A needs assessment: a study of perceived need for student health services by Chinese international students.
The authors would like to thank Yasushi Onodera, Director of International and Multicultural Student Services Arkansas Tech University (ATU) for supporting this project; Earnest Yang, Academic Advisor (ATU) for translation services; Peng "Jack" Feng, undergraduate student in the Department of Nursing (ATU) who served as research assistant for one semester; and ATU Department of Nursing for publication support.
The rise in international students on college campuses will require accurate assessment and intervention to provide appropriate student health care services. The number of international students on college campuses in the United States (U.S.) continues to rise (Institute of International Education, 2010; Lewin, 2010). International students "... enrich the campus community and expand our intellectual, ethnic, and cultural experiences" (Carr, Koymama, & Thiagarajan, 2003, p. 131). According to the Institute of International Education, the number of international students in the U.S. rose 3% to 690,923 during the 2009/2010 academic year. "This year's growth was primarily driven by a 23% increase in Chinese student enrollment in the United States to a total of nearly 160,000 students, or more than 18% of the total international student population, making China the leading sending country" (Institute of International Education, 2010, p. 1; Mellman, 2011). The Chinese international student represents a rise in the middle class in China. These students are able to pay full tuition (Bartlett & Fischer, 2012) to universities that have taken a hit in other areas during hard economic times. The increase in international students on college campuses is an important consideration for university administrators, student health service providers, as well as primary care providers in the community.
Working with personnel in the office of International & Multicultural Student Services (IMSS) at Arkansas Tech University, China was identified as the largest group of international students on campus. Institutional Research for Arkansas Tech University groups Asian with Pacific Islander for student demographic purposes. The number of Asian/ Pacific Islander students rose from 65 enrolled in the fall of 2006 to 137 enrolled in the fall of 2011 (Institution Research, 2011). The director of IMSS provided the fall enrollment for Chinese students as 134 and Taiwan 14 (Onodera, 2011). The health care concerns identified by IMSS personnel included; a lack of education on how to care for self, overuse of the emergency department, and lack of education about how their body works including reproductive health. Working with the director of IMSS allowed a firsthand glimpse into the life of the international student on campus. Participation in the mandatory orientation program for all new international students allowed an opportunity to see what type of information the student is receiving about health and wellness and the services that are available to them on campus and in the community.
Review of the Literature
Chinese students bring with them a set of beliefs and values that can cause stress for the student (Yan & Berliner, 2009) and also challenges for university faculty and staff. There have been several studies devoted to the emotional health of the Chinese student (Yan & Berliner, 2009; Wei, Heppner, Mallen, Ku, Liao, & Wu, 2007), but little attention has been focused on their physiological health care needs.
Yan & Berliner (2009) reported in their qualitative study, which looked specifically at the Chinese international student, that the background and culture alone produce more challenges for them in the U.S. The researchers identified three categories of stressors; language, achievement, and interaction with faculty. Topics concerning health did emerge during the interviews. For instance, one student reported he never smoked in China but now smokes heavily to assist with coping and academic stress. Another student reported problems with sleep secondary to stress.
Thomson, Rosenthal and Russell (2007) found that international students attending school in Australia under-utilized health and counseling services. Their research included a sample size of 6,828 international students of which 22.9% reported their country of origin as China. When looking at failure of use of the available health services, reasons reported included the student did not know the problem was important, lack of information about health services including its existence, location, appointment procedures and absence of fees. The authors reported, "About 30% of students gave reasons that could relate to cultural differences and challenges: the feeling of discomfort, the concern about being understood, and doubt that the service would be able to help them" (p. 68). The researchers also found that students from non-Asian countries were more likely to seek help when needed; "... being a student from People's Republic of China was a significant predictor of not acting on a perceived need for help from the health services" (p. 72).
McLachlan and Justice (2009) conducted a study at a private university in southwestern United States of 20 international students from Africa, Asia, Europe, and South America. The researchers found that the first 6-12 months of the students life in the United States were the most challenging with 20% of the participants reporting "... serious health problems during their first six to twelve months of living in the U.S." (p. 31). In their study, problems with adjustment of the international student emerged that can result in negative implications for overall health. One subject reported "... eating one meal a day and sleeping four hours per night on a good day" (p. 29).
