Does Identification Matter? How Felt-Connectedness among University Students in Kenya and the USA Influences Health Seeking Behaviours

Guided by social identity theory (SIT), this study considers how identification influences health seeking behaviours among college students in Kenya and the USA. The study sought to investigate how felt-connectedness among students influenced the health choices they made and the relevance of identification to health. Data were collected using responsive interviews with 22 students in a large Kenyan university and 21 students at a Midwestern university. The age of the participants from both countries ranged from 20 to 29 years. Data were coded and analysed using thematic analysis. The findings of the study indicate that identification influenced students’ health seeking behaviours, especially on use of contraceptives, vaccination, choosing a physician, offering advice, eating habits, and in ensuring safety for friends at risk. This study point to the need of health communicators to utilize identification in health interventions targeting college students.


Introduction
The people in a person's life influence how that person views the world and makes decisions (Paquin & Keating, 2017). Although most extant studies have investigated how people make health choices, there is minimal research into how identification influences health-seeking behaviours among college students. Identification refers to the dynamic social process by which we create identities that guide us and influence our perceptions of the world (Scott, Corman, & Cheney, 1998). Examining how identification influences the decision making of health-related issues can help health practitioners to design effective health campaigns.
Identification is an important concept in health because past studies have found that health-promoting behaviours, such as exercise and vaccination, can be considered social behaviours that most people engage in alongside others (Yun & Silk, 2011). Additionally, people maintain relationships by adopting attitudes, values, and behaviours of the people they interact with (Brown & Basil, 2010). Although college students often get sick, they are less studied compared to other groups in the population (Nicoteri & Arnold, 2005). Therefore, using the social identity theory, the overarching goals of this study were: to consider how identification at personal and collective levels influence students' health seeking behaviours and how health communicators can utilize this information to design effective health messages when targeting students. We begin by reviewing the relevant literature on identification and health seeking, followed by a discussion of the guiding theoretical framework, and the research questions.

Literature Review
It is common for people to be invested in relationships that help them to achieve their goals (Burke, 1950) and to be attracted to people who share similar identities and views on issues (Hall & France, 2012;Pratt, 2001). In fact, some studies have argued that people act in ways that are consistent with their identities in order to satisfy their psychological and sociological needs (Paquin & Keating, 2017). Thus, the desire to identify is common to humans and suggests why students belong to different social groups that shape their identities and influence their choices.
Identification concerns a person's self-identity and the extent to which a person is open minded in accepting divergent opinions (Stets & Burke, 2000). Self-identity is the enduring and salient reflection of oneself (Ries, Hein, Pihu, & Armenta, 2012;Stets & Burke, 2000). In past research, self-identity has emerged as an important health concept and some studies have identified it as a significant predictor of intention to engage in behaviours such as physical activities (Ries et al., 2012). One's identity is formed through interaction with other people and engaging in identification, a process in which a person classifies him/herself in particular social categories (Stets & Burke, 2000). The motivation behind self-identity is to reinforce the sense of self. Self-identity is different from group identity in that self-identity relates to the "I" identification rather than the "we" identity, which forms the basis for group identification (Rise, Sheeran, & Hukkelberg, 2010). This study views both the self-identity and group identity as important in understanding health-seeking behaviours among students. For example, a student might make a health choice because of the influence of people in his/her social circle or due to personal agency motivated by his/her own desire.
The relevance of identification to health is evidenced in preventative health behaviours in which most people adopt a particular behaviour because those in their social networks approve of such actions (Harwood & Sparks, 2003;Yun & Silk, 2011). When adopting a behaviour, people rely on both self-image and groups they belong to and reinforce the behaviour through repetition (Harwood & Sparks, 2003). Past studies have identified the role of self-image in influencing the willingness of individuals to engage in activities such as voting, blood donation, and indulgence in food and alcohol (Yun & Silk, 2011). Other studies have found that the approval from friends influences the decision of students to get the HPV vaccine (Richards, 2016) and to engage in exercise (Ries et al., 2012). Therefore, to maintain social ties, people make choices that do not violate the beliefs and values of people in their social circles (Kahan, 2013). Thus, these aspects of identification, when applied to health interventions, may help health professionals in designing health interventions that achieve the desired outcomes. Closely related to identification, the next section introduces and discusses the theoretical framework of this study.

Theoretical Framework
This study is premised on social identity theory (SIT). SIT contends that the social group that one belongs to influences a person's self-image and interactions with other people (Mckinley, Mastro, & Warber, 2014). Tajfel (1979) argued that group membership is important because it gives members a sense of pride and a lens through which group members view the world. SIT can assist in understanding how the desire to maintain interpersonal relationships among college students influence the choices they make about their health. Hall and LaFrance (2012) argued that individuals are motivated to act in ways that reinforce group prototypes and avoid actions that threaten group harmony. Students, for example, might make certain choices such as to start exercising if people in their social groups engage in or are supportive of such activities. They may also eschew risky behaviours such as smoking and indulgence in alcohol if those in their social circles do not approve of those behaviours. Tajfel and Turner (1979) proposed three mental stages involved in evaluating ingroups and outgroups: social categorisation, social identification, and social comparison. Social categorisation entails the group assigning a category to an individual, while social identification involves the individual adopting the identity of the group, and social comparison happens when the individual starts comparing that group to other groups (Tajfel & Turner, 1986). Such categorisation influences one's perceptions toward other groups in ways that elevate the status of his/her own group. Past studies contend that self-image influences the willingness of individuals to engage in activities such as vaccination, voting, blood donation, and indulgence in food and alcohol (Richards, 2016;Yun & Silk, 2011). Therefore, based on SIT and relevant literature, this study poses the following research question: RQ: How does identification influence students' health seeking behaviours?
The methodology including choices that were made in collecting and analysing data are provided in the next section.

Methodology Participants
This qualitative study involved 43 undergraduate students, of whom 22 (7 men and 15 women) were from a university in Kenya and 21 (6 men and 15 women) were from a large university in the USA. The age of the participants ranged from 20 to 29 years. Participants were recruited using snowball sampling, in which participants known to the researcher passed on the knowledge of the research project to other people who met the sampling criteria.

Data Collection
After approval of the study by the Institutional Review Board (IRB), data were collected over the summer of 2019 using face-to-face responsive interviews because of they allow for an in-depth study of implicit beliefs and attitudes (Keyton, 2014;Lindlof & Taylor, 2011;Rubin & Rubin, 2012). Additionally, responsive interviews allow for flexibility and enable a researcher to guide the interview and adjust to the emerging needs or comments of an interviewee (Rubin & Rubin, 2012). The interviews lasted approximately 25 to 60 minutes and were audio-recorded to increase accuracy during transcription. To protect the confidentiality of participants, all identifying information from the transcriptions was removed and the participants were assigned pseudonyms. The focus of the interviews was to understand the extent to which identification among students influences the choices they make about their health.

Data Analysis
Data were analysed using thematic analysis, where only the emerging themes and patterns that are relevant to the research question were considered. Braun and Clarke (2006) defined thematic analysis "as a way of analysing and reporting patterns within data" (p. 79). Before coding the data, each interview was saved as a separate file to ensure clear organisation (Haas & Mattson, 2015). Thereafter, the interviews were coded to establish concepts, categories, and themes that aligned with the research question of the study. The coding process involved the following steps; familiarisation with the content in the transcripts, separating the qualitative material into idea units, and establishing the categories into which the idea units could be classified (Haas & Mattson, 2015;Rubin & Rubin, 2012). In this study, the units of analysis were words, phrases, and emerging patterns that aligned with the research question (Lincoln & Guba, 1985;Lindlof & Taylor, 2011). The categories were then developed into overarching themes depending on the similarities of content in the categories (Lindlof & Taylor, 2011;Rubin & Rubin, 2012;Saldaña, 2016). The findings of the study are presented in the next section.

Findings of the Study
The categories that emerged from the interviews coalesced into the following themes: cancer screening, HIV testing, recommendations, social pressure, offering advice, eating habits, use of contraceptives, vaccination, coping with distress, safety for friends, and one's body as the temple of God. Generally, the content of these themes suggested that the students' health seeking behaviours were influenced by their desire to identify with other students and to maintain existing friendships with peers. The participants also suggested that people in their social circles influenced their health decisions such as screening for breast and cervical cancers in women, seeking voluntary counselling and testing (VCT) for HIV, and their likelihood of using contraceptives and condoms during sex. These themes are discussed below.
Cancer screening. Some participants reported being advised by their friends to go for cancer screening. In the following comment, Doreen explains how her friends advised her to go for cervical cancer screening out of concern that her profuse menstrual bleeding could be indicative of an underlying condition.

Doreen [Kenya]:
Yes, I remember in January this year there was a certain cancer screening. People were walking around being screened for cancer on campus. So, my friend told me I'm not saying that you could be suffering from it [cancer] but I think your cramps are excessive [and] you need to go and get screened. So, I went for the screening.
This comment by Doreen highlights the concern students had for their friends. This concern motivated them to look out for one another and offer advice that could encourage their friends to go for treatment. This is also reflected in the vaccination theme below.
Vaccination. In other instances, the students reported influencing each other to go for vaccination shots. In the following example, Bernice explains how she influenced her friends to go for shots together.

Bernice [USA]
: I hate shots. So I always bring my friends with me so I don't have to do it myself because I don't like getting shots by myself and I don't know how often you do like shots.
This comment reveals that the social network of a student can motivate him/her to go for shots. Since the study focusses on how identification influences health seeking, this comment shows that group identification can motivate students to go for vaccination. This tendency to be influenced by friends was also observed in the comments about HIV/AIDS testing among Kenyan students that is presented next.
HIV/AIDS screening. The findings also suggested that students in Kenya influenced each other to go for HIV/AIDS testing and screening for other diseases when someone had persistent symptoms. Usually, HIV/AIDS screening is conducted in a Voluntary Counselling and Testing (VCT) center where one is first counselled about HIV/AIDS and how they can deal with it if their test is positive.

Kyle [Kenya]
: It [friends' influence] may be like going to be tested for the HIV or other illnesses. So sometimes maybe I have some illness and my friends push me to get tested. Maybe I have flu and because of the pressure I decide to go to make sure am okay.
This comment by Kyle shows that friends in students' social circles influenced them to get tested for HIV/AIDS and to seek treatment if they became ill. HIV/AIDS, like HPV, is sexually transmitted and students' ability to influence each other to go for testing lends evidence to the importance of identification with others and its influence in health seeking behaviours. The next theme highlights how students relied on identification for emotional support when ailing.
Emotional support. The respondents also revealed that they perceived identification as a source of emotional support when a friend was sick. The following comment showcases this.

Becky [USA]:
And just like if I'm not feeling well like they [friends] will usually help me out and you know bring me food and just like hang out with me when I'm sick.
The comment by Becky shows how having a functional network of friends can help students when they are sick. The emergence of this theme from the interviews, for instance, shows that friends looked out for one another and offered support especially when someone became ill.
The interviews also revealed that students looked to each other for answers to questions that they had. The comment by Allegra below shows how friends were resourceful and supportive when a peer had questions.

Allegra [USA]:
Like if I ask them a question about something, they will tell me. Like it's that type of open honest conversation because like I know that they want to be there for me, and I want to be there for them.
This comment shows that students sustained friendships by being open with one another and being there for each other. Allegra seems confident that her friends are there for her and so she would also want to be there for them when they need her. This reinforces the importance of identification among students and shows how it was an important source of support to students. This is closely related to the theme of friends ensuring safety for their peers, which is described next.
Ensuring safety for friends. In other instances, students reported that they took measures to ensure the safety of friends whom they perceived to be engaged in risky behaviour. In the following excerpt, Bobby explains how he drove his drunk friend's home out of concern that it would not be safe for them to drive when intoxicated.

Bobby [USA]:
Yeah so like I did end up at a party a few weeks ago. But like everyone was drinking and I could have very easily drunk because like I didn't want to be like a buzzkill or whatever. Yeah and these group of friends were not within the religious groups like they were all like getting trashed and they were all super drunk. And instead, I was like well maybe, I could do good with this. And so, I decided instead I could just drive them all home. So, I ended up driving. I had like three or four trips to make. So, I just kept carpooling people in my car and taking them back. So, I think that just like trying to figure out what could I do in this situation instead of what the normal thing to do would be. It would've been normal to drink. Instead I was like, well I can do good in this moment and I feel like that was like God [guiding me] yeah.
This comment reveals the role that felt connectedness among friends had in safeguarding the wellbeing of friends. Toward the end of the excerpt, Bobby reveals that his actions were inspired by his identification with God to ensure the safety of his friends. This nuance reveals that identification among students occurred both at the interpersonal level and the macro level, in which students acted in ways that enhanced their relationship with their friends and with God. The next theme explains how friends advised those in need about where to seek treatment based on their previous experience with various physicians.

Recommendations.
Referrals from students to their peers were based on the recommender's past experience with healthcare providers. If the past experience was positive, the students would recommend to their friends that they go for treatment to that healthcare provider. The following comment serves as an example of the comments made by some participants.

Mo [Kenya]:
They told me I went to this physician and the services were good or not good. They also told me that this hospital is better than that, and then they told me it's up to you to make the decision.
The comment by Mo shows how friends influenced where their friends sought treatment by offering advice about which healthcare provider to visit. Usually, that advice was based on previous interactions with a healthcare provider and indicated how having a positive identification with a physician can increase satisfaction of a patient and increase the likelihood of more referrals.
Offering advice. Besides recommending where a friend could get treatment, the students in one's network also broadened the worldview regarding health choices and offered advice to each other. The following comments illustrate this. These comments show how friends expressed concern for each other by offering advice if one was involved in potentially risky habits such as lack of sleep. Additionally, Adi suggested that she broadened her perspective on health issues through her interactions with her friends. Closely related to Adi's comments, Alejandra suggested that she would be willing to advise a friend if she ever saw them make a poor choice. These findings show that the identification among students is not only important for social reasons but also for health purposes. Students also revealed that their friends influenced their choice of diet as described in the next section.

Choice of diet.
The participants revealed that their friends' input influenced the food they ate. They did this by talking about some foods and the health benefits as well as the effects of not eating such foods. The following comments show how students influenced the eating habits of their friends.

Lily [Kenya]
: They [friends] influence a lot especially the food I eat. You will find some of my friends telling me by the way Lily when you try this type of food it brings these benefits, and when you stop eating it, you start experiencing this [health effect].

Maddie [USA]:
In particular I know that we'll talk about making sure you get all your meals. Making sure that you're looking out for them and making sure they like eating healthy in general, like eating right. And trying to be healthy even though like I know college is really stressful.
These comments show how friends influenced each other regarding staying healthy by eating right. Besides explicitly advising their friends on the kind of food to eat, students implicitly influenced the choice of food by observing what their friends ate. The following comment illustrates how going out for meals with her roommates influenced her eating habits.

Becky [USA]:
But you know if we go out for food or whatever, one of my friends like one of my roommates she is vegetarian and gluten free and dairy free. So she eats lots of like super healthy foods because she can't have a whole lot of processed foods. And my other roommate she's like never home so she never cooks anything, so she usually does like microwave meals. And so I like the two extremes. I would say of my roommates. So I try and be in the middle of it because they're both too extreme for me. Therefore, I would say that they have a relatively big impact on my life just because I spend a lot of time with my friends here.
This comment shows how being close to other peers may influence the eating habits of students. In this example, Becky compares her eating habits with that of her friends and deciding what is best for her. The element of comparison shows how students might engage in a behaviour by comparing themselves with others and weighing the benefits of such a behaviour. The next theme refers to how students influenced each other in choosing contraceptives.

Choice of contraceptive.
Students also influenced their friends on the choice of contraceptives to prevent pregnancy and use of condoms to guard against sexually transmitted diseases. The following excerpts show some of the comments that were made by participants regarding the use of contraceptives and condoms.

Doreen [Kenya]:
My friends influence me especially on contraception. We talk about contraceptives a lot. Yeah. So, I would say from the advice from the stories I know about what [contraceptive] to use.

Becky [USA]
: I wasn't originally on birth control my freshman year and then like all my friends were on it like you know [they were] you should probably go for it. And I had I hadn't really thought of it before. So, I talked to my doctor and I was like I mean I might as well start it. So I would say that they were pretty big influence on that too. You know it's not the feeling of being left out per say but I feel like they're having a positive experience with you know a certain birth control or a different thing. And so you know I didn't have that so I was like ok well, I will try it out and then if I that same experience then it'll be good for me too.
These comments show how friends influenced each other when deciding to start using contraceptives and choosing the type of contraceptive based on what their friends were using. These two comments indicate how the social norms of a group toward a health issue can influence the behaviour of members of that group. Usually, members would engage in behaviours that their friends approve of and those that can enhance the group as a whole. In particular, the comment by Becky evidences how her friends influenced her to decide on using contraceptives. This was driven by the need to identify with her friends and the desire to have similar satisfaction from contraceptives that her friends were getting. These comments resonate with the next comment, which indicates how friends influenced each other into practicing safer sex and ensuring safety of their peers in general.

Eva [Kenya]
: Yeah, they [friends] influence me. Most of my close friends ensure that I am not into unsafe sex. They make sure that any time I meet with this guy we do it [sex] safely, we practice it safely and they give me ideas on what to use and the best way to prevent the STIs.
The influence of students to practice safer sex is something worth noting, especially because of the high prevalence of sexually transmitted infections, such as HPV and HIV/AIDS among young people both in Kenya and the USA. Thus, this finding shows that students wanted to safeguard the health of their friends by encouraging them to practice safer sex. These findings support the influence of identification on health seeking behaviours among students. The next section discusses these findings and their implications for theory and practice.

Discussion
This study offers interesting findings and sheds light on how health practitioners can utilize identification in health contexts. The findings, for instance, indicate that the desire to identify with other students can influence the health choices they make. In particular, the findings suggested that the need for identification among students influenced their choice of diet, likelihood of practicing safer sex, propensity of referring their friends to healthcare providers whom they perceived as caring, and inspired students to encourage their peers to seek care when they were ill. The next section discusses, the implications of these findings and how they contribute to communication theory.

Theoretical and Practical Implications of the Findings
This study utilised SIT to explain how the need to identify with other students might influence their decision-making concerning health-related choices. This highlights the utility of SIT in health research by showing how identification among students can motivate health-seeking behaviours, such as group vaccination and screening. The findings of the study buttress the arguments in SIT that one's social group influences self-concept and this in turn influences the interactions with other people (Mckinley et al., 2014). The findings also highlight the influence of group membership in shaping the behaviours of members and influencing their worldviews (Hall & LaFrance, 2012;Tajfel, 1979). Often, individuals are motivated to act in ways that reinforce group behaviour and avoid situations that threaten group harmony (Hall & LaFrance, 2012;Tajfel & Turner, 1979). This may explain why students followed the health suggestions given by their friends and acted in ways consistent with the expectations of their peers.
This study supports extant research on identification and its application in health. For example, consistent with arguments made by Harwood and Sparks (2003), this study shows that people rely on others in their social networks to make health choices. This supports the centrality of identification in our social world (Leach et al., 2008;Scott et al., 1998). Additionally, to maintain social ties, people tend to make choices that do not violate the beliefs and values held by those close to them (Kahan, 2013). This was illustrated by the respondents' willingness to follow the referrals of their friends in making decisions about where to go to hospital and the contraceptives to use. Therefore, this shows the importance of considering the social norms and culture of a target audience when rolling out a health intervention because they can provide a context through which health issues can be better understood (Airhihenbuwa & Webster, 2012;Tindall & Vardeman-Winter, 2011).
It is interesting that students in both Kenya and the USA indicated that identification with their peers influenced their health choices regardless of the cultural differences between the two samples. This highlights the potency of identification in addressing health behaviour change. For example, these findings indicate that targeting the social networks of students with health messages can help to increase the likelihood of them adopting desired behaviours. This is particularly important in dealing with health conditions that mostly affect students, such as sexually transmitted infections like human papillomavirus (Markowitz et al., 2014). The next section considers some possible future research areas that augment the current study and expand our understanding of the role that identification plays in health.

Directions for Future Research
From the findings of this study, it seems obvious that identification plays an important role in health behaviours and researchers need to continue exploring this intersectionality. The focus of the present study was on the student population, therefore, another possibility for future study is to explore if identification has the same influence on health in both non-student and older populations. This can help to shed more light into how identification can shape the attitudes of the target population with regard to various health issues.

Limitations of the Study
It is important to identify some limitations of this study. First, these findings cannot be generalised to an entire population. Additionally, health-related topics are sensitive, and it is possible that students forgot or even distorted information they provided to avoid disclosing their health habits.
However, regardless of these shortcomings, the findings of this study highlight the important role that identification plays in our lives, especially in shaping our health behaviours. The use of interviews, which are convenient in the study of implicit behaviours, lends credibility to the validity of these findings and their reliance in healthrelated contexts.

Conclusion
The findings of this study show that identification is an important factor that influences health behaviours and the choices that people make in their daily lives. From the findings, for example, it was clear that the people in a student's social circle influenced their choice of diet, likelihood of getting vaccinations, referrals for friends, and use of contraceptives. Taken together, this study reveals the need for health communicators to utilize identification in health campaigns aimed at changing the behaviours of college students. This is important because it can give insights into how health practitioners can target the social networks for effective design of health messages focusing on students.