The impact of concealable chronic health conditions on college students’ academic outcomes: A two-wave study

Abstract

College students (N = 125) with concealable chronic health conditions (CCHCs) completed online surveys at the beginning and end of the semester assessing stigma experiences and academic outcomes. Correlations showed stigma, alienation, and lack of campus fit were associated with greater illness-related academic interference (ps < 0.001), negative academic self-comparison (ps < 0.001), academic anxiety (ps < 0.001), academic dissatisfaction (ps < 0.001), and lower expected grades (except alienation; ps < 0.001–0.03) over time. Hierarchical multiple regressions identified a lack of campus fit as an important predictor across academic outcomes (ps < 0.001–0.019). Students with CCHCs face health- and stigma-related challenges that can interfere with academic performance.

Keywords

chronic illness health psychology stigma students well-being

Nearly half of American adults have at least one physical or psychological chronic health condition, and one in four adults has multiple health conditions (Ward et al., 2014). The U.S. spends approximately $60 billion providing financial support and medical care to those living with chronic health conditions, and treating these conditions accounts for 78% of the total U.S. health care spending (Bodenheimer et al., 2009). Many health conditions are concealable, meaning their symptoms are not visibly detected and can be hidden from others (e.g. mental illnesses, diabetes, ADHD, autoimmune diseases), referred to as concealable chronic health conditions (CCHCs). This concealability, or invisibility, can create a unique set of challenges, such as individuals actively hiding their illnesses from others, feeling isolated, and going unnoticed or untreated (Link and Phelan, 2006; Quinn et al., 2017).

CCHCs and academic outcomes

Among college students, psychological and physical CCHCs are one of the top factors affecting academic performance (American College Health Association, 2019). Students diagnosed with depression or anxiety are more likely to receive lower grades and drop out of college compared to their healthy counterparts (Eisenberg et al., 2009). More than 4.29 million people have not graduated because of physical or mental health related issues, creating additional barriers to future employment and financial loss (Kessler et al., 1995). The 2019 National College Health Assessment found that more than 19% of students had been diagnosed with depression, 24% had been diagnosed with anxiety, and 8% reported having Attention Deficit and Hyperactivity Disorder. In addition, 7% of students reported having chronic pain, 4% had irritable bowel syndrome, and 3% had been diagnosed with a thyroid condition.

Students living with CCHCs often experience significant limitations in their daily activities that interfere with their ability to work or attend school (Anderson and Horvath, 2004; Livneh and Antonak, 2005; Ravert et al., 2017). CCHCs can have physical and emotional consequences, such as greater pain, fatigue, stress, or feeling like one does not fit in, which might impact students’ academic performance. Compared to students without CCHCs, those with a chronic illness experienced greater intrusive thoughts and uncertainty that increased their risks for anxiety and depressive symptoms (Mullins et al., 2017). These heightened symptoms and associated limitations might help explain why students with CCHCs experience poor academic outcomes.

These issues illustrate the seriousness of CCHCs for college students, yet research is needed to understand the diverse nature of students’ CCHCs, as well as how CCHCs impact academic well-being. For example, research on students with chronic illnesses and disabilities has shown that students were mixed in how helpful or supportive they rated faculty and peers (Hughes et al., 2016), and that their conditions interfered with their ability to complete assignments and participate in and attend class (Osborne, 2019). Moreover, students typically had more than one condition and at least one psychological condition (Hughes et al., 2016; Osborne, 2019). Examining how students’ CCHCs impact academic success and performance, and understanding differences in characteristics of students’ CCHCs, may identify specific aspects that make college more challenging for these students. Therefore, the first objective of this study was to identify the connections between features of students’ CCHCs (i.e. type, length, number, and severity) and their academic outcomes over the course of the semester.

