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This is to certify that the

thesis entitled
A STUDY OF SOMATIC SYMPTOMATOLOGY:
OCCURRENCE AND SEVERITY AS REPORTED BY
INTERNATIONAL GRADUATE STUDENTS AT
MICHIGAN STATE UNIVERSITY

presented by

.,
Dolores L. Rustic

has been accepted towards fulfillment
of the requirements for

Master of Sciencedegree in Nursing

 

 

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Major professor

Date February 242 1992

0-7639 MS U is an Affirmative Action/Equal Opportunity Institution

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TO AVOID FINES return on or before due due.

DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

 

 

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MSU Is An Affirm-mo ActiorVEquel oppomnny Inetltution
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A STUDY or SOMATIC SYMPTOMATOLOGY: OCCURRENCE AND SEVERITY
As REPORTED BY INTERNATIONAL CRAogATsflsrngNTs

Mm“

AT MICHIGAN STATEEUNIVERSITY

 

BY

Dolores L. Rustic

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

College of Nursing

1992

ABSTRACT

A STUDY OF SOMATIC SYMPTOMATOLOGY: OCCURRENCE AND SEVERITY
AS REPORTED BY INTERNATIONAL GRADUATE STUDENTS
AT MICHIGAN STATE UNIVERSITY

BY

Dolores L. Rustic

Researchers often describe the adaptation process of

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international students negatively as leading to development

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of physical or emotional problems. A descriptive study of
types, frequency, and severity of common physical symptoms

reported by international graduate students in association

with length of stayin the Unitsd States, nationality, and

 

living arrangements was conducted using Roy's Theory of
Adaptation as the theoretical framework. -

-A stratified random sample (N=436) of the 10 most
populous graduate international student groups at Michigan
State University were surveyed with a response rate of 35
percent (N=153). Study results identified significant
differences between frequency and severity of cold and skin
symptoms and living arrangements, some nationalities, and
new and returning students.

This researcher concluded that the adaptatigpyprpcessw

had little effect on the development of physical symptoms. _

Muss-um;

 

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Implications for advanced nursing practice focused on
wellness interventions. Questions for further research were

raised.

Copyright by
Dolores L. Rustic

'1992

Acknowledgements

I am very thankful for my wonderful family without whose
love and support I would have forsaken this project long
ago. My sincere gratitude and love to my husband for his
unwavering support and patience throughout this entire
endeavor; to my daughter, Sheri, my gratitude for her
admiration, encouragement, and faith in me; to my son,
Gerry, many thanks for your patience and listening ear.

My sincere gratitude goes to all the faculty in the
Family Clinical Nurse Specialist Graduate Nursing Program at
Michigan State University. The challenges and rewards I am
experiencing in advanced nursing practice were made possible
through completion of this program.

Special thanks to my committee chairperson, Rachel
Schiffman, for her encouragement, prodding, critical
analysis and patience with a sometimes reluctant and trying
student. Thanks also to Manfred Stommel, our statistician,
without whose input into tool development and statistical
analysis I could not have completed this project. To Jackie
Wright and Patty Peek, a special thank-you for their
motivating support and kind encouragement throughout my
entire graduate experience.

Thank you also to my friend and colleague, Judy Kraska,
for her everlasting patience, guidance, and presence for me

during the painful process of growth.

iv

Many thanks also to Dave Kiefer for his assistance with
my tool development; to my friends, Walt & Edie for their
computer expertise and assistance.

Finally, a big thank-you to Peg Arbanas of the Office of
International Students and Scholars at Michigan State
University without whose support, trust and assistance this

project could not have been undertaken.

TABLE OF CONTENTS

LIST OF TABLES . . . . . . . . . .

LIST OF FIGURES O O O O O O O O O 0

CHAPTER I
Introduction to the Study

Statement of the Problem . . . . .
Significance of Problem . . . . . .
Definition of Terms . . . . . . . .
Overview of Chapters . . . . . . .

CHAPTER II

Introduction . . . . . . . . . .
Roy's Adaptation Model . . . . . .
Summary . . . . . . . . . . . . . .

CHAPTER III

Introduction . . . . . . . . . . .
Review of Literature . . . . . . .
Summary . . . . . . . . . . . . . .

CHAPTER IV

Overview . . . . . .
Procedures . . . . .
Research Questions .
Sample . . . . . . .
Instrument . . . . .
Data Collection . . . .
Instrument Reliability and Validi
Operational Definitions of Variab

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Data Analysis . . . . . . . . .
Human Rights Protection . .
Assumptions . . . . . . . .
Limitations . . . . . . .

summary 0 O O O O O O O 0

CHAPTER V

Sample Characteristics . . .

Reliability of the Subscales of the
Symptom Instrument . . . . . . . .

Data Related to Research Questions

Summary . . . . . . . . . . . . . .
vi

Somatic

(”GINO-‘9‘

Odd

21
21
32

33
33
33
35
36
37
37
38
4O
42
42
42
43

45

47

48
62

Chapter VI

Overview . . . . . . . .
Summary and Discussion of
Implications for Practice
Further Research . . . .
Limitations . . . . . . .
Summary . . . . . . . . .

LIST OF REFERENCES . . .

APPENDICES . . . . . . .

Findings

vii

63
64
72
75
76
77

80

84

LIST OF TABLES

ELL;

1 Frequencies, Percentages, and Severity of Symptom
Occurrence Reported by Respondents (N=153).
Frequency Indicates Number of "Yes" Responses to
Symptoms. Percentage Indicates Reported Severity
of Symptoms if Responded "Yes" to Symptom . . . .

2 Means of Cold and Skin Symptoms and Severity
Scales and ANOVA F-Values for the Scales by Type
of Student and Living Arrangement . . . . . . . .

3 ANOVA of Cold Symptom Scale by Country of Origin .

4 ANOVA of Cold Symptom Scale Severity by Country
of Origin . . . . . . . . . . . . . . . . . . . .

5 ANOVA of Skin Symptom Scale by Country of Origin .

6 ANOVA of Skin Symptom Severity by Country.of
origin 0 O O O O O O O O O O O O O O O O O O O O 0

viii

LI ST OF FIGURES

1mm

1 Roy Model, Physiologic Mode, Adapted .
2 Roy Model, Physiologic Mode, Adapted .

ix

CHAPTER I
Introduction to the study

Psychological stress may be commonly experienced by
those traveling in foreign countries where customs, social
structures, and languages are unfamiliar. If enduring or
intense psychological stress can lead to premature
termination of travel or to residual physical ill-effects
such as anxiety, chronic fatigue, headaches, stomach
problems and other somatic complaints (Locke & Feinsod,
1985). Early studies (Jammaz, 1973; Klineberg & Hull, 1979;
Shepard, 1970) of the international study populations at
various sites indicated that 15 percent to 25 percent of the
students experienced significant adjustment problems with
emotional symptoms such as homesickness or depression.
Later studies (Ebbin & Blankenship, 1988; Locke & Feinsod,
1985; Nishio & Bilmes, 1983; Sennhauser, 1983) revealed that
physical symptoms in international students are likely to
occur. The exact percentage of international students
affected in this manner is unknown.

Statement of the Problem

Students studying abroad face extraordinary life changes
as a result of their temporary relocation to a new country.
The dimensions of cultural and geographic changes added to
personal, social, familial and financial stressors may
predispose this group to a greater likelihood of illness
compared to the domestic student population (Sennhauser,

1985). Not all campuses may recognize that international

2
students have special needs and that programs must be
instituted to help promote their successful adjustment to
the new host culture.

This study will attempt to add to the existing knowledge
regarding the types, frequency and severity of physical
symptoms reported by graduate international students at
Michigan State University. The difference in physical
symptomatology among nationalities, between type of student,
and living arrangements by roommate and spouse will also be
examined.

The Family Clinical Nurse Specialist as well as other
health care professionals at university health facilities
have a need to understand that a person from a different
culture or country presenting to them with physical
complaints may be experiencing difficulty or problems with
coping with the host environment. Blom (1986) stated that
culture barriers faced by both students and college health
personnel due to differences in language, lifestyles,
‘customs, health care practices and health care delivery
systems may interfere with high quality health care for
international students. A working knowledge of cultural
adjustment patterns and cross-cultural understanding is
essential for all professionals who deliver services to
international students in order to provide effective health

care (Berry, Kessler, & Fodor, 1983).

3
Significance of the Problem

Student retention is a major issue in the literature
among colleges and universities, especially regarding
international students. Blom (1986) stated that not only
are the international students faced with the typical risks
and ailments of life, but they are also confronted with new
risks and stresses due to cultural adjustment, lifestyle
changes and exposure to new bacteria and viruses not present
in their home environment. At the seminar on International
Students jointly sponsored by the American College Health
Association and the National Association for Foreign Student
Affairs held in Washington D.C. in 1985, many campus and
federal government representatives indicated that medical
problems are the single most important reason for
termination of studies by international students. No
concrete empirical studies were available to support that
claim. However, early termination of studies due to medical
problems could represent a severe financial loss to host
institutions that may not be necessary.

The subject of health care for international students
studying on college and university campuses is of vital
importance to health professionals serving in health
services because of the large number of foreign students
attending American universities. Blom (1986) stated that
the percentage of international students can be as high as
15 percent of the student population on many campuses.

According to Ebbin & Blankenship (1986), there has been a

4

marked increase in the number of international students
entering the United States. In 1981-82 there were 326,000
international students at colleges and universities in the
U.S., a 4.6 percent increase over the past year and a ten-
fold increase over the prior 30 years. In fact, during
1981-83, the University of Southern California had
approximately 13 percent of its student body comprised of
international students (Ebbin & Blankenship 1986). At
Michigan State University, currently ranked 17th in the
nation by number of international students enrolled, there
has been an average of three to five percent increase in the
number of international students enrolled each year since
1970. There had been a 14 percent increase in international
students from 1985 to 1989 and a 61 percent increase from
1980 to 1989 (MSU Office of Students and Scholars, 1989).

Primary interventions for problems and illnesses of
international students have been a neglected part of college
campuses. Fisher (1985) proposed a comprehensive wellness
program for prevention of illness among international
university students while Sennhauser (1985) proposed
psychological counseling as primary prevention of illness
among international university students.

The research questions which evolved were:
1. What are types, frequency and severity of physical

symptoms reported by graduate international students at

Michigan State University?

5

2. Does type, frequency or severity of symptoms reported by
graduate international students at Michigan State
University differ by length of stay in the U.S. as
indicated by student type (new or returning student)?

3. Does type, frequency or severity of physical symptoms
reported by graduate international students at Michigan
State University differ by living arrangements
(roommate or spouse)?

4. Does types, frequency and severity of physical symptoms
as reported by graduate international students at
Michigan State University differ by nationality?

