There is an array of reasons why acculturation can be stressful, and acculturative stress can be triggered by a plethora of factors. The aim of the study was to identify factors associated with acculturative stress among international students enrolled in a public medical university from Romania. 265 students were included in the research. Sociodemographic, academic, and family data, comfortability with living in study city, satisfaction with administrative staff, colleagues, and professors and Acculturative Stress Scale for International Students were gathered. Data have been processed using SPSS Statistics v23.0.0 for MAC.OSX. Female students are more prone to experience homesickness and stress due to change compared to male students. International students with Romanian origins had lower scores on perceived hate and stress due to change/culture shock compared to those with no Romanian origins. Students with relatives or friends enrolled in the same university had significantly lower levels of acculturative stress, perceived discrimination, perceived hate/rejection, and general/nonspecific concerns. Age and year of study are associated with homesickness and stress due to change/culture shock. The existence of factors associated with acculturative stress demand institutional, social, and psychological support for international students.
Universities all over the world accommodate a large number of international students. In recent years, Romania, as many other Eastern European countries, also attracted many international students who enrolled especially in medical studies. The main reasons for studying in Romania are cheaper academic taxes, affordable accommodation and transport, peaceful university city, religious tolerance, and a European country [
Acculturation is the process of both cultural and psychological change that occurs when two or more cultural groups (along with their individual members) come into contact [
Given the fact that acculturation can be perceived as a stressful experience, the term acculturative stress is generally used to describe the unique stressors of immigration [
In the case of college students, they already are a population prone to experience higher levels of stress and depression [
International students represent an important contribution to the intellectual capital of their host country and to the workforce by bringing with them a variety of knowledge and skills in many areas [
Within the international student literature, there are some frequently documented acculturative stressors. One of the most well-documented such stressors is the language barrier. English fluency is a good predictor of acculturative stress [
Sociocultural stressors represent another challenge for international students. In a study conducted by Zhang and Brunton [
When studying in another country, students might also experience practical or lifestyle acculturative stressors such as financial difficulties, accommodation, and transportation [
The research on students’ acculturative stress is not yet conclusive, especially from the point of view of medical studies. Clarity is essential to ensure that appropriate interventions are introduced which will positively impact international medical students and research on this area needs to extensively identify factors that can influence acculturative stress. The aim of the study was to evaluate the presence of acculturative stress among international students from a medical university in Romania and to identify associated factors. We addressed three main categories of factors: sociodemographic (age; sex; having relatives, friends or siblings enrolled in the same university; if parents are doctors; etc.), comfortability with various aspects of living in the study city (speaking English and Romanian, neighbors, climate, transportation, and food), and satisfaction with administrative staff, colleagues, and professors. The present research is part of a larger study and previous results revealed that climate and food appeared to be the most uncomfortable aspects that students must deal with [
A number of 300 questionnaires were distributed among international medical students enrolled in General Medicine and Medical Dentistry faculties. The Medical University is located in the northeast part of Romania, specifically in the city of Iasi. They were invited to participate voluntarily in the research. They had to provide information concerning sociodemographic, academic, and family data. Several items were constructed especially for the research, in order to identify the level of student’s comfortability with living in the university city and the level of satisfaction with administrative staff, colleagues, and professors. The third part of the data sheet measured the acculturative stress by using a psychological instrument.
Students were informed about the purpose of the study and confidentiality of collected data; withdrawal was accepted at any time. A total of 289 questionnaires were returned to the researchers. For statistical analysis, 265 were finally considered; 24 questionnaires were eliminated for failing to complete at least 90% of the items.
Various sociodemographic, academic, and family data were registered: age, sex, year of study, nationality, if parents are doctors, if the student speaks Romanian, if parents speak Romanian, if at least one parent is a doctor, if parents visit every year, if the student is satisfied with living conditions, and having relatives, friends, or siblings enrolled in the university.
