Author: LIFESTYLE AND HEALTH FOR FOREIGN STUDENTS

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Lithuanian University of Health Sciences

Faculty of Medicine

LIFESTYLE AND HEALTH FOR FOREIGN

STUDENTS

Author:

LAYANA YASEEN

Supervisor:

Prof. Rūta Ustinavičienė

Department of Environment & Occupational Medicine

A Thesis Submitted For The Degree

of Master of Medicine

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Table of content

8. AIMS AND OBJECTIVES OF THESIS

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9. LITERATURE REVIEW:

9.1 STRESS AMONG STUDENTS 11

9.2 STUDENTS’ COPING STRATEGIES 12

9.3 STUDENTS’ MENTAL HEALTH AND HEALTH BEHAVIOR

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9.4 THE NUTRITIONAL HABITS OF STUDENTS

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9.5 THE CORRELATION BETWEEN STUDENTS’ SLEEPING QUALITY AND THEIR PHYSIOLOGICAL AND SOCIAL HEALTH

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9.6 STUDENTS’ SUBJECTIVE HEATH 15

10. RESEARCH METHODOLOGY AND METHODS

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11. RESULTS:

11.1 FIRST AND FIFTH YEAR STUDENTS’ LIFESTYLE

11.1.1 DESCRIPTION OF PARTICIPANTS

CHARACTERISTICS

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11.1.2 THE PSYCHOLOGY OF STUDENTS AND ITS’ EFFECTS

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11.1.3 THE STUDENTS’ LIFESTYLE TOGETHER WITH ITS EFFECTS

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11.1.4 THE NUTRITIONAL HABITS OF STUDENTS

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11.1.5 STUDENTS’ RELATION AND CONTACT WITH THEIR FAMILIES.

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11.2 FIFTH AND FIFTH YEAR STUDENTS’ SUBJECTIVE HEALTH

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11.3 COMPARISION BETWEEN FIRST AND FIFTH YEAR INTERNATIONAL MEDICAL STUDENTS SUBJECTIVE HEALTH AND LIFESTYLE

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12. DESCUSSION

12.1 STRESS AMONG STUDENTS 33

12.2 COPING STRATEGIES STUDENTS ARE EVOLVING

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12.3 STUDENTS’ NUTRITIONAL HABITS 35

12.4 STUDENTS’ SLEEPING HABITS 36

12.5 STUDENTS’ SUBJECTIVE HEALTH 37

13. CONCLUSION 38

14. RECOMMENDATIONS 39

15. REFERENCES 40

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1. SUMMARY

The researcher: Layana Yaseen

Title: Lifestyle and health for foreign students.

This study was conducted with the aim of evaluating the lifestyle and the health profile among first and fifth international medical students in LUHS and then to compare the results between the international medical students in the two study years.

To evaluate this aim, three tasks and objectives were set and searched: 1- to evaluate the lifestyle of first and fifth year international medical students in LUHS, 2- To evaluate the subjective health profile of first and fifth year international medical students in LUHS, 3- To compare the results between first year and fifth year international medical students in LUHS.

For achieving this goal, questionnaires were sent to 100 international medical students of LUHS from first and fifth years, proportionately. Furthermore, the students’ confidentiality and privacy were assured.

After undertaking the results and the statistical analysis, we came to the conclusion that most of the international medical students from first and fifth year of study are seen to be implementing unfit lifestyles and misadjusting to stress by consuming alcohol, smoking, not practicing any type of sports and fulfilling unhealthy nutritional habits, also that the majority of first and fifth year international medical students’ popular health was described as good, the same as one year ago with slightly interfering with their social life and finally that fifth year international medical students besides showing their low healthy lifestyles it is seen that compared to the first group of students they have implemented better lifestyles and instigated better coping strategies owing this to their higher level of education and knowledge. Moreover, the health profile aspect is seen to be similar in the two groups.

Therefore, it is of a great importance that the university and its’ staff educate the students and increase their knowledge about healthy ways for adapting and coping to the new environment they are living in as well as to the high level of stress they are facing, awareness about the harmful effects of smoking and consumption of alcohol on their body should also be increased, as this is the main way students face their stress with. Also, various ways and techniques for healthy sleeping patterns and qualities should be introduced to the students, as healthy sleep can be demonstrated in healthy

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lifestyle, healthy psychology and healthy educational results as well. Students should be educated more about the benefits of healthy nutritional habits such as eating 3 meals daily, eating lots of vegetables and fruits and limiting their sugar and salt intake as well. Furthermore, programs and strategies to promote health and wellbeing should be provided to the students.

Moreover, ways for students to combat these stressful events can be by physical exercising, joining members and groups, or and joining gyms. Leisure times every weekends can be of a positive effect on their psychology. Additionally, regular contact with friends, family can also be supportive and give them a push to continue and face their difficulties.

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2. ACKNOWLEDGMENTS

First and foremost I sincerely would like to thank Professor Rūta Ustinavičienė for all her guidance, her insightful feedbacks and mostly for her patience. Thank you for your support and dedication.

And of course I would love to thank my family and friends, for their love and support that they gave me throughout this beautiful journey, and for believing in me. Everything that I have achieved and accomplished I owe to them.

3. CONFLICT OF INTEREST

No conflict of interests.

