Factors associated with the mental health of Chinese international students: protocol for a systematic review

Abstract

Background

University students are an at-risk population for developing mental health problems which can negatively impact their academic performance, social relationships, physical health, and future life. Among this population, the cohort of international students is more vulnerable. Chinese international students (CIS) form the largest international student group in the world, but research on their mental health is limited. Although researchers have become increasingly interested in their mental health in recent years, a comprehensive review of existing evidence is not yet available. The proposed review aims to integrate quantitative and qualitative findings concerning factors associated with CIS mental health.

Methods

The systematic review will follow the PRISMA guidelines. Nine online databases—six English language and three Chinese language—will be searched. Peer-reviewed journal articles will be examined and screened according to the inclusion and exclusion criteria. Both quantitative and qualitative data will be extracted and narratively synthesised to generate an improved understanding of factors associated with the mental health of CIS.

Discussion

Findings from this systematic review will provide researchers, education professionals, mental health workers, and universities with knowledge concerning the factors associated with CIS mental health that is necessary for practical actions and will inform further research.

Systematic review registration

PROSPERO CRD42023402503.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13643-025-03006-8.

Background

The mental health of university students is a global concern as this population group is crucial for social and economic development [1, 2]. The transition to university is regarded as a stressful period [1], and mental health problems have negative impacts on academic performance, physical health, personal relationships, and life satisfaction of university students [1, 3]. Also, having mental health problems may be related to impairment of cognitive function and a higher risk of self-harm and suicide; the lifespan of people with a severe mental disorder is 10 to 20 years shorter than that of others [4]. According to an international project conducted by the World Health Organization (WHO) on the mental health of university students across eight countries, more than one-third reported having experienced at least one mental disorder [2]. Among this at-risk cohort, international students are more vulnerable, as they face greater challenges such as cultural shock, language difficulty, social adaptation, homesickness and loneliness [5, 6]. China is the leading source of international students in tertiary education settings with more than one million CIS studying abroad and CIS are the largest international student cohort in many countries, including the USA, Australia, the UK and Japan [7]. Despite the large number of CIS the existing literature on their mental health is limited.

Research on the mental health of Chinese international students (CIS)

The earliest research on Chinese university students’ mental health can be dated back to the 1970 s in the USA. The first study [8] explored the relationship between acculturation and mental illness among Chinese students in an American university, including both American-born and foreign-born Chinese students. In the following years, 1976–1989, only one relevant study was published, comparing the stress levels and distress symptoms between Chinese students in Hong Kong and Canada [9]. Since the 1990 s, however, more studies have investigated the Chinese cohort’s mental health in foreign countries [10–16], samples including Chinese international students (CIS), Chinese visiting scholars, Chinese immigrants, and Chinese born in the country of the study context. From 2010, a growing interest can be seen in the mental health of CIS in Western universities among researchers [6, 17–22] which may be linked to the massive increase in the number of CIS. According to the Ministry of Education of the People’s Republic of China [23, 24], the number of CIS has grown steadily from 284,700 to 703,500 between 2010 and 2019 [25]. In the academic year 2019/2020, around 300,000 CIS were in the USA higher education system [26], more than 160,000 CIS enrolled in UK universities [27], and the same number in Australia [28]. Although there was increased research on CIS mental health, most studies were conducted in the USA [16, 29–31] and CIS in other host countries remained understudied. Quantitative and qualitative studies consistently reported that CIS suffered from depression, anxiety, and stress [17, 19, 32]. Furthermore, their mental health was found to be worse than that of local students in the host countries [19] and worse than that of their counterparts in China [33, 34]. However, many studies have investigated only one or two stressors rather than a full range of factors that are potentially associated with the mental health of CIS.

Mental health challenges for CIS during COVID-19

During the COVID-19 pandemic, the percentage of young people experiencing mental health problems substantially increased, and CIS have been no exception. Longitudinal data showed that during COVID-19 the prevalence of major depression among a sample of CIS in an Australian university increased from 22.1% to 43.8%, and anxiety increased from 24.7% to 45.7% [35]. Compared to domestic university students in China, CIS reported a significantly higher level of depression (t(684) = 4.47, p < 0.0001, d = 0.34, no confidence interval provided) and a significantly higher level of anxiety (t(682) = 6.65, p < 0.0001, d = 0.51, no confidence interval provided) [33]. Racism, fear of the pandemic, social isolation, negative experiences of online learning, financial pressure, and uncertainty regarding the future are all positively correlated with mental health problems, most commonly depression and anxiety among CIS [35–38].

Rationale

To the best of our knowledge, no systematic review has synthesised research findings on the factors associated with the mental health of CIS in the global context. Relevant existing literature includes a meta-analysis on discrimination and mental health of Asian people [39] and a systematic review of the psychological well-being of international students from East Asia [40]. Neither study focused specifically on the mental health of CIS. Another review of the experiences of CIS in the American higher education setting [41] focused on their overall experiences but did not investigate mental health stressors and outcomes experienced by CIS. The review conducted by Zhao, Chapman and O’Neill [42] researched the mental health risks encountered by CIS in Australia prior to COVID-19. Their review, the first to specifically target CIS mental health, had some limitations. First, only English articles were included in the review. A fuller understanding of the relevant issues requires the inclusion of Chinese literature. Second, the review did not follow any systematic guidelines. Third, the review focused only on CIS in the Australian context. A systematic review of factors affecting CIS mental health by Xie and Xu [43], focused only on the CIS cohort in the USA and included only English articles published between 2010 and 2021. All of the reviews cited above were carried out prior to the COVID-19 pandemic.

