Prevalence of Depression, Anxiety among International Students in the Health Professions at Southern Medical University, P. R.

Introduction: International students experience acculturative stress during the adaptation period into a new country, leading to the development of mental health issues such as depression and anxiety. This issue may be particularly important for international students in the health professions who are exposed to more stressors than usual. This study aims to determine the prevalence of depression, anxiety, and associated factors among international students in the health professions. Methods: This study employed a descriptive cross-sectional research design. A sample of 114 international students from Southern Medical University (SMU) was screened for depression and anxiety using the Hospital Anxiety and Depressive Scale (HADS) during the 2019-2020 academic year. Descriptive statistics, including percentages and frequencies, were performed to determine the prevalence of depression and anxiety. Multiple linear regression analysis was utilized to examine associations between depression and anxiety and socio-demographic characteristics. Results: Overall, the prevalence of depression and anxiety was found to be 36% and 52.63%, respectively. Undergraduate students studying medicine and postgraduates pursuing master’s degrees in Plastic Surgery and Laboratory Science had the highest levels of anxiety (60%), while Ph.D. students had the highest level of depression (50%). The period of study in China (p = 0.037), the discipline of study (p = 0.004), and the level of preparedness for coming to China (p = 0.037) were significant predictors of depression, while the discipline of study (p = 0.004) and socialization (p = 0.040) were significant predictors of anxiety. Conclusion: The prevalence of depression and anxiety among the study population was relatively predictors of depression, while socialization was a significant predictor of anxiety. The discipline of study was a predictor of both depression and anxiety. Provision of key information before students arrive in the host country, access to multilingual interactions with school counselors and current students, and social and academic contacts with domestic students are recom-mended to mitigate the adverse effects of stress faced by international students in the health professions.


Introduction
Depression and anxiety are common mental illnesses among students in the health professions. Recognition of the factors that cause stress among this population has gained more traction in recent years. Two recently published meta-analyses reported that the global prevalence of depression and anxiety among medical students was 27.0% (Tam, Lo, & Pacheco, 2019) and 33.8% (Quek et al., 2019). According to a systematic review by Ngasa et al. (2020), the prevalence of depressive symptoms among medical students in Africa is between 23.3% and 76.5%. Among medical students in China, the mean prevalence of depression and anxiety was 32.74% and 27.22% receptively (Mao et al., 2019). Studies from various parts of the world conclude that the prevalence of depressive symptoms is higher among students in the health professions than in individuals in the same age group in the general population (AlFaris, Irfan, Qureshi, Naeem, Alshomrani, Pon-namperuma et al., 2016;Felicilda-Reynaldo et al., 2019;Gomathi, Ahmed, & Sreedharan, 2012;Kebede, Anbessie, & Ayano, 2019;Rotenstein, Ramos, Torre, Segal, Peluso, Guille et al., 2016). However, the majority of these studies focused on domestic medical students and generally overlooked international students in the health professions.
While crucial mental health and well-being concerns for international students have been identified, factors influencing the mental health of international students enrolled in health degree courses have yet to be fully determined. Unlike domestic students, international students are likely to have unique characteristics in that they are away from home, and may face several negative experiences during the adjustment process into a new country and culture. International students may develop feelings of hopelessness, depression, and anxiety due to acculturative stress (Deb, McGirr, & Sun, 2016;Philip, Colburn, Underwood, & Bayne, 2019;Sümer, Poyrazli, & Grahame, 2008;Wen & Hu, 2018).
Furthermore, the environment of health professional education institutions provides unique and significant stressors for students in the health professions.
This may be particularly important for international students in the health pro- fessions who are exposed to more stressors than usual that could cause them to develop depression and anxiety. If left unchecked, the consequences of depression and anxiety will not only have a noticeable negative effect on students' function in school but also later on in their careers as they deliver services to individuals, families, and communities (Deb et al., 2016;Pan, Wen, Zhao, Hu, Li, Zhang et al., 2016). Considering the challenges faced by international students in the health profession, their mental health condition needs further investigation (Moutinho et al., 2017). Moreover, China has a growing population of international students, but only a few studies on depression and anxiety among this population are covered in the English language literature (Liu et al., 2016).
Therefore, it is essential to bring more attention to this topic to understand the extent and severity of the problem. This study aims to determine the prevalence of depression, anxiety, and the associated socio-demographic factors among international students in the health professions studying at Southern Medical University (SMU) in Guangzhou, China.  (Yu et al., 2014). There are approximately 328,000 students from more than 200 countries and regions across the globe in China (Yu et al., 2014). With the rise in the number of international students in China, there is a need to examine and evaluate the mental health issues developed by these students as they adapt to China's culture, norms, and expectations (Yu et al., 2014).