Poyrazil and Grahame (2007) examined the adjustment needs of international students utilizing focus groups. They found that international students are more in need of help during initial transition to life in the U.S. and that there are many barriers to successful adjustment. Problems with the healthcare system were reported by the subjects but appeared to be more of a concern later versus initially.
C. Msengi, I. Msengi, Harris and Hopson (2011) conducted a study utilizing international students that looked at the health status and physical health of international students at American universities "to gain a better understanding of the ways in which life in the US had impacted international students' health behaviors, wellness levels, and overall health" (p. 62). The researchers found that the overall health of the international student declined after coming to the U.S. with a positive correlation between the length of time in the U.S. and reported decline in overall health. "Females statistically scored lower in their overall health status after coming to the U.S. compared to males" (pg. 72). The researchers found a change in diet, quality of sleep, and lack of time for leisure activity as contributing factors in the decline of health.
Lartey, Mishra, Odonwodo, Chitalu and Chafatelli (2009) conducted a study involving all international students enrolled in courses at Western Kentucky University. Seventy-five percent of the participants in the survey reported their area of origin as Asia. "On the use of health care services, 56% reported not to have used any of the services within the past year ..." (p. 134). In particular, lack of understanding of cultural practices was identified as a barrier to using health care services for international students from Africa and Asia.
"Assessing and understanding the health needs and capacities of college students is paramount to creating healthy campus communities" (The American College Health Association, 2008, p. 469). Prescott (2011) stated "Some have argued that student health services not only help the individual student, they can actually improve an institution's bottom line by enhancing student retention" (p. 468).
Grace (1997, p. 244) reported, "Minority students, international students, and students with spouses and families represent an increasing proportion of the college population". The change in demographics is just one of many factors which must be taken into consideration when planning the health care services for the university campus.
Sadler (2005) cited the importance of student health services, including the students' inability to take complete responsibility for their own health care and Grace (1997) reported that delay of treatment on the students' part which results in an immediate need for health care when required. With the range of potential health problems which could present at student health services, it is important that health service providers identify and prepare for the unique needs of the international student.
The purpose of this Doctorate in Nursing Practice (DNP) project is to identify the unique health related needs of the Chinese international student in the United States. In addition, it is the intent of this investigator to identify barriers to utilization of the available health care services on the university campus. The findings from this needs assessment will be shared with the head of the IMSS to work towards meeting the unique needs of this vulnerable population.
This needs assessment took place on a university campus in Arkansas which had an overall enrollment of 8864 students on the main campus during the fall of 2011 (Institution Research, 2011) with 351 international students of which 148 declared China or Taiwan as their home country (Onodera, Y., 2011). The study design is a needs assessment utilizing a survey approach. A needs assessment is a "... systematic method of identifying unmet health and healthcare needs of a population and making changes to meet those unmet needs" (Wright, Williams, & Wilkinson, 1998). The survey was developed and administered utilizing the Qualtrics survey system. The survey was developed specifically for this project based on a review of literature and working with personnel in the IMSS. The survey was reviewed by a Chinese international student who is employed in the IMSS to identify any changes that needed to be made based on literal translation of language. The survey was translated to Mandarin by the same student.
The survey was reviewed a second time by a faculty member from the English as a Second Language (ESL) Department who works directly with the Chinese international students. Additional changes in word use were made based on that review. The survey was available to the study participants in English and Mandarin. Prior to making the survey available to the students in the fall of 2011, the translated form of the survey was reviewed by four Chinese international students to ensure proper translation. The international students read the survey questions aloud to the researcher to identify any mistakes in translation. Some characters where changed based on this process. A final check of the translated survey was made by the ESL faculty member. Data is reported utilizing descriptive statistics.
The sample was a convenience sample. The subjects (N=148) were identified by marking China (96%) or Taiwan (4%) as their country of origin on their university application. Chinese/Taiwanese students were the only international students that were included in this study. All subjects were enrolled as either an undergraduate (83%) or graduate (17%) student on the main campus of the university. The subjects were both male (43%) and female (57%) with an average age of 20.66 years. Health status of the subjects met requirements set forth by the United States government to enter the U.S. on a student Visa. In order to participate, the subjects were accepted to the university and participated in the mandatory university orientation program that is conducted by personnel from the IMSS office for all new international students.
