Introduction
The increased globalization of education has enabled the development of an educational industry in New Zealand [
1] and overseas [
2]. New Zealand is highly valued as an English-speaking destination due to its reasonable cost of living, low student fees, high-quality education, and ease of access to information about courses [
1]. Provision of education to international students is also a profitable business enterprise with over 93,000 foreign paying students studying in New Zealand in 2009, contributing to financial gains for the country in the vicinity of 2 billion New Zealand dollars per annum [
1]. Contingent on their visa status, students are classified as either domestic or international students (foreign fee-paying students). If the student holds New Zealand citizenship or a residency permit, then the student is classified as domestic, otherwise as international.
Quality of life (QoL) measures are seen as important in providing a comprehensive profile of a person’s health status. QoL has been defined by the World Health Organization working group as: ‘individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns’ (p. 551) [
3]. This definition tends to focus on aspects of health and well-being and complements more objective measures related to functional health status [
4]. A commonly used instrument measuring QoL is the abbreviated version of the World Health Organization QoL questionnaire (WHOQOL-BREF), which employs the domains of physical health, psychological health, social relationships and environment [
3,
4]. There are numerous other measures of health-related QoL cited in the literature, each with their own strengths and limitations according to the criteria of feasibility, validity, responsiveness and interpretability [
5]. The WHOQOL-BREF has been systematically appraised across numerous cultural groupings [
6,
7] and was considered to be suitable for the medical student group [
8].
QoL, well-being and mental health issues have been studied in reference to student populations [
9] including medical students [
10‐
12]. Leahy et al. [
9] measured psychological distress in students in Australia and found that students from all tertiary disciplines expressed levels of distress which were higher than age-matched peers within the general population. Explanations for this difference range from financial commitments, intensive study regimes and family obligations [
9]. However, not all comparative studies have concluded that tertiary students have higher levels of mental ill-health than their non-student peers. One large US study compared the 12-month prevalence of psychiatric disorders (by diagnostic interviews) in students and non-student peers and found that there was no difference [
13].
It is clear that the mental health and well-being of medical students has become a prominent issue over the last few years [
11,
12,
14‐
16]. Some of the major issues cited are related to psychopathology [
11,
14], the pressures of the medical learning environment, and external factors affecting student well-being such as debt and transitioning into the clinical environs [
11,
12,
15,
16]. In New Zealand, Henning et al. [
10] found that medical students early in their clinical training experienced sleep problems, and felt anxious and uncertain in the clinical setting. Moreover, a recent systematic review of student mental health reported that studying at medical school was often associated with high levels of stress [
17]. Interestingly, none of these studies have focussed on specific concerns related to international students.
To address concerns related to wellness amongst students, a
guild was formed in the United Kingdom to further develop the promotion of mental well-being in higher education [
18]. The formation of this guild was driven by alterations being made to disability legislation and communities being at risk of social exclusion. Similarly in Australia, recent guidelines [
19] have been developed for tertiary education institutions to ‘facilitate improved educational outcomes for students with a mental illness’ (p. 1), as it is clear that the ability to deal with emotional stress has an impact on academic performance and the successful completion of a qualification [
17]. The report by the Royal College of Psychiatrists in London: ‘
Mental Health of Students in Higher
Education’ summarized the challenges specific to international students. These challenges included adjusting to a new cultural and academic environment, financial constraints impeding regular visits to family overseas, lack of English language skills affecting academic achievement, and the pressure of expectations from self and others [
18]. It has been shown that international students, when making decisions to study abroad, may consider safety and security, the international reputation of the university, cost of living, visa and entry requirements, and QoL issues [
20].
