The role of Perception of Academic Stress and Emotion-focused Coping Style for International Medical Students’ Mental Health in China

The role of Perception of Academic Stress and Emotion-focused Coping Style for International Medical Students’ Mental Health in China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The role of Perception of Academic Stress and Emotion-focused Coping Style for International Medical Students’ Mental Health in China Shisi Zhou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5372228/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Lots of previous researches had suggested that medical students are higher rates of mental health problems than other age-matched groups, however, there was little attention caring about international medical students’ mental health status and influential factors. The research aims to investigate the present mental health status of international medical students and assess the role of perception of academic stress, emotion-focused coping style in international medical students’ mental health in China. By using data of international medical students (17-27 years old) providing information on their demographics, Perception of Academic Stress, The Coping Style Questionnaire, Generalized Anxiety Disorder Assessment (GAD-7), the Center for Epidemiological Studies Depression Scale Revised (CESD-R10), the WHO Well-being Index Scale (WHO-5), this study found that the depression (mean score=13.55, SD=5.85) and anxiety (mean score=9.78 , SD=4.49) was high among international medical students, perception of academic stress was a significant positive predictor of depression (β=0.22) and anxiety (β=0.17) , the emotion-focused coping style was a significant negative predictor of depression (β=-0.90) and anxiety (β=-0.69) and have positive association with well-being (β=0.97). mental health the role of perception of academic stress emotion-focused coping style international medical students INTRODUCTION With the development of science and technology, more students choose to study abroad all over the world. For example, the number of international students has increased from 6.4–16.2% over the last decade in Canadian [ 1 ]. Besides cultural adaption, mental health of international students has also gained lots of attention from researchers. Studies showed that medical students are more prone to encounter variety of psychological problems than age-matched samples and the general population [ 2 , 3 ]. However, medical students studying in local are main participants which collected in these researches. China is a large receiving country for international students, and the majority of these students come from developing countries in Asia and Africa [ 4 ]. Western medicine is a favorable subject for international students who choose to study in China [ 5 ]. It is necessary to explore mental health and psychological well-being of international medical students studying in Chinese universities. University life is an important transition period in the improvement and preservation of mental health towards impartial adulthood, as they may have different subjects, new studying environment, being away from families and unrealized goals for future. Comparing to general university population, medical students are higher rate of various mental health problems in university stage [ 6 , 7 ]. It is also proved by numerous studies that anxiety and depression are highly prevalent among medical students [ 8 – 10 ]. Among medical students, mental health problems and psychological well-being of international medical students who facing more difficulties in cultural adaption, academic stress and new environment should be payed a special attention by researchers. Influenced by rapid development of society, people have continuous high expectation in life and stress is commonly experienced by most people. Stress refers to perception of discrepancy between environment stimulus and individual available resources [ 11 , 12 ]. The factors stimulating stress of university students are multiform, arising from academic and non-academic elements [ 13 ]. Academic stress contributes to the predominant factor of stress among most students, as they have to compete with other students, perform well in exams and survive academically for future graduation, and this stressful state likely to affect individuals’ life and mental health level [ 14 ]. Recently, studies have implied that academic stress emerges as significant mental health problems, like psychological adjustment and emotion experience [ 15 , 16 ]. International medical students face numerous academic tasks and there are little researches focusing on it. It is necessary to advance academic stress and its impact on mental health among international medical students. Coping styles have been proved to be a predictor of subsequent psychological adjustment to different negative life events, like serious disease [ 17 , 18 ]. There are different coping styles people may use to confront various situations. Emotion-focused coping style usually focused on the emotions generated by the problem and two different emotion-focused coping approaches (positive reappraisal which a problem is reinterpret through making a subjective benign appraisals; avoidance which deny or avoid negative emotion by escaping or avoiding) are examined in lots of psychological analysis [ 19 , 20 ]. In a cross-sectional research, positive emotion-focused coping is found to relate with higher levels of psychological well-being [ 21 ]. Mental health problems are also deeply explored with coping style [ 22 , 23 ]. International medical students facing heavy academical workload, limitations of time and cultural adaption may be more accessible to experience increased depression, more negative mood, less psychological well-being [ 24 ]. Unfortunately, few studies pay attention to international medical students. In summary, we are inspired to investigate the mental health status of international medical students and explore the importance of the perception of academic stress, emotion-focused coping style on international medical students’ mental health (depression, anxiety symptoms and well-being) in China. Underpinning previous works, we hypothesize that perception of academic stress, emotion-focused coping style have effect on mental health of international medical students. MATERIALS AND METHODS Participants The participants of this study were international medical students in China who came from different countries. Before the survey, it was confirmed that all the English questionnaires were understood by the participants. The perception of academic stress, coping style, generalized anxiety, depression and well-being were evaluated. In total, a sample of 116 