Healthcare-seeking behaviours in college students and young adults: a review

Abstract

Background/aims

To review the literature on college students’ healthcare-seeking behaviours to uncover the current evidence and promote better healthcare-seeking behaviours and essentially better health outcomes in young adults.

Methods

The researchers conducted an extensive literature review using CINAHL, Cochrane, PubMed, EBSCOhost and Google Scholar in the years 2018 and 2019. The search was limited to the past 18 years (2000–2018) and to studies reported in the English language focused on the general healthcare-seeking behaviour of college students. The search was also extended to young adults (aged 18–39 years).

Results

A total of 56 articles were identified for abstract review and only 28 articles met the inclusion criteria for the final review. The following themes emerged to organise our findings: healthcare-seeking behaviour among college students, health information resource utilisation and its influence on healthcare-seeking behaviours and barriers to accessing care among college students.

Conclusions

This review summarises the current body of knowledge related to healthcare-seeking behaviour among college students, health information resource utilisation and its influence on healthcare-seeking behaviour and barriers to accessing care among this population. Important measures further to address the health needs and interventions for addressing these needs among the college student population are discussed.

Keywords

barriers college students healthcare-seeking behaviours review young adults

Introduction

According to the US Department of Education (2018), 19.9 million young adults were enrolled in colleges and universities across the US. This constitutes 17% of the general population (US Census Bureau, 2018). College students attend postsecondary institutions at the undergraduate and post-baccalaureate levels and have the option of attending 4-year public, private non-profit and private for-profit institutions. College student age varies depending on the type and level. As an example, at the undergraduate level, younger students aged 25 years and under constitute the majority (90%) for public and private non-profit institutions; meanwhile, at private for-profit institutions, student ages are more evenly distributed among the various age groups (33% for under 25 years; 39% for 25–34 years; and 28% for 35 years and over). This trend is relatively consistent for 2-year undergraduate institutions and post-baccalaureate institutions (US Department of Education, 2018). College student enrolment in postsecondary education programmes is expected to increase to 20.5 million by the year 2027 (US Department of Education, 2018). College students represent a population with heightened health needs due to lifestyle factors, and so this is an important time for providers to educate on the prevention of chronic disease relating to lifestyle (Turner and Keller, 2015).

Despite the presence of health centres in most colleges, healthcare utilisation is low among this population. The College Health Surveillance Network studied healthcare utilisation at 23 universities across the US and found that only 32% of enrolled students utilised the student health services in a year (Turner and Keller, 2015). Of the 32%, only 15.6% were preventive services. It would seem unlikely that the utilisation rate is an indication that college students are healthy, and therefore have no need to seek healthcare. College students have significant health risks related to stress, poor sleep habits, sexual activity, poor diet, lack of physical activity and tobacco, alcohol and drug use (Deasy et al., 2014; Kenney et al., 2013). Changing their behaviour and mitigating the impact early will be likely to keep college students healthy and reduce future health risks as adults. Therefore, healthcare-seeking behaviours and service utilisation among college students is a topic deserving of attention from an early intervention and public health perspective.

For many students, the college years represent a challenging transition developmentally to adulthood (Hunt and Eisenberg, 2010). What happens during these years has profound and long-lasting implications for their future career, economic security and physical, psychological and emotional wellbeing (Stroud et al., 2015). Student health centres are convenient and accessible and exist to address healthcare needs for students (Hunt and Eisenberg, 2010; Turner and Keller, 2015). However, student health centre services and resources are underutilised (Lemly et al., 2014). This underutilisation of healthcare services may contribute to students’ failure to transition developmentally to adulthood or to make meaningful healthcare decisions, and when to seek healthcare (Lemly et al., 2014).

Green et al. (2003) interviewed 470 students and found that two-thirds of them did not accurately perceive their risk of developing heart disease. In another study, 92.1% of students who were identified as having at least one risk factor for chronic disease stated that they had never been told they were at risk of chronic disease (Romero et al., 2005). Of special note, almost half (45.4%) of the students interviewed reported that they would most likely change their lifestyle if their healthcare provider informed them that they were at risk of cardiovascular disease (Romero et al., 2005). Chronic health problems can be prevented if college students engage in healthy behaviours and are screened for health risks and early signs of health problems (Bonnie et al., 2014). Considering that college students are generally unaware of their health risks (Arts et al., 2014; Lynch et al., 2006), they are not inclined to seek healthcare services to alleviate those risks. It has been observed that college students are more likely to utilise the internet for health information instead of student health centres (Basch et al., 2018). Students usually seek treatment for acute symptoms including upper respiratory infections and for mandated services such as physical examination and immunisations (Keeton et al., 2012). In addition, many college students require mental health and preventive care services (screening and intervention); however, they do not seek such services (Champlin and Nisbett, 2018). If not detected and managed early, these health concerns can negatively impact students’ wellbeing and academic success (Champlin and Nisbett, 2018).

The Centers for Disease Control and Prevention (CDC) has proposed a college health safety initiative that includes strategies to prevent and stop smoking and alcohol consumption, increase daily exercise, adopt healthy food choices and improve sleep patterns in student populations. Considering that approximately 33% of college students visit their student health centre for different reasons multiple times a year (Keeton et al., 2012), this can be a point of access to implement the CDC’s college health safety initiative by conducting risk assessment and teaching management and prevention strategies for chronic diseases. There are additional benefits to focusing on improving the healthcare delivery and capacity to serve students. College years provide an opportunity for students to transition into accessing and navigating the healthcare system without the assistance of their parents or guardians and to participate in health and wellness practices (Bonnie et al., 2014; Lau et al., 2013). As well as providing treatments to health issues when contacted directly, student health centres have the potential to meet the demands of providing health promotion and disease prevention services to college students. For that potential to be fulfilled, there is a need to understand the needs of the target population and the gaps in supply. Therefore, the purpose of this study was to review the literature on college students’ healthcare-seeking behaviours and service utilisation, with the specific aim to uncover the current evidence and promote better healthcare-seeking behaviours and service utilisation and essentially better health outcomes in this population.

