Asian medical students: quality of life and motivation to learn ...

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Issues linked with the notions of quality of life (QOL) and motivation to learn among Asian medical students have not been well documented. This is true in both ...
Asia Pacific Educ. Rev. (2011) 12:437–445 DOI 10.1007/s12564-011-9148-y

Asian medical students: quality of life and motivation to learn Marcus A. Henning • Susan J. Hawken • Christian Kra¨geloh • Yipin Zhao • Iain Doherty

Received: 15 February 2010 / Revised: 16 December 2010 / Accepted: 10 January 2011 / Published online: 25 January 2011 Ó Education Research Institute, Seoul National University, Seoul, Korea 2011

Abstract Issues linked with the notions of quality of life (QOL) and motivation to learn among Asian medical students have not been well documented. This is true in both the international and the New Zealand contexts. Our paper addresses this lack of research by focusing on the QOL of international and domestic Asian students studying in New Zealand, where Asian students form a significant proportion of tertiary students. Although there is evidence to suggest that Asian students do well academically, it was felt that an investigation into their QOL would be instructive as QOL will likely have an impact on cognition, behavior, general well-being, and motivation. The present study surveyed fourth- and fifth-year medical students to examine the relationship between QOL and motivation to learn and to consider how Asian medical students compare against European medical and non-medical student peers. The study utilized the World Health Organization— Quality of Life questionnaire (BREF version) and a shortened version of the Motivated Strategies for Learning

M. A. Henning (&)  Y. Zhao Centre for Medical and Health Sciences Education, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand e-mail: [email protected] S. J. Hawken Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand C. Kra¨geloh Department of Psychology, AUT University, Private Bag 92006, Auckland 1142, New Zealand I. Doherty Learning Technology Unit, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand

Questionnaire. The results show that the Asian medical students in this study generated significantly lower scores in terms of their satisfaction with social relationships compared with their non-Asian peers. In addition, international Asian medical students appear to be more at risk than domestic Asian students with respect to test anxiety. The paper considers the findings and the implications for quality of life, motivation to learn, medical education, and the Asian student community. Keywords Asian  Medical students  Quality of life  Motivation to learn

Introduction The international student market has become a major industry for New Zealand (Perrott 2003). New Zealand is one of the so-called Main English-Speaking Destination Countries and is, therefore, a popular study destination. Figures from 2009 revealed that there were more than 50,000 foreign fee-paying students studying in New Zealand (Ministry of Education 2009), and with 84.2%, the clear majority of international students in New Zealand come from Asian countries (Healey 2008). Furthermore, 16% of all domestic tertiary students in New Zealand were classified as domestic Asian students (Scott 2002). Contingent on their visa status, students are classified as either domestic or international students. If the student holds New Zealand citizenship or a residency permit, then the student is classified as domestic, otherwise as international. It is anticipated that New Zealand will continue to benefit from increasing numbers of Asian students seeking to study abroad, with an estimated annualized growth rate for Asian students of 7.8% over the period 2003–2020

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(Healey 2008). In the medical sciences, students with Asian backgrounds, both domestic and international, are strongly represented. Fitzjohn et al. (2003) indicated that, in the Auckland Medical School, 30.5% of medical students were Asian, and more recent informal observations show this proportion is increasing just as it is in the USA (Akins 2007). In educational terms, both domestic and international Asian students are considered to be high achievers (Kember 2000a; Ng 2003; Scott 2002). Census statistics for New Zealand indicates that 32% of the domestic Asian group had a post-secondary qualification and 16% of this group achieved a bachelor degree qualification (Statistics New Zealand 2006). This makes Asians (e.g., Chinese, Korean, Southeast Asian, Indian, and Japanese) the group with the highest proportion of post-secondary qualifications. In addition, Asian students, both domestic and international, have the highest tertiary education completion rates of all ethnic groups in New Zealand, from certificate level through to doctorate (Scott 2002). There have been numerous studies exploring the studyrelated experiences of domestic and international Asian students (Ho et al. 2002; Holmes 2005; Kanagawa et al. 2001; Kember 2000b; Leung 2002). However, much of the research has investigated Asian students studying abroad as opposed to those studying in their home countries (Ho et al. 2002; Holmes 2005; Kember 2000b; Leung 2002). The majority of international students studying in New Zealand have cultural experiences dissimilar from the New Zealand context and thus may have different educational values from the host country mainstream. Many international students also experience language problems, as English is often their second or third language. These differences can result in diverse expectations about teaching and learning as well as cultural identity issues, difficulties with adapting to the New Zealand context and problems when communicating with New Zealanders (Ho et al. 2002). Holmes (2005) explored the learning experiences of international students, studying in New Zealand, from China, Hong Kong, Malaysia, and Taiwan. According to Holmes, these students appear to have been influenced by their Confucian heritage that affected their communication practices and expectations about classroom etiquette. They also had a strong belief in effort and willpower and tended to form study groups and networks outside the lecture theaters. In addition, several authors have considered the differences between Asian and Western cultures in terms of perception about self and other (Markus and Kitayama 1991). For example, Markus and Kitayama suggested that Japanese people have an interdependent view of self and other in contrast to the independent view upheld by Western Americans; the implication being that quality of life issues are dependent on the collective response in Japanese

