Wellness is a fundamental aspect of overall health and well-being, encompassing physical, emotional, and mental health.1 There is growing interest in understanding wellness among young adults, particularly college students. Postsecondary education is a time of significant transition and change, and it presents unique challenges to students’ health and well-being. Moreover, the college environment provides unique opportunities to promote wellness among students. It is imperative to assess the wellness knowledge, attitudes, and behaviors of students and identify potential demographic variations.

The importance of behavior in promoting public health cannot be disputed as behaviors can affect one’s health and well-being. It is clear from the evidence how effective healthy lifestyle practices including a balanced diet, regular exercise, and quitting smoking are at lowering morbidity and mortality.2 A main risk factor for mortality and disability, according to a survey quantifying the burden of disease in the United States, is nutrition.3 In the US, avoidable and nutrition-related conditions are the leading causes of death.3 Four of the top seven chronic disease risk factors - diabetes, high cholesterol, high blood pressure, and obesity - are linked to food habits and nutrition.4

Although the value of a healthy diet and regular exercise is generally known, a more prominent place for stress in these recommendations has yet to be found. At the physiological and mental levels, stress is complicated and challenging to evaluate due to its numerous sources. The body’s reaction to any mental, emotional, or physical disturbance is stress. Anxiety, migraines, substance misuse, obesity, and heart disease are all conditions where stress can both be a symptom and a significant risk factor.5 College students experience stress, anxiety, and depression at higher rates than the overall population.6,7 More than 80% of medical students also say they have experienced some sort of psychological distress.8 This can have a direct impact on quality of life.9

The idea that college years are often a time of excellent health and wellbeing has been challenged by studies.10 For instance, fewer than 10% of college students consume the recommended amounts of fiber, fruits, and vegetables.11 This demographic only engages in aerobic exercise on an average of 2.8 days per week, and the likelihood that a student will exercise decreases with age.10,12 There is a dearth of research in this area primarily focusing on a chiropractic student population. According to a poll, however, chiropractors in training, faculty members, and practicing chiropractors all had a favorable opinion of preventive care and health promotion, particularly food and physical activity.13 Despite showing promise, college students continue to routinely participate in harmful behaviors, which raises their risk of later-life health issues.14–18

In the context of this research, wellness is a key concept to define. It should be noted that the literature frequently uses phrases like “wellness,” “well-being,” and “quality of life” interchangeably. The term “wellness” might be seen as a more inclusive description of “health.” Health, according to the World Health Organization (WHO), is “a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity,” and this definition has been in place for more than 70 years.19 While this definition covers wellbeing, it leaves out some multifaceted elements including intellectual, spiritual, emotional, and occupational aspects.20 As a result, wellness goes beyond simply being free from sickness, health depends on having enough wellbeing, and our view includes the WHO definition in a multidimensional way.

The chiropractic profession views wellness as a patient-centered practice that emphasizes disease prevention, promotion of good health, and the pursuit of overall well-being with a focus on the spine.21,22 Supporting student wellness is a crucial component of chiropractic education, and because doctors frequently oversee the American health care system, wellness education is essential. This presents an opportunity to raise awareness of the value of wellness in maintaining good health and preventing sickness and to establish oneself as a leading advocate.

Key components of enhancing public health are assessment, intervention, and evaluation of health and health habits. Understanding how health habits and risk factors are influenced is crucial because it can lead to behavioral changes that are both health-preserving and health-improving. The Knowledge, Attitudes, and Behavior (KAB) Model is a well-known strategy for implementing wellness education. Attitudes change as information is gained, and there is a higher likelihood that behavior will change as well.23 The main driving force behind this paradigm is the growth of knowledge. Although knowledge gain is thought to be more complex than changes in behavior, gaining information can help frame outcome beliefs that inspire healthy behaviors that may have an impact on wellness.

The objective of this study was to ascertain the relationship between demographics and wellness knowledge in chiropractic students. This research will contribute to the understanding of wellness among chiropractic college students and identify potential areas for intervention to promote health and well-being among diverse populations.


Palmer College of Chiropractic’s Institutional Review Board (IRB) granted approval for the study. The questionnaire was distributed together with an informed consent form. The primary investigator (PI) was available to respond to inquiries and make sure that responses were understood. At the Palmer College of Chiropractic Florida campus, the Wellness Knowledge, Attitude, and Behavior Instrument (WKABI) was given to students enrolled in the first through thirteenth quarters over the course of 21 days. The principal investigator discarded surveys in which any of the instrument’s questions were left unanswered. Participation of the students was voluntary, and there were no incentives for answering the questionnaire.