Methods

We conducted an extensive literature review that included the following search terms: health seeking, health promotion, healthcare, college students, young adults, health risk, student health and health behaviour. Our focus for this literature review was aimed at healthcare-seeking behaviour among college students. The electronic search databases we used were CINAHL, Cochrane, PubMed, EBSCOhost and Google Scholar. The search was limited to the past 18 years (2000–2018) and to studies reported in the English language. An extensive timeframe would allow us to find additional important information related to the topic. The inclusion criteria were studies that focused on the general healthcare-seeking behaviour of college students and extended to young adults (aged 18–39 years) and studies conducted in the US and other countries. We conducted the initial literature search by reading the abstracts, and we identified 56 articles for abstract review to be completed by two independent reviewers. Additional studies were identified from the reference list. A total of 28 articles met the inclusion criteria for the final review focusing on healthcare-seeking behaviour among college students.

There were three qualitative studies while the remaining were quantitative studies. The studies were conducted mainly using questionnaires, online surveys and focus groups. Two independent reviewers read the articles that met the inclusion criteria for the review and independently determined common themes. Each reviewer developed a list of themes and compared to one another, discussed discrepancies until consensus and finalised the themes and associated subthemes. Among the review articles related to college student healthcare-seeking behaviour, the following themes emerged to organise our findings: healthcare-seeking behaviour among college students, health information resource utilisation and its influence on healthcare-seeking behaviours and barriers to accessing care among college students.

Results

Approximately 50% of the studies included in this review were conducted in the US, whereas the remaining studies were from Asia, Africa, and the Middle East. There were 15 studies conducted in the US, three studies in India, two in Nigeria, one in Ghana, one in Taiwan, one in Saudi Arabia, one in Lebanon, one in Pakistan, one in the United Arab Emirates, one in Oman and one in Canada. The studies in the US focused on healthcare-seeking behaviours related to general and mental health; perceived stigma related to seeking healthcare; expenditures associated with healthcare; the association between medical mistrust and the use of health services; the use of online tools to seek healthcare; and the staffing for and scope of services offered in student health centres (Basch et al., 2018; Burlaka et al., 2014; Davies et al., 2000; Dennis and Hicks, 2006; Eisenberg et al., 2009; Fortuna et al., 2009; Gavgani et al., 2013; Han and Pong, 2015; Lau et al., 2014; McBride et al., 2013; Mesidor and Sly, 2014; Nicoteri and Arnold, 2005; Price et al., 2013; Turner and Keller; Zhang, 2013). Similarly, the studies in India, Nigeria, Lebanon, Canada, Oman, Pakistan, Taiwan and Ghana focused on general healthcare-seeking behaviours among college students and the use of online tools in seeking healthcare (Afolabi et al., 2013; Ahmad et al., 2017; Ajaegbu and Ubochi, 2016; El Kahi et al., 2012; Kuuire et al., 2015; Luo et al., 2018; Menon et al., 2017; Moazzam et al., 2018; Osei Asibey, et al., 2017; Sultan et al., 2017; Vaz et al., 2012). Other studies outside of the US conducted in Saudi Arabia and the United Arab Emirates focused on whether being in a health sciences profession affected healthcare-seeking behaviour and the prevalence of self-diagnosis and self-treatment (Asraj et al., 2013; Sawalha et al., 2017).

We were able to identify the following themes: healthcare-seeking behaviour among college students; health information resource utilisation and its influence on healthcare-seeking behaviour; and barriers to accessing care among college students.

Healthcare-seeking behaviour among college students and young adults

Among the 28 articles reviewed, 14 articles focused on healthcare-seeking behaviour among college students and young adults. Of these studies, the following associated subthemes emerged in the studies: demographic variations, decision-making related to healthcare, accessibility, from whom advice is sought, for which conditions healthcare would be sought, overall expectations regarding healthcare and stigma associated with seeking care (Afolabi et al., 2013; Dennis and Hicks, 2006; El Kahi et al., 2012; Sultan et al., 2017). Three articles detailed the effect of studying in a health-related discipline on healthcare-seeking behaviours (Al-Asraj et al., 2013; Sawalha et al., 2017; Vaz et al., 2012). Five articles discussed healthcare-seeking behaviours related to mental healthcare (Burlaka et al., 2014; El Kahi et al., 2012; Menon et al., 2017; Mesidor and Sly, 2014). Table 1 provides a summary of each article related to healthcare-seeking behaviour among college students.

Table 1.

Healthcare-seeking behaviour among college students and young adults.