4. ETHICS COMMITTEE CLEARANCE

Title: Lifestyle and health for foreign students.

Date of issue: 2018-11-02

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5. ABBREVIATION LIST

1- Hour (h)

2- Lithuanian university of health sciences (LUHS) 3- Minute (min)

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6. TERMS

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7. INTRODUCTION

Nowadays, admission and starting university is an important milestone in students’ lives, as it is their way to find themselves, to identify their identities, to recognize their responsibilities and to prepare for their life careers.

Choosing universities and studies is tough and confusing for the students and their parents, as some would already know what they want before finishing their secondary education, whereas others still don’t know what they want as a profession. Moreover, some want to study in their countries, and some want to travel abroad to get an education. Furthermore, when deciding to study abroad; nobody really consider how hard and tough it will be for the students to accept the new environment they put themselves into and were excited to try. Students think moving to another country to start university is an exciting adventure but as soon as their excitement subsides, this new adventure of leaving their hometowns, cities, countries or even continent as well as leaving their parents, relatives and close friends can be stressful and worrying, not only because they have a bigger study workload comparing to the previous secondary schools’ amount of work they had to do, but also because they will start facing cultural, social, and environmental changes which could be hard to adapt and accept at first for some people while on the other hand, others wouldn’t be able to adjust at all and will result in them giving up and going back to their countries.

Furthermore, some of the things international students will face is feeling lonely, missing their relatives and family, not be able to sleep at night, getting sick, feeling anxious and stressed. And as a way to adapt they will start evolving various coping strategies which may include eating more junk food, start smoking, start drinking, and finally stop focusing on their studies.

And because this is an important issue most of the international students are facing,

questionnaires were sent to first and fifth year international medical students in order to conduct the study with the aim of evaluating their lifestyle and health profile and compare the results between the two year groups. The goal was to evaluate how students with each passing year evolve, change and produce new techniques and strategies to face their stressors and factors which have a big influence on their daily lives as well as to evaluate how their health profile is affected by these factors.

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8. AIM AND OBJECTIVES OF THE THESIS

Objective of research – to evaluate the lifestyle and health profile among first year international

medical students and compare it to fifth year international medical students in LUHS.

Tasks of research:

1. To evaluate the lifestyle of first and fifth year international medical students in LUHS.

2. To evaluate the subjective health profile of first and fifth year international medical students in LUHS. 3. To compare the results of first and fifth year students.

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9. LITERATURE REVIEW

Our study was established with the task of evaluating the students’ lifestyle as well as their subjective health. Therefore, we looked closer on how they react, adapt, and adopt to the new environment they are in and more attention in this study was paid to the stress that students face, to their coping strategies, to their mental and subjective health, their nutritional habits, and last but not least to their sleeping qualities. Hence, to prove our results and to look at students from all over the globe, different cases and publications with similar if not exact goals were looked through.

9.1 STRESS AMONG MEDICAL STUDENTS:

Students leaving their home countries and starting medical school abroad can affect their life quality and increase their stress level mostly in concern with academic and psychosocial attributes [1]. Even though stress can be positive ‘eustress’ as well as negative ‘distress’, the negativity is more dominating since it can cause intense mental, emotional and behavioural impressions on medical students [2].

Several studies were conducted in different countries to prove this point and to acknowledge the correlation between stress and different factors, and to compare its’ level between different school years.

A cross sectional study at the medical school of Karwar, Karnataka, India was conducted to study the perceived stress and its association with sleeping quality assessed by Perceived stress scale -14 (PSS-14) and Pittsburgh sleep quality index (PSQI) respectively, in a sample of 121 students in their first year of studies. The study showed that less than half of the sample had perceived stress scores of >28. The academic stress students faces are mostly stressing about examination performance (37.4%), lack of recreation time (30.6%), the curriculum (24.8%), the examination frequency (24.8%), and the psychosocial stress with the highest scores were the quality of food (50.4%) and lack of entertainment (39.7%). The study showed a positive correlation between stress and the quality of sleeping. The study

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reached the conclusion that first year medical students have a high level of academic and psychosocial stress [3]. Another study in the King Saud medical university in Riyadth showed that the highly stressed group suffered from more oily, waxy patches or flakes on scalp, dry/sore scalp, warts, pimples, itchy skin, itchy rash, hair loss, pull-out own hair, scaly skin, troublesome sweating, nails biting. Concluding that there’s a high correlation between the perceived stress and the skin conditions [4].

A study in Palacky University, Czech Republic was conducted to compare psychological distress using Medical students’ wellbeing index (MSWBI) in medical students of an English program in a non-English speaking country with that of a local medical students. The sample enrolled 235 international students and 1043 local students. The study showed 44% of international students and 53% of local students being positive for the psychological distress. The study showed no huge difference between the stresses both internationals and local students are facing [5].

We can conclude that these studies [1-5] showed that international medical students are facing a high degree of stress which interferes and has a correlation with their sleeping. Furthermore, some studies showed that their stress level is reflected by the presence of skin symptoms and signs which mostly affect first year students.