Chiropractic students in quarters 1 through 13 met the qualifying criteria for participating in this study. The WKABI included 72 items in multiple choice and 5-point Likert scale forms (ranging from “always” to “never” and “strongly agree” to “strongly disagree”). 829 students received it via email and a college-wide learning platform notification for convenience sampling. A minimum sample size of 263 was recommended by power analysis to yield a 95% confidence interval and a 5% error margin. 271 students in all took part in the study.

A modified version of the WKABI, created by Dinger, Watts, and Barnes, was used to gather data on wellness knowledge, attitudes, and behaviors as well as demographic data.24 The WKABI satisfies requirements for internal consistency reliability, with reliability studies carried out separately for each section and as a whole.24 This makes it possible to measure each section separately as needed. The WKABI had a number of small modifications for this investigation. The following changes were made to a sample nutrition label in order to suit modern standards: “Calories from fat” was eliminated, “Trans Fat” was added, and “Sugars” was renamed “Total Sugars” with “Added Sugars” being included. Current academic quarter, gender, general health, current marital status, body mass index, ethnicity, and greatest level of education attained were added as demographic questions. These modifications were in line with past studies in which target population variations necessitated small changes to the WKABI.25,26

With respect to the intervention areas of physical activity, nutrition, and stress management, the WKABI instrument assesses knowledge, attitudes, and behaviors on three scales. A consent statement, 7 demographic questions, and 33 knowledge questions in multiple choice style with 1 right answer and 3 wrong answers are included in the survey’s contents. For knowledge questions, the scoring system was 1 point for a right answer and 0 points for a wrong one. On a 5-point Likert scale, which awards 5 points to 1 point for each response, attitude (14 items) and behavior (17 items) were rated. Greater overall scores on each of the three scales represent higher levels of knowledge, attitude, and behavior. 33, 70, and 85 are the maximum possible scores, accordingly.

Descriptive statistics were used to analyze demographic information. Statistical significance was set at p < .05. Univariate analysis was used to examine the effect of demographic characteristics on levels of wellness knowledge. Mann-Whitney U and Kruskal-Wallis H tests were performed. Spearman’s Rho correlations, standard deviation, mean, and percentage were used to analyze the data.


Characteristics of the Sample

The WKABI was administered to 271 students,139 male and 132 female. The majority of the student participants described their overall health as very good, were single, had normal body weight, were Caucasian, and had completed a bachelor’s degree. Respondents were spread throughout the 13-quarter curriculum, with the greatest number of respondents in the 7th and 8th quarters.

Characteristics of Wellness Knowledge,Attitude, and Behavior

Mean score for all subjects on the knowledge section was 25.5 (± 5.8), with a low of 4 and a high of 33, resulting in a 77.3% average of the highest possible score. Mean score on the attitude section was 60.6 (± 6.6), with a low of 35 and a high of 70, resulting in an 86.6% average of the highest possible score. Mean score on the behavior section was 56.0 (± 10.1), with a low of 30 and a high of 77, resulting in a 65.9% average of the highest possible score.

Knowledge scores were significantly correlated with attitude scores (r = 0.29231, p = 0) and were also significantly correlated with behavior scores (r = 0.14175, p = .01957). Attitude scores were significantly correlated with behavior scores as well (r = 0.50718, p = 0).

Characteristics of Demographic Variation in Wellness Knowledge

Demographic variations in wellness knowledge are presented in Table 1. Statistical analysis demonstrated several instances in which demographics produced significant variation in wellness knowledge levels.

Table 1.Univariate analysis of demographic variation in wellness knowledge.
Characteristics n % Mean SD Significance
Gender SIG (p = 0.02088)
Male 139 51.3 25.7 6.6
Female 132 48.7 25.2 4.9
Description of Health SIG (p = 0.00004)
Poor 1* 0.4 - -
Fair 20 7.4 19.3 7.8
Good 74 27.3 24.6 5.3
Very Good 132 48.7 26.6 5.1
Excellent 44 16.2 26.0 6.0
Marital Status NS (p = 0.13362)
Single 227 83.8 25.6 5.9
Married, Living as Married, or Previously Married 44 16.2 24.5 5.6
Body Mass Index NS (p = 0.5729)
< 18.5 (underweight) 9 3.3 25.7 5.6
18.5 – 24.9 (normal weight) 143 52.8 25.6 6.1
25.0 – 29.9 (overweight) 97 35.8 25.1 5.4
30 or above (obese) 22 8.1 26.0 6.4
Ethnicity SIG (p < 0.00001)
Caucasian 201 74.2 26.3 5.7
African American 17 6.3 21.0 5.9
Asian/Pacific Islander 7 2.6 26.9 3.0
Hispanic/Latino 39 14.4 22.5 5.8
Middle Eastern/Other 7 2.6 26.7 2.1
Highest Level of Education NS (p = 0.76418)
Bachelor’s Degree 250 92.3 25.6 5.7
Master’s Degree 17 6.3 24.8 6.6
Doctorate 4* 1.5 21.5 12.0

* not included due to low sample size
SIG - significant; NS - not significant
Level of significance = p < 0.05


The results of the present study provide awareness of the level of wellness knowledge and the influence of demographics within a United States chiropractic student sample. Strengths of the study include the use of a revised and validated instrument, demographic information, the use of anthropometric data, and research into a student population that is not well represented in the literature.

