by A thesis submitted in conformity with the requirements for
the degree of Graduate Department of Community Health, University of Toronto © Copyright by Angela W. Y. Shik 1995 Chapter | 1 | 2 | 3 | 4 | 5 | 6 | References | Appendices ABSTRACT The present study investigated the adaptation process and the mental health of visa-students from Hong Kong. This study was carried out using a qualitative research design along with the grounded theory approach. Nineteen visa-students enrolled in the first year of their undergraduate studies at the University of Toronto participated in the study. Data collection was carried out using face-to-face semistructured interviews which lasted between one to two hours. Eight concepts emerged through the analysis of data. The four concepts relating to adaptation were: (1) physical barriers, (2) cultural barriers, (3) marginality, and (4) educational adaptation. The four concepts relating to mental health were: (1) the role of social networks, (2) family pride as a motivating force, (3) the effect of having an alternative route, and (4) the importance of a clear and specific goal. The theoretical proposition emerged from this study was that the mental health of visa-students is influenced by three components: (1) the process of adaptation, (2) the student’s goal, and (3) the student’s expectations. Furthermore, a positive mental health has a reciprocal relation with the process of adaptation. That is, good mental health facilitates adaptation just as adaptation contributes to good mental health. TABLE OF CONTENTS Chapter 1 Introduction Chapter 2 Literature Review Chapter 3 Methodology Chapter 4 Adaptation Chapter 5 Mental Health Chapter 6 Discussion and Conclusion Appendices INTRODUCTION 1.1 Background Canada has always been an attractive destination for foreign students because it is a developed country with a good education system. Canadian universities began their first major involvement with foreign students in 1945 and it has been increasing ever since (Mickle, 1984). Another significant step in the involvement in international education was made with the introduction of the Commonwealth Scholarships. In July 1959, Canada offered 250 places in the first Commonwealth Scholarship Plan which emerged during the first Commonwealth Education Conference in Oxford, England. Before 1978, an individual could come to Canada as a visitor, become a student, and then have the choice of applying for Canadian citizenship. In 1978, Canada passed a new immigration act which placed restrictions on the status of foreign students. Under the new regulations, foreign students are allowed to come to Canada to study in a specified educational institution provided that they have the documentation ensuring fees and transportation to and from Canada can be paid. Once entry to Canada is granted, the student will be issued a student-visa for entrance to Canada. Foreign students carrying a non-immigrant student-visa are referred to as visa-students today. These students are required to leave Canada on completion of their studies. Over the years, the number of foreign students in Canada has risen continuously. According to the Canadian Bureau of International Education, the number of visa-students enrolled in Canadian educational institutions increased by 62% from 53,823 in 1985-86 to 87,005 in 1990-91. In the past decade, Hong Kong has been the largest sender of visa-students to Canada. In 1990-91 alone, the total number of visa-students from Hong Kong was 13,854; making up 16% of the total visa-student population in Canada. Based on January 1993 University of Toronto data, there were 3,789 visa-students from 123 countries enrolled at the University; and among them, students from Hong Kong represented the largest group numbering 1,097 students - almost one third of the total visa-student population.
1.2 Brief Description of Education System in Hong Kong The education system in Hong Kong is very competitive, and it is sometimes described as a ‘pyramid system’, with a decreasing number of available openings as a student advance in his or her academic pursuit. The education system in Hong Kong follows the British education system: Grades one to six constitute the primary school stage. At the end of grade six, all students are required to write a public examination, and depending on the marks the student gets, he or she will be allocated to a secondary school of his or her choice, or to a school of lower standard. Since it is required by law in Hong Kong that all children must complete at least form three (grade nine); all grade six students are entitled to advance to form one (grade seven), but not all secondary schools are of the same standards. The next set of public examinations that all students have to face on completion of form five (grade eleven) are the Ordinary-level exams; and again depending on their marks, only 60%-70% of the students will advance to the next stage, form six and form seven (grades twelve and thirteen). By the end of form seven, the student has to write the Advanced-level exams, and the marks from these examinations will determine his of her chance of getting into a university. Approximately 40%-50% of the students who apply to a university will get admitted. For those students who decide to leave Hong Kong and continue their education overseas, it is the nearness of the Ordinary-level and the Advanced-level examinations that usually precipitates the decision. Generally speaking, the majority of students who leave decide to do so before the examinations because they want to avoid the intense work required to prepare for those exams. Other students may decide to leave after they have written the examinations, because they cannot find a place in a Hong Kong university. Still another group of departing students are those who are making significant academic achievements in Hong Kong and are encouraged by their parents to leave Hong Kong and seek a better and more prestigious education overseas.
