Muhammad Afzal Javed ( Department of Psychiatry, Mayo Hospital, Lahore. )
Cohn M. Shapiro ( Department of Psychiatry, The Toronto Hospital, Toronto, Canada. )
As immigration for higher education is becoming more common now a days, the adjustment of overseas students to the host country is receiving more attention. This paper describes the results of a study which examined the prevalence and pattern of psychological disturbances among overseas and British students studying at Edinburgh University. The practical implications of these findings and suggestions for future research are discussed (JPMA 42:115, 1992).
More than a million students now migrate from their home countries to obtain higher education and this figure is rising every year at an estimated rate of 7.5%1. The adjustment of overseas students to the host country is receiving more attention currently because of reports that they experience greater symptomatology with qualitative and quantitative differences in disturbances as compared to the local students2-7. This concern has also led to the publication of a WHO document on the health of foreign students with the aim of improving their quality of life8. Investigations into the mental health problems of students have used various methods. The methodology has included surveys/questionnaires/enquires7-9. consultation rates and pattern of use of psychiatric services by the students4-10 and studies correlating academic performance with psychological wellbeing of these swdents11,12. Estimates provided by these studies have frequently been criticised on many grounds such as lack of standard diagnostic criteria, absence of a control group, the limitations that not all who have psychiatric problems consult their doctors, variation in the attitude of consulting physicians towards psychiatric illnesses and the reliability of self-report enquiries13-15. It was from this perspective that the present study was planned to examine the prevalence and pattern of psychological distress among overseas students studying at Edinburgh University, avoiding some of the above mentioned methodological problems.
PATIENTS AND METHODS
The study population consisted of 50 postgraduate overseas students enrolled with the University of Edinburgh in 1987-1988 session. This group was identified by drawing a random sample from a total list of 225 who were foreign by domicile or birth, had never before resided in this country and had joined the university for any higher degree or diploma course. A matched British student for each overseas student was then approached and in case of non-compliance, another local student of the same age, sex and faculty was included in the study. The investigation took place about six months after the start of the academic year. Each student was interviewed at his or her convenience. The study was carried out using a semi-structured interview and a set of questionnaires. The data were collected using following instruments:
The 30-item version of the General Health Questionnaire (GHQ)16 was used to measure psychiatric disturbance.
Five common symptoms (anxiety, depression, backache, tiredness and headache) were measured in two ways, i.e., paired statement method and visual analogue scale, both of which utilized statements indicating different levels of severity. In the first method, the subject was presented with selective pairs of statement and asked to say which of the statements in each pair nearer to the truth for him personally during the past month. In the same statements were spaced along a 10 cm line. The subject was asked to place a mark anywhere on the line to indicate how bad the symptoms had been for him during the past month. These methods have been used successfully in some previous studies9,17.
The subjective version of the Social Functioning Schedule (SFS) was used in the present study18. This is a brief semi-structured interview that assesses social functioning in twelve different areas. The items covered are work, house chores, finance, self- care, marital relationship, child care, relationship with child, relationship with parents, household relationships, extra-marital relationships, social contacts and spare-time activities. Within each of the sections, evidence is sought of any problems in the performance of the role during the past month. The rating is made on a 10 cm line which is labelled ‘severe difficulties’ at one extreme and ‘none’ at the other. Scores in individual areas of functioning can be obtained as well as a summary functioning score, which is the mean of all rated items. A low mein summary score is indicative of a better (i.e., more problem-free) level of social functioning. Reported validity and reliability and sensitivity of this scale are satisfactory19.
Non-parametric tests appropriate for matched pairs were used for statistical analysis. These included Wilcoxon signed rank tests and McNemars tests.
The present results are based on 41 pairs of students who completed the questionnaires and interview. A description of the demographic information is given in table I.
The GFIQ score showed higher ratings for the overseas students. Using Goldberg’s suggested cut off score on this scale’6, 27 cases (65.9%) were found among the overseas group as compared to 10(24.4%) cases among the British students (Table II).
As the two groups were matched, comparison between the two samples using McNemar test showed a highly significant (P <0.001) difference, Symptom scales The scores on two rating scales-paired statement method (scale A) and visual analogue (scale B) are shown in Table III.
The results showed that overseas students had higher median score on symptoms of depression, backache, tiredness and headache than the British students with a statistically significant difference.
Overseas students scored higher than the British group on the Social Functioning Schedule which indicated presence of more problems and difficulties in this area for the foreign students. The results showed that overseas students’ median score was 3.100 as compared to 2.200 of the British students. The difference was highly significant (Pc 0.001).
The evidence furnished by this study supported earlier findings that overseas students experience more mental health problems than local students. The level of psychopathology, measured by the General Health Questionnaire in this study, was higher among these students. The score on two self-rating scales also showed more pronounced symptomatology in the overseas group and the frequency of both psychological and somatic symptoms was again high among foreign students as compared to British students. Based on the GHQ score of 5 or more, the estimated prevalence of psychiatric cases was found to be 45.12% for the whole sample and the overall ‘case’ rate was 65.8% for the overseas students and 24.3% for the local students. The number of these ‘probable cases’ also varied among different nationalities. In all there were nine Africans (81.9%), eight Europeans (72.8%), seven Asians (53.2%) and three Americans (50%) who scored five or above on the GHQ. The association of different nationalities with case status, however, did not show any statistically significant difference. This finding was at variance with reports3,20 who found differences in prevalence of psychological problems among different national groups. The sub grouping of British students according to place of birth and permanent home address showed that seven Scottish students (16.9%) met the criteria to be a ‘case’ as compared with three English born students (20%). The difference was non-significant (x2 = 0.014, p=N.S.). This is also at variance with the results of a similar study21, in which English students studying at Scottish university showed more emotional problems than local Scottish students. Luyombya’s hypothesis that native students who move away from their home communities experience the same problems as foreign students did not receive any support from the present study. It looks more probable that geographical shifting may be less important than the cultural dissimilarities, in terms of the causation of distress. The overall frequency of psychological disturbances, in this study, was higher than reported in literature2,7,11. However, the comparison between present findings and most of the earlier studies may be limited because of methodological differences. It is in fact very difficult to find an examination comprising a similar procedure in this area of research and, even if it was possible, any comparison would also be contaminated by the differences that exist among the student populations examined. Findings such as these provide strong evidence that there is a higher incidence of psychological disturbance in foreign as compared to native students. This disturbance may take many forms and may be linked with impaired social functioning. These results strongly point to the need for further exploration of the phenomenon of maladjustment among these students who represent the educational investment of their own country’s future. There is also a great need to look at the possible indicators of proneness to psychiatric disorders. Although there are no grand theories attempting to explain this phenomenon, various concepts may be worthy of future investigations. Partial severance of these students’ interaction with their primary milieu, confrontation with unknown or indifferent host milieu, coping with a massive number of life changes and deficiencies in social network may, for example, be involved at different stages and in various combinations, it is therefore suggested that more work should be carried out in this area which would probably provide more accurate psychiatric morbidity rates and would throw more light on the aetiological factors underlying the correlation between psychosocial factors and mental health problems of overseas students.
This study was completed when one of the authors (AJ) was working as a clinical assistant at the Department of Psychiatry, University of Edinburgh. Warm thanks are expressed to Drs. Patrick Miller and S.D. Platt for their cooperation and helpful advice. Secretarial help of Mr. Mukhtar Hussain is also well appreciated.
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