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Health Promotion, Education, and Behavior Theses and Dissertations

Theses/dissertations from 2023 2023.

Exploration of the Association Between Obesogenic Environments and Childhood Overweight/Obesity Rates In Rural Counties in the United States , Kara Lea Ferguson Davis

Social Network Attributes Associated With Conversations About Smoking And Cessation And Differences By Socioeconomic Status , Victoria Catherine Lambert

Babe (Body Appreciation and Better Eating), Just Add a Dash of Self-Compassion: A Randomized Controlled Pilot Study for Black/African American Teenage Girls , Nkechi Bianca Okpara

No More Loosies: A Mixed-Methods Study on the Implementation and Enforcement of the Loose Cigarette and Bidi Sale Ban in India , Mayank Sakhuja

Theses/Dissertations from 2022 2022

Food Insecurity Resilience of Refugee Families in the United States: A Qualitative Study , Maryam Suliman Alhabas

Homestead Vegetable and Poultry Production and Related Practices: An Assessment in Nepal , Shiva Bhandari

Living With Ulcerative Colitis: Exploring Dietary Inflammatory Intake, Physical Activity, and Methods to Manage the Burden of Illness , Kelli E. DuBois

Exploration of the Role of Neighborhood Residential Segregation by Race and Ethnicity in Obesity Risk Among School-Aged , Melissa L. Fair

Perspectives About Food Safety in Diverse Low- And Middle-Income Countries , Sejla Isanovic

Nutrition Facts Label Use Among U.S. Adolescents , Jennifer Beth Mandelbaum

HIV-Related Stigma, Sexual and Gender Minority-Related Stigma, and Health Outcomes Among MSM Living With HIV: Measurement, Impact, and Intersectionality , Tianyue Mi

Greenspace Across the United States: Exploring Equity and Associations With Physical Activity, Obesity, and Health-Related Quality of Life , Ellen W. Stowe

Theses/Dissertations from 2021 2021

Pre-Exposure Prophylaxis (PrEP) Knowledge, Willingness to Use & Uptake Among Black Heterosexual Men , Akeen Lowell Hamilton

A Contextual Evaluation of the Fresh Fruit and Vegetable Program in South Carolina and Related Child Health Behaviors , Kathryn Irene Hoy

Food Choice Decision-Making Among School-Going Adolescents Amidst the Nutrition Transition in Urban Accra, Ghana , Krystal Krsna Rampalli

Neighborhood Socioeconomic Status, Green Space, and Walkability and Risk for Falls and Fracture Among Postmenopausal Women: The Women’s Health Initiative , Marilyn Elizabeth Wende

Evaluation of a Clinic-Based Peer Navigation Program (PNP) For African Americans Living With HIV In South Carolina , Kimberly Butler Willis

Applying Health Stigma Framework to Examine the Mechanisms Of HIV-Related Stigma on Clinical Outcomes , Chengbo Zeng

Theses/Dissertations from 2020 2020

Determinants of Nutrition Agenda Setting in the Context of the Double Burden of Malnutrition in Tamil Nadu, India , Shilpa Vimalananda Constantinides

Understanding the Role of Political Commitment and Coherence Across Sectors and Across National and Sub-National Levels in Enabling Improvements in Nutrition in Rwanda , Elyse Iruhiriye

Rethinking the Customer Experience: An Empirical Comparison of Airbnb and Hotels , Jing Li

Does Marriage, Employment and Having Children Matter? A Secondary Analysis on Physical Activity Levels, Leisure Time Physical Activity, and Social Roles Among Women in the United States , Tramaine Paul McMullen

Influences on Parents’ Food Shopping for Children’s Consumption in South Carolina , Nazratun Nayeem Monalisa

Social Networks, the Local Food Environment, and Maternal Food Choice for Children Ages 1 to 5 Years Old in Rural Mexico , Ligia Ivette Reyes

Studying the “Snip”: A Multi-Methods Exploration of Vasectomy in the Southern United States , Ashley Lauren White

Examining the Organizational Capacity of Public Libraries That Offer Obesity Prevention Programs , Olivia Whitt

Theses/Dissertations from 2019 2019

Women’s Socio-Economic Empowerment and Uptake of HIV Testing in Ethiopia , Dawit Alemu

Role of Resources for Care in Improving Care Behaviors, Children’s Nutritional Status and Early Childhood Development in Low- and Middle-Income Countries , Sulochana Basnet

Social Networks, Social Support, and Contextual Factors That Affect Blood Glucose Control Among Individuals with Type 2 Diabetes Mellitus in Urban Ghana , Marian O. Botchway

Examining the Relationships Between Stress, Depressive Symptoms, and the Neighborhood Food Environment on Diet Quality Among Racially-Diverse Pregnant Women in South Carolina , Alycia K. Boutté

Experience of Persistent Pain Among Military Service Members Participating in an Interdisciplinary Intensive Outpatient Program , Barbara Katarzyna Bujak

The Plant-Based and Soul-Full Study (PASS): Examining How Owners of Local Vegan Soul Food Restaurants Promote the Consumption of Vegan Foods in the African American Community , Anthony Crimarco

Applying the Health Action Process Approach (HAPA) in Program Evaluation of a Theory-Based Parental HIV Disclosure Intervention Among Parents Living With HIV (PLH) in China , Wendi Da

Sociocultural Factors Influencing Cervical Cancer Prevention and Control Behaviors in Cusco, Peru , Venice Elizabeth Haynes

Evaluating Impacts of a Multilevel Resilience-Based Psychosocial Intervention on Mental Health of Children Affected by Parental HIV in China , Yanping Jiang

Expanding Immediate Postpartum Contraceptive Options: South Carolina’s Medicaid Policy , Amy Mattison-Faye

Parenting and Child Self-Regulation as Mechanisms for the Relationship of Household Food Insecurity with Child Dietary Behavior , Hoa Thi Mai Nguyen

Helping South Carolina’s Children Thrive: Promoting Protective Factors to Prevent the Long-Term Impact of Adverse Childhood Experiences Through the Development of Evidence-Based Public Health Policies , Aditi Srivastav

Pre-Exposure Prophylaxis (PrEP) for HIV Prevention: A Mixed-Methods Study of Sexual Risks and Knowledge, Perceptions, and Willingness of PrEP Use Among African American Women in the South , Jamie Troutman

Theses/Dissertations from 2018 2018

Healthy Motivations for Moms-To-Be (Healthy MoM2B) Study: A Mobile Health Intervention Targeting Gestational Weight Gain among U.S. Women , Alicia Anne Dahl

The Impact of False Positive Mammography Results on Breast Cancer Screening Intention Among Black Women , Deeonna E. Farr

Examining Faith-Based Communities As Leverage Points For The Prevention Of Childhood And Adolescent Obesity , Caroline Glagola Dunn

Body Mass Index Trajectories And The Relationship Between Stressful Life Changes And Nutrition-Related Health Outcomes Among United States Army Soldiers , Julianna Marie Jayne

Understanding The Mechanisms Linking Gendered Intrahousehold Bargaining Power And Child Nutrition In Rural Nepal , Shibani Kulkarni

Interpersonal Communication About Cigarette Warning Labels Among U.S. Smokers: Differences Between Latinos And Whites , Victoria Catherine Lambert

The Effects Of The Affordable Care Act On The Receipt Of Colonoscopies Among Insured Elderly , Min Jee Lee

Racism, Black College Students’ Mental Health, And The Efficacy Of Diversity And Inclusion Initiatives: A Case Study. , Kaleea R. Lewis

Intervention For Women In Costa Rica Who Are Discouraged And Have Food Insecurity And Excess Body Weight , Tatiana Martínez-Jaikel

The Effect Of Neighborhood Characteristics And Acculturation On Vegetable Intake Among U.S. Hispanics , Anna Victoria Mesa

A Qualitative Exploration Of Experiences And Motivations For Diabetes Self-Management In African American Men Between The Ages Of 40-85 With Type 2 Diabetes , Anthony Q. Walker

Theses/Dissertations from 2017 2017

Effectiveness of Pictorial Health Warning Labels for Indonesia's Cigarette Packages , Dien Anshari

“An Uphill Battle”: Psychosocial Health and Self-Care among Advocates who work Against Gender-Based Violence in South Carolina , Ebru Cayir

Exploring Spatial Patterning and the Impact of Obesogenic built Environments for Youth Obesity , S. Morgan Hughey

Involvement Of Men In Responsible Parenthood In Croatia, India, And Mexico: Major Factors, Correlates, And National Policy , Salima Kasymova

Multilevel and Multisectoral Processes of Implementing Nutritionsensitive Ideology and Programming in Ethiopia’s Development Landscape , Andrea Marie Warren

Theses/Dissertations from 2016 2016

Breastfeeding Among Working Mothers in Saudi Arabia , Maryam Suliman Alhabas

Social Capital And Social Networks: The Importance Of Social Ties For Health Among Residents Of Disadvantaged Communities , Stephanie Child

Implementation Processes And Impacts Of School Store Policies In South Korea , Seul Ki Choi

Conversations About Sexuality On A Public University Campus: Exploring Perspectives From Campus Ministry Leaders And Students , Charis Rebecca Davidson

Sleep Disruption and Cancer Incidence in a Southeastern Veteran Population , Alexandria F. Delage

Non-Steroidal Anti-Inflammatory Drug Effects On Core Temperature, Hydration, Gastrointestinal Distress, And Performance In Exercising Humans , Dawn Marie Emerson

Sustainability Of Food And Nutrition Security Policies During Presidential Transitions: Integrating Socio-Political And Nutritional Sciences , Jessica Liana Escobar-Alegría

A Qualitative Study Of How Communities Think About And Act Upon Hunger In The Presence Of A Food Banking System , Eliza Miriam Fishbein

Examining Crowdsourced Social Media Platforms And Their Association With College Students' Alcohol Consumption, Perceived Risk, And Behaviors , Danielle Gentile

Quality Over Quantity: Positive Interactions During Family Meals In Food-Insecure Households Compensate For The Negative Impacts Of Household Chaos On Child Emotional Well-Being, But Not Diet Quality , Tiara Nicόl Rosemond

Enhancing Parent-Child Communication and Promoting Physical Activity and Healthy Eating Through Mobile Technology: A Randomized Trial , Danielle E. Schoffman

Examining Infant Health Outcomes Impacted By South Carolina's Regionalized System of Perinatal Care , Michael Grady Smith

Understanding Conceptualizations and Structural Environment for Improving Pre-Pregnancy Planning for Adolescent Girls and Young Women in Harare, Zimbabwe , Chiwoneso Beverley Tinago

Bayesian Semiparametric Quantile Regression for Clustered Data , Xin Tong

The Roots Of Perspective In The American Context: News Media Discourse And Stakeholder Perspectives About The Supplemental Nutrition Assistance Program , Nicholas Younginer

Theses/Dissertations from 2015 2015

Telling a Different Narrative: Exploring the Values and Challenges of Performing Enslaved Community Members’ Stories at U.S. Southern Plantation Museums , Stefanie Kate Benjamin

Post-Fall Decision Making Among Older Women Living in Continuing Care Retirement Communities: A Mixed Methods Study , Caroline D. Bergeron

eCPAT: Development and Testing of Mobile Technology to Engage Youth in Active Living Policy, Systems, and Environmental Health Promotion Efforts , Gina M. Besenyi

Building Capacity for Advocacy for Local Food Systems Change: An Ethnographic Study Documenting the Process of Change in South Carolina Communities , Casey Denise Childers

Refinement and Pilot Testing Social Networks for Encouraging Healthy Behaviors: The Social Pounds Off Digitally (Social POD) Study , Sarah B. Hales

A Qualitative Study of the Massage Therapy Foundation's Best Practices Symposium: Clarifying Definitions and Creating a Framework for Practice , Ann Blair Kennedy

Support for Comprehensive Sexuality Education and Adolescent Access to Condoms and Contraceptions in South Carolina , Sarah H. Kershner

By Word of Mouth: A Qualitative Approach to Understanding the Integration of Preventive Dental Health in Primary Care Settings , Joni D. Nelson

Ethnic Discrimination: Measurement And Associations With Smoking-Related Outcomes Among Arab Male Current And Former Smokers In Israel , Amira Osman

Addressing Disparity: one Unique School’s Efforts to Provide Holistic Education in a low-income, Black Community , Allison Anne Parsons

The Influence of Self-Reported Degree of Masculinity/Femininity on Condom Use Among Black Men Who Have Sex with Men in the Deep South , Elizabeth D. Peeler

Framing Risk, Responsibility, and Resolution: A Mixed-Methods Study Exploring Traditional and Social Media Coverage of the 2014 Elk River Chemical Spill , Tracey Thomas

Statewide Scale-up of Group Prenatal Care in South Carolina , Kristin M. Van De Griend

Theses/Dissertations from 2014 2014

The Emergence of U.S. Hospital-Based Doula Programs , Violet Dawn Beets

The Association between the Social Context of Mealtime, Children's Diet, Caregiver's Experiences with Discrimination and Household Food Insecurity , Michael Patrick Burke

The Comparative Effectiveness of Group Prenatal Care on Women's Psychosocial Health , Emily Heberlein

The Development, Implementation, and Testing of an Interactive Sexual Health Web-Based Application Intervention to Reduce Sexual Risk Behaviors Among College Students , Dawnyéa Dominique Jackson

A Community-Driven Approach to the Development of a Digital Decision Aid to Facilitate Informed Decision Making for Prostate Cancer Screening among African-American Men in Communities of Faith , Otis LaShaun Owens

Elucidating Perceived and Actual Cancer Risk in Disadvantaged Neighborhoods Differentially Impacted by Environmental Hazards to Inform Future Public Health Interventions , LaShanta J. Rice

Food Insecurity and Physical Activity among U.S. populations , Quyen G. To

Theses/Dissertations from 2013 2013

Understanding Online and offline Sex Seeking Behavior Among Young Men Who Have Sex With Men: Implications For HIV/AIDS Interventions , Winston Eromosele Abara

Smokers' Neurological Responses to Imagery From Cigarette Package Warning Labels , Johann Fridrik Fridriksson

Exploring African American and White 18-19 Year Old Males' Communication Experiences With Their Parents and Partners About Sex and Contraception , Charlotte Toole Galloway

Investigating Developmental Patterns of Symptom and Impairment Change Among Youth With ADHD, Subthreshold ADHDand Youth Without ADHD , Lorie Love Geryk

Understanding the Early Stages of Development of A Global Health Partnership , Wendy Raquel Gonzalez Navarrete

Promoting Early Childhood Development Through Community Health Worker Interventions: Implementation and Measurement Issues In Rural Pakistan , Zaeem Haq

Evaluation of Mass Media Campaigns to Change Smokers' Knowledge, Attitudes, and Behaviors In China and Taiwan , Li-Ling Huang

Race, Ethnicity, and Differential Perceptions of Sexual Victimization (Assault) , Kaleea Regina Lewis

Postnatal Depression In Mexico: Healthcare Provider Conceptualizations and Policies In the Public Health Sector , Jean Marie Sims Place

Examining the Relationships Between Religiosity, Spirituality, Internalized Homonegativity, and Sexual Risk Behaviors Among African-American Men Who Have Sex With Men: The Sexual Health In Faith Traditions (SHIFT) Study , Stacy Whichard Smallwood

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Home > College of Public Health > Health Promotion, Social & Behavioral Health > Theses & Dissertations

Theses & Dissertations: Health Promotion and Disease Prevention Research

Theses/dissertations from 2024 2024.

