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1.  A randomized control trial: training program of university students as health promoters 
BMC Public Health  2013;13:162.
Several studies have reported the following as determining factors for the adoption of healthy lifestyles among undergraduate students: gender, socioeconomic level, prior lifestyles, environment, parental lifestyles and health status, career choice, and healthy support networks. However, these factors are influenced by students’ knowledge about healthy lifestyles.
We will carry out a randomized trial in a sample of 280 new undergraduate students at the National Autonomous University of Mexico’s Faculty of Higher Studies-Zaragoza (FES-Zaragoza, UNAM). There will be an experimental group (n = 140), comprising 20 students from each of the seven university departments (careers); these students will receive training as university student health promoters through an e-learning course. This course will allow the topics necessary for such promoters to be reviewed. There will be a control group (n = 140), comprising 20 students from each of the seven departments (careers); these students will not undergo the training. Later, the students who comply satisfactorily with the e-learning course will replicate the course to 10 of their classmates. A healthy-lifestyle questionnaire will be given to all the participants, and the parameters established in the self-care card will be recorded before and after the training. The study variables are as follows: (i) independent variable—compliance with the e-learning course; (ii) dependent variables—lifestyles changes prior to the educative intervention (including healthy eating, physical activity, and addiction prevention) and parameters related to health status established in self-care (including weight, body mass index, waist circumference, and hip circumference). Data will be analyzed using Student’s t test and logistic regression analysis odds ratios with 95% confidence intervals. The analysis of the open answers will be carried out with ATLAS. ti 5.5 software.
Health promotion among university students should incorporate options that are feasible for and attractive to students. Thus, as proposed in the present protocol, e-learning courses offer excellent possibilities because they allow students to program their learning in their available time without affecting their academic studies.
Trial registration
PMCID: PMC3608970  PMID: 23433061
University health promoter; University student health promoter; Self-care; Health promotion
2.  (S)Partners for Heart Health: a school-based program for enhancing physical activity and nutrition to promote cardiovascular health in 5th grade students 
BMC Public Health  2008;8:420.
The American Heart Association Position Statement on Cardiovascular Health Promotion in Public Schools encourages school-based interventions for the primary prevention of cardiovascular disease (CVD) through risk factor prevention or reduction in children with an emphasis on creating an environment that promotes healthy food choices and physical activity (PA). In an effort to address issues related to CVD risk factors including obesity in Michigan children, a multi-disciplinary team of Michigan State University (MSU) faculty, clinicians, and health profession students was formed to "(S)partner" with elementary school physical education (PE) teachers and MSU Extension staff to develop and implement a cost-effective, sustainable program aimed at CVD risk factor prevention and management for 5th grade students. This (S)partnership is intended to augment and improve the existing 5th grade PE, health and nutrition curriculum by achieving the following aims: 1) improve the students' knowledge, attitudes and confidence about nutrition, PA and heart health; 2) increase the number of students achieving national recommendations for PA and nutrition; and 3) increase the number of students with a desirable CVD risk factor status based on national pediatric guidelines. Secondary aims include promoting school staff and parental support for heart health to help children achieve their goals and to provide experiential learning and service for MSU health profession students for academic credit.
This pilot effectiveness study was approved by the MSU IRB. At the beginning and the end of the school year students undergo a CVD risk factor assessment conducted by MSU medical students and graduate students. Key intervention components include eight lesson plans (conducted bi-monthly) designed to promote heart healthy nutrition and PA behaviors conducted by PE teachers with assistance from MSU undergraduate dietetic and kinesiology students (Spartners). The final 10 minutes of each lesson, MSU Spartners conduct small breakout/discussion groups with the 5th grade students. Additionally, each Spartner case manages/mentors two to three 5th grade students using a web-based goal setting and tracking protocol throughout the school year.
This paper describes the rationale, development, and methods of the Spartners for Heart Health program. This is a multi-level intervention designed to promote heart healthy behaviors and prevent or manage CVD risk factors in children. We believe this will be a viable sustainable intervention that can be disseminated and adopted by other institutions with minimal cost by engaging college students as an integral part of the measurement and intervention teams.
PMCID: PMC2628664  PMID: 19102777
3.  Inaccurate Weight Perception is Associated With Extreme Weight Management Practices in US High-School Students 
To examine whether adolescents’ weight perception accuracy (WPA) was associated with extreme weight-management practices (EWPs) in differing body mass index (BMI) categories.
WPA, overassessment, and underassessment were determined by comparing self-reported BMI and weight perception among US high-school students in the 2009 National Youth Risk Behavior Survey. BMI was classified as: underweight (<5th percentile), healthy weight (5th–<85th), overweight (≥85th–<95th), and obese (≥95th). WPA was considered inaccurate if BMI and weight perception were discordant. Overassessors thought they were heavier than they were (among underweight/healthy groups); underassessors thought they were lighter than they were (among healthy/overweight/obese groups). EWPs included one or more of fasting, use of diet pills, or purging/laxative use. Logit models were fitted for different BMI sex strata.
In the final sample of 14,722 US high-school students with complete data, 20.2%, 85.7%, 5.8%, and 80.9% of those who were underweight, healthy weight, overweight, and obese, inaccurately assessed their weight, respectively. In turn, 11.4% and 17.6% of accurate and inaccurate assessors engaged in EWPs, respectively. After adjustment, underweight females who overassessed their weight had 12.6 times higher odds of EWPs (95% CI: 3.4–46.6). Also, there were elevated odds of EWPs among healthy weight students who overassessed their weight.
Overassessing healthy weight students and underweight girls had higher odds of 3 EWPs, likely related to an unhealthy desire to lose weight. This study demonstrates a need to further educate clinicians on WPA and its relationship to EWPs even among those of healthy weight who may be seen as non-risk.
PMCID: PMC3982798  PMID: 24172585
weight perception; eating disorder; obesity; YRBSS; Adolescent; dieting
4.  Endurance Capacity Is Not Correlated with Endothelial Function in Male University Students 
PLoS ONE  2014;9(8):e103814.
Endurance capacity, assessed by 1000-meter (1000 m) run of male university students, is an indicator of cardiovascular fitness in Chinese students physical fitness surveillance. Although cardiovascular fitness is related to endothelial function closely in patients with cardiovascular diseases, it remains unclear whether endurance capacity correlates with endothelial function, especially with circulating endothelial microparticles (EMPs), a new sensitive marker of endothelial dysfunction in young students. The present study aimed to investigate the relationship between endurance capacity and endothelial function in male university students.
