Examining the multidimensional structure of stress among international medical students: a construct-based approach

Abstract

Background

International medical students experience diverse stressors that extend beyond academic demands to include challenges of cultural adaptation, institutional management, and experiences of discrimination. Understanding the structure of these interrelated stress domains is essential for developing effective educational and support strategies. This study examined the multidimensional structure of stress among international medical students using a construct-based analytical approach grounded in the Transactional Model of Stress and Coping.

Methods

A cross-sectional survey was conducted with 322 international students enrolled in the English-language medical program at the Medical University of Varna, Bulgaria. Participants completed a self-report questionnaire informed by standardized instruments, including the University Stress Scale and the Academic Stress Scale. Confirmatory factor analysis (CFA) was used to test a four-factor model comprising academic, adaptation, management, and discrimination-related stress.

Results

The proposed model demonstrated good fit to the data (χ²(48) = 70.08, p = .020; CFI = 0.941; TLI = 0.918; RMSEA = 0.047; SRMR = 0.060), supporting the conceptualization of stress among international medical students as a multidimensional construct. Academic stress emerged as the strongest factor, while strong correlations were observed among the stress domains, particularly between adaptation and management stress, indicating that adjustment difficulties and institutional challenges are closely interconnected.

Conclusions

The findings underscore the need for comprehensive institutional strategies that address multiple dimensions of student well-being. Implementing culturally responsive counseling, peer mentoring, and transparent administrative communication may reduce overall stress and enhance adaptation and resilience among international medical students.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-08667-0.

Introduction

Medical education is widely recognized as one of the most demanding academic and personal pursuits. Yet, international medical students face an even greater psychological burden because they must navigate unique challenges beyond the standard academic stressors. These include acculturation to new cultural and linguistic environments, academic adjustments to unfamiliar teaching methods, and the navigation of systemic inequities such as discrimination, restricted access to support services, and legal or financial barriers [10]. The cumulative impact of these stressors extends beyond academic performance to affect mental and physical well-being, as chronic stress has been shown to heighten risks for anxiety, depression, and maladaptive coping behaviors such as substance use or social withdrawal [65]. Recent evidence indicates that medical students experiencing sustained stress report higher levels of psychological distress, burnout, and depressive symptoms, and these effects are amplified in the presence of financial or social pressures [79]. Addressing the multidimensional nature of stress in this population is critical not only for their academic success and overall well-being but also for admitting institutions, as supporting student wellness contributes to improved retention, performance, and institutional reputation within an increasingly globalized medical education landscape.

In relation to psychological distress, cultural differences often influence help-seeking behaviors among international students. Research indicates that they are generally less inclined to seek psychological support, which further complicates the challenge of addressing their mental health needs. Stigma, limited awareness of available resources, and systemic barriers have all been identified as factors that reduce willingness to access mental health services [62]. Self-stigma, fear of professional repercussions, and confidentiality concerns are additional deterrents among medical trainees [17, 37]. Moreover, legal or administrative limitations, including restricted access to health insurance may heighten vulnerability among international cohorts [46]. These intersecting stressors highlight the need for a more nuanced, contextually grounded understanding of stress experiences within this population.

Institutional responses play a critical role in mitigating stress and promoting student resilience. Evidence shows that structured peer and faculty mentoring, wellness initiatives, and culturally responsive support services can significantly reduce perceived stress and foster adaptive coping among health sciences students [51]. Yet academic challenges and financial pressures may carry heavier consequences for international students, who often invest substantial personal and family resources to study abroad. Debt-related stress, in particular, has emerged as a significant predictor of emotional and academic distress [35, 79].

Gap and rationale

Although research has examined stress among university and medical students, fewer studies have empirically tested models that capture the range of stressors experienced by international medical students within a single theoretical framework. Many existing studies focus on individual stress domains and most commonly emphasize academic stress, without fully accounting for the combined academic, cultural, institutional, and social demands that shape international students’ experiences. As a result, the structure and interrelations of these stress domains remain insufficiently examined in this population.