Definition of Terms

International Student. This is a student registered at

Michigan State University from a country other than the

United States. Only graduate international students were

eligible for this study.

fitggggt_zyp§. Student type refers to the length of time the

student was at MSU. New or returning students meant whether

the international student was newly registered at MSU during

Fall, 1990 or was a returning student. Length of stay in

the Unites States experienced by subjects of this study

varied from three or four months to many years of study.
£hy§1§§l_§ymptgm_. Physical symptoms are those bodily
sensations perceived by students as variations from what
they experience as their normal health. Examples of
physical symptoms taken form the literature as increased

among international students as compared to the indigenous

6
student population include change of appetite, undue
fatigue, muscle or joint aches, stomach problems, sleep
disturbances, homesickness, headaches, intestinal

disturbances and heart palpitations (Ebbin & Blankenship,

1986).
Sevetity 9f Symptoms. Severity of symptoms denotes a

subjective feeling by the subject as to the degree to which
symptom interfered with normal functioning.
Nationality. Nationality refers to the country of origin of
the international student.
Overview of Chapters

This study is presented in six chapters. The
background, significance, and statement of the problem,
along with the purpose of the study, the research questions,
definition of terms and assumptions and limitations of the
study are presented in Chapter I. In Chapter II, the
conceptual framework and its relationship to nursing theory
and nursing practice is discussed. In Chapter III, a review
of literature and research pertaining to the problem is
presented. Research design, methodology and techniques for
analysis of data are described in Chapter IV. The research
results are presented, analyzed and discussed in relation to
the research questions in Chapter V. In Chapter VI, a
summary of research findings, conclusions, and implications

for nursing practice is presented.

CHAPTER II
CONCEPTUAL FRAMEWORK
Introduction

In this chapter, the author presents a conceptual
framework which integrates principles of Roy's Adaptation
theory and current research findings regarding culture shock
with the research questions regarding the somatization of
symptoms reported by international students in a university
setting. An explication of the model for nursing practice
as it applies to this investigation is included.

Roy's Adaptation Model

The four main concepts of Roy's adaptation model involve
the person as the recipient of nursing care, the
environment, health and nursing. Roy's model is holistic in
that the human system functions as a whole and adaptive in
that the human system has the capacity to adjust effectively
to a constantly changing environment and in turn affects the
environment. Health is viewed as a state and a process of
being and becoming an integrated and whole person. The goal
of nursing is to promote adaptation in all four adaptive
modes of the person.

The following underlying assumptions describe Roy's
concepts of person and the process of adaptation: 1) The
person is a bio-psycho-social being in constant interaction
with a changing environment; and 2) to cope with a changing
world, the person uses both innate and acquired mechanisms

which are biologic, psychologic and sociologic in origin.

7

8
Roy maintains that health and illness are one inevitable
dimension of a person's life. To respond positively to
environmental changes, the person must adapt. The person's
adaptation is a function of the stimulus he/she is exposed
to. Roy conceptualizes the person as having four modes of
adaptation: 1) physiologic needs; 2) self-concept; 3) role
function; and 4) interdependence relations (Roy, 1980).
rn er'e ce an R0 's d t o

A sojourn may be defined as a relatively short-term
visit to a new environment where permanent settlement is not
the purpose of the visit. Sojourners may be international
students studying abroad and other cross-cultural groups
such as Peach Corps volunteers, businessmen and professional
scholars (Church, 1982). The international student (person)
in a new environment (MSU campus) experiences many focal,
contextual and residual stimuli such as new climate, food,
environment, change in living arrangements, new language,
new culture with new norms, beliefs and values from his/her
home culture. The process of adjustment requires
adaptation.

According to Klein (1977), adaptation can be defined as
a process of attitudinal or behavioral change in response to
new stimuli. Roy (1980), in her theory of adaptation,
states that the person must adapt to a constantly changing
environment.

According to Roy's theory, the stimuli enter the person

from the environment affecting the regulator and/or cognator

9
systems. The regulator system houses the General Adaptation
Syndrome (GAS) of the physiologic mode generated by the
central nervous system and various glandular responses to
adaptation. The cognator system regulates emotion, learning
and social responses of the role function, interdependent
and self-concept modes. The general adaptation syndrome may
activate the local adaptation syndrome (LAS). If adaptation
is successful, no change in local adaptation sites occurs
and the individual stays healthy or symptom-free. If
adaptation is unsuccessful, the local adaptation syndrome is
activated resulting in illness, or the report of various
physical symptoms.

In this study, the stimulus of being a new student
versus a returning student carries with it new environmental
factors (stimuli) such new language, new foods, new culture
with new customs and the Michigan State University campus
and housing. Other stimuli such as living arrangements by
spouse or roommate or nationality may affect the person's
inner environment and affect the adaptation response. The
Family Clinical Nurse Specialist (FCNS) can impact at
various stages of the GAS, LAS or with system input from the
environment prior to onset of the adaptation response (see
Figure 1 for explication of this model adapted from Roy's
Adaptation Theory, Physiologic Mode).

According to several researchers in the literature,
sojourners, hereafter referred to as international students,

may be faced with stress due to relocation to an unfamiliar

10

 

 

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11
environment and/or separation from a familiar one and
experience some degree of culture shock. Culture shock, or
the stress produced by relocation, has been described by
researchers (Adler, 1975; Garza-Guerrero, 1974; Oberg, 1960;
Klein, 1977) as an inability to perceive and interpret
cultural cues and an unfamiliarity with culturally normative
behavior. Stress may be experienced if customs, social
structures and languages are unfamiliar. Locke and Feinsod
(1982) state that stress may be expressed in feelings of
anxiety or depression, altered perceptions of self and
environment, diminished self-confidence and
misinterpretation of the meaning and significance of
environmental cues to more frightening episodes of identity
confusion and depersonalization.

Roy describes the coping mechanisms the person uses to
adapt to the environment as well as personality
characteristics, social interactional patterns, affectional
needs and physiologic processes. In some situations, normal
coping mechanisms of the individual may not be adequate to
alleviate the stress of relocation which may result in
maladaptation or physical illness for the international
student. According to Church (1982), the primary problems
faced by international students were language difficulties,
financial problems, adjustment to a new educational system,
homesickness, adjustment to social customs and norms, racial

discrimination and physical complaints. Church (1982) also

12
contended that students from different cultures differ in
the degree to which they experience certain problems.
The Envitonmeat

The external environment is a source of input into the
adaptive system (Roy, 1980). Three types of stimuli make up
the environment: 1) focal stimuli; 2) contextual stimuli;
and 3) residual stimuli.

A focal stimuli is a stimulus which immediately
confronts the person in a given situation. An example of
this is arrival to a new culture, which may herald the onset
of the first stage of cultural shock. There is new language
to learn, new customs, a new culture, as well as new foods
in a totally new environment. An initial state of euphoria,
a time of optimism and elation about the new culture is
usually experienced upon arrival where the international
student usually views the new environment ethnocentrically
and is more attuned to cultural similarities. Klein (1977)
views the initial stage as a spectator phase where the
sojourner is optimistic about his/her ability to adjust, is
favorably disposed toward the new culture and interacts as a
cultural ambassador.

A contextual stimulus is a background stimulus present
in a situation. Included are genetic make-up, sex,
developmental stage, self-concept, role functions,
interdependence, social interaction patterns, coping
mechanisms and styles, physical and emotional stress,

cultural orientation, religion and environment. The

13
contextual stimuli affect the adaptation response when
adjusting to a different culture as all are very different
from one's home culture. Contextual stimuli differences
create the phase differences in adjustment to new cultures.
No contextual stimuli are directly included in this study.

The onset of physical symptoms may herald a
disintegration phase described by several researchers
(Adler, 1975; Church, 1982; Oberg, 1960) as marked by
tension, confusion, alienation, depression and withdrawal
during which cultural differences become increasingly
noticeable and the individual's normal coping mechanisms do
not work and which may occur at any time after arrival or
during the sojourn experience. Klein (1977) called the
second phase a period of stress and adaptation when conflict
between home roles and expectations abroad are maximized and
there is progressive disappointment and fault-finding of the
host culture.

Residual stimuli are those which have an immeasurable
effect on a situation such as beliefs, attitudes, experience
or traits. Roy's theory is unclear in expressing exactly
which is a contextual or residual stimuli since the same
factor (values, beliefs, religion) may, at different times,
be the different types of stimuli, depending on the
situation. No residual stimuli are included for this study.

To summarize, the external environment changes as a
result of relocation and the international student must use

coping mechanisms to effect adaptive behavior. When the

l4
focal stimulus or relocation occurs, the contextual and
residual stimuli including culture, beliefs, values, and
roles the international student continues to experience may
no longer be appropriate to the new culture. The
international student may perceive the need for change but
may not have the necessary knowledge (customs), skills
(language) or coping mechanisms to affect the necessary
changes. Physically, changes in food, rest and sleep
patterns, alterations in normal exercise patterns, hobbies
and relationships make demands upon the internal physical
environment of the international student. Ineffective
adaptation may be manifest through illness; i.e., the
physical symptoms in the model.
e s n

As an adaptive system, the person has two major internal
processor subsystems, the regulator and the cognator (Roy,
1980). The regulator mechanism involves the neural,
endocrine and perception-psychomotor portions of the person.
The regulator subsystem works mainly through the autonomic
nervous system to set up reflect action. The cognator
mechanism involves psychosocial pathways and apparatus for
perceptual-information processing, learning, judgment and
emotion. The person, through the cognator mechanism, acts
consciously by means of thought and decision and
unconsciously through the defense mechanisms of personality.

Perception links the cognator and regulator subsystems.

Activity is manifested through coping behavior in four

15
adaptive modes: physiologic needs, self-concept, role
function and interdependence. The adaptive modes are
predicated on the person's needs for physiologic integrity,
psychic integrity, and social integrity.

Because of relocation, the cognator system involving
learning, judgment and emotion must adapt to the new
culture. Anxiety and depression, common experiences of the
sojourn experience, may be the result of the maladaptation
of the regulator endocrine system and autonomic nervous
system to stress resulting in the physical symptoms of
illness.

Physiologic Mode

Two basic internal processes of the person as a system
are the regulator and cognator subsystems. The regulatory
receives input from the external environment and from
changes in the person's internal state. It then processes
the changes through neural-chemical-endocrine channels to
produce responses.

The internal and external stimuli are basically chemical
or neural and act as inputs to the central nervous system.
The chemical stimuli travel through the circulatory system
and be transduced to neural inputs. The spinal cord, brain
stem and autonomic reflexes act through effectors to produce
automatic, unconscious effects on the body responses. The
chemical stimuli in the circulation influence the endocrine
glands to produce the appropriate hormone. The

responsiveness of target organs or tissues effects body

16
responses. A psychomotor response follows which activate a
body response. These bodily responses are fed back as'
additional stimuli to the regulator system.

The second adaptive process, not important to this
study, but important to total understanding of the function
of stress in relation to the adaptation response is the
cognator system. The inputs for the cognator are external
stimuli. There are four kinds of processes triggered:
perception/information processing, learning, judgment, and
emotion. Perceptual/information processing is the person's
internal activity of selective attention, coding and memory.
Learning involves such processes as imitation,
reinforcement, and insight. The judgment process includes
problem-solving and decision-making. Through the emotional
pathways, the person uses defense to seek relief and
affective appraisal and attachment.