Forty-seven healthy male university students (mean age, 20.1±0.6 years; mean height, 172.4±6.3 cm; and mean weight, 60.0±8.2 kg) were recruited in this study. The measurement procedure of 1000 m run time was followed to Chinese national students Constitutional Health Criterion. Endothelium function was assessed by flow-mediated vasodilation (FMD) in the brachial artery measured by ultrasonic imaging, and the level of circulating EMPs was measured by flow cytometry. Cardiovascular fitness indicator - maximal oxygen uptake (VO2 max) - was also measured on a cycle ergometer using a portable gas analyzer.
1000 m run time was correlated with VO2max (r = −0.399, p<0.05). However, there were no correlations between VO2max and FMD or levels of circulating CD31+/CD42- microparticles. Similarly, no correlations were found between 1000 m run time and FMD, and levels of circulating CD31+/CD42- microparticles in these male university students (p>0.05).
The correlations between endurance capacity or cardiovascular fitness and endothelial function were not found in healthy Chinese male university students. These results suggest that endurance capacity may not reflect endothelial function in healthy young adults with well preserved FMD and low level of circulating CD31+/CD42-EMPs.
PMCID: PMC4125158  PMID: 25101975
5.  Engaging Rural Youth in Physical Activity Promotion Research in an After-School Setting 
Preventing Chronic Disease  2005;2(Spec No):A15.
West Virginia, the second most rural state in the nation, has a higher than average prevalence of chronic diseases, especially those related to physical inactivity and obesity. Innovative educational approaches are needed to increase physical activity among adults and youth in rural areas and reduce rural health disparities. This paper describes West Virginia's Health Sciences and Technology Academy (HSTA) Education and Outreach on Healthy Weight and Physical Activity. The project involved teachers and underserved high school students in social science research aimed at increasing physical activity among student and community participants.
The HSTA is an ongoing initiative of university–school–community partnerships in West Virginia that offers academic enrichment to high-school students in after-school clubs. For this project, six HSTA clubs were awarded grants to conduct research on physical activity promotion during the 2003–2004 school year. The project was funded by the Centers for Disease Control and Prevention.
Focus groups, workshops, and targeted technical assistance were used to assist teachers and students with developing, implementing, and evaluating their research projects. Each club completed one project, and students reported on their research at the annual HSTA symposium held in the spring. Teachers documented their experience with the projects in process journals before and during implementation.
Data from the teachers' process journals revealed that they believed this research experience increased their students' interest in health and health science careers and increased their students' understanding of social science research methods. Challenges included lack of time after school to complete all activities, competing student activities, limited social science research experience of both teachers and students, and delays that resulted from a lengthy human subjects approval process.
The entire process was too ambitious to be achieved in one school year. Recommendations for future implementation include offering training modules on social science research methods for both teachers and students. These modules could be offered as a graduate course for teachers and as an in-school elective within the curriculum or as a summer institute for students. This preparatory training might alleviate some of the time management issues experienced by all the projects and could result in more skilled teacher and student researchers.
PMCID: PMC1459460  PMID: 16263048
6.  The relationship between students’ study habits, happiness and depression 
One of the important requirements for cultural, social and even economic development is having a book-loving nation. In order to achieve this, there is a need for purposeful and continuous programming. The purpose of this research was to determine the relationship between students’ study habits, happiness and depression in Isfahan University of Medical Science.
This research was a kind of descriptive and correlation survey. Statistical population included all MSc and PhD students in the second semester of the Isfahan University of Medical Science (263 students). In this research, stratified and random sampling was used in which a sample of 100 students was selected. Data collection instruments were Beck Depression Inventory (BDI), Oxford Happiness Inventory and a researcher-made questionnaire to determine the amount of students’ study. Validity of this questionnaires was determined by structure and content related validity and its reliability was calculated by Cronbach's alpha coefficient for the first (r = 0.94), second (r = 0.91) and third (r = 0.85) questionnaire. Analysis of research findings was done through descriptive and inferential statistics.
Findings showed that 68.8 percent of students study less than 5 hours and only 2.5 percent of students study more than 10 hours. 65 percent of students had high amount of happiness and 35 percent had medium amount of happiness. In 60 percent of students there was no symptom of depression and 7.5 had depression symptoms. Also, there was no significant relationship between happiness and studying but there was a significant and negative relationship between studying and depression and happiness and depression.
The amount of study and tendency for reading are among the most important indices of human growth in terms of potential abilities for achieving a perfect human life and to prevent one-dimensional thinking. Thus, finding ways to encourage students to study is considered essential to achieve a healthy and developed society.
PMCID: PMC3249802  PMID: 22224110
Students’ study habits; depression; happiness
7.  Medical Students' Exposure to and Attitudes about the Pharmaceutical Industry: A Systematic Review 
PLoS Medicine  2011;8(5):e1001037.
A systematic review of published studies reveals that undergraduate medical students may experience substantial exposure to pharmaceutical marketing, and that this contact may be associated with positive attitudes about marketing.
The relationship between health professionals and the pharmaceutical industry has become a source of controversy. Physicians' attitudes towards the industry can form early in their careers, but little is known about this key stage of development.
Methods and Findings
We performed a systematic review reported according to PRISMA guidelines to determine the frequency and nature of medical students' exposure to the drug industry, as well as students' attitudes concerning pharmaceutical policy issues. We searched MEDLINE, EMBASE, Web of Science, and ERIC from the earliest available dates through May 2010, as well as bibliographies of selected studies. We sought original studies that reported quantitative or qualitative data about medical students' exposure to pharmaceutical marketing, their attitudes about marketing practices, relationships with industry, and related pharmaceutical policy issues. Studies were separated, where possible, into those that addressed preclinical versus clinical training, and were quality rated using a standard methodology. Thirty-two studies met inclusion criteria. We found that 40%–100% of medical students reported interacting with the pharmaceutical industry. A substantial proportion of students (13%–69%) were reported as believing that gifts from industry influence prescribing. Eight studies reported a correlation between frequency of contact and favorable attitudes toward industry interactions. Students were more approving of gifts to physicians or medical students than to government officials. Certain attitudes appeared to change during medical school, though a time trend was not performed; for example, clinical students (53%–71%) were more likely than preclinical students (29%–62%) to report that promotional information helps educate about new drugs.