To address this gap, the present study proposes and empirically evaluates a multidimensional, construct-based model of stress grounded in the Transactional Model of Stress and Coping [43]. Importantly, this model continues to be applied in contemporary stress research, including studies of student adjustment and coping, because it provides a robust explanatory mechanism linking stress exposure to individuals’ cognitive appraisal processes and coping responses [49, 76, 77]. Within this framework, stress is understood as arising from the appraisal of environmental demands in relation to available coping resources.

From this perspective, academic, adaptation, management, and discrimination-related stressors represent distinct categories of demands that international medical students must continuously appraise and manage. Academic stress reflects demands related to workload and performance expectations; adaptation stress reflects demands associated with cultural, linguistic, and social adjustment; management stress reflects demands arising from interactions with institutional and administrative systems; and discrimination-related stress reflects demands linked to perceived unfair treatment or social exclusion.

Prior research supports the relevance of these domains, indicating that stress among international students is shaped by academic pressures, cultural adjustment challenges, institutional barriers, and social or identity-related stressors [44, 50, 63, 67]. Importantly, more recent evidence continues to support a multidimensional view of international student stress, showing that academic pressures interact with acculturative demands (e.g., language and cultural adjustment), practical or institutional constraints, and social stressors including discrimination [5, 9, 31, 78]. Recent studies in health professions education have similarly adopted multidimensional approaches, demonstrating how distinct but interrelated stress domains jointly shape student well-being in high-pressure learning environments [7]. Validation studies among medical and health science students likewise suggest that these domains are distinct yet interrelated sources of strain associated with mental health and academic outcomes [32, 64, 71]. However, few studies have examined how these stress domains are structured and interrelated among international medical students using a theory-driven analytical approach.

The Eastern European context provides an appropriate setting for this inquiry. Bulgaria has become a destination for international students enrolled in English-language medical programs [34], and recent institutional and national reports indicate ongoing growth in international enrolments, with international students concentrated in health-related fields, including medicine (BTA, [20], European [27], NSI, [52]). Despite this growth, empirical models of student stress in this context remain limited. Comparative findings from Bulgaria and Turkey suggest that, while overall levels of psychological distress may vary across educational systems, specific stress domains show consistent associations with mental health outcomes [73]. Developing contextually grounded models of student stress is therefore important for understanding how international medical students experience and manage stress within specific institutional and cultural environments..

Literature background and conceptual framework

This section reviews the literature on four key stress domains among international medical students: academic stress, cultural adaptation stress, financial and management stress, and social–discrimination stress. These domains inform the conceptual model used in this study.

Academic (Study) stress

Academic stress remains one of the most pervasive and well-documented challenges in medical education [59]. High workload, competitive grading, and continuous assessments create a sustained environment of pressure. Among international medical students, these academic demands are compounded by linguistic barriers, unfamiliar pedagogical approaches, and expectations for self-directed learning. Such factors contribute to emotional exhaustion, impaired academic performance, and burnout [23, 59]. Limited institutional support and difficulty navigating unfamiliar educational systems can further exacerbate distress, emphasizing the need to understand academic stress as both a cognitive and cross-cultural phenomenon.

Cultural adaptation stress

Cultural adaptation involves continuous adjustment to new social norms, communication styles, and values, often accompanied by uncertainty, frustration, and identity negotiation [70]. Contemporary evidence continues to show that acculturative demands are a central driver of international students’ stress and adjustment outcomes, with social support acting as a key protective resource [40]. This process can produce significant psychological strain, manifesting as confusion, alienation, or marginalization [67]. Recent meta-analytic findings further confirm that acculturative stress is strongly associated with depressive symptoms among international students, highlighting its continued relevance for understanding psychological vulnerability during cross-cultural transition [22]. Language barriers intensify these challenges by restricting classroom participation and clinical communication, limiting both social integration and perceived competence [56]. Current research continues to document that language barriers undermine academic engagement and social inclusion in international student populations [26], and systematic evidence from foreign-language medical education shows that linguistic challenges can interfere with learning, communication, and confidence in clinical contexts [33]. For medical students whose education relies heavily on interaction and teamwork, difficulties in adaptation may impair academic learning and clinical confidence, thereby reinforcing stress across multiple domains.