Author/year	Purpose	Population/design	Result/limitation
1. Afolabi et al., 2013^a	To examine health-seeking behaviour of university students, their use of healthcare services in the community and barriers to seeking help at the university health centre	1608 College students Mixed-methods study (questionnaire survey followed by focus group interviews)	1) University health centre was the last choice for care due to excessive waiting time 2) Cost of care posed the highest health-seeking barrier 3) Location was not a barrier
2. Al-Asraj et al., 2013	To assess the health-seeking behaviour of Saudi senior nursing students, and to evaluate whether it is influenced by their knowledge of health-related studies	74 Senior nursing students Mean age 22.7 ± 2.1 years Cross-sectional design with structured interview	1) 78.37% of the students stated that they only visited the doctor when they felt ill 2) 95% of the students used medications without prescription 3) 95.9% of the students believed that nursing and medical courses influenced their health behaviours
3. Burlaka et al., 2014	To gain perspectives on attitudes towards health-seeking behaviours associated with mental health problems of college students	College students (n = 40; mean age 20.6 years – focus group) Psychiatrists (n = 29; mean age 44.6 quantitative) Sequential mixed design	1) The least utilised mental health services are those provided by psychiatrists 2) The use of psychological services is a less popular choice among students 3) Students with mental health problems need two kinds of resources; continued emotional commitment and economic support
4. Dennis and Hicks, 2006	To conduct a baseline investigation of self-rated health behaviour and quality of life among college students	College students (n = 514; Aged 18–23 years, 68% women) Survey design	1) 39.3% first year students did not seek health care related to physical or psychological problems during the academic year compared to 29.9% non-first year students
5. El Kahi et al., 2012^a,^b	To assess the healthcare-seeking behaviour, barriers to accessing care and associated factors in Lebanese college students	College students (n = 543; aged 17–21) Cross-sectional survey	1) 69.9% sought informal help from family members; 35.7% sought formal healthcare from a physician or health facility; 57.2% that had psychological issues, 3.3% consulted a healthcare provider or health facility, 2.1% sought no help, while 76% sought informal help from family or friend (mostly friends) 2) Confidentiality and accessibility were barriers to health seeking
6. Fortuna et al., 2009^c	To characterise ambulatory care of young adults	Young adults (n = 13,897; aged 20–29) Cross-sectional survey study	1) Young men had lower rates of annual utilisation of ambulatory medical care per capita 2) Young men had nearly half the rate of preventive care visits and accessed care less than any other age group 3) Insured young adults had more annual visits per capita than those without insurance
7. Han and Pong, 2015	To explore the relationship between cultural contextual variables, demographic characteristics and willingness to seek mental health services and to examine factors contributing to mental health-seeking behaviours in Asian American community college students	Asian American community college students (n = 66) Cross-sectional survey study	1) Asian American college students conceptualised mental illness as controllable and personal and preferred self-help and self-control methods for dealing with difficulties 2) Asians are unlikely to seek help from mental health professionals due to stigma 3) Participants who identified as being American were more willing to seek mental health services, while participants who identified as being Asian were less willing to seek mental health services 4) Women are more likely to seek mental health help than their male counterparts
8. Kuuire et al., 2015^c	To examine the factors that influence healthcare services utilisation in a resource-poor setting	Randomly selected adults 18 years and older (n = 1137) Cross-sectional survey	1) Individuals who lived 0.5 km from a health facility, had secondary education and were traditionalists were less likely to seek treatment in a health facility 2) Individuals 35 years or older rated their health status as fair were more likely to seek treatment in a health facility
9. Lau et al., 2014^c	To examine young adults’ health care utilisation and expenditures prior to the Affordable Care Act	Young adults (n = 3768; aged 18–25) Retrospective survey study	1) Partially insured young adults used the emergency room more often than full-year privately insured young emergency room visits 2) Young adults without a usual source of care were less likely to use health services overall than those with a usual source 3) Women had significantly higher overall utilisation 4) Minority young adults were less likely to utilise healthcare overall and incurred lower expenditures compared to whites
10. Menon et al., 2017^a	To compare the self-reported barriers to healthcare seeking for mental and physical health services separately between 1st year and final year medical students	1st year medical students (n = 119) and final year medical students (n = 58) Cross-sectional study	1) There were differences between medical students in the 1st versus final year of medical school regarding self-reported barriers and perceptions 2) Lack of time, unawareness about where to seek help, cost issues and fear of future academic jeopardy were more common concerns among 1st year students to the usage of mental health services 3) Issues of stigma were more commonly reported by final year students for using mental health services
11. Mesidor and Sly, 2014	To investigate the extent to which social-cognitive factors and psychological distress predicted help-seeking intentions for international and African American college students aged 18 and above	College students (n = 111; 45.9% men) Cross-sectional survey study	1) Perceived behavioural control was the only social cognitive variable that was a significant predictor of intentions to seek mental health services 2) Perceived behavioural control and psychological distress were positively correlated with help-seeking intentions 3) Students who experienced psychological distress were more likely to seek out mental health services
12. Sawalha et al., 2017	To study and analyse the health-seeking behaviour of medical students, determine the prevalence of self-diagnosis and self-treatment behaviour among medical students in the University of Sharjah and identify the factors influencing medical student behaviour	Pre-clinical medical students (n = 152) and clinical medical students (n = 209) Cross-sectional study	1) Medical education, excessive waiting times, cost and inaccessible medical services affected student health-seeking behaviours 2) Self-prescription was the most common health-seeking behaviour 3) The majority of the students have the tendency to ignore a health problem 4) Medical education impacted the students’ health-seeking behaviour
13. Sultan et al., 2017^b	To study various types of health information-seeking behaviour among college students and to study the factors affecting students’ health information-seeking behaviour and sources of health information	College students (n = 200; aged 18–24) Cross-sectional survey study	1) <90% of the students are likely to seek information actively when they experience health problem 2) 65% of students often search for detailed information when they encounter health topics in the media 3) 86% of the students were likely to use family members as primary source of health information
14. Vaz et al., 2012	To study the health-seeking behaviour of medical students studying at a medical college	Medical students (n = 281) Cross-sectional study	1) Self-investigation and self-treatment is prevalent among the students 2) Students consulted informally with doctor or intern friends 3) There was a preference for private doctors compared to consultants in college

Barriers to accessing care among college students.

Health information resource utilisation and its influence on healthcare-seeking behaviour.

Healthcare-seeking behaviours among young adults.