Forty-five percent of the students reported years on campus as one, 12% two, 7% three, 10% four and 6% five or more years. Top majors reported were management/marketing, emergency management, economics and finance, teaching English as a Second Language and hospitality. Primary language reported was Chinese (64%), Chinese/English (21%), and Chinese/Japanese (1%). Not all subjects listed their primary language on the demographic portion of the survey. Years of education prior to arrival in the U.S. were less than 12 years (7%), 12-15 years (61%), and over 15 years (32%). Translators from the English as a Second Language (ESL) program were available to assist the student during the survey. Thirty-four percent of the students reported using a translator during the survey.
The subjects were recruited though the IMSS. A list of student emails belonging to the 148 Chinese/Taiwanese students was supplied to the researcher and entered into the Qualtrics survey system. University email information is available to all students and faculty on campus and is not considered confidential information. The computer survey system supplied each subject a number to keep the responses anonymous. There were no identified risks for participating in this study. There were no incentives offered for completing the survey. After full IRB approval from Union University (home to the DNP student) and Arkansas Tech University (where the research took place), the survey opened with an invitation to the students on October 1, 2011. The first page of the survey was the informed consent (in both Mandarin and English). Privacy was maintained by not utilizing any identifying information during data collection. During the survey, participants were provided a participant number and all data was recorded utilizing that number. Electronic data was protected through password protection on the primary computer of the investigator. All data was collected and maintained utilizing the Qualtrics survey system. Three scheduled reminders were sent by the researcher over the course of the two months that the survey was open utilizing the Qualtrics system. One email reminder was sent by the head of IMSS which resulted in an increase in subject participation. An instructor in the English as a Second Language department assisted students during her course to open and complete the survey if translation was needed.
The Qualtrics survey system allowed for question logic, meaning not every participant received all of the available questions. Total surveys started were 91 out of 148 (61%). Completed surveys were 74 which equaled an 81% completion rate (see Table 1 for Questionnaire with response rates). A decision was made by the researcher to include all data regardless of completion status. The survey itself was not set to force a response to each question. The researcher felt that forced response would result in the subject stopping the survey if an inability to understand the question resulted or if the subject was concerned about confidentiality when answering questions of a sensitive nature.
The survey served three purposes. The first purpose was to determine how the students felt about their own health. This included how they describe their health prior to travel to the U.S., how often they thought about health and wellness, and who they felt was responsible for their health while attending school in the U.S. The second purpose was two determine what resources the students felt were important to have access to in order to stay healthy. This included availability of student health services (SHS), community resources, likelihood of attending on campus health information programs, and to determine what resources the students had used prior to completing the survey. The third purpose was to identify areas of concern with this special population of international students. Questions included; what types of risky behaviors they currently participate in (smoking, use of alcohol, unsafe sex), what they would do if faced with illness or injury while in the U.S., perceived barriers to utilization of health and wellness services (lack of transportation, fear of not being understood, inability to pay) and if there is a delay in seeking medical care when needed.
Feelings about own health
When asked how they would describe their overall health prior to arrival in the U.S., 50% reported excellent and 45% good. Five percent were "unsure". Sixty-one percent reported they had thought about how they would get medical care if needed after deciding to attend college in the US while 39% did not. Of the 61% who thought about healthcare in the U.S., 20% reported at least once weekly and 73% reported once or twice. When asked who they felt was responsible for their health care needs while in the U.S., 34% reported the university, 31% reported themselves, 14% reported an individual in the IMSS office, 3% their family, while 18% were unsure.
Utilization of services
When asked where they would find medical care if they became sick tomorrow (with sick being defined as cough, cold, fever) 77% reported student health services (SHS), 4% emergency department, and 9% a local clinic. Of those students who choose the answer SHS, 84% reported they knew where SHS was located while 16% did not. Forty-five percent reported not knowing what types of services are provided at SHS. Information about SHS is reviewed in detail during the mandatory international student orientation. Information includes location of SHS, the level of provider (which is currently an RN), and services provided (allergy injections, medical screening by RN with assistance in making appointment at local clinic if needed, and health/wellness information).