Financial and management stress

Financial strain constitutes a critical, though often underestimated, source of stress for international students. Tuition fees, living expenses, visa requirements, and restricted employment opportunities frequently generate financial insecurity and anxiety [53]. Further research indicates that financial anxiety is common among international students and varies depending on national and institutional conditions [41]. Financial stress has also been consistently linked to psychological distress, reduced wellbeing, and impaired academic functioning [2], and a recent scoping review confirms that financial hardship remains strongly associated with mental health burden and reduced engagement among university students [61]. The “management” component of this domain reflects stress arising from perceived institutional inefficiencies, lack of administrative support, and difficulty balancing competing academic and personal demands. Together, these factors undermine students’ sense of control and efficacy in managing their overall experience. While financial strain and perceived institutional support are conceptually distinct, they are treated here as closely related resource-based stressors. This broad operationalisation may partly explain the weaker empirical performance of the Management Stress factor and should be refined in future validation studies.

Social and discrimination-related stress

Social isolation and discrimination represent interconnected stressors that significantly affect international students’ well-being. Barriers to social integration, such as cultural distance and language difficulties, limit opportunities for peer connection and emotional support [10]. Experiences of exclusion, stereotyping, or microaggressions contribute to feelings of alienation and psychological distress [3, 19]. Although discrimination may not always emerge as the most salient quantitative predictor, its cumulative and indirect effects on belonging, motivation, and help-seeking are profound. Perceived unfair treatment can erode trust in institutional structures and exacerbate both adaptation and academic challenges. Addressing these issues through inclusive policies, mentorship, and culturally competent support services is essential for fostering equitable learning environments [29].

Theoretical framework

This study is grounded in Lazarus and Folkman’s [43] Transactional Model of Stress and Coping, a foundational framework that conceptualizes stress as a dynamic and reciprocal process arising from ongoing interactions between individuals and their environments. From this perspective, stress is not determined solely by objective external demands, but by how individuals appraise those demands in relation to their perceived ability to cope [18, 30]. Contemporary scholarship continues to affirm the centrality of appraisal-based processes in stress research and emphasizes the importance of clearly distinguishing coping strategies and their measurement across contexts [72]. Stress responses emerge when situational or internal demands are evaluated as exceeding available coping resources, resulting in emotional or physiological strain. In addition, recent empirical work supports Folkman’s theoretical extension of the model through meaning-focused coping, showing that meaning-based coping is associated with more adaptive psychological adjustment and lower levels of depression and anxiety in student populations [47, 69].

Two interrelated cognitive processes, primary appraisal and secondary appraisal, define this interaction. Primary appraisal involves judging whether an event poses a threat, challenge, or opportunity to one’s well-being, while secondary appraisal concerns the perceived ability to manage or alter the situation, considering personal strengths, social supports, and institutional resources [43]. These appraisals collectively shape emotional responses and determine subsequent coping behaviors.

Coping refers to the cognitive and behavioral efforts individuals use to manage demands perceived as taxing or overwhelming [66]. Within the transactional framework, coping is typically differentiated into problem-focused strategies that aim to modify the stressor itself, and emotion-focused strategies that regulate distress and maintain functioning. Importantly, later refinements of the theory introduced meaning-focused coping, emphasizing the capacity to sustain hope, derive purpose, and maintain positive affect under adversity through processes such as positive reappraisal and meaning-making [30]. Contemporary evidence reinforces the relevance of meaning-focused coping in university settings, indicating that these strategies support psychological adjustment and buffer distress, including depression and anxiety [47, 69]. Coping effectiveness is also shaped by broader personal and contextual conditions, including resilience, social networks, cultural familiarity, and institutional responsiveness [75].

Applied to international medical education, the Transactional Model provides a framework for understanding how different categories of environmental demands are appraised and managed. Academic stress reflects primary appraisal of academic workload, performance expectations, and evaluation demands as taxing or challenging. Adaptation stress reflects appraisal of cultural, linguistic, and social adjustment demands that may threaten students’ sense of competence or belonging. Management stress reflects secondary appraisal processes, in which institutional structures, administrative procedures, and access to support services are evaluated in terms of their adequacy for managing ongoing demands. Discrimination-related stress reflects appraisal of social interactions as unfair, exclusionary, or threatening, which may undermine perceived coping resources and contribute to sustained strain.

