A qualitative assessment of college students' perceptions of health behaviors.
Findings from the 1995 National College Health Risk Behavior Survey [NCHRBS] suggest that many college students engage in health risk behaviors including binge drinking, cigarette smoking, drug use, and unsafe sexual practices that increase their likelihood of serious health problems (i.e., unintentional and intentional injuries, unintended pregnancy, sexually transmitted diseases, HIV infection) (Douglas et al., 1997). Many health professionals have focused their efforts on the study of health issues and behaviors of college students (Dinger, and Parsons, 1999; Page, Scanlan, and Gilbert, 1999; Perkins et al., 1999; Siegel, Klein and Roghmann, 1999; Wechsler and Dowdall, 1997). While these studies have provided valuable data about college health issues, each study has tended to emphasize a specific single set of behaviors (i.e., tobacco use, sexual practices, alcohol and drug use). Nonetheless, it is important to emphasize that any single behavior is influenced by other health risk behaviors among young people and that there is an interrelationship among multiple behaviors (e.g., substance abuse and sexual practices) (Zweig, Lindberg, and McGinley, 2001). In addition, college students' perceptions and opinions of the health risk behaviors have an impact on the way they ultimately behave. For example, students' perceptions of alcohol and drug use on college campuses have been associated with the student's own behavior (Page, et al., 1999; Perkins et al., 1999). By understanding college students' perceptions of their behaviors and the relationship across behaviors, health educators at college/ university settings can provide suitable health programs for their specific populations.
During this investigation, a group of health educators, working on a need assessment during the planning process of a health promotion initiative, chose to conduct a qualitative study to obtain data that could be used in the development of campus health promotion activities. The group wanted to gain insights into students' experiences, perceptions, concerns, beliefs, thought, and behaviors; specifically, in the areas of alcohol, drug use, and sexual activity. In particular, the group was interested in examining why do college students still engage in risky behaviors in spire of serious health consequences and what type of health promotion activities would appeal more to students.
As part of this investigation, the authors chose focus groups, a commonly employed qualitative data collection method. Focus groups allow participants to express freely their beliefs and ideas within the context of the group and willingly discuss personal issues that they may not disclose otherwise (Baumgartner and Strong, 1998). Moreover, "the goal of a focus group is to collect data that are of interest to the researcher--typically to find the range of opinions of people across several groups" (Krueger and Casey, 2000, p.11). In addition, the use of focus groups has been identified as a valuable tool in health education and promotion needs assessment (Tipping, 1998).
A convenience sample of college students was recruited through announcements in 12 sections of wellness (i.e., personal health) classes offered during the fall and spring semesters at a northeastern metropolitan university. All students attending the particular institution are required to take a three-credit personal health course as part of the requirement for graduation. The University Institution Review Board approved the study. Forty undergraduate students between the ages of 18 to 24 years old (Mean = 20 yrs, SD = 1.62) participated in seven focus groups. Slightly more than half of the participants were male (n=23). With respect to race and ethnicity, the sample consisted of mostly White (n=18) and African American (n=16) students. The other six students identified themselves as Hispanic (n=3), Asian/Pacific Islander (n=1) and "other" race (n=2). With respect to academic status, 12 students reported being freshman, 14 students were sophomores, 6 students were juniors and 8 were seniors. All, but one student, repotted full-time status. All the students were single and most of them (n=34) lived in campus residence halls.
Based on the literature review (Broadbear, O'Toole, and Angermeier-Howard, 2000; Davies et al., 2000; Emery, Ritter-Randolph, Strozier, and McDermott, 1993; Walden and Fennell, 1995) and findings of our previous survey (Luquis, 1998), the researcher developed thirteen focus group questions, with some of the questions having multiple parts, that assessed the three areas of interest. The three general areas included: a) perceptions and concerns of personal health, b) assumptions and beliefs concerning substance use, and c) beliefs and issues surrounding sexuality, pregnancy, and prevention of STDs (see Table 1). The principal author developed the questions according to the guidelines identified by Krueger and Casey (2000) (see Table 2). They specify that good questions are those that are conversational, easy to say with clear meaning, short and open-ended, one-dimensional, and use words commonly used by participants. In addition, they suggest that after a set of ideas for questions are generated, the researchers should examine, edit, and rephrase the questions so they will work in a focus group format. Moreover, the questions must follow a sequence to allow participants to "anchor their opinions and then build on those views" (Krueger & Casey, 2000, p.61). For example, questions should go from general to specific, from positive to negative, and from uncued to cued to prompt additional discussion. Finally, the researchers should request feedback from others before using the questions in a group. As part of this investigation, the principal author revised the questions based on comments from members of the University Wellness Advisory Committee. Members of this group included professionals from the fields of public health, health education, and social marketing. In addition, the graduate students involved in the research examined the questions and provided further comments to the principal investigator. Finally, the responses to the questions after the first focus group was conducted were examined, and some of the questions were revised as needed.
