Abstract

COVID-19 has become a worldwide pandemic, causing immense physical, social & emotional repercussions. Unbalanced nutrition and social isolation can lead to compromised immune systems, which can increase vulnerability to this viral infection. There is limited research addressing college students’ beliefs of COVID-19 related to nutrient intake. The purpose of this qualitative study is to ascertain health-related beliefs related to COVID-19 risk and prevention among undergraduate students enrolled in a New Jersey university. Semi-structured interviews were conducted with twenty-five undergraduate, full-time students (18 females, 7 males) between the ages of 18 to 25. In-depth qualitative interviews were conducted virtually on Zoom and audio-recorded for transcription. An interview protocol consisted of seven open-ended questions related to COVID-19 using tenets of Health Belief Model. Perceived susceptibility and severity to the virus were ascertained along with perceived benefits of adopting diet-related behavior. Questions pertaining to perceived barriers and self-efficacy were queried. All interviews were transcribed verbatim with qualitative analyses performed by two independent researchers who coded the transcripts to achieve inter-rater reliability. Codes were merged into broad themes to derive an original theoretical framework addressing participants’ risk and prevention of COVID-19. Participants expressed their susceptibility to COVID-19 ranging from low-risk to high-risk based on their age, public exposure, and pre-existing health conditions. Perceived severity included notable physical, mental, and social effects. Perceived benefits included the consumption of fruits and vegetables and vitamin supplementation. Perceived barriers in adopting a healthy diet included financial and time constraints. Nutrition and health practitioners need to assess young adults’ beliefs and susceptibility to COVID-19. Educators should assess college students’ motivation to adopt healthy diets to balance their immune systems.

1. Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or COVID-19 has become a worldwide pandemic, causing immense physical, social & economic repercussions. To date, there are over 57 million COVID-19 cases and more than 800,000 fatalities in the U.S. ¹. COVID-19 is characterized by fever, dry cough, and myalgia, and can lead to severe respiratory infections ². Mild and even asymptomatic cases have resulted in the spread of infections worldwide. Individuals who are at high risk include older adults, immunocompromised groups, and those with chronic diseases ³. COVID-19 infects pulmonary epithelial cells using the angiotensin converting enzyme-2 (ACE-2) receptor ⁴, which can lead to activation of macrophages, neutrophils, and T-cells. A surge of pro-inflammatory cytokines including interleukin (IL)-1, IL-6, and tumor necrosis factor (TNF) alpha can precipitate a ‘cytokine storm.’ This is responsible for some of the devastating manifestations such as acute respiratory distress syndrome (ARDS). Studies have documented that COVID-19 patients undergo a dysregulation of their immune response ⁵. On the other hand, recovery from symptoms can occur within days with an effective immune response, associated with successful clinical recovery ⁶.

Environmental factors such as unbalanced nutrition and toxins, as well as social isolation from lockdowns, can lead to physiochemical and psychological stress. These factors may result in a compromised immune system, which in turn can make a person more vulnerable to viral infections ⁷. An optimal nutritional state is essential for a balanced immune system, establishing a defense system against viral infection ⁸. Deficiencies of essential nutrients such as vitamins (C and D) and minerals (e.g.: zinc) can lead to impairment of cell-mediated immunity. Excess consumption of refined carbohydrates, saturated fats, and sedentary lifestyle contribute to obesity, which can deregulate the immune system ⁹. Increased hours spent in self-isolation and quarantine during the pandemic promotes inactivity and other unhealthy behaviors ¹⁰. The transition to virtual learning can be an immense social, emotional, and physical adjustment. With these outcomes in mind, Kee (2021) mentions five main themes of virtual learning’s impact on graduate students, including 1) managing disappointment, 2) managing feelings of anxiety and fear, and 3) incorporating coping strategies and finding relief ¹¹.

2. Theoretical Framework

The Health Belief Model provides a framework for understanding why individuals tend to engage in certain health behaviors based on their perceptions ¹². This model is used widely in health behavior research and focuses on six constructs that help determine the likelihood of adopting health behavior to prevent a disease: (a) perceived susceptibility reflects an individual’s perception of disease risk; (b) perceived severity refers to the seriousness and consequences of contracting the condition; (c) perceived benefits include health actions that can be taken to reduce the risk of disease; (d) perceived barriers are the obstacles that may prevent someone from adopting a health behavior; (e) cues to action are internal and external factors that prompt decision making to take action; and (f) self-efficacy refers to an individual’s confidence to enact a behavior.

