The Health Belief Model and smoking cessation behaviours

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J Community Health (2017) 42:1204–1212 DOI 10.1007/s10900-017-0371-2

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ORIGINAL PAPER

Perceptions of Health Care and Access to Preventive Services Among Young Adults

Raffy R. Luquis1  · Weston S. Kensinger1 

Published online: 9 May 2017 © Springer Science+Business Media New York 2017

Keywords Preventive services · Access to health care · Health promotion

Introduction

In the United States (U.S.), many people are not attaining their highest health potential because of preventable con- ditions. In addition, many Americans received only half of the preventive care services that are recommended, which highlights the need for the improvement of health promo- tion services [15]. The enactment of the Patient Protec- tion and Affordable Care Act (ACA) in 2010 increased the emphasis on health promotion and disease prevention by making preventive care more accessible and affordable for many Americans [15, 27]. The ACA required insurance companies to cover evidence-based preventive services without cost sharing, such as those services recommended by the U.S. Preventive Services Task Force (USPSTF), vaccinations, and preventive care and screenings [20, 28]. Under the law screening services such as breast cancer, cervical cancer, colorectal cancer, HIV, alcohol-misuse, depression, tobacco use, and obesity are covered; regard- less of the type of health insurance coverage. Thus, by moving chronic disease prevention and health promotion toward the mainstream population in healthcare, it was anticipated that the ACA would have a positive impacts in population health [15].

Moreover, one of the objectives of the policy was to increase access to care for young adults, as people without insurance are more likely to delay or defer care, especially preventive care, because of cost [21]. As such, the ACA has significantly reduced the number of uninsured young adults by allowing them to stay on their parents’ or legal guard- ians’ health insurance plan until the age of 26, instituting

Abstract The enactment of the Affordable Care Act increased the emphasis on health promotion and disease prevention by making preventive care accessible for many Americans, especially young adults, who could remain on their parents or legal guardians’ health insurance until the age of 26. Yet, many Americans receive only half of the recommended preventive care services, which highlight the need for the improvement of health promotion and pre- vention services. The aim of this study was to assess the relationship among access to health care insurance, percep- tions about health insurance, and use of preventive care ser- vices among young adults. Nine hundred and forty-six par- ticipants ages 19–34 completed a 40 question web-based survey. Data analysis suggested that while the majority of participants had health insurance, there were significant dif- ferences in opinions about the ACA, health insurance, and use of preventive services by gender, education level, and health insurance status. Overall, participants with health insurance were more likely to have received at least three of the basic preventive care services; however, most of them were not getting the preventive care as recommended. Results reaffirm the need for further studies on the impact of health insurance among young adults and the need for the emphasis on health promotion to educate young adults about the importance of disease prevention and preventive services.

* Raffy R. Luquis rluquis@psu.edu

1 School of Behavioral Sciences and Education, Penn State Harrisburg, W314 Olmsted, 777 West Harrisburg Pike, Middletown, PA 17057-4898, USA

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new insurance market regulations and state or regional insurance exchanges, and expanding Medicaid eligibil- ity for those with a demonstrated financial need regardless of age. By providing increased access to health insurance plans, the law promotes the use of preventive services and protects against catastrophic costs in the event of a seri- ous accident or injury to the insured individual [7]. While there were differences of opinions about the ACA among Americans across all age groups, the majority of young adults age 19–29 (62%) were strongly or somewhat in favor of the requirements for health insurance coverage. Nota- bly, the support was stronger among young adults with low incomes (67%), women (65%), and Blacks/African Ameri- cans and Hispanics (74%) [7]. Still barriers to health care coverage exist as some young adults, who overall perceived themselves to be healthy, may not enroll in health care insurance coverage, as they may continue to face severe finance trade-offs among the costs of housing, food, and health insurance.

