 year olds.

Sexually transmitted infections are common in young adults, and the emergence of human immuno deficiency virus (HIV) infection about 40 years ago was a major development for college students. STI data on college students from the 1970s are not available. A seroprevalence study conducted in the late 1980s showed that 0.2% of college student blood samples (drawn for any reason) tested positive for HIV. Almost all of the positive tests were in men, and the rate increased with age.¹⁷ A study in 18-24 year olds (not necessarily college students) from 2001-02 showed that about 0.4% tested positive for gonorrhea and 4.2% for chlamydia.¹⁸ The ACHA Pap Test and STI survey has collected data annually since 2007.¹⁹ The rates of STI’s that year were as follows: gonorrhea 0.6%, syphilis 0.3%, chlamydia 3.7% and HIV less than 0.1%. The 2019 report shows that the rates for gonorrhea (1.5%) and chlamydia (7%) have both increased. These numbers are based on clinical samples, so they don’t necessarily show the rate of infection in the population.

Perhaps the biggest concern in our field for the last decade has been the mental health of students. The demand for counseling services has increased dramatically, but it’s unclear whether this represents increased psychopathology or decreased reluctance to seek care. We do have some data on depression over the last half-century. The MMPI has been administered to college students for many years, and the mean D scale score (measuring depressive symptoms) increased from 53 in 1970 to 58 in 2008—a statistically significant change.²⁰ The NCHA survey showed that 10.3% of students reported a diagnosis of depression in 2000; in 2019, 19% reported that diagnosis.

Anxiety is now a more common presenting problem in counseling centers than depression. The same group that reported the MMPI findings for depression has done work on anxiety in college students.²¹ They reported that anxiety symptoms increased by one standard deviation between 1952 and 1993. The NCHA survey in 2000 reported symptoms of an anxiety disorder in the last year by 6.7% of respondents. In 2019, 23.6% of respondents reported having anxiety symptoms.

It’s difficult to draw a firm conclusion about whether the health of college students has changed in the last fifty years—access to care and smoking rates are better, but obesity rates and mental health appear to be worse. A brief review such as this must not be relied upon as the definitive word on health trends in a constantly renewing population of millions. It does illustrate some of the challenges that college students and college health professionals will face in the next fifty years. Just as ACHA was founded on the heels of the 1918-19 influenza pandemic, only to be faced with another pandemic on its 100 anniversary, we will have more problems to address after COVID-19 is behind us. We will be in a much better position to solve those problems if we have robust data to support our decisions. I hope it will be obvious to readers of this editorial that ACHA’s data warehouse—the Connected College Health Network—it an essential component of our plans for the future. Whoever writes the history of the next fifty years of ACHA and examines the health of college students over those five decades should have easy access to all of the relevant data.

Conflict of interest disclosure

The authors have no conflicts of interest to report.