JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 50, NO.
Antibiotic-Seeking Behavior
in College Students:
What Do They Really Expect?
Katherine A. Haltiwanger, MD; Gregory F. Hayden, MD; Thomas Weber, MD;
Brent A. Evans, MS; Adam B. Possner, BA
Abstract. Injudicious use of antibiotics contributes to increased
bacterial resistance, and patient expectations encourage physicians
to overuse antibiotics. The authors evaluated the level of ill college
students’ antibiotic-seeking behavior to determine if receiving an
antibiotic prescription influenced patients’ satisfaction with visits
to a clinician. Of 129 students with upper respiratory complaints
presenting to a university health center, 55% expected an antibiot-
ic prescription. Antibiotic expectation was significantly more like-
ly among students who thought they had a bacterial versus a viral
infection (90% vs 40%; p < .01). A clear diagnosis, an explanation
of the rationale for treatment, and an antibiotic prescription were
significantly associated with patient satisfaction. Clinicians pre-
scribed an antibiotic for 36% of the students; only 13% of these 46
had requested an antibiotic during the visit. At some previous time,
one third of the students had taken an antibiotic prescribed for an
earlier illness or for another person. Better patient education and
improved clinician-patient communication can potentially help to
reduce the injudicious use of antibiotics.
Key Words: antibiotic resistance, antibiotic use, college students,
patient satisfaction, student health
ecent increases in rates of bacterial resistance to
R antibiotics have caused great concern because of the
potential for adverse clinical consequences.1 Injudi-
cious antibiotic use has contributed to this growing problem.
Patient expectations and satisfaction have been cited as fac-
tors that can stimulate antibiotic overuse.2–5 The beliefs and
behaviors of college students regarding antibiotic use have
not been well studied. Many students are away from home
for the first time and are accustomed to being cared for by
their parents rather than assuming responsibility for their
All of the authors are with the University of Virginia Health
System in Charlottesville. Katherine A. Haltiwanger and
Gregory F. Hayden are with the Department of Pediatrics,
Thomas Weber is with the Department of Family Medicine,
Brent A. Evans is with the Department of Health Evalua-
tion Sciences, and Adam B. Possner is an undergraduate
student at the university.
9
own healthcare. Thus, they are still strongly influenced by
parental opinion. Others begin to make independent deci-
sions on the basis of their own medical knowledge, that of
their peers, and increasingly, on health information they find
on the Internet.6–8 Instead of thinking in terms of diagnoses,
some college students may define illness in terms of the lim-
itations it places on their daily activities. In the life of a busy
student, this is likely to translate into a desire or demand for
a “quick fix,” often in the form of a prescription medication.
Our purpose in conducting this study was to evaluate the
level of antibiotic-seeking behavior by college students with
respiratory symptoms who were evaluated during the win-
ter season at a student health center at a large university in
central Virginia. We examined the relationships among
knowledge about antibiotics, expectation of antibiotic treat-
ment, satisfaction with the clinician visit, and the prescrip-
tion of an antibiotic.
METHOD
We administered a questionnaire during January and
March 2000 to college students presenting to a university
student health center serving a student body of approxi-
mately 15,000. We adapted the survey from a similar ques-
tionnaire used in a previous study and modified it with input
from several of the student health clinicians.9 This nonex-
perimental questionnaire received an exemption from the
University’s Human Investigation Committee. Chief com-
plaints of students selected for inclusion in the study were
sinusitis, runny nose, cough, cold, congestion, bronchitis,
sore throat, or other presenting signs and symptoms consis-
tent with respiratory tract infection. As they checked in at
the registration desk, those students with the appropriate
chief complaints were invited to participate in the survey.
We excluded students complaining specifically of strep
throat or flu after exposure to friends or roommates who
had been diagnosed with those illnesses because their com-
plaints are so commonly treated with an antibiotic or an
HALTIWANGER ET AL