Among the 28 articles, three of the reviewed articles examined healthcare-seeking behaviour in young adults with a large sample size (Fortuna et al., 2009; Kuuire et al., 2015; Lau et al., 2013). These three articles were included in this review because college students are often in this age range. Fortuna et al. (2009) conducted a national cross-sectional survey in the US, which examined 13,897 young adults aged 20–29 years and found that young adults who have insurance had more annual visits compared to those without insurance. In terms of gender, young men accessed healthcare less and nearly half the rate of preventive care visits than any other age group in addition to lower rates of utilisation of ambulatory care. Young black and Hispanic men had considerably lower annual visits compared to white young men. Kuuire et al. (2015) also conducted a cross-sectional study on adults aged 18 years and older on 1137 subjects (18–34 years, n = 672 vs. 35+ years, n = 465) examining the factors that influence healthcare service utilisation in a poor setting. They found that subjects who lived 0.5 km or more from a health facility, had secondary education and traditionalists (those who are resistant to change and an advocate of maintaining tradition) were less likely to seek treatment in a health facility; and especially poor subjects were less likely to seek treatment in health facilities even when they have health insurance. Likewise, Lau et al. (2013) conducted a retrospective study examining young adults’ healthcare utilisation and expenditures prior to the Affordable Care Act on 3768 young adults aged 18–25 years old. The results were similar to those of Fortuna et al. (2009) and Kuuire et al. (2015), who also added that young adults without a usual source of care were less likely to use health services compared to those with a usual source of care. Also, young adults with low income had the highest number of emergency room visits (Lau et al., 2013).

Dennis and Hicks (2006) conducted a baseline investigation of self-rated health behaviour and quality of life among college students. A total of 514 college students were included and data were collected using a survey. More first-year students failed to seek healthcare for physical and psychological problems during the academic year, compared to students in more advanced years of study.

In general, research has shown that being in a health-related discipline affects healthcare-seeking behaviours of college students. Vaz et al. (2012) studied the healthcare-seeking behaviour of medical students and found that self-investigation and self-treatment is prevalent among students, and interestingly students saw this behaviour as acceptable. Students consulted informally with doctors or intern friends, and there was a preference for private doctors compared to consultants. Al-Asraj et al. (2013) and Sawalha et al. (2017) had similar findings to Vaz et al. (2012). Al-Asraj and colleagues (2013) assessed healthcare-seeking behaviour of Saudi senior nursing students and evaluated whether their behaviour was influenced by their studies in a health-related area. Results indicated that the majority of students only visited the doctor when they felt ill, students used medications without prescriptions and students believed that nursing and other medical courses influenced their health behaviours. Sawalha et al. (2017) found factors affecting healthcare-seeking behaviours were medical education, excessive waiting times, cost and inaccessible medical services. Self-prescription was a common healthcare-seeking behaviour and the majority of students had a tendency to ignore a health problem. Overall, medical education impacted healthcare-seeking behaviour.

Burlaka et al. (2014) examined healthcare-seeking behaviours associated with the mental health problems of college students. These researchers found the least utilised mental health services are those provided by psychiatrists, the use of psychological services is a less popular choice among students, and students with mental health problems need both continued emotional commitment as well as economic support. Mesidor and Sly (2014) investigated the extent to which social-cognitive factors and psychological distress predicted helpcare-seeking intentions for international and African American college students, and they found that perceived behavioural control was a significant predictor of intentions to seek mental health services. This and psychological distress were positively correlated with help-seeking intentions; students reporting high psychological distress and perceived they had some control over the situation were more likely to seek mental health services.

Han and Pong (2015) also focused on mental healthcare-seeking behaviours, and explored the relationship between cultural contextual variables, demographic characteristics and willingness to seek mental health services. The results indicated that these students conceptualised mental illness as controllable and personal, and preferred self-help and self-control methods to manage life challenges. Also noted was that Asians were unlikely to seek help from mental health professionals due to stigma. Interestingly, participants identifying as American were more willing to seek mental health services compared to those identifying as Asian; women were also more likely to seek mental health services compared to their male counterparts. Menon et al. (2017) compared self-reported barriers to healthcare-seeking for both mental health and physical health services between first-year and final-year medical students. There were differences between the two groups in terms of perceptions and barriers to healthcare. Among first-year students, lack of time, unawareness about where to seek help, cost and fear of academic jeopardy were common barriers to mental healthcare. Issues surrounding stigma were reported by final-year medical students as it pertained to seeking mental health services. El Kahi et al. (2012) also examined healthcare-seeking behaviours related to mental health. Of the 57.2% that reported psychological issues, only 3.3% consulted a healthcare provider or facility. Confidentiality and accessibility were reported barriers to healthcare-seeking behaviours.

Health information resource utilisation and its influence on healthcare-seeking behaviour

Among the 28 articles, 12 of the reviewed articles examined health information resource utilisation and its influence on healthcare-seeking behaviour and their main methodology was a descriptive cross-sectional design. Of note, two of the 12 articles were referenced under this category and the healthcare-seeking behaviour among college students and young adults category because they also explored the factors that influenced healthcare-seeking behaviour (El Kahi et al., 2012; Sultan et al., 2017). In the 12 articles, six articles found that the subjects utilised the internet for health-related information as well as to make health decisions (Ahmad et al., 2017; Basch et al., 2018; Gavgani et al., 2013; Moazzam et al., 2018; Osei Asibey et al., 2017; Zhang, 2013). Five articles found that family members or friends who they can discuss with or who have experienced similar conditions were an important resource for their health information (El Kahi et al., 2012; Gavgani et al., 2013; Nicoteri and Arnold, 2005; Sultan et al., 2017; Zhang, 2013). These articles found that television, books and other traditional media sources were also utilised for health information. One article discussed perceived usefulness and information quality, and how these variables significantly encouraged users to seek health-related information on the internet (Ahmad et al., 2017). Table 2 provides a summary of each article related to health information resource utilisation and its influence on healthcare-seeking behaviour.

