Social Isolation, Loneliness, and Mental and Emotional Well-being among International Students in the United States

Background: Loneliness and social isolation can have an effect on an individual’s mental and physical health. With research linking both to morbidity and premature mortality, their effects must be viewed as important public health problems. Loneliness and social isolation is common especially in the international student community, particularly at the university level, as this population encounters challenges assimilating to their host university, surrounding community, and host country. This study explores the risks and sociocultural factors associated with loneliness, social isolation, and psychological distress with regards to the overall adjustment of international students. Methods: In this qualitative, narrative case study, 10 international graduate students at a university in the United States participated in two focus group sessions followed by individual interviews. Thematic areas and topics were identified using Barrera’s three models of social support. Study was completed between December 2016 and September 2017. Results: All of the participants shared that they had experienced loneliness and social isolation at some point during their acculturative process resulting in perceived xenophobia and a sense of insincerity on behalf of domestic students when attempting to forge connections. For some, these experiences elicited feelings of depression, a disinterest in building connections with domestic students, and in attending social events held on campus and within the community, further exacerbating feelings of loneliness and social isolation. Conclusions and Implications for Translation: Results shed light on the impact that poor acculturation can have on the student’s mental and physical health and how bridges between the international and non-international communities can be built and more importantly, sustained. There is a critical need for more effort to be focused on attending to both the mental and physical health needs of migrant students during their stay at the host university.


Introduction
Although research indicates that "social isolation can be as damaging to health as smoking 15 cigarettes a day" and that nearly 8 million adults have been affected by isolation, the connection between social isolation, loneliness, and health is still unrecognized as a vital component in ensuring and sustaining emotional and physical well-being. 1 However, due to its rising prevalence, clear connection to morbidity, and link to life expectancy, social isolation and loneliness have solidified their spots as important public health concerns, and being classified as the "loneliness epidemic." 1 Social isolation is categorized by whether an individual belongs to a social network; loneliness, however, refers to the perception that one's "intimate and social needs are not being met." 2 Research suggests that individuals who lack social connectedness and social support, and have fewer social ties are at an increased risk for premature mortality and experience of loneliness. 3,4Social isolation and loneliness have also been linked to detrimental emotional and physical health problems such as heart disease, high blood pressure, cognitive decline, anxiety, and depression. 5Research also suggests that health-related factors are potential risk factors for social isolation and loneliness. 1 In order to provide insight into the relationship between sociocultural factors, social support, acculturative stress, and psychological distress, this study applied Barrera's three models of social support. 6The three models include the: (1) Direct Effects Model, (2) Stress-Buffering Model, and (3) Social Support Deterioration Model.The direct effects model suggests that the international students' social support networks have a direct effect on their psychological health.This model posits that all human beings have needs that are rooted in attachment and connections with others.In this regard, social support helps the international students meet their social and emotional needs by allowing for human contact, which, in turn, has a positive effect on their psychological well-being.These needs are not contingent upon the presence nor absence of acculturative stressors. 6Applying Barrera's three models of social support helps to examine how loneliness and social isolation can certainly become poignant emotions experienced by international students.The amount of social interactions and connections affects whether the international students' adjustment experience is a positive or negative one, subsequently impacting their mental and physical health.
According to Bochner, there are four ways that individuals respond to acculturation: (1) Passing, (2) Chauvinist, (3) Marginal, and (4) Mediating. 7He suggests that international students with a passing response to acculturative stressors have a more embracing approach to the host environment while lacking cultural identity to their home countries.To this end, once international students arrive at the host university, they will likely be more receptive to the adjustment experience but will also have a sense of detachment with their native cultural identity.Conversely, the chauvinist international student rejects the host culture altogether while inflating their native cultural identity and its values.Individuals with marginal responses are not connected to either their native or host culture. 7Finally, the international student with a mediating response takes the acculturation process a step further and integrates both cultures and ultimately develops their own cultural system. 7Thus, host academic institutions should be aware of the needs of international students and the different ways that students might respond to acculturative stressors.
A study examining the importance of social networks for international students found that nearly two-thirds of 200 international students experienced problems of loneliness and/or isolation, especially within the first few months of their arrival to the host university. 8The study further suggest that there are three types of loneliness that international students experience (1) personal loneliness -this is due to loss of contact with family and friends; (2) social loneliness -this is due to loss of social networks; and (3) cultural loneliness -this is triggered by the absence of the culture and language that the international student is accustomed to. 8This is supported by qualitative researchers Sandhu and Asrabadi who posit that the two major acculturative stressors that are particular to international graduate students are language barriers and lack of social connectedness as well as the accompanying emotions of inferiority, loneliness, and perceived alienation. 9For this reason, it is important for host universities to be aware of these forms of loneliness in order to understand the differences and causes of the loneliness experienced by international students compared to their domestic counterparts.
The primary objective for this qualitative, narrative case study was to gain a deeper understanding of the acculturative challenges involved in the migration experience of international students and the ways in which their mental and physical health were affected.This study fills a gap in literature by providing insight into potential options for university staff to be able to overcome adjustment barriers, thus allowing for a more positive acculturation process for international students.
Additionally, this study sheds light on the reciprocal nature of isolation and various forms of loneliness as it relates to the international student population.The experiences of social isolation and loneliness have significant implications for the immigrant student's mental and emotional wellbeing.More importantly, the results will crystallize the need for university staff to be appropriately trained on the risk factors that perpetuate loneliness and isolation while focusing on sustainable efforts to remediate acculturation challenges as they present for international university students.