international medical students was recruited in this study, their age 20.7 ± 1.94, on average. In the current study, 54.3% of the participants were female, while 45.7% of the participants were male. Most of the international participants are from Pakistan, Bangladesh, India. And their religion are also different, including Muslims, Hinduism, Islam, Christians. Table 1 showed the distribution of the participants by social demographic groups. Procedure Study was carried out in conformity with relevant standards and regulations, the permission was obtained from the Institutional Review Boards. This research was carried out from September to November 2023. All participants obtained the informed consent before completing the questionnaire which was presented in English in this study. For protecting personal information of participants, the data was anonymously collected. All participant joined the survey voluntarily in the classroom. Table 1 Demographic characteristic of the sample Characteristic Category Numbers Gender Male 53 Female 63 Age 16–19 31 20–24 79 25 or above 6 Religion Christians 7 Muslims 56 Hinduism 8 Islam 41 Non-religions 3 Jews 1 Nationality Pakistan 56 India 16 Ghana 4 Bangladesh 37 British 1 Tanzanian 1 Nigeria 1 Measurements The Perception of Academic Stress Scale The Perception of Academic Stress Scale (PAS) by Bedewy and Gabriel is a self-report instrument which has been widely used to measure the perceptions of academic stress faced by respondents [ 25 , 26 ]. The scale is 18-item tool, and four dimensions ( performance stress, workload exam perception, academic self-perception, time constraints) are included. Each item is rated on 5-point Likert scales from 1 (strongly disagree) to 5 (strongly agree). An example of the scale is “I have enough time to relax after work”. The Perception of Academic Stress Scale (PAS) has shown good reliability and stability cross time in other researches, and the Cronbach’s alpha coefficient was 0.70 in the present study. The Coping Style Questionnaire In this research, the coping style was investigated by the Coping Style Questionnaire, which contains three dimensions, problem-focused, emotion-focused, and escape-focused [ 27 ]. The scale is a 4-point self-reported instrument ranging from 1 to 4, with 1 indicating the coping style is not used and 4 implies the coping style is regularly used, and it aimed to measure each participant’s preferred coping style. An example of emotion-focused coping style is “Encourage myself to try my best”. The Cronbach’s alpha coefficient of this scale was 0.71 in this study. The Generalized Anxiety Disorder Assessment The Generalized Anxiety Disorder Assessment (GAD-7) is an instrument commonly used worldwide to evaluate anxiety [ 28 ]. The GAD-7 consists of 7 items which is calculated by assigning scores of 0 to 3 of each item. Here are examples of items “Being so restless that it’s hard to sit still”; “Worrying too much about different things”. The higher scores show the higher level of anxiety. Scores of 5, 10, and 15 are considered to be the cut-off points for mild, moderate and severe level of anxiety, respectively. In previous researches this measurement showed good reliability and stability, and also the Cronbach’s alpha coefficient in the present study was 0.70. The Center for Epidemiological Studies Depression Scale-Revised Participants completed the The Center for Epidemiological Studies Depression Scale-Revised (CESD-R10) to assess an individual’s depression [ 29 ]. The CESD-R10 is a self-reported measurement which contains 10 items. Here are example of the items “I had trouble keeping my mind on what I was doing”; “I felt fearful”. Each item is given a score on a 4-point scale ranging from 0 to 3, with higher scores demonstrating the higher level of depression. In our research, the scale’s internal consistency was 0.71. The WHO-5 Well-Being Index In the present study, well-being was assessed by The WHO-5 Well-Being Index which is widely used in different countries for assessing psychological well-being [ 30 ]. It is a self-reported scale which contains five statements and each statement is rated on a five-point scale. Total raw scores range from 0 to 25, and they are multiplied by 4 to obtain a final score ranging from 0 to 100. Examples of the items are “I woke up feeling fresh and rested ”; “ My daily life has been filled with things that interest me”. The Cronbach’s alpha coefficient in the present study was 0.71. Table 2 Sample Characteristics and group differences in mental health and well-being status scores Variables N Depression M(SD) t P Anxiety M(SD) t P Well-being M(SD) t P Gender Male 53 13.26 (5.41) 9.38 (4.46) 14.28 (4.55) Female 63 13.79 (6.23) −0.48 0.629 10.13 (4.51) −0.90 0.372 13.41 (4.49) 1.04 0.303 Often Exercise Yes 69 12.43 (5.48) 8.52 (4.60) 14.80 (4.50) No 47 15.19 (6.05) −2.55 0.012* 11.63 (3.63) −3.89 0.000* 12.36 (4.19) 2.94 0.004* Staying up late Yes 72 14.57 (5.83) 10.51 (4.42) 14.19 (4.56) No 44 11.89 (5.56) 2.448 0.016* 8.60 (4.37) 2.280 0.024* 13.18 (4.43) 1.17 0.243 * P < 0.05 Statistical Analysis Statistical analysis was executed by employing SPSS Statistics ( version 21.0 for Windows). Descriptive statistics were presented by using frequency and proportions of categorical data. For all continuous variables, linearity and normality were first measured. The differences in depression, anxiety and well-being scores between categorical variables was assessed by using Student’s t -test. Spearman rank correlation coefficient was performed to examine the strength and direction of correlations between the ordinal variable. The multivariate linear regression and univariate linear regression was employed to test the role of the perception of academic stress and emotion-focused coping style for mental health of international medical students. The statistical significance level was set at p < 0.05 and p < 0.01 as tables showing. Table 3 Correlations between mental health, well-being status and indicators The Perception of Academic stress Emotion-focused Coping Style r p r p Depression 0.22 0.020* −0.27 0.003** Anxiety 0.36 0.000** −0.33 0.000** Well-being −0.175 0.060 0.36 0.000** * p < 0.05 ** p < 0.01 Table 4 Linear Regression Analysis of factors related to mental health and well-being Contents Variables β S.E. t P 95%CI Depression The Perception of Academic stress 0.22 0.22 2.51 0.013* 0.03, 0.26 Emotion-focused Coping Style −0.90 0.29 −3.15 0.002* −1.47,−0.34 Anxiety The Perception of Academic stress 0.17 0.04 4.03 0.000* 0.09, 0.25 Emotion-focused Coping Style −0.69 0.21 −3.23 0.002* −1.11,−0.27 Well-being Emotion-focused Coping Style 0.97 0.22 34.49 0.000* 0.55, 1.40 * p < 0.05 RESULTS In the present study, the mean score was 13.55 (SD = 5.85) of depression, 9.78 (SD = 4.49) of anxiety, and 13.81 (SD = 4.52) of well-being. The results of group differences which selected as social demographic variables in mental health related factors were presented in Table 2 . Results showed that there were no differences in symptoms of depression, anxiety and well-being by gender. Across all group differences, the students who often exercise showed significant differences (P < 0.05). International medical students claiming often exercise reported fewer depression and anxiety symptoms (P < 0.05). Meanwhile, those who often excise reported better well-being than those who do not often excise (P < 0.05). In addition, students who stay up late or not showed significant group differences in depression and anxiety (P < 0.05). International medical students claiming stay up late reported higher depression and anxiety than those who do not stay up late (P < 0.05). As shown in Table 3 , it can be revealed that the perception of academic stress have a significant positive association with depression (P < 0.05) and anxiety (P < 0.01) based on correlations on depression, anxiety, well-being with the perception of academic stress and emotion-focused coping style; the emotion-focused coping style have a significant negative association with depression and anxiety, and a significant positive association with well-being (P < 0.01). International medical students who rated their perception of academic stress higher were likely to show higher level of depression (r=0.22) and anxiety (r༝0.36). More use emotion-focused coping style was associated with better well-being (r༝0.36), and fewer use emotion-focused coping style was related to higher level of depression (r༝―0.27) and anxiety (r༝―0.33). Bases on associations on the perception of academic stress and emotion-focused coping style with depression, anxiety and well-being of international medical students in China, linear regression was employed to measure the role of the perception of academic stress and emotion-focused coping style in international medical students’ mental health. The univariate and multiple linear regression model was created to predict depression, anxiety and well-being, for measuring results of beta (β), standard error (S.E.), 95% confidence interval (95%CI). Results were detailed in Table 4 , the perception of academic stress and emotion-focused coping style were significant predictors for depression and anxiety of international medical students (all P < 0.05); the perception of academic stress(P = 0.000) was a stronger predictor for anxiety compared with emotion-focused coping style(P = 0.002), however, emotion-focused coping style (P = 0.002) was stronger predictor for depression than the perception of academic stress(P = 0.013). In addition, emotion-focused coping style was also identified as a significant predictor for well-being (β = 0.97, P < 0.05). DISCUSSION It is well known that medical students are at increased risk of mental health issues by reporting higher rates of depression, anxiety and other mental health problems than other age-matched groups [ 31 , 32 ]. International medical students who not only face the same academic knowledge as local medical students but also live in a different environment should be paid more attention from researchers. While lots of studies have focused on mental health of local medical students, to our knowledge few studies investigate mental health and its related variables based on international medical students. Our study examine depression, anxiety and well-being status of international medical students in China and explore the importance of the perception of academic stress and emotion-focused coping style in terms of international medical students’ mental health. The results of this study reported that the prevalence of depression and anxiety was quite high, and about psychological well-being international medical students were not very satisfied with their lives. Specifically, it is consistent with many previous researches that the level of depression and anxiety of international medical students was higher than other age-matched groups, based on the results in this study that the mean score in depression and anxiety was 13.55 (SD = 5.85), 9.78 (SD = 4.49), compared with the research investigating international students [ 33 , 34 ]. The preliminary evidence reported that the perception of academic stress and emotion-focused coping style had a significant correlation with depression and anxiety(see Table 3 ), which was also proved in the line regression analysis as shown in Table 4 . Line regression analysis indicated that the perception of academic stress and emotion-focused coping style played important roles in predicting international medical students’ depression and anxiety, emotion-focused coping style was also a significant predictor of well-being. This was consistent with previous results, where the perception of academic stress was predictive of depression and anxiety in university students [ 35 , 36 ]. Academic stress is very common in university stage, as they need to get good academical performance for graduation or professional training, especially among global medical students who face more difficult academic tasks and experience longer years of learning and training, therefore, they were likely to susceptible to the mental health problems [ 37 ]. Moreover, our findings indicated that emotion-focused coping style was also a significant negative predictor for depression and anxiety, which was revealed in study conducted by Işık Ulusoy and Kal [ 38 ]. Positive emotion-focused coping helps individuals to mange emotional reaction to different stressful events, which may function as reducing mental health problems. And we also found that emotion-focused coping style predicts significantly for well-being. LIMITATIONS Here are a few limitations of this study. First, the sample size was not very large because of a total limited number of the foreign medical students in Sichuan, China. Second, the general sample of the international medical students in Sichuan is formed with different mix of nationalities and religions, which is the reason that it is heterogeneous of this sample. Additionally, we used self-reported questionnaires and cross-sectional design was adopted, it may influence on the casual association among variables. Therefore, adopting a longitudinal design should be considered in future researches. Finally, as cultural differences and diverse religion traditions, some factors of mental health may be obstructions that can not be acceptable for them, like perceived discrimination, acculturation stress. These factors may be important predictors of the mental health problems among international medical students, however, they are not selected