The degree of comfort with living in the study city was measured using a self-rated scale. Participants responded using a Likert-type scale from 1 to 5 (1—not at all comfortable, 2—somewhat comfortable, 3—comfortable, 4—very comfortable, and 5—extremely comfortable). The items referred to their comfort with communicating in English, Romanian, and with neighbors. We also inquired about comfortability with climate, transportation, and food.
To assess the satisfaction with administrative staff, colleagues, and teachers, several items were formulated, and responses were rated on a scale from 1 (very dissatisfied) to 10 (very satisfied).
ASSIS (The Acculturative Stress Scale for International Students) is a tool developed by Sandhu and Asrabadi in 1994 [ perceived discrimination (8 items; “I am treated differently in social situations”) homesickness (4 items; “Homesickness for my country bothers me”) perceived hate/rejection (5 items; “I feel rejected when people are sarcastic toward my cultural values”) fear (4 items; “I fear for my personal safety because of my different cultural background”) stress due to change/culture shock (3 items; “I feel uncomfortable to adjust to new cultural values”) guilt (2 items; “I feel guilty to leave my family and friends behind”) nonspecific concerns (10 items; “I feel nervous to communicate in English”)
The total scores range from 36 to 180, higher scores suggesting higher levels of stress. For the present study, the alpha Cronbach coefficient for the entire instrument is
The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by Centre de Reussite Universitaire, under the coordination of University of Medicine and Pharmacy and Agence Universitaire pour la Francophonie (AUF).
Collected data were analyzed using IBM SPSS Statistics, version 23. Percentages, means, and standard deviations were used for the descriptive analysis. Pearson (for quantitative variables) and Spearman (for analyses involving ordinal variables) correlations were used to investigate the associations between variables. The independent samples
265 students from 34 countries took part in the research (four students have dual nationality). The distribution according to gender is reasonably homogenous: 151 male (57%) and 114 females (43%). The participants were aged from 17 to 40 (
Participants were from all years of study (first to sixth). Students were asked if they had friends, relatives, or colleagues among international students registered in the same university. Collected data showed that, of the students who reported having relatives/friends attending the same university, 33.9% of the them have brothers/sisters, 32.1% have cousins, 29.4% have other friends, and 4.6% other relatives. Data regarding Romanian origins (at least one parent is Romanian but migrated to another country), if at least one parent is a physician, if the student/mother/father speaks Romanian, if the parents visit them every year, and if students are satisfied with their living conditions are presented in Table
Sociodemographic characteristic and family-related data.
Variables | % | |
---|---|---|
Sex | Male | 57 |
Female | 43 | |
Year of study | 1st | 44.9 |
2nd | 13.2 | |
3rd | 17.4 | |
4th | 6.4 | |
5th | 6.8 | |
6th | 11.3 | |
Age ( | 21.38 (3.32) | |
Romanian origins | 9.1 | |
Parent physician | 22.6 | |
Friends or other relatives enrolled in the same university | 42.3 | |
Student speaks Romanian | 7.9 | |
Mother speaks Romanian | 9.8 | |
Father speaks Romanian | 13.6 | |
Parents visit every year | 35.1 | |
Satisfied with living conditions | 69.1 |
The level of comfortability of international students is presented in Table
The distribution of answers to items regarding students’ comfortability with some aspects of life in the university City.
How comfortable are you with… | Not comfortable | Somewhat comfortable | Comfortable | Very comfortable | Extremely comfortable | |
---|---|---|---|---|---|---|
Speaking Romanian | 35.8 | 34.0 | 18.1 | 7.5 | 4.5 | 2.10 (1.11) |
Speaking English | 2.6 | 4.9 | 25.3 | 35.8 | 31.3 | 3.88 (0.99) |
Country’s climate | 12.1 | 24.2 | 40.8 | 18.5 | 4.5 | 2.79 (1.02) |
City transportation | 17.0 | 26.0 | 38.1 | 15.8 | 3.0 | 2.61 (1.03) |
Neighbors | 12.1 | 15.5 | 41.9 | 20.8 | 9.8 | 3.00 (1.11) |
Local food | 15.5 | 26.8 | 37.0 | 10.2 | 10.6 | 2.73 (1.16) |
Communicating with the homeowner | 6.4 | 15.1 | 39.2 | 21.9 | 17.4 | 3.28 (1.16) |
Mean levels of satisfaction with colleagues, teachers, and administrative staff were as follows:
The results for Acculturative Scale for International Students (total score for ASSIS and values for each subscale) are presented in Table
Total score and scores for each subscale of ASSIS.