Using the WHOQOL-BREF, Chai et al. [
21] found that international students studying courses other than medicine at a New Zealand university rated their experiences of physical and environmental QoL lower than domestic students but found no differences with respect to psychological and social relationships. Using a similar sample, Hsu et al. [
22] found that international students rated physical and environmental QoL lower than domestic students. In addition, Asian international students studying medicine in New Zealand were found to be more anxious about tests, whilst also scoring lower on environmental QoL than their domestic Asian peers [
23]. These results are consistent with findings presented in studies conducted in other countries [
24,
25]. For example, Sam [
25] incorporated a life satisfaction measure and surveyed international students studying in a Norwegian university. In Sam’s study, African students rated life satisfaction lower than expected in relation to normative data but other international students were within normative expectations. Lee et al. [
26] suggested that one reason why international students may have greater difficulties with quality of life when studying abroad is that they experience ‘acculturative stress’ or stress resulting from the strain of educational and social adaptation.
There appears to be a wealth of data about international students in general, but very little related to the medical student context. Consequently, the aim of the present paper is to explore the levels of QoL experienced by students studying medicine in New Zealand, and to compare data from international and domestic student groups. It was expected that international students are likely to encounter more challenges in terms of their QoL.
Results
Preliminary analyses
All WHOQOL-BREF domains exhibited high levels of internal consistency (αphysical = 0.76, αpsychological = 0.82, αsocial relationships = 0.72, αenvironment = 0.76). A precursor MANCOVA showed no differences between year 4 and 5 students’ QoL domain scores; hence, this variable was not included in the subsequent multivariate analyses.
Multivariate analyses
The multivariate statistical analyses revealed significant main effects for ‘enrolment status’ (International; Domestic) [F(4, 521) = 5.17, Wilks’ lambda = 0.96, p < 0.01]. Further main effects were noted for ‘cohort’ (2009; 2011) [F(4, 521) = 4.31, Wilks’ lambda = 0.97, p < 0.01], and ‘gender’ (Male; Female) [F(4, 521) = 2.83, Wilks’ lambda = 0.98, p < 0.05]. The covariate age also yielded a significant result [F(4, 521) = 2.85, Wilks’ lambda = 0.98, p < 0.05]. No significant interaction effects were noted.
Between-group analyses: WHOQOL-BREF domains
The between-group analyses (Table
2) yielded five significant main effects in terms of the WHOQOL-BREF domains.
Table 2
Tests of between-subjects effects for cohort, enrolment status, and gender over the four WHOQOL-BREF domain measures with age and year of study as covariates
Covariate (age) | Physical | 1.46 | 5.02* | 1 | 524 |
Psychological | 0.11 | 0.29 | 1 | 524 |
Social | 0.50 | 0.87 | 1 | 524 |
Environment | 2.42 | 7.82* | 1 | 524 |
Enrolment status (ES) | Physical | 1.12 | 3.83 | 1 | 524 |
Psychological | 0.95 | 2.46 | 1 | 524 |
Social | 7.33 | 12.78** | 1 | 524 |
Environment | 3.32 | 10.71** | 1 | 524 |
Cohort (CO) | Physical | 3.96 | 13.59** | 1 | 524 |
Psychological | 0.44 | 1.13 | 1 | 524 |
Social | 0.22 | 0.39 | 1 | 524 |
Environment | 0.20 | 0.66 | 1 | 524 |
Gender (GE) | Physical | 1.00 | 3.45 | 1 | 524 |
Psychological | 2.75 | 7.13* | 1 | 524 |
Social | 0.08 | 0.14 | 1 | 524 |
Environment | 1.92 | 6.19* | 1 | 524 |
ES × CO | Physical | 1.86 | 6.37* | 1 | 524 |
Psychological | 0.54 | 1.41 | 1 | 524 |
Social | 0.21 | 0.37 | 1 | 524 |
Environment | 0.01 | 0.02 | 1 | 524 |
ES × GE | Physical | 0.10 | 0.36 | 1 | 524 |
Psychological | 0.17 | 0.45 | 1 | 524 |
Social | 0.57 | 0.99 | 1 | 524 |
Environment | 1.17 | 3.79 | 1 | 524 |
CO × GE | Physical | 1.31 | 4.50* | 1 | 524 |
Psychological | 0.12 | 0.32 | 1 | 524 |
Social | 0.27 | 0.46 | 1 | 524 |
Environment | 0.46 | 1.48 | 1 | 524 |
ES × CO × GE | Physical | 0.53 | 1.80 | 1 | 524 |
Psychological | 0.24 | 0.61 | 1 | 524 |
Social | 0.00 | 0.00 | 1 | 524 |
Environment | 0.86 | 2.77 | 1 | 524 |
1.