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cultures while more autonomously directed in the Western sense. This sense of self can include cognitive, emotional, and motivational frames of reference. In a more recent study (Heine and Hamamura 2007), the notions of self were extended to the ways in which different cultural groups express themselves in an open forum. Through the meta-analysis they conducted, Heine and Hamamura found indications that indicated that Western cultural groups tended to self-enhance themselves more than Southeast Asian groups and reasons for this difference center around the relational sense of self, differences in perceptions of importance, and the way cultural groups express themselves may differ in terms of who they actually are. Leung (2002) also revealed that Asian students reported a lower sense of confidence and interest in their studies, which may be related to the notions of modesty and humility when answering questionnaires. Issues linked with the notions of quality of life and motivation among medical students in general have been well documented (Gupchup et al. 2004; Mitmansgruber et al. 2009; Robotham and Julian 2006; Ross et al. 2006; Srivastava et al. 2007). However, in reviewing the literature for Asian medical students’ quality of life and motivation, very few studies were located. Nevertheless, the reasons that Asian medical students decide to study medicine are often reported to be more extrinsically oriented than those of European students. Asian medical students follow medicine as a career choice in response to parental expectations, and these expectations, especially for international students, may be linked to status orientations and residency options in host countries (Dundes et al. 2009). Interview data presented in a pilot study by Akins (2007) suggested that Asian American students tend to study medicine because the profession is related to their parents’ ideal of academic achievement and a part of a family tradition. There is, therefore, a suggestion that extrinsic motivation may play a significant part in driving Asian medical students’ learning, and consequently, some students may feel ‘‘pressured’’ into medicine which will likely have an adverse effect on their quality of life. This finding further suggests that there is probably a link between quality of life and motivation in relation to Asian medical students, and this link has, thus far, not been located in the literature. The aim of this paper is to explore the relationship between motivation and quality of life with respect to Asian medical students in New Zealand. To achieve this aim, two main areas of analysis are considered important. First, a between-groups analysis comparing the Asian medical group with European medical and non-medical cohorts was proposed to unravel the unique aspect of the Asian and medical combination. Second, a within-group analysis comparing the international and domestic groups was seen as critical given that the international group, in

Asian medical students

this study, has a fairly homogenous sample of Malaysian students, while the domestic sample is very heterogeneous. A further within-group analysis was instigated to explore the connections linking the notions of quality of life and motivation to learn.

Method Participants This study examined the responses of 97 self-identified Asian participants (51 women, 46 men) who voluntarily participated in the study. The average age of the sample was 22.00 years (SD = 1.43). The participants were enrolled in two clinical years (65 from fourth year, 32 from fifth year) and comprised both international (n = 40) and domestic (n = 57) students. As a comparison group, the study further examined the responses of 99 self-identified European participants from the same cohort (61 women, 38 men) who voluntarily participated in the study. The average age of the sample was 23.45 years (SD = 3.54). The participants were enrolled in two clinical years (59 from fourth year, 40 from fifth year), and all European students were classified as ‘‘domestic’’. Three further ethnicity classification options were available: ‘‘Ma¯ori’’ (the indigenous peoples of New Zealand, n = 14), ‘‘Pacific Island/Pasifika’’ (n = 14) and ‘‘Other’’ (n = 47), but these groups were not included in these analyses. The total response rate was 80%. Procedure Data collection for this correlational study was conducted during the middle of 2009. Students were asked to fill in a demographic survey, the Australian version of the World Health Organization-BREF questionnaire (WHOQOLBREF) (Murphy et al. 2000) and a shortened version of the Motivated Strategies for Learning Questionnaire (MSLQ) (Pintrich and De Groot 1990). Ethics approval was gained from the University of Auckland Human Participants Committee. After, permission from senior faculty was obtained, and the researchers introduced the purpose and nature of the study to fourth- and fifth-year medical students during lecture times and invited students to fill in the questionnaires. The first author, and three assistants, collected participants’ completed questionnaires, which took approximately 10–15 min to complete. Measures As previously mentioned, two main measures were incorporated into the study design; these were the WHOQOLBREF and MSLQ.