CCHCs and stigma

In addition, individuals with CCHCs experience various forms of stigma that might help explain the academic toll of CCHCs. According to the concealable stigmatized identity outcomes model, stigma refers to the degree to which individuals anticipate, internalize, and experience stereotyping, prejudice, and discrimination because of their stigmatized attribute (i.e. CCHC; Earnshaw and Quinn, 2012; Quinn and Earnshaw, 2011). For example, individuals may distance themselves from others and avoid seeking help for or disclosing their CCHC because they anticipate future stigma and internalize negative stereotypes (Quinn and Earnshaw, 2011; Quinn et al., 2014). Feeling stigmatized, alienated, or like one does not fit in because of a CCHC has been associated with increased psychological and physical symptoms, such as depression and physical health problems (Mak et al., 2007; Shrout and Weigel, 2021), reluctance to engage in treatment (Crowley and Kirschner, 2015; Quinn et al., 2017), and a decreased quality of life (Earnshaw et al., 2012). Indeed, individuals with CCHCs who anticipated and experienced stigma from healthcare workers avoided and underutilized healthcare services (Earnshaw and Quinn, 2012). Additionally, individuals who actively concealed their CCHCs through distancing themselves from others, lying about CCHC appointments, and avoiding conversations had poorer psychological and physical quality of life than their more disclosing peers (Quinn et al., 2017).

Therefore, in addition to the psychological and physical health consequences associated with their CCHCs, college students may experience negative outcomes because of illness-related stigma. Initial evidence suggests that chronic illnesses can interfere with student success, and students experience stigma, alienation, and a lack of fit because of their health conditions (Hughes et al., 2016; Osborne, 2019; Vaccaro et al., 2015). Assessing how stigma, alienation, and a lack of fit impact academic success may help explain why students with CCHCs are more likely to experience poor academic outcomes. Accordingly, a second objective of this study was to test how perceived stigma, alienation, and lack of campus fit is associated with the various academic success and performance indicators over the course of a semester.

The present study

This two-wave study assessed how characteristics of students’ CCHCs, as well as their perceptions of stigma, alienation, and campus fit, impacted their academic outcomes over the course of the semester. We examined the degree to which the CCHC affected students’ academic performance, views of themselves as students, expected grades, academic-related anxiety, and overall satisfaction with their academic performance. Given how CCHCs can impact daily activities, we expected that the more serious the CCHC characteristics (longer diagnosis, greater number of CCHCs, and worse symptom severity), the poorer the students’ academic outcomes at the end of the semester. In addition, we hypothesized that greater stigma, alienation, and lack of campus fit would be associated with poorer academic outcomes at the end of the semester.

Given the large percentage of college students experiencing CCHCs (American College Health Association, 2019), this research is important for several reasons. First, the nature of students’ health conditions may worsen the normal stressors associated with college life, and this study examines how having a CCHC affects students’ academic outcomes. Second, stigma experiences pose additional psychological, social, and physical consequences (Quinn and Earnshaw, 2011; Shrout and Weigel, 2021), and this research assesses the degree to which students experience stigma, alienation, and lack of campus fit due to their CCHC. Third, this study sheds light on whether the nature of the CCHC, as well as the associated stigma, alienation, and lack of campus fit, are related to students’ academic outcomes over time. Finally, assessing the prevalence, types, and characteristics of students’ CCHCs helps inform campus health providers of their students’ needs.

Method

Participants

Students with CCHCs (N = 125) participated in a two-wave study that consisted of two online surveys at the beginning (Time 1) and at the end (Time 2) of the academic semester, approximately 4 months apart. The study took place at a mid-sized university in the Western U.S. The sample consisted of 79 women and 46 men. Students ranged from 18 to 59 years old (M = 24.24 years, SD = 8.04). The majority of respondents were undergraduate students (74.4%), and junior (third year undergraduate) was the most frequently selected grade level (19.2%). Most students were White (75.2%), followed by Latinx/Hispanic (11.2%), Asian American or Pacific Islander (4.8%), multi-ethnic or multi-racial (6.4%), Native American/Alaskan Native (1.6%), and Black/African American (0.8%).

Study design

A random sample of undergraduate and graduate students who agreed to release their email addresses with the university were asked to first complete an online screening questionnaire sent via email. The screening questionnaire included a list of CCHCs from which students could select any diagnosed CCHCs (e.g. autoimmune disease, endocrine, psychiatric), including the option to specify a condition not listed. A total of 361 students had at least one diagnosed CCHC and were thus emailed an invitation to participate in the two-wave study, along with the first survey. A total of 133 students completed the first survey, and approximately 4 months later, 125 of the 133 individuals completed the second survey (94% retention rate). This study includes those students that completed both surveys. Students received a $5 e-gift card for completing the first survey and a $15 e-gift card for completing the second survey. All procedures were approved by the university Institutional Review Board.

Measures

CCHC characteristics

We assessed the type, length, number, and severity of students’ CCHCs at the beginning of the semester (Time 1). Students selected the type of CCHC they had and were allowed to check all that apply and write in additional CCHCs. In addition, students reported how long they had been diagnosed with their CCHC (1 = less than a year, 2 = 1–2 years, 3 = 3–5 years, 4 = 5–10 years, and 5 = more than 10 years). We also coded for their total number of diagnosed CCHCs (ranging from 1 to 6), and whether the CCHCs involved a psychiatric diagnosis (0 = no, 1 = yes). Students indicated their CCHC symptom severity over the past 2 weeks (1 = not at all to 5 = extreme). We also assessed healthcare utilization at Time 1, including whether they were currently seeing a doctor or counselor on campus (0 = yes, 1 = no) and off-campus (0 = yes, 1 = no), as well reasons for not seeing a doctor or counselor on or off campus; whether they participated in on or off campus support groups related to their CCHCs (0 = yes, 1 = no); how often they tell others about the CCHC (1 = never, 7 = always); and whether they were taking medications for their CCHCs (0 = yes, 1 = no) and if those medications were helpful (1 = not helpful at all, 7 = very helpful).

Stigma-related measures

Three measures assessed various aspects of stigma, including stigma experiences, alienation, and fit on campus, at the beginning of the semester (Time 1). First, the 10-item Stigma Experiences Scale (Stuart et al., 2005) was used to determine the degree to which students experienced stigma because of their health condition. We adapted the items to specify health conditions rather than mental illnesses (e.g. “People discriminate against me because I have a health condition”). Response options ranged from 1 (strongly disagree) to 6 (strongly agree). Items were averaged with higher scores indicating greater CCHC-related experienced stigma (α = 0.87). Next, students completed the 6-item Alienation subscale from the Internalized Stigma of Mental Illness inventory (Ritsher et al., 2003) using a scale from 1 (strongly disagree) to 6 (strongly agree). The scale also was adapted to fit health conditions rather than mental illnesses (e.g. “I feel out of place in the world because I have a health condition”). A higher score indicated more perceived alienation due to the CCHC (α = 0.86). Finally, students were asked how often they felt like they did not fit in on campus, ranging from 1 (never) to 5 (always).

Academic outcomes

Five items measured various aspects of students’ academic outcomes at the end of the semester (Time 2). We created these items assessing different aspects of academic life to capture a more comprehensive understanding of academic success and performance beyond grades. Students were asked how much the CCHC has interfered with their academic performance during the current semester (1 = never to 5 = often). Students also indicated their expected grades for the semester (1 = mostly A’s to 5 = mostly F’s). To measure participants’ views of themselves as students (i.e. negative academic self-comparison), they were asked to rate themselves in comparison to other students (“Overall, I think I am. . .” 1 = way above the average student to 5 = way below the average student). Students also reported on how often they felt anxious about college in general (1 = never to 5 = always). Finally, students were asked to indicate how satisfied they were with their academic performance so far this semester on a scale from 1 (very satisfied) to 5 (very dissatisfied). Higher scores on the five academic outcome measures indicate that students experienced more academic interference because of their CCHC, expected lower grades at the end of the semester, saw themselves as below average compared to other students, experienced greater academic anxiety, and were more dissatisfied with their academic performance.

Statistical analyses

Analyses began by looking at the descriptive characteristics of students’ reported CCHCs and healthcare utilization. T-test comparisons were then used to examine potential differences in the stigma-related variables and academic outcomes by whether the CCHC included psychiatric diagnoses and by gender. Next, Pearson correlation analyses explored the relationships among the CCHC characteristics, stigma-related variables, and academic outcomes. Finally, to determine how strongly the CCHC-related characteristics and stigma-related variables predicted academic outcomes, two-step hierarchical multiple regression models were computed for each academic outcome. In the first step, we included gender and the four characteristics of the CCHC at Time 1: length of CCHC diagnosis, total number of CCHCs per individual, severity of CCHC symptoms, and whether the CCHC included a psychiatric diagnosis (no/yes). Stigma experiences, alienation, and lack of campus fit were entered in the second step to determine whether the stigma-related variables were associated with the academic outcomes above the characteristics of the CCHCs. We also identified individual variables that accounted for significant variance in each of the multiple regression models. An a priori power analysis suggested that 103 participants were necessary to provide power of b = 0.80 at the alpha = 0.05 level of significance (effect size = 0.15, predictors = 7; Faul et al., 2007).

Results

Descriptive nature of the CCHC

Our first set of analyses was designed to create a descriptive picture of students’ CCHCs. Participants reported one or more of the following types of CCHCs: psychiatric (59.7%), neurologic (26.4%), rheumatologic (24.8%), other (e.g. chronic sexually transmitted infections; 13.6%), endocrine (11.2%), pulmonary (8%), digestive (4%), hematologic (1.6%), and cardiovascular (1.6%). A total of 86 students (68.8%) reported at least one psychological (i.e. psychiatric or neurologic) CCHC, with 20.0% reporting having both psychological and physical CCHCs. A total of 39 students (31.2%) reported physical CCHCs only. Compared to those reporting only physical CCHCs, those with at least one psychological CCHC reported more: severe CCHC symptoms [M_{psychological} = 4.41, SD = 0.79; M_Physical = 4.00, SD = −1.02; t(123) = 2.83, p < 0.01]; stigma experiences [M_{psychological} = 2.77, SD = 0.75; M_Physical = 2.18, SD = 0.76; t(117) = −3.97, p < 0.001]; alienation [M_{psychological} = 3.65, SD = 1.14; M_Physical = 2.84, SD = 1.38; t(116) = −3.40, p < 0.05]; lack of felt campus fit [M_{psychological} = 3.16, SD = 1.18; M_Physical = 2.45, SD = 1.35; t(119) = −2.93, p = 0.001]; CCHC interference with academic performance [M_{psychological} = 2.40, SD = 1.19; M_Physical = 1.41, SD = 1.24; t(115) = 4.16, p < 0.001]; and academic anxiety [M_{psychological} = 3.69, SD = 1.20; M_Physical = 2.81, SD = 1.18; t(116) = −3.72, p = 0.001]. Men reported having been diagnosed for a longer period of time then women [M_Men = 3.52, SD = 1.18; M_Women = 3.04, SD = 1.26; t(123) = −2.15, p < 0.05], while women expected better grades at the end of the semester than men [M_Women = 4.41, SD = 0.79; M_Men = 4.00, SD = 1.02; t(116) = 2.45, p < 0.05].

In addition, the median length of students’ CCHC diagnoses was 3–5 years, and most participants reported one CCHC (44%), followed by two CCHCs (33.6%) and three or more CCHCs (21.6%). Students also reported moderate CCHC symptom severity (see Table 1 for means and standard deviations). Almost two-thirds (65.0%) of students reported never or rarely talking about their CCHC with others. When asked if they were currently seeing a doctor for their symptoms, 69.6% said yes, with 18% seeing a doctor or counselor on-campus and 58% seeing one off-campus (some students were seeing doctors both on-and off-campus). The most often cited reasons for not seeing a doctor or counselor were a belief that the symptoms were under control (23.2%), time constraints (19.2%), financial reasons (15.2%), and a belief that it would not help (12.8%). Regarding taking medications for their CCHCs, 55.5% said yes, and most of those felt the medications were helping (M = 5.42, SD = 1.50). Few students (7.6%) reported participating in on- or off-campus support groups related to their condition. No significant differences or associations were found for how long the student had been diagnosed, having talked with others about the CCHC, or receiving treatment for the condition in relation to stigma experiences or academic outcomes and thus were not included in subsequent analyses.

Table 1.

Pearson correlations among CHC characteristics, stigma, and academic outcomes.

	1	2	3	4	5	6	7	8	9	10
1. Number of CCHCs
2. Severity of CCHC	0.25**
3. Stigma experiences	0.43***	0.35***
4. Alienation	0.32***	0.37***	0.63***
5. Lack of campus fit	0.22*	0.36***	0.56***	0.56***
6. CCHC-related academic interference	0.28**	0.43***	0.44***	0.37***	0.46***
7. Lower expected grades	0.19*	0.25**	0.20*	0.13	0.31***	0.49***
8. Negative academic self-comparison	0.21*	0.27**	0.31***	0.33***	0.35***	0.39***	0.57***
9. Academic anxiety	0.18*	0.22*	0.34***	0.36***	0.52***	0.62***	0.33***	0.32***
10. Academic dissatisfaction	0.26**	0.32***	0.39***	0.36***	0.49***	0.61***	0.64***	0.49***	0.49***
Mean	1.84	2.70	2.59	3.40	2.93	3.09	1.74	2.36	3.42	2.73
SD	0.96	0.80	0.79	1.27	1.28	1.28	0.90	0.97	1.26	1.35
Range	1–6	1–5	1–6	1–6	1–5	1–5	1–5	1–5	1–5	1–5

CCHC: concealable chronic health condition.

p < .05. **p < 0.01. ***p < 0.001.

Bivariate findings

Table 1 presents the Pearson correlation findings. In terms of CCHC characteristics, a higher number of CCHCs and more severe CCHC symptoms were related to greater stigma experiences (ps < 0.001), alienation (ps < 0.001), and lack of campus fit (ps < 0.001–0.02); a higher number of CCHCs and symptom severity were also associated with greater CCHC-related academic interference (ps < 0.001–0.002), lower expected grades (ps 0.006–0.04), worse academic social-comparisons (ps 0.003–0.02), greater academic anxiety (ps 0.02–0.048), and greater academic dissatisfaction (ps < 0.001–0.005). In addition, greater stigma experiences were associated with worse academic outcomes. Specifically, higher experienced stigma, alienation, and lack of campus fit were associated with greater CCHC-related academic interference (ps < 0.001), lower expected grades for the semester (except for alienation; ps < 0.001–0.03), seeing oneself as a lower quality student compared to peers (ps < 0.001), greater academic anxiety (ps < 0.001), and greater dissatisfaction with academic performance for the semester (ps < 0.001). Overall, the correlations reflect expected connections among more detrimental CCHC characteristics, greater stigma-related experiences, and reduced academic outcomes over the semester.

Hierarchical regression analyses

Table 2 presents the results of the multiple regression analyses for each academic outcome. Overall, in each model, the block of CCHC characteristics (Step 1) and the block of stigma-related variables (Step 2) explained significant variance in the academic outcomes. In other words, as a whole, CCHC characteristics and stigma both played significant and unique roles in regards to students’ reported academic outcomes over the semester. Moreover, although characteristics of the CCHC accounted for significant variance in academic outcomes in Step 1, the three stigma-related variables added significant explanatory power in Step 2 above the variance accounted for by CCHC characteristics in Step 1 for all five academic outcomes.

Table 2.

Results from hierarchical regression analyses related to academic experiences of college students with CCHCs.

Academic outcome	Predictors	Step 1	Step 2
CCHC-related academic interference	Gender	−0.03	0.03
	Number of CCHCs	0.08	0.03
	Severity of CCHC symptoms	0.36***	0.26**
	Psychological CCHC	0.25**	0.19⁺
	Stigma experiences		0.18
	Alienation		0.02
	Lack of campus fit		0.23*
	R² change		0.09**
	Total adjusted R²	0.24***	0.31***
Lower expected grades	Gender	0.24**	0.29**
	Number of CCHCs	0.13	0.12
	Severity of CCHC symptoms	0.25*	0.17⁺
	Psychological CCHC	−0.04	−0.10
	Stigma experiences		0.05
	Alienation		0.11
	Lack of campus fit		0.35**
	R² change		0.09*
	Total adjusted R²	0.11**	0.17***
Negative academic self-comparison	Gender	0.01	0.07
	Number of CCHCs	0.19⁺	0.14
	Severity of CCHC symptoms	0.25**	0.14
	Psychological CCHC	−0.05	−0.13
	Stigma experiences		0.02
	Alienation		0.17
	Lack of campus fit		0.23*
	R² change		0.10**
	Total adjusted R²	0.08*	0.16***
Academic anxiety	Gender	−0.17⁺	−0.10
	Number of CCHCs	0.07	0.05
	Severity of CCHC symptoms	0.14	0.01
	Psychological CCHC	0.29**	0.20*
	Stigma experiences		0.06
	Alienation		0.07
	Lack of campus fit		0.44***
	R² change		0.16***
	Total adjusted R²	0.15***	0.29***
Academic dissatisfaction	Gender	0.12	0.19*
	Number of CCHCs	0.16	0.10
	Severity of CCHC symptoms	0.30**	0.17⁺
	Psychological CCHC	0.02	0.08
	Stigma experiences		0.12
	Alienation		0.07
	Lack of campus fit		0.33**
	R² change		0.15***
	Total adjusted R²	0.13**	0.26***

Coefficients are standardized. Gender: 0 = women, 1 = men.

CCHC: concealable chronic health condition.

p < 0.10. *p < 0.05. **p < 0.01. ***p < 0.001.

We first examined predictors of CCHC-related academic interference over the current semester. Students with a psychological CCHC (Step 1 p = 0.007; Step 2 p = 0.056), more severe CCHC symptoms (Step 1 p < 0.001; Step 2 p = 0.005), and greater perceived lack of campus fit (p = 0.03) at Time 1 had greater perceived academic interference at Time 2 compared to those with a physical CCHC, lower symptom severity, and greater campus fit. Overall, the CCHC and stigma-related variables accounted for 31% of the variance in reported interference with academic performance during the semester.

At the end of the semester, students also were asked what types of grades they expected to receive that semester. Results revealed that men (Step 1 p = 0.009; Step 2 p = 0.001), those with more severe CCHC symptoms (Step 1 p = 0.009; Step 2 p = 0.088), and those who felt poor fit on campus (p = 0.003) at Time 1 expected to receive lower grades at Time 2 than women, those with less severe symptoms, and greater campus it. In total, the CCHC and stigma-related variables accounted for 18% of the variance in expected grades at the end of the semester.

In terms of how students felt they compared to the average student (negative academic social-comparison), the only significant predictors were symptom severity in Step 1 (Step 1 p = 0.01; Step 2 p = 0.144) and lack of perceived campus fit in Step 2 (p = 0.049). Thus, the more severe CCHC-related symptoms and the more students felt unfit on campus, the less likely they were to see themselves positively compared to the average student. CCHC characteristics and stigma experiences explained 15% of the variance.

Regarding academic anxiety, the results showed that those with psychological CCHCs (Step 1 p = 0.004; Step 2 p = 0.039) had greater academic anxiety at the end of the semester compared to those with physical CCHCs. Further, greater perceived lack of campus fit at the beginning of the semester (p < 0.001) also was related to greater academic anxiety at the end of the semester. Overall, the variables accounted for 35% of the variance in reported academic anxiety.

Finally, men (Step 1 p = 0.197; Step 2 p = 0.03), those with more severe symptoms (Step 1 p = 0.002; Step 2 p = 0.069), and those who felt a lack of fit on campus (p = 0.003) at Time 1 had greater academic performance dissatisfaction at Time 2 than did women, those with less severe symptoms, and those who felt greater fit on campus. Overall, the variables in the multiple regression accounted for 25% of the variance in reported academic performance dissatisfaction over the semester.

Discussion

This two-wave study helps paint a picture of college students’ CCHCs and their impacts on academic outcomes during a semester. The results showed that the nature of students’ CCHCs varied, including the type, number, and severity of their CCHCs, each of which was associated with their academic outcomes 4 months later. In addition, CCHC-related stigma experiences, alienation, and lack of campus fit were correlated with more negative academic outcomes over the course of a semester. These findings suggest that students with CCHCs face additional health- and stigma-related challenges on top of managing their CCHC that can interfere with their academic performance and success.

Overall, students reported being diagnosed with a variety of health conditions, although psychological, neurologic, rheumatologic conditions, were the most frequent, consistent with the National College Health Assessment (American College Health Association, 2019). The higher frequency of psychological CCHCs is not surprising given their prevalence in the general population (Substance Abuse and Mental Health Services Administration, 2020). Over half of the students reported having a psychological CCHC, and one in five reported having both psychological and physical CCHCs. It also was interesting that even though 44% of students reported one CCHC, a majority reported having two or more CCHCs with moderate symptom severity. Students also had been diagnosed with their CCHC for 3–5 years on average, suggesting that many students have been dealing with their CCHCs for several years. Overall, the descriptive results show that the nature of CCHCs in college students is varied and complex, suggesting a need for support services to be multi-faceted and creative to address both the psychological and physical nature of their health conditions.

Beyond this descriptive picture of students’ CCHCs, the findings demonstrate that characteristics of those CCHCs are associated with diminished academic outcomes over time. The correlations showed that students with a higher number of CCHCs and more severe symptoms experienced greater CCHC-related academic performance interference, worse academic anxiety, lower anticipated grades, diminished academic social comparisons, and lower overall academic experiences satisfaction. Likewise, those with at least one psychological CCHC reported greater academic interference and anxiety than those with only a physical CCHC. The multiple regression results showed students with more severe symptoms and a psychological CCHC had consistently worse negative academic outcomes than those with less severe symptoms and a physical CCHC. Previous research has shown that individuals living with concealable psychological and physical CCHCs experience a range of psychological and social consequences, which can increase the risks of negative health behaviors (Ravert et al., 2015), social isolation, substance abuse (Crowley and Kirschner, 2015), psychological distress (Quinn and Chaudoir, 2009), feelings of shame, guilt, and embarrassment, and decreased self-worth (Person et al., 2009). The current study suggests academic risks can be added to the list of negative outcomes. Worsened CCHC characteristics may make managing academic tasks more challenging, especially for those with more severe symptoms and psychological diagnoses. Indeed, chronic illnesses and disabilities can also interfere with students’ ability to complete academic tasks, such as submitting assignments on time and participating in and attending class (Osborne, 2019; Vaccaro et al., 2015). Students with CCHCs may also have difficulty connecting with their peers and feeling supported by faculty and staff (Hughes et al., 2016; Vaccaro et al., 2015). Overall, the findings demonstrated that, as predicted, the nature of the CCHC can impact students’ academic outcomes.

Another important finding is that students also reported experiencing CCHC-related stigma. Many CCHCs are highly stigmatized and are associated with physical health limitations, substance abuse, and social isolation (Crowley and Kirschner, 2015). These CCHC-related stigma experiences contribute to poor psychological, behavioral, and physical health, such as increased depression symptoms, poor CCHC management, and greater physical health problems (Chesney and Smith, 1999; Shrout and Weigel, 2021; Vanable et al., 2006). In addition to health consequences, the findings demonstrated that CCHC-related stigma can also impact students’ academic outcomes over a semester. Greater reported stigma experiences, alienation, and lack of campus fit were correlated with greater academic interference and anxiety, lower expected grades, poorer academic social comparisons, and lower academic satisfaction. Lack of campus fit was especially predictive of the academic outcomes in the multiple regression models. Thus, it is not just the CCHCs, but the feeling like one does not belong because of a CCHC can impact academic outcomes over the semester. Sense of belonging is key for college students’ academic success and well-being, particularly for marginalized and minoritized students (Gopalan and Brady, 2020). Our findings support Vaccaro et al. (2015) theoretical model of belonging which posits that sense of belonging, social relationships, and academic mastery are interconnected among college students with invisible disabilities. Accordingly, this study’s results suggest that feeling like one does not belong because of their CCHC might hinder their ability to fit in on campus, connect with others, and succeed academically. These findings also contribute to the concealable stigmatized identity outcomes model by identifying lack of fit as an important aspect that can impact one’s daily life, including their academic success (Quinn and Earnshaw, 2011).

Implications

We believe that by gaining a better understanding of the needs of students with CCHCs, campus practitioners and service providers can increase outreach and minimize the barriers to accessing campus health and academic resources. It is interesting that most students were currently seeing a doctor or counselor for their symptoms, but only 18% were seeing a practitioner on-campus, suggesting that students are not turning to campus health services for help with their CCHCs. Students may prefer receiving care off-campus, but it is also possible that students are unaware of the campus services, that there is limited availability on-campus, or that the services are cost prohibitive. Therefore, campus student and health centers may need to be more creative in marketing services so students with existing CCHCs, as well as students diagnosed during the semester, can receive the necessary care.

An important finding is that many students expressed a sense that they did not fit in on campus. Accordingly, students may avoid campus counseling or health centers for their conditions because they feel like they do not belong. Most students with CCHCs experience some degree of stigma because of the health condition, and they may be especially reluctant to initiate contact with health and academic resources on campus. A majority of students said they never or rarely talked about their CCHC with others. Therefore, campus student and health services may need to be more visible and actively engaging so that students feel comfortable reaching out to campus resources. Student and health services may want to take steps to reduce the social stigma, such as communicating that CCHCs are common, should be talked about, and that students with CCHCs are welcome on campus and at student health clinics.

Also, students revealed a wide variety of psychological and physical health conditions that could impact their academic success. Campus health and academic services can work together to ensure that appropriate resources are available on campus for students with these various health conditions. For instance, students may not be aware that disability resource centers offer academic help and services for those with psychological or physical CCHCs. University, college, and department initiatives could highlight these services to ensure all students are aware of these necessary resources. We believe that interventions targeting students with CCHCs may lead to more positive outcomes for college students with chronic illnesses. Given that physical and psychological CCHCs impact academic performance, campus health care providers and academic services departments can work together to create an integrated, united effort to assist students with CCHCs.

Strengths and limitations

This study’s strengths include assessment of students’ experiences across the semester. This two-wave design allowed us to understand how students’ CCHCs and stigma experiences early in the semester were related to academic outcomes at the end of the semester. This two-wave study also had very low attrition, with nearly all students (94%) completing both surveys. In addition, this research provided novel insight into CCHC characteristics, healthcare utilization, stigma experiences, and academic success across students with a variety of CCHCs. Including multiple types of CCHCs also allowed us to test similarities and differences between psychological and physical CCHCs. Lastly, by including multiple stigma and academic measures, this study showed a CCHC’s impact across several important dimensions of stigma and academic success.

This study had limitations that should be noted. First, although the study had two surveys 4 months apart, students may have experienced academic issues during that 4-month time period. Future research needs to sample students with CCHCs on a regular basis during a semester to examine continuous impacts of CCHCs on academic performance. Second, the study included only students that had CCHCs. We do not know how the findings apply to students with less concealable, more visible, health conditions and disabilities. Third, although an a priori power analysis suggested this study was adequately powered, we included a relatively small number of students with CCHCs due to funding restrictions for participant stipends, which limits its generalizability. Finally, students participating in the study had moderate symptom severity. The adverse effects of CCHCs on academic outcomes may be even stronger among those with more severe symptoms. However, given the wide number of non-health-related factors that can impact students’ academic performance, it is meaningful that CCHCs and their related stigma have significant negative connections to academic outcomes over time.

Conclusions

This two-wave study explored the characteristics of psychological and physical CCHCs among college students and the impact of those CCHCs on their academic outcomes. It is clear that students with CCHCs can experience both health and academic challenges as they navigate college and university while simultaneously managing their CCHCs. We found that the characteristics of the CCHCs, as well as the stigma experiences related to the CCHCs, resulted in more negative academic outcomes over the course of a semester. The results demonstrate that stigma experiences and lack of campus fit interfere with academic performance, as well as illustrate the need to help students with CCHCs navigate these challenges to enhance their academic success.

Research Data

sj-sav-1-hpq-10.1177_13591053211068111 – Supplemental material for The impact of concealable chronic health conditions on college students’ academic outcomes: A two-wave study

sj-sav-1-hpq-10.1177_13591053211068111 for The impact of concealable chronic health conditions on college students’ academic outcomes: A two-wave study by M Rosie Shrout and Daniel J Weigel in Journal of Health Psychology

This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

Research Data

sj-sps-1-hpq-10.1177_13591053211068111 – Supplemental material for The impact of concealable chronic health conditions on college students’ academic outcomes: A two-wave study

sj-sps-1-hpq-10.1177_13591053211068111 for The impact of concealable chronic health conditions on college students’ academic outcomes: A two-wave study by M Rosie Shrout and Daniel J Weigel in Journal of Health Psychology

Footnotes

Declaration of conflicting interests

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

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by a University of Nevada, Reno Graduate Student Association Research Grant awarded to M Rosie Shrout.

ORCID iD

M Rosie Shrout

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