9.2 STUDENTS’ COPING STRATEGIES

International students in their medical journey are at a high risk for insomnia, stress, smoking, harmful alcohol consumption and substance abuse therefore, an important part during their journey is to cope with all these factors mentioned in order to help themselves to progress and be successful [6]. Moreover, according to Lazarus and Folkman (1984) coping is defined as “the constantly changing cognitive and behavioral efforts to manage a specific external and/or internal demands’’ [7]. Coping can be expressed as either problem-focused which aims to reduce the stressful loads or increase the methods to deal with it, or as emotional-focused aiming to modify the persons’ emotional reply towards the situation [2].

Furthermore, several studies have analyzed the coping strategies students use to progress and survive their studies period. A study was made in the school of medicine, university of Tasmania, Australia, to assess the copying strategies, skills perceptions and knowledge of assessment of 3rd and

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4th year students as they progress. The sample enrolled a total of 46 students; 19 from third year, and 27 from fourth year. The study involved questionnaires, group discussion and individual interviews that showed that the students have developed different strategies to cope as they are more

concentrating on their future and feeling more responsible towards their families [11]. Students uses active coping, religion, planning, self-distraction, physical exercises, listening to music, emotional support and acceptance as a way to cope with their stressors [1, 8-10, 12]. However, there’s a need for social and psychological support and interventions to improve the quality of life for students and to prevent maladaptive coping strategies [1, 13].

The studies [1, 6, 11-13] mentioned how that students are in need for coping skills since a lot of them use alcohol, smoking as a way to cope. Doctors and teachers should help students find better approaches for students to prevent maladaptation.

9.3 STUDENTS’ MENTAL HEALTH AND HEALTH BEHAVIOR

(Terebessy et al, 2016) has conducted a cross sectional study in the university of Semmelweis, Hungary to evaluate the students’ health behavior in four consecutive years (2009-2012), the health behavior assessment involved factors such as smoking, drinking alcohol, diet and physical activity. 76.1 % for the Hungarian and 63.4 % for the international students were enrolled in the study. From this sample, 15.3 % were following dietary recommendations, 75% reported the performing of physical exercises, 18.6% reported smoking, 13.8% reported alcohol consumption [14]. These results together with those of similar studies indicate the need for concerning educating method and programs for a healthier lifestyle particularly due to the excessive alcohol drinking and tobacco use [15-18].

All in all, these studies [14-18] showed how medical students need further education on how to have healthy and fit lifestyles due the high level of smoking and alcohol consumption.

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9.4 NUTRITIONAL HABITS OF STUDENTS

Since the university is considered the final arena for nutritional knowledge, and since students usually transition from the healthy food to the fast food, different studies in different countries were conducted to evaluate the eating habits, lifestyle, and socio-demographic characteristics on students’ weight [14, 19-23].

A cross sectional study in the Lebanese American University, Lebanon was conducted to examine a sample of 220 students and to assess their body weight using their Body Mass Index (BMI) and their eating habits as well as drinking and smoking habits by filling a self-reported questionnaire. The study showed that the majority of the student were within a normal weight range nonetheless there were some underweight students [18]. Some students reported not having regular intake of meals with high intake of vegetables and fruits. Results showed the poor behavior of students toward nutrition and it has reflected the need for nutritional and health promotion programs to decrease the probability of overweight or malnutrition among students and to improve the eating habits and their lifestyle [20-25].

Studies [14, 19-23, 25] have shown that students are not following the healthy dietary recommendation and more relying on the junk and fast food, and because of this poor behavior to nutrition more knowledge should be giving to students about the nutrition value and how it can affect them and increase as well as change their energy and performance level.

9.5 THE CORRELATION BETWEEN STUDENTS’ SLEEPING

QUALITY AND THEIR PHYSICAL AND PSYCHOLOGICAL

HEALTH

A good night sleep is one of the many factors that are important for the mental and physical health of students whether they are medical students or not. However, even if its benefits are quiet acknowledged; stress, pressure, worrying about exams and exams results can play a big role in affecting their sleeping quality [26-27].

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A cross-sectional study made by Tafoya, 2013 in Mexico enrolled 572 Medical students that were assessed by the SCL-90 and the study showed 3.5% of students reporting to have a hard time sleeping, 6.3% had difficulty staying asleep and 11.4% waking up very early [28]. These students who faced sleep difficulties were showing some symptoms of stress, anger, worry, cognitive hyperarousal and hypervigilance, excessive daytime sleepiness as well as insomnia symptoms [3, 28]. Another study by (Ahmed, 2017) showed that students in their clinical years showed more difficulties and less duration of sleeping compared to pre-clinical years [26]. Increasing the students’ knowledge and awareness about sleep importance, providing consultations and giving them strategies about how to sleep is required in these cases, since the lack of students sleep will affect their work and their performance especially in their clinical years as well as their mental health [26-27].

Studies [3,26-28] have showed that students’ sleeping quality have a correlation with the

students’ psychological health, that is why students’ knowledge and awareness about the importance and the best conditions for sleep as well as accommodating the living environments should be taken into consideration.

9.6 STUDENTS’ SUBJECTIVE HEALTH

(Henna, 2016) has reported a study describing the students’ health behavior. The study was cross-sectional in Germany which involved medical students in their 1st, 3rd and 5th years of studies. The total sample was 2935 students, 1289 from Germany, 1057 from Hungary and 148 from Norway. 84.5%, 60.3% and 70.7% respectively of students reported their health as Excellent / very good [6].