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The Australian version of the WHOQOL-BREF is an abbreviated version of the WHOQOL-100 (WHOQOLGroup 1998). The WHOQOL-BREF questionnaire was chosen as an instrument to assess quality of life because of its established psychometric robustness and acknowledged cross-cultural validity (Hsu et al. 2009; Lewis et al. 2009). The WHOQOL-BREF has 26 items; this includes two global items about health-related quality of life and 24 items relating to four domains (physical, psychological, social, and environmental quality of life). The respondents rate the items using a five-point Likert scale: a low rating toward 1 suggests a negative evaluation and a high rating toward 5 indicates a more positive perception of quality of life. An earlier version of the MSLQ (Pintrich and De Groot 1990) was considered appropriate for this study. This version has 44 items and five subdomains, namely self-efficacy, intrinsic value, test anxiety, cognitive strategy use, and self-regulation. These five subdomains are categorized within two domains: motivational beliefs and self-regulated learning strategies. As with the WHOQOL-BREF, the respondents rate the items using a five-point Likert scale: a low rating toward 1 suggests lower levels of motivation and self-regulation, except for test anxiety which implies that higher ratings indicate greater anxiety. Data analysis For this study, between-groups and within-group analyses were computed. As appropriate, several demographic variations were considered as potential confounding factors employing a multivariate analysis approach. Elsewhere, z-tests and zero-order correlations were computed. Between-groups analyses The WHOQOL-BREF and MSLQ scores for the Asian medical student group were generated and compared with a group of European medical students from the same study cohort and with a sample of New Zealand university students studying various non-medical subjects, mainly social sciences and business. Within-group analyses First, the scores for the domestic and international Asian medical students were compared. Second, associations in relation to WHOQOL-BREF and MSLQ domain measures were considered for the Asian (international and domestic) sample.

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Results

MSLQ comparisons

Between-groups analyses

Given that a non-medical student group data set was available, as it was collected as part of an earlier study by the present author (Henning 2007), a MANCOVA approach was instigated. Using Wilks’ Lambda, the multivariate statistical analyses showed a significant effect for student groups (Asian; European; non-medical) (F(10, 998) = 18.17, p = .00); the confounding variables of age (F(5, 499) = 1.87, p = .10) and gender (F(5, 499) = 1.69, p = .14) yielded no significant differences. Tests of between-subjects groups yielded significant differences for intrinsic value (F(2) = 6.54, p = .00), test anxiety (F(2) = 2.95, p = .05), and self-regulation (F(2) = 35.01, p = .00), with a marginal result for selfefficacy (F(2) = 2.72, p = .07). Table 2 shows the mean scores and standard deviations of the subscales that were transformed according to the MSLQ guidelines (Pintrich and De Groot 1990). A priori simple contrasts were conducted to determine how the groups may differ with respect to the dependent variables (MSLQ subscales, presented in Table 2). These contrasts showed that for self-efficacy, intrinsic value, and self-regulation, there were significant differences (p \ .05) between the Asian medical students and the non-medical students. Furthermore, the contrasts showed that for test anxiety and self-regulation, there were significant differences (p \ .05) between the European students and the other two student groups (non-medical and Asian).