Physiologic needs are based on physiologic processes:
exercise and rest, nutrition, elimination, fluid and
electrolytes, oxygen and circulation, regulation of
temperature, the functions of the senses and the endocrine
system. These are all part of the focal stimuli affecting
the adaptation response in this study. Relocation may
affect the physiologic mode of the international student in
several ways: through fatigue or "jet lag" upon arrival;
climate variations, different types, combinations and
amounts of food and fluids; varied times for rest and sleep;

varied types and amounts of exercise different from one's

17
home environment. Because of disruption of the internal
environment of the sojourner through the physiologic mode,
stress in the form of physical illness may occur. Common
physical complaints involving the physiologic mode include
constipation or diarrhea, abdominal discomfort, extreme
fatigue, sense of anxiety, respiratory problems, headache
and other common symptoms.

The following is a short discussion of the self-concept
mode, role function mode and interdependence mode. These
areas of Roy's theory are not important for this study but
are important for understanding of the holistic nature of
Roy's theory. Maladaptation in any of the four modes may
lead to illness.

Self-concept, focusing on the need for psychic
integrity, is defined as the composite of beliefs and
feelings that one holds about oneself at a given time formed
from perceptions of others' reactions and directing one's
behavior. It encompasses perceptions of a physical self
regarding physical attributes, functioning, wellness-illness
state and appearance and the personal self regarding morals,
ethics, self-identity and self-esteem. Self concept of the
international student may be threatened due to inability to
respond to cultural cues and to being unfamiliar with
culturally normative behavior.

Role function, emphasizing the need for social
integrity, is defined as positions people hold in society

and how they play out the interaction based on that

18

position. Roy describes three types of roles: primary role
which determines the majority of behaviors engaged in by the
individual during a particular growth period of life based
on developmental level; secondary role which influences
behavior in a variety of settings and is occupied according
to the tasks of individual must accomplish to achieve
autonomy at a particular time in life; and tertiary role, a
temporary role of choice than an individual occupies for the
purpose of fulfilling some minor task associated with the
current developmental stage.

The primary role of the international student may be as
a national representative sensitive about his or her ethnic
background and national status. A secondary role may be as
a maturing, developing person concerned about purposes,
meaning and goals. A tertiary role may be as a student
adjusting to the stress common to all beginning students
(Bochner, 1986). Successful role transitions may mark a
final independence stage in culture shock described by Adler
(1975). This final state is marked by a cherishing of
cultural differences. Behavior emerges that is expressive,
mutually trusting with increased self and cultural awareness
which enables the sojourner to undergo further life
transitions characteristic of a successful sojourn
experience.

e e c ode

The interdependence mode, defined by Roy as the balance

between dependence and independence in relationships with

19
others, emphasizes the need for social integrity through
affectional adequacy or the feeling of security of nurturing
relationships. Significant others and support systems
contribute to the meeting of interdependence needs.
Receptive behavior and contributive behavior apply to the
ability to both give and receive love, respect and value in
relationships.

Evers (1979) posited that the personality of the
international student is viewed as the product of the
interactions within the basic socializing structure of
family, community and peers. These social interactions
provide a base for the individual to fulfill psychological
needs. When a move to another environment is made, the
international student has to seek, through social
interactions, the bases where the needs can now be met.
Stress may develop if the differences between environments
are large and if inconsistency exists for the habits and
norms of the social institutions. Stress is a result when
the needs of the international student are no longer met
through normal, familiar means.

u ' n ea t

In the Roy model, Nursing acts to enhance the
interaction of the person with the environment. The
fulfillment of one's purpose in life is reflected in
becoming an integrated and whole person. Roy defines the
goals of nursing as the promotion of adaptation in each of

the four modes thereby contributing to the person's health,

20
quality of life and dying with dignity (Roy, 1980). In this
study, nursing may impact at any point in the model
manipulating the environment to enhance wellness in the
international student. The FCNS may impact on the new
student with various wellness programs or may intervene when
the student reports physical symptoms or actually presents
to the health care personnel with illness.
Summary
In this chapter, Roy's adaptation theory with its
adapted physiologic model was presented as the conceptual
framework for this study. The basic concepts of person,
environment, health and nursing were discussed in relation
to the physiologic mode. Functions of the various modes
(physiologic, self-concept, interdependence and role) in
relation to the international students' adaptation processes

were also discussed.

CHAPTER III
REVIEW OF THE LITERATURE
Introduction
This chapter includes a discussion of major research
findings related to the concepts under investigation.
Recent studies (Ebbin & Blenkenship, 1986; Allen, 1987)

related to the physical symptomatology perceived to be a

M‘s—nae.” —.-.....--__,_n. "w r.

 

, . wmqm.‘_ -v‘

variation from normal health among domestic and
international students enrolled in a course of university
study are included as the basis for the development of the
questionnaire used by this researcher for this study.
Discussion of recent theories regarding culture shock,
provide the background for a major question regardingdie’ngth~

of stay in the United States. Nationality and living

 

arrangements by spouse or roommate as related to physical
symptomatology is addressed.
Review of Literature
A review of the literature strongly supports a
significant relationship between stressful life events and

'44-»... “4;... ,_ H. vvr—~

subsequent ill-health.‘ Beginning a college program is

.-...-..1.; wrw. _....4 .,

W—owumw-a-a ._.. .-
~..___

stressful to many students. Significant life changes in
financial status, living conditions, eating and sleeping
habits, work and social activities can precipitate
significant levels of additional stress (Hill, Smith, &
Jasmin, 1981). Campus and government representatives at the
seminar on International Students jointly sponsored by the

American College Health Association and the National

21

22
Association for Foreign Students Affairs held in Washington

D.C. in 1985 indicated that medical problems were the single

“Ag.
w H~m_u‘m ._ ._.,,.....L. AW

 

most important reason for termination of studies by

O l'
\ -fimfihnuwr WP.— vh- "er‘ . 5 van-41“)“ "1M . i. . Wu". -wv‘l N" ‘H

international students (Blom, 1986). Blom also contended
that international students are not only faced with the
typical risks and ailments of life, but they must also
confront new risks and stresses due to cultural adjustment,
lifestyle change and exposure to new bacteria and viruses
not present in their home countries.

Theorists from various disciplines have attempted to
explain the occurrence of somatic complaints among
international students and sojourners as being related to
increased stress caused by adjustment to the new culture or
culture shock. Oberg (1972), in describing an
anthropological view, explained cultural awareness leading
to an increase in anxiety levels and inability to cope with
the demands of new surroundings. Espousing and
psychoanalytic view, Garz-Guerrero (1974) suggested that
culture shock consists of mourning the lost culture plus the
threat to identity posed by the new culture. Adler (1975),
a phenomenologist, viewed culture shock as a "transitional
experience." He proposed that, although culture shock is
often defined as an illness and associated with negative
consequences, it can be a good experience as it promotes
cultural learning and personal growth. Dimarco (1974)
viewed culture shock as an adaptation to stress. Befus

(1988) proposed an integrated definition of culture shock as

23
"an adjustment reaction syndrome caused by cumulative,
multiple and interactive stress in the intellectual,
behavioral, emotional and physiologic levels of a person
recently relocated to an unfamiliar culture and is
characterized by a variety of symptoms of psychological
distress" (p. 387). He designed a treatment program which
integrates cross-cultural training methods with
psychotherapeutic techniques in order to provide sojourners
with coping skills for dealing with the multilevel impact of
culture shock.

In a study which used physical symptomatology and
frequency of clinic visits of physical problems as a
manifestation of distress among domestic college students
embarking on a course of university study, Hill et al.
(1981) developed a modularized stress management program
using both a control and experimental group. The
significance of the study as related to this investigation
was that stress was measured by types and frequency of
physical symptoms and number of clinic visits to physicians.
During the first three weeks of the program, the
experimental group received the modularized stress reduction
packet which included individual, self-paced modules aimed
at helping students to assess their life stresses, to
understand the impact that stress had on their health and
developed individualized stress management skills. The
control group received no interventions. As early as week

four, the experimental group related fewer visits to

24
physicians, fewer nosebleeds, colds and sore throats; fewer
gastrointestinal problems and fewer skin problems. Results
at the fifteen week measurement indicated that the students
in the experimental group did report feeling less anxiety as
measured by a Health Outcome Scale questionnaire. These
results supported the hypothesis that knowledge of the
association of high stress levels and beginning college
would be helpful in reducing the negative effects of that
stress. An increased awareness of stress and maintenance of
a healthy lifestyle was promoted through use of the
modularized units.

Few empirical research articles are available on the
topic of use of health care facilities or health care needs
of international students at United States universities.
Ebbin and Blankenship (1986), in a major article used by
this researcher as the basis for construction of the
questionnaire used for this study, reviewed student health
records from the Student Health Center at the University of
Southern California from 1980 to 1983. During that time
period, the University of Southern California had
approximately 4,000 international students which comprised
approximately 13 percent of the student body.

Ebbin and Blankenship (1986) reviewed 96,804 diagnoses
from student visits to the University Health Center from
1980 to 1983. The diagnoses coded for international
students were compared to those for domestic students. More

than 50 disease entities were found to be significantly

25
increased while 30 were significantly decreased in
international students when compared to domestic students.
Frequencies of clinic visits were compiled and comparison
made between international and domestic students. The
international students comprised 21 percent of total number
of individuals seen during the specified time period with 18
percent of total number of visits while comprising only 13
percent of the total student population.

One reason for increased health center use by
international students in this study were offered by the
authors. Many domestic students were not in residence at
the University of Southern California and had well-
established health care systems in Los Angeles area and did
not use university health care centers. However, the
international students living onfcampus housing had a need

W"fl'*~‘"l-Fnadw x.’ 1..., i

for nearby health services which providedweasy access and
which had specialmproqrams to orient them and provide
interaction to relieve loneliness, depression and stress
(Ebbin & Blankenship, 1986).

Physical symptoms such as cough and inflammation of the
trachea were found to be increased among international
students while the common cold and ear infections were less
commonly seen. The authors theorized that perhaps prior
exposure to the organisms that cause these problems may
facilitate greater immunity to some diseases. The following

were also significantly higher among international students

than domestic students: hepatitis, venereal disease,

26
hemorrhoids, sexual dysfunction concerns, seizure disorder,
fever unknown origin, and no pathology. There was a
strikingly increased use of the health center by
international students for psychiatric problems of anxiety,
depression, insomnia, and sexual dysfunction as compared to
the domestic student population.

In a study which addressed the frequency of clinic
visits as a manifestation of illness, Allen & Cole (1987)
contended that differential rates of clinic attendance among
foreign and domestic students do not reflect stress-induced
morbidity. These authors claimed that factors such as
cultural differences in attendance rates, proximity to the
health center, lack of other sources of advice, lifestyle,
and presentation in the doctor-patient encounter as
determinants of the frequency and patterns of consultation.
Allen & Cole (1987) offered the possibility that foreign
students may enjoy better health as measured by the
consultation rates than their counterparts studying in their
home country. The significance of the study for the present
study was that types and frequency of physical symptoms were
measured among international and domestic students. Allen &
Cole (1987) compared that frequency of clinic visits among
the international students studying in Australia to the
frequency of clinic visits of students from the same
nationality who stayed home. This study also generated

major types of illness or major themes of physical

27
symptomatology listed in the questionnaire for the present
study.