Before the enactment of the ACA in 2010, 31.4% of young adults ages 19–25 were found to lack health insur- ance, which was twice the percentage of the general public [2, 11]. These young adults with a lack of health coverage faced increased barriers (i.e. cost, access to health care ser- vices) to receive preventive health care services that likely would drastically reduce the rate of chronic disease in their futures. Fortunately, several studies have shown a rapid and significant increase in health insurance coverage among young adults ages 19–25 under the ACA early provision of dependent coverage [1, 9, 21, 22]. For example, using data from the National Health Interview Survey and the Annual Social and Economic Supplement to the Census Bureau’s Current Population Survey, Sommers et  al. [21] estimated as closed as 3  million young adults received health care coverage by September 2011 and that the policy signifi- cantly increased private health insurance and access to care for those ages 19–25 (4.7% points higher) compared to those ages 26–34 due to the provision to allow health insur- ance under parents’ and legal guardians’ coverage. While the benefits among those ages 19–25 were widely distrib- uted, some groups benefited more than others including men, unmarried adults, non-students, and those in worse health. Also, those with coverage were less likely to report that they did not obtain or delay care because of cost. Thus, the results showed evidence that the ACA’s dependent coverage provision has expanded insurance coverage and access to care as intended [21].

Similarly, using the Current Population Survey, Som- mers and Kronick [22] found that there was a significant increase in insurance coverage among young adults, espe- cially among private insurance as expected by the law. The health insurance coverage increase occurred among all racial and ethnic groups, with gains greatest in minority

populations. Likewise, Collins et al. [9] found that an esti- mated 13.7  million young adults ages 19–25 (nearly 47% of their survey participants) stayed on or joined their par- ents’ health plans between November 2010 and November 2011, including approximately 6.6  million young adults who could not have been covered by their parents’ health coverage prior 2010. Still, results suggested that since not all young adults could join their parents’ health insurance almost 40% of those ages 19–29 were uninsured for part of 2011, especially those in low and moderate-income fami- lies. Lack of health insurance among this group is still con- cerning as this had significant health and financial implica- tions for this group. For example, 41% reported that they did not get needed health care because of cost and 36% reported problems paying medical bills or paying medical debts over time [7]. There are adverse consequences for those persons lacking health insurance. Those with gaps in their health coverage and those without insurance had fewer connections with the health care system, were less likely to have a regular relationship with health care provid- ers, were less likely to receive preventive care services, and were more likely to postpone or avoid recommended health care. The authors concluded that affordability has been the major barrier to gaining health care coverage among this group of young adults [7]. Still, data from 2014 showed that there has been a significant decline in the number of uninsured young adults. As of the end of June 2014, there were 5.7 million fewer uninsured young adults than in 2013 [8].

Finally, one of the focal points of the ACA is prevention of chronic disease in young Americans. Of the ten major titles in the ACA legislation, most called for prevention efforts for chronic diseases and improving public health status by utilizing various new funding opportunities and initiatives [15]. With these new regulations, the federal government calls on all health care providers to actively participate in health promotion and prevention activities to help reduce the incidence of chronic illness and nega- tive health outcomes [27]. New regulations should encour- age young adults to access affordable preventive services, thereby reducing the risk of chronic disease and lowing future medical costs [7]. Still, while the provision of health care insurance provides access to preventive services, researchers have not perceptions of preventive services among this group or whether young adults are actually receiving these services.

Young adulthood encompasses a time when many indi- viduals are exposed to the highest rates of negative pre- ventable health conditions, such as substance use, mental health problems, sexually transmitted infections, motor vehicle and homicide fatalities, and an increase in chronic health problems [18]. Despite the risk of such condi- tions, 70% of young adults received no preventive care or

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counseling. Further, studies have suggested that screening rates for sexually transmitted infections, obesity, injury pre- vention, mental health, HIV, and exercise were low within the young adults as compared to adolescents or older adults [12]. Preventive diseases such as cancer, stroke, coronary heart disease, and diabetes make up approximately 60% of the total deaths per year in the U.S [17, 29]. Researchers have suggested that utilization of preventive health services may reduce disparities in a person’s health and is often a first step to treating and managing many chronic diseases [25]. In addition, researchers have suggested that enroll- ment in health insurance has been shown to be associated with higher utilization of preventive health services such as the flu vaccination, colorectal cancer screening, cervi- cal cancer screening, mammography, and prostate-spe- cific antigen testing among older adults, which may lead to better future health outcomes [14]. This can ultimately help to reduce mortality and morbidity within a young adult population, and enhance positive health outcome as they grow older. However, several questions still remain. What is the perception of health care insurance among young adults given the new provisions of the ACA? Does access to health insurance increase the use of preventive care services among young adults? What is the perception of young adults regarding chronic illness and preventive behaviors? Does access to preventive care services increase the likelihood of young adults to engage in health promot- ing and disease prevention behaviors? Given the ACA law and provision of coverage for all young adults since 2010, a research study to try to answers these questions was war- ranted. Thus, the aim of this study was to assess the rela- tionship among demographic variables and access to health care insurance, perceptions about health insurance cov- erage, and preventive care services among young adults residing in the Northeast region of the United States.