WHOQOL-BREF comparisons First, the medical student cohort was appraised in terms of ethnicity (Asian; European) with consideration of the confounders’ age, gender, and year of study. Table 1 shows the mean scores and standard deviations of the domain scores that were transformed according to the WHOQOLBREF guidelines (Murphy et al. 2000). The multivariate statistical analyses (Wilks’ Lambda) produced a significant effect for ethnicity (Asian; European) (F(4, 182) = 3.85, p = .01). The confounding variables of age (F(4, 182) = .55, p = .70), gender (F(4, 182) = .17, p = .97), and year (F(4, 182) = 2.21, p = .07) yielded no significant differences. Tests of between-subjects groups for ethnicity yielded a significant difference for social relationships only (F(1) = 7.04, p = .01). The WHOQOL-BREF data for the Asian group were also compared with some established data for New Zealand university students from a variety of non-medical faculties (Hsu et al. 2009; Lewis et al. 2009). Since the demographic information collected in these studies was in a different format compared with the present one, comparisons were made using z-tests, thus not controlling for demographic variables. In order to test the significance of differences in WHOQOL domain scores, z-tests were conducted, where a critical z-value of 1.96 or above must be obtained in order to claim a significant difference at a = .05 (Glass and Hopkins 1996). When compared with the study by Lewis et al. (2009), Asian medical students scored significantly lower in terms of the psychological (z = 3.13) and social relationship (z = 4.25) domains. In comparison with the study by Hsu et al. (2009), Asian medical students’ scores were significantly lower on the social relationship (z = 2.46) and environmental (z = 6.25) domains. Hence, in relation to these two studies, the Asian medical students scored significantly lower on the social relationship domain.

Within-group analyses Comparisons between domestic and international Asian medical students Table 3 shows the mean scores and standard deviations for the domestic versus the international Asian medical students on the WHOQOL-BREF domains (using item means as opposed to transformed domain scores) and the MSLQ subscale scores.

Table 1 Means and standard deviations of the WHOQOL-BREF domains by Asian medical students, European medical students, and two New Zealand university non-medical groups Domains

Asian medical group (n = 97) M (SD)

European medical group (n = 99)

Lewis et al. (2009) (n = 282) M (SD)

Hsu et al. (2009) (n = 382) M (SD)

Physical

69.00 (13.42)

74.10(14.64)

72.10 (14.40)

67.62 (15.67)

Psychological

61.44 (15.86)

67.30(17.53)

67.13 (14.23)*

62.22 (14.54)

Social

60.13 (20.58)

72.31(21.69)*

70.43 (20.53)*

65.98 (20.32)*

Environmental

66.05 (14.56)

70.99(13.86)

65.65 (15.00)

55.48 (14.61)*

* Tests of difference (p \ 0.05) in terms of the Asian medical group versus the other groups

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Asian medical students

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Table 2 Means and standard deviations of the MSLQ domains by Asian medical students, European medical students, and one New Zealand university non-medical group

* Test differences (p \ .05) between the Asian group and the non-medical group

Subscales

Asian group (n = 97) M (SD)

European group (n = 99) M (SD)

Henning (2007) (n = 317) M (SD)

Self-efficacy

3.35(.60)

3.48(.59)

3.53(.54)*

Intrinsic value

3.88(.44)

4.00(.53)

4.12(.48)*

Test anxiety

2.91(.86)

2.74(.92)

2.88(.92)

Cognitive strategy use

3.63(.46)

3.54(.47)

3.69(.50)

Self-regulation

3.53(.47)

3.50(.47)

3.19(.40)*

Table 3 Means and standard deviations of the WHOQOL-BREF domains by status of enrollment Asian domestic (n = 57) M(SD)

Asian international (n = 40) M(SD)

Physical

3.84(.52)

3.72(.54)

Psychological

3.52(.70)

3.46(.51)

p = .01), with a marginally non-significant result for selfefficacy (F(2) = 1.95, p = .09). The means shown in Table 3 indicate that the domestic group generated lower test anxiety and higher environment scores than the international group.