antiviral medication. We entered students into the study
only on those days during the study period when the
authors’ schedules allowed them to interview new patients.
Even on those days, all eligible patients could not be includ-
ed because of time constraints.
The survey consisted of 30 questions and was divided
into two parts. Part 1, which the students completed before
seeing the clinician, addressed the students’ understanding
of their illnesses and general knowledge of antibiotics. Part
2, which the students completed after seeing the clinician,
assessed the students’ satisfaction with their visits and
inquired about past antibiotic use, medical visits, and gen-
eral demographics.
The questionnaire could be self-administered, but most
(85%) were orally administered by one of three resident
physicians. Most of the data were collected in the health
center’s waiting room, but we communicated with a few
students by telephone later that same day to complete Part
2 of the survey. Physicians examined two thirds of the stu-
dents, and nurse practitioners examined the remaining third.
The clinicians were not informed which students were par-
ticipating in the study.
For analyzing the study data, we used S-PLUS 2000
(MathSoft, Seattle, WA). We used likelihood ratio chi-
square tests of independence to analyze associations
between pairs of categorical responses and logistic regres-
sion to examine the relationship between a binary outcome
and a continuous variable. We also used one sample test of
proportions to compare the results of a binary response with
pure chance (50%).
RESULTS
scription. Antibiotic expectation was significantly associat-
ed with the type of infection the students felt they had (see
Table 1). Students who thought they had bacterial infections
had higher expectations for antibiotic treatment than did
students who thought they had viral infections (90% vs
40%; p < .01). One hundred six students (82%) believed an
antibiotic would cure a bacterial infection, whereas 4 (3%)
students did not, and 19 (15%) were unsure. Of the 106
believers, 29 (27%) thought they had a bacterial infection;
of those, 26 (90%) thought that they needed a prescription
for an antibiotic. Ninety (70%) students correctly believed
an antibiotic would not cure a viral infection. Of those 12
(13%) thought they had a viral infection. Of those, 12, 3
(25%) nevertheless thought they needed an antibiotic, and
another 2 (17%) were unsure.
Antibiotic expectation varied according to the presenting
complaint. Those complaining of sinusitis (85%), bronchi-
tis (71%), and cough (68%) were more likely to expect an
antibiotic (Table 2). However, perhaps because of the rela-
tively small numbers in each category, none of these pro-
portions was significantly greater than 50% when testing at
alpha = .01. Forty-three percent of the students with these
three chief complaints thought they had a bacterial infec-
tion, and another 50% were unsure of the type of infection
they had. Students’ antibiotic expectations were positively
but not significantly associated with female gender (p = .08)
and longer symptom duration (p = .10).
TABLE 1
Antibiotic Expectations Among 129 Students
Seen at a Student Health Service

One hundred thirty-two students were invited to partici-

pate, and all agreed to do so. Three participants failed to com- Expecting
antibiotic
plete Part 2 of the survey, however, and we excluded them
from the statistical analysis, leaving a study sample of 129 Variable N n %
students. Slightly more than half (57%) of the patients were
women, and roughly equal numbers were in their first (17%), Gender
Male 56 26 46
second (26%), third (16%), or fourth (21%) years of college Female 73 45 62
or in graduate school (20%). Only 4 students were in medical Year at university
or nursing school. The ages of the participants ranged from 1st 22 12 55
18 to 36 years (median 20.0 years, 25th–75th percentiles = 2nd 33 17 52
19–22 years), and the median number of visits to the student 3rd 21 12 57
4th 27 18 67
health center per year was 2.0 (25th–75th percentiles = Graduate student 26 12 46
1.0–3.0 visits). None of these variables was significantly Perceived type of infection
associated with an expectation of receiving an antibiotic. Viral 15 6 40
When asked if they thought they needed a prescription Bacterial 29 26 90*
medication, 85 (66%) students said yes, 6 (5%) said no, and Not sure 85 39 46
Think antibiotic cures bacterial infection
38 (29%) said not sure. Of the 85 patients who said yes, 71 Yes 106 57 54
(84%) said antibiotic, 8 (9%) said decongestant, 1 (1%) said No 4 2 50
cough medicine, and 5 (6%) said other. Of the 71 students Not sure 19 12 63
who asked for an antibiotic, 14 (20%) had a specific one in Think antibiotic cures viral infection
mind. After the clinician visit, 4 (29%) of these 14 patients Yes 18 8 44
No 90 50 56
reported that they had asked their clinician for a specific Not sure 21 13 62
antibiotic. Two asked for azithromycin, one asked for ery-
thromycin, and one didn’t specify the requested antibiotic. *p < .01.
Overall, 71 (55%) students expected an antibiotic pre-

10 JOURNAL OF AMERICAN COLLEGE HEALTH

 ANTIBIOTIC-SEEKING BEHAVIOR

TABLE 2
Antibiotic Expectations Among 129 Students,
by Complaint and Perceived Type of Infection

Type of perceived infection

Not Antibiotic
Viral Bacterial sure expectation
Chief complaint N n % n % n % n %

Sore throat 25 2 8 3 12 20 80 11 44
Cold 24 3 13 4 17 17 71 10 42
Cough 22 2 10 8 36 12 55 15 68
Sinusitis 13 1 8 7 54 5 38 11 85
Congestion 8 3 38 1 13 4 50 3 38
Bronchitis 7 0 0 3 43 4 57 5 71
Earache 6 0 0 1 17 5 83 3 50
Other† 24 4 3 2 1 18 14 13 10

†Complaints reported by fewer than 5 patients each.