From Survivors to Care Providers: A Multi-Dimensional Study on Physical Activity in Cancer Care , Gaurav Kumar

Theses/Dissertations from 2023 2023

Translating a pediatric weight management intervention into medically underserved areas , Caitlin Golden

Understanding the Compositional and Contextual Factors Influencing Maternal Health Experiences and Outcomes , Tambudzai P. Ndashe

Applications of the RE-AIM Framework in Health Promotion , Emiliane L. Pereira

A Community-Based Participatory Research Approach to Addressing Pediatric Asthma Disparities in Douglas County, Nebraska , Aislinn Rookwood

Theses/Dissertations from 2022 2022

Strengthening Capacity for Clinical and Translational Science: A Multi-Method Assessment of Research Capacity Development in a Regional Clinical and Translational Research Network , LaKaija Johnson

Mental Health Promotion, Early Identification & Treatment Services and Supports in Public K-12 School Districts: Three Case Studies to Explore Available Resources, Interventions, and Community Partnerships , Keenan Krick

Understanding the Perceived Risk and Biopsychosocial Impact of the COVID-19 Pandemic on People Living with HIV and Pre-Exposure Prophylaxis Users in Nebraska: A Mixed Methods Approach , Titilola O. Labisi

Contextual Factors and STI/HIV Sexual Risk Behaviors Among Hispanic Youths aged 13 to 24 years , Mariam Taiwo

Depression and Parenting: A Mixed Method Analysis of Some Protective Factors for Depression Among African American Fathers Using a Community-Based Participatory Research Approach , Tatiana Tchouankam

A Study to Determine the Most Important Leadership Skills for Entry-Level Public Health Practitioners , Taelyr Weekly

Theses/Dissertations from 2021 2021

The Development of a Mobile Application to Capture Healthy Eating and Physical Activity Policies and Practices in Family Child Care Homes , Alethea Chiappone

An Explanatory Sequential Mixed Methods Nutrition and Physical Activity Intervention Study on Changes in Knowledge, Self-Efficacy, and Outcome Expectations of Fathers , Sarah Hortman

From Pipeline to Health Equity: A Case Study of Health Profession Pipeline Students , Sonja F. Tutsch

Theses/Dissertations from 2020 2020

Identifying, Adapting, and Implementing a Weight Management Program in Rural Primary Care , Gwenndolyn Porter

Theses/Dissertations from 2019 2019

Health Literacy Changes in a Technology-Enhanced Diabetes Prevention Program , Cody Goessl

God, I Hope This Part of My Life is Over: A Focused Ethnography of a Correctional Youth Facility’s Therapeutic Climate , Eric Meyer

Potentially Reduced Exposure Products, Occupational Variations in Smoking, and Hardcore Smokers: Examining Important Elements in the Tobacco Use Spectrum , Raees A. Shaikh

Theses/Dissertations from 2018 2018

Determining the Adoption and Implementation of Nutrition Policies at Food Pantries Across the United States , Meagan Helmick

Examining Barriers to Sexual and Reproductive Health Services for Adolescents and Young Adults in Nebraska , Marisa Rosen

Theses/Dissertations from 2017 2017

Sex and Sexuality of Breast Cancer Survivors , Aja D. Kneip Pelster

Public Health Perspectives on Sexual Health and Family Planning , Molly McCarthy

Epigenetic Modifications of Human Placenta Associated with Preterm Birth , Drissa Toure

Theses/Dissertations from 2016 2016

Behavioral Care for Children in Urban and Rural Integrated Primary Care , David I. Taylor

Leisure Time Physical Activity Preferences, Behaviors, and Hypertension: Evidence From the China Health & Nutrition Survey, 2004-2011 , Junmin Zhou

Theses/Dissertations from 2015 2015

School Design to Promote Physical Activity , Jeri Brittin

Understanding Access to Health Information: The Role and Measurement of Social Location , Megan S. Kelley

Theses/Dissertations from 2014 2014

Architecture and design for healthy eating in schools , Leah Frerichs

Characterizing culturally relevant food preparation in the home food environment: promoting healthy dietary behaviors in Mexican American families , Teresa Mary Smith

Theses/Dissertations from 2013 2013

Increasing girls' physical activity in afterschool programs through an enhanced staff professional development training , Danae Dinkel

A study measuring the effectiveness of public health leadership institutes: improving skills, instilling behaviors and the limitations that exist in moving towards outcome based results , Brandon Grimm

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Education Improves Public Health and Promotes Health Equity

Robert a. hahn.

1 Centers for Disease Control and Prevention, Atlanta, GA, USA

Benedict I. Truman

This article describes a framework and empirical evidence to support the argument that educational programs and policies are crucial public health interventions. Concepts of education and health are developed and linked, and we review a wide range of empirical studies to clarify pathways of linkage and explore implications. Basic educational expertise and skills, including fundamental knowledge, reasoning ability, emotional self-regulation, and interactional abilities, are critical components of health. Moreover, education is a fundamental social determinant of health – an upstream cause of health. Programs that close gaps in educational outcomes between low-income or racial and ethnic minority populations and higher-income or majority populations are needed to promote health equity. Public health policy makers, health practitioners and educators, and departments of health and education can collaborate to implement educational programs and policies for which systematic evidence indicates clear public health benefits.

Education is a process and a product . From a societal perspective, the process of education (from the Latin, ducere, “to lead,” and e, “out from,” yield education, “a leading out”) intentionally engages the receptive capacities of children and others to imbue them with knowledge, skills of reasoning, values, socio-emotional awareness and control, and social interaction, so they can grow as engaged, productive, creative, and self-governing members of a society. 1 Of course, not all educational institutions achieve these goals for all children – far from it; educational institutions in the United States often fall short of goals, and too many students may be led into school failure, social dysfunction, and marginal living conditions with lifelong disadvantages.

Not all learning is acquired in a formal school setting. The process of education occurs at home, in school, and in the child’s community. Children in the United States spend a relatively small proportion of their waking hours in school – approximately 1,000 hours per year or about one fifth of their waking hours. 2 Thus there are many opportunities for informal education outside the school setting. 3 When researchers find evidence linking mental capacities, knowledge, feelings, and values with health outcomes, 4 not all consequences can be attributed to formal education.

As the product of the educational process, an education is the array of knowledge, skills, and capacities (ie, intellectual, socio-emotional, physical, productive, and interactive) acquired by a learner through formal and experiential learning. An education is an attribute of a person. And, although a person may be said to “have” a certain level of education at any particular moment, educational attainment is a dynamic, ever-evolving array of knowledge, skills, and capacities.

Although we conceive of education broadly, including both its formal and informal sources, the focus of our evidence review is the formal education that is measured in most research. Our recommendation also focuses on the formal education, from early childhood to college and beyond, that is, the subject of educational policy and, we argue, should also be the subject of public health policy.

In public health, researchers and practitioners have examined 3 principal relationships between education and health. First, health is a prerequisite for education : hungry children or children who cannot hear well, or who have chronic toothaches, eg, are hindered in their learning. 5 Second, education about health (ie, health education) occurs within schools and in many public health interventions; it is a central tool of public health. 6 Third, physical education in schools combines education about the importance of physical activity for health with promoting such activity. 7 Here we focus on 2 additional relationships between education and health. First, we propose that education as a personal attribute is a central conceptual component and essential element of health , similar to physical fitness. Second, we summarize the extensive literature demonstrating that formal education is a contributing cause of health .

We argue that education – the product and personal attribute acquired – is both a critical component of a person’s health and a contributing cause of other elements of the person’s concurrent and future health. Consistent with other definitions of health, a person who lacks basic elements of an education is not fully healthy. 8 , 9 For example, the 1978 Alma Ata International Conference on Primary Health Care defined “health” to include “a state of complete…mental and social well-being” – which we see as largely products of education. Attainment of a certain level of formal education by young adulthood affects lifelong health through multiple pathways. 8 , 10

We then argue that, because it is both an essential component and a major contributing cause of health, educational achievement broadly should be a legitimate arena for public health intervention. Thus, public health practitioners could legitimately promote educational programs to advance public health. Education should also be recognized as an essential requirement for the disruption of the cycle of poverty and inequities in health. The public health community should expand research to better understand the causal relationships between education and health, and thereby identify evidence-based educational policies that have great potential to improve public health.

A Broad Concept of Education

We propose a broad concept of education as a personal attribute, which includes not only subject-matter knowledge, reasoning, and problem-solving skills, but also awareness of one’s own emotions and those of others and control of one’s emotions (ie, “emotional intelligence”) 11 and associated abilities to interact effectively. “Education improves health because it increases effective agency, enhancing a sense of personal control that encourages and enables a healthy lifestyle. Education’s beneficial effects are pervasive, cumulative, and self-amplifying, growing across the life course.” 12

In 1983, the National Commission on Excellence in Education’s report, A Nation at Risk , launched a national conversation about the need for educational reform. 13 In 1990, the US Department of Labor initiated a program – the Secretary’s Commission on Achieving Necessary Skills – to determine critical capacities for a US workforce to be provided by the educational system. 14 The capacities proposed were based on “a three-part foundation” reflecting the broad notion of education that we propose: Basic Skills (reading, writing, arithmetic, mathematics, listening, speaking), Thinking Skills (creative thinking, decision making, problem solving, seeing things in the mind’s eye, knowing how to learn, reasoning), and Personal Qualities (responsibility, self-esteem, sociability, self-management, integrity/honesty). The project recommends as a central educational goal: “All American high school students must develop a new set of competencies and foundation skills if they are to enjoy a productive, full, and satisfying life.” 14 (p1) We would expand this list of outcomes to include a healthy life.

Education as an Element of Health

In our conception, basic education is an integral part of being healthy. A person is unhealthy if he or she lacks basic knowledge, the ability to reason, emotional capacities of self-awareness and emotional regulation, and skills of social interaction. These embodied personal attributes or mental capacities, the products of formal education as well as other learning experiences, are conceptually comparable to physical capacities of fitness and coordination – well-established components of health. “Education teaches a person to use his or her mind: Learning, thinking, reasoning, solving problems, and so on are mental exercises that may keep the central nervous system in shape the same way that physical exercise keeps the body in shape.” 8 (p738) A person is unhealthy who cannot conduct himself or herself effectively and achieve some level of “social well-being” – a critical element of the World Health Organization (WHO) conception of health, which recognized the contributions of social sectors beyond the health sector in promoting health. 9

The projects of several US and international health agencies reflect this concept of education as a component of health. For example, the US Centers for Disease Control and Prevention recognizes “cognitive health” in its Healthy Aging Program; although the focus of this program is prevention and control of Alzheimer’s disease, the “cognitive health” rubric suggests far broader considerations: “The public health community should embrace cognitive health as a priority, invest in its promotion, and enhance our ability to move scientific discoveries rapidly into public health practice.” 15 (p1) The National Institutes for Health similarly has a “healthy brain” program that recognizes cognitive as well as emotional capacities as elements of health. 16

Similar concepts are recognized internationally by the WHO, in accordance with its definition of health cited above. More recently, a WHO paper 17 included cognition and affect as 2 of 6 domains for the international comparison of health status .

Measures of Education as a Personal Attribute

Education is measured in a variety of ways. A common measure, years of schooling/educational attainment, is problematic insofar as time spent in school gives little indication of how the time is spent and what is learned. 2 School-level completion may be a better measure, but also varies in terms of the quality and quantity of what is learned. Standardized tests of subject-matter knowledge and reasoning skills may be still better for some purposes, but may offer challenges when compared across populations. 18

Some 19 , 20 have argued that teacher-assigned grades are an alternate, if not better, predictor of long-term outcomes than standardized tests because they reflect not only academic achievement, but also classroom social and learning skills that indicate abilities to learn and to interact successfully. The breadth of skills addressed by this measure better reflects the broad concept of education argued here. Subjectivity, personal preferences, and comparability are challenges with teacher-assigned grades as a measure of achievement.