1.3 Need for the Study Even though the number of visa-students entering Canada has been rising continually, little attention has been given to how these students adapt; and Canadian studies investigating the components which facilitate or hinder the successful adaptation of visa-students have been scarce. Nowadays, almost every person must deal with changes at one time or another. For example, it is not unusual that in a person’s lifetime, he or she will have to deal with the problem of moving from one place to another, or changing from one job to another. Even with these comparatively small changes, people have to spend some time making adjustments to adapt to their new circumstances. In the case of visa-students, coming to Canada to study means they have to adapt not only to a new physical environment, but also to new values, new customs, and an entirely new culture. This is a very stressful process which may lead to many health problems for the visa-students even though the length of their stay in Canada is limited. Beginning in July 1994, any health service provided to visa-students in Ontario is no longer covered by the Ontario Health Insurance Plan (O.H.I.P.). Visa-students have to either purchase their alternate health insurance or pay for their own health services. Under these new circumstances, there is an added need to examine the relationship between the process of adaptation and the health status of visa-students. Since January 1977, after the Ontario government announcement that fees for visa-students would jump to approximately twice the amount paid by Canadian students, fees for visa-students have been rising steadily. At the University of Toronto, academic fee per full course at the undergraduate level in the 1994-95 academic year is $445.60 for a Canadian citizen, while it is $1680.60 for a visa-student, a staggering difference of $1235 per course! In other words, visa-students are paying almost four times the amount paid by Canadian students for their undergraduate education at the University of Toronto. On top of these high fees, visa-students are required to pay an additional premium of almost $600 for the University Health Insurance Plan (U.H.I.P.) as a result of the O.H.I.P. cut. This financial burden has become an added stress to visa-students. Furthermore, under this new University Health Insurance Plan, not all health service charges for visa-students will be fully covered. For example, if a visa-student requires hospitalization, U.H.I.P. will only cover up to two-and-a-half times the rate charged for a Canadian citizen. To give a real case example, on July 12, one week after the O.H.I.P. cut took effect, a visa-student from Hong Kong (who is also one of the participants of the present study) was involved in an accident which resulted in third degree burns to the right side of her body. Her injuries required her to undergo surgery and to stay in hospital for three weeks. After being discharged, she received an invoice from the hospital demanding her to pay $20,000 for her hospital stay because her insurance will only cover $30,000 of her $50,000 bill. Now she is worried that she will not be able to find the money and will have to give up her education, since she may have to use her school fees to pay for the hospital charges. The effect of the termination of O.H.I.P. for visa-students in Ontario, plus the stressful process of adaptation points to the importance of understanding how these students perceive their own health status, so that necessary measures dealing with illness prevention and health promotion for these students may be taken.
1.4 Purpose and Significance of the Study The purpose of the present study is to examine the process of adaptation experienced by visa-students from Hong Kong, their perceived mental health status, and the relationship between the adaptation process and the mental health of these visa-students. Visa-students from Hong Kong were chosen for this study because they represent the largest group of foreign students in Canada. The decision to focus this study on the mental health of the visa-students was made because of personal interest. It is beyond the scope of the present study to examine both the mental and the physical health of visa-students, although their physical health status is also important and very likely connected to their mental health. Results from this study will add to the body of literature on adaptation of foreign students, specifically the adaptation of Hong Kong visa-students in Canadian educational institutions. Also, it will provide information which relates adaptation to the mental health of foreign students; a subject which has received little attention in the literature.