Allen & Cole (1987) also addressed "foreign student
syndrome" using two separate hypotheses to test its
existence among a student population in Australia. "Foreign
student syndrome" had been described as vague physical
complaints and a belief by foreign students that complaining
of emotional problems as anxiety, loneliness or distress
would entail loss of face. As part of the syndrome, the
students would then somatize their complaints to permit
attendance for medical care for physical problems which they
found more acceptable. Three groups of university students
were used as comparison groups for the foreign students
studying in Australia: one group in Hong Kong, one in
Singapore, and a group of native-born Australians.
Consulting patterns for Asian students were obtained from
the annual reports for the year 1976-77. The mean number of
consultations per student per year for Asian students in
Asia was four. In Australia, native-born and foreign
students differed significantly in the mean frequency of
consultations. Foreign students made an average of three
visits per student per year in the health service compared
with 1.4 visits per student per year among Australian
students (Allen & Cole, 1987). The conclusion from the data
was that foreign students, despite having the added stress
of emigration, consulted less often than their counterparts

at home. The main differences in the consulting patterns

28
between Australian and Asian students concerned respiratory
disease, genitourinary diseases, accident poisonings and
violence. Of all clinic visits of foreign students, 50
percent were for respiratory ailments as compared to 19
percent in the Australian population. Among Australians,
genitourinary dysfunction accounted for 20 percent of visits
as compared to 4 percent in the foreign population (Allen &
Cole, 1987). Allen and Cole (1987) offered several
explanations for the decreased clinic use by Asian students
in Australia as compared to Asian students in Asia. Social
class differences in reactions to relocation, the likelihood
that foreign students would be the most adventurous and
adaptable of their cohort and that they may be physically
more vigorous than those who stayed at home were plausible
explanations of the differences inferred. The authors
concluded that the foreign student syndrome did not exist
(Allen 8 Cole, 1987).

In another study which addressed physiologic and
psychologic distress among sojourners, Befus (1988) designed
a treatment program to provide coping skills for dealing
with the multilevel impact of culture shock of Americans
studying abroad. Unfortunately, although the treatment
program was well-planned, comprehensive in nature, and
deemed successful by the author, the study failed to support
more than intuitive evidence that a culture shock problem
did indeed exist. The significance of the Befus (1988)

study to the present study is that there seems to be a

29
pervading intuitive sense throughout the literature that
physiologic and psychologic distress occurs as a result of
the adaptation process to a new environment. To address the
physiological stress reportedly experienced by the
sojourner, a program of deep breathing, progressive
relaxation and wellness promotion consisting of planned
recreation, good nutrition and exercise was implemented. To
address the behavioral aspects of culture shock, the
sojourners were guided through application of Social
Learning Theory to their daily lives. To deal with the
emotional needs of the sojourners, a support group was
established and Rational-Emotive therapy was used to alter
their emotional tone and reactions. To assist with coping
with the intellectual aspects of cultural shock, a
facilitator was used to increase cultural awareness.

In another study which again addressed cultural
adaptation as a negative stress, Hammer (1987) replicated
research through which scholars have identified three
behavior skills/abilities important in facilitating
intercultural effectiveness: the ability to manage
psychological stress, the ability to effectively communicate
and the ability to establish interpersonal relationships.

The significance of the study for this research was
again the intuitive assumption of the negative impact of
culture shock on the international students. The study by
Hammer (1987) on adaptation to a different culture was

conducted on Americans in a university setting. There are

30

very few studies on international students adapting to the
American culture. This research supports other literature
on sojourner adjustment and culture shock in that the
ability to deal with psychological stress is critically
important to effective functioning in a foreign culture.

Living arrangements may affect the adaptation process.
Adelman (1988) stated that when people first encounter a new
culture, forming accurate or functional attributions may be
difficult since the sojourner often encounters unfamiliar
behaviors and demands in the new environment. In the case
of culture shock, physical and psychological disorientation
can undermine the international student's sense of mastery
and self-esteem (Adelman, 1988). Social feedback that
reassures persons undergoing cross-cultural adjustment that
these are temporary and pervasive reactions to a new
situation can help restore cognitive and behavioral control.
For international students threatened by the demands of the
new culture, compatriot support networks can reaffirm the
home values and decrease the possible homesickness and
disorientation that may accompany the adjustment process
(Bochner, 1981). This compatriot culture may not always be
ultimately beneficial and can be detrimental to successful
cross-cultural adjustment. Albrecht & Adelman (1984)
contended that, although these compatriot groups may
alleviate initial stress, reliance on these groups may
create a "fortress effect" by insulating the newcomer from

cultural change. Adelman (1988) claimed that, for families

31
that experience severe culture shock, mutual dependency can
intensify the stress rather than solidify relational bonds.
The contagion effect can inadvertently arise as common
experiences that are shared among the compatriot groups.
Feelings of homesickness can be easily stirred and the
telling of "war stories” can serve as a form of ventilation
of stress or can generate tremendous anxiety. Thus marital
status and living arrangements can affect the adjustment
process. Access to support outside the distressed unit can
help to restore equilibrium by facilitating the adjustment
process.

In a study conducted among Mexican and Central American
Immigrants in the United States, Padilla (1988) found that
use of a social support network was effective as a coping
response to basic adjustment difficulties. The study is
relevant to this researcher in that it identified major
areas where cultural adjustment is required by another
nationality to the U.S. culture. Thirty-five percent of the
respondents stated that adapting to the different food,
transportation and life-style constituted the major changes
that the Latino family had to make. Twenty-five percent
stated that having to learn English altered the family.
Forty percent cited additional family concerns regarding
children's education, finding good friends and abstinence of
drug, alcohol, or tobacco habits (Padilla, 1988). In
addition, males were more likely to be subjected to more

stressors as they were more likely to be employed, had fewer

32

coping strategies open to them, experienced role strain
caused by loss of social status and had fewer economic
resources available to use in family care (Padilla, 1988).

There have been no empirical studies found by this
investigator to date that measure the differences in
somatization of symptoms between or among different
nationality groups or ages. “Marital status, living
arrangements or family concerns may affect the process of
adjustment to a new culture.

Summary

This chapter examined current, relevant literature on
concepts of*somatic symptomology among international
students and its relationship to culture shock, marital

status, andmliving arrangements.

—-.'.-a~ Fu-

CHAPTER IV
METHODS
Overview
In the following chapter, the research questions and the
operational definitions of the variables are presented,
along with a description of the sample, the procedure for
data collection, instrumentation and scoring, and human
rights protection procedures are also discussed.
Procedures
This study describes the relationship between types,
frequency and severity of physical symptoms and length of
stay in the United States, nationality and living
arrangement. A researcher-developed instrument based on
symptomatology reported to be higher among international
students than among domestic students was employed to
measure types and severity of physical symptoms among
international students. Sociodemographic data were
collected to describe the study sample.
Research Questions
The following questions and derived hypotheses were
addressed in this investigation:

1. What are types, frequency, and severity of physical
symptoms as reported by graduate international students
at Michigan State University?

2. Does type, frequency or severity of symptoms reported by

graduate international students at Michigan State

33

34
University differ by length of stay in the U.S. as
indicated by student type (new or returning student)?
Hypothesis 2.1: Students relocated to the
United States less than one year will report
higher mean frequency of physical symptoms
than those students relocated more than one
year.
Hypothesis 2.2: Students relocated to the
United States less than one year will report
a higher mean severity of physical symptoms
than those students relocated more than one
year.

3. Does type, frequency or severity of physical
symptoms as reported by graduate international
students at Michigan State University differ by
living arrangements (roommate or spouse)?

Hypothesis 3.1: Married graduate
international students at Michigan State
University will report lower mean frequency
and severity of physical symptoms than non-
married graduate international students.
Hypothesis 3.2: Those graduate international
students with a roommate will report lower
mean frequency and severity of physical
symptoms than those with no roommate.

4. Does type, frequency and severity of physical

symptoms as reported by graduate international

35

students at Michigan State University differ by

nationality?

Hypothesis: Types, frequency, and severity
of physical symptoms will differ by
nationality group among graduate
international students at Michigan State
University.

Sample

Several criteria were established to determine
student eligibility for inclusion in the study. These
criteria were: 1) the student was a graduate student
enrolled in a course of study at Michigan State
University; and 2) the student belonged to one of the
ten most populous foreign nationalities at Michigan
State University.

Of a total graduate international student
population of 2,072, 1,109 students belonged to the ten
most prevalent nationalities. From this target
population of 1,109, a sample of 436 subjects was
selected through stratified random sampling technique.
The new students to Michigan State University campus,
who constitute a relatively small part (21%) of the
target population, were oversampled to obtain
sufficient numbers for the sample. The number of new
students selected for the sample was 154 or 66 percent
of the total number of 233 eligible new students. The

number of returning students was 282 or 32 percent of

36
the total eligible returning population of 876. The
size of each of the two subsamples was determined on
the basis of the requirement that the 95 percent
confidence limits be the same for both groups. In
other words, inferences about both groups would be
subject to the same sampling error.
Instrument

The instrument for this study, the Somatic Symptom
Instrument, was developed by this researcher based on
symptomatology that, according to the literature, is
more prevalent among international students than among
domestic students. Many of the items are based on the
Longitudinal Health Care Study on International versus
Domestic Students by Ebbin & Blankenship (1986). The
Somatic symptom instrument was put together by
including the most frequent symptoms from their list.
Other researchers described similar physical
symptomatology in their research. Joint aches and
myofascial symptoms are reported by Eskola (1985).
Befus (1988) described fatigue, asthma, hives,
headaches or ulcers, heart palpitations, and change in
appetite. Locke & Feinsod (1982) and Nishio & Bilmes
(1985) found constipation or diarrhea, abdominal
discomfort, and sense of anxiety in their research.
The Somatic Symptom Instrument included symptoms such
as fatigue, headache, skin changes, abdominal

discomfort, and diarrhea or constipation.

37
Data Collection

Prior notification by announcement at the club
meeting for international students preceded mailing of
a questionnaire. The questionnaire and cover letter
explaining the study were sent by first-class mail to
each student in the sample by name in January, 1991.
An identification number was assigned to each student.
The subjects were asked to return the questionnaire
within three weeks of receipt to the International
Center in person or by mail to the researcher in a
self-addressed, stamped envelope which was provided
with the mailed questionnaire. Due to budget and time
constraints, no follow-up phone call or post card was
sent if the original questionnaire was not returned
within the specified length of time. Subjects were
directed to identify whether they had experienced any
of the symptoms listed within the prior three months
and, if they had experienced symptoms, to indicate
their perceived severity of the symptom.

Instrument Reliability and Validity

Since this was a new instrument, no prior
reliability data was available. According to Polit &
Hungler (1987), the reliability of an instrument is the
degree of consistency with which it measures the
attributes it is supposed to measure. Internal
consistency reliability reflects the extent to which

all of the subparts are measuring the same

38
characteristic. If symptom complexes can be
identified, then reliability estimates can be
calculated.