Undergraduate medical education provides substantial contact with pharmaceutical marketing, and the extent of such contact is associated with positive attitudes about marketing and skepticism about negative implications of these interactions. These results support future research into the association between exposure and attitudes, as well as any modifiable factors that contribute to attitudinal changes during medical education.
Please see later in the article for the Editors' Summary
Editors' Summary
The complex relationship between health professionals and the pharmaceutical industry has long been a subject of discussion among physicians and policymakers. There is a growing body of evidence that suggests that physicians' interactions with pharmaceutical sales representatives may influence clinical decision making in a way that is not always in the best interests of individual patients, for example, encouraging the use of expensive treatments that have no therapeutic advantage over less costly alternatives. The pharmaceutical industry often uses physician education as a marketing tool, as in the case of Continuing Medical Education courses that are designed to drive prescribing practices.
One reason that physicians may be particularly susceptible to pharmaceutical industry marketing messages is that doctors' attitudes towards the pharmaceutical industry may form early in their careers. The socialization effect of professional schooling is strong, and plays a lasting role in shaping views and behaviors.
Why Was This Study Done?
Recently, particularly in the US, some medical schools have limited students' and faculties' contact with industry, but some have argued that these restrictions are detrimental to students' education. Given the controversy over the pharmaceutical industry's role in undergraduate medical training, consolidating current knowledge in this area may be useful for setting priorities for changes to educational practices. In this study, the researchers systematically examined studies of pharmaceutical industry interactions with medical students and whether such interactions influenced students' views on related topics.
What Did the Researchers Do and Find?
The researchers did a comprehensive literature search using appropriate search terms for all relevant quantitative and qualitative studies published before June 2010. Using strict inclusion criteria, the researchers then selected 48 articles (from 1,603 abstracts) for full review and identified 32 eligible for analysis—giving a total of approximately 9,850 medical students studying at 76 medical schools or hospitals.
Most students had some form of interaction with the pharmaceutical industry but contact increased in the clinical years, with up to 90% of all clinical students receiving some form of educational material. The highest level of exposure occurred in the US. In most studies, the majority of students in their clinical training years found it ethically permissible for medical students to accept gifts from drug manufacturers, while a smaller percentage of preclinical students reported such attitudes. Students justified their entitlement to gifts by citing financial hardship or by asserting that most other students accepted gifts. In addition, although most students believed that education from industry sources is biased, students variably reported that information obtained from industry sources was useful and a valuable part of their education.
Almost two-thirds of students reported that they were immune to bias induced by promotion, gifts, or interactions with sales representatives but also reported that fellow medical students or doctors are influenced by such encounters. Eight studies reported a relationship between exposure to the pharmaceutical industry and positive attitudes about industry interactions and marketing strategies (although not all included supportive statistical data). Finally, student opinions were split on whether physician–industry interactions should be regulated by medical schools or the government.
What Do These Findings Mean?
This analysis shows that students are frequently exposed to pharmaceutical marketing, even in the preclinical years, and that the extent of students' contact with industry is generally associated with positive attitudes about marketing and skepticism towards any negative implications of interactions with industry. Therefore, strategies to educate students about interactions with the pharmaceutical industry should directly address widely held misconceptions about the effects of marketing and other biases that can emerge from industry interactions. But education alone may be insufficient. Institutional policies, such as rules regulating industry interactions, can play an important role in shaping students' attitudes, and interventions that decrease students' contact with industry and eliminate gifts may have a positive effect on building the skills that evidence-based medical practice requires. These changes can help cultivate strong professional values and instill in students a respect for scientific principles and critical evidence review that will later inform clinical decision-making and prescribing practices.
Additional Information
Please access these Web sites via the online version of this summary at
Further information about the influence of the pharmaceutical industry on doctors and medical students can be found at the American Medical Students Association PharmFree campaign and PharmFree Scorecard, Medsin-UKs PharmAware campaign, the nonprofit organization Healthy Skepticism, and the Web site of No Free Lunch.
PMCID: PMC3101205  PMID: 21629685
8.  Association of Medical Students' Reports of Interactions with the Pharmaceutical and Medical Device Industries and Medical School Policies and Characteristics: A Cross-Sectional Study 
PLoS Medicine  2014;11(10):e1001743.
Aaron Kesselheim and colleagues compared US medical students' survey responses regarding pharmaceutical company interactions with the schools' AMSA PharmFree scorecard and Institute on Medicine as a Profession's (IMAP) scores.
Please see later in the article for the Editors' Summary
Professional societies use metrics to evaluate medical schools' policies regarding interactions of students and faculty with the pharmaceutical and medical device industries. We compared these metrics and determined which US medical schools' industry interaction policies were associated with student behaviors.
Methods and Findings
Using survey responses from a national sample of 1,610 US medical students, we compared their reported industry interactions with their schools' American Medical Student Association (AMSA) PharmFree Scorecard and average Institute on Medicine as a Profession (IMAP) Conflicts of Interest Policy Database score. We used hierarchical logistic regression models to determine the association between policies and students' gift acceptance, interactions with marketing representatives, and perceived adequacy of faculty–industry separation. We adjusted for year in training, medical school size, and level of US National Institutes of Health (NIH) funding. We used LASSO regression models to identify specific policies associated with the outcomes. We found that IMAP and AMSA scores had similar median values (1.75 [interquartile range 1.50–2.00] versus 1.77 [1.50–2.18], adjusted to compare scores on the same scale). Scores on AMSA and IMAP shared policy dimensions were not closely correlated (gift policies, r = 0.28, 95% CI 0.11–0.44; marketing representative access policies, r = 0.51, 95% CI 0.36–0.63). Students from schools with the most stringent industry interaction policies were less likely to report receiving gifts (AMSA score, odds ratio [OR]: 0.37, 95% CI 0.19–0.72; IMAP score, OR 0.45, 95% CI 0.19–1.04) and less likely to interact with marketing representatives (AMSA score, OR 0.33, 95% CI 0.15–0.69; IMAP score, OR 0.37, 95% CI 0.14–0.95) than students from schools with the lowest ranked policy scores. The association became nonsignificant when fully adjusted for NIH funding level, whereas adjusting for year of education, size of school, and publicly versus privately funded school did not alter the association. Policies limiting gifts, meals, and speaking bureaus were associated with students reporting having not received gifts and having not interacted with marketing representatives. Policy dimensions reflecting the regulation of industry involvement in educational activities (e.g., continuing medical education, travel compensation, and scholarships) were associated with perceived separation between faculty and industry. The study is limited by potential for recall bias and the cross-sectional nature of the survey, as school curricula and industry interaction policies may have changed since the time of the survey administration and study analysis.