The principal investigator served as the moderator for all focus groups, while one of the graduate students served as the note-taker. Seven focus groups were conducted as part of this investigation. Each focus group was held in a conference room on campus. Each focus group was completed within one and one-half hours. The groups included a mix of male and female students, as well as students from different ethic/racial groups. In addition to taking "minutes" of focus group discussions, each session was audio taped (with participants' permission) to ensure a more reliable data gathering process.
The researchers transcribed the audiotapes, a common procedure used to analyze qualitative data (Krueger and Casey, 2000). These transcripts were compared with written notes to prevent misinterpretation of the data and to supplement the data collected on the audiotapes. Once the final transcripts were completed, the principal investigator and the two graduate assistants met to discuss how to identify themes and code the responses of each group. The authors, then, analyzed and compared the results of each focus group to describe commonalties and differences in the responses of each group. This process resulted in several themes that were then coded in specific categories. In addition, the researchers selected specific quotes from the data to show common themes throughout the focus groups. These direct quotes served to provide internal validity of the findings (Baumgartner & Strong, 1998).
PERCEPTIONS OF PERSONAL HEALTH
Students' health issues and concerns are reported in Table 3. When asked to define health, most respondents had similar responses, and many of them gave a definition based on what they learned in their personal health or other related classes. Overall, health was defined as the absence of disease, mental, and physical problems, while wellness was defined as the way people feel about their physical, mental, social, and emotional health and well being. When asked how concerned they were about health, most participants agreed that while some of their peers were concerned about it and engaged in some physical activity or watched what they eat, most of their peers were not seriously concerned about their health. In one group, a student said "it's not like we're 40 and have to worry about high cholesterol," similarly in another group, a student stated that "it is a concern, but not a top priority" and another participant added that "[students] do not care unless it's serious." Many students also felt that because they are in college it is okay for them to "let themselves go," that is, engage in unhealthy behaviors such as excessive drinking, not getting enough sleep, poor eating habits, and other unhealthy activities.
When asked if being in college made it more difficult to stay healthy, most participants answered yes. Many of the students felt that it was difficult to keep a balance between their busy schedules of classes, work, and desire in maintain a social life. When asked about their eating habits, many students said that they were eating more junk food than before coming to college, and expressed a strong dissatisfaction with the food selection available at the dining hall in the University. Many students felt that the food was not nutritious and that there was not a good selection for those who want to eat healthy or follow a vegetarian diet. Some of their comments included: "the selection for a vegetarian is poor or not edible," and "the dining ball is not that great." However, others felt that the food was not that bad, and that students just needed to make better selections from what was available. Some students reported that there should be a better variety of healthy food (i.e., fresh vegetables) available at the dinning hall and throughout campus. Another group of students felt that many times they choose to go off campus to eat or order delivery food, which generally consisted of junk food, especially if they were hungry after the dining facility on campus were dosed for the day.
Most students also reported dissatisfaction with the campus facilities for recreation/fitness because of limited access and cost. For example, many of them noted that the time available for students' use of recreational/fitness buildings was limited or was only open at times they could not go because of their class schedules. Further, the usage of a particular fitness facility in a residence hall was not free. Many students acknowledged that they did not want to pay the required usage fee for fitness facilities and that they should be available without any additional cost. For example, a student said, "people are aware [fitness facility at residence hall], but they charge $40, the free one [facility] has old equipment that breaks when you use them." This was echoed by another student that mentioned "[students] should not have to pay gym membership at the fitness center." Some students also suggested free passes to the fitness center to increase attendance. Most students agreed that the campus' recreation and fitness facilities should be open and available longer for general use.