Depression and Anxiety among International Students
Studies show that due to adjustment problems, international students face a higher risk of developing mental health problems such as depression and anxiety (Dao, Lee, & Chang, 2007;Liu et al., 2016;Sümer et al., 2008;Hu & Zhang, 2013). A study among international students in a United States university revealed that 45% of the students had depressive symptoms, while 24% were suffering from anxiety (Shadowen, Williamson, Guerra, Ammigan, & Drexler, 2019). Another study carried out on a sample of international students in northern Japan indicated that 41% of the participants had depressive symptoms (Eskanadrieh et al., 2012). Several authors have demonstrated that unlike domestic students, international students are faced with several challenges that hinder their adjustment and affect their mental health (Ogunsanya, Bamgbade, Thach, Sudhapalli, & Rascati, 2018;Skromanis et al., 2018;Yeh & Inose, 2003). A study carried out in Japan indicated that the prevalence of depressive symptoms among international students was 37.1%, which was higher than that of domes-Open Journal of Social Sciences tic students at 29% (Nguyen, Le, & Meirmanov, 2019). Influential factors such as language competency, lack of preparedness, lower income, lower educational attainment, and high anxiety affect their mental health and well-being (Ogunsanya et al., 2018).

Mental Health Challenges among International Students in the Health Professions
Health professional education institutions around the globe have long been considered stressful environments for students entering tertiary education due to the long hours of study, and the stress associated with the high workload (Haldorsen, Bak, Dissing, & Petersson, 2014). For international students pursuing health professional courses, their stress is further compounded by learning difficulties, acculturative stress, cultural stress, financial burdens, and the fact that they are required to engage in complex communication in foreign languages (Malau-Aduli, 2011;McKenna et al., 2017;Yeh & Inose, 2003). This complex situation is true for both undergraduate and postgraduate international students. However, for international graduate students, the combination of a rigorous postgraduate education with the challenges of dealing with a different environment and culture could add even more stress that could lead to mental health issues (Ogunsanya et al., 2018).
Language barriers, poor social adjustment, and stigma on mental health prevent most international students, especially from Asian and African countries from seeking much needed psychological assistance (Hyun, Quinn, Madon, & Lustig, 2007;Iskra, 2017;Poyrazli et al., 2004). The level of social adjustment depends on the international student's ability to interact with members of the host country (Poyrazli, Kavanaugh, Baker, & Al-Timimi, 2004). Reduced levels of social interaction with the members of the host country can lead to cultural stress (Iskra, 2017;Poyrazli et al., 2004). Depression and anxiety amongst students in the health profession students not only affects students' lives but may perhaps also have ramifications on patient care in the end (Puthran, Zhang, Tam, & Ho, 2016).

Variables Related to Depression and Anxiety
Studies show that socio-demographic factors influence the manifestation of mental health issues in university students; however, there are inconsistent associations between factors such as age, marital status and religion, and the indication of mental health issues such as depression and anxiety (Gulec Oyekcin, Sahin, & Aldemir, 2017). Furthermore, inconsistencies are present in studies assessing factors such as gender and ethnicity that contribute to depression and anxiety in university students (Gulec Oyekcin et al., 2017;Jasso-Medrano & López-Rosales, 2018;Sarokhani et al., 2013;Shamsuddin, Fadzil, Ismail, Shah, Omar, Muhammad et al., 2013). A study in Malaysia showed a noteworthy correlation between gender, age, and mental health issues in university students (Shamsuddin, Fadzil, Ismail, Shah, Omar, Muhammad et al., 2013). A study in Kenya indicated a significant link between religion, age, and depressive symptoms among univer-  (Othieno, Okoth, Peltzer, Pengpid, & Malla, 2014).
Studies among international students also show inconsistent relationships between socio-demographic factors and levels of depression and anxiety. A study in the United States on international students showed a significant correlation between age, English proficiency to both depression and anxiety, but no association was found between gender and student's depression and anxiety levels (Sümer et al., 2008). Another study in northern Japan indicated a correlation between gender and depression (Eskanadrieh et al., 2012), while another study in southern Japan found no association between age, gender, and depression among international students, but noted a positive relationship between the length of stay and depression (Nguyen et al., 2019). Reports also indicated that international students face financial constraints that have a significant impact on Studies show that poor English language proficiency while studying in English speaking developed countries affects academic performance, leading to stress and mental health issues for international students in the health professions (Mori, 2000;Yeh & Inose, 2003). There is little research to ascertain whether this is true for international students studying in China. Universities in China offer courses in both English and Chinese. A majority of international students in the health professions in China's higher education intuitions are enrolled in English-taught courses. However, these students still face language barriers and difficulties navigating with little to no Chinese proficiency on University campuses.
It is important to ascertain whether these factors pertain to international students in the health professions studying at SMU. Therefore, the study aims to examine the variables covered in literature such as age, gender, socio-economic status, the discipline of study, length of stay in the country, including preparedness, socialization, and Chinese language proficiency and their relation to the manifestation of depressive symptoms and anxiety among international students in the health professions in this setting.