A valid and reliable instrument, the Wellness Knowledge, Attitude, and Behavior Instrument (WKABI), was used in a preliminary study on a group of chiropractic students, and results showed significant correlations across the three categories of wellness knowledge, attitudes, and behaviors. The average scores on the knowledge, attitude, and behavior domains were, respectively, 77.3%, 86.6%, and 65.9% of the highest scores attainable.27 It is believed that as knowledge grows, people make wiser decisions and lead healthier lives. Few studies have looked into the relationship between demographics and understanding of wellness, and no research has been completed on a chiropractic student population.

A total of 33 questions were provided in the instrument under the knowledge section. Of the 33 questions, 11 were related to physical activity, 13 to nutrition, and 9 to stress awareness and management. The mean score for the knowledge section was 77.3% (25.5 ± 5.8).

Questions that were directly reflected on this instrument in the chiropractic curriculum include basic nutrition, clinical nutrition, pain and stress management, health psychology, special populations and active care, public health, and wellness and chiropractic. However, almost 27% of the respondents in this study had not taken any of these classes. The additional education obtained in the Doctor of Chiropractic program, or an unmeasured influence of their undergraduate education, most likely contributed to a better score in the chiropractic student population.

This research identified significant demographic variation in wellness knowledge for gender, description of health, and ethnicity. There are several variables that have influence on wellness knowledge and not all were captured in this study. However, existing data does provide some illumination of possible relationships that will be explored.

A previous study completed on this population measuring nutrition knowledge with a validated instrument also reported significant demographic variation with respect to gender, description of health, and ethnicity.28 This comparison is relevant as almost 40% of the questions on the WAKABI instrument that measured wellness knowledge were nutritionally oriented.

According to a meta-analysis, the association between nutrition knowledge and demographic variables such as age, gender, educational level, and family income have been identified in most studies.29 However, the demographic questions that reached statistical significance in this study were different from those in the meta-analysis except for gender.29 Without a direct means of comparison for the statistically significant demographic variables, those associations will be explained only within the context of this study.

The results of this study indicated significant demographic variation in wellness knowledge for gender. Males scored higher (25.7) than females (25.3), and this was statistically significant. As previously stated, wellness knowledge was captured in the WAKABI instrument with questions pertaining to physical activity, stress awareness and management, and nutrition. While the topic of nutrition knowledge has been studied in this population, the impact of physical activity and stress is not well represented in the literature.

Regarding physical activity, 72% of Canadian chiropractic students were meeting the Canadian Physical Activity Guidelines.30 Furthermore, 88% held the belief that chiropractors must adhere to a healthy lifestyle in order to effectively model that lifestyle for their patients.30 Research has indicated that physical activity levels are higher among men than women at the college level and in general.31–33 Physical activity has been demonstrated to affect the brain and cognitive function, and to promote an overall condition of wellbeing.34 While direct comparisons between this population and others is not possible, this could offer a potential explanation if males in this study exercised more than females, and this increased activity level improved exercise-related wellness knowledge resulting in a statistically significant higher score on this section.

Chiropractic students experience higher levels of perceived stress than the general population and may experience levels of burnout similar to medical students.35 Research has indicated that academic stress was a stronger predictor of mental health impairment for female students compared to male students.36 In addition, for female students, academic stress predicted changes in mental health status.36 Future research would be necessary to confirm any relationship between the impact of stress on knowledge and management of stress in this population.

From the perspective of nutrition knowledge, prior research has indicated that females have greater nutrition knowledge levels than males.37–41 However, the results of this study indicated that males demonstrated a higher score in wellness knowledge. Knowledge of nutrition as measured in this study falls under the category of declarative knowledge. Formal investigation into gender differences in declarative memory found interesting results that could be applicable. For example, of the 4 1st-order factors of declarative memory, women have better recall, recognition, and fluency, but men have better knowledge.42 As this is not a consistent finding in the literature, further research will be required to clarify its significance.