For those students who chose to go to the emergency department for services, 100% responded that they felt like the care in the emergency department would be better. When asked what they would do if they felt they had a medical emergency, 46% reported they would call 911, 34% would ask someone to take them to the emergency department while 17% chose call someone in the IMSS office. The other 3% choose the option of fill in the blank with responses of "call medical help line" and "go to the emergency room".
The students were questioned about utilization of community services during their stay in the U.S. Twenty-eight percent reported use of a local pharmacy, 25% a local clinic, 15% the emergency department, 10% the hospital, and 6% the health department. Forty-nine percent reported none of the above.
To determine what students felt they needed to stay healthy while in the U.S. (allowing the student to choose all that apply) eating healthy foods (91.67%) was the top answer. Other responses included exercising on a regular basis (79.17%), seeing a health care provider like a doctor or nurse, for a routine physical exam (44.44%), attending health-related education programs sponsored by SHS or IMSS (30.56%), taking vitamins or herbal remedies that are easy to find in their home country (27.78%), and being able to get over-the-counter medications (9.72%).
Only 6% of respondents reported being on prescribed medication. Fifty percent reported they would go to SHS to get more of the medication when needed. The other 50% reported that someone from home would mail the medication.
Twenty-four percent reported they had experienced a medical problem since arrival in the U.S. Fifty percent reported the medical problem as minor (defined as cough, cold or slight fever) while 50% reported the medical problem as severe (defined as injury, high fever, severe pain).
Seventy-one percent of respondents wanted more information on the types of services provided by SHS, 65% community services, 37% counseling services, 28% safe sex, 18% smoking cessation, and 3% help with partner abuse (defined as when a boyfriend or girlfriend physically hurts you).
Forty-five percent of respondents reported they would take advantage of health information programs on campus. An additional 34% reported they would be more likely to attend if the program was sponsored by the IMSS and specific to the Asian student. Twenty-one percent reported they would attend only if required for one of their courses. Forty-seven percent of respondents reported that having a full-service SHS (defined as staffed with a health care provider with prescriptive privileges, equipment to perform minor procedures like suturing a cut, lab, counseling services) as somewhat important (defined as "I thought about it but it did not change my decision on which college to attend"). Forty percent responded very important (defined as "I would rather be at a college with a full service SHS"), and 13% reported not important (defined as "This is not something that I looked at when deciding which college to attend").
Barriers to healthy lifestyle
Thirty-eight percent of students reported waiting one to two days to seek medical care when needed, 31% waiting more than two days, 19% sought care the same day, 6% waited more than one week and 6% chose other with a recorded response of "toothache but I did not go". If the student chose any response other than seeking care on the same day, they were asked to choose a response that best described why they waited to seek medical care. Forty-three percent chose the response "I thought the problem would go away on its own". Twenty-one percent tried to treat it with over-the-counter medications or herbal remedies, 14% did not have transportation, 7% felt medical care was expensive and they did not have the money and 7% were afraid that they would not be understood by the medical provider.
Eighteen percent reported currently drinking alcohol when they are with friends, 15% currently smoke, 9% have unprotected sex (which was defined as having sex without the use of a condom or other forms of birth control), 3% currently drink alcohol on a regular basis while none of the respondents reported use of medications that were not given to them by a doctor.
It is clear from past research involving the Chinese international student that they are a vulnerable population on the college campus. Research has shown that international students report declining health when studying abroad (C. Msengi, I. Msengi, Harris, & Hopson, 2011). The Chinese international student is less likely to utilize student health services (Lartey, Mishra, Odnwodo, Chitalu, & Chafatelli, 2009) even when there is a perceived need for medical attention (Thomson, Rosenthal, & Russell, 2006). From this needs assessment, it is noted that Chinese international students on our campus experience the same reluctance to utilize the available health services both on campus and in the surrounding community. With the majority of students waiting to seek medical care (81%), it is important for university healthcare providers to maintain an ongoing relationship with the IMSS to ensure that the Chinese international student is receiving the care they need. Maintaining an ongoing relationship and providing information in multiple information sessions versus a "one time" orientation has been reported in the literature (Misra & Castillo, 2004; Harju, Long, & Allred, 1998). With the daunting amount of information presented to international students upon arrival to the U.S., it is no wonder that presented information concerning healthcare services on campus and in the surrounding community is not something that the student is able to recall when needed.