Evidence of Causal Association

It may seem odd that, in the perspective developed here, education – the product and the personal attribute – is at once an element of health and a cause of health. The relationship is similar to that of physical fitness and health. Fitness is an element of health and an important cause of subsequent health – not only of physical fitness, but of other facets of health as well, including cardiac health and mental health. 21 – 23 In addition to providing extensive evidence that education is associated with health, we argue that the underlying causal process is conceptually similar to the causal relationships between physical activity or an infectious agent and health. We provide some evidence of causation, noting that the notion of causal proof in a traditional deterministic sense has been challenged. 24

Criteria to determine causality in public health developed by Sir Bradford-Hill in 1965 25 are still useful. They are:

• Strength of association linking hypothetical cause and outcome (as assessed, eg, by the magnitude of relative risks)
• Consistency of findings, eg, by different researchers in different settings
• Specificity – the connection of specific, narrow causes to specific outcomes
• Temporal sequence—the necessity of cause preceding consequence
• Dose–response relationship
• Plausibility in terms of current knowledge
• Coherence – similar to plausibility, the fit with other contemporary knowledge
• Experiment – offering the strongest support
• Analogy – the comparability of postulated causality with causality in similar phenomena

Most of the Bradford-Hill criteria clearly apply when linking education to health. An obvious exception is specificity, because education itself is a broad concept including many elements, and the causal consequences of education are also numerous and heterogeneous. Bradford-Hill did not regard specificity as essential, as in the case of cigarette smoke with its multiple health consequences. As Susser has argued, “Specificity enhances the plausibility of causal inference, but lack of specificity does not negate it.” 26 (p153)

The associations presented below satisfy several standard criteria for causation. At least 3 approaches are used: 1) observational cohort studies with concurrent controls, 2) natural quasi-experiments in education policy, and 3) educational experiments. In the sections that follow, we provide samples of evidence of the causal association between education and health, assessed first by various health-related outcomes: health risk and protective behaviors, wages and income (resources for health), self-assessed health, morbidity, mortality, and life expectancy. We then provide evidence from experimental studies. The literature on these topics is extensive 4 , 8 and here we describe only a few examples, from early childhood and beyond. Evidence of the association between measures of education – the personal attribute – and other health-related outcomes is positive, strong, and consistent.

Health Risk and Protective Behaviors Are Associated With Academic Achievement

Evidence of an association between high school student grades and risk behaviors in the United States is remarkably consistent; higher average grade achievement is associated with lower rates of risk behavior ( Figure 1 ). 27 One plausible explanation is that there is causation in the reverse direction of what is proposed here, ie, that risk behavior interferes with academic achievement; such reverse causation seems reasonable, eg, for watching television and using alcohol. Also plausible is that other factors, such as strong values, promote both academic achievement and self-protective behaviors, or that academic achievement is associated with knowledge, which leads to risk avoidance. Another explanation is that underlying psychological or environmental conditions are associated with risk behavior and academic problems. Causation in both directions is likely. The consistency of a dose response for multiple behaviors is consistent with an effect of educational success on the avoidance of risky behavior.

Health-risk behaviors and school grades, United States, 2009.

Source: www.cdc.gov/healthyyouth/health_and_academics/pdf/health_risk_behaviors.pdf .

There is also strong evidence of a dose response between years of education and many health-related risk and protective behaviors among US adults. Analysis of a representative survey of adults aged >25 years between 1990 and 2000 indicates that the prevalence of several risk behaviors is generally higher among those with fewer than nine years of formal education, begins to decline among those who have nine to 12 years of formal education, and continues to decline with additional years of education; this finding corresponds to the recognized importance of high school completion for subsequent health. 28 , 29

Wages and Income, Resources for Health, Are Associated With Educational Success

Wages and income are not health outcomes, but are closely linked with health outcomes because they provide access to health-related resources, such as healthy food, a safe environment, and healthcare. A recent analysis 30 of trends in US wages over more than 20 years finds higher wages consistently associated with higher educational attainment and a trend toward increasing differences in wages by educational status. In the causal chain, high educational attainment is antecedent to high wages or income. A recent study 31 linking individual kindergarten standardized achievement tests with wages at ages 25–27 years indicates a remarkable linear association accounting for 17% of the variability in the wage outcome – 20 years later ( Figure 2 ). Although high family income precedes and predicts educational success in children, controlling for such demographic characteristics of the kindergartner (including family income, household ownership, and marital status) diminishes, but by no means eliminates, the association found in this study.

Association between kindergarten test score percentiles and mean wage earnings, ages 25–27 years, Tennessee STAR program.

Source: Chetty, 2010.

Self-Assessed Health Is Associated With Educational Attainment

Self-assessed health is a well-established index of morbidity and predictor of mortality. 32 , 33 A recent study compares the association of educational attainment with self-assessed health in US and Canadian populations. 34 , 35 Controlling for basic demographics and income, those with less than a high school education in the United States are 2.4 times as likely as high school graduates and 4.1 times as likely as those with post-secondary education to rate their health as poor. Further adjusting these ratios for risk behaviors only moderately reduces the ratios, suggesting that education is related to self-reported health due to important factors in addition to risk behaviors.

It is plausible that health status affects the likelihood of educational achievement, but it is likely that the major force of causation is in the opposite direction. Not only is educational attainment closely associated with self-rated health, but the association increases with age when measured by the number of days per week reported as free of major symptoms. With increasing age, the gap in symptom-free days increases between those with a college degree, those with a high school degree or some college, and those with less than a high school degree, suggesting that the effects of education are pervasive throughout the lifespan, and that its consequences have cumulative effects on health over time. 36

Morbidity is Associated With Educational Attainment

In the United States, although higher self-reported rates of several conditions, such as prostate cancer and sinusitis, are reported among more adults with greater levels of education, for most conditions the reverse direction of association is evident. Rates of major circulatory diseases, diabetes, liver disease, and several psychological symptoms (sadness, hopelessness, and worthlessness) show higher rates among adults with lower educational attainment. 35

Mortality and Life Expectancy Are Associated With Educational Attainment

Evidence also exists of a strong association between educational attainment and mortality from many diseases. 37 The parallel relationship for three heterogeneous groups of illness or injury again suggests an underlying connection unrelated to the specific etiologic pathways of each cause of death ( Figure 3 ). 37 In addition, the modal age for completing formal education (the mid-20 s) substantially precedes the peak age for mortality in the United States (77 years of age) by many years, consistent with another Bradford-Hill principle, ie, the precedence of cause before effect.

Age-adjusted death rates among persons ages 25–64 years for several condition groupings, by sex and educational attainment. Selected US states, 1994–2005.

From the perspective of life expectancy, at age 25 in 2005, a man in the United States with less than a high school education could expect to live an additional 44.2 years to age 69.2 years; a man with a graduate degree could expect to live more than 15 years longer. At age 25 years, a woman in the United States with less than a high school education could expect to live to age 74.9 years; a woman with a graduate degree could expect to live more than 11 years longer. 38

Educational Experiments and Quasi-Experiments

True experiments in the field of education are uncommon. Nevertheless, several experiments have been conducted. Groups of children, often from low-income or minority families, have been exposed, sometimes with random assignment, to different forms of education and followed over time to determine long-term outcomes, including health-related outcomes, as shown in the following 3 examples of early childhood programs.

In the early 1960s, 3- and 4-year-olds with low IQs from low-income families were randomly assigned to either the High/Scope Perry Preschool Program – an educational program including home visits – or no intervention. Home visits were designed to strengthen parental engagement in the child’s education. Participants were periodically assessed until age 40. 39 Over several follow-up assessments, intervention participants had greater levels of educational attainment, income, and health insurance, lived in safer family environments, and had lower rates of tobacco and drug use and risky driving behavior than controls. At age 40 years, however, more intervention than control participants had chronic diseases, but fewer intervention participants had died.

In 1972, healthy infants at risk of academic difficulties because of their demographic circumstances (eg, poor, minority, single parents) were randomly assigned to the Carolina Abecedarian Project or a control intervention (offered social services, nutritional supplements, and healthcare services, but no educational program). 40 The Abecedarian preschool program focused on developing cognitive, social, language, and motor skills from birth through age 5 years. Before entering kindergarten, control and experimental children were again randomized into either routine schooling or a strengthened school program complemented by home visits for parental guidance to reinforce child learning. At follow-up, both the preschool and the early schooling programs were shown to be beneficial in terms of academic achievement; the preschool program had the larger effect. By age 21 years, participants in the early childhood education intervention (combining those with and without the strengthened primary school programming) had better health behaviors and better health than those who did not receive the early childhood education intervention. 41 By their mid-30 s, those exposed to the intervention, particularly males, had substantially more favorable cardiovascular risk profiles than those exposed to the control condition. 42

Finally, though not a true experiment, the Chicago Child-Parent Center program followed two groups of poor Chicago children aged 3 and 4 years: one exposed to an early childhood program and the other not exposed. Children residing in Chicago districts with federally funded kindergarten programs were eligible and selected on a “most-in-need basis”; comparison children lived in similarly poor neighborhoods with locally funded kindergarten programs. The Chicago Child-Parent Center provided educational enrichment from prekindergarten through the third grade, required parental involvement in the classroom a half-day per week, and provided nutrition and health services. At age 24 years, in comparison with control subjects, participants had lower rates of out-of-home placement (indicating child abuse), lower rates of arrests and conviction for violent behaviors, and lower rates of disability. 43

A recent review of the effects of early childhood educational programs indicates that programs with strong instructional components and those evaluated with strong study designs have large and enduring effects on the educational, social, and health outcomes of participants. 44

Several researchers have made use of natural quasi-experiments involving education policies that rapidly change years of schooling required, to evaluate the effects of the requirement on health-related and other outcomes. When state educational requirements change from 1 year to the next from 7 to 9 years, eg, cohorts of children of a certain age in that state will receive approximately 7 years of education, while their younger siblings will receive 9 years. The state where this policy is implemented may be compared by regression discontinuity analysis from before to after the change, but also with other states that have not made this change at the same time.

In one such study, Lleras-Muney 45 uses a sample of US census data to estimate the effects on mortality of changes in compulsory education requirements in 30 states, comparing birth cohorts before and after such changes between 1915 and 1939 with long-term follow-up data. Lleras-Muney concludes that each year of additional required schooling resulted in a reduction of mortality by 3.6% over 10 years, or gain of 1.7 years to life expectancy at 35 years of age. Although these data are old, it is likely that the general effects of increased educational requirements on mortality have not changed substantially. Other researchers have used regression discontinuity analysis to estimate the effects of education on rates of crime, arrest, and incarceration in the United States 46 and on teenage births in the United States and Norway. 47 Among researchers using this design, only Arendt 48 finds equivocal evidence regarding the effects of additional years of education on self-rated health, body mass index, and smoking in the United States, Canada, and Denmark. The heterogeneity of conditions affected by educational exposure again suggests a broad, nonspecific underlying “mechanism.”

The Fallacy of the Endowment Hypothesis

Gottfredson has proposed that intelligence – innate intellectual and associated ability – rather than educational attainment is the “fundamental cause” of socioeconomic inequalities in health, a proposal referred to as the “endowment hypothesis.” 49 Several basic features distinguish Gottfredson’s notion of intelligence from the concept of education as defined in this article: intelligence is regarded as “natural, not cultural,” “context-free,” and “highly heritable” – indicating a largely innate, biological foundation, little affected by environmental variability. From this vantage, education as conceived in this article may be regarded as largely determined by intelligence insofar as those with greater intelligence are both more likely to seek education and to succeed in acquiring it.

Gottfredson’s hypothesis is explicitly evaluated by others in a study of 2 US cohorts that assesses the contributions of education, income, and intelligence to 3 health outcomes: mortality, life-threatening illness, and self-rated health. 50 The researchers posit an alternative model, in which there are underlying “background influences on [socioeconomic status] and intelligence.” In this model, intelligence affects education and income, and both of these socioeconomic status characteristics in turn affect intelligence; a summary of research on this linkage 51 indicates that a year of education is associated with a gain of between 2 and 4 IQ points. In both study cohorts, intelligence during high school is measured by standardized and validated tests, the Henmon-Nelson test and the Wechsler Adult Intelligence Scale. The researchers find generally consistent evidence of pairwise dose–response associations between levels of education, income, and intelligence with each of 3 health outcomes.

The researchers then examine the questions: what is the effect of controlling the association of education and health outcomes for intelligence; of income and health outcomes controlling for intelligence; and of intelligence and health outcomes controlling for both education and income? This assessment allows answering 2 basic questions: how much does intelligence contribute to the effects of education and of income on health, ie, what are the effects of these determinants net the contribution of intelligence? And, to what extent are the effects of intelligence on health mediated by income and education? The researchers find that separately controlling the effects of education and income on health outcomes for intelligence alters the coefficients for education and income minimally and leaves all associations statistically significant at the 0.05 level or less, indicating that little of the effect of education on health is mediated by intelligence.

The effects of controlling the effects of intelligence on health for education and income are more complex. Only 1 of the 2 surveys finds a significant effect of intelligence on mortality ( P <.05); controlling for education and income eliminates the significance of this finding. Thus, the effect of intelligence on mortality is largely mediated by income and education. Both surveys find statistically significant effects of intelligence for both life-threatening illnesses and self-rated health; however, the effect magnitudes are diminished by a mean of 69.4% and statistical significance is again eliminated for all findings except for self-rated health in one of the surveys. These findings indicate that the effects of intelligence on health outcomes are largely mediated by education and income. 50 There is thus substantial evidence that education has a strong effect on health, independent of background intelligence. Innate intelligence may be a “fundamental cause” principally insofar as it leads to higher education and income.

