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The Factors Associated with Health Promotion Behavior of International Students in South Korea

Background: We aimed to explore the factors associated with health promotion behavior of international students in South Korea. Methods: The convenience sample of 263 participants was recruited from two universities in Gangwon-do and Jeollanam-do, South Korea. The data were collected by using structured questionnaires from Apr to Jun 2019. Demographic characteristics, health conception, acculturative stress, self-efficacy, interpersonal support, and health promotion behavior were assessed. T-test, ANOVA, and multiple regression analyses were used for statistical analyses. Results: Participants from Vietnam (P=.040), with more health conception (P<.001), more acculturative stress (P<.001), more self-efficacy (P<.001), and greater interpersonal support (P<.001) were more likely to engage in more health promotion behaviors. Conclusion: This study is meaningful as it collected the data on which to design health promotion programs for international students. Future studies are needed to investigate further factors relating to international students’ health promotion behavior, including internal and external environments.


Introduction
According to the Korean ministry of education, in 2019, the number of international students who were studying at domestic universities was 160,165. This number has increased 2.1 times since 2009 (1). China provided the largest number of international students (44.4%), followed by Vietnam (23.4%), Uzbekistan (4.7%), Mongolia (4.6%), and Japan (2.7%), while students from America, Africa, and Europe are increasing (1). Given the growing number of international students in South Korea, attention and support are needed for them to complete their studies and become members of Korean society. International students experience many difficulties, such as low foreign language skills, cultural barriers, low academic achievement, lack of financial support, interpersonal problems, and homesickness. Together with these difficulties, they have various physical and mental health problems (2,3). Previous studies found that they presented health issues such as sex-related problems, oral disease, eye fatigue, indigestion, stress, and depression (4,5). Even if international students in South Korea displayed health-promoting behaviors, such as walking, healthy eating, sleeping sufficient hours, and stress management (4,5), they still face a high probability of health risk behavior due to peer pressure, curiosity, difference in lifestyle, and socio-cultural background (6,7). Health is the basic premise for maintaining an optimal life and functioning as a human being. Today, the approach to health is changing from a focus on disease treatment to disease prevention and health promotion. Steady and continuous healthpromotion behavior is essential for a healthy life. In particular, college is a critical time for individuals, who are transitioning from late adolescence to early adulthood, to establish a healthy lifestyle through firm individual will (8). At the same time, it is also the phase where they tend to engage in health-threatening behaviors such as alcohol, smoking, and poor diet (9). Crucially, international students live in other countries during this important time, thus lacking a supportive environment, which would normally encourage healthy behavior. Therefore, more attention and consideration are needed to promote healthy behaviors in international students (2,10). Pender's health promotion model (HPM) (11) consists of two major categories of predictors. One predictor is related to the individual characteristics and experiences, which include personal factors such as age, gender, self-esteem, perceived health status, culture, and socioeconomic status. The other predictor is related to behavior-specific cognition and affect as the major motivational mechanisms for health promotion behavior. These include perceived benefit of action, perceived barriers to action, perceived self-efficacy, activity-related affect, interpersonal influences, and situational influences. In HPM, the behavioral outcomes are defined as health-promoting behaviors. Health promotion is an action performed by an individual or group to achieve optimal well-being and to promote self-realization and the satisfaction of individual needs (11)(12)(13). Previous studies on international students in South Korea were conducted mainly in relation to cultural adaptation, depression, stress, use of medical service, and physical health conditions (3)(4)(5). However, little to no research has been conducted on their health promotion behaviors and other related factors. A study explored health promotion behaviors in Chinese students (14), but it was limited in the current domestic situation in which international students are flowing in from various countries. Moreover, although social support and self-efficacy were presented as major factors affecting university students' health promotion behavior (7,9), it is also necessary to examine the health perceptions of international students and to consider the stress caused by cultural adaptation, shown to affect behavior negatively (14). The purpose of this study was to explore the factors associated with health promotion behaviors of international students in South Korea. Based on Pender's HPM, we considered the individual characteristics, self-efficacy, interpersonal support, and stress from cultural adaptation of people of different nationalities. Through this study, we intended to identify the main variables that affect health promotion behaviors of international students in South Korea and provide data for the development of health promotion programs addressed to them.

Participants and Data collection
For this cross-sectional descriptive survey, participants were recruited from two universities in Gangwon-do and Jeollanam-do, South Korea, through convenience sampling. Participants had lived in South Korea for more than three months to study. They were able to self-report in English or Korean with the aid of the research assistants. The sample size for the regression analysis, calculated with the G*Power 3.1.9 program based on the effect size of 0.15, power of 0.9, significance level of P<.05, and 18 associated variables, was 183. We considered an attrition rate of 20% and set the sample size at 260. Overall, 263 participants were recruited and responded to the questionnaire from Apr to Jun 2019. Finally, 240 participants were included in our study, after excluding 23 respondents who presented incomplete response and any outliers.