Students also mentioned that when intramural activities are offered, the activities should be better publicized. While the intramural activities are open to all the students, some students felt that these activities are intended for student athletes. Thus, it was suggested to have a field day in which all the students feel welcome to attend.
When asked what health promotion activities they would like to see and what would increase their participation in health promotion programs, the students had many suggestions to help increase attendance. They suggested that health promotion events be scheduled at a variety of times so that more people are able to attend. In particular, students added that activities should be offered during the late afternoon or evening. In addition, these activities should be scheduled close to or in the residence halls or in nearby facilities where students can access them easily. Many of the students mentioned that they do not like lecture style presentations. Some students said that they preferred fun and interactive activities such as group discussion and presentation by famous people (i.e., celebrities).
With respect to information about activities on campus, the issue of lack of awareness about what activities were available on campus was identified. Flyers, often used to communicate news, were found to be ineffective in capturing students' attention. One student said, "people don't pay attention to flyers, especially when older flyers .stay up for many weeks." Thus, it was suggested that electronic boards be used for advertisement.
PERCEPTIONS AND ISSUES REGARDING SUBSTANCE USE
Participants' perceptions about substance use among college students are listed in Table 4. Substance use was seen as common among college students, with estimates of 80-90% of students using some type of drug. However, estimates of use were substantially lower (50-70%) when participants were asked to describe peer (i.e., friends) behaviors. When asked to specify what substances students use, most agreed that alcohol, tobacco (i.e., cigarette), ecstasy, marijuana, and acid are the drugs of preference among students. Alcohol was identified as the most commonly used drug by students because of easy access and peer expectations. For example, one student said that, "They [students] use alcohol the most because it is easier to get than illegal drugs."
When the moderator asked about what other specific beliefs or perceptions students have of illegal drugs, the responses varied, and included "students believe their [bad] actions are not drug related," "everyone is doing it," "people just think drugs are not that bad," "it serves as a coping mechanism for stress and depression," and "some do not see drugs as a big deal." Beliefs about alcohol were verbalized as: "it is fun--party," "socially accepted," "serves as a reward from a stressful week,"" alcohol tends to alleviate boredom," "supposed to drink while in college," "guys binge drink to show tolerance," "girls get drunk to become a new person," and "it helps you be less inhibited." Thus, it was clear that whether they used alcohol or other types of drugs, they perceived that it is okay and acceptable to use some type of drug during their lives in college.
The reasons students gave for smoking cigarette include the tendency to smoke while drinking, the use of cigarettes as a stress reducer, and the easy access on campus. Several of their comments included "when you are out drinking socially then you smoke," "[it] relieves stress," "out of boredom" and "smoking is all over campus." Most students recognized that cigarette smoking could be addictive, and as expressed in their comments "[smoking] is like a tranquilizer, altering your mood," "addicted because they started at an early age," "it is hard, you cannot say you can just stop," and "smoking is an addiction worse than alcohol, so, it is hard to quit." Students also agreed that the behavior of parents and peers influence their smoking behaviors. For example, a student commented about how he began smoking: "I was bored and stressed out--my Dad smokes and hey; I tried it. Three years later, I am still going strong." Another student stated, "If they [parents] smoked, the more likely you would smoke." A male student said, "[I] never smoked cigarettes until I lived with a girl last year ... quit [smoking] when I stopped living with her." Finally, some students mentioned that the University setting enables them to continue smoking by selling cigarettes on campus and allowing them to smoke in their rooms.
PERCEPTIONS AND ISSUES CONCERNING SEXUALITY
When students were asked about their beliefs concerning sexuality, most participants agreed that sexual activity at this age is acceptable and expected in college (see Table 5). A student said, "it is addictive, it is the freshmen fever" when referring to why many students engage in sexual activity in their first year. Once in college, students feel pressure to engage in sexual activity. For example, one student mentioned, "I thought when I came to college that it was about having sex every night." In contrast, other students focused on staying a virgin, therefore, emphasizing the importance of waiting until marriage. Indeed, one student specifically said, "a lot of people honor sex, and wait until they get married," and another student added, "some people hold strong to their morals (i.e., waiting to be married)."