Causal Pathways and Evidence Linking Education and Health

Building on the work of others, 10 , 52 we constructed a model indicating the three major pathways linking education and health outcomes in adulthood and including the several facets of education – knowledge, problem solving, emotional awareness and self-regulation, values, and interactional skills ( Figure 4 ). First is the psycho-social environment, including the individual’s sense of control, social standing, and social support, which reflects and bolsters capacity and agency. Second is work, through which the individual may achieve satisfaction and income, which allows access to many health-related resources. Finally, healthy behavior may protect an individual against health risks and facilitate negotiation of the healthcare system.

Pathways from educational attainment to health outcomes.

Ross and Wu 8 used 2 national probability samples of US adults to assess the effects of completed education on self-perceived health and reported physical functioning. They first assessed the association between education and each of three broad covariate groups – psycho-social environment; work; and health knowledge, literacy, and behaviors – that are themselves determinants of health outcomes ( Figure 4 ). 8 For each data source, they began with a model including as covariates only demographic characteristics of their samples. To the basic model, they first added employment and economic covariates, then social-psychological covariates, and finally risk behavior covariates, noting the changes in regression coefficients for educational exposures on health outcomes. This approach allowed assessment of the magnitude of each of these groups of covariates as pathways linking education to health-related outcomes. However, the relative contribution of each group of factors cannot be determined precisely, because these groups are unlikely to be causally independent, and covariate groups entered into the regression early are thus likely to show greater reductions in regression coefficients than those entered later.

In both samples, education was associated with all covariates in expected directions. The largest effect was for work-related variables, including income. Those with lower income not only had limited resources useful in maintaining health, but also may have experienced anxieties that exacerbate health problems. The effects of psycho-social resources were also statistically significant and of similar magnitude. Risk behavior and knowledge also contributed to the association between education and health by both measures. The 3 clusters of covariates together explain between 55% and 59% of the variance in self-reported health and between 46% and 71% of physical functioning in these surveys. This suggests that the smallest contribution to health outcomes is associated with health behaviors, which were entered last into the regression model. In both samples, education has a significant residual “direct” effect, independent of the three examined pathways. In summary, education’s association with improved health is attributable to greater work opportunities and rewards, a greater sense of control and social support, healthier behaviors, and a direct effect on health. Similar results are found by Cutler and Lleras-Muney, 28 who use different sources to assess associations between educational attainment, health behaviors, and mortality in the United States and Great Britain.

In a separate study, Ross and Mirowsky 53 provide evidence that the effect of higher levels of education on health is mediated principally by its contents, including values and skills imparted, and far less by means of status markers such as the diploma or the prestige of the degree-granting institution. Evidence for this conclusion derives from a regression analysis of national data including measures of years of education, receipt of diplomas, and school selectivity (based on test scores of entering freshmen). In another study, Reynolds and Ross 54 provide evidence that “the direct effect of education on well-being is greater than the direct effect of social origins, and the total effect of social origins is mediated mostly by education.” 54 (p226) Evidence derives from a regression analysis of two national data sources in which the researchers control for parental education, father’s occupation, and childhood poverty. They also find that a person’s level of education has a far greater effect on health if his or her parents were poorly educated than if they were well-educated. Unfortunately, in our society, parental and child educational levels are highly positively correlated, so that the children of parents with little education, who might benefit the most from higher levels of education, are least likely to receive that education. 55

Ross and Mirowsky 55 (pp597,598) conclude (emphasis added): “…certain policy implications follow. First, education policy is health policy. Second, health policy must address the educational opportunities of children raised by poorly-educated parents. Otherwise those children, in adulthood, will suffer the multiplicative health consequences of low parental education and low personal education…Structural amplification condemns some families to the concentration of low education with poor health across generations… Break that mediating link, and the moderating effect of higher education will suppress the health disadvantages of the socially disadvantaged origins. ”

High Societal Price in Health of Education Forgone

An estimate of the number of annual deaths attributable to lack of high school education among persons 25–64 years of age in the United States (237,410) exceeds the number of deaths attributed to cigarette smoking among persons 35–64 years of age (163,500) (Krueger et al., unpublished manuscript, 2013). 56 (The estimate of smoking-attributable mortality does not include adults younger than 35 years of age because mortality from smoking is negligible at this age.)

Several recent estimates have been made of economic costs to individuals, the government, and society of the failure of each American to achieve an optimal education. Although it may be argued that there is a moral duty to redress injustice and inequity regardless of cost, these estimates indicate the economic magnitude of this loss and the potential value of its redress.

Schoeni and colleagues 57 , 58 estimate the annual economic value of health forgone in the United States in 2006 by adults who lack a college education. For a population of 138 million aged 25 years or older with less than a college education, the economic value of the life and health forgone is US$1.02 trillion per year – 7.7% of US gross domestic product.

Levin and colleagues 59 provide an estimate of benefits to the government (in 2004 dollars) if those who did not finish high school had completed a high school education (or higher) with a diploma. Based on governmental benefits of income taxes associated with greater earnings of high school graduates and reduced costs of welfare and incarceration, Medicaid, and lifetime savings of approximately US$40,000 per capita in public health expenses, they estimated a total lifetime benefit of US$209,000 for each high school dropout if he or she had instead completed high school. They then examined the costs and benefits of 5 programs with demonstrated efficacy in improving rates of high school completion. Cost–benefit ratios range from 1.5 to 3.5, indicating substantial governmental benefit. 59

Education as a Domain of Public Health Action

Just as many areas of daily life are recognized domains of legitimate public health action – agriculture (eg, nutrition and food safety), transportation (eg, vehicle injuries, air pollution, and walking), immigration (eg, immigrant health and infection control), justice (eg, violent crime and prison health), urban design (eg, safety, walkable communities, and food deserts), and labor (eg, occupational safety and health) – so should education (beyond health education in schools) be recognized as a legitimate domain of public health action. Education is a critical component of health and, we argue, education is a major, long-term, multifaceted cause of health. In particular, education is a powerful means of breaking the cycle of poverty (which greatly affects ethnic and racial minority populations) and promoting health equity.(As this article was in press, the authors encountered an excellent paper by Cohen and Syme 60 which draws similar conclusions.)

Several federal agencies have supported “health in all policies,” 61 particularly through the National Prevention, Health Promotion and Public Health Council. 62 The US Department of Health and Human Services includes in its mission 63 to “engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge” and in its overarching goals to “Create social and physical environments that promote good health for all.”

States and the District of Columbia have also adopted a “health in all policies” perspective. California’s “CAL Health in all Policies” 64 – 66 recognizes the potential for education as a means of moving toward health equity. “Promote efforts that demonstrate positive effects in closing the achievement gap. Collaborate on advancing strategies, addressing the major factors that inhibit the learning of all students.” Counties (eg, Los Angeles, Baltimore) also have adopted a “health in all policies” perspective. 64 , 67 , 68

The effort to pursue multi-sectoral strategies for health improvement is international, practiced in the European Union, Australia, and elsewhere. The European Union has adopted a social determinants-based approach: “Health in All Policies addresses the effects on health across all policies such as agriculture, education, the environment, fiscal policies, housing, and transport. It seeks to improve health and at the same time contribute to the well-being and the wealth of the nations through structures, mechanisms, and actions planned and managed mainly by sectors other than health.” 69 (pXVIII)

In “A Framework for Public Health Action: The Health Impact Pyramid,” 71 Frieden writes, “Interventions that address social determinants of health have the greatest potential public health benefit” and contrasts social determinants – the base of the “health impact pyramid” – with higher strata in the pyramid. 70 (p594) Among social determinants, education is fundamental, because education forms the new members of society – children and youth. Effective teachers are facilitators of long-term health benefits. Beyond school health promotion, education as a means of public health intervention is more difficult to define, to administer, to measure, and to evaluate. It is cumulative, formative, and transformative, both for the individuals who experience it and for the society it recreates and modifies. Although these features make education more challenging than some other tools of public health, such challenges must not deter the public health community from working closely with the education community to investigate and understand this form of social determinant causation, evaluate the wide array of educational program types, and mobilize for action on this powerful force for public health benefits.

Acknowledgments

Many thanks to thoughtful readers and editors Randy Elder, Catherine Ross, Barbara Rimer, Kate W. Harris, Amy Brown, Heba Athar, and Kristen Folsom.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Biographies

Robert A. Hahn received his PhD in anthropology at Harvard University (1976) and his MPH in epidemiology from the University of Washington (1986). Since 1986, he has served as an epidemiologist at the US Centers for Disease Control and Prevention (CDC) in Atlanta and is a member of the Senior Biomedical Research Service. He is the author of Sickness and Healing: An Anthropological Perspective (1995) and co-editor of Anthropology and Public Health: Bridging Differences in Culture and Society (2008), with a second edition recently published. In 1998–1999, he worked as a Capitol Hill Fellow in the US House of Representatives Committee on Veterans Affairs and in the office of Congresswoman Louise Slaughter. He is currently coordinating scientist of systematic reviews on health equity for the CDC Guide to Community Preventive Services .

Benedict I. Truman earned his BS in chemistry and MD from Howard University and his MPH from the Johns Hopkins Bloomberg School of Public Health, where he completed a residency in preventive medicine and public health and served as chief resident. He has held scientific and leadership positions in state, local, and federal public health agencies and is the associate director for science at the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at the US Centers for Disease Control and Prevention (CDC). In this role, he works with other scientists and program managers to ensure that the CDC’s scientific products and research ethics meet the highest standards of quality and integrity. He has published many peer-reviewed journal articles on educational interventions for health equity; prevention and control of infectious diseases and chronic noninfectious diseases; adolescent and school health; community preventive services guidelines; minority health and health disparities; employee performance and public health workforce development; and applied epidemiologic methods. He serves as the Consulting Editor for Infectious Diseases for the Journal of Public Health Management and Practice .

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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Public Health Theses and Dissertations

Theses/dissertations from 2023 2023.

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Evaluation of a Story-telling Approach to Educate Minority Populations About Inherited Cancer , Celestyn B. Angot

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Student Perceptions of the Nonmedical Use of Prescription Stimulants and Preferences for Health Education , Ana Gutierrez

Relationships between Leading and Trailing Indicators at Construction Sites in Yanbu Industrial City, Saudi Arabia , Anas H. Halloul

Variability of Air Sampling Results Using Air-O-Cell Cassettes , Christina M. Haworth

Use of Silica Dust and Lunar Simulants for Assessing Lunar Regolith Exposure , Layzamarie Irizarry-Colon

The Aging Workforce: How it Relates to Incident Rates within a Distribution Warehouse and a Chemical Manufacturing Building , Elisabeth V. Jones

Fuzzy KC Clustering Imputation for Missing Not At Random Data , Markku A. Malmi Jr.

Piloting a Spanish-language Web-based Tool for Hereditary Cancer Genetic Testing , Gretter Manso

Development of a ddPCR Multiplex to Measure the Immune Response to Borrelia burgdorferi. , Kailey Marie McCain

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Theses/Dissertations from 2022 2022

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Alpha Synuclein: A therapeutic target and biomarker for Parkinson’s Disease , Max Chase

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Exploring Adult Attachment in Intimate Relationships among Women who Were Exposed to Intimate Partner Violence in Childhood: A Convergent Mixed Methods Approach , Ngozichukwuka C. Agu

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Theses/Dissertations from 2020 2020

Journey Mapping the Minority Student’s Path Toward Genetic Counseling: A Holistic Picture , Tatiana E. Alvarado-Wing

Using Observations from the UAW-Ford Ergonomic Assessment Tool to Predict Distal Upper Extremity Musculoskeletal Disorders , Zachariah T. Brandes-Powell

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Theses/Dissertations from 2019 2019

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The Relationship Between Hand and Wrist Musculoskeletal Disorders and Hand Activity and Posture , Warren M. Henry

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Mitigating Barriers to Chronic Disease Risk Factor Prevention and Management in Disadvantaged Communities , Krys M. Johnson

Comparing Family Sharing Behaviors in BRCA Carriers with PALB2 Carriers , Joy E. Kechik

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Exploring Young Women’s Choice to Initiate Use of Long-acting Reversible Contraception: A Mixed Methods Approach , Helen Mahony

Evaluation of Clinical Practices and Needs about Variants of Uncertain Significance Results in Inherited Cardiac Arrhythmia and Inherited Cardiomyopathy Genes , Reka D. Muller

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A Retrospective Study of the Opioid Epidemic and Fentanyl Related Overdose Fatality Cases in a Florida West Coast Medical Examiner District Population , Anne Terese Powell

Using Predicted Heat Strain to Evaluate Sustainable Exposures , Samantha L. Thacker

Isokinetic Sampling Efficiency Differences for Blunt Edge vs Sharp Edge Sampling Probes , Cory A. Treloar

Using the Consolidated Framework for Implementation Research to Investigate Daily Pre-exposure Prophylaxis (emtricitabine/tenofovir DF) Implementation via Community-based HIV Testing Sites in Florida , Deanne E. Turner

“We can learn some things from them, but they can learn some things from us too”: Intergenerational Perceptions of Shared Infant Feeding Information , Alexis L. Woods Barr

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Dissertations / Theses on the topic 'Health education Health promotion'

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Halcomb, Kathleen Ann. "HEALTH PROMOTION AND HEALTH EDUCATION: NURSING STUDENTS’ PERSPECTIVES." UKnowledge, 2010. http://uknowledge.uky.edu/gradschool_diss/13.