As medical schools review policies regulating medical students' industry interactions, limitations on receipt of gifts and meals and participation of faculty in speaking bureaus should be emphasized, and policy makers should pay greater attention to less research-intensive institutions.
Please see later in the article for the Editors' Summary
Editors' Summary
Making and selling prescription drugs and medical devices is big business. To promote their products, pharmaceutical and medical device companies build relationships with physicians by providing information on new drugs, by organizing educational meetings and sponsored events, and by giving gifts. Financial relationships begin early in physicians' careers, with companies providing textbooks and other gifts to first-year medical students. In medical school settings, manufacturers may help to inform trainees and physicians about developments in health care, but they also create the potential for harm to patients and health care systems. These interactions may, for example, reduce trainees' and trained physicians' skepticism about potentially misleading promotional claims and may encourage physicians to prescribe new medications, which are often more expensive than similar unbranded (generic) drugs and more likely to be recalled for safety reasons than older drugs. To address these and other concerns about the potential career-long effects of interactions between medical trainees and industry, many teaching hospitals and medical schools have introduced policies to limit such interactions. The development of these policies has been supported by expert professional groups and medical societies, some of which have created scales to evaluate the strength of the implemented industry interaction policies.
Why Was This Study Done?
The impact of policies designed to limit interactions between students and industry on student behavior is unclear, and it is not known which aspects of the policies are most predictive of student behavior. This information is needed to ensure that the policies are working and to identify ways to improve them. Here, the researchers investigate which medical school characteristics and which aspects of industry interaction policies are most predictive of students' reported behaviors and beliefs by comparing information collected in a national survey of US medical students with the strength of their schools' industry interaction policies measured on two scales—the American Medical Student Association (AMSA) PharmFree Scorecard and the Institute on Medicine as a Profession (IMAP) Conflicts of Interest Policy Database.
What Did the Researchers Do and Find?
The researchers compared information about reported gift acceptance, interactions with marketing representatives, and the perceived adequacy of faculty–industry separation collected from 1,610 medical students at 121 US medical schools with AMSA and IMAP scores for the schools evaluated a year earlier. Students at schools with the highest ranked interaction policies based on the AMSA score were 63% less likely to accept gifts as students at the lowest ranked schools. Students at the highest ranked schools based on the IMAP score were about half as likely to accept gifts as students at the lowest ranked schools, although this finding was not statistically significant (it could be a chance finding). Similarly, students at the highest ranked schools were 70% less likely to interact with sales representatives as students at the lowest ranked schools. These associations became statistically nonsignificant after controlling for the amount of research funding each school received from the US National Institutes of Health (NIH). Policies limiting gifts, meals, and being a part of speaking bureaus (where companies pay speakers to present information about the drugs for dinners and other events) were associated with students' reports of receiving no gifts and of non-interaction with sales representatives. Finally, policies regulating industry involvement in educational activities were associated with the perceived separation between faculty and industry, which was regarded as adequate by most of the students at schools with such policies.
What Do These Findings Mean?
These findings suggest that policies designed to limit industry interactions with medical students need to address multiple aspects of these interactions to achieve changes in the behavior and attitudes of trainees, but that policies limiting gifts, meals, and speaking bureaus may be particularly important. These findings also suggest that the level of NIH funding plays an important role in students' self-reported behaviors and their perceptions of industry, possibly because institutions with greater NIH funding have the resources needed to implement effective policies. The accuracy of these findings may be limited by recall bias (students may have reported their experiences inaccurately), and by the possibility that industry interaction policies may have changed in the year that elapsed between policy grading and the student survey. Nevertheless, these findings suggest that limitations on gifts should be emphasized when academic medical centers refine their policies on interactions between medical students and industry and that particular attention should be paid to the design and implementation of policies that regulate industry interactions in institutions with lower levels of NIH funding.
Additional Information
Please access these websites via the online version of this summary at
The UK General Medical Council provides guidance on financial and commercial arrangements and conflicts of interest as part of its good medical practice document, which describes what is required of all registered doctors in the UK
Information about the American Medical Student Association (AMSA) Just Medicine campaign (formerly the PharmFree campaign) and about the AMSA Scorecard is available
Information about the Institute on Medicine as a Profession (IMAP) and about its Conflicts of Interest Policy Database is also available
“Understanding and Responding to Pharmaceutical Promotion: A Practical Guide” is a manual prepared by Health Action International and the World Health Organization that medical schools can use to train students how to recognize and respond to pharmaceutical promotion
The US Institute of Medicine's report “Conflict of Interest in Medical Research, Education, and Practice” recommends steps to identify, limit, and manage conflicts of interest
The ALOSA Foundation provides evidence-based, non-industry-funded education about treating common conditions and using prescription drugs
PMCID: PMC4196737  PMID: 25314155
9.  Social interactions of eating behaviour among high school students: a cellular automata approach 
Overweight and obesity in children and adolescents is a global epidemic posing problems for both developed and developing nations. The prevalence is particularly alarming in developed nations, such as the United States, where approximately one in three school-aged adolescents (ages 12-19) are overweight or obese. Evidence suggests that weight gain in school-aged adolescents is related to energy imbalance exacerbated by the negative aspects of the school food environment, such as presence of unhealthy food choices. While a well-established connection exists between the food environment, presently there is a lack of studies investigating the impact of the social environment and associated interactions of school-age adolescents. This paper uses a mathematical modelling approach to explore how social interactions among high school adolescents can affect their eating behaviour and food choice.
In this paper we use a Cellular Automata (CA) modelling approach to explore how social interactions among school-age adolescents can affect eating behaviour, and food choice. Our CA model integrates social influences and transition rules to simulate the way individuals would interact in a social community (e.g., school cafeteria). To replicate these social interactions, we chose the Moore neighbourhood which allows all neighbours (eights cells in a two-dimensional square lattice) to influence the central cell. Our assumption is that individuals belong to any of four states; Bring Healthy, Bring Unhealthy, Purchase Healthy, and Purchase Unhealthy, and will influence each other according to parameter settings and transition rules. Simulations were run to explore how the different states interact under varying parameter settings.