Whether they have sex or wait to be in a committed relationship, most students agreed that the use of alcohol and drugs increase the likelihood that sexual intercourse will occur. In fact, students mentioned that drugs and alcohol help decrease their inhibitions and increase their sexual pleasure. In addition, students said that their views about sexuality are also influenced by what they see on TV, information they receive from friends, and what they see as social expectations (i.e., okay for guys to engage in sexual activity). Many of the participants talked about the double standard that exists regarding gender and sexual activity. The double standard suggest that it is okay for men to be actively engaged in sexual activity, but it not okay for women to do so. For example, a mate student said, "a guy sleeps around he's a stud. What is acceptable for guys is not for girls; girls would still be considered sluts." While students reported that it is okay to have either/or vaginal, oral and anal intercourse, violent sex (e.g., rape) is not acceptable.
Students were also asked what type of sexual issues they face in college. For the most part, students are concerned about pregnancy, sexually transmitted disease, condom use, sexual responsibilities/consequences, sexual harassment and rape. Some of them said that they were more concerned about pregnancy than STDs. Most students reported apprehension in seeking STD testing and counseling from the University Health Center because they were concerned about confidentiality. In every group, Planned Parenthood was mentioned as a viable and acceptable place to go to receive any examination and/or treatment for STDs and/or pregnancy.
In regard to communication with current and future sex partners, students expressed several points of view. Participants who advocated communication said that "[it is] a must," "should discuss always, because whomever you sleep with, they are sleeping with," "if it is a person who you care about--you will take the time to talk about it," and "if it's a long-term relationship then you talk about it". In contrast, students who did not endorse communication mentioned that the "need to talk to partners only if you are serious about relationship," "some people lie about it [sexual history], so it doesn't make a difference," and a male said "she doesn't need to know [about my sexual history] unless there is an STD problem."
When asked about contraceptive use, most students agreed that both partners should take equal responsibility for the use of contraceptives. Most of them emphasized that it is important to use condoms. However, when probed about how many of them and their friends used condoms, only half of them reported that they or their friends use condoms consistently. Relationship type mattered with students saying that it is important to use condoms in a casual relationship, but less so in a steady relationship. For example, a male student said, "I have a friend, who if be is sleeping with someone who is not his girlfriend, he will always use a condom," and then added, "if he sleeps with his girlfriend who is on the pill, then he never uses a condom." Finally, they all agreed that condoms should be more accessible on campus (i.e., health center, residence halls). In their view, if the University would provide condoms, then more students would use them.
In this study, we found that, although college students continue to engage in unhealthy behaviors, the majority of the students remain concerned about risky health behaviors. First, most students acknowledged and believed that, while in college, it is difficult to stay healthy. Most young people in college find themselves in a transition period, wherein they can behave as they want without realizing the long-term consequences. Moreover, many students believed that they are expected to engage in these behaviors (i.e., drinking, smoking, unhealthy eating) while in college. Many students believed that part of the reason why they engage in unhealthy behaviors, such as lack of physical activity and poor eating habits, stems from the lack of access to facilities that support healthy behaviors. It seems that those structural services (i.e., dining hall, recreation facilities) offered by universities to help students during this transition are failing to satisfy their needs. In our particular case, these results were immediately shared with the administration with recommendations to further explore the students' concerns regarding the availability of healthy food and usage of recreational facilities and possibilities for improvement.
Second, the findings showed that students believe that drugs and alcohol are widely used among their peers. Likewise, when asked about the reasons for using and abusing alcohol, participants reported alcohol drinking as part of the college experience and viewed by their peer as socially supported. In addition, these results are in accordance with prior studies wherein researchers have found that perceptions of peer alcohol and drug use are associated with individual's own behaviors (Broadbear et al., 2000; Emery et al., 1993; Page et al, 1999; Perkins et al., 1999). Students not only agreed that a high percentage of their peers are using alcohol and drugs, but they also suggested that these behaviors are harmless. Finally, while most students agreed that alcohol was the drug of choice among their peers, they also mentioned ecstasy, acid, and marijuana as drugs preferred by this population. While these findings may not provide all the answers to our inquiries, these students' perceptions help to explain our previous results that showed that 63% of the our students reported ever using marijuana, 24% had used other drugs with alcohol, 59% had engaged in binge drinking, and 33% have drunk alcohol and driven a car (Luquis, 1998). Finally, when dealing with tobacco use, many students felt that they were getting a double message when it comes to smoking. While the buildings on this campus are smoke-free environments, cigarettes still are sold on campus. This particular result may give a reason for why 45% of our students reported smoking cigarettes regularly (Luquis, 1998).