Total score and subscales | Results |
---|---|
ASSIS (total score) | 85.82 (23.03) |
Perceived discrimination | 18.95 (5.91) |
Homesickness | 11.35 (3.40) |
Perceived hate/rejection | 11.64 (3.97) |
Fear | 8.74 (3.09) |
Stress due to change/culture shock | 7.52 (2.44) |
Guilt | 4.77 (1.77) |
Nonspecific concerns | 22.83 (6.96) |
When comparing male and female students on the total score of ASSIS and each of its dimensions, two statistically significant differences emerged concerning homesickness (
The fact that students had Romanian origins revealed two statistically significant differences on two subscales of the ASSIS: perceived hate (
The fact that one parent was a doctor revealed two differences between participants concerning homesickness (
When taking into account the existence of other relatives enrolled in the same university, the results showed several statistically significant differences between international students in terms of acculturative stress (
Analyses also revealed significant differences in stress due to change/culture shock between students who spoke Romanian (
Also, there was a difference between participants whose parents visited them every year compared to those who did not visit them as often on the homesickness subscale:
The results of the correlation analysis revealed several significant and negative associations between the study variables and are presented in Table
Correlations between ASSIS (total score and subscores) and variables.
ASSIS | Perceived discrimination | Homesickness | Perceived hate/rejection | Fear | Stress due to change/culture shock | Guilt | Non-specific concerns | |
---|---|---|---|---|---|---|---|---|
Age | ||||||||
Year of study | ||||||||
Comfortable speaking Romanian | ||||||||
Comfortable speaking English | ||||||||
Comfortable with country’s climate | ||||||||
Comfortable with local transport | ||||||||
Comfortable with neighbors | ||||||||
Comfortable with local food | r=−0.240 | r=−0.185 | r=−0.114 | r=−0.210 | r=−0.243 | r=−0.328 | r=−0.188 | r=−0.205 |
Comfortable communicating with homeowner | r=−0.126 | r=−0.131 | r=0.053 | r=−0.105 | r=−0.166 | r=−0.108 | r=−0.015 | r=−0.163 |
Satisfaction with colleagues | r=−0.266 | r=−0.222 | r=−0.155 | r=−0.244 | r=−0.221 | r=−0.242 | r=−0.135 | r=−0.232 |
Satisfaction with teachers | r=−0.258 | r=−0.265 | r=−0.007 | r=−0.220 | r=−0.300 | r=−0.257 | r=−0.141 | r=−0.234 |
Satisfaction with administrative staff | r=−0.275 | r=−0.294 | r=−0.047 | r=−0.218 | r=−0.271 | r=−0.152 | r=−0.169 | r=−0.275 |
The results of our study indicated that acculturative stress and perceived discrimination correlated negatively with the degree of comfort regarding: communication in English, climate, neighbors, communication with the homeowner and food in the host country; perceived discrimination correlated with local transport and acculturative stress was found to correlate with age.
The statistical analysis revealed that homesickness was significantly correlated with age, year of study, the degree of comfort communicating in English, and climate of the host country.
Perceived hate/rejection and fear were found to be correlated significantly and negatively with the degree of comfort with English communication, climate, neighbors, and food.
Correlational analyses also showed stress due to change/culture shock correlated negatively with age, year of study, and with the degree of comfort with communication in English, communication in Romanian, climate, neighbors, and food from Romania.
The results suggested that guilt correlated significantly with age, year of study, and with the degree of comfort with communication in English, climate, and food in Romania.
According to the results, general/nonspecific concerns correlated significantly with age and with the degree of comfort studied by the research (communication in English, climate, neighbors, communication with the homeowner, and food).
