college health college health college health is a desired outcome created by a constellation of services, programs and policies directed at advancing the health and wellbeing of individuals enrolled in an institution of higher education, while also addressing and improving both population health and community health. many colleges and universities worldwide apply both health promotion and health care as processes to achieve key performance indicators in college health. the variety of healthcare services provided by any one institution range from first aid stations employing a single nurse to large, accredited, multi-specialty ambulatory healthcare clinics with hundreds of employees. these services, programs and policies require a multidisciplinary team, the healthcare services alone include physicians, physician assistants, administrators, nurses, nurse practitioners, mental health professionals, health educators, athletic trainers, dietitians and nutritionists, and pharmacists. some of the healthcare services extend to include massage therapists and other holistic health care professionals. while currently changing, the vast majority of college health services are set up as cost centers or service units rather than as parts of academic departments or health care delivery enterprises. skorton center for health initiatives at cornell university to continually achieve college health, many institutions engage in both the process of healthcare and the process of health promotion. the advancement of student health through educational, political, regulatory and organizational supports is referred to as health promotion in higher education. as the current era of public health, health promotion goes beyond bio-behavioral influences using a settings approach, with the settings including: school health, institution/community health, and work sites. the american college health association is one national body in the states that provides measurable guidelines for enhancing the quality of services, programs and policies. another national body in the field of college health is the national collegiate ems foundation (ncemsf), which is dedicated to the promotion and support of emergency medical services on college and university campuses. other national and international associations include national association of student personnel administrators (naspa) and national intramural-recreational sports association (nirsa). ever increasing levels of college health often requires comprehensive environmental management, the coordination of resources, and institutional accountability for addressing the negative health impacts from alcohol use disorder and other substance abuse, mental illnesses such as depression and general anxiety disorders, sexual assault and discrimination among others. the creation of innovative strategies to address the behavioral determinants of health among post-secondary students continues to pose challenges for institutions worldwide. common health concerns of college and university students building e23 (right) at the massachusetts institute of technology houses its health services. distress a common college health key performance indicator relates to levels and the management of stress. distress is the a negative result from the body's adaptation to change. a post-secondary education contains both distress and eustress. many institutions of higher education have a reputation for being high-stress environments. throughout college or university, students often experience increased academic-related expectations, as well as a heightened level of overall responsibility that can adversely affects a student's wellbeing. likewise, students in post-secondary are often expected to balance social, financial, personal and professional responsibilities, while maintaining a strong academic performance. as a result, students in post-secondary often experience an increase in their overall stress level, compounded by a decreased perception of their own quality of life. with stress being a common aspect of students’ academic experiences, the correlation between stress and compromised quality of life has become an area of increasing concern in post-secondary. in recent studies, stress has been shown to contribute to the formation of maladaptive coping strategies in post-secondary students, which can subsequently increase one's risk for developing adverse health complications throughout college or university, including depression. additionally, factors such as physical and mental exhaustion, along with decreased sleep performance as a result of stress at university or college can be a major detriment to a student's perceived life satisfaction. academic post-secondary students experience stress from a variety of sources in their daily life, including academics. in a 2017 american college health association report, 47.5% of post-secondary students claimed that they considered their academic stress to be 'traumatic or very difficult to handle.’ disturbed sleep patterns, social problems, and homesickness are all major factors that can increase a student's perceived level of stress, including academic stress. academic competition is another major source of stress in post-secondary students' lives. high levels of colleague competitiveness has been reported to have a positive correlation with depression and anxiety in post-secondary students. furthermore, while competition in academic environments can often be a perceived as a strong motivator to students, overall evidence suggests that it can also contribute to unhealthy levels of stress in an individual. learning how to develop effective strategies to manage personal stress in an academic setting can therefore help protect one against the risk of developing health complications in post-secondary. yoga, breathing-techniques, and mindfulness interventions are all practices that have been proven to reduce stress among college students. specifically, cortisol in students who engage in cognitive- and behavioral-based techniques has been proven to decrease post-intervention. furthermore, studies suggest exercise and physical activity may have a protective effect against stress in post-secondary students. personal intra-personal distresses, including perceived concerns relating to body-image and self-esteem, are common in adolescence. furthermore, unhealthy body-image has been associated with a number of negative health complications, notably depression and disordered eating behaviors. post-secondary institutions have therefore become widely recognized as ideal grounds for implementing evidence-based health interventions that provide students the opportunity to manage and improve their overall self-image. financial stress is also a major burden on students’ health and wellbeing, as the academic term employs the expenditure of one's financial resources “without guarantees of a satisfactory return." in a 2019 report by the college board on "trends in college pricing," the average tuition for full-time students attending a four-year-long post-secondary institution in the 2019–2020 academic year was about $12,700. with the costs of post-secondary education growing significantly over the last decade, many students are choosing to take out student loans to support their education. as a significant source of stress, student debt