This study, through simulations, illustrates that students will change their eating behaviour from unhealthy to healthy as a result of positive social and environmental influences. In general, there is one common characteristic of changes across time; students with similar eating behaviours tend to form groups, represented by distinct clusters. Transition of healthy and unhealthy eating behaviour is non-linear and a sharp change is observed around a critical point where positive and negative influences are equal.
Conceptualizing the social environment of individuals is a crucial step to increasing our understanding of obesogenic environments of high-school students, and moreover, the general population. Incorporating both contextual, and individual determinants found in real datasets, in our model will greatly enhance calibration of future models. Complex mathematical modelling has a potential to contribute to the way public health data is collected and analyzed.
PMCID: PMC3598476  PMID: 23046793
10.  Frequency of Human Immunodeficiency Virus Infection Among Students of Tertiary and Secondary Institutions in An Endemic State 
Students are pivotal to manpower development and technological advancement of any nation. Nigerian nation was recently ranked third human immunodeficiency virus (HIV) most endemic nation in the world
The study was designed to determine the frequency of HIV infection among Nigerian tertiary and secondary institution students.
Materials and Methods:
A HIV screening test was conducted on 1,978 apparently healthy students composed of 981 males and 997 females aged 11–35 years, randomly selected from some Nigerian tertiary and secondary institutions
Overall, the sero-prevalence rate of 13.7% was recorded consisting 9.9% in the tertiary and 3.8% in secondary institutions. The distribution of the infection showed no significant difference by age (χ2=1.07, P>0.05) and by gender (χ2=0.85, P>0.05). Also, the prevalence had no significant association with the settlement of students (χ2=0.96, P>0.05) and the status of educational institutions (χ2=1.42, P>0.05).
The findings indicate a high HIV prevalence rate among students in this part of the globe. General behavioral changes about sex among the students are suggested.
PMCID: PMC3334256  PMID: 22536559
Educational-institutions endemic-state; Frequency; Human immunodeficiency virus; Students
11.  Interactive Learning Activities for the Middle School Classroom to Promote Healthy Energy Balance and Decrease Diabetes Risk in the HEALTHY Primary Prevention Trial 
Health promotion practice  2012;15(1):10.1177/1524839912469377.
The HEALTHY trial evaluated the effectiveness of a multicomponent intervention program to reduce risk for type 2 diabetes in middle school students. The comprehensive intervention addressed nutrition, physical activity, and behavior in the context of a social marketing–based communications campaign to promote healthy energy balance. One element was a classroom-based program called FLASH (Fun Learning Activities for Student Health). Five FLASH modules were delivered, one per semester. Process evaluation data were collected from teachers at 21 schools and study staff at seven national sites via survey, interview, and in-class observation. Data from the first four modules were evaluated and showed that FLASH was delivered with high fidelity. Sessions that required peer interaction were rated as the most effective in engaging students and promoting knowledge. Study-provided material resources and onsite support were identified as key facilitators. Student misbehavior was viewed as the greatest barrier. Although the high level of support provided by the study is not likely to be replicated in school systems, those developing wellness policies, health curricula, and teacher training programs may benefit from using the evidence-supported, publicly available HEALTHY materials in their efforts to reduce diabetes risk factors in middle school youth.
PMCID: PMC3718847  PMID: 23271717
process evaluation; obesity; diabetes prevention; physical activity; school nutrition; health promotion; health curriculum; school health; health teaching; teacher training
12.  The effect of a healthy school tuck shop program on the access of students to healthy foods 
Nutrition Research and Practice  2012;6(2):138-145.
The objective of this study was to evaluate the effect of a healthy school tuck shop program, developed as a way of creating a healthy and nutritional school environment, on students' access to healthy foods. Five middle schools and four high schools (775 students) participated in the healthy school tuck shop program, and nine schools (1,282 students) were selected as the control group. The intervention program included restriction of unhealthy foods sold in tuck shops, provision of various fruits, and indirect nutritional education with promotion of healthy food products. The program evaluation involved the examination of students' purchase and intake patterns of healthy foods, satisfaction with the available foodstuffs, and utilization of and satisfaction with nutritional educational resources. Our results indicated that among of the students who utilized the tuck shop, about 40% purchased fruit products, showing that availability of healthy foods in the tuck shop increased the accessibility of healthy foods for students. Overall food purchase and intake patterns did not significantly change during the intervention period. However, students from the intervention schools reported higher satisfaction with the healthy food products sold in the tuck shop than did those from the control schools (all P < 0.001), and they were highly satisfied with the educational resources provided to them. In conclusion, the healthy school tuck shop program had a positive effect on the accessibility of healthy food. The findings suggest that a healthy school tuck shop may be an effective environmental strategy for promoting students' access to healthy foods.
PMCID: PMC3349036  PMID: 22586503
School tuck shop; healthy eating; intervention program; fruits and vegetables
13.  State Laws Governing School Meals and Disparities in Fruit/Vegetable Intake 
Home access to fruits/vegetables (FV) is a consistent predictor of adolescent FV intake, but many adolescents face barriers to home access.
To determine if state laws that require FV in school meals are positively associated with FV intake, particularly among students with limited home access to FV.
Student data on home food access and FV intake were obtained from the National Youth Physical Activity and Nutrition Study (n=9574) and linked to state laws regarding FV requirements for school meals. All data were collected in 2010. Ordinary least-squares models were utilized in 2012 to estimate differences in intake between states with different FV laws, overall and by whether students had access to various foods at home (FV, unhealthy snacks). Models were weighted to account for the sample design and controlled for race, gender, age, fast-food intake, and school lunches consumed per week.
The association between FV requirement laws and FV intake was strongest among students without regular home access to FV. Particularly among students who had home access to only unhealthy snacks and who regularly consumed school meals, mean FV intake was 0.45 and 0.61 cups/day higher, respectively (95% CI=0.07, 0.84 and 0.21, 1.00) in states with FV requirements. Students with access to healthier foods at home tended to consume more FV, but such disparities in intake were smaller in states with FV laws.
Laws that require FV in school meals may improve FV intake, particularly among students with limited access to healthy foods at home.
PMCID: PMC3664760  PMID: 23498102
14.  The Effect of Individual Factors on Health Behaviors Among College Students: The Mediating Effects of eHealth Literacy 
College students’ health behavior is a topic that deserves attention. Individual factors and eHealth literacy may affect an individual’s health behaviors. The integrative model of eHealth use (IMeHU) provides a parsimonious account of the connections among the digital divide, health care disparities, and the unequal distribution and use of communication technologies. However, few studies have explored the associations among individual factors, eHealth literacy, and health behaviors, and IMeHU has not been empirically investigated.
