College Students’ Preferences for Health Care Providers when Accessing Sexual Health Resources

Abstract

Objective

Many emerging adults (18–25 year olds) report unmet health needs and disproportionately experience problems such as sexually transmitted infections. This study was conducted to examine college students’ perceptions of health care providers, specifically in the context of accessing sexual health resources.

Design and Sample

Students (N=52) were recruited from five diverse colleges in one state to participate in a one-to-one interview that involved walking and virtually exploring resources on and near campus. Interviews were conducted from May to November 2010.

Results

Inductive qualitative analysis yielded six themes summarizing students’ perceptions of provider characteristics, health care resources, the role of their peers, and students’ suggestions for strengthening health care services. Importantly, students consider a variety of staff—and their student peers—to be resources for sexual health information and services.

Conclusions

Findings emphasize the importance of collaboration between health service staff and broader campus staff because students often turn to campus staff initially. Post-secondary students welcome opportunities to know a provider through interactive websites that include details about providers on campus; their decisions to seek sexual health care services are influenced by their perceptions of providers’ characteristics and interpersonal skills.

Introduction

Despite being a relatively healthy population, emerging adults (18–25 year olds) disproportionately experience some health problems that could be minimized with timely attention and intervention. When left unaddressed these problems can yield serious negative consequences. Examples include sexually transmitted infections (STIs) [Center for Disease Control & Prevention, 2009], substance use and addictions, and mental health problems (Hunt & Eisenberg, 2010; Twenge, Gentile, DeWall, Ma, Lacefield & Schurtz, 2010). Unlike adolescents, who often rely on parents to schedule and facilitate health care appointments, emerging adults are learning to act much more independently in many aspects of life including their health care seeking (Arnett, 2000). Simultaneously, they are embarking on new educational or career endeavors; one result is that emerging adults in the United States (U.S.) are the cohort that is the least likely to have health insurance coverage, compared with all the other age groups (Collins, & Nicholson, 2010).

Many emerging adults report unmet health care needs (Marshall, 2011) and encounter barriers to accessing health care, such as lack of knowledge about an appropriate new health care provider (needed because they have outgrown their pediatrician or moved to attend college in another city), concerns related to health care coverage (i.e., lack of coverage, or dependent care coverage that results in parents receiving documentation of sought care; Frerich et al, 2012; Allen, Glicken, Beach, & Naylor, 1998), logistics (i.e., location/hour of services, schedule conflicts), and perceptions about the need for care and benefits of seeking care. In addition, young adults face help-seeking barriers associated with perceptions of health care provider and staff characteristics and actions. These include a perception of the provider as not being able to ensure confidentiality (Roth, Van Der Pol, Dodge, Fortenberry & Zimet, 2011), or the provider being judgmental (Baldwin, Johnson, Gotz, Wayment, Elwell, 2006), hostile (Campbell, Auerbach, Kiseler, 2007), discriminatory (Heistand, Horne & Levitt, 2007), or unprofessional (Roth et al., 2011). Non-malleable provider characteristics have been shown to influence care-seeking, including gender (Balfe, Brugha, O’Donovan, O’Connell & Vaughan, 2010) and professional level (Baldwin et al., 2006).

Differences in help-seeking for sexual health concerns have been documented based on the gender and sexual minority status of the emerging adult (Allen et al., 1998; Heistand et al., 2007; Balfe et al., 2010; Marshall, 2011). For example, females are more likely than males to discuss sexual behavior, broadly, with their provider, yet males and females are equally likely to talk about specific prevention of a sexually transmitted infection (Merzel, Vandevanter, Middlestadt, Bleadley, Ledsky, Messeri, 2004). Certainly, knowledge about how barriers and facilitators to health care seeking might vary by gender or sexual minority status is vital to health care providers who are seeking to provide preventive sexual health care and interventional care.