Tarro, Sanchez Lucia. "HEALTHY LIFESTYLES -EDUCATION AND HEALTH PROMOTION. EDUCACIÓ EN ALIMENTACIÓ (EDAL) COHORT." Doctoral thesis, Universitat Rovira i Virgili, 2014. http://hdl.handle.net/10803/284707.

Björklund, Erika. "Constituting the healthy employee? : Governing gendered subjects in workplace health promotion." Doctoral thesis, Umeå universitet, Pedagogik, 2008. http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-1953.

Kimbrough, Jennifer Bennett. "Towards equity in health envisioning authentic health education in schools /." Greensboro, N.C. : University of North Carolina at Greensboro, 2007. http://libres.uncg.edu/edocs/etd/1393/umi-uncg-1393.pdf.

Stay, Grace Elizabeth. "The impact of a health promotion program on student health concerns." W&M ScholarWorks, 1999. https://scholarworks.wm.edu/etd/1539618794.

Glew, Angela Marie-Maynard. "A descriptive analysis of worksite health promotion courses in undergraduate health education programs." Virtual Press, 2000. http://liblink.bsu.edu/uhtbin/catkey/1177974.

Eke, Hilda. "The health promotion center A business plan." Thesis, California State University, Long Beach, 2017. http://pqdtopen.proquest.com/#viewpdf?dispub=10260115.

This business plan proposes a health promotion center to help educate low-income families in Compton suffering from obesity on how to begin and maintain weight loss. Obesity is one of the leading causes of preventable deaths in adults and children. By creating a family and community-based center that provides individualized and group nutrition and fitness services, the rate of obesity can be significantly reduced.

The center which will be located in east Compton will operate as a non-profit organization. It will offer nutrition and fitness services through certified nutritionist and fitness specialist with emphasis placed on gradual weight loss. Meal planning, label reading and training, and grocery store tours are some of the nutrition services that will be offered, while aerobic training and weight training will be part of the fitness service. There will be a life coach and an on-site daycare at the center. The life coach will help potential families establish their weight loss needs, while the on-site day care will provide care for children while families exercise. Services will be offered at reduced prices, and payment will only be made out-of pocket.

Schira, Norma. "A Survey of Health Promotion Activities of Health Systems Agencies." TopSCHOLAR®, 1986. http://digitalcommons.wku.edu/theses/1980.

Glenn, L. Lee, and Kimberly R. Dinsmore. "Effectiveness of Health Education and Promotion for Influenza Immunization." Digital Commons @ East Tennessee State University, 2018. https://dc.etsu.edu/etsu-works/7455.

Runciman, Phyllis Janet. "Interpreting health promotion with older people in community health nursing : education and practice perspectives." Thesis, Glasgow Caledonian University, 2010. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.547440.

Latter, Susan Marianne. "Health education and health promotion : perceptions and practice of nurses in acute care settings." Thesis, King's College London (University of London), 1994. https://kclpure.kcl.ac.uk/portal/en/theses/health-education-and-health-promotion--perceptions-and-practice-of-nurses-in-acute-care-settings(ad41c917-a4f4-4db4-9e02-2f20555f91b5).html.

Douchand, Brown Sandra Elaine. "Health Promotion Behaviors among African American Women." Scholarly Repository, 2009. http://scholarlyrepository.miami.edu/oa_dissertations/205.

Williams-Johnson, Lori Michelle. "Preventive Health Education Media and Older Worker Health Literacy." ScholarWorks, 2016. https://scholarworks.waldenu.edu/dissertations/2388.

Weare, Katherine. "Building bridges : the relationship of medical education to health promotion." Thesis, University of Southampton, 1998. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.242681.

Johnston, Georgia Neikirk Lewis. "Faith based health promotion : a descriptive case study /." Digital version accessible at:, 2000. http://wwwlib.umi.com/cr/utexas/main.

Ellington, Renata Denise. "Sexual Health Education Policy: Influences on Implementation of Sexual Health Education Programs." ScholarWorks, 2016. https://scholarworks.waldenu.edu/dissertations/2971.

Watson, Brenda Ivy. "African American Pastors' Perspectives on Health Promotion Ministries." ScholarWorks, 2017. https://scholarworks.waldenu.edu/dissertations/3846.

Alton, Sarahjane. "Peer education as a strategy for health promotion in older women /." Title page, contents and abstract only, 1994. http://web4.library.adelaide.edu.au/theses/09HS/09hsa469.pdf.

Johnson, Bridget Ann. "Mental health promotion in Western Cape schools :an exploration of factors relating to risk, resilience and health promotion." Thesis, University of the Western Cape, 2005. http://etd.uwc.ac.za/index.php?module=etd&amp.

Wright, Dawna Reneé. "Collaborative transfer of a public health program." Access restricted to users with UT Austin EID, 2001. http://wwwlib.umi.com/cr/utexas/fullcit?p3037025.

Ng'uurah, Julius Nyagah. "Health education needs among individuals with low back pain." Thesis, University of the Western Cape, 2004. http://etd.uwc.ac.za/index.php?module=etd&amp.

Oliveira, Mariza Silva de. "Health promotion mastectomized womenâs: assessment of educational strategy." Universidade Federal do CearÃ, 2009. http://www.teses.ufc.br/tde_busca/arquivo.php?codArquivo=4819.

Weston, Nicolett Marie. "Identifying perceptions of health promotion barriers and benefits in individuals at risk for coronary heart disease." Thesis, Montana State University, 2008. http://etd.lib.montana.edu/etd/2008/weston/WestonN0508.pdf.

Maduakor-Ugo, Augustina Chinyelu. "Effect of Education on Stigma of Epilepsy in South Eastern Nigeria." ScholarWorks, 2011. https://scholarworks.waldenu.edu/dissertations/1130.

Tsang, Woo Che-moy Betty. "A participatory action research : the effectiveness of a health education/promotion programme." Thesis, University of Exeter, 2007. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.438758.

de, Montigny Joanne G. "Toward the Creation of Healthy Schools: Constructing a School Health Partnership Model for Student Well-being to Inspire and Guide Public Health and Education Professionals, at All Levels, and Mental Health Leads." Thesis, Université d'Ottawa / University of Ottawa, 2019. http://hdl.handle.net/10393/39223.

Flynn, Kathryn M. "College Health Clinic Population Health Improvement Plan Project." ScholarWorks, 2017. https://scholarworks.waldenu.edu/dissertations/3881.

Kaplanis, Gina Ferra. "Harnessing Nature for Occupational Therapy: Interventions and Health Promotion." Diss., NSUWorks, 2019. https://nsuworks.nova.edu/hpd_ot_student_dissertations/66.

Chaney, Robert A. "A Spatial Epidemiological Approach to Adolescent Drug Use for Health Promotion and Education." University of Cincinnati / OhioLINK, 2014. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1397467432.

Lynch, Peter. "Alternative constructs of adolescent smoking : an inquiry into health education practice." Thesis, University of Reading, 1996. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.339753.

Bruce, Rebecca. "Barren River District Health Department Health Education/Risk Reduction Demonstration Projects." TopSCHOLAR®, 1989. https://digitalcommons.wku.edu/theses/2172.

Chen, Lei-Shih. "An assessment of health educators' likelihood of adopting genomic competencies for the public health workforce." [College Station, Tex. : Texas A&M University, 2007. http://hdl.handle.net/1969.1/ETD-TAMU-1323.

Clarke, Jacy. "A comparison of lifestyle intervention sessions and clinical screening as motivators in the South Dakota WISEWOMAN program." ScholarWorks, 2009. https://scholarworks.waldenu.edu/dissertations/675.

Dai, Chia-Liang. "Evaluation of an Afterschool Obesity Prevention Program: Children's Healthy Eating and Exercise Program." University of Cincinnati / OhioLINK, 2014. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1406810233.

Cook, Kristian Ciarah. "Designing and Assessing New Educational Pedagogies in Biology and Health Promotion." BYU ScholarsArchive, 2020. https://scholarsarchive.byu.edu/etd/8403.

Daniels, Karin Elizabeth. "Health promotion : the design of a School Health Index Score Card to assess psychosocial health and well-being in early childhood development at primary schools." University of the Western Cape, 2016. http://hdl.handle.net/11394/5437.

Wallace, Maria. "Public Health Nurses’ Perceptions of High School Dropout Rates as a Public Health Issue." ScholarWorks, 2019. https://scholarworks.waldenu.edu/dissertations/7766.

Fritz, Alicia Cutrice. "Social Demography of Health Seeking Experiences Among Transgender African Americans." ScholarWorks, 2016. https://scholarworks.waldenu.edu/dissertations/2352.

Wesley, Jennifer. "Examining Health Disparities and Childhood Obesity in Florida and Georgia." ScholarWorks, 2018. https://scholarworks.waldenu.edu/dissertations/4408.

Njemanze, Ulunma. "Factors Impacting HIV Post Exposure Prophylaxis among Health Care Workers." ScholarWorks, 2017. https://scholarworks.waldenu.edu/dissertations/4086.

Grebner, Leah A. "Learning Style Needs and Effectiveness of Adult Health Literacy Education." ScholarWorks, 2011. https://scholarworks.waldenu.edu/dissertations/1125.

Sitton, Nelson. "Health Disparities among Hispanic Americans with Type 2 Diabetes." ScholarWorks, 2018. https://scholarworks.waldenu.edu/dissertations/4987.

Wylie, Ann Mary. "Health promotion and medical undergraduate education : an exploration of the epistemology and challenge." Thesis, King's College London (University of London), 2004. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.405593.

Wiggins, Noelle. "La Palabra es Salud: A Comparative Study of the Effectiveness of Popular Education vs. Traditional Education for Enhancing Health Knowledge and Skills and Increasing Empowerment Among Parish-Based Community Health Workers (CHWs)." PDXScholar, 2010. https://pdxscholar.library.pdx.edu/open_access_etds/442.

Singh, Shenuka. "A critical analysis of the provision for oral health promotion in South African health policy development." Thesis, University of the Western Cape, 2004. http://etd.uwc.ac.za/index.php?module=etd&action=viewtitle&id=init_4116_1178278944.

Buchanan, Julia K. "The Role of Kentucky State-Supported Postsecondary Education in Creating a Healthier Citizenship." UKnowledge, 2015. http://uknowledge.uky.edu/edl_etds/10.

Jackson-Howard, Cynthia Darlene. "Teachers' Perceptions of Multimodal Literacies in Middle School Health Literacy Programs." ScholarWorks, 2015. https://scholarworks.waldenu.edu/dissertations/322.

Morris-Paxton, Angela Ann. "Impact of a holistic lifestyle management education programme on health and education outcomes of socioeconomically disadvantaged university students." Thesis, Nelson Mandela Metropolitan University, 2016. http://hdl.handle.net/10948/11909.

Uduji, Ifeoma Edna. "Donor Coordination and Health Aid Effectiveness in the Nigerian Health Sector." ScholarWorks, 2016. https://scholarworks.waldenu.edu/dissertations/2510.

Thomas, Mitzie Eumarie. "Health Education to Decrease Obesity in Adolescents with Asthma." ScholarWorks, 2015. https://scholarworks.waldenu.edu/dissertations/1752.

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Rehabilitation Sciences Theses & Dissertations

Teaching social determinants of health in physical therapist professional education programs: exploring curricular approaches and examining an assessment tool.

Emily Jordan Hawkins , Old Dominion University Follow

Date of Award

Summer 8-2023

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Rehabilitation Sciences

Program/Concentration

Kinesiology and Rehabilitation

Committee Director

Julie Cavallario

Committee Member

Daniel Russell

Zachary Rethorn

There is a growing emphasis and need for physical therapists (PTs) to serve not only as clinicians but also as advocates to pursue health equity. Clinical practice for preventing and rehabilitating injuries and promoting physical activity will not eliminate health disparities resulting from the social determinants of health (SDH). Leaders in the field of physical therapy have charged physical therapist professional education programs to teach future PTs to address SDH, however, as of August 2023, the Standards and Required Elements for Accreditation of Physical Therapist Education Programs does not specifically require curricular content regarding SDH. The purposes of this dissertation were to explore what is known about teaching SDH in physical therapist professional education programs and examine an assessment tool that programs could use to evaluate student outcomes regarding SDH training.

A scoping review of 91 articles describing how SDH is taught in health professional training programs in the United States revealed the only published articles addressing physical therapy were through interprofessional education (IPE). The review demonstrated variability in content, educational methods, assessment methods, and curricular logistics across health professional training programs.

Consensual qualitative research methodology was used to explore the phenomenon of teaching SDH content as experienced by core faculty in physical therapist professional education programs. Five themes and associated categories emerged regarding the 14 faculty members’ educational approaches, preparedness, and resources for incorporating SDH into curricula at their respective programs.

Finally, pilot testing of the Physical Therapy Social Determinants of Health Scale (PTSDHS) was conducted to assess structural validity and internal consistency of the tool. Exploratory factor analysis suggested a 4-factor model of a 27-item instrument, with 3 of the factors having acceptable internal consistency as subscales.

Findings suggest that faculty must look to other health professional training programs to determine how to incorporate SDH content into a physical therapist professional education program’s curriculum and will need to decide what topics and educational approaches are most appropriate for their program and context. Faculty already teaching this content should pursue dissemination to share knowledge and resources. Further development of the PT-SDHS is warranted to provide a robust, validated tool.