Methods
The authors employed a qualitative, narrative case study approach in order to identify and provide an account of the details involved in the acculturation process of the participants.Qualitative research does not begin with a hypothesis that is proved or disproved but instead with a plan of simply exploring the phenomenon at hand. 10 This was beneficial as the authors sought to identify the loneliness and social isolation related emotional experiences of the participants. 11The qualitative approach allowed for the focus to remain centered on understanding the how's and why's involved in the phenomenon and, furthermore, the meanings attached to that phenomenon. 10Therefore, the authors were also able to understand how the participants personally interpreted these experiences.
To garner interest from participants from diverse backgrounds, the final selection criterion was that the international student was currently enrolled in either a Master's or Doctoral program at the host university.After recruiting 10 international graduate students from Southern Illinois University Carbondale (SIUC), two focus group sessions were held followed by individual interviews with each participant (Table 1).Southern Illinois University, located in Carbondale, Illinois in the United States (U.S.), was founded in 1869 and is a public research university and the oldest campus of the Southern Illinois University system.The university enrolls students from all 50 states of the U.S. and international students from more than 100 countries.
The data collection process was held via Google Hangouts and telephone.These modes of communication were selected in order to best accommodate the participants' schedules.Each participant was provided with a thorough explanation of the goals of the study and was notified that their participation was purely voluntary.They were also provided with informed consent forms which they The study questionnaires focused on understanding the students' feelings of loneliness and social isolation and how those emotions affected their mental and physical health.This included exploring topics such as academic, social, and financial stressors; social connectedness and support; language proficiency; and culture shock.All participants were English speakers, thus not requiring a translator and were informed that their participation was voluntary.In order to protect the identities of each participant and promote confidentiality, pseudonyms were ascribed.
The data collection and subsequent analyses procedurally consisted of two stages.The first author began by holding two focus group sessions, the first with five-female participants and the second with five-male participants.During both sessions, each of which lasted nearly an hour and a half, participants were prompted with questions designed to elicit dialogue regarding their experiences while at the host university.For the focus groups, participants were separated in order to provide a comfortable environment to ensure that discussions were not altered due to fear of judgment.Following both focus group sessions, hour long one-to-one interviews were held with each of the participants in order to delve deeper into thoughts previously shared with the larger group and further expound upon any area discussed during focus group sessions.
In regards to credibility (or internal validity), there was an ongoing process that involved member checking post interviews with each participant to ensure that what was shared during the interview was documented in the right context and to help guarantee that bias was eliminated as much as possible.The study was approved by the Human Subjects Committee at the Southern Illinois University, Carbondale.

Results
The most poignant emotions that were expressed during both the focus group sessions and interviews were that various types of loneliness and isolation can manifest during the acculturative process.There was a consensus among participants that as they began their adjustment process at the host university, the isolation experienced was always preceded by feelings of loneliness.Additionally, perceived xenophobia on behalf of the participants played a substantial role in how the participants viewed and labeled their acculturation experience.

