international student stress due in 20 hours

Stress-Related Diagnosis and Barriers to Health Care among Foreign Students:

Results of a Survey

ALLAN J . EBBIN, M.D., M.P.H., and EDWARD S. BLANKENSHIP, Ph.D.

This survey of 476 college health center directors was made to determine if certain stress-related diagnoses were more prevalent among foreign than domestic students and to identify barriers to health care among foreign students. Pre- viously, a pilot longitudinal study at the University of South- ern California (UX) Student Health Center (SHC) revealed that 50 disease entities were significantly increased and 30 were significantly decreased in international students. Fur- ther analysis of the diagnoses that may be stress related revealed a greater proportion of those conditions among in- ternational students.

The findings in this survey of college health centers corre- lated with the results of the pilot study at USC in two major ways: (1) foreign students had higher frequencies than do- mestic students i n 10 of the stress-related diagnoses; and (2) the barriers to health care found among the U X foreign stu- dents were also described by the health center directors. These included language difficutties, different health beliefs, lack of knowledge and acceptance of stress as causes for so- matic complaints, and reluctance to see a mental health counselor.

Do international or foreign students experience more of certain disease entities than domestic students? To answer these questions, a pilot, exploratory, longitudi- nal study was undertaken at the University of Southern California (USC) Student Health Center (SHC). It cov- ered 96,804 coded diagnoses at the SHC over a three- year period from July 1980 to June 1983.

USC has more foreign students than any university in the c o ~ n t r y , ~ , ~ with 3,741 students representing 112 na- tions in 1985. Special programs are geared to health

care of foreign students. These are continually reevalu- ated because the philosophy at USC-SHC is prevention oriented. In spite of this, results of the pilot study showed USC foreign students had higher frequencies of 50 disease entities; 21 of these appeared to be stress related. The findings also revealed barriers to health care, supporting the “foreign student s y n d r ~ m e ” ~ and ”uprooting disorder“’ established by previous in- vestigators.

These revelations gave impetus for further investiga- tion to determine if other colleges with significant pop- ulations of foreign students have similar findings. If so, what programs could be planned to reduce barriers to health care for foreign students and to teach coping skills for dealing with stress-related disorders?

The goals of this national survey of college health center directors were to validate the differences in fre- quency of disease entities in foreign and domestic stu- dents that were found among the USC students and t o identify additional barriers to health care that foreign students at other schools might have.

Although surveys have limitations in data collection and potential for errors in recall and comprehension of questions, they are the most feasible way to obtain such data as the providers’ perspectives reported in this article. The authors concur with Maha4 and Akka‘ that foreign students use the SHC more frequently than do- mestic students and are more prone to stress-related somatic complaints.

In a recent study, Allen and Cole’contend that differ- ential rates of attendance among foreign students do not reflect, as has been claimed, stress-induced mor- bidity among them.

Allan J. Ebbin is executive director, Student Health and Counseling Services, and an associate professor of pediatrics, University of Southern California, Los Angeles. Edward S. Blankenship i s director of International Student Services and Study Abroad, Center for International Education, California State University, Long Beach.

VOL. 36, MAY 1988

METHODS

In October 1984, questionnaires were sent to 476 college health center directors at two- and four-year

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COtL EGE HEALTH

American College Health Association member colleges and universities that had more than 200 foreign stu- dents, according to the National Association of Foreign Student Affairs.

Health center directors were asked to compare the frequency of visits to their clinics by foreign and domes- tic students, to rank order in separate lists the 25 most diagnosed conditions among international and domes- tic students, and to list the barriers t o health care for foreign and domestic students.

Each variable was compared against each category response and then compared against each variable and category i n the USC-SHC study. A separation of the re- sponses of the two- and four-year colleges showed no significant differences, so all responses were pooled. Comparisons were made by proportion and percent- ages based on actual frequency of cross tabulations. References to “majority” refer t o more than 50% of the respondents. Not all respondents, however, answered every question.