Enrolment status—two significant main results with respect to the social relationships domain [
F(1, 524) = 12.78,
p < 0.01] and the environment domain [
F(1, 524) = 10.71,
p < 0.01] (see Table
3 for mean comparisons).
Table 3
Means (and standard deviations) with Cohen’s d values (and confidence intervals) for the WHOQOL-BREF domains and facets with respect to cohort, enrolment status and gender
1. Physical health | 4.02 (0.55) | 3.85 (0.56)* | 0.31 | 0.07 | 0.55 |
Pain and discomfort | 4.54(0.73) | 3.89 (1.07)** | 0.82 | 0.58 | 1.07 |
Dependence on medication | 4.55 (0.74) | 4.52 (0.68) | 0.04 | −0.20 | 0.28 |
Energy and fatigue | 3.55 (0.86) | 3.49 (0.73) | 0.07 | −0.17 | 0.31 |
Mobility | 4.43 (0.80) | 4.03 (0.95)** | 0.49 | 0.24 | 0.73 |
Sleep and rest | 3.39 (1.07) | 3.52 (1.06) | −0.12 | −0.36 | 0.12 |
Activities of daily living | 4.00 (0.83) | 3.83 (0.81) | 0.21 | −0.03 | 0.44 |
Work capacity | 3.68 (0.92) | 3.64 (0.88) | 0.04 | −0.19 | 0.28 |
2. Psychological | 3.64 (0.64) | 3.50 (0.54) | 0.22 | −0.02 | 0.46 |
Positive feelings | 3.95 (0.76) | 3.65 (0.70)* | 0.40 | 0.16 | 0.64 |
Meaningfulness of life | 3.88 (0.91) | 3.73 (0.83) | 0.17 | −0.07 | 0.41 |
Thinking, learning and concentration | 3.22 (0.79) | 3.19 (0.72) | 0.04 | −0.20 | 0.28 |
Body image | 3.64 (0.93) | 3.52 (0.97) | 0.13 | −0.11 | 0.37 |
Self-esteem | 3.73 (0.88) | 3.60 (0.81) | 0.15 | −0.09 | 0.39 |
Negative feelings | 3.39 (0.93) | 3.30 (0.91) | 0.10 | −0.14 | 0.34 |
3. Social relationships | 3.82 (0.76) | 3.47 (0.71)** | 0.46 | 0.22 | 0.70 |
Personal relations | 3.83 (0.94) | 3.47 (0.97)* | 0.38 | 0.14 | 0.62 |
Sex | 3.63 (1.06) | 3.16 (0.98)** | 0.45 | 0.21 | 0.69 |
Social support | 3.98 (0.81) | 3.76 (0.85)* | 0.27 | 0.03 | 0.51 |
4. Environment | 3.81 (0.58) | 3.57 (0.47)** | 0.42 | 0.18 | 0.66 |
Physical safety and security | 4.25 (0.75) | 4.00 (0.62)** | 0.34 | 0.10 | 0.58 |
Physical environment | 3.96 (0.82) | 3.75 (0.76)* | 0.26 | 0.02 | 0.50 |
Financial resources | 3.28 (1.17) | 3.57 (0.98)* | −0.25 | −0.49 | −0.01 |
Information and skills | 3.84 (0.79) | 3.61 (0.69)* | 0.30 | 0.06 | 0.54 |
Recreation and leisure | 3.36 (0.91) | 3.15 (0.94)* | 0.23 | −0.01 | 0.47 |
Home environment | 4.06 (0.91) | 3.76 (0.84)* | 0.33 | 0.09 | 0.57 |
Access to health services | 3.95 (0.95) | 3.37 (0.88)** | 0.62 | 0.37 | 0.86 |
Transport | 3.81 (1.06) | 3.35 (1.06)** | 0.43 | 0.19 | 0.67 |
2.