From this needs assessment, it was determined that Chinese international students reported a desire for more health related information (44%) and an additional 34% of respondents reporting they would attend health and wellness information sessions if provided by the IMSS and if specific to the Chinese international student. It would be beneficial to students to allow SHS to partner with the IMSS to provide educational programs throughout the semester.
The Chinese international students who participated in this needs assessment provided valuable information on the type of information and resources they felt were necessary to remain healthy while in the U.S. This information can be utilized to prepare health related information sessions that are specific to the Chinese international student and presented in a format that allows for proper translation in a nonthreatening environment such as the IMSS office.
The survey was translated to Mandarin and presented to the student in both English and Mandarin. The translation appeared directly below the question and answers. Literal translation may have been different for respondents when attempting to read both the Mandarin and English translation. Some respondents utilized a translator from the English as a Second Language department to complete the survey (34%) while some respondents did not (66%). Interpreter training was not provided and translation could sway the answer chosen by the student.
The needs assessment was conducted utilizing a convenience sample. According to LoBiondo-Wood and Haber (2010) the ... "major disadvantage of a convenience sample is that the risk of bias is greater than in any other type of sample" (p. 226). The question must be asked, did the participants choose to complete the survey because they are more motivated to participate and if those who normally do not participate where included, would the data be different (LoBiondo-Wood & Haber)?
From this needs assessment, it is clear that the current orientation program could be improved to meet the needs of the Chinese international student. The current orientation includes information about student health services (SHS) including location and services provided. However, 16% of respondents reported they did not know where SHS is located and 45% reported that they did not know what services are provided.
There is also a strong connection between the Chinese international student and IMSS. Seventeen percent of respondents reported they would contact someone in IMSS if they had a medical emergency. Thirty-four percent of respondents reported they would attend a student health information program if it was sponsored by IMSS and specific to the Asian student.
The Chinese international students reported their overall health as good or excellent (95%) prior to their arrival to the U.S.; however, 24% of respondents reported experiencing a medical problem since their arrival to campus. The respondents provided information about topics they would like to receive more information which could be utilized by both the IMSS and SHS.
It is the opinion of this researcher that a working relationship between the IMSS and SHS is imperative to provide successful health care to the Chinese international student. Information related to health care services should be provided at the initial orientation and then provided again at additional sessions throughout the school year. Additional health related programs should be specific to Asian students and their health concerns. The initial orientation should include a tour of the SHS to ensure that students know where to go for medical problems.
Traveling to a foreign country to attend college can be challenging. International students have multiple challenges that other students may not experience; including language barriers, transportation issues and an over dependence on international student services. Forty percent of the respondents reported having a full service SHS as "very important". In order to provide appropriate medical care to this population, the university must be willing to support the IMSS and SHS.
