Behavioral health morbidity for those studying or working internationally
Authors: Quigley Robert Lawrence , Claus Lisbeth , Nixon Ashley 
Published: November 2015

Purpose
– The increase in prevalence of behavioral health issues among college and university students is burdening the scholastic sector both domestically and internationally. More American students participate in study abroad programs than ever before. These provide educational institutions with additional duty of care challenges and responsibilities especially when it comes to their health status while studying or working abroad. The requests for assistance to an assistance service provider of students from US universities studying abroad were compared to international assignees from US employers in terms of closing diagnoses and case outcome types. The purpose of this paper is to indicate that there are differences in diagnoses and case outcomes between students studying abroad and employees working abroad. Students are more likely than international assignees to be diagnosed with behavioral health issues, to be referred to a health provider (rather than being treated through in-patient care) and to be evacuated or repatriated. It is recommended that US universities change their duty of care practice from the “inform and prepare” to a higher level benchmark, commonly practiced in the US corporate sector, of “assess, assist and protect.”

Design/methodology/approach
– US employers and universities often contract with a service provider for international travel assistance for their traveling employees/students. The sample consisted of case records of a large assistance service provider based on request for assistance (RFAs) by international assignees and students from its different US client organizations (US employers and universities) over a 24-month period (January 1, 2010 to December 31, 2011), with all client travel originating in the USA and traveling abroad. A two-year framework was used to include a larger sample of short- and long-term international assignees. The individual requesting assistance (student or international assignee) was the primary unit of analysis. The multiple case records can be viewed as a “case study” of an assistance provider (Yin, 2014). According to Yin’s case study design typology, this research used a single case (embedded) design. It is a single case study of client records from a global assistance provider of medical and security services for international travelers. The case study was embedded because it involved more than one unit of analysis. The case study included 17,071 records from two different subunits: 831 students studying abroad from 82 US universities and 16,240 US international assignees working for 889 US employers requesting assistance for health-related issues from the global service provider. The US client organizations included universities with study abroad programs and employers of different sizes and industries who have global mobility programs.

Findings
– The hypotheses related to different diagnoses and outcomes based on RFAs while working or studying internationally were confirmed in spite of the fact the age and gender (important antecedents of morbidity) were controlled. Compared to international assignees, students are more likely to be diagnosed with behavioral health issues, more likely to be referred to a health provider (rather than being treated) and more likely to be evacuated/repatriated. This not only shows the importance of behavioral issues among students while studying abroad but also indicates that the corporate organizational support structures for international assignees are different than those universities provide to students.

Research limitations/implications
– This study assessed how RFAs by students studying abroad differed from international assignees working in corporate organizations. With this type of case study, the mode of generalization is “analytic” rather than “statistical.” In analytic generalization, the empirical results of the case study are compared to a previously developed theory (Yin, 2004, p. 38). As a result, the authors are striving to generalize the particular empirical results of students and international assignees to the broader institutional theory.

Practical implications
– The research has implications for further research. First, these results can be replicated with other samples of students studying abroad. If replications result in similar findings, indicating that students have increased risk of being diagnosed with behavioral health conditions, this finding can be probed for a better understanding of both process and outcome. For instance, future research can delineate the specific behavioral health diagnoses the students are receiving, which can have important implications for behavioral health care providers, educational duty of care considerations, as well as direct future research in this area. An additional area of critical importance for future research will be elucidating the students’ systemic experience of increased stress associated by studying abroad, the subsequent psychological and physiological responses, as well as how students are impacted by this stress. There are also some systemic stresses that are unique to the study/work abroad context. Many of the administrative requirements (such as required paperwork for travel, visas, travel scholarships, funding, vaccinations, health care, etc.) are taken care of for international assignees by their employers through the global mobility division. They are not necessarily done by universities for their students. Students are largely responsible for these themselves although with some guidance through the study abroad program staff. Researchers can also examine how cultural adjustment models apply to students studying abroad. For instance, how might changes in anticipatory adjustment impact student development of behavioral health conditions, including both individual factors such as pre-travel training, as well as organizational factors such as selection systems designed to identify those that could need additional behavioral health support while they are abroad. Likewise, in-country adjustment can also be evaluated in future research to identify individual, organizational and cultural aspects that could be associated with increased behavioral health diagnoses in students. Such research can shed more light on this understudied population, illuminating the steps that university can take, with regard to duty of care concerns, to ensure students have safe and beneficial experiences abroad.

Social implications
– The population of corporate international assignees is emotionally more mature and more experienced in world travel and therefore more likely to be adaptable to the challenges of traveling and living abroad than the study abroad population of students. As more students enroll in study abroad programs, the absence of an infrastructure to support behavioral health issues at the time of enrollment, while on-site and upon return will only result in more exposure for both students and educational institutions. E-learning tools, and even anonymous student self-exams can assist in determining fitness for study abroad. Simultaneously, colleges and universities must educate their local and distant faculty/team leaders, host institutions as well as other students to recognize and react appropriately to a behavioral health crisis. Adherence to such a strategy will certainly help to mitigate the risk of a failed study abroad experience. Although this study is limited to US students traveling overseas, behavioral health is an issue with students globally. American institutions hosting foreign students should, therefore, re-evaluate their existing domestic resources to accommodate the psychological needs of their visiting international students. It is the authors recommendation that, prior to travel, students should develop greater self-awareness, with or without the assistance of a professional. Implementing these recommendations will move university duty of care practice from the “inform and prepare” to a higher level benchmark, commonly practiced in the corporate sector, of “assess, assist and protect.”

Originality/value
– With regard to case outcomes, students had lower odds of experiencing severe outcomes, such as in- and out-patient care, than international assignees. Similarly, students had lower odds of being evacuated or repatriated than international assignees.