WHOQOL domains

Social

3.57(.76)

3.46(.77)

Environmental

3.74(.61)

3.51(.50)*

MSLQ subscales Intrinsic value

3.94(.48)

3.81(.37)

Self-efficacy

3.48(.60)

3.17(.57)

Test anxiety

2.68(.80)

3.24(.85)*

Cognitive strategy use

3.65(.51)

3.58(.37)

Self-regulation

3.58(.52)

3.46(.40)

* p \ 0.05

The status of the Asian medical students (domestic; international) was compared employing a MANCOVA approach with age, year, and gender considered as possible confounders and the WHOQOL-BREF and MSLQ scores as dependent variables. Using the Wilks’ Lambda, the multivariate statistical analyses showed a significant effect for status (domestic; international) (F(9, 78) = 2.00, p = .05), the variables of age (F(9, 78) = .81, p = .61), gender (F(9, 78) = 1.29, p = .26), and year (F(9, 78) = 1.17, p = .33) yielded no significant differences. For the status variable, the tests of between-subjects effects generated significant results for environment (F(1) = 2.86, p = .02) and test anxiety (F(1) = 3.14,

Correlations for domestic versus international Asian medical students Tables 4 and 5, respectively, show the zero-order correlations calculated separately for Asian international and Asian domestic students. For the international students (Table 4), the motivational measures of self-efficacy, intrinsic value, and test anxiety were significantly associated with all the quality of life domain scores. No other significant associations were noted. For the domestic students (Table 5), more scattered levels of association were shown. More specifically, significant associations were found between the following: (1) the physical quality of life domain and motivational measures of self-efficacy and intrinsic value; (2) the psychological quality of life domain and self-efficacy, test anxiety, and self-regulation; and (3) the environmental quality of life domain and test anxiety. No other significant associations were noted.

Discussion The present investigation aimed to explore the relationship between quality of life and motivational factors associated with Asian medical students within the New Zealand context. To fully consider this interesting subgroup of

Table 4 Summary statistics and zero-order correlations for the WHOQOL domains and the MSLQ subscales: International students (N = 40) WHOQOL domains

Physical

MSLQ subscales Self-efficacy

Intrinsic value

Test anxiety

Cognitive strategy use

Self-regulation

.54*

.34*

-.33*

.03

.08

*

*

-.62*

.22

.24

Psychological

.66

Social

.67*

.60*

-.51*

.31

.32

*

*

*

.06

.07

Environmental

.41

.47 .37

-.42

* p \ 0.05

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Table 5 Summary statistics and zero-order correlations for the WHOQOL domains and the MSLQ subscales: Domestic students (N = 57) WHOQOL domains

MSLQ subscales Self-efficacy

Physical Psychological Social Environmental

.33* .37 -.04 .13

*

Intrinsic value

Test anxiety

Cognitive strategy use

Self-regulation

.28*

-.25

.08

.23

.02

-.44*

.14

.32*

-.19

.12

.05

-.18

.10

-.10 -.02

-.32

*

* p \ 0.05

medical students, two levels of analyses were computed. First, a between-groups analysis was instigated to unravel the unique aspect of the Asian and medical student combination by comparing this group with European medical and non-medical student groups. Second, a within-group analysis was considered desirable, given the differing characteristics of domestic versus international students. Domestic students tend to be a heterogeneous group from mixed educational and cultural backgrounds while many of the international students studying at the Auckland medical come from Malaysia (unpublished faculty statistics shows this to be 84%). Furthermore, the fees for domestic students tend to be lower than for international students. To further compound the problem, international students are often more at risk to feelings of loneliness and alienation than domestic students (Ho et al. 2002). Between-groups analyses: Asian medical students versus others In terms of quality of life, the current findings showed that Asian medical students consistently scored lower than the other New Zealand students, both European medical students and general non-medical student groups (Hsu et al. 2009; Lewis et al. 2009), on the WHOQOL-BREF social relationship domain. This domain encompasses the ideas of satisfaction with personal relationships, social support, and sexual activity (WHOQOL-Group 1998). The low scores on this domain suggest that Asian students perceive themselves to be less satisfied with their personal relationships, social support, and sexual activity than other students in general. There are several possible explanations for this finding. First, Asian students may feel isolated and may distance themselves from majority cultures (Sam 2001). Sam (2001) found that Asian international students, studying in Norway, expressed themselves as having low levels of satisfaction with respect to their quality of life. Several factors contributed to this perception, such as lack of meaningful social networks and social support systems and the experience of racial discrimination. In New Zealand, a large proportion of the Asian international medical student