Table 2.

Health information resource utilisation and its influence on healthcare-seeking behaviour.

Author/year	Purpose	Population/design	Result/limitation
1. Ahmad, et al., 2017	To explore the factors that determine the behaviour of students seeking health-related information in the virtual world by analysing the role of perceived ease of usefulness, perceived usefulness, self-efficacy and information quality on the intention of the internet users to seek health-related information	210 College students (men n = 95). Above (n = 116) and below (n = 49) 25 years old Randomised controlled trials	1) Except self-efficacy, all other factors have a positive relationship with the intention of the users to seek health-related information 2) Perceived usefulness and information quality significantly encouraged users seeking health-related information over the internet than perceived ease of usefulness
2. Basch et al., 2018	To identify and assess the resources college students use when exercising health information-seeking behaviour and examine perceptions and behaviours regarding adoption of online tools	258 College students Cross-sectional survey study	1) 74% of participants used the internet for health information 2) Women were more likely to use the internet for health information, to consult a health professional and to confirm the health information they receive from a health or medical professional 3) Non-white students were significantly more likely to use the internet to find health information
3. Gavgani, et al., 2013	To increase the understanding of the ways that people find health information and to identify how people evaluate the roles of public libraries in providing health information	(n = 200; Mostly age 21–30) Descriptive study	1) Statistically significant relationship between education level and use of internet for seeking health information and between peoples’ age and job and ‘discussions with other people such as family, relatives or close friends’ for meeting health information needs 2) The most common resources for seeking health information were ‘TV’ and ‘discussions with others’
4. Luo, et al., 2018	To investigate the associations among gender, eHealth literacy, and health services utilisation	College students (n = 489; mean age 21.51 years) Cross-sectional survey study	1) College students with interactive eHealth literacy were more likely to have a higher rate of outpatient care use 2) College students with critical eHealth literacy were more likely to make full use of health services than those with functional eHealth literacy
5. McBride et al., 2013	To understand better the scope of services, utilisation, and staffing of student health services nationally.	College students (n = 172; aged 18–24) Cross-sectional survey study	1) Total medical visits per eligible student were higher at private campuses compared to public campuses
6. Moazzam et al., 2018	To determine that students’ health-seeking behaviour using the internet is an important part of making a health decision	University students (n = 300; aged 18–44) Cross-sectional survey study	1) Students used internet for their health decision 2) eHealth literacy influenced by age, gender, degree programme and semester 3) Demographic and educational background do not effect eHealth literacy
7. Nicoteri and Arnold, 2005	To gather qualitative data to help illuminate the process of the development of healthcare-seeking behaviours in traditional age undergraduate college students	Undergraduate college students (n = 8; aged 18–23). Qualitative study – focus group	1) Five major themes emerged: needing help or care, expectations, decision-making, healthcare accessibility and future needs 2) Participants perceive they make their own decisions regarding healthcare but seek advice from their families when they are ill 3) Participants expected healthcare on demand
8. Osei Asibey, et al., 2017	To investigate university students’ use of the internet for health purposes	650 University students (mean age 27 years) Cross-sectional study	1) 67.7% of participants use internet for health purposes
9. Turner and Keller, 2015	To describe the college health surveillance network methodology and present demographic, epidemiological and healthcare utilisation trends using 41 months of data from participating universities	Students from 23 universities (n = 730,785) Retrospective study	1) Over 800,000 individuals used the health centres, primary care visits (60%), mental health (13%), vaccination (9%), miscellaneous services (31%) 3) The five most common specific diagnostic categories were: preventive, respiratory, skin, hair and nails, infectious non-sexually transmitted infection and mental health
10. Zhang, 2013	To understand what sources college students use and prefer, and how they evaluate the sources	Undergraduate students (n = 20; aged 18–24) Qualitative study using interviews	1) Traditional internet sources as highly important sources for health information 2) Social ties were deemed important 3) Traditional media sources (books, newspapers, magazines and pamphlets) and mass media (TV) received a lower ranking but were still favoured 4) Web 2.0 sources were not favoured and were underused 5) Close to half mentioned the university health service as a source 6) Source accessibility, authoritativeness of the content, trustworthiness and usability were used as criteria for using the sources

Three of the 12 articles found that the student health centre was a source for their health information (McBride et al., 2013; Turner and Keller, 2015; Zhang, 2013). In particular, McBride and colleagues (2013) found that the student health centre visits were higher at private campuses compared to public campuses. Besides the health information resource utilisation, other influences on healthcare-seeking behaviour included eHealth literacy or the ability to search, find and use health information using electronic resources, source accessibility, authoritativeness of the content, trustworthiness, usability, perceived usefulness, information quality and self-efficacy (Ahmad et al., 2017; Luo et al., 2018; Moazzam et al., 2018; Zhang, 2013).