Research Questions
1) What is the prevalence of depressive and anxiety symptoms among international students in the health professions at SMU?
2) Is there a relationship between socio-demographic characteristics and mental health among the study population?
3) What are the socio-demographic predictors of depression and anxiety among the study population?

Setting and Population
This study was carried out on both graduate, and undergraduate international

Study Design and Sampling
This study employed a descriptive cross-sectional research design. Participants of the study were requested to complete an online-based questionnaire containing items about their socio-demographic characteristics and mental health status at the end of the fall semester in the 2019-2020 academic year (January 2020). A Sample of 114 international students from SMU participated in this study by completing an online survey.
Students who agreed to participate in the study were screened according to the following inclusion and exclusion criteria.

Inclusion criteria
• Students of foreign nationality.
• Came to China to obtain a formal education.
• All international graduate and undergraduate students pursuing medicine and healthcare science degrees, where English is the primary medium of instruction.

Exclusion criteria
• Refusal to participate in the study.
• Students with Chinese Citizenship.

Description of the Procedure
The study obtained approval from the Ethics Committee involved in research at SMU before subject recruitment and data collection. The questionnaire was distributed online through class monitors on the students' specific WeChat class

Socio-Demographic Data
The questionnaire used in the study comprised of self-designed questions on the socio-demographic characteristics of the study population. Data collected included age, gender, marital status, religion, country of origin, educational level (undergraduate or graduate), the discipline of study, social-economic status, length of stay in China, and proficiency in the Chinese language. An item measuring the student's social contact patterns was included to assess which groups of people they socialized with the most-Chinese or non-Chinese students.

Hospital Anxiety and Depressive Scale (HADS)
Depressive and anxiety symptoms were measured using the Hospital Anxiety and Depressive Scale (HADS). HADS is a commonly used scale to assess depression and anxiety levels in an individual (Djukanovic, Carlsson, & Årestedt, 2017). The questionnaire contains 14 questions, with seven items related to depression and another seven related to anxiety. Each item has a score ranging from 0 -3. Thus, depending on the level of depression and anxiety, the scores can vary from 0 -21 (Bocerean & Dupret, 2014). The cut-off score for each subscale is a score greater or equal to 8 (Kebede et al., 2019;Tesfaw et al., 2016).

Data analysis and Management Procedures
Statistical Package for Social Sciences (SPSS) version 25 was used to tabulate and analyze data obtained. Descriptive statistics including percentages, frequencies, means, and standard deviations were utilized to analyze the variables concerning the study participants. The study used multiple linear regression analysis to examine associations between depression and anxiety and socio-demographic characteristics.

Socio-Demographic Characteristics of the Students
Out of the 114 students that participated, 49.12% identified as female and 50.88% identified as male (see Table 1 to 5 years. The findings captured by the study indicated that most students (72.81%) rated themselves as not proficient in the Chinese language. In comparison, less than a third (27.19%) rated themselves as proficient in the Chinese language. In terms of socialization, the majority of the students (87.72%) socialized with non-Chinese students, while only 12.28% socialized with Chinese students.