Validity refers to the degree to which an
instrument measures what it is intended to measure.
Like reliability, validity has several different
aspects and approaches to assessment. However, a
validity of an instrument, according to Polit & Hungler
(1987), is extremely difficult to establish. Content
validity, or the sampling adequacy of the content area
being measured, is necessarily based on judgement
(Polit & Hungler, 1987). Content validity is
determined by the degree to which items of a scale
represent all relevant aspects of the concept. Content
validity was accepted based primarily on the work of
researchers in cited literature. A panel consisting of
clinical nurse specialists, a social scientist and
statistician, and family therapist also reviewed the
instrument. A factor analysis of the data was done to
determine relationships of the various symptoms to each
other and examine patterns or clustering of symptoms.

Operational Definitions of Variables

Types of physical symptoms were operationalized by
asking subjects to indicate whether they had any of the
25 symptoms listed in the instrument.

Severity of symptoms was operationalized by asking

whether symptoms experienced were mild, moderate or

39
severe based on degree of discomfort the subject
perceived from the symptom.

Living arrangement was determined by asking the
question, "Who lives with you?" on the demographic
portion of the questionnaire. Subjects were to check
if they had a roommate, spouse, and the number and ages
of children.

Nationality was determined by asking the subject
about their country of origin which was verified by the
list provided by the Office of International Students
and Scholars.

Age of the student was determined by a question
that asked the respondent to record his/her age in
years.

Sex was determined by answering whether the
respondent was male or female.

Type of housing was determined by a question which
asked the respondent whether he/she lived in residence
halls, off campus or in campus apartments.

Type of visa was determined by a question asking
the type of visa the respondent was issued.

Prior disease of the respondent was determined by
asking the respondent to check "yes" or "no” in
response to several diseases.

Information obtained about the demographic data was

summarized in order to described the sample population.

40
Data Analysis

Sociodemographic characteristics of the sample and
scores on the instrument were described using
percentages, frequencies, means, and standard
deviations. In response to each of the symptoms, a
"Yes" scores a 1; "No" scored a 0; If a "Yes" response
was obtained for a symptom, a score for symptom
severity was obtained: "Mild" scored a 1; "Moderate"
scored a 2; "Severe" scored a 3. The dependent
variables for the study were types, frequency, and
severity of physical symptoms. The independent
variables under study were: 1) type of student
reflecting length of stay in the United States; 2)
nationality; and 3) living arrangements.

Exploratory factor analysis was performed on the
symptom instrument to determine if groups of symptoms
emerged that tended to occur together. The subscales
that did emerge were tested for their reliability
employing Cronbach's alpha as the measure of internal
consistency. The correlational pattern of the items
was analyzed and the clusters of items were compared to
conceptually defined clusters. This researcher
accepted a coefficient alpha of 0.50 as the level at
which a scale would be accepted for further analysis.

The hypotheses were tested using one-way Analysis
of Variance. ANOVA is a method of analysis that

enables the researcher to determine if the mean

41
differences between sub-samples are large enough so
that it is unlikely that they resulted from sampling
error. ANOVA consists of several steps: computation
of the between group variance, the value of the within-
group variance, the ratio of the between-group variance
and the within-group variance (F ratio). The within
group variance is also referred to as the error
variance of residual variance. The between-groups
variance represents the influence on the variable of
interest or the outcome variable. If the between-
groups variance is not substantially greater than the
within-group variance, the researcher would conclude
that the difference between the means is probably a
reflection of sampling error. If the F ratio were
substantially greater than one, the ratio of the
between-groups variance and the within-groups variance
would not be attributed to sampling error.

The significance of the F ratio is found in an F
table which indicates the critical values necessary to
test the null hypothesis at selected levels of
significance. An alpha level of .05 was set as the
significance level for this study. This means that
there is a 5 percent chance that the rejection of the
null hypothesis that there is no difference between the

group means is in error.

42
Human Rights Protection

A cover letter explaining the research study and
goals, the approximate time involved in participation,
and assurances of confidentiality was mailed to each
participant. Participation in the study was voluntary
and the subjects could choose not to answer the
questionnaire by not returning it. An identification
number was assigned to each questionnaire by this
researcher to insure confidentiality. No attempt was
made to identify the subject by name. Approval of
proposed methods to protect the rights and welfare of
human subjects was obtained from the Michigan State

University Committee on Research involving Human

Subjects (see Appendix B letter).

Assumptions
The researcher made the following assumptions:

1. Each international student was able to understand
the English language sufficiently to fill out the
questionnaire.

2. Each international student was able to recall and
report the physical symptoms experienced during the
specified time period.

Limitations
The researcher acknowledges the following
limitations of this investigation:

1. Age and sex of student are potential modifying

variables that may affect study outcomes. These

43
and other factors may contribute to the adaptation
response and may affect the outcome of this study.
No attempt to control for these variables was made
in this study. This researcher is concerned only
with the independent variables of nationality,
student type and living arrangements by roommate or
spouse.

2. Although this was a stratified random sample of
MSU's graduate international students, the
conclusions may not be generalizable to the entire
international student population at MSU. The
subjects who agreed to participate in the study
could be different from subjects who refused.

3. The study results is not generalizable to any other
population of international students because it
cannot be assumed that international students at
MSU are representative of internatinoal students at
other American universities.

4. Data were collected at one point in time. Changes
may have occurred before the time period specified
or will occur after the response time.

5. The researcher-developed questionnaire is an
untested instrument of unknown reliability and
validity.

Summary
In Chapter IV, the research questions and the

operational definitions of the study variables were

44
presented. Also discussed were the sample criteria,
procedures for data collection, instrument development,
scoring and data analysis. Reliability and validity of
the instrument were also addressed. In the following
chapter, the data are presented and the results

analyzed in relation to the research questions.

CHAPTER V
RESULTS
Overview

A description of the study sample and the research
results are presented in this chapter. Reliability measures
for the subscales of the Somatic Symptom Instrument and the
mean scores on the subscales are included for groups defined
by the independent variables. Results of the one-way
ANOVA's for testing hypotheses are also presented.

Sample Characteristics

Of the 436 questionnaires mailed to the sample, 153
questionnaires were returned for a response rate of 35
percent. The number of new students responding to the study
was 59 or 38.3 percent of the 153 respondents. These
percentages corresponded well to the proportion in the total
target population (1109 subjects) of 35.5 percent new
students and 64.7 percent returning students.

Taiwan was the moSt highly represented country with 64
or 41.8 percent of respondents. China followed with 24 or
15.7 percent of respondents. Korea had 18 or 11.8 percent
responding. India followed with 12 subjects responding or
7.8 percent. Japan had nine or 5.9 percent, Hong Kong with
eight or 5.2 percent, Canada with seven or 4.6 percent and
Malaysia with five or 3.3 percent. There were no responses
from Turkish subjects. Again, with the exception of Turkey,
_the respondent sample does reflect the target population

well.

45

46

The mean age of the respondent sample was 28.8 years
with a mode of 25 years. The age group of 24-30 years was
most highly represented with 101 of the 153 respondents
falling within this group. Twenty-five respondents were
between 31 and 39, six were 40 to 48, and nine between 20
and 23 years of age. Twelve questionnaires had no age
reported. Of these respondents, 90 individuals (or 60
percent) were male, 50 (or 40 perCent) were female, with
three questionnaires not indicating sex. This corresponds
directly to the target population's sex ratio.

Most (100 or 67 percent) of the respondents lived in
campus apartments. Thirty-four (22.2 percent) lived in
residence halls and 15 (10.1 percent) lived in off-campus
housing. There were 103 (67.3 percent) respondents who were
not married, 45 or 29.4 percent who were married and five
respondents who did not indicate marital status. Only 25
(16.3 percent) had any children living with them. Ages of
the children varied with most of the children under the age
of ten.

Very few of the respondents had been diagnosed with
previous diseases. One respondent had been diagnosed with
TB, one respondent with heart disease, eight respondents
with allergies, four respondents with asthma, and two

respondents with prior stomach ulcer.

47
Reliability of the Subscales of the
Somatic Symptom Instrument

Exploratory factor analysis resulted in two clusters of
symptoms. The clusters of symptoms were also conceptually
linked and demonstrated a correlation pattern that indicated
that they typically varied together. Two separate scales
emerged which were then subjected to a reliability analysis.
The first scale labelled "Cold Symptom Scale" consisted of a
count of four symptoms: Symptom 1 (Cold); Symptom 3 (Sore
Throat); Symptom 4 (Chest pain/cough); and Symptom 21
(Headache) with an average inter-item correlation of .4139.
The coefficient Alpha for the Cold Symptom Scale of four
symptoms was .7793. The second scale emerged for skin
symptoms. This was labelled as "Skin Symptom Scale" and
consisted of a count of five items: Symptom 2 (Nosebleeds);
Symptom 8 (Dry skin/scalp); Symptom 9 (Hair loss); Symptom
10 (Skin rash); and Symptom 11 (Acne) with an average inter-
item correlation of .1809. The coefficient Alpha for the
Skin Symptom Scale was .5348 which is low by conventional
standards. This researcher decided this level was still
acceptable and defensible given the conceptual uni-
dimensionality of the scale items.

Several of the other symptoms emerged as heterogenous
symptoms forming no systematic pattern. These include
Symptom 5 (Cold sore); Symptom 6 (Joint pains); Symptom 7
(Low back pain); Symptom 14 (Hard bowel movements); Symptom

15 (Loose bowel movements); Symptom 16 (Nausea or upset

48
stomach); Symptom 17 (Unusual fatigue); Symptom 20
(Inability to get to sleep or stay asleep); Symptom 22
(Fever of unknown origin); Symptom 23 (Accidents). Simple
frequencies are included in the analysis for this group of
symptoms because several occur in frequencies high enough to
warrant recognition as potential subject problem areas.
Data Related to Research Questions

Question 1: What are types, frequency, and

severity of physical symptoms as reported by

graduate international students at Michigan State

. University?

A listing of the frequencies and percentages of all the
symptoms and severity levels of the items in the Somatic
Symptom Instrument is presented in Table 1. Calculation are
based on the respondent sample of 153 returned
questionnaires.

The items on the Cold Symptom Scale had the most
numerous average "Yes" responses with 54. Seventy-three or
47.7 percent of the respondents reported colds, 69 or 45.1
percent reported sore throats, 30 or 19.6 percent reported
chest pain or cough, and 73 or 47.7 percent reported
headache. Because of the different number of items in the
Cold Symptom and Skin Symptom Scales, an ayazaga of the
”yes" responses was computed. Individual symptom scores are

also reported.

49

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50

Items of the Skin Scale had an ayazaga of 46 "Yes"
responses. Forty-four or 28.8 percent of respondents
reported nosebleeds, 74 or 48.4 percent reported dry skin
orscalp, 39 or 25.5 percent reported loss of hair, 28 or
18.3 percent with skin rash, and 23 or 15 percent reported
worsening of acne.

The discharge symptoms had very few responses with four
"Yes" responses. In the "Other Symptom" list, the most
notable responses included 46 or 30.1 percent with unusual
fatigue, 27.2 percent with nausea, 33 or 21.6 percent with
back pain, 29 or 19 percent with itchy eyes followed with 25
or 16.3 percent with abdominal pain (Table 1).