Barriers to accessing care among college students

Seven of the articles reviewed examined barriers to accessing care. Davies et al. (2000) conducted a study to identify college men’s health concerns, barriers to seeking help and recommendations to help college men adapt to healthier lifestyles. Themes emerging from this qualitative study were that the men’s socialisation to conceal vulnerability and to be independent was the greatest healthcare-seeking barrier. It was also noted that seeking counseling carried a greater social stigma than seeking medical services. Other barriers were lack of time, feeling invulnerable to health concerns and reluctance to use the student health centre because they erroneously believed that the centre was staffed by trainees rather than trained medical professionals. Other barriers to accessing care noted in the literature include accessibility (El Kahi et al., 2012), fear of side effects, fear of unwanted intervention, fear of impact on academic performance, being unsure of where to seek help and lack of confidentiality (Menon et al., 2017). In addition, there is a greater mistrust of healthcare organisations leading to underutilisation of health services, including failure to take medical advice, failure to seek needed medical care, failure to fill a prescription, postponing needed medical care, failure to keep a follow-up appointment and the student health centre being the last choice of care for students due to the cost of care. Cost of care was the highest barrier to healthcare-seeking behaviour, while the location of the health centre was not a barrier for students (Afolabi et al., 2013; Price et al., 2013). Other findings included using the community pharmacy, using herbs as a treatment method because of the perception that they are more effective than other health interventions and personal stigma being associated with the use of the health centre (Ajaegbu and Ubochi, 2016; Eisenberg et al., 2009). Table 3 provides a summary of each article related to barriers to accessing care among college students.

Table 3.

Barriers to accessing care among college students.

Author/year	Purpose	Population/design	Result/limitation
1. Ajaegbu and Obochi, 2016	To investigate various health-seeking behaviours exhibited by undergraduates in the Department of Health Science and Technology	302 College students 162 men (mean age 25 ± 3 years) 140 women Cross-sectional survey study	1) Students utilise community pharmacy, they feel it is cheaper and saves time 2) Student use herbs because they feel they are more effective than other health helps 3) Students use health institutions because they believe their symptoms are major and that treatment from this source is more effective
2. Davies et al., 2000	To identify college men’s health concerns, barriers to seeking help and recommendations to help college men adopt healthier lifestyles	Male college students (n = 49) Qualitative study	1) The number one barrier to health-seeking behaviour was socialisation followed by counseling, lack of time and feeling invulnerable 2) Participants were reluctant to use the health centre because they believed that the centre was staffed by trainees rather than trained medical professionals
3. Eisenberg et al., 2009	To identify the association between help-seeking behaviour and perceived public stigma and people’s own stigmatising attitudes	College students (n = 5555, age ≥18 years old) from 13 universities Women (n = 3435) Cross-sectional survey study	1) Perceived public stigma was considerably higher than personal stigma 2) Personal stigma was higher among students with the following characteristics: male, younger, Asian, international, more religious, or from a poor family 3) Personal stigma was significantly and negatively associated with measures of help seeking
4. Price et al., 2013	To develop a college student’s mistrust of healthcare organisations scale and determine the relationship between medical mistrust with the use of a variety of healthcare services	College students (n = 545, aged 19–26) Convenience sample – four groups (n = 80)	1) Higher mistrust of healthcare organisations found to be statistically significantly associated with all five measures of underutilisation of health services: failure to take medical advice, failure to seek needed medical care, failure to fill a prescription, postponing needed medical care and failure to keep a follow-up appointment

Discussion

Articles included in this review were from studies conducted both in the US and in other countries. Of the 28 review articles on college students’ healthcare-seeking behaviour, the common themes were the consideration of the healthcare-seeking behaviour among college students, health information resource utilisation and its influence on healthcare-seeking behaviours and barriers to accessing care among college students. This review asserts that there are different demographics and characteristics that contribute to the differences in healthcare-seeking behaviours in college students and young adults. This contributed to the underutilisation of healthcare by college students and young adults, resulting in the implication that healthcare providers should be approaching this population proactively with a focus on preventive care services.

Major themes noted included general behaviours, the influence of studying in a health-related discipline and behaviour specific to mental health. Demographic variations emerged in the review, and young men are noted to access healthcare significantly less frequently than any other age group. In addition, young black and Hispanic men had considerably lower annual visits compared to young white men. These findings are in line with the older adult population as well in that African Americans were less likely to seek care, pertaining only to using health technology (Bhuyan et al., 2016). Targeted efforts towards young men for preventive screenings will help to address this disparity. Another common barrier was distance from a healthcare facility. Those who lived more than 0.5 km from a facility were less likely to seek care; therefore, efforts should be made to reach this population closer to where they frequently visit, such as at home, at school, or in commonly visited places such as the grocery store or mall by using outreach efforts and mobile health clinics. Another finding was that those who were traditionalists were less likely to seek care. Healthcare delivery efforts need to be creative in their approach to target this population.

First-year college students are less likely to seek care. Including healthcare access information in programme orientation may be helpful. Underutilisation and using alternatives to formal care could be addressed by healthcare administrators by increasing the ease of filling prescriptions, instituting a process for follow-up communication, decreasing wait times and offering student health insurance or subsidised expenses. Strategies such as health fairs and community outreach events could help to increase engagement in preventive services among this population, while addressing personal stigmas and alternative preferences.

Students studying in a medical-related discipline have both advantages and disadvantages as it relates to healthcare-seeking behaviours. In particular, seeking care informally may lead to medical issues being inadequately addressed and may leave the student without needed treatments and referrals. Including this as an aspect of their education may also be beneficial. Understanding the experience of a college student shines a light on the idea that mental health issues are likely to surface while in college. Taking a proactive approach in mitigating these issues may be helpful, perhaps by offering support services early on to students who are notably struggling academically or in any other way. It is important to note as well that Asians and women are less likely to seek mental healthcare when needed, so these students should be monitored closely for signs of struggles with mental health. Of note, no literature was located addressing older adults’ healthcare-seeking behaviour patterns pertaining to mental health. Having a department within the college that focuses on the mental health needs of students would likely be a heavily utilised resource. All of the described recommendations have the potential to promote success among young adults and college students, which will contribute to their success in higher education overall.