Prevalence of Depression and Anxiety
Overall, the prevalence of depression and anxiety was found to be 36% (n = 41) and 52.63% (n = 60), respectively (see Figure 1). Findings show that the mean score for anxiety was 7.69 with a standard deviation of 4.25, while the mean score for depression was 6.49 with a standard deviation of 3.98. Two-thirds (64%) of the students fell within the normal range (0 -7) for depression, however less than half (48.2%) scored within the normal range for anxiety. Those that fell within the mild range (8 -11) were 22% and 24.6%, those within the moderate range (11 -14) were 9.6% and 21.1%, and those within the severe range (15 -21) were 4.4% and 6.1% for depression and anxiety respectively.  The study revealed that the prevalence of depression was highest among older students above 35 years of age (n = 11, 46%), while anxiety was highest among students between 18 to 24 years old (n = 48, 59%) (see Table 2). Female students showed higher levels of anxiety (n = 32, 57%) compared to male students (n = 28, 48%), while depression levels were the same for both genders (36%). Students from Europe, the United States, and Oceania countries were found to have higher scores for anxiety (n = 3, 60%). Whereas African students had higher scores for depression (n = 18, 42%), but the lowest scores for anxiety (n = 19, 45%).
Prevalence of depression and anxiety was highest for students who had been in China for one to two years (n = 21, 41%, and n = 28, 55% respectively) and lowest among students who had been in China for more than two years (n = 8, 31%, and n = 8, 31% respectively). Both first-year and second-year students, had a higher prevalence of anxiety (n = 15, 42% and n = 28, 55%) compared to third, fourth and fifth-year students (n = 8, 31%).

Students enrolled in MBBS and those pursuing master's degrees in Plastic
Surgery and Laboratory Science had the highest level of anxiety (n = 48, 60% and n = 3, 60% respectively), while Ph.D. students scored higher for depression (n = 2, 50%). Students from low socio-economic backgrounds had a significantly higher prevalence of depression compared to other socio-economic backgrounds (n = 10, 67%), however, those from middle-income socio-economic backgrounds scored higher for anxiety (n = 42, 55%). Prevalence of depression and anxiety was highest among students who did not prepare well before coming to China (n = 31, 40%, and n = 47, 60% respectively). Higher scores for anxiety were also reported from students who socialize with non-Chinese students (n = 55, 55%). Students who were not proficient in the Chinese language scored higher for depression (n = 39, 47%).

Multiple Linear Regression
Multiple linear regression was calculated to predict depression based on socio-demographic factors including socialization, Chinese proficiency, and period of study in China. The multiple linear regression revealed that the model accounted for 21.4% (R 2 = 0.214) of the variance (see Table 3). The F value of the model, (F(12, 100) = 2.264) was statistically significant at p-value = 0.014. The period of study in China (p = 0.037), the discipline of study (p = 0.004), and level of preparedness before coming to China (p = 0.037) were significant predictors of depression. Length of study was negatively correlated with depression (β = −0.104, p-value < 0.05). Thus, the longer international students lived in China, the less likely they were to suffer from depression. The discipline of study was also found to be a significant predictor of depression (β = −0.284, p-value < 0.05). The findings suggest that students who pursued Ph.D. were more likely to have higher levels of depression.
Likewise, a multiple linear regression was calculated to predict anxiety based on socio-demographic factors, including factors mentioned earlier. A significant regression equation was found (F(12, 100) = 1.930, p = 0.039, with an R 2 of 0.188 (see Table 4). The multiple linear regression revealed that the discipline (p = 0.004) and socialization (p = 0.040) were significant predictors of anxiety. The discipline of study and socialization were negatively correlated with anxiety (β = −0.331, p-value < 0.05, and β = −0.255, p-value < 0.05). The findings suggest that students who pursued MBBS and master's degrees in Plastic Surgery and Laboratory Science were more likely to have a higher severity of anxiety. The results also indicate that international students who socialized with Chinese students were less likely to report anxiety symptoms.

Prevalence of Depression and Anxiety
This study sought to determine the prevalence of depression and anxiety among international students in the health professions and their socio-demographic predictors. The study results indicate that the proportion of the students who had anxiety was higher than those who had depression. Over half (52.63%) of the students were found to have anxiety. The results of this study are in line with study results from Germany among international medical students, where about half (49%) were found to have moderate to severe levels of anxiety (Akhtar et al., 2019). Similarly, a study in Bahrain found that the magnitude of medical students with anxiety was (51%) (Mahroon et al., 2018) Hamed, 2017) using the Depression Anxiety Stress Scale (DASS 21) and higher than the global prevalence of 33.8% (Quek et al., 2019). Literature shows that the prevalence of anxiety was consistently higher among medical students compared to other students pursuing humanities and the general public, irrespective of the measuring scale utilized (Dyrbye, Thomas, & Shanafelt, 2006;Sahoo & Khess, 2010).