Furthermore, the study made by (Terebessy, 2016) has showed that Mediterranean and Scandinavian students reported better mental health compared to Hungarian and Iranian students these results indicate that both country of origin and exercise showed the presence of a significant positive relationship with mental and physical health[14].

Studies [6, 14] have showed that even if the students’ subjective health is stated as good, very good or excellent, students are still in need for health promotion programs

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10. METHODOLOGY

SAMPLING:

This cross-sectional study was conducted in LUHS and in the department of environmental medicine. The data was collected from a sample of 100 students from the medical faculty. It consisted of 50 students from first year and 50 students from fifth year.

DATA COLLECTION:

The data was collected in winter 2018, using self-composed online questionnaires that were sent to all students through emails and social medias. The questionnaires contained descriptive questions about lifestyle, behaviors and health status. It was explained to the students that participation is not obligatory and anonymously which would not disturb their privacy. Furthermore it was explained that all unclear and doubtful question can be explained by the maker of the questionnaires.

QUESTIONNAIRES:

The self-composed questions of the survey as mentioned above included two aspects; subjective health and lifestyle behaviors.

Firstly the questionnaires started by asking the students in which year they currently are in and whether their accommodation in their school year is in the dormitory or in a residence (flats or houses), the students were asked about the majority of their grades and of how much they spend on studies compared to the time they go and have fun with their friends outside studies, questions about the students opinion about the university was included and if they would study abroad or not and whether they would attend the same university or not if they could start over again.

Concerning the lifestyle behavior, questions were asked about personal habits such as smoking, drinking, exercising, and participating in school sports events and tournaments, also involved questions about the students’ nutrition and diet. Moreover the students’ emotions were mentioned and how it is affecting their relationship with people surrounding them.

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Furthermore, two questions about their relation and contact with their parents were asked, and about how many times per year they travel back to their home countries during the school time.

Last but not least, the subjective health which involved descriptive questions about how the students can describe their health now and how they can compare it to one year ago, and about the presence of health insurance and how their health and emotions have affected their working frequency and capacity.

STATISTICS:

Later on, after collecting all the results from all the students, the SPSS 25th version for windows program (SPSS Inc., Chicago, IL, USA) was used to conduct and to do the statistical analysis. The data was analyzed by assessing and comparing results by the study year.

Chi square test was used to analyze the data and statistically significant differences were established when p-value was <0.05

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11. RESULTS

11.1 FIRST AND FIFTH YEAR INTERNATIONAL MEDICAL

STUDENTS’ LIFESTYLE

11.1.1 DESCRIPTION OF THE PARTICIPANTS CHARACTERISTICS.

In this part of the results, questions were focusing on how the students accommodate and try to adapt in the new environment they live in. Therefore, questions about students’ accommodation, number of friends, studies time as well as leisure time, students’ opinion about the university and whether they would choose it again if they could were asked.

From the first year international medical students: the sample involved 50 students, which 19 (38%) of them accommodate in residence while 31 (62%) live in the universities’ dormitory. Among them, 25 (50%) live alone, 23 (46%) live with students from the same university, 1 (2%) live with students from other universities, while 1 (2%) live with their partners. 3 (6%) of students have no friends, 17 (34%) have 1-2 friends, 30 (60%) have 3 friends or more. 18 (36%) of the students’ informed that the majority of their marks is between 9-10, 24 (48%) between 7-8, and 8 (16%) between 5-6. About the studying hours, students reported that 9 (18%) of them study 5 or few h /week, 15 (30%) study 6-10 h/week, 13 (26%) study 11-15 h/week, 9 (18%) study 16-20 h/week and 4 (8%) study more than 20 h/week. However, on the other hand, 15 (30%) of these students stated that their leisure times are every day, 15 (30%) have leisure activities every weekends, 12 (24%) at the end of modules and 8 (16%) chose others as their answer. The final part of this section was about students’ opinion about the university, 7 (14%) said that they don’t like it, 21 (42%) that they are more or less neutral about it, and 22 (44%) like it. Moreover, 32 (64%) among them would attend the university again if they got to choose again while 18 (36%) would not.

On the other hand, fifth year international medical students reported that among them 40 (80%) live in residences while 10 (20%) live in the universities’ dormitory. 20 (40%) live alone, 22 (44%) live with students from the same university, 1 (2%) live with students from different university and 7 (14%) live with their partners. Students’ revealed that 2 (4%) of them have no friends, 22 (44%) have 1-2 friends and 26 (52%) 3 or more. Furthermore, students conveyed that 13 (26%) of them study 5 or few h/week, 8 (16%) study 6-10 h/week, 10 (20%) study 11-15 h/week, 14 (28%) study 16-20 h/week

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and 5 (10%) study more than 20 h/week. 9 (18%) of students said that the majority of their marks is between 9-10, 35 (70%) said it is between 7-8, while 6 (12%) said it is between 5-6. Also, leisure times were evaluated, and 5 (10%) of fifth year medical students stated that it is every day, 26 (52%) said it is every weekend, 12 (24%) said it is at the end of modules and 7 (14%) chose others as their option. The students’ opinion about the university was questioned and 9 (18%) said that they don’t like it, 30 (60%) are more or less neutral about it, while 11 (22%) like it. Further to include, 28 (56%) of the students said that they would choose the same university if they could choose again while 22 (44%) said that they would not.