Social isolation
All of the 10 participants shared that they had experienced some form of social isolation since entering their respective academic programs at the host university, especially during the period of arrival.These experiences were multi-factorial and at times compounded by other adjustment stressors.Many of the participants expressed that the social isolation which they experienced was so extreme that they felt more comfortable staying home than going out.During her interview, Jill (Nigeria, Doctor of Philosophy) explained that she experienced bouts of loneliness and felt isolated from other students and the university as a whole.She shared that since being in her academic program for over 10 weeks (at the time of data collection), she had only spoken to two domestic students.Jill further shared thoughts regarding how this might be due to inherent cultural differences.She explained that in Nigeria, people were more communal while she believed that American culture promotes independence.Jill explained, "African people are social and everyone wants to be a family." Another female participant, Liana (Bangladesh, Master's) explained that she too had experienced social isolation and loneliness.Coming from a tightknit family base in Bangladesh, she found it difficult to navigate her way in a culture that was so different than what she was used to.She explained that because she did not have any family or many friends with her in the university and town, her routine became monotonous.Her schedule was typically going to class and coming home to study.She further said, "There has been no formal conversations with classmates, so I began to concentrate on my studies and research."The lack of social interaction was a very challenging adjustment for Liana.She said, "We are all social beings that need to be around others in order to survive."Similar to both Jill and Liana, Myra (India, Doctor of Philosophy) shared her experiences of loneliness and social isolation while at the host university.For Myra, eating alone was something that posed a major adjustment challenge for her.She explained that in India, meal times were considered opportunities for laughter and sharing updates with one another.She said, "I have learned that food is such an important part of our society.Eating food without socializing, is new for me.It was very disconcerting to come here and notice that people don't share food or lunches, like a peace offering."She explained that the mere act of eating together can serve as an educational opportunity as students are able to learn about the native foods and cultures of others.
Ryan, a male participant, (India, Doctor of Philosophy) shared that he often felt that if he was not the one to initiate conversation with domestic students, a conversation beyond initial greetings would not result.He believed that the American students had no interest to know more and acquaint with international students, "Especially the students from rural areas."He had more positive experiences with domestic students that were originally from larger cities and shared, "They were more accepting and open minded."He also shared that students from rural areas "Are not friendly and look at you as though you are something different.They seemed nervous and I don't know if that is because of how they're raised.It seems like they don't want to be involved with international students."For Stephen (Colombia, Master's), stereotyping had been a barrier in his adjustment as domestic students and staff made several comments regarding his being from Colombia and its history with drugs.He expressed that this affected his ability to assimilate as some domestic students seemed fearful of him.

Interpersonal loneliness
The participants shared how physical distance from their loved ones caused distress and were sources of emotional stress.For seven out of the 10 participants, their immigration to the host university country was their first experience away from family and friends.
For these participants, it was especially difficult to adjust to living abroad.For the majority of the participants, keeping in contact with their families and friends in their home country was a priority and a part of their daily routine.
There were gender differences on the extent to which distance from families affected participant adjustment.Many of the male participants, regardless of whether they had prior experiences living away from their homes and families, seemed to be less affected by this type of isolation than the female participants.Many participants shared that they understood that the distance from their families in their home country was a necessary part of the process in order to obtain their degree.Serving as a source of comfort was their ultimate plan to return to their home country after graduation.

Academic loneliness
Nine out of 10 of the participants had experienced stress related to their academic life, which in turn had initiated feelings of isolation.Studies have shown that compared to the various potential acculturative stressors that visiting students might encounter, the academic adjustment-related challenges have the strongest ability to impact their psychological adjustment and overall adjustment experience. 12,13cademic stress is a unique challenge in that it incorporates several acculturative stressors such as language barriers and classroom environment.In attempting to get adjusted to their new academic environment at the host university, the participants said that they dedicated more hours to their studies than what they believed their domestic colleagues were required to due to language barriers and their inability to grasp much of the instructional material due to the speed in which the instructors spoke.
Another academic-related adjustment challenge was academic workload.For Michael (Nigeria, Doctor of Philosophy), adjusting to the amount of daily assigned work was a leading source of stress.He explained that in Nigeria, the workload is much lighter than that of the workload at the host university.During the focus group, Liana and Myra also shared that they both have experienced high levels of stress related to adjusting to the American educational system.They spoke about how the differences in classroom environment was very challenging to adjust to, especially the student-teacher dynamic.In their home countries of Bangladesh and India, respectively, instructors were revered and rarely spoken to, even when instructions were unclear.

New environment loneliness
In listening to the stories shared by the participants, it was evident that being in a new environment and adjusting to new foods and general ways of life were overwhelming.For many of the participants, adjusting to living in a rural area was as a major challenge in their adjustment.Participants Jenn (Zambia, Doctor of Philosophy), Myra, Ryan, and Stephen shared stories about how they found it difficult to sleep at times due to the lack of street noise.As they hail from larger, metropolitan cities, the quietude of the university town was an adjustment challenge.
The participants explained that the lack of cultural awareness by some staff, students, and community members toward international students was challenging.Current literature supports the idea of programs being developed to increase an intercultural classroom and community environment. 14Participants painfully recounted experiences where they felt that they were viewed as second class citizens, treated as showcases, or overlooked for academic related opportunities.As a female participant, Myra shared during the focus group, if it were not for the annual International Festival held on campus, the many cultures that are present at the university would never be appreciated.

Social isolation and university support
All but one participant expressed that the university can do more to ensure that their social needs were met.As John (Japan, Master's/Doctor of Philosophy) clarified during the focus group discussion, the university should adequately train their staff to be able to accommodate the international student population.John believed that many of the adjustment issues that plague international students could be remedied if the staff were well-informed about the possible adjustment challenges that international students might encounter on campus.
In addition to staff training, participants suggested that the university should employ various methods for advertising social events geared toward attracting all students.In particular, graduate students typically do not participate from campus events due to living off campus and having more challenging academic demands.Therefore, the participants felt that graduate students is a population that might require more than a single approach to advertising.

Discussion
The objectives of this study were to delve deeper into the topics of loneliness and social isolation and understand the relationship and effects(s) on the mental and physical health of international students.The results highlight the detrimental outcomes of the host university negating or overlooking the potential health outcomes of experienced loneliness and social isolation for this population of students.International graduate students face a great risk of experiencing depression due to loneliness and social isolation.Moreover, they are less likely than domestic students to utilize mental health services to help combat related issues, which should be deemed both a university and community-level concern.
In understanding the interconnected nature of acculturative stressors, such as new classroom environment to elicit emotions related to loneliness and isolation, we are better able to address the needs of this population.This supports researchers such as Erichsen and Bollinger, where they explored the interrelated nature of adjustment stressors and the resulting effects of loneliness and emotions related to isolation. 15The experiences shared by the participants have the ability to, at the very least, initiate the discussion about ways in which university staff will be able to implement services that will hopefully bridge the gap between what is already being offered on campus and within the community and what may be lacking.It is also the responsibility of staff, students, and community members to not only be tolerant of other cultures but accepting and welcoming of their visiting student population.
A potential limitation of the study is the smaller sample size.However, as a qualitative study, the goal was not to garner data that would be generalizable.Thus, this did not prevent the author's from gaining a true understanding of the participants' experiences related to loneliness and social isolation.Additionally, this study was performed with participants from a single, rurally located university, thus the study findings may not be representative of international graduate students at other universities, particularly those in metropolitan areas.

Conclusions and Implications for Translation
The results shed light on the impact that poor acculturation can have on the students' mental and physical health, and how bridges between the international and non-international communities can be built and more importantly, sustained.Moreover, the results highlight the critical need for more effort to be focused on attending to both the mental and physical health needs of migrant students during their stay at the host university.This study's significance rests in its ability to provide institutions and their select staff who work alongside international student population with valuable inputs that they could utilize as they welcome their visiting students.Considerable data exist regarding the need for sustainable efforts to address the growing social isolation and loneliness epidemic.As awareness of risk factors increases, it is crucial that public health workers, serving in all capacities, strive to meet the needs of those affected by offering attention and resources and deeming this issue one worthy of significant global health attention.► Social isolation and loneliness are growing public health epidemics with the potential to cause detrimental health problems such as heart disease, high blood pressure, cognitive decline, anxiety, depression, and premature mortality.► There is a reciprocal relationship between health-related factors and risk factors of social isolation and loneliness among international students.► University and community support are crucial in the potential remediation of adjustment needs for the international student population in U.S. universities.

Financial Disclosure:
None to report.Funding/ Support: None.Conflicts of Interest: None.Disclaimer: The views expressed are the authors' and not necessarily those of the US Department of Health and Human Services or the Health Resources and Services Administration.Ethical Approval: This project was reviewed and approved by the Southern Illinois University at Carbondale Human Subjects Committee.