For all symptom severities reported, the greatest number
of respondents reported symptoms as mild. The symptoms
enumerated in the Cold Symptom Severity scale were noted on
average as mild by 53 to 67 percent of the respondents, as
moderate by 28-40 percent of respondents, and as severe by
less than 15.6 percent of respondents. Items on the Skin
Symptom Severity Scale were noted, as mild by more than 61.9
percent of respondents, as moderate by 11.6 to 33.3 percent
of respondents, and as severe by less than 9.5 percent.
Items in the Other Symptom list were also reported as mild
by most of the respondents. Those students reporting
discharge symptoms reported 50 percent as mild and 25
percent each of moderate and severe (Table 1).

After testing the Somatic Symptom Instrument for

scalability, the hypotheses related to the remaining

51
research questions were revised to reflect the two scales
which emerged, the Cold Symptom Scale and the Skin Symptom
Scale. The subsequent presentation of results represents
these revisions. All hypotheses were tested using one-way
Analysis of Variance and the results are summarized in Table
2.

The overall mean values for both the Cold Symptom Scale
and the Skin Symptom Scale were low with an average of fewer
than two symptoms for either scale across all groups. The
overall symptom severity was reflected the mostly mild
nature of symptoms reported.

Question 2: Does type, frequency, and severity of
physical symptoms reported by international
students at Michigan State University differ by
length of stay in the United States as indicated
by student type (new or returning student)?
Hypothesis 2.1: Students relocated to the United
States less than one year (new students) will
report higher mean frequency of cold symptoms than
students relocated more than one year (returning
students).

This hypothesis was not supported. There were no
significant differences in mean number of cold symptoms
between new and returning students.

Hypothesis 2.2: Students relocated to the United
States less than one year (new students) will

report higher mean severity of cold symptoms than

52

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53
students relocated more than one year (returning
students).

This hypothesis was not supported. There were no
significant differences between new and returning students
with respect to mean severity of cold symptoms.

Hypothesis 2.3: Students relocated to the United
States less than one year (new students) will
report higher mean frequency of skin symptoms than
those students relocated more than one year
(returning students).

This hypothesis was supported. New students reported
1.66 number of skin symptoms as compared to a mean of 1.17
for returning students.

Hypothesis 2.4: Students relocated to the United
States less than one year (new students) will
report higher mean severity of skin symptoms than
those students relocated more than one year
(returning students).

This hypothesis was supported. New students reported a
higher mean severity as compared to a milder mean severity
for returning students.

Question 3: Does type, frequency, and/or severity
of physical symptoms as reported by international
students at Michigan State University differ by
living arrangements (roommate or spouse)?

This researcher discovered an ambiguity in the

demographic data response set with regard to this question.

54

According to the question as it appeared on the
questionnaire, it was very difficult to determine whether
absence of roommate and presence of a spouse were mutually
exclusive of each other. Therefore, responses for these
variables may not be an accurate reporting of these
arrangements. All hypotheses related to this question were
tested using one way ANOVA's and the results are summarized
in Table 2.

Hypothesis 3.1: Married graduate international

students at Michigan State University will report

lower mean frequency of cold symptoms than non-

married students.

This hypothesis was not supported. There was no
significant difference between married and non-married
students with respect to mean number of cold symptoms.

Hypothesis 3.2:. Married graduate international
students at Michigan State University will report
lower mean severity of cold symptoms than non-
married students.

This hypothesis was not supported. There were no
.differences of mean severity of cold symptoms between
married and non-married students.

Hypothesis 3.4: Married graduate international
students at Michigan State University will report
lower mean severity of skin symptoms than non-

married students.

55

This hypothesis was supported. Married students
reported a mean severity of 0.22 which is low as compared to
a mean severity of 0.44 for non-married students.

Hypothesis 3.5: Graduate international students
with a roommate will report higher mean frequency
of cold symptoms than those students without a
roommate.

This hypothesis was not supported. There was no
significant mean difference in frequency of cold symptoms
between those students with or without a roommate.

Hypothesis 3.6: Graduate students with a roommate
will report higher mean severity of cold symptoms
than those students without a roommate.

This hypothesis was not supported. One-way ANOVA
revealed no significant mean difference in severity of cold
symptoms between students with or without a roommate.

Hypothesis 3.7: Graduate international students
with a roommate will report higher mean frequency
of skin symptoms than those students without a
roommate.

This hypothesis was supported. There was a significant
difference in mean number of skin symptoms between those
students with and without a roommate.

Hypothesis 3.8: Graduate international students
with a roommate will report higher mean severity
of skin symptoms than those students without a

roommate.

56

This hypothesis was supported. Those students with a
roommate scored a symptom severity of 0.49 while those
students without a roommate scored a mean symptom severity
Of 0.32.

Question 4: Does type, frequency, or severity of
physical symptoms as reported by graduate
international students differ by nationality?
Hypothesis 4.1: Frequency of cold symptoms as
reported by graduate international students at
Michigan State University will differ by
nationality.

This hypothesis was supported. The frequency of cold
symptoms are significantly different in the sample by
country of origin (Table 3). Analysis of the confidence
intervals of the means of all countries indicated that
China's confidence intervals did not overlap with the
confidence interval for Taiwan indicating those two
countries differ significantly from each other in mean
number of symptoms. Other countries confidence intervals
overlapped indicating similarity of response patterns.

Hypothesis 4.2: Severity of cold symptoms as
reported by graduate international students at
Michigan State University will differ by
nationality.

This hypothesis was not supported. There were no mean

differences in severity of symptoms by country of origin.

57

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58

This was determined by analysis of the confidence intervals
of the means. All the confidence intervals
overlappedindicating no significant differences among all
the countries in response patterns (Table 4).

Hypothesis 4.3: Mean frequency of skin symptoms

as reported by graduate international students at

Michigan State University will differ by

nationality.

This hypothesis was supported. There was a significant
difference in mean number of skin symptoms by country of
origin. Analysis of the confidence intervals of the means
indicated that Canada significantly differed from Taiwan,
Japan, Indonesia, and India. Korea also differed
significantly from Taiwan, Indonesia, and India on mean
number of symptoms but overlapped with Canada indicating
more similarity with that country by response patterns.
Countries showing most similarity in response pattern were
Taiwan, Indonesia, and India (Table 5).

Hypothesis 4.4: Severity of skin symptoms as
reported by graduate international students at
Michigan State University will differ by
nationality.

This hypothesis was supported. Analysis of the
confidence interval indicated that Canadians differed
significantly from most other countries except Korea and

Turkey on mean severity of skin symptoms. Countries

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62
indicating most similarity of response patterns were Taiwan,
Indonesia, and India (Table 6).
Summary

In this chapter, a detailed analysis of the mean
frequencies and mean severity scores of the subscales of the
Somatic Symptom Instruments were compared across the groups
of interest. Types, frequency, and severity of physical
symptoms were presented.

New graduate international students to MSU campus have
higher numbers and increased severity of skin symptoms but
no higher cold symptom frequency or severity.

International students with a roommate or a spouse have
a greater number and more severe skin problems than those
without a roommate or a spouse. However, presence or
absence of spouse or roommate does not seem to have an
effect on cold symptoms.

Mean frequency of cold symptoms differed significantly
by country of origin with China scoring the lowest mean
number of symptoms. However, country of origin did not seem
to be related to cold symptom severity.

Mean frequency and severity of skin symptoms differed by
country of origin. Canada differed from all other countries

with the lowest mean number and severity of symptoms.

Chapter VI
SUMMARY INTERPRETATION AND CONCLUSIONS
Overview

In this chapter, a summary of the study results is
presented. This summary and interpretation includes a
discussion of the study results as it pertains to the
variables of student type, living arrangements, and
nationality in conjunction with application of Roy's
Adaptation Theory. Findings for the research questions are
discussed within the context of previous related research.
Limitations of the study are addressed and implications of
the study for advanced nursing practice, nursing education,
and nursing research are presented.

The significance of the problem of student retention on
university campuses with a focus on international students
as having significantly more health problems than the
domestic student population was addressed. There is a
paucity of intercultural nursing research. Much needs to be
learned about the actual problems in the adjustment process
and the effects which the international students actually
experience. Most of the studies attempt to measure or
predict this process and its effects on the international
students in some way. The purpose of this study was a
descriptive analysis of the types, frequency, and severity
of common physical symptoms the international students

reported within a specific time frame and determining if a

63

64
relationship existed with the variables of type of student,
nationality, and living arrangements.
Summary and Discussion of Findings

With factor analysis of the Somatic Symptom Instrument,
two separate scales emerged: 1) the Cold Symptom Scale
consisting of four symptoms (cold, chest pain/cough, sore
throat, and headache); and 2) the Skin Symptom Scale
consisting of five symptoms (nosebleeds, dry skin/scalp,
loss of hair, skin rash, and acne). These scales were the
dependent variables in subsequent analysis using one-way
ANOVA with the independent variables of student type, living
arrangements, and nationality.

The remainder of symptoms consisted of eleven
heterogenous symptoms which did not show high inter-item
correlation with each other. This list of other symptoms
consisting of the symptoms (cold sores, joint pains, itchy
eyes, abdominal pain, constipation, diarrhea, nausea,
unusual fatigue, fever of unknown etiology, and accidents)
were descriptively analyzed. Frequencies, percents, and
means of the total numbers of frequencies and severity of
symptoms were computed.

This researcher was surprised that most of the symptoms
did not form other sub-scales. Conceptually, many of the
symptoms may occur together such as the gastrointestinal
symptoms. The respondents did not answer in that way.

Perhaps the results would have been different if a

65
homogeneous sample were used or a greater sample response
were generated.

Most of the symptom severity for all symptoms were
listed as mild, approximately one-third were listed as
moderate with less than ten percent listed as severe. It is
not known whether the students seek aid for the these
symptoms or if these symptoms are represented in increased
frequency among the international populations in general.

Several explanations could be offered for the general
frequency and severity of symptoms in this list. First, the
symptoms were scored as relatively mild. In young, healthy
individuals, severe disease is rare. Secondly, in young
individuals, one also does not usually see well-developed
disease processes as among an older population so symptoms
may occur in an isolated manner. Most respondents in this
study were 24-28 years of age. Also, the international
students must be healthy in order to be able to study in the
United States. Most respondents reported no prior existing
diseases and may, in fact, be more disease-resistent based
on the selection process.

Mime

There was no statistical mean difference between new
students and returning students on the cold symptom scale.
This researcher would have expected that new students,
because of the adjustment process and new environment, might

have experienced and reported an increase in frequency and

66
severity of symptoms in this category. This was not shown
to be true in this study.

For the skin symptom scale, results were statistically
significant both in symptom frequency and severity. New
students showed both a higher frequency and increased
severity of skin symptoms than did the returning students.
Climate, environment, as well as different skin product
availability in addition to the changes involved in the
adaptation process, may account for these results. This
finding could support the hypothesis that the adaptation
process affects physical health with new students
experiencing significantly more skin symptoms with increased
severity than the returning students. It remains unknown
exactly which factors in the adjustment process can be
attributed to this result.