In Copyright. URI: http://rightsstatements.org/vocab/InC/1.0/ This Item is protected by copyright and/or related rights. You are free to use this Item in any way that is permitted by the copyright and related rights legislation that applies to your use. For other uses you need to obtain permission from the rights-holder(s).

10.25777/fxp1-2d73

9798380393515

Recommended Citation

Hawkins, Emily J.. "Teaching Social Determinants of Health in Physical Therapist Professional Education Programs: Exploring Curricular Approaches and Examining an Assessment Tool" (2023). Doctor of Philosophy (PhD), Dissertation, Rehabilitation Sciences, Old Dominion University, DOI: 10.25777/fxp1-2d73 https://digitalcommons.odu.edu/pt_etds/26

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• Open access
• Published: 11 May 2024

Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates

• Jacqueline Maria Dias 1 ,
• Muhammad Arsyad Subu 1 ,
• Nabeel Al-Yateem 1 ,
• Fatma Refaat Ahmed 1 ,
• Syed Azizur Rahman 1 , 2 ,
• Mini Sara Abraham 1 ,
• Sareh Mirza Forootan 1 ,
• Farzaneh Ahmad Sarkhosh 1 &
• Fatemeh Javanbakh 1  

BMC Nursing volume  23 , Article number:  322 ( 2024 ) Cite this article

430 Accesses

Metrics details

Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses’ sources of stress and coping styles in the Arab region, there is limited understanding of these stressors and coping strategies of nursing students within the UAE context thereby, highlighting the novelty and significance of the study.

A qualitative study was conducted using semi-structured interviews. Overall 30 students who were undergoing their first clinical placement in Year 2 at the University of Sharjah between May and June 2022 were recruited. All interviews were recorded and transcribed verbatim and analyzed for themes.

During their first clinical training, nursing students are exposed to stress from different sources, including the clinical environment, unfriendly clinical tutors, feelings of disconnection, multiple expectations of clinical staff and patients, and gaps between the curriculum of theory classes and labatories skills and students’ clinical experiences. We extracted three main themes that described students’ stress and use of coping strategies during clinical training: (1) managing expectations; (2) theory-practice gap; and (3) learning to cope. Learning to cope, included two subthemes: positive coping strategies and negative coping strategies.

Conclusions

This qualitative study sheds light from the students viewpoint about the intricate interplay between managing expectations, theory practice gap and learning to cope. Therefore, it is imperative for nursing faculty, clinical agencies and curriculum planners to ensure maximum learning in the clinical by recognizing the significance of the stressors encountered and help students develop positive coping strategies to manage the clinical stressors encountered. Further research is required look at the perspective of clinical stressors from clinical tutors who supervise students during their first clinical practicum.

Peer Review reports

Nursing education programmes aim to provide students with high-quality clinical learning experiences to ensure that nurses can provide safe, direct care to patients [ 1 ]. The nursing baccalaureate programme at the University of Sharjah is a four year program with 137 credits. The programmes has both theoretical and clinical components withs nine clinical courses spread over the four years The first clinical practicum which forms the basis of the study takes place in year 2 semester 2.

Clinical practice experience is an indispensable component of nursing education and links what students learn in the classroom and in skills laboratories to real-life clinical settings [ 2 , 3 , 4 ]. However, a gap exists between theory and practice as the curriculum in the classroom differs from nursing students’ experiences in the clinical nursing practicum [ 5 ]. Clinical nursing training places (or practicums, as they are commonly referred to), provide students with the necessary experiences to ensure that they become proficient in the delivery of patient care [ 6 ]. The clinical practicum takes place in an environment that combines numerous structural, psychological, emotional and organizational elements that influence student learning [ 7 ] and may affect the development of professional nursing competencies, such as compassion, communication and professional identity [ 8 ]. While clinical training is a major component of nursing education curricula, stress related to clinical training is common among students [ 9 ]. Furthermore, the nursing literature indicates that the first exposure to clinical learning is one of the most stressful experiences during undergraduate studies [ 8 , 10 ]. Thus, the clinical component of nursing education is considered more stressful than the theoretical component. Students often view clinical learning, where most learning takes place, as an unsupportive environment [ 11 ]. In addition, they note strained relationships between themselves and clinical preceptors and perceive that the negative attitudes of clinical staff produce stress [ 12 ].

The effects of stress on nursing students often involve a sense of uncertainty, uneasiness, or anxiety. The literature is replete with evidence that nursing students experience a variety of stressors during their clinical practicum, beginning with the first clinical rotation. Nursing is a complex profession that requires continuous interaction with a variety of individuals in a high-stress environment. Stress during clinical learning can have multiple negative consequences, including low academic achievement, elevated levels of burnout, and diminished personal well-being [ 13 , 14 ]. In addition, both theoretical and practical research has demonstrated that increased, continual exposure to stress leads to cognitive deficits, inability to concentrate, lack of memory or recall, misinterpretation of speech, and decreased learning capacity [ 15 ]. Furthermore, stress has been identified as a cause of attrition among nursing students [ 16 ].

Most sources of stress have been categorized as academic, clinical or personal. Each person copes with stress differently [ 17 ], and utilizes deliberate, planned, and psychological efforts to manage stressful demands [ 18 ]. Coping mechanisms are commonly termed adaptation strategies or coping skills. Labrague et al. [ 19 ] noted that students used critical coping strategies to handle stress and suggested that problem solving was the most common coping or adaptation mechanism used by nursing students. Nursing students’ coping strategies affect their physical and psychological well-being and the quality of nursing care they offer. Therefore, identifying the coping strategies that students use to manage stressors is important for early intervention [ 20 ].

Studies on nursing students’ coping strategies have been conducted in various countries. For example, Israeli nursing students were found to adopt a range of coping mechanisms, including talking to friends, engaging in sports, avoiding stress and sadness/misery, and consuming alcohol [ 21 ]. Other studies have examined stress levels among medical students in the Arab region. Chaabane et al. [ 15 ], conducted a systematic review of sudies in Arab countries, including Saudi Arabia, Egypt, Jordan, Iraq, Pakistan, Oman, Palestine and Bahrain, and reported that stress during clinical practicums was prevalent, although it could not be determined whether this was limited to the initial clinical course or occurred throughout clinical training. Stressors highlighted during the clinical period in the systematic review included assignments and workload during clinical practice, a feeling that the requirements of clinical practice exceeded students’ physical and emotional endurance and that their involvement in patient care was limited due to lack of experience. Furthermore, stress can have a direct effect on clinical performance, leading to mental disorders. Tung et al. [ 22 ], reported that the prevalence of depression among nursing students in Arab countries is 28%, which is almost six times greater than the rest of the world [ 22 ]. On the other hand, Saifan et al. [ 5 ], explored the theory-practice gap in the United Arab Emirates and found that clinical stressors could be decreased by preparing students better for clinical education with qualified clinical faculty and supportive preceptors.

The purpose of this study was to identify the stressors experienced by undergraduate nursing students in the United Arab Emirates during their first clinical training and the basic adaptation approaches or coping strategies they used. Recognizing or understanding different coping processes can inform the implementation of corrective measures when students experience clinical stress. The findings of this study may provide valuable information for nursing programmes, nurse educators, and clinical administrators to establish adaptive strategies to reduce stress among students going clinical practicums, particularly stressors from their first clinical training in different healthcare settings.

A qualitative approach was adopted to understand clinical stressors and coping strategies from the perspective of nurses’ lived experience. Qualitative content analysis was employed to obtain rich and detailed information from our qualitative data. Qualitative approaches seek to understand the phenomenon under study from the perspectives of individuals with lived experience [ 23 ]. Qualitative content analysis is an interpretive technique that examines the similarities and differences between and within different areas of text while focusing on the subject [ 24 ]. It is used to examine communication patterns in a repeatable and systematic way [ 25 ] and yields rich and detailed information on the topic under investigation [ 23 ]. It is a method of systematically coding and categorizing information and comprises a process of comprehending, interpreting, and conceptualizing the key meanings from qualitative data [ 26 ].

Setting and participants

This study was conducted after the clinical rotations ended in April 2022, between May and June in the nursing programme at the College of Health Sciences, University of Sharjah, in the United Arab Emirates. The study population comprised undergraduate nursing students who were undergoing their first clinical training and were recruited using purposive sampling. The inclusion criteria for this study were second-year nursing students in the first semester of clinical training who could speak English, were willing to participate in this research, and had no previous clinical work experience. The final sample consisted of 30 students.

Research instrument

The research instrument was a semi structured interview guide. The interview questions were based on an in-depth review of related literature. An intensive search included key words in Google Scholar, PubMed like the terms “nursing clinical stressors”, “nursing students”, and “coping mechanisms”. Once the questions were created, they were validated by two other faculty members who had relevant experience in mental health. A pilot test was conducted with five students and based on their feedback the following research questions, which were addressed in the study.

How would you describe your clinical experiences during your first clinical rotations?

In what ways did you find the first clinical rotation to be stressful?

What factors hindered your clinical training?

How did you cope with the stressors you encountered in clinical training?

Which strategies helped you cope with the clinical stressors you encountered?

Data collection

Semi-structured interviews were chosen as the method for data collection. Semi structured interviews are a well-established approach for gathering data in qualitative research and allow participants to discuss their views, experiences, attitudes, and beliefs in a positive environment [ 27 ]. This approach allows for flexibility in questioning thereby ensuring that key topics related to clinical learning stressors and coping strategies would be explored. Participants were given the opportunity to express their views, experiences, attitudes, and beliefs in a positive environment, encouraging open communication. These semi structured interviews were conducted by one member of the research team (MAS) who had a mental health background, and another member of the research team who attended the interviews as an observer (JMD). Neither of these researchers were involved in teaching the students during their clinical practicum, which helped to minimize bias. The interviews took place at the University of Sharjah, specifically in building M23, providing a familiar and comfortable environment for the participant. Before the interviews were all students who agreed to participate were provided with an explanation of the study’s purpose. The time and location of each interview were arranged. Before the interviews were conducted, all students who provided consent to participate received an explanation of the purpose of the study, and the time and place of each interview were arranged to accommodate the participants’ schedules and preferences. The interviews were conducted after the clinical rotation had ended in April, and after the final grades had been submitted to the coordinator. The timings of the interviews included the month of May and June which ensured that participants have completed their practicum experience and could reflect on the stressors more comprehensively. The interviews were audio-recorded with the participants’ consent, and each interview lasted 25–40 min. The data were collected until saturation was reached for 30 students. Memos and field notes were also recorded as part of the data collection process. These additional data allowed for triangulation to improve the credibility of the interpretations of the data [ 28 ]. Memos included the interviewers’ thoughts and interpretations about the interviews, the research process (including questions and gaps), and the analytic progress used for the research. Field notes were used to record the interviewers’ observations and reflections on the data. These additional data collection methods were important to guide the researchers in the interpretation of the data on the participants’ feelings, perspectives, experiences, attitudes, and beliefs. Finally, member checking was performed to ensure conformability.

Data analysis

The study used the content analysis method proposed by Graneheim and Lundman [ 24 ]. According to Graneheim and Lundman [ 24 ], content analysis is an interpretive technique that examines the similarities and differences between distinct parts of a text. This method allows researchers to determine exact theoretical and operational definitions of words, phrases, and symbols by elucidating their constituent properties [ 29 ]. First, we read the interview transcripts several times to reach an overall understanding of the data. All verbatim transcripts were read several times and discussed among all authors. We merged and used line-by-line coding of words, sentences, and paragraphs relevant to each other in terms of both the content and context of stressors and coping mechanisms. Next, we used data reduction to assess the relationships among themes using tables and diagrams to indicate conceptual patterns. Content related to stress encountered by students was extracted from the transcripts. In a separate document, we integrated and categorized all words and sentences that were related to each other in terms of both content and context. We analyzed all codes and units of meaning and compared them for similarities and differences in the context of this study. Furthermore, the emerging findings were discussed with other members of the researcher team. The final abstractions of meaningful subthemes into themes were discussed and agreed upon by the entire research team. This process resulted in the extraction of three main themes in addition to two subthemes related to stress and coping strategies.

Ethical considerations

The University of Sharjah Research Ethics Committee provided approval to conduct this study (Reference Number: REC 19-12-03-01-S). Before each interview, the goal and study procedures were explained to each participant, and written informed consent was obtained. The participants were informed that participation in the study was voluntary and that they could withdraw from the study at any time. In the event they wanted to withdraw from the study, all information related to the participant would be removed. No participant withdrew from the study. Furthermore, they were informed that their clinical practicum grade would not be affected by their participation in this study. We chose interview locations in Building M23that were private and quiet to ensure that the participants felt at ease and confident in verbalizing their opinions. No participant was paid directly for involvement in this study. In addition, participants were assured that their data would remain anonymous and confidential. Confidentiality means that the information provided by participants was kept private with restrictions on how and when data can be shared with others. The participants were informed that their information would not be duplicated or disseminated without their permission. Anonymity refers to the act of keeping people anonymous with respect to their participation in a research endeavor. No personal identifiers were used in this study, and each participant was assigned a random alpha-numeric code (e.g., P1 for participant 1). All digitally recorded interviews were downloaded to a secure computer protected by the principal investigator with a password. The researchers were the only people with access to the interview material (recordings and transcripts). All sensitive information and materials were kept secure in the principal researcher’s office at the University of Sharjah. The data will be maintained for five years after the study is completed, after which the material will be destroyed (the transcripts will be shredded, and the tapes will be demagnetized).