Unfortunately, despite the availability of a student health centre; very few articles identified college students’ utilising the student health centre as a source for their health information. It was more prevalent among the studies that the internet, family members or friends and other media resources were utilised more for their health information. This may be problematic due to the reliability of these resources that the students tend to seek for their health information and health decision compared to the student health centre or their healthcare provider. Interestingly, we found that one reason a sample of college students did not utilise the student health centre is because they believed that the health centre was staffed by trainees rather than trained medical professionals. This misconception dramatically affected their healthcare-seeking behaviours and correcting this would greatly benefit this population, which should be done sooner than later. In addition, contrary to the older adult population, a sample of college students identified healthcare providers as their main resources for their health information and health decisions whereas social media such as the internet is the last on their list for health information (Chaudhuri et al., 2013).

This review emphasised the importance of lack of time, feeling invulnerable to health concerns, access to care, cost, confidentiality, fear and most importantly the stigma to show vulnerability in young men as barriers to seeking healthcare. The majority of these barriers are not new or unique in college students and were also found in other populations (Thompson et al., 2016). The unique barriers to college students are fear and showing vulnerability. The good news is that if these are truly based on misconceptions from the college student population, the most basic intervention would be delivering knowledge education as the initial step which should also include debunking the student health centre staffing. This can be done creatively during one of the events that are hosted for incoming students, such as orientation or welcome-back events.

Recommendations for future research

The current state of the research on healthcare-seeking behaviours for college students reveals some identifiable patterns which can guide future research efforts. Learning more about the determinants specific to the male population, especially black and Hispanic men, would be helpful in encouraging healthy behaviours. Researching interventions aimed at bringing healthcare to those who are not able to travel is needed. Learning more about the perceived barriers for those who have secondary education, traditionalists and first-year students would be helpful in addressing their needs. Gearing research towards targeted interventions that are unique to addressing the needs of the college student population with regards to mental health is important at this time. Finally, researching interventions addressing lack of time, invulnerability, access to care, cost, confidentially and fear will prove useful based on this review.

Conclusions

College students are prone to certain health risks due to some of the experiences they have that are inherent to life circumstances as a student. They are known for significant health risks related to stress, poor sleep habits, sexual activity, poor diet, lack of activities and tobacco, alcohol and drug use. The findings of this review summarise the current body of knowledge related to healthcare-seeking behaviour among college students, health information resource utilisation and its influence on healthcare-seeking behaviour and barriers to accessing care among this population. Taking important measures to address further the health needs and to research interventions for addressing these needs among the college student population is imperative.

Key points for policy, practice and/or research

College students have identifiable patterns associated with healthcare-seeking behaviour.

Health information resource utilisation has an influence on healthcare-seeking behaviours among college students and young adults.

Barriers to care are evident among college students and young adults as a population.

Targeted efforts to increase healthcare utilisation can be employed based on healthcare-seeking behaviours especially nurses during the assessment encounter.

Footnotes

Declaration of conflict of interests

The author(s) declared no potential conflict of interest with respect to the research, authorship and/or publication of this article.

Ethics

Not applicable due to the review nature of this paper.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Dieu-My T Tran

Dieu-My T Tran earned her BSN and PhD from the University of Nebraska Medical Center, Nebraska, USA. She is an Assistant Professor at the University of Nevada Las Vegas (UNLV): School of Nursing.

Angela Silvestri-Elmore earned her BSN at Salve Regina University and PhD from UNLV. She is an Assistant Professor and BSN program Director for UNLV.

References

Afolabi

Daropale

Irinoye

, et al.(2013) Health-seeking behaviour and student perception of health care services in a university community in Nigeria. Health 5(05): 817.

Ahmad

Khan

Rahman

(2017) Exploring the use of internet by university students for seeking health related information. Interactive Technology and Smart Education 14(4): 279–295.

Ajaegbu

Ubochi

(2016) Health seeking behaviour among undergraduates in the faculty of health sciences and technology, University of Nigeria Enugu Campus. International Journal of Evaluation and Research in Education 5(3): 181–188.

Arts

Fernandez

Lofgren

(2014) Coronary heart disease risk factors in college students. Advances in Nutrition (Bethesda, Md.)5(2177–187. DOI: 10.3945/an.113.005447.

Al-Asraj

Habib

Binahmed

(2013) Assessment of the health seeking behavior of senior nursing students in Saudi Arabia. J Edu Pract 4(10): 31–37.

Basch

MacLean

Romero

, et al.(2018) Health information seeking behavior among college students. Journal of Community Health 43(6): 1094–1099.

Bhuyan

Chandak

, et al.(2016) Use of mobile health applications for health-seeking behavior among US adults. Journal of Medical Systems 40(6): 153.

Bonnie

Stroud

Breiner

(2014) Investing in the health and well-being of young adults, National Academies Press.

Burlaka

Churakova

Aavik

, et al.(2014) Attitudes toward health-seeking behaviors of college students in Ukraine. International Journal of Mental Health and Addiction 12(5): 549–560.

10.

Champlin

Nisbett

(2018) Promoting mental health resource use on campus by “Trying something new”. American Journal of Health Promotion 32(4): 1140–1144.

11.

Chaudhuri

White

, et al.(2013) Examining health information-seeking behaviors of older adults. Computers, Informatics, Nursing: CIN 31(11): 547–553. DOI: 10.1097/01.NCN.0000432131.92020.42.

12.

Davies

McCrae

Frank

, et al.(2000) Identifying male college students’ perceived health needs, barriers to seeking help, and recommendations to help men adopt healthier lifestyles. Journal of American College Health 48(6): 259–267.

13.

Deasy

Coughlan

Pironom

, et al.(2014) Psychological distress and lifestyle of students: Implications for health promotion. Health Promotion International 30(1): 77–87.

14.

Dennis

Hicks

Health behavior patterns among first-year and non-first-year college students attending a North Carolina historically black university. Journal of College Orientation, Transition, and Retention 13(2): 10–17.