Methods

Sample Selection

Following Institutional Review Board approval, a sample of 1000 young adults between the ages of 19–34 years old, with equal numbers of both males and females, residing on the Northeast region of the U.S. were recruited to par- ticipate in this study. According to the U.S. Census 2014 population estimates, there were approximately 12.2  mil- lion young adults 19–34, residing in the Northeast region of the U.S., which includes the following states: Pennsyl- vania, New York, New Jersey, Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, and Maine. The Census estimated that of the 19–34 years of age popula- tion, 36.5% were between the ages of 19–24, 32.7% were

between the ages of 25–29, and 30.8% between the ages of 30–34 years old. The population estimates show that there was an equal distribution of males (50.1%) and females (49.9%) [26]. Thus, an online survey platform was used to recruit participants for this study; the potential participants were recruited based on the demographic targeting criteria, both males and females ages 19–34. The sample size of 1000 was calculated using an online sample size calculator based on the 12.2  million estimated young adults, a confi- dence level of 95% and confidence interval of 3% to repre- sent the target population [10].

Measures

The instrument included 40 questions, including partici- pants’ demographic characteristics, views and perceptions about health care coverage and the ACA, and preventive and current health behaviors. The instrument included eight standard demographic questions about participant’s gender, age, income and educational level, and race/ethnic- ity. The second set of questions of the survey, which were taken from the Health Insurance Tracking Survey of US Young Adults 2011 [24], included 11 questions regarding health care insurance and perceptions of the ACA. This section inquired whether participants have health insur- ance coverage and type of coverage, perceptions of the law and whether they purchased insurance coverage through one of the marketplaces, source of health care, and barriers to care due to cost. The third section included three main questions regarding whether participants receive preventive services, reason for not getting it, and their perceptions of susceptibility and severity of acquiring a health condition (e.g., cancer, diabetes, STIs, etc.). Participants were asked whether they have received one of the health preventive services as required by ACA, regardless of type of health insurance coverage, including healthy lifestyle, smoking, weight and stress management, physical activity, cardiovas- cular, diabetes, and cancer prevention [3, 27]. The last sec- tion of the survey included 14 questions about participants’ health status and behaviors including physical and mental health, tobacco use, alcohol use, physical activity, weight, and height. These questions were taken from the 2013 Behavioral Risk Factor Surveillance System questionnaire, a national standard survey conducted by the Centers for Disease Control and Prevention (CDC) [4] to assess preva- lence of many health risk behaviors among populations.

Data Collection and Analysis

After consideration of different online survey platforms, the authors selected to use the Survey Monkey platform due its unique ability to gather data from diverse partici- pants, provide greater assurance of anonymity, completion

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by a respondent at his or her convenience, and accessibility to a wide geographical area among other advantages. Par- ticipants received an email invitation from Survey Mon- key Audience asking them to complete the survey. Survey Monkey sent an invitation to a large sample of participants on their Audience group to ensure the number of completed surveys identified in the sample selection criteria. Survey Monkey Audience provided the advantage to recruit par- ticipants from the diverse population of nearly 1 million people who complete surveys every month on its sites and collaboration with a global partner network, which pro- vides access to millions more respondents. Survey Monkey Audience provides high quality responses by taking a dis- ciplined approach to recruitment, incentives and engage- ment: (a) by limiting the number of surveys members can take per week to ensure that no one member is over par- ticipating, (b) by rewarding members with non-cash incen- tives to encourages respondents to provide honest, thought- ful responses, and (c) by conducting regular benchmarking surveys to ensure that their participants are representative of the U.S. population. Once the participants agreed to par- ticipate, they were instructed to read the informed consent letter including issues regarding anonymity, and contact information of the Principal Investigator (PI) and Co-Inves- tigator (Co-PI). By completing the survey, participants gave consent to answer the questions.