For providers working in college health services, or in health care settings nearby but not located on campus, it is important to understand not only the differences in how male and female students perceive potential providers, but also how these perceptions might vary based on college type. In fall 2008, there were 12.1 million students attending 4-year institutions for post-secondary education in the U.S., and 7.1 million students attending 2-year institutions (Institute of Education Sciences, National Center for Education Statistics, 2010). To date, no study has examined the ways in which students’ perceptions vary depending on if they are attending a 2-year or 4-year institution. Our previous work suggests that student expectations of sexual health resources vary by type of college (Eisenberg, Garcia, Frerich & Lust, 2012; for example, students attending two-year colleges do not expect the depth of sexual health resources that are expected by students attending four-year colleges. Gaining additional insights about perceptions of health care providers has the potential to further inform sexual health outreach efforts to emerging adults attending college in the U.S. and strengthen these resources. Therefore, the purpose of this study was to examine college students’ perspectives on health care provider characteristics, and trends in perspectives by student gender and college type.

Design and Sample

The study team conducted interviews with 78 post-secondary students about college sexual health resources, including 52 who provided information relevant to the present analysis. This qualitative study was approved by the Institutional Review Board at the University of Minnesota—Twin Cities and by each of the participating institutions’ Review Boards.

We recruited a sample of two- and four-year students from diverse college environments. All participants were recruited from five colleges in one Midwestern state. Campuses were selected because there was administrative willingness to participate, and because they represented a diversity of campus type (i.e., campuses included two-year and four-year institutions, both public and private, in metropolitan and non-metropolitan locations). Additional care was taken to ensure diversity of participants’ gender, race/ethnicity, and class year through our recruitment efforts, including a wait-list strategy.

Recruitment by two graduate research assistants included tabling (i.e., sitting at a table with brochures and inviting students to come hear about the study) in high-traffic areas of each campus, and fliers and tailored email announcements from Health Service on certain campuses. Students were eligible for participation if they were between 18–24 years of age and had neither worked nor volunteered for the campus Health Service. We obtained written informed consent from all participants. Additional details of the sample and recruitment are available elsewhere (Eisenberg et al. 2012; Garcia, Eisenberg, Frerich, Letner, & Lust, 2012).

Measures

We used a four-question, semi-structured interview guide for each go-along interview to explore students’ perceptions of sexual health resources on campus (See Table 1). A go-along interview is conducted by moving through a physical or virtual environment (i.e., college campus, world wide web) at the guidance of the participant, as compared with an interview conducted in a single location (e.g., office, meeting room) (Carpano, 2009). The go-along interview technique encourages the participant to choose each relevant destination, making it a particularly good methodological fit for this study’s research questions about campus resources. Interviews were conducted by a co-investigator and two trained graduate assistants; training included strategies for effective interviewing, shadowing at least one interview, and mock interview practice. Example probe questions that yielded elaboration on comments about provider characteristics include: “What makes a [professor/provider/doctor] approachable?”, “You said [campus staff/health care provider] was nice, what does that mean?”, and “Tell me a little more about ‘approachable.’”

Table 1.

Interview Guide

Type of Question	Question Wording
Introductory	If you wanted to get a snack on campus, where would you go?
Content	How do you find information on sexuality, or sexual health at [name of college]?
Content	If you had a sexual health concern – say a friend came to you and thought they had an STI – what could [name of college] do to help?
Content	Do you have a clear idea of what [name of college] wants for students in terms of their sexual health?
Content	You’ve given me a lot of examples of sexual health resources at [name of college]. Can you tell me what your top five most important or helpful resources on campus would be, including what is actually here and any other ideas you might have?

Analytic Strategy

All interviews were audio recorded with lapel microphones, professionally transcribed, and checked for accuracy by study staff by reading the transcript while listening to the audio recording. The finalized transcripts were entered into the qualitative software ATLAS.ti (Muhr, 2010). We conducted inductive, descriptive, simultaneous coding (Garcia et al, 2012; Saldaña, 2009); the coding team (a co-investigator with qualitative research expertise and two trained graduate assistants) generated a codebook (alphabetical list of descriptive labels assigned to sections of text) after coding three interviews. This codebook was used independently by each coder. If a new idea was identified while coding a transcript, the coder added the code, rechecked previous transcripts to be sure the idea was not missed or represented by an existing code, and informed the other coders of the additional code. Research team discussions about codes or their meanings ensured consistency across the coding team. Inter-coder reliability was high (.88), confirmed with 10% of the transcripts coded by two team members independently and then compared for congruence.