The proposed systematic review aims to overcome the limitations mentioned above by including peer-reviewed articles in both English and Chinese language journals, with no limitation on the publication date or the countries in which the research was conducted, and will include an attempt to identify factors that were specific to the particular circumstances during the pandemic.

Objectives

This paper describes a protocol for a systematic review aiming to synthesise findings on CIS mental health and associated factors reported in the English and Chinese language literature. Qualitative and quantitative findings will be included. The main goal of the systematic review is to provide a comprehensive understanding of the factors related to CIS mental health in higher education settings. Our objective is to synthesise findings from English and Chinese academic journal articles investigating factors associated with the mental health of CIS studying in any country.

The research questions of the systematic review are:

1. What are the factors associated with the mental health of CIS in the tertiary study context?

2. What specific COVID-19-related factors are associated with the mental health outcomes of CIS?

Methods

This systematic review will use the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines [44].

Eligibility criteria

Research articles published in English and Chinese language will be eligible for screening. English language papers published in peer-reviewed journals and Chinese language papers published in journals included in the CSSCI (Chinese Social Sciences Citation Index) [45] or the PKU (Peking University) core journals list [46] will be eligible for inclusion. No publication date limits will be applied in the search.

Quantitative, qualitative, and mixed-methods studies will be eligible for inclusion if the question of factors associated with CIS mental health is addressed. For the purpose of this review, CIS are defined as students 18 + years old, self-identified as Chinese and enrolled in a college or university course in any country other than China, excluding Chinese visiting scholars. Quantitative studies must have at least one scale to measure a specific mental health outcome, such as depression, anxiety, stress, and post-traumatic stress disorder (PTSD). Qualitative studies must have a main research question investigating the experiences of CIS and provide empirical data such as interviews, journals/diaries, and personal stories. We will scrutinise the reports of participants’ narratives to determine whether there are contents closely related to, factors that may be associated with, mental health. Expressions such as ‘feeling depressed’, ‘feeling anxious’, ‘feeling stressed’, ‘feeling desperate’, or ‘feeling hopeless’, will be considered relevant. Qualitative studies will be eligible if any factors or circumstances are considered to be related to CIS mental health by the participants and/or the researchers. Mixed-methods studies will be eligible for inclusion if either the quantitative or qualitative components meet the above inclusion criteria.

Information sources

On the advice of the university librarian concerning which databases are the most likely to include articles of interest, six English databases were identified: ERIC, PsycINFO, MEDLINE (Ovid), EMBASE, Scopus, and Web of Science. Three Chinese databases, CNKI (China National Knowledge Infrastructure), Wanfang Data and VIP, were selected by the first author because these are the most frequently used academic databases in China and have a collection of journal articles, conference papers, dissertations and other publications covering a wide range of disciplines.

Note that, a high academic quality is not guaranteed for all the publications collected by the three Chinese databases. To ensure selection of journal articles of high quality from these databases, only academic research papers published in the journals on the CSSCI and the PKU core journals list will be eligible for review, as the journals in these two lists are widely recognised and cited by researchers in academia.

Search strategy

The search will be completed within a week. No limitation was applied to the date of publication. See Additional File 1 for the detailed search strategy used for each database. A brief example of the combinations of the search terms is as follows:

1. ‘mental health’ OR ‘mental disorder’ OR ‘mental illness’ OR ‘psychological stress’ OR ‘depression’ OR ‘anxiety’ OR ‘stress’ OR ‘suicide’ OR ‘self harm’ OR ‘eating disorder’ OR ‘sleeping disorder’.

2. ‘China’ OR ‘Chinese’.

3. ‘international students’ OR ‘overseas students’ OR ‘exchange students’.

4. 1 AND 2 AND 3.

Study selection

Records from the databases will be imported to EndNote. After duplicate records are listed automatically in EndNote, the first author will remove them and check the remaining records to manually remove any remaining duplicates. Other ineligible records that have not been removed by database filters and automatic tools will be removed manually. Next, the first author and a fellow PhD student will independently screen the same 10% of the title/abstract records. The Cohen’s kappa coefficient [47] will be employed to assess the inter-rater reliability (IRR). To proceed, a minimum Cohen’s kappa coefficient of 0.85 needs to be achieved. Any conflicts will be resolved by a third, senior, reviewer. The first author will then screen the remaining 90% of the records. Next, the same procedure for the title/abstract screening will be consistently applied to the full-text screening. A manual citation search of all included articles will be conducted to identify potentially relevant articles that were missed in the search.