In this study, the four-factor construct of stress, which includes academic, adaptation, management, and discrimination-related domains, is situated within the Transactional Model [43]. Each domain reflects a context in which appraisal and coping processes take place and are shaped by both individual and institutional circumstances (Fig. 1). Conceptualizing these domains together allows stress to be examined as an interconnected process rather than a single undifferentiated outcome. This framework therefore guides the confirmatory factor analysis and supports interpretation of the model in relation to institutional practices affecting international medical students.

Fig. 1.

Conceptual framework of stress domains and their relationship to student well-being, informed by the Transactional Model of Stress and Coping. Note: This figure provides a conceptual illustration of the proposed stress domains and their theoretical relationships and does not represent a statistical output of the confirmatory factor analysis

Rather than treating stressors as isolated or domain-specific, this study extends existing stress frameworks by empirically testing how academic, adaptation, management, and discrimination-related stress function as distinct yet interrelated domains within one theoretically grounded model. This approach addresses limitations in earlier research that focused primarily on academic or general psychological stress among medical students [16, 23] by specifying a structure that better reflects the multidimensional realities of international medical training. In doing so, it strengthens understanding of the contextual determinants of international students’ well-being and helps identify stress domains most directly relevant for institutional intervention.

Methods

Study design and setting

A cross-sectional, observational study design was employed to examine the multidimensional structure of stress among international medical students. Data collection occurred between February and May 2019. The investigation was conducted at the Medical University of Varna, Bulgaria, an institution that hosts a population of international students enrolled in English-language medical programs. The primary objective was to validate a four-factor conceptual model of stress encompassing academic, adaptation, financial, and discrimination-related domains. The single-site design was chosen to ensure feasibility and to allow access to a clearly defined and concentrated population of international medical students within a shared institutional and curricular context.

Measures

Stress was assessed across four domains, academic, adaptation, management, and discrimination-related stress, using a structured self-report questionnaire. The instrument was informed by established measures of student stress, including the University Stress Scale (USS) [24, 68] and the Academic Stress Scale [38, 58, 74], which were used to guide domain conceptualization and item content. The USS was used to capture a broad range of university-related stressors, with selected items addressing discrimination, language or cultural difficulties, financial strain, and accommodation-related challenges informing the discrimination, adaptation, and management stress domains in the confirmatory factor analysis. Additional USS items were retained to contextualize students’ overall stress experiences. Academic stress was informed by core domains of the Academic Stress Scale, reflecting workload, examinations, and study-related demands, rated on a five-point Likert scale ranging from 0 (never to 4 (very often. Neither instrument was administered in its original standardized form,rather, selected items were adapted and combined within a composite questionnaire to reflect the specific educational and cultural context of international medical students. The final instrument comprised four items assessing academic stress, four items assessing adaptation stress, two items assessing management stress, and two items assessing discrimination-related stress, with the full item set provided in Supplementary File 1. A separate sociodemographic questionnaire collected information on participants’ demographic characteristics, educational background, and living conditions. Internal consistency across the four stress domains was acceptable, with Cronbach’s alpha values ranging from 0.81 to 0.90.

Instrument development and item selection

The questionnaire was developed by the research team specifically for this study to assess stress among international medical students. Development involved adapting constructs and selected items from the University Stress Scale and the Academic Stress Scale, supplemented by newly written items reflecting context-specific academic and institutional challenges. Importantly, the University Stress Scale and Academic Stress Scale were not administered as standardized instruments; instead, relevant components were used to guide domain conceptualization and item wording. In addition, the item pool also included content addressing study workload intensity, accommodation and living conditions, administrative challenges, and adjustment-related experiences commonly discussed in the literature on international students and medical education. To ensure clarity and content relevance, the items were reviewed by faculty members with experience in medical education and international student support. This review focused on item clarity, relevance to the proposed domains, and consistency with the study’s theoretical framework. Minor revisions to item wording were made based on this feedback. The final instrument comprised items grouped into four domains: academic stress, adaptation stress, management stress, and discrimination-related stress, drawing on Academic Stress Scale–informed items, selected University Stress Scale items, and additional context-specific indicators. A complete list of items included in each domain is provided in Supplementary File 1. Item parceling was not employed; all selected items were included as individual observed indicators in the CFA.