11.1.2 THE PSYCHOLOGY OF MEDICAL STUDENTS AND ITS’ EFFECT.

The students’ psychology is the first thing to be affected when they start a new university in a new country. Some feels lonely, depressed, stressed, anxious, and unable to sleep the night while others demonstrate no special effects.

Table 1. Students’ psychology

First year students Count Fifth year students Count Statistics analysis Never Sometimes always Never Sometimes always

Lonely in the past 5months n=18 36% n=27 54% n=5 10% 50 100% n=13 26% n=31 62% n=6 12% 50 100% χ2= 1.173 df= 2 p= 0.556 Worried that couldn’t sleep n=18 36% n=25 50% n=7 14% 50 100% n=11 22% n=33 66% n=6 12% 50 100% χ2= 2.870 df= 2 p= 0.238 Yes No Yes No Sleep 8h/night n=10 20% n=40 80% 50 100% n=24 48% n=26 52% 50 100% χ2=8.734 df= 1 p= 0.003

20 Sleep easily through the night n=26 52% n=24 48% 50 100% n=32 64% n=18 36% 50 100% χ2= 1.478 df= 1 p= 0.224

Table 2. Students’ psychology and its’ effect on their work/activities

Students’ emotional problems affecting work/activities in the last 4 weeks:

First year students Fifth year students

cut down the time spent on work/activities n=11 22% n=12 24% accomplished less n=8 16% n=16 32%

didn’t do work carefully n=13

26%

n=7 14%

no effect on duration or quality n=18 36% n=15 30% Count of students: 50 100% 50 100% Statistical analysis: χ2= 4.783, df= 3 and p= 0.188

Based on the result observed in table 1 and 2, we can conclude that the majority of first and fifth year international medical students either felt worried or felt lonely proving the involvement of their psychology. Furthermore, the psychology of the majority of the first year students is affecting their sleeping quality and duration as well as their work/activities quality and duration. However, the psychology of the majority of fifth year students is affecting their work/activities quality and

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11.1.3 THE LIFESTYLE OF MEDICAL STUDENTS TOGETHER WITH THEIR COPING STRATEGIES.

Besides the psychology, the lifestyle is another factor to be affected during this new journey. Students tend to gain coping strategies during the study years, which can be positive or negative.

Table 3. Students’ lifestyle behaviors

First year students count Fifth year students count Statistics analysis Yes No Yes No Smoking n=22 44% n=28 56% 50 100% n=23 46% n=27 54% 50 100% χ2=0.040 df= 1 p=0.841 Alcohol consumption n=31 62% n=19 38% 50 100% n=30 60% n=20 40% 50 100% χ2= 0.042 df= 1 p= 0.838 30mins of exercise daily n=22 44% n=28 56% 50 100% n=27 54% n=23 46% 50 100% χ2= 1 df= 1 p= 0.317 Member of sport club or group n=23 46% n=27 54% 50 100% n=16 32% n=34 68% 50 100% χ2= 2.060 df= 1 p= 0.151 Participation in school sports’ tournaments n=21 42% n=29 58% 50 100% n=12 24% n=38 76% 50 100% χ2= 3.664 df= 1 p= 0.056

Based on the results shown in table 3, we can finalize the results as that students in both groups are drifting away from the healthy coping strategies such as being active and exercising or

participating in schools’ tournaments or activity groups and that they are producing maladaptive coping strategies either with smoking or alcohol consumption.

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11.1.4 THE NUTRITIONAL HABITS OF MEDICAL STUDENTS.

Students’ transition to university life will give them the lack of restrictions to choose the type and the amount of food they eat. Furthermore, these new food habits students are establishing are not essentially healthy [29].

Table 4. Students’ nutritional habits

First year students Count Fifth year students Count Statistics analysis

Yes No Yes No

Manage body weight and image

n=30 60% n=20 40% 50 100% n=24 48% n=26 52% 50 100% χ2= 1.449 df= 1 p= 0.229 On a calorie restricted diet n=9 18% n=41 82% 50 100% n=9 18% n=41 82% 50 100% χ2= 0 df= 1 p= 1 Food habits changed from home n=23 46% n=27 54% 50 100% n=25 50% n=25 50% 50 100% χ2= 0.160 df= 1 p= 0.689 Eat 3 meals/day n=19 38% n=31 62% 50 100% n=35 70% n=15 30% 50 100% χ2=10.306 df= 1 p= 0.001 Eat 5 fruits/ veggies daily n=7 14% n=43 86% 50 100% n=20 40% n=30 60% 50 100% χ2= 8.574 df= 1 p= 0.003

Limit sugar and salt intake n=18 36% n=32 64% 50 100% n=26 52% n=24 48% 50 100% χ2= 2.597 df= 1 p= 0.107 Get nutritional supplements n=17 34% n=33 66% 50 100% n=23 46% n=27 54% 50 100% χ2= 1.500 df= 1 p= 0.221

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Table 5. Students’ diet

Special diets:

First year students Fifth year students

No special diet n=42 84% n=43 86% Vegetarians n=2 4% n=2 4% Vegans n=1 2% n=3 6% Gluten free n=4 8% n=1 2% Lactose free n=1 2% n=0 0% Pescetarians n=0 0% n=1 2% Count of students: 50 100% 50 100%

Statistical analysis: χ2= 4.812 , df= 5 and p= 0.439

Based on the results seen in tables 4 and 5, conclusion can be summarized as first year

international medical students are not following a healthy diet specially because the majority don’t consume 3 meals daily nor they eat at least 5 fruits or vegetables per day and also because the majority do not limit their sugar and salt intake. However, fifth year international medical students are not consistent with a healthy diet since their majority do consume 3 meals daily and do limit their sugar and salt intake but do not eat at least 5 fruits or vegetables per day. Furthermore, these

following results indicate the need for rising more awareness towards healthy diet and healthy nutritional habits in the students’ life.

