Students ’ Utilization of Health Services : A Hospital-Based Study in Mansoura University , Egypt

This study aims to describe the patterns of morbidity, investigations and drug prescription among patients of Students’ Hospital, Mansoura University. This is a hospital-based descriptive study including both outpatients and inpatients students. The questionnaire for the outpatients’ students was completed by the treating doctor. Data of inpatients’ students was collected retrospectively from the records. Diseases of the skin and subcutaneous tissue and diseases of the eye and adnexa were the most frequent outpatients’ morbidity. The most frequent morbidities among inpatients are diseases of the skin and subcutaneous tissue, diseases of the musculoskeletal system and connective tissue, and diseases of the respiratory system. The average length of hospital stay was 2.8 days. The mean number of drug prescribed for outpatients and inpatients were 1.5 and 5.9; respectively. University students suffer a variety of morbidities. College health must move away from focusing on disease and move towards health promotive and preventive measures.


INTRODUCTION
The health and wellness of college students is impacted by their overall lifestyles and the environment around them (1).University students are mainly in the late adolescent and early adulthood (2), at the same time they are just beginning to made independent decisions about health (3).Previous research described a pyramid approach to understand college student' health issues, serious troubles including chronic diseases are at the top of this pyramid (4,5).Characteristics of students attending to higher education sometimes can show us the description of society, because they come from very different regions representing the all country (6).Health research has relatively neglected the young adult population, most likely attributable to the fact that young adults typically perceive themselves to be unsusceptible to infirmity and usually experience optimal levels of health (7).Institutions of higher education (i.e.universities, colleges) provide a venue for providing interventions to assist students in coping with their health problems/ issues (7).University students to some extent reflect their community with regard to health and health-related problems.This age group is vulnerable to multiple factors that induce morbidity and encourage certain disease conditions.Definition of the patterns and variations of these problems will help in the provision of comprehensive health care and subsequent health promotion of this important age group (8).
Youths, especially those enrolled in university education are nation's strength, hopes and future.Thus it is pertinent to study the health situation of university students in Egypt.There are some small-scales studies on mental and psychiatric morbidities among students of the Egyptian universities (9,10).However data regarding physical morbidity among university students are not available.Data on morbidity condition of university students, if made available will help to design the preventive and therapeutic measures.The objectives of this study are to identify patterns of morbidity, investigations and drug prescription among both outpatients and inpatients of Students' Hospital, Mansoura University.

Methods:
The outpatients' study was carried out through a period of one year (from January to December, 2010).During this period a total of 14409 out-patients visits were recorded, out of these 443 (3.1%) were admitted to inpatients departments.All attendants during a day in each week were included in the study.The days were changing every week to cover all the 6 working days throughout the year to cover any seasonal or diurnal variations in the pattern of morbidity.A total of 2050 outpatients' students were interviewed.The inpatients' study covered all admissions throughout the year of 2010.

Approach:
The questionnaire for the outpatients' students was completed by the treating doctor, after adequate orientation about the objective of the study and questionnaire contents.Data of inpatients students was collected retrospectively from the records.Data collected included sociodemographic features, diagnosis, investigation done and treatment provided.Hospital admission was included in questionnaire of outpatients' student and length of hospital stud was included in the data collection form of inpatients students.
The morbidity was analyzed using the International Classification of Diseases-10 (ICD-10) coding for identifying the morbidity patterns presenting at both outpatients and inpatients departments of the hospital.
The study protocol was approved by the research ethics committee of College of Medicine, Mansoura University.Also outpatients' students gave their verbal consent to participate in the study.Data was analyzed using SPSS Packages version 16.Categorical variables were presented as number and percent, while quantitative variables were presented as mean ± SD. *General surgery (22), Orthopedics ( 8), Urology (6) and Internal medicine (3) departments

RESULTS
Table 1 reveals that mean ages are 20.2 and 19.8 years for both outpatients and inpatients students; respectively.About 52% of outpatients and 36.6% of inpatients students are females.Most of outpatients' students are from rural areas (64.2%).Table 2 reveals that more than half of the outpatients' students attend the internal medicine/chest and dermatology clinics.On the other hand, the most frequent admissions were to Orthopedic, and Ear, Nose and Throat departments.About 77% and 91% of outpatients and inpatients visits were initial ones.Among the outpatients, 3% were admitted to the hospital.The average length of hospital stay was 2.8 days.Diseases of the skin and subcutaneous tissue and diseases of the eye and adnexa were the most frequent outpatients morbidity, 25.8 and 14.7%; respectively.The most infectious diseases are upper respiratory tract infections (data not shown in tables).
The most frequent morbidity among inpatients are diseases of the skin and subcutaneous tissue (14.4%), diseases of the musculoskeletal system and connective tissue (14.2%), and diseases of the respiratory system (12.2%)(Table 3).

DISCUSSION
Both the number and percentage of university students among the general population in Egypt have been gradu-ally increasing.In conjunction with this trend the health status of this population has come under more focus than ever (11).Some medical conditions occur more frequently in the college-age population (12).Studying pattern of disease distribution among university students would help to inform policy makers for screening serious and important diseases.In fact we did not find any similar work to compare with; however this study might pave the way for other population-based research on health status of university students.In this hospitalbased study both outpatients and inpatients students represent different colleges of the university.This heterogeneity or students mix could reflect the morbidity pattern among the general population of students.It is noteworthy that the higher percentages of sick students were from the non-practical colleges, especially col-

Table 4. Radiological and laboratory investigations done for outpatients and inpatients students
Categories are not mutually exclusive leges of law, commerce and arts.Also the percentage of both sexes is more or less equal in the outpatients students while the inpatients show excess males than females.Most of the outpatients students are from rural localities.This could be a reflection of health seeking behavior of students or differentials in both the rates and severity of morbidities.This necessitates population based study to explore these possibilities.
More than two-third of outpatients attended the departments of internal medicine/ chest, dermatology and ophthalmology.These are probably mostly a trivial or mild condition treated with drug prescriptions or correc-tion of refractive errors.The low hospital admission rate (3.0%), the low rate of outpatients surgery (0.7%) and a very high rate of drug prescription (80.6%) support this possibility.A previous study (13) reported that hospital admission rates of Mansoura University Hospitals ranged from 9.7% to 13.9% during the period of 1996 to1999.The majority of inpatients were admitted to for surgical reasons as 91.9% of them received surgical interventions e.g.orthopedics (23.5%), and ear, nose and throat surgery (22.8).The length of hospital stay is a function of both the severity and complexity of the patient's problems (14).The average length of hospital stay was 2.8 *% was calculated from the total number of drugs prescribed Table 5. Treatment provided to studied students days.A previous study13 reported that average length of hospital stay in Mansoura University Hospitals was 10.5 days during the period of 1996 to1999.In an Indian hospital the average days of youth hospitalization was 10.8 days (15).
The distribution of the clinically confirmed morbidities according to ICD-10 classification revealed that the comments outpatients morbidities are diseases of the skin and subcutaneous tissues (25.8%), disease of the eye and adnexia (14.7%), and certain infectious and parasitic diseases (11.8%).The most infectious diseases are upper respiratory tract infections.A study at King Faisal University medical center, Saudi Arabia, revealed that about 58% of outpatients morbidities were infectious in nature, mostly respiratory, dental, gastrointestinal and skin infections.The most frequent non-infectious morbidities were muscle and joint problems, allergic conditions, gastrointestinal diseases and trauma8.In another Saudi Arabian study revealed that upper respiratory tract infections constituted 43% of complaints among adolescents aged 11 to 21 years attending primary health care centers (16).The most frequent morbidities among university students in UK were diseases of the respiratory system (16%), sexual, pregnancy and child birth consultations (16%), diseases of skin and subcutaneous tissue (12%), diseases of the genitourinary system (10.5%),severe or moderately severe mental health disorders (7%), diseases of the nervous system and sense organs (7%), infective and parasitic diseases (6.5), accidents, poisoning and violence (6.5%), diseases of digestive system (6%), and diseases of the musculoskeletal system and connective tissues (4%) (17).Two studies among students of the University of Zimbabwe revealed that the most prevalent disease conditions were respiratory tract infections, mental and nervous disorders and urinary tract infections (18,19).Nichol, et al (20) concluded that upper respiratory tract illnesses were common and associated with substantial morbidity in university students.The authors reported about 91% college students at the University of Minnesota had upper respiratory infections.A survey of new University students in Turkey revealed that headache, allergy, anemia and gastritis were the most frequent diseases (21).
In Ahmadu Bello University Health Center, Nigeria the commonest consultations was due to venereal diseases together with sex problems (17%), followed by psychiatric, respiratory and specific infections and parasitic diseases (22).A recent study in Turkey revealed that skin diseases are frequent among university students especially acne vulgaris (40% and fungal diseases (17.1%) (23).
The diseases of the skin and subcutaneous tissues are frequently encountered among both inpatients and outpatients.A Turkish study (24) found that acne and allergic/pruritic dermatosis were the most frequent among university students.It is worthy to note that no sexual and reproductive system problems were reported among our study population.This is a reflection of the conservative and religious society that prohibits out of marriage sexual relationship.About two-thirds of outpatients and about 3% of inpatients did not have investigations.This reflects the nature and severity of the diseases in both groups of students.The most frequently requested investigation for outpatients are CBC, urine analysis and stool analysis.This is going with the finding that the infectious and parasitic diseases constitute a sizable segment of morbidities.ECG, CBC, liver functions, ESR, serum creatinin and blood glucose are the routine investigation carried out for most of the inpatients.It is noticeable that bacterial culture and sensitivity was done for 71.8% of inpatients.This raises the possibility of post-surgical infections.
The outpatients' drug prescription appears to be rational with the mean number of drug per prescription was 1.5.Antibiotics/antiparasitics are by far the most frequent prescribed drugs.Analgesics/antipyretics/NSAID/ muscle relaxants/antiinflammatory, and vitamines/minerals/tonics/lipotropics comes next to antibiotics/antiparasitics.Again this reflects the morbidity patterns.Bvochora et al. (18) in Zimbabwe reported an average of 1.7 drugs per case of diseases university students with analgesics and anti-infectives were the most frequently prescribed drugs (28.5% and 28.2%; respectively).A recent study in Mozambique revealed that antiinflammatory and analgesics, systemic antiinfective and vitamins/minerals were the most frequently used drugs among university students (25).On the other hand, the inpatients drug prescription is irrational with the mean of 5.9 drugs per prescription.It seems that prophylactics antibiotics were routinely prescribed before and after surgery.Also intravenous fluids and analgesics/ antipyretics/NSAID/muscle relaxants/antiinflammatory are widely used for patients underwent surgery.

Study limitations:
The study is of a local nature being carried out in one university.Being a hospital-based, it does not reflect the actual morbidity pattern among all university students.The findings are affected by health care utilization pattern of students.This hospital-based study support the necessity to a wide scale population study among the university students nationwide to give a full picture of health status both physical and mental of this important sector of youth population.Such findings could help in the formulation of a feasibility preventive and curative health care program.It is a common need to involve health-promoting education programs in the curriculum of all faculties and to improve the university health services.College health must move away from focusing on disease and move towards health promotive and preventive measures to decrease the load on the hospital.The use of electronic health record is recommended to monitor trends and variation in disease pattern in university students.It is necessary that physicians working in students' hospital understand students' health problems with importance of regular health screening of university students.
Further studies are needed to explore the problems of high rate of investigations as well as polypharmcy and antibiotics prescription in inpatients.Hospital staff may needs training in the rational prescription.

:
Mansoura Students' Hospital is a secondary care 14 beds hospital providing both preventive and curative free health services to students affiliated to Mansoura University, Egypt.Mansoura University was founded in 1972 in Mansoura city, Egypt.It is one of the

Table 1 .
Socio -demographic features of studied students biggest public Egyptian universities and has contributed much to the cultural and scientific life in Mansoura and Egypt.The University provides a number of students' services within the campus which include: Students' services complex containing restaurants, stationeries and a student hospital, three students' accommodation complexes, and Olympic village.The main Campus is located in Mansoura city.It comprises 13 faculties: medicine, education, science, pharmacy, dentistry, commerce, law, engineering, agriculture, nursing, veterinary medicine, physical

Table 2 .
Distribution of studied students according to clinic/department they attended, nature of visit, referral and admission rates, and length of stay.

Table 3 .
Pattern of disease among studied students