Researchers have utilized the Health Belief Model to examine American college students’ perceptions of COVID-19 using an online survey administered at a Midwestern university to undergraduate and graduate students ¹³. Another group of investigators have used the model to assess predictors of intention to receive the COVID-19 vaccinations ¹⁴ and examined the impact of demographic and psychological factors in the decisions to receive vaccines ¹⁵. Other researchers reported that college students with higher scores of perceived susceptibility, perceived benefits and self-efficacy were more likely to adopt preventive measures to lower their risk of contracting Middle East Respiratory Syndrome Coronavirus (MERS-CoV) than individuals with lower scores ¹⁶.

As of 2019, approximately 41% of American adults (18 to 24-year-olds) were enrolled in college education and nationwide, this totals 17.5 million undergraduate students ¹⁷. Those aged 18 to 24-years old, also known as Gen Z or Zoomers, make up roughly 12.2% of the U.S. workforce ¹⁸. Studies have documented marked decline in nutritional priorities and poor dietary habits among college students as reflected by fast food consumption and low intakes of fruit and vegetables ^{19, 20}. Understanding COVID-19 related beliefs, perceptions, and health behaviors of college students is vital in mitigating the spread of the virus. The purpose of this research study is to conduct qualitative interviews with undergraduate students enrolled at a state university in New Jersey to uncover their beliefs and behaviors regarding COVID-19 risk factors and dietary interventions to mitigate viral contraction.

3. Methods

A convenience sample of college students was recruited at a large northeastern state university in the United States. Eligibility criteria included (a) full-time undergraduate students enrolled at a state university in New Jersey and (b) male and female individuals between the ages of 18 to 25 years (IRB Number: IRB-FY20-21-1881, Project Title: College Students' Perceptions of Risk and Prevention of COVID-19). Participants were recruited via campus-wide student listservs and academic clubs targeting students across different disciplines. Eligible individuals were given information sheets and informed consent forms to complete. Of 28 students who agreed to participate, 3 did not meet the study’s eligibility criteria, resulting in a sample size of 25. The researchers continued to recruit and interview until data saturation was reached, or at the point where no new information emerged from the respondents.

All interviews were conducted on Zoom and lasted between 10 to 15 minutes. Each interview followed a semi-structured protocol with open-ended questions. Probes were interjected to elicit additional responses or clarification. All interview questions were developed based on Health Belief Model constructs. The interviews were conducted between March 2021 to June 2021. Upon completion of the interview, each participant received a $10 gift card for Starbucks.

Open-ended questions addressed participants’ perception of susceptibility and severity, benefits of diet-related actions, perceived barriers, and self-efficacy to enact health behaviors (Table 1). The interview protocol consisted of the following queries:

(1) What are the main risk factors of contracting COVID-19?

(2) Describe your overall risk of contracting COVID-19.

(3) What are the consequences of contracting COVID-19? You may describe physical, mental or social effects?

(4) What are some diet-related factors that can reduce young adults' risk of contracting COVID-19?

(5) Describe your degree of willingness to adopt these diet-related factors.

(6) How would you increase young adults' confidence to engage in dietary practices?

(7) What are some barriers or obstacles that affect young adults' ability to make these health-related changes?

All virtual interviews were audio-recorded and transcribed verbatim. The researchers derived qualitative insights and in-depth analysis of the transcribed interviews. The transcriptions were imported into NVivo qualitative data analysis software (Version 1.6.1, 2022, QSR International Pty Ltd, Doncaster, Victoria, Australia). Using a constant comparative method for qualitative analysis, codes were identified in the responses of participants. Thematic analysis was conducted to ascertain themes that emerge within the codes (Table 2). Two researchers coded the transcripts independently to minimize possible biases. To achieve inter-rater reliability, the codes were compared and discussed for discrepancies in interpretations. A code manual was established during the coding process. Both authors compared the transcripts against the code manual to determine confirmation or the need for modification of the themes.

4. Results

Coding or segments of the transcripts were identified and integrated into broad themes. No codes were developed a priori, instead an inductive, grounded theory approach was used to create a code book. Codes were merged into themes, and relationships among themes were uncovered to derive an original theoretical framework based on college students’ perceptions and risk management of COVID-19 (Figure 1).

Participants were queried about the main risk factors for contracting COVID-19 (Question #1). Qualitative data analysis of transcripts yielded 14 codes of which four major themes were derived. Eight out of 25 respondents indicated older-aged individuals (>60 years) as being more susceptible. Another risk factor was having pre-existing health conditions, as mentioned by 14 out of 25 respondents. These health conditions included weak immunity, asthma, obesity, diabetes, respiratory illnesses, hypertension, and cardiovascular disease. Poor hygiene (13/25) such as lack of proper handwashing, carelessness, and improper mask wearing contributed to risk of contraction. Social contact (11/25) encompassed lack of social distancing, large public gatherings, and in-person work/educational settings would further enhance risk of contracting the virus.