Data extraction

We will use an Excel sheet to document the extracted data. Relevant information items will be independently recorded in Excel sheets by the two reviewers. Any disparities or necessary modifications to the extraction sheet will be discussed, with the third reviewer resolving any differences, to achieve consistency in data extraction by the two reviewers. The two reviewers will each then independently extract information from half of the remaining articles. Information to be extracted will include the first author, title, year of publication, study setting, sample description, sample size, age, gender, recruitment methods, research question, theoretical framework (where applicable), data collection methods, measurements of the factors (where applicable), measurements of the outcomes (where applicable), data analysis methods, ethics approval evidence, limitations, and findings that contribute to the aim of this systematic review.

Quality appraisal

We will use the Mixed Methods Appraisal Tool (MMAT) [48] to assess the quality of articles. The MMAT has been selected because it is designed for a wide range of empirical studies. Given that we will include quantitative, qualitative, and mixed-methods studies, it is more desirable to appraise them using just one tool instead of two or more. The 2018 version was modified from the previous 2009 version through a two-round e-Delphi process, which improved its content validity [49].

The MMAT has two screening questions at the beginning, followed by five methodological quality criteria for each type of study. However, for mixed-methods studies, 15 criteria need to be assessed, including 5 for the qualitative part, 5 for the quantitative part, and the remaining 5 for the entire mixed-methods study. As suggested [48], an overall methodological quality score is not sufficiently informative, so we will use a table to display the score of each criterion using stars for each article. Therefore, in our review, a star will be given when a criterion is achieved, and the number of stars will be displayed. Two reviewers will independently complete the quality appraisal of all the studies included followed by a discussion to reach a consensus. Disagreements will be resolved by a senior academic.

Data synthesis

This systematic review will include quantitative and qualitative data because synthesis of a combination of quantitative and qualitative data is expected to generate a fuller understanding of the issues of interest, despite the difficulty of synthesising evidence with quantitative and qualitative features [50]. We searched the literature for guidance in selecting suitable synthesis methods. Hong and colleagues [50] reviewed 459 systematic reviews that reported on both quantitative and qualitative data and categorised the synthesis methods used in those reviews into ‘convergent’ and ‘sequential’ synthesis designs. In convergent designs, both sets of data—quantitative and qualitative—are extracted and synthesised simultaneously, and then integrated during data presentation. In sequential designs the different data types are synthesised and reported separately [50]. In this review, the convergent synthesis design will be adopted and the rationale for this choice is outlined below.

Characteristics of the included studies

We will provide descriptive information on the sample population, study settings, research methods, measurements, outcomes and main findings.

Outcome data

To answer the research question What factors are associated with CIS mental health? we will consider mental health problems, including depression, anxiety, stress, and PTSD as the main outcomes. For quantitative studies, outcomes will include at least one result measured on depression, anxiety, stress, or PTSD. For qualitative studies, outcomes will be any findings on factors that are considered by CIS and/or researchers to be associated with CIS mental health.

Narrative synthesis

As mentioned above, based on the definition by Hong and colleagues [50], we will use a data-based convergent synthesis design, in which ‘all included studies are analysed using the same synthesis method and results are presented together’ (p.7). Given that this review will include quantitative, qualitative and mixed-methods studies, we do not intend to conduct meta-analyses [51]. Both quantitative and qualitative data will be synthesised in a narrative form. Each potential factor will be considered in a separate section of synthesis, with narrativesynthesis of quantitative findings followed by synthesis of qualitative findings. Where applicable, essential figures, such as summary statistics (e.g. mean, standard deviation), and estimates (e.g. odds ratios), 95% confidence intervals and p-values will be presented [52, 53]. Consistencies and discrepancies between quantitative and qualitative findings will be discussed.

Discussion

The strengths of this systematic review lie in the searches that included both English and Chinese literature, and convergent synthesis of findings from qualitative and quantitative studies. The findings on factors associated with CISs’ mental health in the existing literature will be reported and we aim to publish the systematic review in a peer-reviewed journal and to present the findings at conferences and other relevant fora.

As previously mentioned, mental health problems, if untreated, are likely to negatively impact all aspects of life for college and university students [3] and the cohort of CIS is vulnerable [19, 33, 34]. The colleges and universities in which these students are enrolled have a clear obligation to create a supportive environment, promote students’ mental health, and provide accessible services [54, 55]. We expect that this proposed systematic review will offer a comprehensive understanding of mental health stressors to inform efforts by tertiary educational institutions to better protect and support the mental health of their students.

Abbreviations

CIS

Chinese international students

CSSCI

Chinese Social Sciences Citation Index

IRR

Inter-Rater Reliability

MMAT

Mixed Methods Appraisal Tool

PKU

Peking University

PRISMA

Preferred Reporting Items for Systematic reviews and Meta-Analyses

PTSD

Post-traumatic stress disorder

WHO

World Health Organization

Authors’ contributions

This protocol paper was drafted by PZ. Other authors (AG, ADS and HM) have been involved in every crucial stage during the process of the design of the systematic review and critically reviewed this protocol. All authors read and approved the final manuscript.

Funding

The authors declare that no external funding was received for the research presented in this manuscript.

Data availability

Not applicable.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.