in the current study. Future researchers could consider these factors. CONCLUSION To sum up, to the best of our knowledge, this research is the first time to measure factors the perception of academic stress and emotion-focused coping style affecting the mental health of international medical students in China. It is showed that the perception of academic stress is a strong positive predictor for depression and anxiety, emotion-focused coping style is a negative predictor of depression and anxiety, and emotion-focused coping style can predict well-being significantly. In addition, this research reported that mental health problems among international medical students are quite common and serious, this group should be payed attention by universities and professional studies. Many actions need to be taken by involving the university educational institution and community in building of better and healthier learning environment, and providing more supportive psychological service which can help them adopt positive coping strategy. Declarations DATA SHARING STATEMENT The date supporting the results and findings of the current study is available from the corresponding author on reasonable inquiries. ETHICAL STATEMENT Approval for the study was obtain from *** ethics committee and institutional review board. All participants were voluntary. There were inform written consent put in the front of the questionnaire. The study was in accordance with the Declaration of Helsinki. DISCLOSURE The author have no conflicts of interest to declare. Funding Declaration The author received no financial support for the research, authorship, and/or publication of this article. 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A study of depression and anxiety, general health, and academic performance in three cohorts of veterinary medical students across the first three semesters of veterinary school. Journal of Veterinary Medical Education . 2012, 39(4): 341-358. https://doi.org/10.3138/jvme.0712-065R Yamada, Y., Klugar, M., Ivanova, K. et al. Psychological distress and academic self-perception among international medical students: the role of peer social support. BMC Med Educ. 2014, 14, 256. https://doi.org/10.1186/s12909-014-0256 Işık Ulusoy S, Kal Ö. Relationship among coping strategies, quality of life, and anxiety and depressive disorders in hemodialysis patients. Therapeutic Apheresis and Dialysis. 2020, 24(2): 189-196. https://doi.org/10.1111/1744-9987.12914 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5372228","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":378686093,"identity":"7130f81a-bfdb-4cf3-afae-e544f3bc496d","order_by":0,"name":"Shisi Zhou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIie3QMQuCQBTA8RPhWs5ofHKgnyBQBGnys3gItkXQ4lRKcI7OfpFoPAlqEVod9RvY3pDQFsRdW8P9twf34/EOIZ3uLzOFYE844FlRDKMawax/5Kt4Ti7HANQICfw6z2IH1nxBVIBbiZBaZ9hge+AIUOQscwnxujilVgs7TBnvtygJQiEjgK6UYDA4ZeU0CHaSEbdq+JvYDQeiQpBITL/mwPik1IjXpUY/thBgwqZP9hRucav7KOJs77jlbRjGLHKk5HPpb891Op1O96UXgS5BSR0mVFsAAAAASUVORK5CYII=","orcid":"","institution":"North Sichuan Medical University","correspondingAuthor":true,"prefix":"","firstName":"Shisi","middleName":"","lastName":"Zhou","suffix":""}],"badges":[],"createdAt":"2024-11-01 09:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5372228/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5372228/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107524574,"identity":"e7792539-ad9e-422a-ba70-0e995a48a5fe","added_by":"auto","created_at":"2026-04-22 09:29:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":387819,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5372228/v1/fe9e7833-6c21-4032-9f1a-5d33458beb3d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The role of Perception of Academic Stress and Emotion-focused Coping Style for International Medical Students’ Mental Health in China","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eWith the development of science and technology, more students choose to study abroad all over the world. For example, the number of international students has increased from 6.4\u0026ndash;16.2% over the last decade in Canadian [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Besides cultural adaption, mental health of international students has also gained lots of attention from researchers. Studies showed that medical students are more prone to encounter variety of psychological problems than age-matched samples and the general population [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, medical students studying in local are main participants which collected in these researches. China is a large receiving country for international students, and the majority of these students come from developing countries in Asia and Africa [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Western medicine is a favorable subject for international students who choose to study in China [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It is necessary to explore mental health and psychological well-being of international medical students studying in Chinese universities.\u003c/p\u003e \u003cp\u003eUniversity life is an important transition period in the improvement and preservation of mental health towards impartial adulthood, as they may have different subjects, new studying environment, being away from families and unrealized goals for future. Comparing to general university population, medical students are higher rate of various mental health problems in university stage [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. It is also proved by numerous studies that anxiety and depression are highly prevalent among medical students [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Among medical students, mental health problems and psychological well-being of international medical students who facing more difficulties in cultural adaption, academic stress and new environment should be payed a special attention by researchers.\u003c/p\u003e \u003cp\u003eInfluenced by rapid development of society, people have continuous high expectation in life and stress is commonly experienced by most people. Stress refers to perception of discrepancy between environment stimulus and individual available resources [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The factors stimulating stress of university students are multiform, arising from academic and non-academic elements [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Academic stress contributes to the predominant factor of stress among most students, as they have to compete with other students, perform well in exams and survive academically for future graduation, and this stressful state likely to affect individuals\u0026rsquo; life and mental health level [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Recently, studies have implied that academic stress emerges as significant mental health problems, like psychological adjustment and emotion experience [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. International medical students face numerous academic tasks and there are little researches focusing on it. It is necessary to advance academic stress and its impact on mental health among international medical students.