When questioned about their susceptibility of contracting COVID-19 (Question #2), ten respondents stated they were at low risk because of their younger age, healthy immune system, adoption of healthful diet (e.g.: minimally processed food), vaccinations, and low public exposure. Eleven out of 25 respondents perceived themselves to be at moderate risk due to their medical diagnoses (asthma, autoimmune disease), unhealthy diet, sedentary lifestyle, and enrollment in in-person classes. Improper mask wearing of students on campus was also cited as promoting increased viral exposure. Four out of 25 students perceived themselves to be at high risk of susceptibility, attributed to being hypertensive and having contracted COVID-19 in recent months. In surveying American college students, Alsulaiman and Renter (2021) found a significant relationship between perceived threat (perceived susceptibility + perceived severity) and likelihood to wear a mask in public settings ¹³. In addition, higher perceived threat to COVID-19 was significantly related to following a healthy diet to strengthen the immune system (p<0.01).

Participants were asked about the physical, mental, and social consequences of contracting COVID-19 (Question #3). Perceived severity included notable physical effects such as fever, fatigue, cough, lung damage, pain, and shortness of breath. Loss of taste, smell, and appetite were cited along with gastrointestinal distress. Mental effects of having COVID-19 included depression, negative mood alterations, anxiety, stress, existential trauma, and fear of fatality. The social effects of having to quarantine for days without interpersonal contact were highlighted by 19 out of 25 respondents. The dread of loneliness and social stigma was prominent in many of the participants. Some individuals feared being judged negatively by peers as being careless for contracting COVID-19. Ahorsu et al. (2020) found significant positive correlations between fear of COVID-19 and depression and anxiety ²¹. Taylor (2019) indicated that psychological vulnerability factors may have a role in the fear of COVID-19, including intolerance of uncertainty and perceived susceptibility to disease and anxiety proneness ²².

Diet-related factors that can mitigate young adults’ risk of contracting the virus encompassed adoption of a balanced diet (Question #4). The perceived benefits of increasing fruit and vegetable consumption such as oranges, apples, spinach, and broccoli would contribute to a healthy diet. Participants mentioned boosting one’s immune system with vitamins C and D can be achieved by drinking orange juice, taking supplements or Emergen-C. Consuming foods with antioxidants such as blueberries, high quality protein-rich foods (e.g.: sustainable farmed meats) and healthy fats (e.g.: nuts and avocado) were also cited by the participants. In addition, aiming to consume less sugar, salt, and refined carbohydrates would contribute to a healthy dietary pattern.

When the respondents were queried about their degree of willingness to adopt these diet-related behaviors, 23 out of 25 individuals affirmed their intention due to feeling more energetic and having a positive mood. Short-term effects were cited more than long-term effects of chronic disease prevention. Three respondents stated their need to adopt healthful eating habits because of a medical diagnosis or autoimmune disease. Two respondents had no intention to adopt healthful dietary practices as a result of their limited time availability to cook or prepare a meal. During the pandemic, individuals were prone to indulge in junk foods sparked by being “cooped up” in their homes. Regardless of their stated willingness, many individuals encountered laziness, depression, anxiety, feeling “slumpy” and fatigued.

Wong et al. (2020) used the Health Belief Model to assess predictors of intention to receive vaccinations to combat COVID-19 and implicated that perceived benefits was influential in developing definitive intention to get vaccinated ¹⁴. Guidry et al. (2021) found that higher perceived benefits and higher perceived susceptibility to COVID-19 was found to be prominent predictors for taking the vaccines ¹⁵. In addition, the study also showed that higher self-efficacy was also a salient predictor of health behavior. Kim et al. (2012) applied the HBM to assess how university students’ nutrition beliefs influence behavioral intention ²⁰. Perceived benefit of healthy eating and perceived barriers had significant effects on students’ intentions.

Factors that would increase young adults’ confidence to engage in dietary practices were solicited (Question #6). Seventeen codes were identified from qualitative analysis of which four overarching themes were derived: education, social norms, sensory pleasure of food, and mental benefits. Among these GenZers, gaining nutrition knowledge can be secured via Google searches, social media platforms (e.g.: Instagram, TikTok, Facebook, YouTube videos and blogs). Consulting health professionals or enrolling in nutrition courses were mentioned as channels to attain information, as well as health and culinary influencers found on these social media platforms. Self-efficacy can be enhanced by social norms entailing peer support, collective influence, and role modeling. Experiencing the sensory pleasure of food can also increase young adults’ confidence by trying new recipes and watching virtual food demonstrations. Reaping the mental benefits of positive mood and “feel good” effects can also boost self-efficacy.