1.5 Research Objectives (1) To investigate the adaptation experiences of visa-students from Hong Kong. (2) To examine the relationship between the experiences during the adaptation process and the mental health status of visa-students from Hong Kong. (3) To derive a theory linking the experiences during the adaptation process with the mental health status of visa-students from Hong Kong using the concepts, themes, and categories that emerge from the empirical observations.
1.6 Definition of Key Terms (1)Visa-student is defined as a foreign student who is here in Canada on a non-immigrant student entry document (student visa), and required to return to his or her home country on completion of his or her studies. (2)Adaptation is defined as the shift in sociological or cultural disposition (Reba, 1985). Within the scope of the present study, adaptation refers to the shift from the sociological and cultural disposition experienced in Hong Kong to the sociological and cultural disposition experienced in Canada. (3) Mental health is defined as both mental disorder and positive mental health (Canadian Task Force on Mental Health Issues Affecting Immigrant and Refugees, 1988). In the present study, mental health is not defined as the presence or absence of mental illness. It is defined as the psychological and emotional states perceived by the participants. LITERATURE REVIEW 2.1 Literature on Adaptation of Foreign Students In the past few decades, there has been a steady flow of foreign students who came to Canada to pursue their education. All of these students have had to experience a period of adjustment in which they tried to adapt to the new culture and environment in Canada. On the whole, the literature on the adjustment of foreign students in Canada is not extensive; in fact most of the research on the adaptation of foreign students has been conducted in the United States. (a) Patterns of Adaptation Some researchers use ‘culture shock’ as the expression to describe the sojourners’ reactions when they first entered their host countries. Hall (1959) described culture shock as: "a removal or distortion of many of the familiar cues one encounters at home and the substitution for them of other cues which are strange" (p.199). Oberg (1960) felt that "culture shock is precipitated by the anxiety that results from losing all our familiar signs and symbols of social intercourse" (p.177). Examples of these signs and symbols are customs, gestures, facial expressions, or words. In other words, culture shock is characterized by feelings of uncertainty and a lack of control. Oberg (1960) went on to describe the four stages of adjustment that sojourners go through in the host culture. The first stage is the ‘honeymoon’ stage, characterized by fascination, elation, and optimism. The second stage is characterized by both hostile and emotionally stereotyped attitudes toward the host country and increased association with fellow sojourners. The third stage is the recovery stage, characterized by increased language knowledge and ability to get around in the new culture. The fourth stage is the stage in which adjustment is as complete as possible, anxiety is largely gone, and the new customs are accepted and enjoyed. The stage model of sojourner adjustment, however, suffers from inherent conceptual and methodological difficulties in classifying individuals. For example, it is unclear whether or not the order of the stages is invariant; or whether all stages must be passed through, since it is conceivable that some stages might be skipped by some individuals. Also, in order to classify individuals, key indicators of each stage are needed, and these indicators may vary depending which culture the sojourner is from. While most foreign students will experience some kind of culture shock when bombarded by a culture different from the one they grew up in, it is not necessarily true that they will go through exactly the process of adaptation as depicted by this stage model. Lysgaard (1955) described the level of adjustment of foreign students in the new culture as a function of time . He plotted the course of adjustment of 200 Norwegian Fulbright grantees in the United States into a U-shaped curve. According to this pattern of adjustment, students initially felt optimistic and elated in the host culture, then fell into a period of ‘crisis’ in which they felt less well adjusted, somewhat lonely and unhappy. Finally they began to feel better adjusted again, becoming more integrated into the foreign community. Support for the U-curve hypothesis has been weak; it has been criticized as being inconclusive, and overgeneralized (Church, 1982). Kleinburg and Hull (1980) have commented that the U-curve pattern of adjustment is occasional rather than universal; since not all foreign students experience a period of depression when they are adjusting to a new environment. (b) Conditions Affecting Adaptation Existing literature presents quite a number of different views on the conditions affecting adaption (Mickle, 1984). These conditions include the student’s personality, religious background, and his or her attitude towards the host country. Also, environmental factors such as the size of the university campus is found to have an effect on adaptation. Overall, quite a large body of literature on foreign students focuses on the effect of social support on the adaptation process. I