and financial instability have been linked to poorer general health outcomes and higher rates of depressive symptoms in young adults. personal debt has also been associated with increased drug and alcohol use. adverse effects on health the mental health of students can sometimes decline when attending college. therefore, this increased stress has highlighted the need for mental health and counseling services available to students on campus. according to the american psychological association (apa), there was a 30% rise in students seeking psychological healthcare services on american campuses between the 2009-2010 and 2014–2015 academic year, with 61% of these students seeking counselling for anxiety, 49% seeking counselling for depression, 45% seeking counselling for stress, and 28% seeking counselling for concerns regarding academic performance. mental illness late adolescents and early adulthood is a window of onset for many psycho-social-behavioral illnesses. therefore, mental health disorders are often first diagnosed in college students. in a survey of 14,000 college students from 8 different countries, researchers found that approximately 35% of students had an undiagnosed mental health illness. an estimated 75% of all lifetime mental disorders are developed by the age of 24. common mental health problems among college students include anxiety disorders, depression, adhd, sleep disorders, and suicide. depression major depressive disorder affects more than 16.1 million americans over the age of 18 in a given year. mental health issues can hinder student success in college. however, oftentimes college students experiencing depression have not been diagnosed. demographically, upperclassmen, college students, and those living off campus are considered more likely to be depressed. common concerns that lead to depression among college students include pressure to perform well academically, worries about success, and thoughts about post-graduation plans. the american college health association has been established for students with depression to provide resources, programs, and guidelines and promote mental health services. anxiety disorders college students can experience significant stress and anxiety from having to balance a multitude of responsibilities such as managing rigorous coursework, participating in extracurricular activities, maintaining relationships, working, and managing finances. anxiety or excessive worry can cause significant impairment in general functioning. symptoms of general anxiety disorder include restlessness, difficulty concentrating, irritability, fatigue and sleep disturbances. in a 2018 survey, the american college health association reported that 63.4% of college students experienced overwhelming anxiety and 22.1% were diagnosed or professionally treated within the last 12 months. students may also experience social anxiety disorder which is characterized by significant anxiety or fear of judgment or embarrassment in social situations such as meeting or conversing with new people, public speaking, and attending parties or social gatherings. as with depression, students with social anxiety disorder are more likely to have lower attendance and participation rates. students that have experienced significant traumatic events such as sexual assault may develop post-traumatic stress disorder. in 2015, association of american universities conducted a survey on sexual assault misconduct in colleges. 11.7% of students reported to have experienced nonconsensual penetration or sexual touch by physical force or incapacitation while in college. students with untreated anxiety disorders are at greater risk for drug and alcohol abuse. sleep disorders sleep is important for a person's physical and mental wellbeing, and the average college student is typically not getting the recommended amount of sleep. not only are parents not around anymore to enforce bedtime but there are also a plethora of classes, parties, extracurriculars, and other events that cause each day to look different from the next. due to the varying schedules, it is difficult for a college student to establish a routine for sleep, and can increase their risk of developing a sleeping disorder. a sleeping disorder is a disorder that causes a person to have an abnormal sleep pattern. it can progress into other health problems if not treated. some common sleep disorders are insomnia, sleep apnea, restless leg syndrome, and narcolepsy. some of these conditions can be due to underlying health problems such as depression, anxiety, and panic disorders. common symptoms include excessive daytime sleepiness, having trouble falling asleep, waking up in the middle of the night and having trouble falling or staying asleep. adhd adhd is prevalent in around 2-8% of students in the united states, and 25% of students with disabilities. several studies state higher incidence of alcohol and substance use in students with adhd. of note, students with adhd who took stimulant medications were found to have more problematic drinking habits than those who did not take stimulant medications. there is a wide prevalence of prescription stimulant misuse among college campuses in the united states. the use of stimulants are increasing in students without adhd, primarily for cognitive and academic improvements. there are numerous misconceptions that entice students to use adderall as "performance enhancers", however scientific evidence illustrates a negative association between stimulant use and academic performance. there are potentially negative health effects that unprescribed stimulants may cause, such as elevated blood pressure, paranoia, serious cardiovascular adverse effects and sudden death which are warranted with a black box warning on amphetamine medications. eating disorders eating disorders are psychological conditions characterized by abnormal and hazardous eating habits. there exist several types, the most common being anorexia nervosa, bulimia nervosa, and binge-eating disorder. anorexia nervosa occurs when individuals consider themselves as overweight despite being concerningly underweight. individuals will monitor their weight by restricting consumption of calories and certain foods, and develop an obsession with their body image. bulimia nervosa is characterized by reoccurring binge-eating episodes following by radical compensatory behaviours including fasting, self-induced vomiting, abuse of laxatives and diuretics, and/or excessive physical exercise. similar to bulimia nervosa, individuals with binge-eating disorder will consume large portions of food in a short amount of time, but will not engage in compensatory behaviours. although eating disorders affect individuals of all genders, ethnicities, and races, many studies show a disproportionately increased risk among post-secondary students, with majority indicating a higher prevalence rate compared to the general population. this trend can be attributed to the unique challenges faced by college students as they attempt to navigate through and adapt to post-secondary life. such difficulties include increased stressors and pressure, a lack of academic, social and/or financial structure, and fear of gaining excessive weight, which can exacerbate underlying mental health issues or, in some cases, create new ones. additionally,