\u003c/p\u003e \u003cp\u003eCoping styles have been proved to be a predictor of subsequent psychological adjustment to different negative life events, like serious disease [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. There are different coping styles people may use to confront various situations. Emotion-focused coping style usually focused on the emotions generated by the problem and two different emotion-focused coping approaches (positive reappraisal which a problem is reinterpret through making a subjective benign appraisals; avoidance which deny or avoid negative emotion by escaping or avoiding) are examined in lots of psychological analysis [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In a cross-sectional research, positive emotion-focused coping is found to relate with higher levels of psychological well-being [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Mental health problems are also deeply explored with coping style [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. International medical students facing heavy academical workload, limitations of time and cultural adaption may be more accessible to experience increased depression, more negative mood, less psychological well-being [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Unfortunately, few studies pay attention to international medical students.\u003c/p\u003e \u003cp\u003eIn summary, we are inspired to investigate the mental health status of international medical students and explore the importance of the perception of academic stress, emotion-focused coping style on international medical students\u0026rsquo; mental health (depression, anxiety symptoms and well-being) in China. Underpinning previous works, we hypothesize that perception of academic stress, emotion-focused coping style have effect on mental health of international medical students.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe participants of this study were international medical students in China who came from different countries. Before the survey, it was confirmed that all the English questionnaires were understood by the participants. The perception of academic stress, coping style, generalized anxiety, depression and well-being were evaluated. In total, a sample of 116 international medical students was recruited in this study, their age 20.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.94, on average. In the current study, 54.3% of the participants were female, while 45.7% of the participants were male. Most of the international participants are from Pakistan, Bangladesh, India. And their religion are also different, including Muslims, Hinduism, Islam, Christians. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e showed the distribution of the participants by social demographic groups.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eStudy was carried out in conformity with relevant standards and regulations, the permission was obtained from the Institutional Review Boards. This research was carried out from September to November 2023. All participants obtained the informed consent before completing the questionnaire which was presented in English in this study. For protecting personal information of participants, the data was anonymously collected. All participant joined the survey voluntarily in the classroom.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristic of the sample\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumbers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChristians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuslims\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHinduism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-religions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNationality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePakistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBangladesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBritish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTanzanian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eMeasurements\u003c/h3\u003e\n\u003cp\u003eThe Perception of Academic Stress Scale\u003c/p\u003e \u003cp\u003eThe Perception of Academic Stress Scale (PAS) by Bedewy and Gabriel is a self-report instrument which has been widely used to measure the perceptions of academic stress faced by respondents [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The scale is 18-item tool, and four dimensions ( performance stress, workload exam perception, academic self-perception, time constraints) are included. Each item is rated on 5-point Likert scales from 1 (strongly disagree) to 5 (strongly agree). An example of the scale is \u0026ldquo;I have enough time to relax after work\u0026rdquo;. The Perception of Academic Stress Scale (PAS) has shown good reliability and stability cross time in other researches, and the Cronbach\u0026rsquo;s alpha coefficient was 0.70 in the present study.\u003c/p\u003e \u003cp\u003eThe Coping Style Questionnaire\u003c/p\u003e \u003cp\u003eIn this research, the coping style was investigated by the Coping Style Questionnaire, which contains three dimensions, problem-focused, emotion-focused, and escape-focused [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The scale is a 4-point self-reported instrument ranging from 1 to 4, with 1 indicating the coping style is not used and 4 implies the coping style is regularly used, and it aimed to measure each participant\u0026rsquo;s preferred coping style. An example of emotion-focused coping style is \u0026ldquo;Encourage myself to try my best\u0026rdquo;. The Cronbach\u0026rsquo;s alpha coefficient of this scale was 0.71 in this study.\u003c/p\u003e \u003cp\u003eThe Generalized Anxiety Disorder Assessment\u003c/p\u003e \u003cp\u003eThe Generalized Anxiety Disorder Assessment (GAD-7) is an instrument commonly used worldwide to evaluate anxiety [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The GAD-7 consists of 7 items which is calculated by assigning scores of 0 to 3 of each item. Here are examples of items \u0026ldquo;Being so restless that it\u0026rsquo;s hard to sit still\u0026rdquo;; \u0026ldquo;Worrying too much about different things\u0026rdquo;. The higher scores show the higher level of anxiety. Scores of 5, 10, and 15 are considered to be the cut-off points for mild, moderate and severe level of anxiety, respectively. In previous researches this measurement showed good reliability and stability, and also the Cronbach\u0026rsquo;s alpha coefficient in the present study was 0.70.