Results also indicated that students believe that sexual experimentation is not only a part of college experiences, but it is expected. Responses by some of the students also suggested that they constantly feel pressured to engage in sexual activities during their college years. Moreover, the majority of the students reported concerns about pregnancy, sexually transmitted diseases, HIV infection, communication between partners, sexual assault, and confidentiality of sexual health services on campus. Although students expressed their worries about adverse health consequences associated with unprotected sexual intercourse, they had not changed their behaviors (i.e., increase condom use). Furthermore, many students reported using alcohol and drugs to enhance their sexual activity, which may hinder the use of condoms. These specific findings may help to explain why while 50% of the students previously surveyed reported using a condom during the last sexual intercourse; only 24% reported always using condoms during sexual intercourse in the last 30 days (Luquis, 1998).
Finally, the results of this study are subject to several limitations. First, the sample size and the methodology (i.e., focus groups) limit the generalization of the results. With respect to sample size, small sample size is typical (or to be expected) of qualitative research. Moreover, the ultimate goal of studies using focus groups is not to provide information that generalizes to other settings or individuals. Rather, as pointed out by Krueger and Casey (2000), the focus is on transferability of the findings. The question then becomes--can these results be transferred into another context. A reader of the results should be interested in the degree to which the results fit his/her particular situation, while taking into account the author's methods and procedures. Thus, the transferability of the results to other University settings warrant thoughtful consideration of the findings. In addition, as with any qualitative data analysis, the potential for bias or misinterpretation of the results existed in this study. To address this concern, each focus group was taped to prevent any misinterpretation of the notes taken during the discussion. In addition, the investigators worked collaboratively to identify commonalities among the groups and used direct quotes in the results to corroborate the interpretation of the different themes. Despite these limitations, focus group methodology is a viable tool for health educators to assess the college students' perceptions of their behaviors, so they can provide suitable health programs for their specific populations. In particular, the results from these focus groups help our University Wellness Advisory Committee on defining and developing appropriate intervention programs for our target population. Hence, these results, while limited, can help other health educators in the development of suitable health promotion programs for college populations.
IMPLICATIONS FOR HEALTH EDUCATORS
Given the results of this study, health educators, at colleges and universities, must advocate for the provision of appropriate services for students to help them develop healthy behaviors and lifestyles (Brener, and Gowda, 2001). Also, health educators in charge of developing and supervising health promotion programs must consider the time, location, type, and advertisement used to promote these activities. After all, in the past decade, many universities and colleges have spent a tremendous amount of time and resources to provide healthy environments for students attending college (Grace, 1997; Jackson and Weinstein, 1997), thus. we must ensure that these resources are properly used. In addition, while institutions of higher education can provide a myriad of health promotion programs, health educators must also encourage students to take responsibility for their unhealthy lifestyles because these lifestyles can be carried into adulthood (Grace; Jackson and Weinstein).
Secondly, as long as college students believe that a high percentage of their peer are using alcohol or other drugs (i.e., perceptions of social norms), alcohol and drug use will continue to be a significant health problem on college and university campuses. Health educators must design programs that, taking into consideration these perceptions, challenge students' views of alcohol and drug use. These types of health interventions may have the potential for lowering the rates of these behaviors (Page et al., 1999). In addition, health educators at all colleges and universities must consider looking at policies regarding smoking on campus, and revise them, if necessary, to reflect the true healthy environment that we want to achieve. Finally, when it comes to sexuality education on campus, health educators must create opportunities, through discussion groups or forums, in which students are encouraged to talk about why they continue to engage in risky sexual behaviors even though they know about the negative consequences. The information gathered through this type of forum can be helpful in the development of health education programs.
Table 1. Focus Group Questions.
Perceptions of Health
1. How do you define health? How interested are your peers in their health or staying healthy?
2. What do you do to stay healthy? What do your peers do to stay healthy? What do you or your peers do that is unhealthy?