Predictors of Depression and Anxiety
The current study revealed that the period of study in China was a predictor of depression. The prevalence of depression was highest among students in their first and second year in China. The results of this study are echoed in other literature that indicates that international students were more depressed in their first year compared to the domestic students in the same academic year (Sümer et al., 2008). In contrast, other studies indicate that medical students in their third year had a higher likelihood of reporting symptoms of depression compared to students in the first year (Nguyen et al., 2019). The possible explanation for the higher rate of depression among first and second-year international students is due to the adjustment difficulties they experienced during their first two years in the host country, coupled with demanding coursework and feelings of loneliness while dealing with culture shock. A related factor is the level of preparation done by the students before coming to China. Findings from our study indicate inadequate preparation before coming to China is associated with depression. Students should be encouraged to learn as much about their new host country before leaving their home country. International education institutions can strengthen their provision of information and resources to new students before their arrival (Liu et al., 2016).
The study results indicate that the discipline of study is a predictor of depres- In this study, socialization is a predictor of anxiety. Students who socialized with Chinese students were less likely to have depression and anxiety. However, the majority of the students indicated that they socialize with non-Chinese Students. The main underlying issue that hinders students from socializing with Chinese domestic students could be the language barrier. A study regarding acculturative and depression among international students in China conducted by Liu, Y., et al. (2016) pointed out that international students who spoke English as their second language faced fewer challenges adjusting in English-speaking countries. The study continued to note that the social adjustment of these students might be more challenging in China since most Chinese are less likely to speak English as a second language (Liu et al., 2016). Programs to teach incoming international students the Chinese language go a long way in aiding the adjustment of international students into China. In addition to these programs, encouraging interactions between Chinese and international students could mitigate the social adjustment problems encountered by these students.

Limitations
There are several limitations to our study. First, the sample used in the study represents the total population of international students enrolled in the university taking courses where English is the primary medium of instruction. However, since the data was collected online, the return rate is only 11%.

Implications and Recommendations
The results of this study will assist educators and school counselors to identify international students in the health professions at risk of developing depression and anxiety. The long-term effects of depression and anxiety amongst these students have negative implications that extend to the individuals, households, and communities they will serve later in their careers. Therefore, early detection of depression and anxiety symptoms among this population is paramount and has a greater impact on our society as a whole.
The results of this study illustrate how inadequate preparation of international students before coming to China is associated with depression. To increase the level of preparedness of students before coming to China, education institutions can strengthen the provision of information on culture, norms and standards of the host university/institution and country including general information such as weather, school and local community maps with key locations to new students before and after their arrival. The provision of information before and after arrival into the host country reduces stress encountered by international students during the adaptation process into a new culture.
The study also found that the discipline of study is a predictor of depression and anxiety. We suggest education institutions increase awareness of and access to psychological support for students pursuing courses that are rigorous in nature since there are more susceptible to developing depressive symptoms and anxiety during their training.
The results of this study illustrate how inadequate preparation of international students before coming to China is associated with depression. To increase the level of preparedness of students before coming to China, education institutions can strengthen the provision of information on culture, norms and standards of the host university/institution and country including general information such as weather, school and local community maps with key locations to new students before and after their arrival. The provision of information before and after arrival into the host country reduces stress encountered by international students during the adaptation process into a new culture. Furthermore, we suggest institutions provide access to multilingual interactions with school counselors and current students who can assist, guide, and mentor students after they arrive and during their stay in the host country.
Social and academic interactions between Chinese and international students and cross-cultural communication training programs should be encouraged. This would have a favorable impact on the students' adjustment process and thereby alleviating acculturative stress and the development of mental health issues. Further research is needed to evaluate the potential reasons for the high rate of anxiety and depression and their associated factors among international students in the health professions.

Conclusion
The prevalence of depression (36%) and anxiety (52.63%) among the study pop-DOI: 10.4236/jss.2020.812014 178 Open Journal of Social Sciences ulation was relatively high. The length of time in China and the level of preparedness before coming to China were significant predictors of depression, while socialization was a significant predictor of anxiety. The discipline of study was a predictor of both depression and anxiety. The findings of this study highlight the growing need to shed more light on the mental health issues facing international students in the health professions.

Conflicts of Interest
The author declares no conflicts of interest regarding the publication of this paper.