15.

Eisenberg

Downs

Golberstein

, et al.(2009) Stigma and help seeking for mental health among college students. Medical Care Research and Review 66(5): 522–541.

16.

El Kahi

Abi Rizk

Hlais

, et al.(2012) Health-care-seeking behaviour among university students in Lebanon. Eastern Mediterranean Health Journal 18(6): 598–606.

17.

Fortuna

Robbins

Halterman

(2009) Ambulatory care among young adults in the United States. Annals of Internal Medicine 151(6): 379–385.

18.

Gavgani

Qeisari

Jafarabadi

(2013) Health information seeking behavior (HISB): a study of a developing country. Health 2: 1–2013.

19.

Green

Grant

Hill

, et al.(2003) Heart disease risk perception in college men and women. Journal of American College Health 51(5): 207–211.

20.

Han

Pong

(2015) Mental health help-seeking behaviors among Asian American community college students: the effect of stigma, cultural barriers, and acculturation. Journal of College Student Development 56(1): 1–14.

21.

Hunt

Eisenberg

(2010) Mental health problems and help-seeking behavior among college students. Journal of Adolescent Health 46(1): 3–10.

22.

Keeton

Soleimanpour

Brindis

(2012) School-based health centers in an era of health care reform: building on history. Current Problems in Pediatric and Adolescent Health Care 42(6): 132–156.

23.

Kenney

LaBrie

Lac

(2013) Injunctive peer misperceptions and the mediation of self-approval on risk for driving after drinking among college students. Journal of Health Communication 18(4): 459–477.

24.

Kuuire

Bisung

Rishworth

, et al.(2015) Health-seeking behaviour during times of illness: a study among adults in a resource poor setting in Ghana. Journal of Public Health 38(4): e545–e553.

25.

Lau

Adams

Irwin

Jr , et al.(2013) Receipt of preventive health services in young adults. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine 52(1): 42–49. DOI: 10.1016/j.jadohealth.2012.04.017.

26.

Lemly

Lawlor

Scherer

, et al.(2014) College health service capacity to support youth with chronic medical conditions. Pediatrics 134(5): 885–891. DOI: 10.1542/peds.2014-1304.

27.

Luo

Yang

Chen

, et al.(2018) Associations of eHealth literacy with health services utilization among college students: cross-sectional study. Journal of Medical Internet Research 20(10): e283.

28.

Lynch

Liu

Kiefe

, et al.(2006) Cardiovascular disease risk factor knowledge in young adults and 10-year change in risk factors: the Coronary Artery Risk Development in Young Adults (CARDIA) study. American Journal of Epidemiology 164(12): 1171–1179.

29.

McBride DR, Van Orman SM, Wera C, et al. (2013) 2010 Survey on the utilization of student health services.

30.

Menon

Sarkar

Kumar

(2017) A cross-sectional analysis of barriers to health-care seeking among medical students across training period. Journal of Mental Health and Human Behaviour 22(2): 97.

31.

Mesidor

Sly

(2014) Mental health help-seeking intentions among international and african american college students: an application of the theory of planned behavior. Journal of International Students 4(2): 137–149.

32.

Moazzam

Anwer

Atique

, et al.(2018) Perceived health literacy and health information seeking behavior among university students in Pakistan. Advances in Medical, Dental and Health Sciences 1(1): 5–7.

33.

Nicoteri

Arnold

(2005) The development of health care-seeking behaviors in traditional-age undergraduate college students. Journal of the American Academy of Nurse Practitioners 17(10): 411–415.

34.

Osei Asibey B, Agyemang S and Boakye Dankwah A (2017) The internet use for health information seeking among Ghanaian university students: a cross-sectional study. International Journal of Telemedicine and Applications 1–90.

35.

Price

Kirchofer

Khubchandani

, et al.(2013) Development of a college student’s mistrust of health care organizations scale. American Journal of Health Education 44(1): 19–25.

36.

Romero

McMahan

Cathorall

(2005) Cardiovascular disease (CVD) risk: should we target college women. Canadian Journal of Public Health 3(1): 117–129.

37.

Sawalha

Salih

, et al.(2017) Health seeking behavior among medical students in the University of Sharjah. Journal of Pharmacy and Pharmacology 5: 561–564.

38.

Stroud

Walker

Davis

, et al.(2015) Investing in the health and well-being of young adults. Journal of Adolescent Health 56(2): 127–129.

39.

Sultan

Joshua

Misra

(2017) Health information seeking behavior of college students in the Sultanate of Oman. KMUJ: Khyber Medical University Journal 9(1): 8–14.

40.

Thompson

Anisimowicz

Miedema

, et al.(2016) The influence of gender and other patient characteristics on health care-seeking behaviour: a QUALICOPC study. BMC Family Practice 17(1): 38.

41.

Turner

Keller

(2015) College health surveillance network: epidemiology and health care utilization of college students at US 4-year universities. Journal of American College Health 63(8): 530–538.

42.

US Census Bureau (2018) Quick facts: United states. Available at: https://www.census.gov/quickfacts/fact/table/US/PST045218 (2018, accessed 11 August 2020).

43.

US Department of Education, National Center for Education Statistics (2018) College enrollment rates. National Center for Education Statistics. Available at: https://nces.ed.gov/programs/coe/indicator_cpb.asp (2018, accessed 11 August 2020).

44.

Vaz

Ferreira

Kulkarni

, et al.(2012) Study of health seeking behavior among medical students in Goa, India. Asian Journal of Medical and Clinical Sciences 1(3): 140–141.

45.

Zhang Y (2013) An exploratory study of users’ preferences and use of sources for seeking health information. iConference 2013 Proceedings (pp. 38–49). DOI: 10.9776/13130.