will concentrate my review on this particular aspect of adaptation. Cobb (1976) claims that social support buffers stress by providing the individual with emotional support and guidance. Furthermore, the author states that social support provides a person with three sorts of information: (1) that he or she is cared for and loved, (2) that he or she is esteemed and valued; and (3) that he or she belongs to a network of communication with mutual obligation. Based on this formulation, it may be predicted that foreign students with a strong and supportive friendship network would be happier and better adjusted than those without such a network. Bochner, McLeod, and Lin (1977) studied the friendship patterns of foreign students and found that foreign students belong to three social networks in descending order of salience: (1) a co-national network whose function is to confirm and express the culture of origin, (2) a network with host nationals, whose function is the instrumental facilitation of academic and professional aspirations; and (3) a multinational network whose function is recreational. The authors termed this pattern of social networks the functional model of academic sojourn. Furnham and Alibhai (1985) replicated and extended the study of Bochner et al. (1977). In this study, the definition of co-nationals was expanded to include co-regionals, that is, people from the same continent or geographic/religion/linguistic area. The findings of this study closely matched the study by Bochner et al. (1977), and they also demonstrated the existence of the salience hierarchy of three social networks. The data from friendship choice confirmed a strong preference not only for co-nationals but for those coming from similar or neighbouring countries which share similar religion, language and climate e.t.c.. The authors suggested that the friendship networks may be related to the research on social support and mental health of foreign students, but their hypothesis was not being tested in the study. A theoretical perspective on the effects of social support on cross-cultural adjustment was presented by Adelman (1988). She adopted the definition of culture shock proposed by Weissman and Furnham (1987) as a stress reaction, where prominent physiological and physical rewards are generally uncertain and difficult to control or predict. She suggested that social support helped to alleviate the uncertainty associated with cross-cultural adjustment by providing individual, group or organizational support in various phases of transition (e.g. pre-departure, initial entry). In addition to decreasing uncertainty, Adelman also argued that social support serves to enhance perceived mastery or control over the environment, and that control is the key component to effective coping and adjustment. The author further commented that there are numerous sources of social support throughout the various phases of cross-cultural adjustment which ranged from close ties with family members, relatives, and intimate friends; or weak ties with people outside the primary social circle like shopkeepers, hairdressers, and bartenders. The ‘contagion effect’, which is a dysfunctional effect of support when recipients and providers face similar threatening and uncertain conditions, has also been described by the author. Finally, the author argued that a social support perspective augments the psychological treatment of cross-cultural adaptation. It adds the notion of a socially constructed reality in which peoples’ perceptions of the world are inextricably linked to their surrounding social milieus. No matter where the support and assistance are from, it all became deeply felt as sojourners were pushed beyond their personal and cultural boundaries in their host countries. (c) Problems Associated with Adaptation In a survey conducted by the University of Toronto Presidential Task Force on Foreign Students (University of Toronto, 1986), the three most important problems facing foreign students were outlined as: financial pressures; heavy work load and insufficient time; and stress and pressure. Other difficulties associated with the process of adaptation include: lack of language facility, task of finding suitable lodgings, financial difficulties, experiences of prejudice and discrimination, lack of satisfactory personal contact or friendly relationships, career choice restrictions, study difficulties, dietary difficulties, and changes in climate (Gunn, 1988; Kleinberg & Hull, 1979). It is inevitable for foreign students to experience life changes associated with the process of adaptation; however, without proper management, these changes may contribute to psychological distress, which can be detrimental to the mental health of these students (Gunn, 1988). Cox (1988) suggested that the difficulties encountered by foreign students can best be discussed with reference to their adjustment to three social roles: that of a student, a client, and a visitor. Following this argument, a visa-student in Canada has to adjust to his or her role as (1) a student who must conform to the demands of the Canadian educational system and specific university system; (2) a client who pays for his or her education in Canada and expects good value for the money; and (3) a visitor who is subject to immigration laws which restrict his or her stay in Canada. These problems that arise within the boundaries of major social roles and role sets, may act as chronic stressors (Pearlin, 1988). Without proper management, these chronic stressors will no doubt be taxing on the mental health of visa-students. 