Health conception
The Laffrey health conception scale (LHCS) (15), was used to measure health conception. Twentyeight self-reported items were rated on a 6-point Likert scale, ranging from 1 to 6, with a higher score indicating better health conception. Cronbach's α for Laffrey's study (15) ranged from .867 to .884 and it was .930 for the present study.

Acculturative stress
The acculturative stress scale for international students (ASSIS) (16), evaluates perceived discrimination, homesickness, fear, guilt, perceived hate, and stress due to change. Thirty-six self-reported items were rated on a 5-point Likert scale, ranging from 1 (strongly agree) to 5 (strongly disagree). Higher scores are indicative of greater acculturative stress perceived. Cronbach's α for the total items in Sandhu and Asrabadi (16) ranged from .87 to .95 and it was .974 for the present study.

Self-efficacy
The general self-efficacy scale (GSE) (17), was used to measure self-efficacy. Ten self-reported items were rated on a 4-point Likert scale, ranging from 1 (not at all true) to 4 (exactly true), with a higher score indicating a higher level of self-efficacy. Cronbach's α for the GSE (18) ranged from .75 to .91 and it was .816 in the present study.

Interpersonal support
The interpersonal support evaluation list (ISEL) scale was used for measuring interpersonal support. ISEL was developed (19) and consisted of 12 self-reported items rated on a 4-point Likert scale, ranging from 1 (definitely false) to 4 (definitely true). A higher score meant the participants received more support from interpersonal relationships. In Cohen's study (19), Cronbach's α ranged from .77 to .90, while it was .691 in the present study.

Health promotion behavior
The health promoting lifestyle profile II (HPLP II) was used to measure health promotion behavior status. HPLP was developed (11) and revised to HPLP II in 1995 (12), which consists of 52 items rated on a 4-point Likert scale, ranging from 1 (never) to 4 (routinely). HPLP II measures the frequency of self-reported health-promoting behaviors in the domains of health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, and stress management. A higher score indicated that the participants displayed more health promotion behaviors. Cronbach's α for the present study was .954.

Data analysis
Data were analyzed using SPSS ver. 24.0 (Chicago, IL, USA). To describe the general characteristics and the research variables, descriptive statistics, including mean, standard deviation (SD), minimum, maximum, frequency, and percentage, were performed. Further, t-test and ANOVA were used to evaluate how the research variables differed according to general characteristics. The relationships among continuous research variables were examined with Pearson's correlation coefficients. Multiple regression analysis was conducted to investigate the factors associated with health promotion behavior.

Ethical approval
This study was approved by the Institutional Review Board (KWNUIRB-2019-03-001-001) of Kangwon National University. All participants were informed of the research purpose and confidentiality. After they agreed to participate and gave their written informed consent, data were collected.

Results
The general characteristics of the 240 participants are described in Table 1. Nationalities included China (42.1%), Vietnam (27.1%), Uzbekistan (12.5%), Mongolia (5.8%), other Asian (7.9%), and other non-Asian countries (4.6%). 65.0% were enrolled in an undergraduate course and 47.9% were living in a dormitory. Most of the participants (82.5%) had the health insurance for international students by the Korean national health insurance plan. Half of them (51.3%) were staying in Korea from 1 to 3 years.  The multiple regression analysis of health promotion behavior is presented in Table 5. The regression model explained 44.1% of the variance. Participants from Vietnam (P=.040), with more health conception (P<.001), more acculturative stress (P<.001), more self-efficacy (P<.001), and greater interpersonal support (P<.001) were more likely to engage in more health promotion behaviors.