This study examines the associations among individual factors, eHealth literacy, and health behaviors using IMeHU.
The Health Behavior Scale is a 12-item instrument developed to measure college students’ eating, exercise, and sleep behaviors. The eHealth Literacy Scale is a 12-item instrument designed to measure college students’ functional, interactive, and critical eHealth literacy. A nationally representative sample of 525 valid college students in Taiwan was surveyed. A questionnaire was administered to collect background information about participants’ health status, degree of health concern, major, and the frequency with which they engaged in health-related discussions. This study used Amos 6.0 to conduct a confirmatory factor analysis to identify the best measurement models for the eHealth Literacy Scale and the Health Behavior Scale. We then conducted a multiple regression analysis to examine the associations among individual factors, eHealth literacy, and health behaviors. Additionally, causal steps approach was used to explore indirect (mediating) effects and Sobel tests were used to test the significance of the mediating effects.
The study found that perceptions of better health status (t520=2.14-6.12, P<.001-.03) and greater concern for health (t520=2.58-6.95, P<.001-.003) influenced college students’ development of 3 dimensions of eHealth literacy and adoption of healthy eating, exercise, and sleep behaviors. Moreover, eHealth literacy played an intermediary role in the association between individual factors and health behaviors (Sobel test=2.09-2.72, P<.001-.03). Specifically, higher levels of critical eHealth literacy promoted students’ health status and their practice of multiple positive health behaviors, including eating, exercise, and sleep behaviors.
Because this study showed that eHealth literacy mediates the association between individual factors and health behaviors, schools should aim to enhance students’ eHealth literacy and promote their health behaviors to help them achieve high levels of critical eHealth literacy. Although some of the study’s hypotheses were not supported in this study, the factors that influence health behaviors are complex and interdependent. Therefore, a follow-up study should be conducted to further explore how these factors influence one another.
PMCID: PMC4275503  PMID: 25499086
demographic; health behavior; mediation; eHealth literacy; quantitative evaluation
15.  Bilateral Pulmonary Emboli in a Collegiate Gymnast: A Case Report 
Journal of Athletic Training  2009;44(6):666-671.
To characterize the diagnosis of pulmonary embolism in collegiate student-athletes and to raise awareness among sports medicine providers of the possibility of this potentially fatal disease in the student-athlete population.
An 18-year-old, previously healthy National Collegiate Athletic Association Division I female gymnast complained of intense pain, bilaterally, deep in her chest. The athlete was referred to her team physician, who identified normal vital signs but referred her to the emergency room because of significant pain. The student-athlete was diagnosed with bilateral pulmonary emboli in the emergency room.
Differential Diagnosis:
Pneumonia, renal calculi, upper urinary tract infection, intercostal muscle strain or rib fracture, pancreatitis, gall bladder disease, gastritis, ulceration, esophagitis, infection, tumor, pulmonary embolism.
The student-athlete was immediately placed on anticoagulants for 6 months. During that time, she was unable to participate in gymnastics and was limited to light conditioning.
Documented cases of female student-athletes developing a pulmonary embolism are lacking in the literature. Two cases of pulmonary embolism in male high school student-athletes have been documented, in addition to many cases in elderly and sedentary populations.
All health care providers, including sports medicine professionals, should be aware that this condition may be present among student-athletes. During the initial evaluation, prescreening should include questions about any previous or family history of pulmonary embolism or other blood clots. Athletes who answer positively to these questions may have a higher likelihood of pulmonary embolism and should be referred for testing.
PMCID: PMC2775370  PMID: 19911095
cardiovascular diseases; vascular diseases
16.  Effect of Nutrition Changes on Foods Selected by Students in a Middle School-based Diabetes Prevention Intervention Program; the HEALTHY Experience 
The Journal of School Health  2012;82(2):82-90.
The HEALTHY primary prevention trial developed an integrated multi-component intervention program to moderate risk factors for type 2 diabetes in middle schools. The nutrition component aimed to improve the quality of foods and beverages served to students. Changes in the School Breakfast Program (SBP), National School Lunch Program (NSLP), and a la carte venues are compared to the experience of control schools.
The intervention was implemented in 21 middle schools from winter 2007 through spring 2009 (following a cohort of students from sixth through eighth grades); 21 schools acted as observed controls. The nutrition component targeted school food service environmental change. Data identifying foods and nutrients served (selected by students for consumption) were collected over a 20-day period at baseline and end of study. Analysis compared end of study values for intervention versus control schools.
Intervention schools more successfully limited dessert and snack food portion size in NSLP and a la carte and lowered fat content of foods served. Servings of high fiber grain-based foods and/or legumes were improved in SBP but not NSLP. Intervention and control schools eliminated >1% fat milk and sugar added beverages in SBP, but intervention schools were more successful in NSLP and a la carte.
The HEALTHY program demonstrated significant changes in the nutritional quality of foods and beverages served in the SBP, NSLP, and a la carte venues, as part of an effort to decrease childhood obesity and support beneficial effects in some secondary HEALTHY study outcomes.
PMCID: PMC3261591  PMID: 22239133
School Food Services; Nutrition and Diet; Child and Adolescent Health
17.  Body Image Dissatisfaction Is Increased in Male and Overweight/Obese Adolescents in Botswana 
Journal of Obesity  2013;2013:763624.
Introduction. The purpose of this study was to examine linkages between obesity, physical activity, and body image dissatisfaction, with consideration of socioeconomic status (SES) and urbanization in adolescents in Botswana. Materials and Methods. A nationally representative, cross-sectional survey in 707 secondary school students included measured height and weight to determine overweight (OW) or obesity (OB) using World Health Organization standards; physical activity (PA) using the International Physical Activity Questionnaire; and body image satisfaction using the Body Ideals Questionnaire. SES was described by private school versus public school attendance. Results and Discussion. OW/OB students felt farther from ideal and greater dissatisfaction with their weight and body proportions than optimal weight students. Boys felt greater difference from ideal and more dissatisfaction with muscle tone, chest size, and strength than girls. Lower SES students and those from rural villages had more minutes of PA than higher SES or urban students. In this rapidly developing African country, these trends reflect the nutrition transition and offer opportunity to motivate OW/OB students and boys for PA as a health promotion obesity prevention behavior. Conclusions. As urbanization and improved SES are desirable and likely to continue, the public health system will be challenged to prevent obesity while preserving a healthy body image.