Description of health produced a statistically significant variation in wellness knowledge. Most of the chiropractic student population (92.2%) rated their health as good, very good, or excellent. Logic might dictate that those that describe their health as good or better might also be likely to have better wellness knowledge. The implication is that the use of that wellness knowledge has in part influenced their perceived health status. Research indicates that positive self-related health is predictive of improved physical health, delayed mortality, a higher quality of life, and more frequent use of health-promoting behavior.43 Young adults perceive their health as positive and this is related to more positive health-related activities such as weight loss and physical exercise.43,44 While research remains elusive on the specific association between description of health and wellness knowledge, this study indicated a significant relationship.

Ethnicity produced a statistically significant variation in wellness knowledge. Within the chiropractic student population studied, 74.2% were Caucasian, 14.4% were Hispanic/Latino, 6.3% were African American, 2.6% were Asian/Pacific Islander, and 2.6% were Middle Eastern/Other. While ethnicity reached significance in this study, it was not included in the most recent meta-analysis on studies related to measuring nutrition knowledge and demographic characteristics of the sample.45 Research evaluating the role of ethnicity, dietary costs, and dietary quality stated that the importance of dietary costs for dietary quality differed between socioeconomic and ethnic subgroups.46 This offers support for the association illustrated in the current study. However, the association between ethnicity and physical activity and stress knowledge in this population is unclear. Future research should attempt to explain this association.

No significant association was found between BMI and wellness knowledge. Research is equivocal regarding the relationship between BMI and nutrition knowledge.47,48 However, 35.8% of the students had a BMI greater than 25, which is classified as overweight. One justification for the increased BMI scores could be related to the inherent weaknesses of this anthropometric measurement. BMI is incapable of distinguishing the different contributions to body weight such as fat mass and muscle mass. Thus, overestimation of adiposity in individuals with increased muscle mass can result in classification as overweight or obese. Greater physical activity leads to muscular adaptations relative to the type of exercise performed. Future research on this population would benefit from the use of a more accurate anthropometric measurement.

No significant association was found between marital status and wellness knowledge. The majority of students reported being single (83.8%) and this may have affected the lack of association. Research has demonstrated that marriage influences health through its effect on behaviors and is predictive of health status and outcomes.49,50 However, research on this chiropractic student population is insufficient to provide any plausible explanation for lack of an association.

No significant association was found between the highest level of education and wellness knowledge. Previous research on this population did indicate a significant association between nutrition knowledge in those with nutrition-related qualifications and/or those that had taken a college level nutrition course.28 However, because the type of major was not identified in this instrument, direct comparisons between previous graduate education and influence on the wellness knowledge section are lacking.

Promoting health and well-being among chiropractic students requires a comprehensive approach that addresses various aspects of their lives. Some potential areas for intervention to enhance students’ understanding of wellness include health education, mental health support, physical activity promotion, healthy eating initiatives, stress management and resilience training, sleep hygiene education, peer support programs, and a positive and inclusive school environment. Looking through the lens of nutrition, while chiropractic schools provide accurate information on this topic, further impactful gains in wellness could be achieved by also promoting healthy behaviors in related classes in the curriculum. One strategy could include an assignment or activity for students to research, analyze, and apply their understanding of nutrition concepts in a practical context. This would encourage critical thinking, creativity, and reflection on personal eating habits. By actively engaging with the assignment, students may be more likely to internalize the importance of healthy eating and make positive changes in their own lives. A logical next step after assessing wellness knowledge would be addressing wellness promotion in this population.


Students from a single chiropractic college campus in the United States participated in this study. As a result, there are limitations on how this data can be applied to other chiropractic colleges. This study may offer preliminary information that was previously unavailable due to a dearth of wellness knowledge data in the specific population of chiropractic students. The participants in this study were dispersed across the curriculum; some had already finished courses on stress management, nutrition, and physical activity, while others had not. The topic might be clarified further by future research looking at wellness knowledge in relation to enrollment term status.

The WKABI has not been specifically validated in a population of chiropractic students, despite the fact that it has been validated in undergraduate populations. Due to the population investigated, there may be limitations in comparing these results to those from other studies employing the WKABI.


This study suggests that demographic variables related to gender, description of health, and ethnicity are significantly associated with wellness knowledge levels of chiropractic students. It demonstrates the importance of ensuring that effective wellness courses within chiropractic curricula are tailored to serve diverse populations. Students who go on to become doctors provide information to their patients. According to the KAB model, increasing patient knowledge should have an impact on patients’ attitudes and behaviors, ultimately resulting in a favorable impact on the health of the general public. These findings provide preliminary information regarding wellness knowledge and demographic variation that could be utilized at a curricular level to promote health and well-being among diverse populations.