Living Arrangements

Those respondents with no roommate had significantly
fewer numbers of skin symptoms and significantly less
severity of skin symptoms. Lower stress from not having to
share living space as well as fewer routes of infection may
account for this finding. However, with analysis of the
cold symptom scale, no difference emerged between those two
groups regarding frequency or severity of cold symptoms.

Those respondents who indicated living with spouse had
significantly few skin symptoms and significantly less
severity of skin symptoms. No difference was found between

the two groups in the cold symptom scale. Being married

67
lends credibility to the hypothesis that married students
report few physical symptoms in some categories and less
severity of symptoms than non-married students. Decreased
stress among married students with a greater social support
system could be plausible reasons for this finding.

Another possible reason for this finding may be that the
question gathering demographic data was somewhat vague.
Hence, having no roommate but having a spouse may not be
mutually exclusive and lend to the results as noted.
M1121

For the cold symptom scale, the mean number of symptoms
was significantly differentby country of origin. Students
from China indicated significantly lower mean number of cold
symptoms and differed significantly in this manner from the
other countries. This researcher has no explanation for
these findings.

In the skin symptom scale, Canadians differed
significantly from students from Taiwan, Japan, Indonesia,
and India with lower mean numbers of symptoms. Students
from Korea differed significantly from students from Taiwan,
Indonesia, and India with lower mean number of symptoms but
overlapped with students from Canada indicating more
similarity with that country. With mean severity of skin
symptoms, Canadians again differed significantly from most
other countries with low mean symptom severity and no
overlap of confidence interval of the mean. Countries

indicating most similarity of response patterns were Taiwan,

68
Indonesia, and India. The other groups indicated
overlapping confidence intervals and were more similar in
their responses. However, the small numbers of respondents
from some of these countries may have affected analysis.
Wide generalizations cannot be made to the entire student
population from those countries based on these findings from
a small sample response.

A plausible explanation for the low occurrences of
symptoms in this category by Canadians may be that Canadians
experience climate, food, and culture similar to the
Michigan State University environment and may have developed
immunity to the many viruses present in the new environment.
The same cannot be said for Koreans. This researcher cannot
account for those patterns of symptom clusters, but only
asked about isolated symptoms.

Several explanations could be offered for the
differences in frequencies and severity of symptoms among
the various nationalities. Perhaps the students from those
countries indicating higher mean ranges found the adaptation
process more difficult due to greater cultural differences.
The increased number of cold symptoms among students from
different countries may indicate lack of exposure to the
various viruses on previous occasions as Michigan cold and
flu season were at their height prior to and during data
collection. Students may also have felt more pressure from
the holiday season for final exams, also occurring during

the three month time period previous to data collection.

69
This researcher cannot generalize that these findings
represent a problem with adaptation. In fact, with the
relative severity of most symptoms reported listed as mild,
adaptation does not seem to be an issue.

Ebbin & Blankenship (1986) found respiratory symptoms
such as chest pain and cough to be increased among
international students as compared to the domestic student
population but they did not do an analysis by nationality.
They also found the common cold or sore throat as being of
lower incidence in international students. Allen (1986)
found that respiratory problems constituted a full 50
percent of clinic visits of Asian students in Asia and 32
percent of the clinic visits for international students in
Australia as compared to 19 percent of Australian students
in Australia. This researcher also found significant
differences among the various groups with regard to
frequency of cold symptoms. But, as this researcher did not
conduct a research design to contrast the international
students from domestic students, general conclusions that
these symptoms constitute a problem cannot be generated.

Ebbin & Blankenship (1986) also found higher incidence
of dandruff, dry skin, hair loss, and some skin rashes among
international students as compared to domestic students.
They posited that some of these symptoms may be stress-
related. This researcher found significant differences in
numbers and severity of similar skin symptoms among the

various groups analyzed but, as this research design did not

70
compare international and domestic students, a
generalization cannot be made except that skin symptoms were
significantly different among different groups.
Implications f0; gnanggs in Bgy's Ingony gf Adantatign

The mean number of symptoms reported by the respondents
was relatively low and most were mild in nature and did not
represent full-blown disease entities. Obviously, these
students have had to adapt to the university setting and yet
the physical manifestations as measured by this study did
not reveal maladaptation or illness. This may represent a
significant modification in Roy's theory. The
interpretation of maladaptation as illness seems to promote
the idea that an individual is either healthy or ill. -This
study seems to promote the idea of a health-illness
continuum with mild changes or physical annoyances not
equalling "illness" in true physiologic sense. Physical
symptoms in themselves can be adaptive to alert the person
to problems that may exist. Hence, a less healthy or more
healthy outcome may be the outcome of adaptation for certain
age groups of the population.

See Figure 2 for change in nursing model from that
presented in Chapter II as proposed by this researcher. The
fact that the physical symptoms were mostly mild and that
students scored relatively few numbers of symptoms may
indicate that these graduate international students did not
experience a negative adjustment process which adversely

affected their health as originally depicted in most of the

71

 

 

 

 

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72
literature. Previous researchers, in using a comparative
analysis between international and domestic students,
differed from this researcher in their approach to the
independent variables. This study provides a different view
of the international student experience from that usually
depicted in the literature by comparing different groups of
international students instead of contrasting domestic
versus international students. The MSU campus may also be
providing very adequately for these students' total needs
which reflected in relatively good health for at least 15
percent of the international population who were eligible
for the study. Another reason may be that the selection
process of these graduate students was fairly rigorous with
only those very healthy individuals being selected for
overseas study by their respective governments.
Implications for Practice

Universities must provide international students with a
program oriented toward their specific needs. Staff well-
trained in the cultural differences of international
students and health care staff well-grained in transcultural
health care methods are only the core elements to a
successful international student program. Also_necessary

are orientation programs which include wellness promotion,

 

 

 

 

 

stress management strategies, cultural learning, and coping

1—

 

W

skills development. Activities which respond to student's

 

needs may provide informal means of social support to the

students and their families. Formal support staff in the

73
form of social workers, the Family Clinical Nurse Specialist
and other transcultural practitioners would assist the
international students and their families through the
adaptation process and throughout their entire stay. All
these factors are important to the international programs'
success at attracting and maintaining its international
population.

The Family Clinical Nurse Specialist, in almost any
setting, will be caring for individuals from different
cultures. If the practice is located on or near a
university setting with an international student body, a
philosophy of transcultural nursing is essential if the FCNS
is to provide quality care and meet the needs of various
minority populations. Leininger (1984) posits that the
purpose of transcultural nursing is to improve and advance
the quality of care to people through the deliberate use of
transcultural differences between Koreans and the other
countries.

Due to the relative paucity of symptomatology generated
through this study, specific interventions are limited to
wellness interventions. In the educator role on campus, the
FCNS may present a seminar of the study results to the
personnel of the International Students and Scholars Office
and Michigan State University student health care services.
If the international students experience few mild symptoms,

it may be unlikely that the FCNS or student health service

 

will see them in clinical practice. The FCNS may facilitate

 

74

international health and wellness by presenting information

 

 

 

“mu—Ir .‘M
~e.__..-~_ \,,-A,,__.,,...w-~-.~—~v

'WM‘F‘

to the studentgwduring their orientation programs. The FCNS

t“

may suggest ways to assist the international student to

 

manipulate the environment to his/her advantage--that is,
better health and wellness. asses or written information
on nutrition, wellness, the advantages of exercise,

“——““*’* ~_.____.
identification and treatment of common health care problems
such as colds, skin care problems may be presented or
developed by the FCNS or student health care service
personnel. New graduate international students can be
assured that, although they may experience physical
annoyances such as colds or skin problems, they are usually
few in number, transient and mild in nature.

In the clinician role, the FCNS may encounter students
from various cultures presenting with physical symptoms of
illness common to their age and living arrangements. An
intercultural perspective is important especially during the
assessment phase of treatment as the FCNS may be able to
determine if other issues are contributing to the symptoms
of the client. Since most students reported few physical
symptoms and mostly mild symptom severity, special attention
should be given to those students who present with severe
physical complaints.

Many universities are instituting programs to assist
their international students to cope with the adjustment

process. The FCNS, in the researcher role, may be in a

position of leadership in the Student Health Center to set

75
up these programs where needed or give input into their
development. A system could be set up whereby the student
health center could identify international students by
country of origin and code their symptoms or diagnoses.
Comparison could then be made of frequencies of clinic
visits and diagnoses of the international students with the
domestic student populations. At risk students could then
be identified and sought out if presenting problems
indicated cause for concern about adjustment problems.
Further Research

This study does not answer many questions as to how the
adaptation process affects the international students in
general. For the most part, there were low mean numbers of
symptoms and mild symptom severity scores. These results
indicated that few physical problems actually occurred, at
least in the respondents who answered the questionnaires.
But, physical symptoms are only a small part of the
adjustment process. As most of the students reported the
symptoms as mild if they reported symptoms at all, one would
wonder if the questionnaire gave the students enough time to
develop symptoms. Was the three month time limit enough
time to develop symptoms or should it have been a longer
time limit such as six months? Perhaps a longitudinal
design following the student through the school year at
various points would yield more conclusive results. Also,

the questions asked in the questionnaire may not have

76
reflected the most important issues to the international
students.

This study raises other questions for further research.
Since student retention seems to be an issue in the
literature, this researcher would like to know the principal
reasons for early return home or incomplete course of study
at MSU. Are medical problems a major problem for
international student retention? Are exit interviews
conducted to determine the problems encountered at MSU?

What international students by nationality frequent the
health center most often? How do diagnoses and treatment
differ among the international student population as
compared to the indigenous student population. Is there a
transcultural health perspective among the health
professionals or is the treatment ethnocentrically western-
oriented? Since many international students are married
with children, what support staff does MSU have to care for
their needs? Perhaps a questionnaire asking them the nature
of their needs may reveal areas that are lacking with the
present system.

Limitations

A limit for generalization of findings to the
international student population is the relatively small
number of responses from some countries which may have
affected statistical analysis. There is no way to determine

if only the students reporting the most symptoms or even the

77

fewest answered the questionnaire or if the results
represented the general international student population.

Another major limitation was the fact that so much
information gathered by the questionnaire regarding the
other symptoms could not be analyzed as originally
anticipated. Also, the researcher did not ask the
respondent to identify nursing knowledge focused on
different cultures of the world with their own particular
health care needs. A knowledge and use of cultural values,
beliefs, and practices of different cultural groups can make
a difference in client satisfactions, improve health
promotion, and help clients recover more quickly from
illnesses or disabilities.

Summary

This study was an attempt to identify types, frequency,
and severity of physical symptoms among graduate
international students at Michigan State University.
Variables of student type, living arrangements and
nationality were analyzed to determine if a relationship
existed between different groups. A research instrument
newly formulated was used for this study. As a result of
factor analysis, only ten of the twenty-five symptoms listed
were able to be analyzed. The other symptoms had either
very few responses or were too varied in response pattern
for subscales to be produced. Hence, much information was

not used in statistical analysis.