\u003c/p\u003e \u003cp\u003eThe Center for Epidemiological Studies Depression Scale-Revised\u003c/p\u003e \u003cp\u003eParticipants completed the The Center for Epidemiological Studies Depression Scale-Revised (CESD-R10) to assess an individual\u0026rsquo;s depression [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The CESD-R10 is a self-reported measurement which contains 10 items. Here are example of the items \u0026ldquo;I had trouble keeping my mind on what I was doing\u0026rdquo;; \u0026ldquo;I felt fearful\u0026rdquo;. Each item is given a score on a 4-point scale ranging from 0 to 3, with higher scores demonstrating the higher level of depression. In our research, the scale\u0026rsquo;s internal consistency was 0.71.\u003c/p\u003e \u003cp\u003eThe WHO-5 Well-Being Index\u003c/p\u003e \u003cp\u003eIn the present study, well-being was assessed by The WHO-5 Well-Being Index which is widely used in different countries for assessing psychological well-being [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. It is a self-reported scale which contains five statements and each statement is rated on a five-point scale. Total raw scores range from 0 to 25, and they are multiplied by 4 to obtain a final score ranging from 0 to 100. Examples of the items are \u0026ldquo;I woke up feeling fresh and rested \u0026rdquo;; \u0026ldquo; My daily life has been filled with things that interest me\u0026rdquo;. The Cronbach\u0026rsquo;s alpha coefficient in the present study was 0.71.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e Sample Characteristics and group differences in mental health and well-being status scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003cp\u003eM(SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003cp\u003eM(SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWell-being\u003c/p\u003e \u003cp\u003eM(SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.26\u003c/p\u003e \u003cp\u003e(5.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.38\u003c/p\u003e \u003cp\u003e(4.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14.28\u003c/p\u003e \u003cp\u003e(4.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.79\u003c/p\u003e \u003cp\u003e(6.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.629\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.13\u003c/p\u003e \u003cp\u003e(4.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.372\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13.41\u003c/p\u003e \u003cp\u003e(4.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.303\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOften Exercise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.43\u003c/p\u003e \u003cp\u003e(5.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.52\u003c/p\u003e \u003cp\u003e(4.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14.80\u003c/p\u003e \u003cp\u003e(4.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.19\u003c/p\u003e \u003cp\u003e(6.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;2.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.012*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.63\u003c/p\u003e \u003cp\u003e(3.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;3.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12.36\u003c/p\u003e \u003cp\u003e(4.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.004*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaying up late\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.57\u003c/p\u003e \u003cp\u003e(5.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.51\u003c/p\u003e \u003cp\u003e(4.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14.19\u003c/p\u003e \u003cp\u003e(4.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.89\u003c/p\u003e \u003cp\u003e(5.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.448\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.016*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.60\u003c/p\u003e \u003cp\u003e(4.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.024*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13.18\u003c/p\u003e \u003cp\u003e(4.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.243\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003e*\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was executed by employing SPSS Statistics ( version 21.0 for Windows). Descriptive statistics were presented by using frequency and proportions of categorical data. For all continuous variables, linearity and normality were first measured. The differences in depression, anxiety and well-being scores between categorical variables was assessed by using Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-test. Spearman rank correlation coefficient was performed to examine the strength and direction of correlations between the ordinal variable. The multivariate linear regression and univariate linear regression was employed to test the role of the perception of academic stress and emotion-focused coping style for mental health of international medical students. The statistical significance level was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 and p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 as tables showing.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations between mental health, well-being status and indicators\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eThe Perception of Academic stress\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eEmotion-focused Coping Style\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.020*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.000**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.000**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWell-being\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.000**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 **\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLinear Regression Analysis of factors related to mental health and well-being\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eS.E.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe Perception of Academic stress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.013*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.03, 0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmotion-focused Coping Style\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;3.