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populations are Malaysian, and the Malay student groups have different religious norms to the majority culture group in New Zealand. We must first note that questions that refer to sexual activity may in fact be offensive to this group, which will likely result in a lower response rating. The fact of having different religious norms may mean that Asian students, in this study, experience social distance between their culture of origin and dominant New Zealand European culture (Ward and Masgoret 2004). Moreover, the loss of close familial and friendship networks would likely impact the sample of Asian international students in this study given their probable cultural sense of interdependence (Markus and Kitayama 1991). The lower QOL rating for Asian students may also be explained in terms of the extent to which different ethnicities view and use counseling services. Students from Asian backgrounds were found to be more reluctant to seek professional psychological help, and only seek assistance when symptoms are very severe (Yi et al. 2003). This would be an interesting area for further research and would likely have important implications for university personnel involved in pastoral care. Second, Asian medical students may be more interested in academic study than other students and thus have less time to develop, or think of developing, social relationships (Kember 2000b; Ng 2003). For example, Ng suggests that in Chinese cultures, there are strong familial networks as well as family and social obligations. Chinese students have strong academic goal orientations that tend to be performance based and highly competitive; Chinese students also tend to mastery so that they can outperform others and achieve at high levels. As such, there is less emphasis on developing personal relationships, developing friendships, and satisfying sexual desires akin to a Western perspective; rather, the focus is on developing pragmatic networks to progress their academic goals (Holmes 2005; Leung 2002). In addition, Diener et al. (1995) suggest that Asian students score lower than their non-Asian counterparts in areas of subjective well-being because of their high expectations around achievement, thus the low scores likely indicate a sense of dissatisfaction and stress related to social relationships rather than a cultural difference in responding.

Asian medical students

The next major between-groups finding of investigation was related to motivation to learn. Asian medical and European medical students appear to have similar perceptions related to motivation to learn. Nevertheless, in this study, the medical students’ groups do differ from a nonmedical student group, comprised of mainly social sciences and business students (Henning, 2007). The differences noted were in the areas of self-efficacy, intrinsic value, test anxiety, and self-regulation. It is interesting to note that the direction of difference was unexpected for self-efficacy, and intrinsic value given than the non-medical students scored higher on self-efficacy and intrinsic value than their medical counterparts, but lower on self-regulation and test anxiety. This may be due to medical students’ stage of development as learners, as this present sample was from a fourth- and fifth-year cohort who have just been introduced to clinical work at a formal level and thus may be facing more uncertainty in their training than the more formalized students studying theoretical concepts in social sciences and business (Rosenthal and Okie 2005). In addition, these medical students are under considerable pressure with respect to their learning demands and in meeting deadlines, and thus, their self-regulation skills are highly tuned (Azer 2009). There may also be a difference in terms of response patterns, given the Asian students have been found to be more conservative when responding to questionnaires that request information about themselves (Heine and Hamamura 2007).

Within-group findings: international versus domestic Asian medical students The major within-group findings, investigating the mean differences between the international and domestic students on the WHOQOL-BREF domains and MSLQ subscales, relate to environment quality of life and test anxiety. The international Asian medical students appear to be more test anxious than their domestic student counterparts, and this may be linked to environmental concerns. There is also a trend that indicates international students may be less self-efficacious. This result is potentially very powerful as it alludes to the notion of interdependence (Markus and Kitayama 1991) and the problems of adapting to an overseas learning environment, which may be exacerbated by difficulties associated with accessing accommodation, transport, and finance. Additionally, Heine and Hamamura (2007) found that the Asian Americans ratings of themselves were between South Asians living in Asia and Westerners living in America. This suggests that culture proximity and familiarity shape the way people view themselves when immersed in a different culture, and hence, over time, the Western notion of independence