2.2 Literature on the Health of University Students Health issues represent an important aspect of the lives of university and college students. Assignments, examinations, part time work and excessive social functions are only a few of the possible conditions that can cause stress and negatively affect a student’s health. Svenson and Campbell (1992) conducted a survey of 457 undergraduate students at the University of Alberta, with results indicating that although 95.7% of respondents rated their health as good or better, only 4.2% felt there was NO need to improve their physical health. On the whole, the areas of physical health perceived by the participants as needing improvement were insufficient physical exercise and poor eating habits. The main barriers identified to improving their physical health were lack of self discipline and a lack of time. Greenberg (1984) attempted to test the hypothesis that college students reporting greater life changes contract more illnesses and diseases than college students reporting less life changes. He conducted a survey of students enrolled at a major northeastern university in the United States. He proposed a stress model that depicted responses to life situations. In this model, those response that are perceived as stressful, result in emotional responses that, in turn, lead to bodily reactions, which can eventually cause illness or disease. Though the survey results failed to support the author’s hypothesis, the proposed stress model served as an important conceptual framework to show that life changes may be related to the frequency of disease and illness. Patrick, Grace, and Lovato (1992) reviewed the main issues of college health in the United States. One major subgroup identified among the college student population was international students, with the majority coming from Asian countries. These international students, who have unique ethnic and culturally-specific beliefs, were shown to have special health needs. One of the key issues of college health addressed by the authors was the importance of health promotion and disease prevention within the college campus because college students are among the most likely group to be uninsured. Even though most college students in Canada are covered by universal health care, the importance of health promotion and disease prevention should not be overlooked in Canadian educational institutions. This is especially true for visa-students in Ontario, who are not covered under O.H.I.P..
2.3 Literature on the Mental Health of Foreign Students Stress is endemic to college life, and especially vulnerable are the foreign students because they have to handle their school work on top of adjusting to the new environment (Huang, 1977). Ebbin and Blakenship (1988) conducted a survey of 476 college health centre directors in the United States. The directors reported that foreign students had higher frequencies than domestic students in ten of the stress-related diagnoses. Among those ten were anxiety, insomnia, and depression. Oei and Notowidjojo (1990) compared the effect of life changes of overseas students with those of native Australian students. They concluded that overseas students who had been in Australia for more than one year were significantly more likely to experience moderate to severe clinical depression and loneliness than were the Australian students. Ying and Liese (1991) carried out a longitudinal study to examine the emotional well being of Taiwan students before and after they arrived in the United States for their studies. The results of their study indicated that more than half of the students experienced a decline in emotional well-being. The authors concluded that while it was true that on the whole the mood of the students who participated in the study worsened from pre- to post- arrival, it was also clear that inter-individual differences existed and they needed to be assessed if one was to more fully understand the experiences of foreign students. Dyal and Chan (1985) provided cross-cultural and cross-situational comparisons in their study of the stress and distress of Hong Kong Chinese students in a Canadian university. They studied subjects that were members of three cultural/situational contexts: (1) Chinese students at the University of Hong Kong (HK/HK), (2) Hong Kong Chinese student sojourners at the University of Waterloo (HK/W), and (3) Euro-Canadian students at the University of Waterloo (C/W). Stress and distress were measured using the stressful life events (SLE) scale (Holmes & Rahe, 1967). The most significant result of the study was that Chinese females (both HK/HK and HK/W) reported more stress symptoms than Canadian females, and Chinese females also reported more stress symptoms than Chinese men. There were no discernible differences among the culture/situational groups in the male samples. The authors concluded that although the difference in total symptom score between female Chinese sojourners and female students at the University of Hong Kong was not statistically significant, the fact that the sojourner’s symptom score is elevated over an already high base score is suggestive of increased somatization as a consequence of acculturative