Fifty-two participants described characteristics they prefer, and prefer to avoid, when they are seeking help to address a sexual health concern. These preferences were coded and organized into representative thematic areas that facilitated examination of similarities and differences by gender and college type. Differences in characteristic preferences were noted by gender and college type; however, no differences were observed by ethnicity or college location (i.e., rural, urban). The six themes are: “Providers need to know their stuff”, “I want someone warm and welcoming”, “My resource to other resources”, “Gender matters, for the most part”, “When intimidated, I turn to my peers (or a cool professor)”, and “How to meet my needs.” Each is described below.

Results

Demographic characteristics for the participants are provided in Table 2 and, generally, the sample reflects greater ethnic diversity than that of the participating colleges.

Table 2.

Characteristics of participants (N=52)

Characteristics	Participants n (%)
Gender
Female	25 (48%)
Male	27 (52%)
Race
White	31 (60%)
Individuals of Color	21 (40%)
Mean age (range=18–24)	20.4
Mean year in School (range=1–4)	2.54
College type
2 year	23 (44%)
4 year	29 (58%)

Although there was not a specific question regarding the characteristics of a provider, participants frequently mentioned aspects of providers when they described existing or desired sexual health resources on campus, leading our research team to investigate the data specific to provider characteristics. Participants identified a range of campus staff they viewed as a resource for sexual health information or care, which included, but were not limited to, health care providers. Participants also described personnel that they would not consider a resource for sexual health for a variety of reasons, such as a teacher or counselor, although this was not consistent across participants. Notably, fewer students from 2-year colleges identified personnel as resources for sexual health (10 2-year students, 20 4-year students) and more females than males identified peers as resources (8 females, 4 males).

Participants’ descriptions of what they look for in health care providers were organized into the following themes: “Providers need to know their stuff”, “I want someone warm and welcoming”, “My resource to other resources”, “Gender matters, for the most part”, “When intimidated, I turn to my peers”, and “How to meet my needs”. These are described in detail below.

Providers need to know their stuff

Not surprisingly, it was important to many college students that the person they seek out for sexual health information is knowledgeable and a professional. As Dave shared, “I would want to talk to somebody that has a decent background in that, a nurse or a doctor of some sort, or a psychologist that deals with sexual-type things.” An appropriate background (i.e., being a nurse, a doctor) was mentioned by males and females on both 2- and 4-year campuses. An interesting opinion emerged regarding perceived limitations of campus-based clinic providers and services; for example, Charity, a student attending a 4-year institution, with a solid health services infrastructure, shared her reasons for returning to an off-campus primary care provider rather than seeking care on campus,

“Well, I usually go to a regular doctor, because I trust them more… I guess if you want a real, real doctor that works in an actual hospital or clinic, I would go there. Here, it’s pretty much the same, but just in the college community, so it feels different. When I go in there, I just feel like they don’t have the technology that real doctors do, so they have to send stuff out and then bring it back.”

I want someone warm and welcoming

Many of the students (n=17; 33% of sample) described provider characteristics that make someone more personable, and therefore more likely to be approached by a student with a sexual health concern. These included providers being caring, welcoming, understanding, friendly and nonjudgmental, making a student feel comfortable, ensuring students’ care was confidential, and listening carefully. Students contrasted these desired attributes with providers who would not be sought out, such as those who are overpowering, judgmental, and make the student feel stupid or uncomfortable. Students shared specific examples of how these qualities were exhibited; for example, a provider being willing to take time and not be rushed from appointment to appointment was very important to males and females on both campus types.