Data was collected during the months of November and December of 2014. The IBM Statistical Package for the Social Sciences (SPSS) version 21 was used to complete the data analysis. Descriptive statistics were used to exam- ine participant’s responses and relationship across vari- ables. Chi-squares analysis was used to assess the percep- tions of the ACA and health insurance coverage, and access to prevention services by participants’ characteristics. The level of statistical significance was set at p < .05 for all sta- tistical measures.

Results

Demographics of Participants

One thousand and eight participants completed the sur- vey, after deletion of those who did not fit the inclusion criteria, 946 participants were included in the study anal- ysis. Participants were between the ages of 18–34, with a mean age of 27.09 (4.56) and 70% falling between the ages of 25–34. Most participants lived in one of the fol- lowing four states NY (37%), PA (25%), NJ (15%) and MA (12%). Almost 70% of participants were White, 54% were female, 62% were single, 50% were employed full- time, and approximately 52% reported being from low income families (annual income of less than 40,000).

Three out of four participants reported having some col- lege education, with almost 39% having had completed a bachelor degree or higher (see Table 1).

Table 1 Participants demographics characteristics

Percentage based on those participants that answered the questions, missing data was excluded

n %

Gender  Male 428 45.2  Female 511 54.0  Transgender 6 0.6

Race/ethnicity  White 629 69.9  Black/African American 76 8.4  Hispanic 104 11.6  Asian 68 7.6  Other 23 2.5

Age  18–19 70 7.4  20–24 216 22.8  25–29 321 33.9  30–34 339 35.8  Mean (SD) = 27.09 (4.56)

Education attainment  Less than high school 31 3.3  High school graduate 193 20.4  Some college/assoc degree 332 35.1  Bachelor degree 265 28.1  Graduate degree/professional degree 123 13.0

Marital status  Single, never married 424 45.3  Single, but cohabitating 154 16.4  Married 294 31.4  Divorced/separated 25 2.7  Domestic partnership/civil union 40 4.3

Employment  Employed full-time (30 h+) 470 50.3  Employed part-time (less than 30 h) 157 16.8  Not employed—stay home parent 98 10.5  Not employed—full-time student 86 9.2  Not employed—seeking employment 81 8.7  Not employed—other 43 4.6

Income  Less than 10,000 32 14.9  10,000 to under 25,000 182 20.6  25,000 to under 40,000 150 17.0  40,000 to under 60,000 151 17.1  60,000 to under 120,000 217 24.6  120,000 or more 51 5.8

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When asked about health insurance status, almost 87% indicated that they had health insurance plan or health coverage. Sixty-four percent of those with health insur- ance reported that they had private health insurance offered through employers (53%) or bought by themselves (11%). In addition, almost 82% reported that the health insurance was in their name or spouse/partner’s name, only 14% reported being on their parents’ or legal guardians’ health insurance. Out of those without health insurance, 36% reported being without health insurance for 1 year or less, with 49% stating that they could not afford/too expensive as a main reason for not having it (see Table 2). When asked if they have a place to go for their health care needs, 66% of the participants indicated that they go to a doctor’s office or private practice, follow by 14% who indicated a com- munity health center or public clinic, outpatient clinic, or health center/hospital inpatient clinic as places to receive

care. Finally, 87% felt that overall their health care needs have been met very well/somewhat well (not in table).

Perceptions of Health and Health Insurance

Data analysis showed that half of the participants reported that their health status was excellent to very good, with another 32% reporting that it was good. Similarly, almost half (48%) have a very or somewhat favorable opinion about the ACA, the majority believed that health insurance is something they need (84%), and over half reported that they have it to protect against high medical bills in case of severe illness (58%). A majority (59%) felt that paying for health insurance was a good value for the cost.