Finally, the degree of satisfaction with colleagues was negatively correlated with the ASSIS and all its subscales. The degrees of both satisfaction with administrative staff and with teachers were correlated negatively with the total score of ASSIS and with its subscales, except homesickness.
Previous studies have shown that there are a considerable number of factors associated with acculturative stress. Some of these factors include personality, social inclusiveness, language barriers, and cultural differences. Gender, age, and language competence are the most well-documented [
The results of our study showed that women are more prone to higher levels of homesickness and stress due to change/culture shock; a fact that is congruent with other research. For example, Castillo et al. [
In our study, the year of study was negatively related to homesickness and stress due to change/culture shock. Also, age was negatively correlated with some subscales of the ASSIS: homesickness, stress due to change/culture shock, guilt, and nonspecific concerns. The research on this association is not yet conclusive. Some studies found no association between age and acculturative stress [
It has been previously documented that international students tend to experience language difficulties [
Studying the acculturative stress among international students from different specialties, Sullivan and Kashubeck-West [
Our study also indicated that friends and family presence decreased the rate of acculturative stress, perceived discrimination, perceived hate/rejection, and nonspecific concerns and might indicate their influence on the choice to study in a certain country. Students speaking Romanian or having one parent speaking Romanian had lower levels of stress due to change/culture shock. Finally, students who were not visited by their parents every year were more prone to experience homesickness. International students with Romanian origins conserved a sort of host-country contact by parents or grandparents (language, food, relatives, family members etc); therefore, the host-culture is not likely entirely new to them and their level of stress is low. Previous studies [
Students who decide to study in another country might experience practical or lifestyle acculturative stressors. When transitioning from their home country to their host country, international college students face various perceived threats and challenges. Among them are the lack of knowledge of the host culture, difficulty in adapting to the host country customs and lifestyle, and maladjustment to the physical environment [
International student satisfaction is an in important factor in strengthening support services for this community [
The drop-out rates in this medical university is about 10%, according to the rates identified by the university career counselling centre. The most important reason declared by the students being the financial one even if the level of annual taxes for medical studies in Romania are among the lowest in Europe.
The results of the present research must encourage teaching and counselling staff to adopt more diversified and efficient strategies for helping international students to cope with acculturative stress: establishing a more developed mentoring program for freshmen students matching them with seniors, for advice and support; increasing the number of intercultural events in order to help students socialize; providing more flexible support services in order to help them adjust to the new academic demands and cultural/local habits); organizing meetings with national and international students for networking and facilitating information change regarding lifestyle, local transportation, facilities for sports, leisure, or hobbies; and enhancing counsellors and therapist awareness in working with international students and providing them with information and knowledge on how to work with multicultural and multilingual groups.
The research on acculturation and acculturative stress among international medical students is scarce, and the present study provides some insights into this population. Because women are more numerous than men in medical universities, most studies provided results for a smaller number of female students than males. The present study included a balanced gender distribution.
This study has several limitations. The research did not evaluate the mental health of students. The authors know the presence of depression, anxiety, or chronic diseases could increase the rate of acculturative stress. Also, we used a convenience sample from a single medical university. Further research should be done with different sampling methods. Our study was correlational, which does not prove causal relations between the variables. Also, the use of the English language is always a concern with international populations, and it raises the question of whether participants’ language skills are adequate to appropriately answer the survey. Considering these limitations, findings should be generalized with caution.
The existence of risk factors for acculturative stress demands institutional, social, and psychological support for international students. Multicultural environments must be provided with resources to maintain a sustainability development of international students during their process of education. Apart from their psychological characteristics and inner motivation, the support from family members, peers, academic community, social media, or professional staff working in the university field can also provide support for students during their academic trajectory and career.
The data used to support the findings of this study are available from the corresponding author upon request.
The authors declare that there is no conflict of interest regarding the publication of this paper.
All authors contributed equally to this work.
This study was funded by a grant supported by “Gr. T. Popa” Iasi University of Medicine and Pharmacy, Centre de Reussite Universitaire et Agence Univesitaire de la Francophonie, Romania.
Table 5: independent samples