RESULTS

O f the 476 schools surveyed, 180 (38%) responded; 150 were four-year schools, 22 were two-year schools, and 8 did not specify. The average enrollment was 11,120; each school reported more than 200 foreign students.

The findings from this provider-perspective survey correlated with the USC-SHC pilot study, which showed that foreign students had higher frequencies of the 10 most diagnosed, apparently stress-related conditions when compared with domestic students. These were anxiety, gastritis, headache, constipation, insomnia, depression, “no pathology,” chest pain, abdominal pain, and peptic ulcer. However, the survey results dif- fered from the USC findings in that domestic students had higher frequencies of hypertension, low back pain, amenorrhea, and neurodermatitis when compared with foreign students.

O f the 162 schools that responded to the utilization question, 102 (62%) found no difference between for- eign and domestic students i n frequency of visits t o the SHC, a finding contrary to the USC pilot study and pre- vious reports’ 4 6 7 that showed foreign students used the health center more frequently than domestic students.

The barriers to health care for international students noted by the majority of the respondents were lan- guage, health beliefs and attitudes, nutrition, sanita- tion, financial concerns, and reluctance to accept men- tal health counseling referrals. For domestic students, the majority of those surveyed listed peer pressure, as in areas of sexuality, alcohol and substance abuse, and noncompliance as major barriers to health care. Many cited inadequate funding, staffing, and time as addi- tional barriers to the optimal delivery of health care to all students.

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DISC U SSl ON

This survey of student health center directors validated, i n part, the earlier pilot study findings at USC-SHC. Specifically, it found that the medical care sought by foreign students i s frequently for stress- related problems (e.g., anxiety, gastritis, headache, constipation, insomnia, depression, “no pathology,” chest pain, abdominal pain, and peptic ulcer). The “no pathology” area may well be the practitioner’s way of diagnosing the loneliness that causes the foreign stu- dent to reach out for care.

Allen and Cole’s report from Australia’ that foreign students made an average of 3.0 visits per student per year t o the health service compared with 1.4 visits per student per year among domestic students i s consistent with the USC pilot study. However, the Australian study attributes cultural differences in attendance rates, proximity to the health care center, lifestyle, and pre- sentation in the doctor-patient encounter as determin- ants of the frequency and patterns of consultation. Sev- eral variables, including the years under study, the numbers of students i n each sample, the geographic or- igin of the foreign students, and the students’ “native” countries, may account for the different findings and conclusions. Additional studies will be needed to re- solve whether the foreign student syndrome is a fact or fable. Whatever the findings are, they should not be used to limit the number of foreign students studying in other countries, but to determine the nature of pro- grams needed in the home and host countries so that foreign students may benefit, in optimal health, from their education.

ACKNOWLEDGMENT

This research was supported in part by a grant from the Na- tional Association for Foreign Student Affairs (NAFSA), Divi- sion of Student Support Services, Bureau of Educational and Cultural Affairs of the United States Information Agency

The authors wish to acknowledge the assistance of Michael Suter and Christina Rojas in preparation of this manuscript and Jing Ling Dai, M P H., for editorial assistance

REFERENCES

1. Ebbin AJ, Blankenship ES. A longitudinal health care study: International vs. domestic students. / Am Coll Health

2. Zikopoulos M (ed). Open Doors 1984-1985. New York, Institute of International Education, 1984-85:49

3. Evangelauf I . Number of foreign students in U.S. rises less than 1 percent. Chronicle of Higher Education 1985;31:31, 34

4. Maha GE. Health survey ot new Asian and African students at the University of Illinois. I Am Coll Health Assoc

5. Zwingmann CAA, Gunn ADG. Uprooting and Health; Psychological Problems of Students from Abroad. Geneva, World Health Organization, Division of Mental Health, 1983

6. Akka R. The Middle Eastern student on the American campus. I Am G o / / Health Asoc 1967;51:251-254

7. Allen FCL, Cole JB. Foreign student syndrome: Fact or fable? / Am Coll Health 1987;35: 182-1 86

IACH

1986;34: 177-1 82

1 964; 1 2: 303-3 1 0