A Chi square analysis showed that males, those who were employed (both full and part-time), those with health insurance and private health insurance, those with college education and those with high income were significantly more likely to report that their health was excellent/very good when comparing it to their counterparts (p < .05). Males, those with health insurance, and those with col- lege education were significantly more likely to have more favorable opinion of the ACA (p < .05). Males and those with health insurance were significantly more likely to feel that paying for health insurance was a good value for the cost than their counterparts (p < .05). While females, those with health insurance and higher educational level were significantly more likely to believe that having health insurance is something they need; males, those without health insurance, and those with private insurance were significantly more likely to report that it was important to have health insurance to protect against high medical bills (p < .05) (see Table 3).

Use of Preventive Services

The majority of participants also reported that they had received a routine health/wellness exam (69%), dental exam (58%), and eye exam (49%) within the past 12 months. When it comes to other preventive services, approximately one-third reported receiving a blood pressure (38%) and cholesterol (32%) screenings and the seasonal influenza shot (38%). Less than a quarter had received sexually infections (23%), depression (22%), obesity (20%), cancer (20%), HIV (18%), and diabetes (17%) screening and/or preventive counseling and counseling on physical activity and fitness (18%), stress management (17%) and diets, eat- ing habits, and nutrition (17%). Finally, less than 10% had received screening and/or counseling on tobacco use and/ or smoking cessation, alcohol misuse, other substances or illicit drugs, suicide.

Chi-squared analyses showed that there were some sig- nificant differences in the use of preventive services by

Table 2 Participants’ health insurance status

Percentage based on those participants that answered the questions, missing data was excluded

n %

Had health insurance  Yes 821 86.8  No 125 13.2

Type of health insurance  Private—through job 448 53.3  Private—bought themselves 96 11.4  Medicaid/medical assistance 210 25  Health insurance military 37 4.4  Single plan (i.e., dental, vision) 5 0.6  Prefer not to answer/don’t know 45 5.4

Primary health insurance carrier  Themselves 576 68.5  Spouse/significant other 110 13.1  Parents 119 14.1  Someone else 8 1  Prefer not to answer/don’t know 28 3.3

Period without health insurance  6 months or less 32 25.6  6 months to 1 year 13 10.4  1–2 years 15 12  2 years or more 42 33.6  Prefer not to answer/don’t know 23 18.4

Main reason for not having health insurance  Can’t afford/too expensive 61 48.8  Not eligible due to work status 18 14.4  Changed in family situation 13 10.4  Other reason 13 10.4  Prefer not to answer/don’t know 20 16

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gender, health insurance, type of health insurance, level of education, and income level (see Table  4). Females were more likely to report having received a cancer screening, while males were more likely to report receiving counseling for physical activity and fitness (p < .05). Older participants were more likely to report to had cholesterol screening and younger participants were more likely to had received sexu- ally transmitted infections (STIs) screening and counseling (p < .01). Those with health insurance were more likely to report receiving routine health and wellness checkups, dental exams, eye exams, blood pressure and cholesterol screenings and flu shots compare to those without health insurance (p < .01). Those with private health insurance were more likely to report receiving dental exams, while those with public health insurance were more likely to had received STIs, depression, obesity, HIV and diabetes screenings and counseling, as well as counseling on stress management compared with their counterparts (p < .05). Study participants with higher educational levels were more likely to have received routine health and wellness

checkups and dental exams than those with lower educa- tional levels (p < .05); while those with lower educational levels were more likely to report having received STIs and HIV screenings and counseling than those with higher edu- cational levels (p < .01). Finally, those with higher incomes were more likely to received dental exams and cholesterol screenings than those with lower incomes (p < .01).

Discussion

As expected, the majority of participants perceived their health status to be good to excellent; this perception was more evident among those with health insurance, college education, current employment, and with higher incomes. The majority of these participants reported that they had health insurance and access to a health care provider and/or facilities, which explains why the majority of them reported that their health care needs were met. Still, the major- ity of them had private health insurance (i.e. provided by

Table 3 Percentage of those who agree with statement regarding health care and health status by characteristics

Percentage based on those participants that answered the questions, missing data was excluded Significant levels *p < .05; **p < .01; ***p < .01