A clear majority (93%) of the patients was very or some-
what satisfied with their student health center visit (Table
3). Satisfaction was significantly more likely when the clin-
ician specified a diagnosis (p < .01) and when the clinician
made it clear why the student did or did not need an antibi-
otic (p < .01). Satisfaction was also more likely when the
student received an antibiotic prescription (p = .01). Clini-
cians prescribed an antibiotic for 46 (36%) students, but
only 6 (13%) of these 46 students had asked the clinician to
prescribe an antibiotic.
When asked if the student health clinicians were more or
less likely than their physicians at home to provide a pre-
scription for an antibiotic, 11 (9%) said a little or much
more likely, 47 (36%) replied about the same, 46 (36%)
replied much or a little less likely, and another 25 (19%)
said not sure.
Thirty-six (28%) students admitted to having previously
taken an antibiotic that was left over from another illness,
and 20 (16%) said that in the past they had taken an antibi-
otic that was prescribed for another person.
COMMENT
With the advantage of higher levels of education and
exposure to current media coverage of increasing rates of
antibiotic resistance, college students might be expected to
be more aware than the general public of the appropriate
use of antibiotics and the dangers of overuse. College stu-
dents might also be particularly well qualified to assimilate
and use this information. Our survey found, however, that
31% of the study participants had at some time taken either
a leftover antibiotic, one that had been prescribed for some-
one else, or both. These findings reflect a worrisome degree
of misunderstanding about the appropriate use of antibiotics
as well as prescription medication in general, even in this
highly educated population.
College students’ reasoning ability about health and ill-
ness varies from preoperational (concrete) to formal opera-
tional (abstract) thought.10,11 Consequently, some students
might find concepts of illness harder to understand, espe-
cially when considering their own illnesses. In our study
sample, for example, 25% of the students who thought they
had a viral infection and knew that antibiotics do not affect
viruses still felt they needed an antibiotic, and another 17%
were not sure if they needed an antibiotic.
A less mature understanding of illness has been associat-
ed with not having a sense of control over the acquisition,
management, or outcome of that illness.10 One potential
means of increasing college students’ perceptions of control
and, therefore, their ability to understand their illnesses, is
to allow them to help make decisions about their own
healthcare. Giving students a choice about treatment
options after an adequate exchange of information may be
of great benefit in enhancing understanding about the risks
and benefits of antibiotic therapy.
One study demonstrated a gradual evolution in healthcare
behavior in students over the first 3 years of college, chang-
ing from behaviors reflecting the beliefs and actions of their
parents to behaviors more consistent with those of their
peers.6 Young adulthood may be an effective time to imple-
ment an intervention strategy. If misconceptions about
antibiotic therapy can be clarified for just a few students,
these knowledgeable students can then share this informa-
tion indirectly with larger numbers of students with whom
they associate.
In addition to parental influence, previous experiences
with illness and interactions with the healthcare system play
a large part in determining the students’ future responses to
somatic complaints. Outpatient antibiotics are often pre-
scribed for episodes of bronchitis, sinusitis, pharyngitis, oti-
tis media, and other nonspecific respiratory illnesses, many
of which are caused by viruses.1,12,13 Many studies have
reported a higher rate of repeat visits for respiratory illness-

VOL 50, JULY 2001 11

HALTIWANGER ET AL

TABLE 3
Student Satisfaction With the Visit to a Clinician

Very Somewhat Not Not very

satisfied satisfied sure satisfied
N n % n % n % n %

Student expected
an antibiotic
Yes 71 45 63 22 31 3 4 1 1
No 58 40 69 13 22 4 7 1 2
Clinician gave
a diagnosis
Yes 105 79 75* 22 21 3 3 1 1
No 19 6 32 11 58 2 11 0 0
Not sure 5 0 0 2 40 2 40 1 20
Clinician prescribed
an antibiotic
Yes 46 37 80 8 17 0 0 1 2
No 83 48 58 27 33 7 8 1 1
Clinician made
antibiotic decision
clear
Yes 109 81 74* 24 22 3 3 1 1
No 18 3 17 10 56 4 22 1 6
Not sure 2 1 50 1 50 0 0 0 0

*p < .01.