Cohort—one significant main result with respect to the physical domain [F(1, 524) = 13.59, p < 0.01].
3.
Gender—two significant main results with respect to the psychological domain [F(1, 524) = 7.13, p < 0.05] and the environment domain [F(1, 523) = 6.19, p < 0.05], with male students (M
psychological = 3.64, SD
psychological = 0.55; M
environment = 3.83, SD
environment = 0.59) scoring higher than female peers (M
psychological = 3.52, SD
psychological = 0.52; M
environment = 3.74, SD
environment = 0.55) on both domains.
A significant interaction effect was noted for cohort by enrolment status [F(1, 524) = 6.37, p < 0.05] for physical QoL. The means scores suggest a marked difference for physical QoL in reference to the 2009 cohort (M
international = 3.69, SD
international = 0.54; M
domestic = 3.97, SD
domestic = 0.57) when compared with the 2011 cohort (M
international = 4.08, SD
international = 0.52; M
domestic = 4.06, SD
domestic = 0.53), which did not show a noticeable difference.
A further incidental interaction was noted for cohort by gender [F(1, 524) = 4.50, p < 0.05]. No other significant results were found.
Facet scores
To gain more specificity to the analysis, facet differences (see Table
3 for details) between the international and domestic students were investigated within each of the WHOQOL-BREF domains. Potential confounding variables (cohort, gender and age) were also entered into the analytical model. The means and standard deviations were compared employing a MANCOVA approach followed by a series of univariate tests on facets within each domain. Cohen
d measures were also generated to estimate effect size differences for each comparison.
From the possible 24 facet differences (Table
3), 14 facets yielded significant differences. Ten of the possible 11 facet differences for social relationships and environment were identified:
1.
In the social relationships QoL domain, domestic students rated ‘personal relations’ and ‘sex’ more positively than their international peers.
2.
In the environment QoL domain, domestic students rated ‘physical safety and security’, ‘physical environment’, ‘information and skills’, ‘recreation and leisure’, ‘home environment’, ‘access to health services’, and ‘transport’ higher than their international peers. However, domestic students rated ‘financial resources’ lower than their international peers. Other differences were also noted in relation to ‘pain and discomfort’, ‘mobility’, and ‘positive feelings’. In each of these differences domestic students out-rated their international peers, suggesting higher levels of QoL according to these facets. The univariate results were in agreement with the effect size measures.
Ethnicity and enrolment status
It was noted that 98 % of international students were self-classified as either Asian (n = 62) or ‘Other’ (n = 17). No differences or interactions were found between the Asian and ‘Other’ cohort [F(4, 255) = 1.40, Wilks’ lambda = 0.98, p > 0.05] in terms of the WHOQOL-BREF measures; controlling of gender, cohort, age and enrolment status.
When investigating differences between international and domestic students within the Asian student cohort, one significant difference was obtained for environmental QoL, with domestic Asian students scoring higher (M = 3.81, SD = 0.57) than their international Asian peers (M = 3.58, SD = 0.49); indicating higher levels of QoL for the domestic group.
Conclusion
The findings of this study suggest that the international medical students differ from the domestic students in terms of their experience of quality life. There is some evidence that quality of life does have an impact on academic achievement [
45,
46], which suggests that international students are likely to be experiencing greater study stress than domestic students. It is also likely that international students within the present study population are experiencing more psychological problems such as depression and anxiety as documented elsewhere [
11,
12,
26,
36]. Mechanisms for minimizing acculturation stress need to be considered at both university and community levels, such as developing more amenable and accessible student accommodation schemes.
Additionally, the assumption in New Zealand, as in other Western countries, is that New Zealanders are good hosts and take care of their overseas visitors and students [
47]. There is some evidence to support this claim but there are also instances of racial discrimination and poor communication within ‘homestay’ situations [
34]. These inconsistencies highlight the need to put in additional measures to address quality of life imbalance between domestic and international students and to address any instances of international students experiencing implicit and/or explicit abuse. Such solutions may include creating stronger social networks, more accessible accommodation, systems to ensure safety and security, and developing peer mentor mechanisms.