PMCID: PMC3619546  PMID: 23634296
18.  Eating Habits and Body-weights of Students of the University of Belgrade, Serbia: A Cross-sectional Study 
The purpose of this survey was to quantify the prevalence of overweight and obesity among a sample of students in Belgrade University, Serbia and to describe their main eating habits. A total of 1,624 questionnaire responses were analyzed (response rate 97.3%). The students were recruited during mandatory annual check-ups in April-June 2009. All subjects completed the questionnaire; height (in cm) and weight (in km) were measured by two physicians. Results were assessed statistically. Almost every fourth male student was overweight. Strikingly, 15% of female students were underweight. Highly-significant difference was found between average body mass index (BMI) of male and female students (F=317.8, p=0.001). Students’ BMI did not correlate with average family income or with the frequency of taking breakfast (p=-0.064, p=0.152 for males and ρ=0.034, p=0.282 for females respectively). There is a growing demand for global health strategies which would encourage healthy body-image and figure; thus, these initiatives should mobilize the society on a national and international level.
PMCID: PMC3805882  PMID: 24288946
Nutritional status; Prevalence; Students; Serbia
19.  A descriptive study of youth risk behavior in urban and rural secondary school students in El Salvador 
Adolescence is an important stage of life for establishing healthy behaviors, attitudes, and lifestyles that contribute to current and future health. Health risk behavior is one indicator of health of young people that may serve both as a measure of health over time as well as a target for health policies and programs. This study examined the prevalence and distribution of youth health risk behaviors from five risk behavior domains–aggression, victimization, depression and suicidal ideation, substance use, and sexual behaviors–among public secondary school students in central El Salvador.
We employed a multi-stage sampling design in which school districts, schools, and classrooms were randomly selected. Data were collected using a self-administered questionnaire based on the United States Center for Disease Control and Prevention's Youth Risk Behavior Survey. Sixteen schools and 982 students aged 12–20 years participated in the study.
Health risk behaviors with highest prevalence rates included: engagement in physical fight (32.1%); threatened/injured with a weapon (19.9%); feelings of sadness/hopelessness (32.2%); current cigarette use (13.6%); and no condom use at last sexual intercourse (69.1%). Urban and male students reported statistically significant higher prevalence of most youth risk behaviors; female students reported statistically significant higher prevalence of feelings of sadness/hopelessness (35.6%), suicidal ideation (17.9%) and, among the sexually experienced, forced sexual intercourse (20.6%).
A high percentage of Salvadoran adolescents in this sample engaged in health risk behaviors, warranting enhanced adolescent health promotion strategies. Future health promotion efforts should target: the young age of sexual intercourse as well as low condom use among students, the higher prevalence of risk behaviors among urban students, and the important gender differences in risk behaviors, including the higher prevalence of reported feelings of sadness, suicidal ideation and forced sexual intercourse among females and higher sexual intercourse and substance use among males. Relevance of findings within the Salvadoran and the cross-national context and implications for health promotion efforts are discussed.
PMCID: PMC1459212  PMID: 16608519
20.  An Approach to Improving Science Knowledge About Energy Balance and Nutrition Among Elementary- and Middle-School Students 
Cell Biology Education  2004;3(2):122-130.
Unhealthy diets, lack of fitness, and obesity are serious problems in the United States. The Centers for Disease Control, Surgeon General, and Department of Health and Human Services are calling for action to address these problems. Scientists and educators at Baylor College of Medicine and the National Space Biomedical Research Institute teamed to produce an instructional unit, “Food and Fitness,” and evaluated it with students in grades 3–7 in Houston, Texas. A field-test group (447 students) completed all unit activities under the guidance of their teachers. This group and a comparison group (343 students) completed pre and postassessments measuring knowledge of concepts covered in the unit. Outcomes indicate that the unit significantly increased students' knowledge and awareness of science concepts related to energy in living systems, metabolism, nutrients, and diet. Pre-assessment results suggest that most students understand concepts related to calories in food, exercise and energy use, and matching food intake to energy use. Students' prior knowledge was found to be much lower on topics related to healthy portion sizes, foods that supply the most energy, essential nutrients, what “diet” actually means, and the relationship between body size and basal metabolic rate.
PMCID: PMC437639  PMID: 15257340
energy balance; nutrition; elementary-school students; middle-school students; science knowledge
21.  Comfort and utility of school-based weight screening: the student perspective 
BMC Pediatrics  2008;8:9.
Weight screening in schools has been proposed as one strategy to address childhood obesity. Students' response to such screening is unexplored, however. In this study we evaluated the perceived comfort, utility and impact of school-based weight screening from the perspective of middle school-aged students.
A cross-sectional study of 852 ethnically diverse 5th–8th grade students. Associations were investigated between measured height and weight screening data and responses to a self-administered questionnaire completed immediately following weight screening in physical education class. BMI categories were based on the revised 2000 CDC growth chart and definitions: 5th–85th BMI percentile = healthy weight, 85th–95th BMI percentile = at risk for overweight, and >95th percentile BMI = overweight.
Overall, students' comfort level with weight screening varied depending on the student's own weight status. More overweight students (38.1%) reported being uncomfortable than healthy weight students (8.1%) (p < 0.001). In particular, overweight female students (54.8%) compared to healthy weight female students (21.6%) reported being uncomfortable (p < 0.01). About half (54.9%) of all students reported knowing their weight prior to screening, and 58.9% reported that it was useful to learn their height and weight. Compared to healthy weight students, overweight students were significantly more likely to report the intention to perform weight modification related activities such as visiting a doctor (Odds ratio (OR) = 2.0, 95% CI = 1.3, 3.1), eating more fruits and vegetables (OR = 2.7, 95% CI = 1.7, 4.1), and increasing physical activity (OR = 4.3, 95% CI = 2.7, 7.0).
Overall, the majority of the middle school students did not report discomfort with school-based weight screening, did report that receiving height and weight information was useful, and generally report appropriate weight control intentions. These proportions varied across weight status categories, however, with students who were at risk for overweight or overweight reporting higher levels of discomfort. For schools that conduct weight screening, it is essential that they also provide comfortable and private settings as well as education or counseling regarding healthy weight control practices.