In total, 30 nursing students who were enrolled in the nursing programme at the Department of Nursing, College of Health Sciences, University of Sharjah, and who were undergoing their first clinical practicum participated in the study. Demographically, 80% ( n  = 24) were females and 20% ( n  = 6) were male participants. The majority (83%) of study participants ranged in age from 18 to 22 years. 20% ( n  = 6) were UAE nationals, 53% ( n  = 16) were from Gulf Cooperation Council countries, while 20% ( n  = 6) hailed from Africa and 7% ( n  = 2) were of South Asian descent. 67% of the respondents lived with their families while 33% lived in the hostel. (Table  1 )

Following the content analysis, we identified three main themes: (1) managing expectations, (2) theory-practice gap and 3)learning to cope. Learning to cope had two subthemes: positive coping strategies and negative coping strategies. An account of each theme is presented along with supporting excerpts for the identified themes. The identified themes provide valuable insight into the stressors encountered by students during their first clinical practicum. These themes will lead to targeted interventions and supportive mechanisms that can be built into the clinical training curriculum to support students during clinical practice.

Theme 1: managing expectations

In our examination of the stressors experienced by nursing students during their first clinical practicum and the coping strategies they employed, we identified the first theme as managing expectations.

The students encountered expectations from various parties, such as clinical staff, patients and patients’ relatives which they had to navigate. They attempted to fulfil their expectations as they progressed through training, which presented a source of stress. The students noted that the hospital staff and patients expected them to know how to perform a variety of tasks upon request, which made the students feel stressed and out of place if they did not know how to perform these tasks. Some participants noted that other nurses in the clinical unit did not allow them to participate in nursing procedures, which was considered an enormous impediment to clinical learning, as noted in the excerpt below:

“…Sometimes the nurses… They will not allow us to do some procedures or things during clinical. And sometimes the patients themselves don’t allow us to do procedures” (P5).

Some of the students noted that they felt they did not belong and felt like foreigners in the clinical unit. Excerpts from the students are presented in the following quotes;

“The clinical environment is so stressful. I don’t feel like I belong. There is too little time to build a rapport with hospital staff or the patient” (P22).

“… you ask the hospital staff for some guidance or the location of equipment, and they tell us to ask our clinical tutor …but she is not around … what should I do? It appears like we do not belong, and the sooner the shift is over, the better” (P18).

“The staff are unfriendly and expect too much from us students… I feel like I don’t belong, or I am wasting their (the hospital staff’s) time. I want to ask questions, but they have loads to do” (P26).

Other students were concerned about potential failure when working with patients during clinical training, which impacted their confidence. They were particularly afraid of failure when performing any clinical procedures.

“At the beginning, I was afraid to do procedures. I thought that maybe the patient would be hurt and that I would not be successful in doing it. I have low self-confidence in doing procedures” (P13).

The call bell rings, and I am told to answer Room No. XXX. The patient wants help to go to the toilet, but she has two IV lines. I don’t know how to transport the patient… should I take her on the wheelchair? My eyes glance around the room for a wheelchair. I am so confused …I tell the patient I will inform the sister at the nursing station. The relative in the room glares at me angrily … “you better hurry up”…Oh, I feel like I don’t belong, as I am not able to help the patient… how will I face the same patient again?” (P12).

Another major stressor mentioned in the narratives was related to communication and interactions with patients who spoke another language, so it was difficult to communicate.

“There was a challenge with my communication with the patients. Sometimes I have communication barriers because they (the patients) are of other nationalities. I had an experience with a patient [who was] Indian, and he couldn’t speak my language. I did not understand his language” (P9).

Thus, a variety of expectations from patients, relatives, hospital staff, and preceptors acted as sources of stress for students during their clinical training.

Theme 2: theory-practice gap

Theory-practice gaps have been identified in previous studies. In our study, there was complete dissonance between theory and actual clinical practice. The clinical procedures or practices nursing students were expected to perform differed from the theory they had covered in their university classes and skills lab. This was described as a theory–practice gap and often resulted in stress and confusion.

“For example …the procedures in the hospital are different. They are different from what we learned or from theory on campus. Or… the preceptors have different techniques than what we learned on campus. So, I was stress[ed] and confused about it” (P11).

Furthermore, some students reported that they did not feel that they received adequate briefing before going to clinical training. A related source of stress was overload because of the volume of clinical coursework and assignments in addition to clinical expectations. Additionally, the students reported that a lack of time and time management were major sources of stress in their first clinical training and impacted their ability to complete the required paperwork and assignments:

“…There is not enough time…also, time management at the hospital…for example, we start at seven a.m., and the handover takes 1 hour to finish. They (the nurses at the hospital) are very slow…They start with bed making and morning care like at 9.45 a.m. Then, we must fill [out] our assessment tool and the NCP (nursing care plan) at 10 a.m. So, 15 only minutes before going to our break. We (the students) cannot manage this time. This condition makes me and my friends very stressed out. -I cannot do my paperwork or assignments; no time, right?” (P10).

“Stressful. There is a lot of work to do in clinical. My experiences are not really good with this course. We have a lot of things to do, so many assignments and clinical procedures to complete” (P16).

The participants noted that the amount of required coursework and number of assignments also presented a challenge during their first clinical training and especially affected their opportunity to learn.

“I need to read the file, know about my patient’s condition and pathophysiology and the rationale for the medications the patient is receiving…These are big stressors for my learning. I think about assignments often. Like, we are just focusing on so many assignments and papers. We need to submit assessments and care plans for clinical cases. We focus our time to complete and finish the papers rather than doing the real clinical procedures, so we lose [the] chance to learn” (P25).

Another participant commented in a similar vein that there was not enough time to perform tasks related to clinical requirements during clinical placement.

“…there is a challenge because we do not have enough time. Always no time for us to submit papers, to complete assessment tools, and some nurses, they don’t help us. I think we need more time to get more experiences and do more procedures, reduce the paperwork that we have to submit. These are challenges …” (P14).

There were expectations that the students should be able to carry out their nursing duties without becoming ill or adversely affected. In addition, many students reported that the clinical environment was completely different from the skills laboratory at the college. Exposure to the clinical setting added to the theory-practice gap, and in some instances, the students fell ill.

One student made the following comment:

“I was assisting a doctor with a dressing, and the sight and smell from the oozing wound was too much for me. I was nauseated. As soon as the dressing was done, I ran to the bathroom and threw up. I asked myself… how will I survive the next 3 years of nursing?” (P14).

Theme 3: learning to cope

The study participants indicated that they used coping mechanisms (both positive and negative) to adapt to and manage the stressors in their first clinical practicum. Important strategies that were reportedly used to cope with stress were time management, good preparation for clinical practice, and positive thinking as well as engaging in physical activity and self-motivation.

“Time management. Yes, it is important. I was encouraging myself. I used time management and prepared myself before going to the clinical site. Also, eating good food like cereal…it helps me very much in the clinic” (P28).

“Oh yeah, for sure positive thinking. In the hospital, I always think positively. Then, after coming home, I get [to] rest and think about positive things that I can do. So, I will think something good [about] these things, and then I will be relieved of stress” (P21).

Other strategies commonly reported by the participants were managing their breathing (e.g., taking deep breaths, breathing slowly), taking breaks to relax, and talking with friends about the problems they encountered.

“I prefer to take deep breaths and breathe slowly and to have a cup of coffee and to talk to my friends about the case or the clinical preceptor and what made me sad so I will feel more relaxed” (P16).

“Maybe I will take my break so I feel relaxed and feel better. After clinical training, I go directly home and take a long shower, going over the day. I will not think about anything bad that happened that day. I just try to think about good things so that I forget the stress” (P27).

“Yes, my first clinical training was not easy. It was difficult and made me stressed out…. I felt that it was a very difficult time for me. I thought about leaving nursing” (P7).

I was not able to offer my prayers. For me, this was distressing because as a Muslim, I pray regularly. Now, my prayer time is pushed to the end of the shift” (P11).

“When I feel stress, I talk to my friends about the case and what made me stressed. Then I will feel more relaxed” (P26).

Self-support or self-motivation through positive self-talk was also used by the students to cope with stress.

“Yes, it is difficult in the first clinical training. When I am stress[ed], I go to the bathroom and stand in the front of the mirror; I talk to myself, and I say, “You can do it,” “you are a great student.” I motivate myself: “You can do it”… Then, I just take breaths slowly several times. This is better than shouting or crying because it makes me tired” (P11).

Other participants used physical activity to manage their stress.

“How do I cope with my stress? Actually, when I get stressed, I will go for a walk on campus” (P4).

“At home, I will go to my room and close the door and start doing my exercises. After that, I feel the negative energy goes out, then I start to calm down… and begin my clinical assignments” (P21).

Both positive and negative coping strategies were utilized by the students. Some participants described using negative coping strategies when they encountered stress during their clinical practice. These negative coping strategies included becoming irritable and angry, eating too much food, drinking too much coffee, and smoking cigarettes.

“…Negative adaptation? Maybe coping. If I am stressed, I get so angry easily. I am irritable all day also…It is negative energy, right? Then, at home, I am also angry. After that, it is good to be alone to think about my problems” (P12).

“Yeah, if I…feel stress or depressed, I will eat a lot of food. Yeah, ineffective, like I will be eating a lot, drinking coffee. Like I said, effective, like I will prepare myself and do breathing, ineffective, I will eat a lot of snacks in between my free time. This is the bad side” (P16).

“…During the first clinical practice? Yes, it was a difficult experience for us…not only me. When stressed, during a break at the hospital, I will drink two or three cups of coffee… Also, I smoke cigarettes… A lot. I can drink six cups [of coffee] a day when I am stressed. After drinking coffee, I feel more relaxed, I finish everything (food) in the refrigerator or whatever I have in the pantry, like chocolates, chips, etc” (P23).

These supporting excerpts for each theme and the analysis offers valuable insights into the specific stressors faced by nursing students during their first clinical practicum. These insights will form the basis for the development of targeted interventions and supportive mechanisms within the clinical training curriculum to better support students’ adjustment and well-being during clinical practice.

Our study identified the stressors students encounter in their first clinical practicum and the coping strategies, both positive and negative, that they employed. Although this study emphasizes the importance of clinical training to prepare nursing students to practice as nurses, it also demonstrates the correlation between stressors and coping strategies.The content analysis of the first theme, managing expectations, paves the way for clinical agencies to realize that the students of today will be the nurses of tomorrow. It is important to provide a welcoming environment where students can develop their identities and learn effectively. Additionally, clinical staff should foster an environment of individualized learning while also assisting students in gaining confidence and competence in their repertoire of nursing skills, including critical thinking, problem solving and communication skills [ 8 , 15 , 19 , 30 ]. Another challenge encountered by the students in our study was that they were prevented from participating in clinical procedures by some nurses or patients. This finding is consistent with previous studies reporting that key challenges for students in clinical learning include a lack of clinical support and poor attitudes among clinical staff and instructors [ 31 ]. Clinical staff with positive attitudes have a positive impact on students’ learning in clinical settings [ 32 ]. The presence, supervision, and guidance of clinical instructors and the assistance of clinical staff are essential motivating components in the clinical learning process and offer positive reinforcement [ 30 , 33 , 34 ]. Conversely, an unsupportive learning environment combined with unwelcoming clinical staff and a lack of sense of belonging negatively impact students’ clinical learning [ 35 ].

The sources of stress identified in this study were consistent with common sources of stress in clinical training reported in previous studies, including the attitudes of some staff, students’ status in their clinical placement and educational factors. Nursing students’ inexperience in the clinical setting and lack of social and emotional experience also resulted in stress and psychological difficulties [ 36 ]. Bhurtun et al. [ 33 ] noted that nursing staff are a major source of stress for students because the students feel like they are constantly being watched and evaluated.

We also found that students were concerned about potential failure when working with patients during their clinical training. Their fear of failure when performing clinical procedures may be attributable to low self-confidence. Previous studies have noted that students were concerned about injuring patients, being blamed or chastised, and failing examinations [ 37 , 38 ]. This was described as feeling “powerless” in a previous study [ 7 , 12 ]. In addition, patients’ attitudes towards “rejecting” nursing students or patients’ refusal of their help were sources of stress among the students in our study and affected their self-confidence. Self-confidence and a sense of belonging are important for nurses’ personal and professional identity, and low self-confidence is a problem for nursing students in clinical learning [ 8 , 39 , 40 ]. Our findings are consistent with a previous study that reported that a lack of self-confidence was a primary source of worry and anxiety for nursing students and affected their communication and intention to leave nursing [ 41 ].

In the second theme, our study suggests that students encounter a theory-practice gap in clinical settings, which creates confusion and presents an additional stressors. Theoretical and clinical training are complementary elements of nursing education [ 40 ], and this combination enables students to gain the knowledge, skills, and attitudes necessary to provide nursing care. This is consistent with the findings of a previous study that reported that inconsistencies between theoretical knowledge and practical experience presented a primary obstacle to the learning process in the clinical context [ 42 ], causing students to lose confidence and become anxious [ 43 ]. Additionally, the second theme, the theory-practice gap, authenticates Safian et al.’s [ 5 ] study of the theory-practice gap that exists United Arab Emirates among nursing students as well as the need for more supportive clinical faculty and the extension of clinical hours. The need for better time availability and time management to complete clinical tasks were also reported by the students in the study. Students indicated that they had insufficient time to complete clinical activities because of the volume of coursework and assignments. Our findings support those of Chaabane et al. [ 15 ]. A study conducted in Saudi Arabia [ 44 ] found that assignments and workload were among the greatest sources of stress for students in clinical settings. Effective time management skills have been linked to academic achievement, stress reduction, increased creativity [ 45 ], and student satisfaction [ 46 ]. Our findings are also consistent with previous studies that reported that a common source of stress among first-year students was the increased classroom workload [ 19 , 47 ]. As clinical assignments and workloads are major stressors for nursing students, it is important to promote activities to help them manage these assignments [ 48 ].