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;1.47,\u0026minus;0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe Perception of Academic stress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.09, 0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmotion-focused Coping Style\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;3.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;1.11,\u0026minus;0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWell-being\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmotion-focused Coping Style\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.55, 1.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eIn the present study, the mean score was 13.55 (SD\u0026thinsp;=\u0026thinsp;5.85) of depression, 9.78 (SD\u0026thinsp;=\u0026thinsp;4.49) of anxiety, and 13.81 (SD\u0026thinsp;=\u0026thinsp;4.52) of well-being. The results of group differences which selected as social demographic variables in mental health related factors were presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Results showed that there were no differences in symptoms of depression, anxiety and well-being by gender. Across all group differences, the students who often exercise showed significant differences (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). International medical students claiming often exercise reported fewer depression and anxiety symptoms (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Meanwhile, those who often excise reported better well-being than those who do not often excise (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In addition, students who stay up late or not showed significant group differences in depression and anxiety (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). International medical students claiming stay up late reported higher depression and anxiety than those who do not stay up late (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, it can be revealed that the perception of academic stress have a significant positive association with depression (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and anxiety (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) based on correlations on depression, anxiety, well-being with the perception of academic stress and emotion-focused coping style; the emotion-focused coping style have a significant negative association with depression and anxiety, and a significant positive association with well-being (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). International medical students who rated their perception of academic stress higher were likely to show higher level of depression (r=0.22) and anxiety (r༝0.36). More use emotion-focused coping style was associated with better well-being (r༝0.36), and fewer use emotion-focused coping style was related to higher level of depression (r༝―0.27) and anxiety (r༝―0.33).\u003c/p\u003e \u003cp\u003eBases on associations on the perception of academic stress and emotion-focused coping style with depression, anxiety and well-being of international medical students in China, linear regression was employed to measure the role of the perception of academic stress and emotion-focused coping style in international medical students\u0026rsquo; mental health. The univariate and multiple linear regression model was created to predict depression, anxiety and well-being, for measuring results of beta (β), standard error (S.E.), 95% confidence interval (95%CI). Results were detailed in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the perception of academic stress and emotion-focused coping style were significant predictors for depression and anxiety of international medical students (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); the perception of academic stress(P\u0026thinsp;=\u0026thinsp;0.000) was a stronger predictor for anxiety compared with emotion-focused coping style(P\u0026thinsp;=\u0026thinsp;0.002), however, emotion-focused coping style (P\u0026thinsp;=\u0026thinsp;0.002) was stronger predictor for depression than the perception of academic stress(P\u0026thinsp;=\u0026thinsp;0.013). In addition, emotion-focused coping style was also identified as a significant predictor for well-being (β\u0026thinsp;=\u0026thinsp;0.97, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIt is well known that medical students are at increased risk of mental health issues by reporting higher rates of depression, anxiety and other mental health problems than other age-matched groups [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. International medical students who not only face the same academic knowledge as local medical students but also live in a different environment should be paid more attention from researchers. While lots of studies have focused on mental health of local medical students, to our knowledge few studies investigate mental health and its related variables based on international medical students. Our study examine depression, anxiety and well-being status of international medical students in China and explore the importance of the perception of academic stress and emotion-focused coping style in terms of international medical students\u0026rsquo; mental health. The results of this study reported that the prevalence of depression and anxiety was quite high, and about psychological well-being international medical students were not very satisfied with their lives. Specifically, it is consistent with many previous researches that the level of depression and anxiety of international medical students was higher than other age-matched groups, based on the results in this study that the mean score in depression and anxiety was 13.55 (SD\u0026thinsp;=\u0026thinsp;5.85), 9.78 (SD\u0026thinsp;=\u0026thinsp;4.49), compared with the research investigating international students [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe preliminary evidence reported that the perception of academic stress and emotion-focused coping style had a significant correlation with depression and anxiety(see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), which was also proved in the line regression analysis as shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Line regression analysis indicated that the perception of academic stress and emotion-focused coping style played important roles in predicting international medical students\u0026rsquo; depression and anxiety, emotion-focused coping style was also a significant predictor of well-being. This was consistent with previous results, where the perception of academic stress was predictive of depression and anxiety in university students [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Academic stress is very common in university stage, as they need to get good academical performance for graduation or professional training, especially among global medical students who face more difficult academic tasks and experience longer years of learning and training, therefore, they were likely to susceptible to the mental health problems [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Moreover, our findings indicated that emotion-focused coping style was also a significant negative predictor for depression and anxiety, which was revealed in study conducted by Işık Ulusoy and Kal [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Positive emotion-focused coping helps individuals to mange emotional reaction to different stressful events, which may function as reducing mental health problems. And we also found that emotion-focused coping style predicts significantly for well-being.