Procedure

Data collection was undertaken during scheduled classroom sessions. Trained research assistants provided standardized instructions, clarified questions as necessary, and ensured voluntary participation. Questionnaires were completed in approximately 20 min under supervision to ensure data quality. Completed forms were placed in sealed envelopes and collected immediately. Data were anonymized upon collection and entered into a secured database using a double-entry verification process to ensure accuracy and reliability.

Ethical considerations

Ethical approval for this study was obtained from the Ethics Committee of the Medical University of Varna (Protocol No. 74/3.05.2018). All participants were informed about the purpose and procedures of the study, the voluntary nature of participation, and their right to withdraw at any stage without penalty. Written informed consent was obtained prior to data collection. To preserve anonymity, no identifying information was collected. Completed questionnaires were stored in sealed envelopes, and all data were processed and analyzed in aggregate form only.

Participants

The study population consisted of first and second year international students enrolled in the English-language medical program at the Medical University of Varna. Participants were recruited through in-class announcements and voluntary participation. Eligibility criteria required that students be enrolled full-time, aged 18 years or older, and capable of providing informed consent. Exclusion criteria included refusal to participate or incomplete questionnaire responses.

Of the 363 distributed questionnaires, 322 were completed in full and retained for analysis, yielding a response rate of 88.7%. Participants ranged in age from 20 to 35 years (M = 23.6, SD = 2.9), with 54.3% identifying as female. The sample represented more than 25 nationalities, predominantly from Europe (e.g., Germany, Britain), Africa (e.g. Nigeria), and Asia (e.g., India), reflecting the diverse composition of the international student body. Most students were single (70.8%), financially stable (95%), and supported by both parents (85.7%). The majority reported studying 2–4 h daily and sleeping between 6 and 7 h per night on average. Only 5.9% reported having a chronic illness, 15.6% identified as smokers, and approximately half consumed alcohol occasionally (Table 1).

Table 1.

Demographic characteristics of the participants

Variable	Category	n	%
Age (years)	Mean (SD) = 23.6 (2.9); range 20–35	—	—
Gender	Female	175	54.3
	Male	147	45.7
Year of study	First year	160	49.7
	Second year	162	50.3
Marital status	Single	228	70.8
	Married/In a relationship	94	29.2
Religious affiliation	Yes	249	77.3
	No	73	22.7
Alcohol consumption	Non-consumers	158	49.1
	Consumers (occasional or regular)	164	50.9
Smoking status	Smokers	50	15.6
	Non-smokers	272	84.4
Daily study time	< 2 h	63	19.6
	2–4 h	179	55.5
	> 4 h	80	24.9
Average sleep duration (hours/night)	Mean (SD) = 6.3 (1.1); range 4–8	—	—
Chronic illness	Yes	19	5.9
	No	303	94.1
Financial status	Financially stable	306	95.0
	Financially unstable	16	5.0
Source of financial support	Supported by both parents	276	85.7
	Other sources	46	14.3

Data analysis

All statistical analyses were performed using IBM SPSS Statistics (Version 29) and AMOS (Version 28). Descriptive statistics were computed to summarize demographic characteristics and stress-related variables. The hypothesized four-factor model of stress was evaluated using Confirmatory Factor Analysis (CFA) with maximum likelihood estimation to examine the structural validity of the proposed construct. The use of CFA for validating theory-driven psychological constructs is consistent with recent research in nursing and health sciences education [12]. Model fit was assessed using multiple indices, including the chi-square to degrees of freedom ratio (χ/df), Comparative Fit Index (CFI), Tucker–Lewis Index (TLI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR). Acceptable model fit was defined by CFI and TLI values ≥ 0.90 and RMSEA and SRMR values ≤ 0.08. Model parsimony was further examined using information criteria, including the Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), and Sample-Size Adjusted BIC (SSABIC).