es in patients who received antibiotics for a previous infec-
tion, suggesting a cycle of expectation based on past expe-
riences.7,14–16 Patients may attribute the resolution of a self-
limiting viral illness to the prescription medication they
received, and they may assume that the association between
medication and relief is causal, not temporal. If so, they
may have trouble understanding why an antibiotic isn’t pre-
scribed the next time they go to the doctor’s office exhibit-
ing similar symptoms. Such scenarios may foster mistrust
and misuse of the healthcare system.
College students often have an impressive command of
language and terminology without a full understanding of
the meaning of the terms they are using or hearing.10 Appro-
priate communication may facilitate effective teaching of
self-care, decrease excessive use of the healthcare system,
reduce the number of inappropriate antibiotic prescriptions,
and enhance patient satisfaction.2,17,18 In our study, patient
satisfaction did not depend solely on the students’ receiving
an antibiotic prescription, but also on their understanding
the diagnosis and the clinician’s choice of therapy.
Improved communication between clinicians and students
may help decrease antibiotic use without negatively affect-
ing (and perhaps even improving) patient satisfaction.
Clinicians' use of specific medical terms such as bronchi-
tis, sinusitis, or even upper respiratory tract infection may
suggest to students the presence of a bacterial infection,
which, in turn, may imply that an antibiotic is desirable or
necessary.14 In this study sample, those students with chief
complaints of sinusitis and bronchitis were more likely than
any other group to assume that their illness resulted from a
bacterial infection and to expect an antibiotic. The treating
clinician’s use of alternative terminology, such as chest
cold, respiratory tract illness, sinus congestion, or viral ill-
ness, may be more practical and less often misunderstood.1
This study has some important limitations. Because the
sample size is relatively small and all of the students attend-
ed one university in the mid-Atlantic area, the results may
not be generalizable to other universities or other geograph-
ic areas. We surveyed only students with respiratory symp-
toms, so we did not determine the extent of antibiotic
expectation for other types of problems. We did not deter-
mine the number of students with similar symptoms who
self-treated with over-the-counter medications independent-
ly because we surveyed only students presenting to the stu-
dent health center. The two-part design of the questionnaire
could have biased some participants by influencing their
thoughts about treatment with antibiotics before they saw
the clinician. However, the results can be used to stimulate
further investigation and intervention in this area.
Despite this group’s level of education, we found dis-
tressing misconceptions about an extremely important pub-
lic health issue. Educating students about the scope of the
problem seems particularly important because they are our
future leaders, educators, and problem solvers. However,
the prescribers themselves have a responsibility to their
patients and to their profession to use antibiotics appropri-
ately, based on current guidelines, and to ensure that their
patients understand the basis of their treatment strategies.

12 JOURNAL OF AMERICAN COLLEGE HEALTH

 ANTIBIOTIC-SEEKING BEHAVIOR

8. Fulop MP, Varzandeh NN. The role of computer-based

TABLE 4
Outline of Patient Information Handout
Your Illness and Antibiotics:
What Everyone Needs to Know
• What is the difference between bacteria and viruses?
• What is antibiotic resistance?
• Why is antibiotic resistance such a big deal?
• Do I always need antibiotics when I am sick?
• Once I start feeling better, should I stop taking my
antibiotic?
• When should I ask my physician for an antibiotic?
• Which illnesses require an antibiotic and which do not?
• What can I do to combat antibiotic resistance?
We have developed an educational handout available online
to help college students understand common illnesses and
the rationale for and against antibiotic treatment of these ill-
nesses. (For an outline, see Table 4; for full text, see
http://www.virginia.edu/studenthealth/.) This information is
intended only to support, not to replace, the face-to-face
communication between clinician and patient that has
become almost more important than the treatment itself.
ACKNOWLEDGMENTS
We wish to express our special thanks to Drs James C. Turner
and Joseph F. Chance for their cooperation and assistance, and the
staff of the Elson Student Health Center for their kindness and
patience, and to Dr Daniel Rossignol for his help with collecting
data.
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9. Collett CA,Pappas DE, Evans BA, et al. Parental Knowl-
edgeabout common respiratory infections and antibiotic therapy in
children. South Med J. 1999; 92:971–976.
10. Oprendek TS, Malcarne VL. College student reasoning
about illness and psychological concepts. J Am Coll Health.
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11. Piaget J. Intellectual evolution from adolescence to adult-
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NOTE
For further information, please send communications to Grego-
ry T. Hayden, MD, Department of Pediatrics, University of Vir-
ginia Health System, PO Box 800386, Charlottesville, VA 22908-
0386 (e-mail: gfh@virginia.edu).

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