Felt very favorable/some- what favorable about ACA

Reason for insurance—to protect against medical bills

Health insurance is something I need

Health insurance is good value for cost

Excellent/very good health status

Gender  Male 55** 63** 80** 63* 58*  Female 43 54 87 55 44

Age  18–24 48 59 81 62 54  25–29 49 52 82 59 53  30–34 49 62 87 55 45

Employment  Full-time 47 60 84 59 59***  Part-time 55 58 80 62 54  Unemployed 47 54 86 56 36

Had health insurance  Yes 50** 56* 86** 60** 52***  No 35 68 57 47 41

Type health insurance  Private 48 59* 87 61 57***  Public 56 51 87 59 39

Education level  HS or less 42* 61 80* 57 44***  Some college 44 54 83 57 43  College grad 54 59 87 60 60

Income  Less than 25,000 46 56 81 57 42***  25–59,999 49 55 84 57 48  60,000 or more 52 61 87 62 63

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employer or self-paid); which suggested that only a small percentage, those with public health insurance, had bene- fited from the requirements of the ACA. Similar to previous studies, those without health insurance cited cost as a reason for not having it [7, 21]. Unlike previous results, those with health insurance and college educations felt more favorable of the ACA than their counterparts. Nonetheless, the vast majority of this sample, especially females and those with health insurance and higher education acknowledged that health insurance is something they need. At least half of the participants agreed that it is important to have health insur- ance as it protects against high medical bills and it is a good

value for the cost. Interestingly, while those without health insurance agreed that health insurance protected against high medical bills, most did not think that it was a good value for the cost; which may help explain why they did not obtain it. Moreover, with the current legislative discussion on repealing and replacing the ACA, it is possible that more young adults would be dissuaded to obtain health insurance if the “individual mandate,” with a penalty of 2.5% of their annual adjusted income, is replaced with a “continuous cov- erage requirement,” which would require that everyone pay a premium surcharge higher than the current policy if they do not maintain continuous health insurance coverage [6].

Table 4 Percentage of those who received preventive services by characteristics

Percentage based on those participants that answered the questions, missing data was excluded Significant levels *p < .05; **p < .01; ***p < .01

Preventive services All Gender Age Hl insurance

Male Female 18–24 25–29 30–34 Yes No

Routine health and wellness check-up 69 58 78 72 68 67 74 34*** Dental exam 58 58 58 59 53 62 63 27*** Eye exam 49 51 48 52 47 48 52 29*** Blood pressure screening 38 35 40 38 36 39 40 24** Cholesterol screening 32 31 32 26 30 38** 34 17*** Seasonal influenza (flu) shot 38 38 38 39 38 38 40 25** STIs screening and/or counseling 23 20 25 29 22 19** 23 21 Depression screening and/or counseling 22 21 23 23 22 21 23 17 Obesity screening and/or weight manage-

ment counseling 20 20 19 20 18 21 20 14

Cancer screening 20 17 23* 17 23 21 20 20 HIV screening and/or counseling 18 20 17 20 19 15 18 20 Diabetes screening and/or counseling 17 17 16 14 19 16 17 13 Counseling physical activity/fitness 18 22 15** 22 18 15 19 17 Counseling on stress management 17 19 15 19 18 15 17 18

Preventive services Type of Hl Ins Educ level Income level

Priv Pub HS SC Coll <25 25–59 60+

Routine health and wellness check-up 73 78 62 73 71* 70 70 68 Dental exam 65 57* 50 57 65** 49 58 67*** Eye exam 52 51 45 51 49 46 49 53 Blood pressure screening 38 43 38 39 35 37 37 39 Cholesterol screening 35 34 29 32 32 27 32 39** Seasonal influenza (flu) shot 42 38 38 36 40 35 40 41 STIs screening and/or counseling 20 31** 28 25 18** 27 23 20 Depression screening and/or counseling 19 31** 27 23 18 26 21 19 Obesity screening and/or weight manage-

ment counseling 18 25* 22 21 16 20 20 19

Cancer screening 21 20 19 19 22 17 23 23 HIV screening and/or counseling 14 28*** 20 22 12** 22 17 16 Diabetes screening and/or counseling 15 22* 17 18 13 17 15 19 Counseling physical activity/fitness 17 22 22 17 15 20 16 20 Counseling on stress management 15 22* 21 18 12 21 15 16

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When it comes to preventive services, the results showed that the majority (i.e. at least half) of the participants had received three of the basic preventive care services includ- ing a routine health and wellness checkup, dental exam, and eye exam. This was not surprising as previous stud- ies have showed that the majority of young adults are not receiving preventive care and/or counseling [12, 18]. Hav- ing health insurance was the main factor in having had a routine health and wellness checkup, dental exam or eye exam. Similarly, those with health insurance were more likely to receive blood pressure and cholesterol screening and the seasonal flu shot. Still, given that most of them reported having health insurance and access to care, it is astonishing that most were not getting the preventive care as recommended [15, 20, 27, 28], thus, it could be possible that health care providers are not offering and/or that young adults themselves are not asking for these preventive care and counseling services given their perception of good to excellent health status. Still, the results of the study showed some interesting findings. It seems like whether partici- pants have received a preventive service depends on their own interest and/or concern based on their demographic characteristics. For example, older participants were more likely to get a cholesterol screening, while younger partici- pants were more likely to had received STI’s screening and/ or counseling. Finally, those with public health insurance were more likely to receive dental exam and screening and/ or counseling on STI’s, HIV infection, depression, obesity and weigh management, and stress management than their counterparts. Thus, it is possible that health care provid- ers who provide services to those with public health insur- ance are more likely to follow the ACA recommendations. Regardless of whether young people are currently receiv- ing preventive services, this may change in the near future as the discussion on the legislation to repeal and replace the ACA includes the elimination of requirements to cover essential health benefits such as those preventive and well- ness services discussed above [19]. Thus, young people, who are otherwise healthy, might choose to participate in health insurance premiums that exclude coverage of pre- ventive services, as these may be cheaper to obtain. Thus, it will be up to the health care provider or other health care professionals to offer and provide preventive services to young people as needed to prevent future chronic diseases.

While the study contributed to the understanding of perceptions and access to health care among young adults, several limitations need consideration. While the sample selection process was calculated to represent the population, the sample included a slightly higher percent- age of those ages 25–34 and females as compare to the estimated percentage of the population of young adults in the Northeastern part of the U.S. Survey Monkey con- ducts regular benchmarking surveys to ensure that their

participants are representative of the U.S. population; however, the nature of voluntary participation probably contributed to the slightly higher percentage of older and female participants, thus, caution is warranted concern- ing the generalization of the findings to all young adults in general, and specifically to those residing in Northeast region of the U.S. Future studies should consider using random sampling methodologies to gather responses from diverse members of this group. Moreover, there is a possibility for bias in responses as participants might have provided “socially acceptable” responses and/or given their self-interest in this study.

Conclusion

While the future of the ACA is uncertain, health care professionals should continue to put emphasis on health promotion and prevention activities to help reduce the incidence of illness and diseases. As such, health care practitioners and health education specialist can play an important role in providing health promotion activities and preventive services that target young adults. For example, increasing opportunities for preventive care and counseling should be part of any health professional who works in col- lege and worksite settings. College settings are the perfect environment to cultivate healthy behaviors among young people beyond substance use, mental health and sexual health, especially if they have health services, counseling, and fitness centers available on site [13]. Similarly, since previous study showed that primary care providers are restricted in the provision of health promotion and preven- tive activities due to their limited time and heavy workload, other health professionals (i.e., health education specialists, patient educators) working in health care settings could col- laborate with primary care provider and/or be incorporated into their practice to provide patients with health promo- tion interventions and preventive services [5, 16]. Finally, regardless of whether new legislation includes coverage for preventive services, health professional and health educa- tion specialists should continue to develop health promo- tion campaigns to educate young adults about the impor- tance of prevention and the utilization of preventive care beyond basic health screening and yearly checkups. As health education specialists continue to promote disease prevention, further research is needed to assess the feasi- bility and effectiveness of different type of initiatives to improve health care, health promotion, and preventive ser- vices among young adults.

Funding The funding was provided by Research Council Grant, Penn StateHarrisburg

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Compliance with Ethical Standards

Conflict of interest The authors declare that they have no conflict of interest.

Ethical Approval The study is compliant with the Office for Research Protections, Human Subjects Research, of the Pennsylvania State University.

References

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