11.1.5 STUDENTS’ RELATION AND CONTACT WITH THEIR FAMILIES.

Family is the main support system a student will need, therefore keeping a regular contact and regular visitation to them may show a big advantageous effect on both the psychology and the attitude of the students.

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Our study has showed that 48 (96%) of first year students are in regular contact with their families while only 2 (4%) among them are not. As well as 41 (82%) of first year students travel back home during the school time and 9 (18%) do not. Whereas, for fifth year students 45 (90%) have regular contact with their families and 5 (10%) do not, furthermore, 43 (86%) do travel back home during the school time while 7 (14%) do not.

Regular contact with their family showed the statistical analysis of χ2= 1.382, df=1 and p=0.240. Furthermore, travelling back home during the school year presented χ2= 0.298, df=1 and p= 0.585.

11.2 FIRST AND FIFTH YEAR INTERNATIONAL MEDICAL

STUDENTS SUBJECTIVE HEALTH.

The physical health of students has an impact on everything starting from their academic performance to success far along in their future lives. Therefore, our study concentrated on how students reflect their health profile and how they describe it.

Table 6. Students’ health

First year students count Fifth year students Count Statistics analysis Yes No Yes No Health insurance n=49 98% n=1 2% 50 100% n=46 92% n=4 8% 50 100% χ2= 1.895 df= 1 p= 0.169

Excellent Good Poor Excellent Good Poor Health in general n=7 14% n=40 80% n=3 6% 50 100% n=10 20% n=35 70% n=5 10% 50 100% χ2= 6.586 df= 2 p= 0.159 Better now The same Worse now

Better now The same

Worse now

25 Compared to one year ago n=9 18% n=38 76% n=3 6% 50 100% n=10 20% n=35 70% n=5 10% 50 100% χ2=1.775 df=2 p= 0.620

Table 7. Students’ health and its’ effect on their work/activities

Students’ physical health affecting work/activities in the last 4 weeks:

First year students Fifth year students

cut down the amount of time spent on work/activities n=10 20% n=11 22% Accomplished less n=11 22% n=18 36% had difficulty performing work/activities carefully n=9 18% n=5 10% has no effect on duration/quality of work/activities n=20 40% n=16 32% Count of students: 50 100% 50 100%

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Table 8. Students’ psychology and health and its’ interference with their social life.

Students’ physical health and emotional problems interfering with their social life in the last 4 weeks:

First year students Fifth year students

not interfered n=18 36% n=21 42% Slightly interfered n=27 54% n=22 44% Moderately interfered n=3 6% n=2 4% Extremely interfered n=2 4% n=5 10% Count of students: 50 100 50 100

Statistical analysis: χ2= 2.227, df= 3 and p> 0.527

From the previous tables 6,7 and 8, we can conclude that the majority of both year groups have described their subjective health as good and that it is about the same as one year ago. Moreover, we can conclude that their physical health has affected their work/activities quality and duration and together with their emotional problems, they have slightly interfered with the students’ social lives.

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11.3 COMPARISION BETWEEN FIRST AND FIFTH YEAR

INTERNATIONAL MEDICAL STUDENTS SUBJECTIVE HEALTH

AND LIFESTYLE.

Based on the results shown above, we can all in all see that international students in different years are proved to show statistical significance in 5 aspects.

First being the accommodation during the study year, second being the fun and going out hours during the school time, third being the sleeping hours, fourth being the number of vegetables or fruits eaten per day and fifth being the number of meals they eat daily.

Figure 1. Students place of accommodation

Fig. 1 shows that the majority of first year international student are shown to accommodate in the dormitory while fifth year international students accommodate in residences (flats/houses) during their study year. While doing the statistical analysis P value was found to be 0,001 (<0,05), df= 1 , and χ2= 18.231 showing statistical significance between the study years.

38% 80% 62% 20% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

first year students fifth year students

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Figure 2. Students’ leisure time

Furthermore, fig. 2 demonstrates that first year international students’ leisure time during the period of their studies is either every day or every weekend while for fifth year international students every weekend or at the end of their module. More to include is that while doing the statistical

analysis P value was found to be 0,046 (<0,05), df= 3 , and χ2= 8.018 showing statistical significance between the years.

30% 10% 30% 52% 24% 24% 16% 14% 0% 10% 20% 30% 40% 50% 60%

first year students fifth year students

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Figure 3. Students sleeping 8 hours/night.