PMCID: PMC2311298  PMID: 18312696
22.  Family joint activities in a cross-national perspective 
BMC Public Health  2007;7:94.
Parents and children joint activities are considered to be an important factor on healthy lifestyle development throughout adolescence. This study is a part of the Cross-National Survey on Health Behaviour in School-aged Children – World Health Organization Collaborative Study (HBSC). It aims to describe family time in joint activities and to clarify the role of social and structural family profile in a cross-national perspective.
The research was carried out according to the methodology of the HBSC study using the anonymous standardized questionnaire. In total, 17,761 students (8,649 boys and 9,112 girls) aged 13 and 15 years from 6 European countries (Czech Republic, Finland, Greenland, Lithuania, Spain, and Ukraine) were surveyed in the 2001–2002 school-year. The evaluation of joint family activity is based on 8 items: (1) watching TV or a video, (2) playing indoor games, (3) eating meals, (4) going for a walk, (5) going places, (6) visiting friends or relatives, (7) playing sports, (8) sitting and talking about things (chatting).
Students from Spain and Ukraine reported spending the most time together with their families in almost all kinds of joint activities, whereas students from Greenland and Finland reported spending the least of this time. Boys were more likely than girls to be spending time together with family. Joint family activity goes into decline in age from 13 to 15 years. Variability of family time in a cross-national perspective was relatively small and related to children age category. Considering national, gender and age differences of studied population groups, we found that the distribution of joint family activities tends to be dispersed significantly by family structure (intact/restructured family) and family wealth.
Our study compares children and parent joint activities in European countries and reveals differences and similarities in these patterns between countries. The findings underline the role of family structure (intact/restructured family) and family wealth in the distribution of time spent in joint family activities, which should be considered by health promoters.
PMCID: PMC1904207  PMID: 17537247
23.  Introducing geriatric health in medical training in Ajman, United Arab Emirates: A co-curricular approach 
The Australasian Medical Journal  2011;4(6):346-353.
Medical students’ knowledge and understanding of the elderly will affect the quality of care to the rising population of older adults which points to a need to identify geriatric health training methods appropriate for the region and curriculum. Therefore the study assessed the effect of a co- curricular introductory workshop on knowledge regarding geriatric health and attitude towards the elderly among fourth year medical students in a medical university
A quasi-experimental before-after study, with control was conducted at Gulf Medical College among 60 medical students from discipline-based curriculum in year IV during May-June 2010 of whom 16 had opted (attendees) to undergo the introductory course, a five day workshop of 10 hours duration. Pre- and post-testing used self-administered questionnaires for demographic variables: age, gender, nationality, close contact with older people; a quiz on old people’s health, and Kogan’s Old People Scale (KOPS) for attitude. The difference in scores on quiz and KOPS were compared for the attendees and 26 non-attendees who participated in both pre and post testing.
The attendees group had 38% male and 62% female participants and the non-attendees group had 21% and 79% respectively. The groups were not significantly different in age, sex, nationality and close contact with the elderly. The scores on the quiz and KOPS showed no statistically significant difference between the two groups before or after the workshop. Almost all the participants evaluated the workshop very positively especially the interaction with healthy elderly and inmates of old people’s home.
A 10-hour introductory co-curricular workshop made no significant change in the knowledge on geriatric health or attitude of fourth year medical students though they reported it as a very enriching experience. A reflective report may have been a better assessment tool and the impact on their clinical practice cannot be predicted.
PMCID: PMC3562954  PMID: 23386898
Fourth year medical students; geriatric health; introductory workshop; knowledge; attitude; before-after study.
24.  Attitudes of Medical Students, Clinicians and Sports Scientists Towards Exercise Counselling 
We compared the amount of exercise undertaken by medical students, clinicians, and sport scientists with the National Australian Physical Activity (NAPA) Guidelines. A second aim was to compare attitudes to exercise counselling as preventive medicine between university- and clinic-based professionals. The research setting was a university medical school and a sports science sports medicine centre. A 20-item questionnaire was completed by 216 individuals (131 medical students, 43 clinicians and 37 sports scientists). Self-reported physical activity habits, exercise counselling practices and attitudes towards preventive medicine were assessed. The physical activity undertaken by most respondents (70%) met NAPA Guidelines. General practitioners had significantly lower compliance rates with NAPA Guidelines than other professionals. More than half of clinicians and medical students (54%) were less active now compared with levels of activity undertaken prior to graduate training. Most physicians (68%) reported they sometimes discuss physical activity with patients. In contrast, the majority of non-medically qualified respondents (60%) said they never discuss physical activity with their doctor. Most respondents (70%) had positive attitudes to exercise counselling. Sports scientists and respondents who were highly active in childhood had more positive attitudes to exercise counselling than others. Health professionals in this study were more active than the general population, however healthy exercise habits tend to deteriorate after the commencement of medical training. Despite the important role of doctors in health promotion, the degree of exercise counselling to patients is low.
Key pointsThe rate of exercise counselling by doctors to patients is lowSports physicians and scientists have substantially more positive attitudes to exercise counselling than clinicians and medical studentsMedical schools have a responsibility to promote physical activity of students and improve training in exercise counselling
PMCID: PMC3737811  PMID: 24150613
Physical activity; exercise; counselling; university; medical school; attitudes.
25.  Urban-rural differences in subjective symptoms of fatigue and their relations with lifestyle factors in young male Japanese students 
The purposes of this study were to investigate the actual status in subjective symptoms of fatigue (SSF) and lifestyles of young male students living in two different life spheres of the Tokyo metropolitan area and a rural area, and to find, regional differences in these characteristics and relations between SSF and lifestyles in school life.
A questionnaire regarding SSF and lifestyle was administered to 412 healthy male students (16–18 yr) attending the two National Colleges of Technology located in the Tokyo metropolitan area (MA) and a local city (LC). Statistical techniques such as a chi-square test and Hayashi’s Quantification Theory I analysis were used to examine relations between SSF and lifestyles.
Results and conclusion
A significant difference was found only in “feeling of physical disintegration,”, and the MA group was higher than the LC group. The MA students showed shorter sleeping hours and earlier awaken time compared with LC students. In the relations between SSF and lifestyles, sleeping habit was an important factor significantly relating to SSF in both groups. Paying attention to good sleeping habits is an important countermeasure for preventing SSF in the male students.
PMCID: PMC2723320  PMID: 21432089
subjective symptoms of fatigue; lifestyle; regional characteristics; adolescence

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