3. How easy/difficult is for you to stay healthy during your college years? What specific things make it easier/ difficult here on campus?
4. What type of health promotion services would you like to see on campus?
5. What would increase the likelihood of your participation in these health promotion activities on campus?
Perceptions of Substance Use
6. What percentages of college students use any type of substances/drugs? How many of your friends or classmate use any type of drugs? What type of drugs do students use most frequently?
7. What are the assumptions/beliefs about drug use among your peers? What are the reasons for using/abusing drugs?
8. What are the assumptions/beliefs about alcohol use among students? What are the reasons for binge drinking (5+ drinks) or getting drunk?
9. What influence college students to smoke cigarettes (i.e., tobacco)? What are the beliefs about smoking on campus?
Perceptions of Sexual Behaviors
10. What are the personal beliefs about sexuality among people your age? What influences these views/beliefs?
11. What issues related to sexuality do you and your peers face during the years in college? What kind of sexual practices are acceptable or unacceptable to people your age?
12. How would you feel about seeking examination or treatment for a STD? How do you feel about discussing your sexual history with a new sexual partner?
13. What are your views on contraception? Who should be responsible for contraception? Should the University provide free or low cost contraceptives and condoms to students?
Table 2. Process to Develop a Questioning Route.
2. Phrasing the Questions
a. Use Open-Ended Questions
b. Avoid Asking Why
c. Keep Question Simple
d. Be Caution About Giving Examples
3. Sequencing the Questions
a. General Before Specific
b. Positive Questions Before Negative Ones
c. Uncued Questions Before Cued Questions
4. Estimating Time for Questions
5. Getting Feedback from Others
6. Testing the Questions
Note: Process taken from Krueger, R. A. and Casey, M. A. (2000). Focus groups: A practical guide for applied research. (3rd Ed.), Thousand Oaks, CA: Sage Publications.
Table 3. Students' Health Issues and Concerns.
1. Physical activity and eating habits
2. Difficulties keeping a balance between classes, work, and social life while in college
3. Limited recreational and fitness facilities on campus
4. Suggestions for improvement of health promotion activities:
a. Schedule events at a variety of times--possibly late afternoon or evening
b. Schedule events close to or in residence halls
c. Use and increase advertisement of activities on campus
d. Expand hours of operation of recreational facilities
Table 4. Students' Perceptions and Issues Regarding Substance Use.
1. Most college students use some type of drugs
2. Alcohol, tobacco, ecstasy; marijuana, and acid are the drugs of choice
3. Alcohol is commonly used by students
4. Alcohol use is socially acceptable and expected in college
5. Alcohol and drugs are used as a coping mechanism for stress
6. Tobacco use associated with drinking
Table 5. Students' Perceptions and Issues Concerning Sexuality.
1. Sexual activity at this age is socially acceptable and expected in college.
2. Abstinence until marriage is important.
3. The use of alcohol and drugs increase likelihood of having sexual intercourse.
4. Students are primarily concerned about pregnancy, but also with STDs, condom use, and sexual responsibility.
5. They were concerned about confidentiality when using the University health center, hence, they preferred to get sexual health services elsewhere.
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HEALTH EDUCATION RESPONSIBILITY AND COMPETENCY ADDRESSED
Responsibility I--Assessing Individual and Community Needs for Health Education
Competency C--Infer needs for health education on the basis of obtained data.
Sub-competency 2--Determine priority areas of need for health education.
Raffy R. Luquis, Ph.D., CHES is an Assistant Professor of Health Education at the School of Behavioral Sciences and Education, Penn State Harrisburg. Erica Garcia, MPH, CHES is currently affiliated with Oxford Health Plans. Darlene Ashford, MPH, CHES is currently affiliated with Anthem Blue Cross and Blue Shield of Connecticut. Address all correspondence to Raffy R. Luquis, Ph.D., CHES, Department of Health Education, School of Behavioral Sciences and Education, Penn State Harrisburg, 777 West Harrisburg Pike, Middletown, PA 17057, PHONE: 717. 948.6730, FAX: 717. 948.6209, E-MAIL: firstname.lastname@example.org.
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|Publication:||American Journal of Health Studies|
|Date:||Mar 22, 2003|
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