Fig. 3 illustrates students’ sleeping hours. It showed that both years students’ majority do not sleep 8 hours per night. However, those who sleep the full 8 hours in first year compared to fifth year showed statistical significance with the P = 0.003 (<0,05), df= 1 and χ2= 8.734

20% 48% 80% 52% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

first year students fifth year students

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Figure 4. Consumption of 5 fruits or vegetables per day

Fig. 4 simplify the number of vegetables or fruits eaten per day, the study showed that the majority of both years’ students do not eat at least 5 fruits and vegetables per day. However, the statistical analysis of P value comparing those who eat in first year compared to those in fifth year was found to be equal to 0.003 (<0.05), df= 1, and χ2= 8.574 proving statistical significance between the years. 14% 40% 86% 60% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

first year students fifth year students

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Figure. 5 Students eating 3 meals per day.

Fig. 5 shows that a significant number of fifth year international students eat 3 meals a day while the majority of first year international student do not with P value being equal to 0.001 (<0.05), df=1 and χ2= 10.306 proving statistical significance between the years.

Moreover, the other topics showed no significant difference and the different years showed similar results. Starting with whom students are accommodating, students in both years presented to be accommodating either alone or with students from the same university. Furthermore, both years showed to have similar opinion about the university as both years are more or less neutral about it, similar majority of marks and similar number of friends. Also showed similar behavior of smoking and consuming alcohol, both showed low physical activity and not being members neither in school group or activities nor the gym. Additionally, students food habits have been looked through and it showed that both year have equivalent results as in both years it has changed from their home town, both years majority follow no specific diet, both years limit their salt and sugar intake, both years majority do not take nutritional supplements as well as not being on a calorie restricted diet.

Students’ subjective health now compared to one year ago as well was described equivalently as ‘the same as one year ago’ in both years also majority of students in both years generally described their health as ‘good’. Students’ contact with their parents is more or less the same in both years. The

38% 70% 62% 30% 0% 10% 20% 30% 40% 50% 60% 70% 80%

first year students fifth year students

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majority travel back home during the study year. Also, students in both years showed that they do face similar levels of emotional or physical problems with similar effects of these problems on their working and studying hours and capacities. Last but not least, students’ psychology was evaluated as well and it surprisingly showed similar results in both years as well.

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12.

DISCUSSION

In our discussion we looked at different studies and various publications that met related goals and objectives like our study. We chose up to 36 studies that focused on the stress that medical students face, on their behavioral lifestyles which students chose as a way of coping, students’ nutritional and dietary habits, sleeping patterns and quality and finally students’ subjective health. Results were proved to be similar to ours in certain topics and different in others.

12.1 STRESS AMONG STUDENTS

Stress was the first factor evaluated in our study. Stress have different types, various predictors and multiple reasons which were exemplified in various studies. (Chan et al., 2011; Chernomas and Shapiro, 2013; Wolf et al., 2015) [33, 35-36] showed that students with low levels of self-esteem or lower confidence were found to have higher levels of stress, whereas (Gibbons et al., 2011) found that students with high levels of dispositional control, self-efficacy and support were less stressed [2].

Moreover, academic performance, lack of recreation and leisure time, curriculum, examination frequency as well as foods’ quality can be tensing for students [3] and as a consequence, students’ start having sleeping difficulties, skin symptoms, losing hair, sweating , nails biting as well as many more effects and results [3-4].

All studies together with our study have showed that medical students face various degrees of stress [1, 3-5]. However, our study results showed that there’s no statistical difference in the stress level between the two groups being evaluated, which was surprisingly quite the contrary of the stress levels evaluated in different studies which showed that first year students are more prone to stress and anxiety which induced other symptoms [4].

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12.2 COPING STRATEGIES STUDENTS ARE EVOLVING

The second variable evaluated was coping. Our study in addition to previous studies demonstrated different adaptive and maladaptive coping strategies that students evolved as a

response to either the intrinsic factors such as the clinical year [31-35] or the extrinsic factors which is mainly the environment [35-36] that they face [2].

Studies made by (Terebessy, 2016; Chu et al., 2016; Gawlikowska-sroka, 2009; voigt, 2009; balogh, 2018) [14-18] together with ours have showed that students are maladaptively leaning to smoking, alcohol consumption as well as to unhealthy dietary habits as a way for combatting their anxiety and stressful event. While other publications written by (Sreeramaredy,2007; Sami,2011; Bunmi, 2011) [1, 11-12], showed that students are implementing fit and applaudable adaptive strategies, such as exercising, having their families and friends as a source of emotional support, listening to music, becoming more religious as well as acceptance.

Table 1. Smoking, alcohol consumption, unfit dietary habits and physical activity prevalence in student’s population according our study and other publications

Population Smoking prevalence Alcohol consumption Unfit dietary habits Physical exercise country Medical students in LUHS 45% 61% 46% 49% Lithuania (international students) Medical students in Semmelweis university 18.6% 13.8% 84.7 75% Hungary (international students) Medical students in German university No data 40.6% 10.7% 48.8% Germany (Chinese students) Students in Pomeranian Medical University in Szczecin, Poland

20% No data No data No data Poland (international

students)

Students in Dresden Medical

School

21.5% 75% No data No data Germany

Students in Dresden and

Munich universities,

18.6% No data No data No data Germany and Hungary

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Semmelweis and Pecs universities

This table demonstrate how students in different countries and different universities adapt inversely to stress and implement various techniques to deal and cope with their difficulties. Some are more likely to lean to physical activity as a way of stress relieving while others can be heaved to the consumption of harmful substances (alcohol, drugs, and cigarettes).