Discussion
In this study, health-promoting behavior score was 2.76 (SD 0.46) out of four. This is similar to the results of previous studies for Chinese and Vietnamese students in South Korea (5,20). The present study included participants of various nationalities, but the majority were from China and Vietnam. Nonetheless, Korean college students' health promotion behaviors were lower than those of the international student (5,21). Moreover, the present results showed that spiritual growth was the highest and health responsibility was the lowest among sub-domain's scores. Contrary to these results, Korean students' health promotion behaviors were the highest in interpersonal support and the lowest in health responsibility (21). These differences in health promotion behaviors between Korean and international students are believed to arise from differences in the perception and behavior towards the health-promoting lifestyle of the environments they grew up in. Therefore, to enhance health-promoting activities for international students in South Korea, it is necessary to adopt a distinct approach and content composition to that adopted for domestic students. There were statistical differences in health promotion behaviors according to age, nationality, academic degree, and whether they lived in a dormitory. Health promotion behavior was higher for those under 25 yr old compared to those over 30. This result was also shown in academic degree, as international students in undergraduate programs presented healthier behaviors compared to those attending a master's program. Another study revealed no difference between students under and over 25 yr old (22). Most international students over 25 yr old advanced to higher education. The older the international students were, the less their academic adaptability decreased (23). Therefore, it is necessary to establish an intervention strategy for health promotion after exploring the relevance of academic adaptation and health behaviors among international students in a master's program or higher. In this study, Vietnamese students had healthier promoting behaviors compared to other Asian students. Until now, studies had been conducted primarily on Chinese students living in South Korea (24). However, few studies have been conducted on health behavior and acculturation of Vietnamese students, who comprise the secondlargest group of international students in South Korea (25,26). It is encouraging for Vietnamese students to improve their health life, but attention to students of other Asian nationalities is also required. Furthermore, in this study, health promotion behaviors among international students residing in dormitories were higher than that of nondormitory residents. This finding differs from another result (22), since the participants of the present study were from universities in small and medium-sized cities in South Korea. Therefore, it is necessary to account for the environment, for instance by providing practical support to enable international students to live in universities and opportunities to access healthcare through out-ofschool communities. The factors associated with the health promotion behaviors of international students in South Korea were nationality, health conception, acculturative stress, self-efficacy, and interpersonal support. High health conception means absence of illness, ability to function as expected roles, adaptation to environmental stresses, and achievement of selfrealization (15). In the results of this study, the higher the perception of health, the more the international students in South Korea may display health promotion behaviors. It is similar to the study targeting domestic college students (27). Therefore, for international students to adopt a healthy lifestyle, they should be allowed to recognize and care about their health. Self-efficacy, a key proposition of HPM, influences perceived barriers to action. Higher self-efficacy results in a lowered perception of barriers and it motivates health-promoting behaviors (28). This study proved that, after controlling for other variables, self-efficacy in international students affected their health-promoting behaviors. In the future, when designing health promotion programs for international students, it is necessary to first check their self-efficacy and focus on low self-efficacious students. Acculturative stress indicates the perceived stress during the process of adapting to different cultural values, languages, and sociocultural environments (29). Acculturative stress in international students may result in poor physical and mental health conditions, such as sleep disturbance, low appetite, fatigue, headache, gastrointestinal problems, and depression (4,5). Asian international students in the USA have shown a positive association between acculturative stress and depression (30). Furthermore, acculturative stress had a negative effect on health promotion behaviors (14). Nevertheless, Chinese students did activities that are more physical after they arrived in the USA (31). The present study showed that higher acculturative stress caused more health-promoting behaviors. In other words, the more stressed the participants were due to cultural adaptation, the healthier a lifestyle they had. The acculturation of health behavior is influenced by individual, environmental, and cultural background factors, and the international student's different attitudes toward the new culture (32). Some international students are more open and active in adopting the new lifestyle and others retain the same lifestyle before and after visiting another country (32). In this study, the acculturative stress mean score of the participants was 2.92 (SD 0.82) on a five-point scale, indicating that it was not high. Moreover, most of them were Chinese and Vietnamese students who belonged to a similar culture to South Korea. It means that they do not experience high levels of stress in adapting to South Korea. In the future, a study on the relationship between acculturative stress and health promotion behavior, which is likely to be mediated by a variety of variables, including acculturation level and degree of similarity between new and original culture, is needed. Furthermore, longitudinal research is needed to explore the process of health promotion lifestyle change in international students from various cultural backgrounds. Cultural intelligence represented a significant moderator of the relationship between acculturative stress and somatic health symptoms (33). Cultural intelligence is an ability that allows individuals to understand and adapt effectively to different cultures (33). Since cultural intelligence affects the individual's behavior, it is needed to explore the relevance of an individual's health, cultural intelligence, and health life behaviors. Interpersonal support for international students affects their academic success and engagement in the new culture (34). Additionally, interpersonal support encouraged health-promoting behaviors. Therefore, it would be advisable to organize and operate health promotion programs for international students using interpersonal resources. There were several limitations to this study. First, the cross-sectional research design is inadequate at making inferences about causality. Therefore, in the future, a longitudinal study is recommended to identify the causal relationship between variables. Second, convenience sampling was employed and the participants were recruited from two universities in South Korea, which limits a generalization of the results. This study presents the basic data for focusing on international students in South Korea and providing them with the health promotion intervention needed to adapt to Korean society and succeed in their studies.

Conclusion
This study identified the factors associated with the health promotion behaviors of international students in South Korea: Vietnamese nationality, high health conception, high acculturative stress, high self-efficacy, and high interpersonal support. This study is meaningful as it collected the data on which to design health promotion programs for international students. Future studies are needed to investigate further factors relating to international students' health promotion behavior, including internal and external environments.

Ethical considerations
Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.