Verbal and nonverbal behaviors of providers were also specified, such as Edwin shared, “[the good providers] look into your eyes when you’re talking…they talk with you, not down to you.” Provider attire was mentioned as a possible deterrent to seeking care by two students at two-year colleges; as Alonzo shared, “I want somebody who’s just in a t-shirt and jeans, somebody I can relate to, not somebody who’s dressed up in a suit.” Opinions on these characteristics did not vary by gender or campus type; however, the two students that commented explicitly on attire were African American and enrolled at a two-year institution and there were no similar comments from students attending 4-year institutions.

My resource to other resources

Participants valued individuals who facilitated their access to sexual health resources on and off campus. Although health care providers were identified, students more often described other people they would seek out for accessing resources. For example, students described their professors or academic advisors; Crystal shared “Because we always talk about sexual things that people have, in terms of whether you’re gay or lesbian and you have confusion about that. We talk about that in class” and Dao-Ming similarly said, “Another great way to ask about any sexual resources is just through our academic advisors. They have a lot of information and resources. Just ask them [academic advisors] and they will refer you to the resources.” Others identified health centers or resource centers designed to promote the well-being of women or vulnerable students; for example, Michelle shared, “it’s called the [name of resource center]. They kind of focus on the same thing that the counseling office focuses on.” Not everyone concurred that academic staff were an adequate or appropriate resource. Andy shared, “More seriously, Planned Parenthood would have a lot more access to resources or help paying for contraceptives and getting to treat diseases. I think they would have a lot more medical resources than a teacher would.”

Gender matters, for the most part

Across genders and campus types, opinions were offered about the gender match, or not, between a health care provider and student seeking sexual health services. Males opined about being cared for by a male or female provider, such as when Ahanu shared, “Well, the fact that he’s male, I think, helps…” John added, “I’d prefer talking to him [trainer] instead of the assistant because he’s a man and she’s a woman, and I feel more comfortable talking to someone of the same gender than someone of the opposite sex.” Females also consistently concurred that gender mattered. Meredith shared, “I don’t know if it’s being a woman or something, and she seemed approachable, but it kind of makes sense to me to go to her in that aspect, too” and Charity added, “I probably wouldn’t go to him if I was pregnant; I would probably go to a woman teacher because they know more, obviously…She would point me in the right direction, because she’s had kids before and been in our place.” No differences were observed by campus type.

When intimidated, I turn to my peers

Many students described the importance of peers as resources for sexual health information, and often contrasted and explained reasoning for turning to a peer for information or support rather than adults or specifically, health care providers. Colin shared, “I think if younger people taught us about this stuff [sexual health], like maybe RAs, and hall directors instead of older doctors or therapists, I think it [would] get across more…someone who can relate more to sexual health in the 2000’s.” Edwin linked this preference to generational value shifting, while perpetuating a belief that providers are “older” or “elders” as he shared, “You want to hear from your peers. You don’t want to hear from your elders, because in today’s society, it’s sad to say, but we don’t respect our elders.” These opinions were represented by both genders and campus types.

How to meet my needs

Students shared specific suggestions for what providers could consider doing to improve the likelihood that they would access care on campus. In addition to suggestions such as displaying pictures and providers providing information about themselves on the clinic website or posted on a bulletin board by the clinic, the students wanted opportunities to personally interact with the providers before seeking care. It was evident that students welcomed mechanisms for getting to know health care providers so that they could have confidence that the provider had the qualities they sought. For example, John shared “I think it’d be helpful if they had the actual people from there, like health services…so they [students] could personally meet them [providers]” at campus events or in comfortable campus settings such as student lounges or dining areas.

Some students also recommended use of specific mechanisms to reach them [students] with information. The use of technology was suggested for two purposes: to increase their likelihood of accessing services, as Meredith shared, “I’d call on the phone and I could hide behind it” and to encourage greater visibility of the available services and of sexual health messaging, as Edwin stated,

“Since our world is so reliant on technology nowadays, why not make an ad from students to students, from teens to teens, age group to age group? Put it on You Tube, put an easy keyword search if one wants to learn more, purchase ad time, purchase feature time, so once you go on a page, that’s the video that’s being featured. [Use] word of mouth [to] make it more viewed so it could hit the news…ads promoting better sexual health from students to students”.