78

However, some interesting results emerged. Contrary to
popular belief as written in the literature, the adaptation
process did not appear to have much of an effect regarding
physical symptoms on this particular group of students.
Most of the physical symptoms were listed as mild and
relatively few numbers of symptoms were reported. So it
would seem that, even though new students exhibited more
symptoms and slightly higher severity of symptoms, the
symptoms were basically minor annoyances about which it is
questionable if the students would seek outside aid to
manage.

Living arrangements showed that married students had few
numbers and severity of physical symptoms, especially skin
symptoms. Those with no roommate showed the similar
results.

Nationality does make a difference in frequency and
severity of physical symptoms. The students from China
showed fewest cold symptoms and differed significantly from
the other countries in this manner. The countries were more
similar in response pattern in the cold severity scale.
Canadians and Koreans differ significantly from the other
countries with low mean numbers and severity of skin
symptoms.

It is evident that more research is necessary to
determine the physical as well as emotional effects the
adaptation process has on individuals. Many researchers

portray the adaptation process in negative ways. In this

79
study, adaptation had few effects on types, frequency, and
severity of physical symptoms among the graduate

international student population at Michigan State

University.

LIST 01' REFERENCES

LIST 0! REFERENCES

Adelman, M. (1988). Cross-cultural Adjustment: a

theoretical perspective on Social Support.

InLerasti2nal_lQurnal_2f_Intsrsultural_fislatign§- 12:
183-204.

Adler, P. (1975). The Transitional Experience: An
alternative view of culture shock. o of

uma ’s c s cho . 5, 13-25.

Akka, R. (1967). The Middle Eastern Student on the American

Campus. 12urnal_2f_Amerisan_ggllsgs_nsalth
Assgciation. 5;, 251-254.
Albrecht, T.L. & Adelman, M.B. (1984). Social Support and

Life Stress: New directions for communication

research. flBEa2.92EEEDiQQEiQE_B§§§é£_h- 11. 3-32-
Allen, F.C. & Cole, J. (1987). Foreign Student Syndrome:

Fact or Fable? EQBIDQl_2i_AE§£12§n_§Qll§Q§_H§§l£h-
g5, 182-185.

Befus, C. (1988). A Multilevel Treatment Approach for

Culture Shock Experienced by Sojourners. International
J2urnal_2f_Intszsultural_zelatign§- 12. 381-400-

80

81
Berry, E., Kessler, J., Fodor, J., Wato, M. (1983).

Intercultural Communication for Health Personnel.

ernat'o Journa of I te c t ' ns. 1,
377-392.

Blom, A. (1986). International Students and Foreign
Travel. Jgurng; of Ameticgn Cgllgge flealt . 14(4),
175-176.

Bochner, 8. (Ed.) (1981). a ' n: 'd e
Between Culturgs. C.K. Hill Co: Boston, Mass.

Church, A. (1982). Sojourn Adjustment. Egygnglggignl
Bglletin. g;(3), 540-572.

Dimarco, N. (1974). Stress and Adaptation in Cross-
cultural Transition. Psygnologicgl gengzts. ;§. 279-
285.

Ebbin, A. & Blankenship, E. (1986). A Longitudinal Health
Care Study: International versus Domestic Students.
l22rnal_2f_Amsrisan_§21lsgs_flsalth- 25(4). 177-182-

Fisher, M. (1985). A Comprehensive Wellness Program for
International Students. ERIC #ED 279940.

Garza-Guerrero, A. (1974). Culture Shock: Its mourning
and the vicissitudes of Identity. annng1_gfi_tng

e 'c c ana s oc' 'on. 22, 408-429.

Hammer, M. (1987). Behavioral Dimensions of Intercultural

Effectiveness: a Replication and Extension..

InLsrnati2nal_l2urnal_2f_Intsrsultural_aelatigns- 11.
65-88.

82

Hill, L., Smith, N. & Jasmin, S. (1981). Modularized

Stress Management for Reduction of Predicted Illness.
u e o s o ' . at,
69-74.

Jammaz, A. (1972). Saudi Students in the United States: A
Study of Their Adjustment Problems. Doctoral
Dissertation, Michigan State University.

Kwok, S. (1982). Culture Conflict: A study of the
Problems of Chinese Immigrant Adolescents in Canada.
Ina Canadian Nutsa. March, 32-39.

Leininger, M. (1977). Culturological Assessment Domains
for Nursing Practice. In Leininger (ed.),
Transcuitural Nursing gangepta, Ihegtiea ang Ezagticea.
John Wiley & Sons: New York.

Leininger, M. (1984). Transcultural Nursing: An essential
knowledge and practice field for today. Qanagian
Nataa. December, 41-45.

Locke, S. & Feinsod, F. (1982). Culture Shock and the
Foreign Student. agaiaaaanaa. at, 817-819.

Nishio, K. & Bilmes, M. (1986). Psychotherapy with
Southeast Asian-American Clients. olo
Bulletin- 195. 342-345.

Oberg, K. (1960). Culture Shock: Adjustment to New

Cultural Environments. Brastisal_Anthrgnglsgxo 1.
177-182.

83
Padilla, A., Cervantes, R., Maldanado, M., Garcia, R.
(1988). Coping Responses to Psychological Stressors
among Mexican and Central American Immigrants. Jgurnai
Q£_QQEEEDLEX_E§XQQQAQQ¥- 16. 418-427-
Polit, D., Hungler, B. (1987). Nursing gasaatgn;

c a e od . J.B. Lippincott & Co.:
Philadelphia.
Roy, C. (1986). Essentiaia at the Boy agaptation Modei.

Appleton-Century-Crofts: London.

Sennhauser, S. (1985). Psychosocial Nursing Intervention:
A vehicle for the prevention of illness among
international students. 1ntatnatianai_flntaing_gagiag.
;;(6), 176-177.

Shepard, N. (1970). The Acculturation of Foreign Students
in Southern Colleges and Universities. Doctoral
Dissertation, University of Mississippi.

Tripp-Reimer, T. (1984). Cultural Assessment: content and
process. Nutsing Outloo . ;2(2), 78-82.

Ward, L. (1962)._ Some Observations of the Underlying

Dynamics of Conflict in foreign Students. gantna1_gt
Anatiaan Coiiega neaitn Association. i9, 430-440.

APPENDIX A

Sample Letter

MICHIGAN STATE. UNIVERSITY

 

COLLEGE Of VL'SQNG EAST MNSING 0 MICHIGAN 0 «lie-UH

Dear

This survey is designed to determine how physical symptoms
affect international students in general. The study is en-
dorsed by the office of International Students and Scholars
and the Organization of Students Health Care personnel at
Michigan State University.

I have mailed a questionnaire.to you asking about physical
symptoms you may have experienced within the past three
months. By answering the questions on the form. you will be
participating in a study that may help to stay healthy.

You are under no obligation to participate in this study.
You indicate your voluntary agreement to participate by com-
pleting and returning this questionnaire. A code number has
been assigned to your questionnaire. Only this researcher
will have access to the number coding system. You will not
be identified in any way by name in any report of study re-
sults. -

The questionnaire will take approximately ten minutes to
complete. Please mail completed questionnaire in the en-
closed self-addressed envelope no later than three weeks from
now. A phone call or another form will be sent as follow-up
if this first form is not received. You may also bring this
completed form into the International Office for Students and
Scholars. The secretary will keep the form for me.

iééz' 2 {16242427
Delores Rustic: RNFNP

3095 Raymond

Saginaw, MI 48601

1-517-777-7064

 

84

MS! I o": . Allm Ana-tau! We..." lama-o

APPENDIX 3

Human Subjects Letter

MICHIGAN STATE UNIVERSITY

 

OMOIWCIWFOIIBEAICM WWemeM‘gu
AND DEAN 0! 11¢ GIAOUAI'I $0.00!.
November 12, I990

Dolores L. Rustic
3095 Ramond Drive
Saginaw. MI 48601

RE: A STUDY OF SOHATIC SYMPTOHOTOLOGY: OCCURRENCE AND SEVERITY AS REPOHED
BY INTERNATIONAL GRADUATE STUDENT POPULATION AT XICRICAN STATE -
UNIVERSITY, IRE! 90-656

Dear Ms. Rustic:

The above project is exempt from full UCRIHS review. I have reviewed the
proposed research protocol and find that the rights and welfare of hunsn
subjects appear to be protected. You have approval to conduct the research.

You are reminded that UCRIHS approval is valid for one calendar year. If you
plan to continue this project beyond one year. please make provisions for
obtaining appropriate UCRIHS approval one month prior to November 12. 1991.

Any changes in procedures involving human subjects must be reviewed by the
061138 prior to initiation of the change. can: nust also be notified
promptly of any problems (unexpected side effects. complaints. etc.) involving
human subjects during the course of the work.

Thankyou for bringing this project to our attention. If we can be of any
future help. please do not hesitate to let us know. ' '

Sincerely.

. - ."q
ma 1:. Wright. 25.8:
cant. ucams V

DEW! doe
cc: Dr. Rachel Schiffman

85

 

APPENDIX C

Somatic Symptom Scale

SOMATIC SYMPTOM SCALE

If you have experienced any of the symptoms listed below within the pastthree months, place a mark under
"Yes" or "No" column. If you have marked ”yes" in the symptom column, also place a mark under the

column which best describes how severe the symptom is to you.

 

 

 

Symptom Severity
In the past three months I have experienced: Yes No Mild Moderate Severe
Cold
Nosebleeds

 

Sore throat

 

Chest pain/cough

 

Cold Sores

 

Joint pains

 

Low back pain

 

Dry flaky skin or scalp

 

Loss of hair

 

. Skin rash (various kinds)

 

Acne, worsening of normal skin

 

Itchy, watery red eyes

 

. Abdominal pain

 

Hard bowel movements

 

Loose bowel movements

 

Nausea (upset stomach)

 

Unusual fatigue (tiredness)

 

Unusual discharge from penis or vagina

 

Painful urination

 

Inability to get to sleep or stay asleep (insomnia)

 

Headache

 

Fever for unknown reasons

 

. Accidents

 

NMNNN—A—L—a—L—L—A—L-J—A—A
ewpepgoooNanewN-OSDFDNQ’WPWNT‘

. A. Females answer the following question:
Increased pain, cramps with menstrual
cycles, lack of menses

 

24. B. Males answer the following question:
Impotence, sexual dysfunction

 

 

25. Other (specify)

 

 

 

 

 

 

 

 

 

 

Please fill out this form completely and return it by to the Office of International
Students and Scholars in the International building of Michigan State University.

Age Sex M F Country of Origin

 

Type of Visa Date of entry to the U.S. / /

Date of arrival to MSU. / /

Have you lived in another city in the U.S. before coming to East Lansing? Yes No

If yes, list all locations by City

 

Where do you currently live? Class Level
Residents Hall Undergraduate
Campus apartments Graduate

Off-campus housing

Who lives with you? Check all that apply:
_ Roommate, no relation
_ Spouse
__ Children
_ If with children, how many?
List ages
_ I live alone
__ Other (Comment)

Before coming to the United States, were you ever told you had any of the following conditions:
Yes No

TB

Diabetes

Heart Disease or Murmur

Allergies to food, medicine, seasonal

Seizure disorder

Asthma

Stomach Ulcer

Arthritis

Kidney problems ID #

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