\u003c/p\u003e"},{"header":"LIMITATIONS","content":"\u003cp\u003eHere are a few limitations of this study. First, the sample size was not very large because of a total limited number of the foreign medical students in Sichuan, China. Second, the general sample of the international medical students in Sichuan is formed with different mix of nationalities and religions, which is the reason that it is heterogeneous of this sample. Additionally, we used self-reported questionnaires and cross-sectional design was adopted, it may influence on the casual association among variables. Therefore, adopting a longitudinal design should be considered in future researches. Finally, as cultural differences and diverse religion traditions, some factors of mental health may be obstructions that can not be acceptable for them, like perceived discrimination, acculturation stress. These factors may be important predictors of the mental health problems among international medical students, however, they are not selected in the current study. Future researchers could consider these factors.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eTo sum up, to the best of our knowledge, this research is the first time to measure factors the perception of academic stress and emotion-focused coping style affecting the mental health of international medical students in China. It is showed that the perception of academic stress is a strong positive predictor for depression and anxiety, emotion-focused coping style is a negative predictor of depression and anxiety, and emotion-focused coping style can predict well-being significantly. In addition, this research reported that mental health problems among international medical students are quite common and serious, this group should be payed attention by universities and professional studies. Many actions need to be taken by involving the university educational institution and community in building of better and healthier learning environment, and providing more supportive psychological service which can help them adopt positive coping strategy.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDATA SHARING STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe date supporting the results and findings of the current study is available from the corresponding author on reasonable inquiries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICAL STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval for the study was obtain from *** ethics committee and institutional review board. All participants were voluntary. There were inform written consent put in the front of the questionnaire. The study was in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDISCLOSURE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eThe author of this work（Shisi） has contributed to all aspects of the research, including the writing of the manuscript, the conceptualization of the study, the design and execution of the experiments or research methods, the collection, analysis, and interpretation of the data, and the critical review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorae J, Jason D, Edgerton A.Descriptive Survey Study of International Students\u0026rsquo; Experiences at a Canadian University: Challenges, Supports and Suggested Improvements. \u003cem\u003eComparative and International Education\u003c/em\u003e. 2023;51.2. 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Relationship among coping strategies, quality of life, and anxiety and depressive disorders in hemodialysis patients. \u003cem\u003eTherapeutic Apheresis and Dialysis.\u003c/em\u003e 2020, 24(2): 189-196. https://doi.org/10.1111/1744-9987.12914\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"mental health, the role of perception of academic stress, emotion-focused coping style, international medical students","lastPublishedDoi":"10.21203/rs.3.rs-5372228/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5372228/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eLots of previous researches had suggested that medical students are higher rates of mental health problems than other age-matched groups, however, there was little attention caring about international medical students’ mental health status and influential factors. The research aims to investigate the present mental health status of international medical students and assess the role of perception of academic stress, emotion-focused coping style in international medical students’ mental health in China. By using data of international medical students (17-27 years old) providing information on their demographics, Perception of Academic Stress, The Coping Style Questionnaire, Generalized Anxiety Disorder Assessment (GAD-7), the Center for Epidemiological Studies Depression Scale Revised (CESD-R10), the WHO Well-being Index Scale (WHO-5), this study found that the depression (mean score=13.55, SD=5.85) and anxiety (mean score=9.78 , SD=4.49) was high among international medical students, perception of academic stress was a significant positive predictor of depression (β=0.22) and anxiety (β=0.17) , the emotion-focused coping style was a significant negative predictor of depression (β=-0.90) and anxiety (β=-0.69) and have positive association with well-being (β=0.97).\u003c/p\u003e","manuscriptTitle":"The role of Perception of Academic Stress and Emotion-focused Coping Style for International Medical Students’ Mental Health in China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-25 15:14:12","doi":"10.21203/rs.3.rs-5372228/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"80316d2d-d002-45d1-8fe3-9d77d79c3121","owner":[],"postedDate":"November 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T09:28:40+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-25 15:14:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5372228","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5372228","identity":"rs-5372228","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}