Discussion

The purpose of this study was to examine college students’ perspectives on health care provider characteristics and to explore how these perspectives varied by gender and by campus type. Our study results demonstrate that college students pay attention to health care provider characteristics when they consider seeking care for sexual health concerns. Our findings shared similar messages across participant gender or college type regarding what is important to college students in a health care provider. The absence of large differences across gender, college type, or ethnicity with respect to qualities sought in a health care provider could indicate greater universality among young people than one might anticipate. Rather than attempting to address differences that don’t necessary exist in preferences, providers can focus on building skills that strengthen communication with young adults, and ensuring their professional qualifications and expertise.

Interestingly, these students described complex perspectives regarding provider characteristics. On the one hand, they articulated wanting providers to be professional, appropriately credentialed, and qualified to address their sexual health needs or concerns. On the other hand, many of the students wanted health care providers to be approachable.

In addition, our study identified new insights that have potential to positively influence college students’ sexual health care seeking. Looking across the six themes, it is notable that students identified a variety of staff they would turn to on campus for sexual health information, including teachers/professors, sports trainers, academic counselors, and—for those residing in dormitories—residence hall advisors, as well as staff at numerous off-campus community-based settings. These findings emphasize the critical importance of collaboration between health service staff, other non-clinic campus staff, and community-based agency staff. For example, clinic staff might facilitate educational meetings that provide campus staff and community partners with information about existing sexual health resources and infrastructure, and simultaneously, encourage an exchange of information and collegial networking that could foster referrals of students to the clinic or a nearby community-based agency. Many two-year institutions do not have health care services on the campus but often have staff or a designated resource person to assist students in obtaining health care; in these situations, the nearby community-based clinic staff might similarly offer opportunities to outreach to campus staff to increase awareness of services and stimulate referrals to their clinic. To our knowledge these types of cross-campus and community, interdisciplinary collaborations between clinic staff, other campus staff, and community partners are not consistently occurring, despite the potential benefits to all parties.

Students also expressed an interest in increasing their awareness of available services through the use of technology. Being that each postsecondary campus is a unique environment it may be beneficial for campus staff to explore the e-technology and mHealth (i.e., use of mobile telecommunication via texting or applications “apps” to educate about health care services or resources) needs of their students through the use of focus groups or other evaluation methods. Gathering data pertinent to their student body would facilitate the best way to balance student needs with specific, individualized campus- and community-based resources.

The students overwhelmingly emphasized the importance of peers as sources of information when they have sexual health concerns or questions. Peer education outreach programs are commonly instituted on college campuses to encourage student health, including sexual health; evidence demonstrates the effectiveness of these programs to reduce risky behaviors and improve protective factors (Becker, McDaniel, Bull, Powell & McIntyre, 2012; O’Grady, Wilson, & Harman, 2009). Some of these originate in the health services on campus but others are located elsewhere, such as through student-led organizations, women’s health resource centers, or similar advocacy centers. When these are not housed within health services, it is important that linkages exist so that peer educators have consistent access to accurate information and are knowledgeable not only about available clinic services but also about the characteristics of health care providers. Importantly, peer educators having knowledge about providers’ characteristics is helpful in their peer outreach roles yet equally important is the responsibility of providers to strive to strengthen their interpersonal and communication abilities with the populations they serve (Hughes, 2008).

Limitations

There are some limitations to the transferability of these qualitative study results. Although the study sample size is relatively large for a qualitative study, it is a nonrandom, self- selected sample and participants might differ from non-participants. All participants were college students, and some chose to provide their perspectives based on a hypothetical situation rather than describing concrete experiences they had had with a provider. Although five institutions representing different sectors and locations were included in this study, it is important that specific institutions consider the findings within the context of their institutional health care infrastructure and related factors.

Conclusions

In summary, college health care services and on- and off-campus sexual health service providers will benefit from employing creative strategies to educate students about their services, including engaging students in sexual health peer education programs. College students appear to welcome opportunities to learn about a provider, and importantly, their decisions to seek care from a provider, whether on or off campus, appear to be influenced in part by their perceptions of that provider’s characteristics and interpersonal skills.