Barriers or obstacles that affect young adults’ ability to make health-related changes were inquired, of which twenty-four codes were identified and grouped into five themes: financial, inconvenience, lack of time, lack of knowledge, and plethora of junk foods (Question #7). Financial constraints were highlighted by 17 out of 25 individuals, making this the most salient barrier. Lack of time, inaccessibility of health foods, limited nutrition knowledge, and the plethora of junk foods were also perceived as major impediments to healthful behaviors. One respondent quoted that “cheap food is engineered to taste good.” The perception that junk food and fast food are cheaper in cost than nutrient-dense foods was pervasive. Using the DoorDash app for fast food deliveries was very convenient during the pandemic. Fake news promoted on social media platforms was referred to by some respondents, which can lead to disordered eating among young adults. Food advertisements on traditional and social media outlets can promote unhealthy addictions, instant gratification, and “psychological hunger.” The scope of social influence on consumption has broadened to include these technological developments and the effect of interactions on social media, only being brought to the foreground during the COVID-19 pandemic ²³.

5. Conclusions

This study provided novel empirical data to investigate the perceived impact of COVID-19 on the lives of undergraduate students at a state university in New Jersey. The identification of dynamic, interrelated relationships among perceived threat, perceived benefits/barriers, and self-efficacy are instrumental for school administrators, health educators and professionals serving this vital population group. In general, college students perceived themselves as less susceptible to COVID-19, as compared with middle- and older adults, particularly those with pre-existing health conditions (e.g.: cancer, cardiovascular disease). Perceived susceptibility to COVID-19 was elevated if these individuals had a health issue that was immuno-compromising such as asthma or an autoimmune disease.

The participants identified fruits/vegetables with vitamin C as beneficial to reduce personal risk of contraction of the virus. Commonly cited foods rich in vitamin C were oranges and citrus fruit, along with taking a supplement such as Emergen-C. Many participants indicated that a balanced diet consisted of eating lots of fruit and vegetables, with good sources of protein from animal & plant-sources.

Barriers to the intake of balanced, nutrient-dense diets included the plethora of fast food and junk foods surrounding their campus and communities. The hyper palatability of convenience foods with added sugars, salt, and unhealthy fats made these ultra-processed foods difficult to resist. Lack of time due to course-related assignments during the academic year also predisposed individuals to poor food choices and inability to cook their own meals.

Financial concerns impacted the food purchasing decisions of this sample of college students. Limited discretionary spending money due to the rising costs of paying for a college education may predispose individuals to purchase cheap, fast-food items high in salt, unhealthy fats, and sugars.

The powerful role of social media as a channel to attain quick information about nutrition and COVID-19-related posts was evident. This sample of participants relied on popular social media platforms such as Instagram, TikTok, and Facebook for culinary tips and dietary guidance by influencers and bloggers. Some students were careful to check for the credibility of nutrition information posted on these platforms by referring to Google Scholar. The use of mobile apps for food delivery was convenient and accessible for home-bound individuals during the pandemic.

The American College Health Association (ACHA) developed guidelines for promoting a safe and healthy environment, involving social media posts and texts to encourage adoption of preventive behaviors ²⁴. Bai (2020) recommended storytelling and audio-visual messages with appealing graphics and emojis to be conveyed in dormitory settings ²⁵. Peer modeling and testimonials can be powerful channels to encourage healthy eating and physical activity. Riley et al. (2021) asserted that education-entertainment strategies have been effective in COVID-19 campaigns to promote behavioral changes ²⁶.

Despite the significant contributions of this qualitative study, several limitations existed. Firstly, the small sample size precluded the underpinning of all perceptions of COVID-19 and health-related beliefs among American undergraduate students. Triangulation of data can be applied to compare findings of this study with future survey data among college students. To minimize this limitation, the researchers continued to interview participants until data saturation was achieved. Secondly, generalizability of findings is limited with a convenience sample since a random sample was not ascertained. However, the researchers aimed to recruit individuals from diverse ethnic backgrounds, academic majors, and genders across campus to secure a near representative sample.

Health professionals and university administrators need to understand the motivations, perceptions, and beliefs inherent in college students during the COVID-19 pandemic. Perceptions of disease risk, and the benefits and barriers to the adoption of dietary-related practices need to be identified for effective campaigns and communication strategies to be developed. New findings in this qualitative study fortify health promotion experts with knowledge of COVID-19 risk and its prevention of future possible variants.

References