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becomes more enmeshed with the Asian notion of interdependence (Markus and Kitayama 1991). In addition, the Asian medical international student correlation data show significant correlations between the motivational measures of self-efficacy, intrinsic value, and test anxiety and all the quality of life domain scores. In contrast, for domestic students, the results are less defined showing some significant results for the physical, psychological, and environment domains with self-efficacy, test anxiety, intrinsic value, and self-regulation. There is, thus, convincing evidence that the international students with lower levels of self-efficacy and intrinsic value and higher levels of test anxiety are experiencing lower levels of quality of life in all domains. There is some, less convincing, evidence that domestic students with lower levels of self-efficacy, intrinsic value, and self-regulation and higher levels of test anxiety experience quality of life issues in some domains but not all. These findings pose important implications for educationalists, university administrators, and those involved in pastoral care and academic learning. It is likely that there are familial and parental factors that strongly influence Asian medical students in their motivation to learn and selection of educational study, and this is likely to be more pronounced for international students, as domestic Asian medical students are more likely to have acculturated to the New Zealand mainstream culture (Dundes et al. 2009). In addition, international students are under more pressure to perform as they are paying higher fees than domestic students and thus accrue larger debts as a result of increased costs, which are clearly linked to environmental quality of life issues (Fitzjohn et al. 2003). The annual student fees for domestic students studying Bachelor of Medicine and Bachelor of Surgery–Year 2 onwards are $11, 324, compared with the international students’ fees of $55, 650 for the same program (The University of Auckland 2009a, 2009b). The fees for domestic medical students are approximately twice as high as those of domestic students studying other degrees, but for international students, this discrepancy is much larger. This fact alone is likely to lead to intense familial and financial pressure on many students to perform well in their studies and to put in long hours of work (Akins 2007). Students in this situation have outcome-oriented educational processes in place. This is understandable as hard work will be perceived to pay off in financial and status terms, especially if the students can gain a medical degree. In Akins’ study, all interviewees emphasized family as a primary motivating factor for studying medicine, and many students were under a sense of obligation to do well. This pressure together with a goal-orientated outlook is interesting, given that the medical profession has an inherent obligation to service the needs of the people in terms of maintaining and promoting

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well-being, which also has major implications for community practice. The family pressure to succeed, together with financial pressures, will likely combine with the need for these students to save face (Holmes 2005). In this context, the belief that willpower and effort will achieve results will likely impact on self-efficacy, intrinsic value, test anxiety, and ultimately quality of life. An issue for university personnel involved in pastoral care and academic support is to be sensitive with respect to the communication differences between Asian students and other ethnic groups, especially international students and to consider their geographical distance from their interdependent cultural links (Markus and Kitayama 1991). Holmes suggested that there are likely to be power differences between teachers, administrators, and students that make it more difficult for Asian international students to communicate problem issues with those in authority. This can be attributed to the different educational expectations of the Western self-directed approach to learning. As one student in Holmes’ interview survey stated, when ‘‘reflecting on his teachers in medical school in China, summed up this relationship: ‘The lecturer[s] they help you in every area, not only the practicing, the training, even the homework. They help you with everything’’’ (Holmes 2005). Other areas of difficulty include English language competency, the ability to interact with others within the lecture theater or when on clinical placement, the ability to express honest opinions and ideas, being interactive within small groups, and interaction with teachers. Holmes (2005) has further indicated ways to meet the needs of Asian students and in particular international students. These are important considerations given the emphasis on recruiting overseas students into domestic academic programs. Areas of importance include building trust and recognition of differences. Developing intercultural communication signifies improved service and an equitable process and intent that will likely enhance teaching and learning by promoting understanding and creating a sense of global consciousness (Kanagawa et al. 2001; Kember 2000b).

Conclusion The findings of this study suggest that the Asian medical student cohort differs from other student groups in terms of developing social relationships. No other differences for this combination were noted. Secondly, international Asian students appear to be more at risk than Asian domestic students in terms of quality of life and motivation to learn issues. There is also strong evidence to suggest that international students who have problems with self-efficacy, test anxiety, and intrinsic value struggle with all areas of

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quality of life. In particular, test anxiety appears to be the most salient area of concern. This is likely to be a vicious cycle and needs to be addressed at all levels: pastoral and academic. The present study also suggests scope for future research, namely investigating Asian subgroups (Chinese, Japanese, Korean and so forth), making research links with academic achievements, and investigating the Asian notion of social relationships. The data also suggest further investigations into the use of the WHOQOL-BREF and MSLQ in terms of the need for locally based normative data. In addition, the present study has highlighted some areas of attention for intervention or further research, in particularly to address the specific needs of both domestic and international Asian students. Moreover, the assumption of independent random sampling was not adhered to as participation was voluntary, although the high response rate for medical students increases the likelihood of representativeness for this group. Lastly, in future studies, a non-medical student group would need to be more systematically matched with the medical student cohort in terms of year of study and gender. Acknowledgments We would like to thank Johanna Beattie, Melinda Smith, the Centre for Medical and Health Sciences Education and the fourth- and fifth-year medical students for their considerable assistance in the collection of data and access to the necessary resources to complete this work.

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