Another major challenge reported by the participants was related to communicating and interacting with other nurses and patients. The UAE nursing workforce and population are largely expatriate and diverse and have different cultural and linguistic backgrounds. Therefore, student nurses encounter difficulty in communication [ 49 ]. This cultural diversity that students encounter in communication with patients during clinical training needs to be addressed by curriculum planners through the offering of language courses and courses on cultural diversity [ 50 ].

Regarding the third and final theme, nursing students in clinical training are unable to avoid stressors and must learn to cope with or adapt to them. Previous research has reported a link between stressors and the coping mechanisms used by nursing students [ 51 , 52 , 53 ]. In particular, the inability to manage stress influences nurses’ performance, physical and mental health, attitude, and role satisfaction [ 54 ]. One such study suggested that nursing students commonly use problem-focused (dealing with the problem), emotion-focused (regulating emotion), and dysfunctional (e.g., venting emotions) stress coping mechanisms to alleviate stress during clinical training [ 15 ]. Labrague et al. [ 51 ] highlighted that nursing students use both active and passive coping techniques to manage stress. The pattern of clinical stress has been observed in several countries worldwide. The current study found that first-year students experienced stress during their first clinical training [ 35 , 41 , 55 ]. The stressors they encountered impacted their overall health and disrupted their clinical learning. Chaabane et al. [ 15 ] reported moderate and high stress levels among nursing students in Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. Another study from Bahrain reported that all nursing students experienced moderate to severe stress in their first clinical placement [ 56 ]. Similarly, nursing students in Spain experienced a moderate level of stress, and this stress was significantly correlated with anxiety [ 30 ]. Therefore, it is imperative that pastoral systems at the university address students’ stress and mental health so that it does not affect their clinical performance. Faculty need to utilize evidence-based interventions to support students so that anxiety-producing situations and attrition are minimized.

In our study, students reported a variety of positive and negative coping mechanisms and strategies they used when they experienced stress during their clinical practice. Positive coping strategies included time management, positive thinking, self-support/motivation, breathing, taking breaks, talking with friends, and physical activity. These findings are consistent with those of a previous study in which healthy coping mechanisms used by students included effective time management, social support, positive reappraisal, and participation in leisure activities [ 57 ]. Our study found that relaxing and talking with friends were stress management strategies commonly used by students. Communication with friends to cope with stress may be considered social support. A previous study also reported that people seek social support to cope with stress [ 58 ]. Some students in our study used physical activity to cope with stress, consistent with the findings of previous research. Stretching exercises can be used to counteract the poor posture and positioning associated with stress and to assist in reducing physical tension. Promoting such exercise among nursing students may assist them in coping with stress in their clinical training [ 59 ].

Our study also showed that when students felt stressed, some adopted negative coping strategies, such as showing anger/irritability, engaging in unhealthy eating habits (e.g., consumption of too much food or coffee), or smoking cigarettes. Previous studies have reported that high levels of perceived stress affect eating habits [ 60 ] and are linked to poor diet quality, increased snacking, and low fruit intake [ 61 ]. Stress in clinical settings has also been linked to sleep problems, substance misuse, and high-risk behaviors’ and plays a major role in student’s decision to continue in their programme.

Implications of the study

The implications of the study results can be grouped at multiple levels including; clinical, educational, and organizational level. A comprehensive approach to addressing the stressors encountered by nursing students during their clinical practicum can be overcome by offering some practical strategies to address the stressors faced by nursing students during their clinical practicum. By integrating study findings into curriculum planning, mentorship programs, and organizational support structures, a supportive and nurturing environment that enhances students’ learning, resilience, and overall success can be envisioned.

Clinical level

Introducing simulation in the skills lab with standardized patients and the use of moulage to demonstrate wounds, ostomies, and purulent dressings enhances students’ practical skills and prepares them for real-world clinical scenarios. Organizing orientation days at clinical facilities helps familiarize students with the clinical environment, identify potential stressors, and introduce interventions to enhance professionalism, social skills, and coping abilities Furthermore, creating a WhatsApp group facilitates communication and collaboration among hospital staff, clinical tutors, nursing faculty, and students, enabling immediate support and problem-solving for clinical situations as they arise, Moreover, involving chief nursing officers of clinical facilities in the Nursing Advisory Group at the Department of Nursing promotes collaboration between academia and clinical practice, ensuring alignment between educational objectives and the needs of the clinical setting [ 62 ].

Educational level

Sharing study findings at conferences (we presented the results of this study at Sigma Theta Tau International in July 2023 in Abu Dhabi, UAE) and journal clubs disseminates knowledge and best practices among educators and clinicians, promoting awareness and implementation of measures to improve students’ learning experiences. Additionally we hold mentorship training sessions annually in January and so we shared with the clinical mentors and preceptors the findings of this study so that they proactively they are equipped with strategies to support students’ coping with stressors during clinical placements.

Organizational level

At the organizational we relooked at the available student support structures, including counseling, faculty advising, and career advice, throughout the nursing program emphasizing the importance of holistic support for students’ well-being and academic success as well as retention in the nursing program. Also, offering language courses as electives recognizes the value of communication skills in nursing practice and provides opportunities for personal and professional development.

For first-year nursing students, clinical stressors are inevitable and must be given proper attention. Recognizing nursing students’ perspectives on the challenges and stressors experienced in clinical training is the first step in overcoming these challenges. In nursing schools, providing an optimal clinical environment as well as increasing supervision and evaluation of students’ practices should be emphasized. Our findings demonstrate that first-year nursing students are exposed to a variety of different stressors. Identifying the stressors, pressures, and obstacles that first-year students encounter in the clinical setting can assist nursing educators in resolving these issues and can contribute to students’ professional development and survival to allow them to remain in the profession. To overcome stressors, students frequently employ problem-solving approaches or coping mechanisms. The majority of nursing students report stress at different levels and use a variety of positive and negative coping techniques to manage stress.

The present results may not be generalizable to other nursing institutions because this study used a purposive sample along with a qualitative approach and was limited to one university in the Middle East. Furthermore, the students self-reported their stress and its causes, which may have introduced reporting bias. The students may also have over or underreported stress or coping mechanisms because of fear of repercussions or personal reasons, even though the confidentiality of their data was ensured. Further studies are needed to evaluate student stressors and coping now that measures have been introduced to support students. Time will tell if these strategies are being used effectively by both students and clinical personnel or if they need to be readdressed. Finally, we need to explore the perceptions of clinical faculty towards supervising students in their first clinical practicum so that clinical stressors can be handled effectively.

Data availability

The data sets are available with the corresponding author upon reasonable request.

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The authors are grateful to all second year nursing students who voluntarily participated in the study.

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Jacqueline Maria Dias, Muhammad Arsyad Subu, Nabeel Al-Yateem, Fatma Refaat Ahmed, Syed Azizur Rahman, Mini Sara Abraham, Sareh Mirza Forootan, Farzaneh Ahmad Sarkhosh & Fatemeh Javanbakh

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JMD conceptualized the idea and designed the methodology, formal analysis, writing original draft and project supervision and mentoring. MAS prepared the methodology and conducted the qualitative interviews and analyzed the methodology and writing of original draft and project supervision. NY, FRA, SAR, MSA writing review and revising the draft. SMF, FAS, FJ worked with MAS on the formal analysis and prepared the first draft.All authors reviewed the final manuscipt of the article.

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Dias, J.M., Subu, M.A., Al-Yateem, N. et al. Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates. BMC Nurs 23 , 322 (2024). https://doi.org/10.1186/s12912-024-01962-5

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Chicago teen who started college at 10 earns doctorate degree at 17

Dorothy Jean Tillman II’s participation in Arizona State University’s May 6 commencement was the latest step on a higher-education journey the Chicago teen started when she took her first college course at age 10.

In between came associate’s, bachelor’s and master’s degrees.

When Tillman successfully defended her dissertation in December, she became the youngest person — at age 17 — to earn a doctoral degree in integrated behavioral health at Arizona State,  associate professor Leslie Manson told ABC’s “Good Morning America”  for a story Monday.

“It’s a wonderful celebration, and we hope ... that Dorothy Jean inspires more students,” Manson said. “But this is still something so rare and unique.”

Tillman, called “Dorothy Jeanius” by family and friends, is the granddaughter of former Chicago Alderwoman Dorothy Tillman.

When most students are just learning to navigate middle school, her mother enrolled Tillman in classes through the College of Lake County in northern Illinois, where she majored in psychology and completed her associate’s degree in 2016, according to her biography.

Tillman earned a bachelor’s in humanities from New York’s Excelsior College in 2018. About two years later, she earned her master’s of science from Unity College in Maine before being accepted in 2021 into Arizona State’s Behavioral Health Management Program.

Most of her classwork was done remotely and online. Tillman did attend her  Arizona State commencement  in person and addressed the graduating class during the ceremony.

Tillman told The Associated Press on Tuesday that she credits her grandmother and trusting in her mother’s guidance for her educational pursuits and successes.

“Everything that we were doing didn’t seem abnormal to me or out of the ordinary until it started getting all of the attention,” said Tillman, now 18.

There have been sacrifices, though.

“I didn’t have the everyday school things like homecoming dances or spirit weeks or just school pictures and things like that ... that kind of create unity with my peers,” she said.

She has found time to dance and do choreography. Tillman also is founder and chief executive of the Dorothyjeanius STEAM Leadership Institute. The program includes summer camps designed to help young people in the arts and STEM subjects.

She said her plans include public speaking engagements and fundraising for the camp, which Tillman said she hopes to franchise one day.

Tillman is motivated and has innovative ideas, said Manson, adding, “And truly, I think what is inspiring is that she embodies that meaning of being a true leader.”

Jimalita Tillman said she is most impressed with her daughter’s ability to show herself and her successes with grace, but to also understand when to “put her foot down” when choosing between social outings and her education.

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Chicago teen earns doctorate at 17 years old from Arizona State

Dorothy Jean Tillman II spoke at her commencement this month at Arizona State University. She successfully defended her dissertation to earn a doctorate in integrated behavioral health last December.

Copyright © 2024 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

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Teen walks at graduation after completing doctoral degree at 17

Dorothy Jean Tillman II was 10 when she entered college as a freshman.

A teenager from Chicago walked in her graduation ceremony this month after earning her doctoral degree at 17.

Dorothy Jean Tillman II told " Good Morning America " that she was homeschooled in her early years before entering college at age 10.

In 2020, she said she earned a Master of Science degree, and then, one year later, at age 15, was accepted into the Doctorate of Behavioral Health Management program at Arizona State University.

In December 2023, at 17, Tillman successfully defended her dissertation to earn her doctoral degree in integrated behavioral health from ASU's College of Health Solutions.

On May 6, she walked at ASU's spring commencement ceremony.

Tillman told "GMA" she has always held education in such high regard in part due to her family's background.

"People in my life like my grandmother, who was part of the Civil Rights movement, she of course harped on the importance of education and consistently learning something always," Tillman said. "But the way I always held education so high on my own, aside from being raised that way, was finding different things to be educated about."

She continued, "I feel like that urge to learn something new just never didn't exist for me."

Teen who battled leukemia and homelessness as a child graduates college at 18

Dr. Lesley Manson, a clinical associate professor at ASU, told "GMA" that Tillman is the youngest person in school history to earn a doctoral degree in integrated behavioral health.

Manson said she oversaw Tillman's dissertation for the doctoral program offered through ASU Online.

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During her studies, Tillman wrote a journal article of her dissertation and completed an internship at a university student health center, according to Manson.

"She really led change and worked on different forms of management to really reduce healthcare stigma and improve that student population there to be able to enter and accept student health services," she said of Tillman. "It was wonderful to see her and help her navigate some of those personal and professional interactions and grow through those experiences."

Manson described Tillman as an "inquisitive" and "innovative" student, and emphasized just how rare it is to accomplish what she has so far.

"It's a wonderful celebration ... but this is still something so rare and unique," she said. "She has innovative ideas and motivation, which is wonderful, and truly, I think what is inspiring is that she embodies that meaning of being a true leader."

Manson said she hopes Tillman continues to inspire people with her love of learning, saying, "That curiosity is always there, and I think all learners come with that, but it's great to be able to see it in someone so young as well."

Her inspiration and how she gives back to community

Tillman said her own journey wouldn't be possible without the support of her mom, who she said is one of her biggest motivators.

"Seeing my mother consistently work so hard to continuously uphold our family's legacy, and be that person that everyone was able to go to, if they needed anything ... always seeing [her] like [a] 'wonder woman' definitely made me want to grow up [into] an accomplished person," she said.

An advocate for education, Tillman is also the founder and CEO of a leadership institute that emphasizes the arts and STEM.

"I feel like adding art and putting a focus on it throughout science, technology, engineering and math makes the kids excited to learn all those things," she said. "And it opens them up to all of the possibilities and all the knowledge provided in that area of just STEM."

'Super dad' graduates with master's while working 3 jobs

As for her plans after graduation, Tillman said she is "just like any other teenager, still figuring out what my specific dreams and goals are."

"I'm really just grateful that the world is my oyster, and that I've done so much so young," she said. "And I have time to kind of think that through."

Tillman added that she hopes young people will take away from her story that it's OK to continually figure out what you want to do in life.

"Always remember that everyone has points in their life where they feel like they're figuring it out," she said. "And so figuring things out, not knowing what you want isn't a bad thing. But making the choice not to sit down and try to figure it out is."

Editor's note: This story has been updated with additional quotes from Tillman since its original publish date of May 13, 2024.

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