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CAREY ELLIS-BOSOLD MSN, FNP-BC, CNE ADVISOR: DENISE THORNTON-ORR, DNSc Union University
Table 1 Question Answer Response % 1. Before your arrival Excellent 37 50 in the US, how would you best describe your Good 33 45 overall health Poor 0 0 Not sure 4 5 2. After deciding to Yes 45 61 attend college in the US, have you thought No 29 39 about how you would get medical care if needed? If answered yes to Daily 3 7 question 2: 3. How many times have At least once a week 9 20 you thought about how you would get medical Once or twice 33 73 care in the US 4. If you became sick Student health services 57 77 tomorrow (cough, cold, fever) where would you The emergency department 3 4 go to find medical care? A local clinic 7 9 I would prefer to return 0 0 home for medical care Not sure 3 4 Other (fill in the 4 5 blank) "Treatment by myself", "take medicines by myself", "take some medicines", "not a big deal" If answered Student Yes 47 84 health services question 4: No 9 16 5. Do you know where student health services is located If answered Student Yes 31 55 health services question 5: No 25 45 6. Do you know what medical services are provided by student health services If answered emergency That is what I would do 0 0 department question 4 if I became sick in my 7. Which of the home country following responses best describes why you would I feel like the care in 3 100 choose to go to the the emergency department local emergency would be better department That is what my parents 0 0 told me to do if I became sick Other (fill in blank) 0 0 8. Which of the Eating healthy foods 66 91.7 following do you consider important to Seeing a health care 32 44.44 staying healthy in the provider, like a doctor United States (choose or a nurse, for a all that apply) routine physical exam Exercising on a regular 57 79.2 basis Being able to get 7 9.72 over-the-counter medications Taking vitamins or 20 27.8 herbal remedies that are easy to find in my country Attending health- 22 30.6 related education programs sponsored by Student Health Services or the International Student Services 9. If you think you have Call someone in the 12 17 a medical emergency, International Student what would you do? Office Call 911 33 46 Ask someone to take me 24 34 to the emergency department Other (fill in the 2 3 blank) "Medical help line", "Go to the emergency room" 10. Are you currently Yes 4 6 taking prescription medications? No 67 94 If answered yes to Yes 2 67 question 10 11. Were the No 1 33 prescription medications given to you by a health care provider in China? If answered yes Student health services 2 50 to question 10 12. Where will you A local clinic 0 0 go to get more of the prescription medication The emergency department 0 0 when you need it Someone from home will 2 50 mail me the medication Other (fill in the 0 0 blank) Have you experienced any Yes 17 24 medical problems since your arrival in the No 55 76 United States If answered yes to Minor, like a cough, 8 50 question 12 cold, or slight fever Which of the following best describes your Severe, like an injury, 8 50 medical problem high fever, severe pain If answered yes to I sought medical care 3 19 question 12 the day the problem How long did you wait started to find or look for medical care I waited one or two days 6 38 I waited more than two 5 31 days I waited more than one 1 6 week I waited over two weeks 0 0 Other (fill in the 1 6 blank) "Toothache but I did not go" If answered anything I thought the problem 6 43 other than sought would go away on its own treatment the day the problem started on I tried to treat it 3 21 question 12 myself with over-the- Which of the following counter medications or best describes why you herbal remedies waited to find or look for medical care I did not have 2 14 transportation for a medical appointment I did not know where to 0 0 go for medical care Medical care is 1 7 expensive. 1 did not have the money I was afraid that I 1 7 would not be able to understand the medical provider I was afraid the medical 0 0 provider would not be able to understand me Other (fill in the 1 7 blank) "All of the above" Which of the following I currently smoke 10 15 apply to you (choose cigarettes all that apply) I currently drink 2 3 alcohol on a regular basis I currently drink 12 18 alcohol when I am with friends I currently use 0 0 medications that were not given to me by a doctor I have sex without using 6 9 a condom or other forms of birth control None of the above 46 68 Which of the following The emergency department 10 15 community services have you used (choose all The hospital 7 10 that apply) A local clinic 17 25 The health department 4 6 A local pharmacy 19 28 None of the above 33 49 Which of the following To learn how to stop 12 18 topics would you like to smoking have more information on (choose all that apply) Safe sex 19 28 Help with drug and 7 10 alcohol abuse Community services that 44 65 are available to me as a student Services that are 48 71 available in Student Health Services on campus Counseling services 25 37 Help with partner abuse 2 3 (when a boyfriend or girlfriend physically hurts you) How important is it to Very important, I would 28 48 you to have a full rather be at a college service Student Health with a full service Center (health care Student Health Center provider with prescriptive privileges, Somewhat important, I 33 47 equipment to perform thought about it but it minor procedures like did not change my suturing a cut, lab, decision on which counseling services) on college to attend the college campus Not important, this is 9 13 not something I looked at when deciding which college to attend If there were student Yes, I would like to 32 45 health information take advantage of programs on campus, programs to learn how to would you attend improve my health No, I do not like to 15 21 attend programs unless required for one of my classes I would be more likely 24 34 to attend a health information program if it was sponsored by the International Student Office and specific to Asian students. Who do you feel is Me 22 31 responsible for your health care needs while The university 24 34 you are in the United States? Individual in the 10 14 International Student Office My family 2 3 Not sure 13 18
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|Date:||Mar 1, 2013|
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