12.3 STUDENTS’ NUTRITIONAL HABITS

The third factor evaluated was nutritional habits. Dietary changing and shifting to the unhealthy profile even while having the knowledge and being aware of the nutritional value can be triggered by various stimuli which require an important attention to solve and change it. Students’ unhealthy profile can be exposed as weakness, no concentration, lack of attention, bad academic performance and even unhealthy physical appearance [29].

The results from our study demonstrate a lower intake of fruits and vegetables per day but a good meal intake daily as well as a higher percent of those with dietary changes, these results prove that students’ are somehow aware of the importance however, they are not acting correctly to achieve the healthy lifestyle they know. These dietary changes and the shifting toward the unhealthy profile that are triggered by various stimuli, require an important attention to solve and change it since similar results and concerns where met among our study and other publications [14, 19-25, 30].

Table 2. Nutritional habits in student’s population according our study and other publications

Population Unfit dietary habit Consumption of fruits and veggies regularly

Country

LUHS students 46% 27% Lithuania

Malaysian university 42.2% 73.5% Malaysia Semmelweis university 84.7% No data Hungary

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Medical students in German university

10.7% No data Germany

In table 1 and 2, we can see that the significant unhealthy nutritional habits are seen in correlation with those students who are also smoking cigarettes, and consuming alcohol.

12.4 STUDENT’ SLEEPING HABITS

The fourth factor evaluated is the sleeping habits. Our study showed that more than two third of our students do not sleep the full 8 hours per night however, their sleeping quality is considered to be good since around 58% sleep easily through the night, and 42% find difficulty in sleeping. Our study factors and results were very similar compared to previous studies [3, 27-28]. However, in our results those that did not have enough hours of sleeping were first years’ students, that if compared to study [26] it states the opposite, showing that clinical years’ students show significant lower sleeping hours.

Table 3. Students’ sleeping patterns in our study and other publications.

Population Sleeping >8 hours Easily sleeping Country

LUHS students 34% 58% Lithuania

Metropolitan medical schools’ students

24.9% No data unknown

Saudi medical schools’ students

No data 70% Saudi Arabia

Spanish universities’ students

No data 96.5 Spain

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12.5 STUDENTS’ SUBJECTIVE HEALTH

The last factor evaluated was subjective health. Our study showed that the majority of students described their health as ‘good’ in addition to other published results students which reported their health as very good/excellent results. Publications made by (Henna, 2016; Terebessy,2016)

mentioned that health can be influenced and hindered by variety of factors which can include country of origin, stress, finance, smoking, drinking alcohol as well as many others [6, 14].

Table 4. Students’ health perception in our study and other publications

Population Health perceived as very good/ excellent

Health perceived as good Country

LUHS students 17% 75% Lithuania

Norwegian students 84.5% 15% Germany and Hungary

Hungarian students 60.3% 32.5%

German students 70.7% 21%

Furthermore, our study included several other variables that were not evaluated in previous studies including accommodation, grades, studying hours per week, the frequency of leisure activities per week, attitude towards the university and studies, number of friends, family contact.

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13.

CONCLUSION

1- Most of first and fifth year international students are seen to be implementing unfit lifestyle and misadjusting to stress since their majority are smoking, consuming alcohol, having unhealthy diets and nutritional habits without valuing their knowledge towards the importance of regular meals, and appropriate number of fruits and vegetables per day as well as limiting their intake of salt and sugar. In addition, among these students only a minority are physically active as they are joining gyms and participating in school tournaments.

2- The majority of first and fifth year international students described their health profile as good, the same as one year ago and slightly interfering with their social life showing that the amount of stress and workload is not affecting their health profile.

3- Fifth year international students have better lifestyle and better coping strategies due to their higher level of education than first year international students. It is seen based on the results that the majority of fifth year students daily consume 3 meals (p=0.001) while on the other hand do not consume 5 vegetables and fruits (p=0.003). Moreover, students of the fifth year are seen to be having less of a leisure time, only at the weekends compared to the first year students which are spending fun times every day and every weekends (p= 0.046). Furthermore, the majority among students of fifth year are seen to be sleeping less than 8 hours per night, however less than the percent of first years that do so (p= 0.003). Whereas, the health aspect is seen to be similar in the two groups with both years popular health description being ‘good’.

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14. RECOMMENDATIONS

It is of a great importance that the university and its’ staff educate the students and increase their knowledge about healthy ways for adapting and coping to the new environment they are living in as well as to the high level of stress they are facing, awareness about the harmful effects of smoking and consumption of alcohol on their body should also be increased, as this is the main way students face their stress with. Also, various ways and techniques for healthy sleeping patterns and qualities should be introduced to the students, as healthy sleep can be demonstrated in healthy lifestyle, healthy psychology and healthy educational results as well. Students should be educated more about the benefits of healthy nutritional habits such as eating 3 meals daily, eating lots of vegetables and fruits and limiting their sugar and salt intake as well. Furthermore, programs and strategies to promote health and wellbeing should be provided to the students.

Moreover, ways for students to combat these stressful events can be by physical exercising, joining members and groups, or and joining gyms. Leisure times every weekends can be of a positive effect on their psychology. Regular contact with friends, family can also support them and give them a push to continue and face their difficulties.

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16. ANNEXES: