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Duke Medical Ethics Journal

First-Generation College Student Health: Disparities and Ethical Implications of Intervention

By: Makayla Gorski

I. Introduction

Of current interest to post-secondary academic institutions is locating methods through which they can support student health. College students are situated at a time in their life where they may not be able to financially support themselves and may be transitioning off of the health insurance plans and care provided through their parental figures. In fact, young adults ages 18 to 34 constitute the US demographic most likely to be uninsured when it comes to health insurance [3]. Yet, specifically first-generation college students (FGCS) are particularly vulnerable to lifestyles and mindsets that can be harmful to their health [5]. For the purposes of this article, references to first-generation college students indicate students who have one or more parents or guardians who did not attend college or who did not obtain a post-secondary degree. As the importance of a college degree drastically increased in the mid-

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20th century, so did the ranks of FGCS, with the population of FGCS reaching one third of all students enrolling in post-secondary education as of 2012 [10]. For a group of students that comprises such a large portion of the modern undergraduate population, there is a significant gap in the body of literature investigating how to ethically bolster student health of FGCS, whose FGCS status impacts the likelihood that these students seek care in the first place. This article explores the disparities in FGCS and non-FGCS health as well as the ethical issues associated with facilitating health interventions to support these students.

II. Mental Health

Literature examining the mental health of FGCS in comparison to Non-FGCS reports higher levels of depression and stress among FGCS [2]. Further research suggests this may be attributed to the self-stigma and attitudes of FGCS about seeking support. Garriott et al. examines the impact of FGCS minimizing personal stigma and focusing on their own self-perception when it comes to pursuing counseling, suggesting, “Although [it] may be adaptive for first-generation students at times, perhaps resulting in grit and resilience, it is also important to consider the potential for this internal focus to be isolating and pressure-filled.” Therefore, the independence that many FGCS develop, though useful in navigating the overall  college experience, may leave these students feeling secluded and be maladaptive to their mental health. The same study found that there was a stronger relationship between attitudes and self-stigma in FGCS than non-FGCS, which indicates that interventions encouraging FGCS to seek professional help should target existing self-stigma, or beliefs one has about their own mental condition, in order to change attitudes FGCS have towards counseling [6]. The greater susceptibility of FGCS to mental illness can also culminate in poorer physical health. In a study conducted by Barry et al., researchers found that college students with challenging life circumstances, such as food insecurity at any level, are more likely to screen positive for an eating disorder [1]. Overall, literature establishes a disparity in the mental health of FGCS and Non-FGCS groups and identifies the mindset of FGCS as one potential origin of this difference.

“For a group of students that comprises such a large portion of the modern undergraduate population, there is a significant gap in the body of literature investigating how to ethically bolster student health of FGCS, whose FGCS status impacts the likelihood that these students seek care in the first place.”

III. Physical Health

Research on the physical health of FGCS currently consists of self-report methods, and further study, by other methods of data collection, is needed. Self-report data thus far reveals that FGCS have lower self-reported ratings of physical health in comparison to Non-FGCS, and specifically FGCS considering discontinuing their college education had poorer perceptions of their physical health [7]. This indicates that support for FGCS should adopt a more holistic approach, as physical health—at least FGCS perceptions of their physical health—may be a predictor of retention rates in this student population. In consideration of the nutritional health of FGCS, literature suggests a slight increase in the prevalence of food insecurity among students in this group, one study finding 56% of FGCS enrolled experiencing food insecurity compared to 45% of the Non-FGCS population [4]. Though the disparity in prevalence is not as drastic as one might expect, this difference manifests as poorer graduation outcomes, which is why food insecurity is of utmost importance to post-secondary institutions aiming to improve the retention rates of FGCS. Wolfson et al. found that food-insecure FGCS were significantly less likely to graduate compared to food-secure FGCS. Similarly, food-insecure

FGCS were less likely to graduate compared to food-insecure Non-FGCS [11]. The body of research investigating how health care providers and student health organizations can mitigate the impact of this difference suggests that interventions targeting beliefs FGCS have about physical health are most effective in eliciting positive health changes. This corroborates research pertaining to the mental health of FGCS; health interventions cannot change FGCS status, but they can alter how FGCS think about their health, resulting in improved health outcomes.

Compensatory Health Beliefs (CHBs), one part of FGCS perception, are part of a human psychological mechanism used to rationalize poor health behaviors by highlighting the merits of good health behaviors. These beliefs resolve conflict between behaviors an individual wants to engage in and what he or she knows is a bad choice for their health, allowing individuals to engage in compensatory health behaviors. An example of this would be a college student justifying a quick trip to the vending machines for dinner by telling themselves they will eat a salad at the dining hall tomorrow after going to the gym. The issue with CHBs, however, is that individuals frequently do not perform the compensatory behavior. In addition to this, the “healthy” behavior they believe will counteract their poor decisions may not effectively compensate for previous unhealthy choices. Gallagher et al. establishes that higher FGCS endorsements of unhealthy CHBs is related to poorer eating behaviors, whereas Non-FGCS showed no relation between the extent of their CHBs and eating behaviors [5]. Again, this illustrates the impact that mindset has on FGCS health.

IV. Ethical Implications of Health Interventions for First-Generation Students

While the body of literature on FGCS health proposes harmful beliefs about health and healthcare as the source of poorer mental as well as physical health, health interventions targeting these beliefs in the FGCS population must do so in a way that protects FGCS autonomy. Health education, for example, is the preferred method of intervention for public health campaigns according to 21st century public health ethical frameworks [8]. Many health care professionals feel obligated to correct false health information, but when it comes to beliefs about mental health and FGCS attitudes towards counseling, encouraging students to seek professional help may do more harm than good. 


First, in an attempt to increase the effectiveness of health education programs for FGCS, programs may unintentionally incorporate dubious ethical practices like coercion and manipulation. As a broader example, a health intervention program with the intent of convincing smokers to stop smoking may portray smokers as unpopular, in doing so, manipulating the attitudes of those being educated. In the context of FGCS health, leading FGCS to think that a cognitive focus on their own self-perception only harms their mental health (based on commonly misinterpreted research by Garriott et al.) may negatively impact the resilience of these students. 


Second, targeting the educational health interventions to FGCS, even if well-intentioned, may negatively impact public health beliefs and result in social stigma towards these students. For example, if student health organizations target programming warning against Compensatory Health Beliefs towards only FGCS, it may lead students to believe that only FGCS groups are at risk of the negative impacts of CHBs. Although there is a statistically significant difference in the extent to which CHBs predict nutritional health between FGCS and Non-FGCS groups, this cannot be interpreted as CHBs do not exist among and impact Non-FGCS. In fact, research has established CHBs as an important consideration in the “adoption and maintenance of health behaviors” of all individuals [9]. Another risk of educational health interventions is the potential for propagation of social stigma regarding FGCS. While health-related educational programs targeted towards FGCS may suggest that FGCS are not capable of healthy cognition, the reality is that FGCS have embraced mentalities that are adaptive in some ways, allowing for resilience in the face of adversity, yet have consequences for their health. Thus, though research identifies targeting beliefs about health as the most effective method of supporting FGCS, improving access to and strengthening existing preventative care—though more challenging to facilitate—may be the most ethical way to support this population of college students.

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Review Editor: Huda Haque
Design Editor: Sofia DiFulvio

[1] Barry, M. R., Sonneville, K. R., & Leung, C. W. (2021). Students with food insecurity are more likely to screen positive for an eating disorder at a large, public university in the Midwest. Journal of the Academy of Nutrition and Dietetics, 121(6), 1115-1124.

[2] Becerra, M. (2017). Mental Health and Academic Performance of First-Generation College Students and Continuing-Generation College Students. UC Merced: Library. Retrieved from

[3] Dauner, K. N., & Thompson, J. (2014). Young adult's perspectives on being uninsured and implications for health reform. The Qualitative Report, 19(4), 1.

[4] Dubick J., Mathews B., Cady C. (2016). Hunger on campus: The challenge of food insecurity for college students. College and University Food Bank Alliance.

[5] Gallagher, K. M. (2019). What Do We Know About the Health of First-Generation College Students? A First Look at Compensatory Health Beliefs and Behavior. Perspectives In Learning, 18(1), 3.

[6] Garriott, P. O., Raque-Bogdan, T. L., Yalango, K., Ziemer, K. S., & Utley, J. (2017). Intentions to seek counseling in first-generation and continuing-generation college students. Journal of Counseling Psychology, 64(4), 432.

[7] Hixenbaugh, P., Dewart, H., & Towell, T. (2012). What enables students to succeed? An investigation of socio-demographic, health and student experience variables. Psychodynamic Practice, 18(3), 285-301.

[8] Kass, N. E. (2001). An ethics framework for public health. American journal of public health, 91(11), 1776-1782.

[9] Rabiau, M., Knäuper, B., & Miquelon, P. (2006). The eternal quest for optimal balance between maximizing pleasure and minimizing harm: The compensatory health beliefs model. British Journal of Health Psychology, 11(1), 139 -153.

[10] Skomsvold, P. (2015). Web tables —Profile of undergraduate students: 2011 –12 (NCES 2015 -167). U.S. Department of Education, National Center for Education Statistics. Washington, DC.

[11] Wolfson, J. A., Insolera, N., Cohen, A., & Leung, C. W. (2022). The effect of food insecurity during college on graduation and type of degree attained: Evidence from a nationally representative longitudinal survey. Public health nutrition, 25(2), 389-397.

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