stress. Bourne (1975) provided a report of 24 Chinese students who were seen in the mental health clinic of a large West Coast university during the three year period of 1966-1969. One of the causes that seemed to create the greatest difficulty in the acculturation process and around which psychopathology and dysfunction seemed most likely to occur, was the student’s demand for excellence. All of the students in treatment described the exceptional pressure placed on them by their families to excel academically. The author also stated that although it was obvious that the pressure to succeed exists for all minority students who see themselves as chosen representatives of their race, this pressure is infinitely more significant among the Chinese students. Some students ended up seeking psychiatric help either because they could not reach their parents’ expectations or standards, or they had tremendous internal anger as a result of their disagreement with the career choices that their parents had made for them, but which they felt they must not reject. The author further noted that adolescence and early childhood is the stage of life in which the greatest demand for adaptive change occurs. For Chinese students, with a shifting milieu of cultural demands and values in the background, the process of becoming adult is made that much more difficult. The University of Toronto psychiatric counselling service reports that there is a proportionate representation of Oriental students to the university at large, who seek psychiatric counselling. The service identifies the most common problems as: those associated with separation from their families, concerns about academic performance, getting into professional faculties, and the right career choice. Even though it is not clear what proportion of these oriental students are visa-students from Hong Kong, problems faced by Oriental students in general can be regarded as reflective of the difficulties encountered by students from Hong Kong. In contrast to the information obtained from the University of Toronto, Huang (1977) stated that in general, reports from the United States indicated that there was an underutilization of services such as counselling and psychiatric programs by foreign students. He suggested that in establishing a systematic mental health intervention program on the college campus, emphasis should be placed on illness prevention. To achieve this aim, he proposed that mental health principles should be integrated into the educational content by the promulgation of values such as equality, compassion, responsibility, mutual respect, and collective well-being. According to this idea, a foreign student would be regarded as a ‘new person’ rather than someone who is ‘foreign’ to the mainstream. He or she becomes a unique cultural and educational asset, someone who adds diversity, vitality, and challenge to learning.
2.4 Literature on Mental Health Issues among the Hong Kong Chinese In Hong Kong, the majority of people do not have a clear understanding of mental illness (Cheung, 1985). Folk attitudes towards mental illness are vague and stereotypical. Images of the mentally ill are associated with craziness and insanity. According to an informal street poll conducted in Hong Kong (Better Mental Health Promoters, 1980), most of the urban respondents conceived of the mentally ill as dangerous maniacs, people who act bizarrely, or people who have gone "haywire". They attributed the cause of mental illness to vague ideas of psychological trauma, irregular lifestyle, or mixed-up nerves. Mental illness is still a myth-ridden and socially stigmatized. The respondents of this street poll were generally ignorant about the method of treatment. They expected the doctors to know how to give medical treatment to those afflicted.
2.5 Summary In summary, all visa-students come to Canada from a different background with a unique set of expectations, and their experiences of the process of adaptation vary accordingly. No matter where they come from, however, it is inevitable that visa students will face life changes in Canada. Entering a new culture and studying under a different educational system may result in problems that will serve as potential stressors to the visa student. Without successful adjustment and stress management, visa students are likely to suffer mental health problems such as anxiety and depression. In general, there is a lack of literature which examines the mental health of visa students in the Canadian context. There are current statistics available on the number and origin of visa students in Canada, and there is also some literature on the problems that foreign students face; but there are few studies relating the process of adaptation to the mental health of visa-students in Canada. The present study aims to investigate the effects of the process of adaptation on the mental health status of visa students at the University of Toronto. Results of this study may be useful in establishing programs to assist visa students to better integrate themselves into the society. They can also be applied to health promotion programs in which visa-students can learn to minimize the negative effects of the process of adaptation and to maintain a positive mental health. Next: Chapters 3-4 Chapter | 1 | 2 | 3 | 4 | 5 | 6 | References | Appendices
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