The proposed four-factor model was developed through an integration of established stress and adaptation frameworks and empirical evidence from prior research. Drawing from the Transactional Model of Stress and Coping [18, 43], stress is conceptualized as a dynamic process arising from interactions between environmental demands and individual coping resources. Within the context of international medical education, prior studies have identified recurring domains of stress, including academic overload and performance pressure [13, 16], cultural and social adaptation challenges [67, 70], institutional and administrative management stressors [28, 36], and experiences of bias or discrimination [1, 54]. These domains were conceptually clustered to form a four-factor framework reflecting the multidimensional nature of stress among international medical students. The model was not directly adopted from any single existing measure but adapted from converging evidence in the literature and refined to capture the educational, cultural, and institutional contexts unique to this population.

Results

Model overview and fit assessment

A confirmatory factor analysis (CFA) was conducted to evaluate the hypothesized four-factor model of stress among medical students. The model demonstrated an acceptable fit to the data, χ²(48) = 70.08, p = 0.020, with the Comparative Fit Index (CFI = 0.941), Tucker–Lewis Index (TLI = 0.918), and Incremental Fit Index (IFI = 0.943) all exceeding the recommended threshold of 0.90. The Root Mean Square Error of Approximation (RMSEA = 0.047) and Standardized Root Mean Square Residual (SRMR = 0.060) also indicated good fit.

Although the chi-square test was statistically significant, this result is likely attributable to the relatively large sample size, as the χ² statistic is known to be highly sensitive to sample size [39]. Therefore, model evaluation relied primarily on incremental and residual-based indices, which collectively confirmed that the proposed four-factor model adequately represented the data.

Fit indices and information criteria

Model adequacy was further supported by the Goodness-of-Fit Index (GFI = 0.949) and McDonald Fit Index (MFI = 0.949), both surpassing the 0.90 benchmark. Information criteria values, including the Akaike Information Criterion (AIC = 5802.62), Bayesian Information Criterion (BIC = 5903.31), and sample-size adjusted BIC (SSABIC = 5808.25), indicated a satisfactory balance between model fit and parsimony. Hoelter’s critical N values (198.15 at α = 0.05; 223.90 at α = 0.01) confirmed that the sample size was adequate for robust model estimation.

Factor loadings

All observed indicators loaded significantly on their respective latent constructs (p < 0.001), confirming the adequacy of the hypothesized four-factor measurement model (Table 2). Within the Study Stress factor, Study semester (λ = 0.756, 95% CI [0.630, 0.881]) and Exam (λ = 0.694, 95% CI [0.568, 0.821]) exhibited the highest standardized loadings, indicating strong associations with the underlying construct. Moderate loadings were observed for Ten to twelve hours of study per day (λ = 0.584, 95% CI [0.431, 0.738]) and Incomplete coursework (λ = 0.378, 95% CI [0.245, 0.511]).

Table 2.

Standardized factor loadings for the four-factor model of stress among medical students

Factor	Indicator	Symbol	Estimate	Std. Error	z-value	p	95% Confidence Interval
							Lower	Upper
Study stress	Ten-twelve h	λ11	0.584	0.078	7.451	<.001	0.431	0.738
	Incomplete	λ12	0.378	0.068	5.559	<.001	0.245	0.511
	Study semester	λ13	0.756	0.064	11.794	<.001	0.630	0.881
	Exam	λ14	0.694	0.065	10.757	<.001	0.568	0.821
Stress due to adaptation	Inability to adapt	λ21	0.403	0.055	7.359	<.001	0.295	0.510
	Having Accomm	λ22	0.393	0.050	7.838	<.001	0.294	0.491
	Family problems	λ23	0.375	0.061	6.100	<.001	0.254	0.495
	Change in eating	λ24	0.388	0.074	5.223	<.001	0.242	0.534
Management stress	Inadequate Support	λ31	0.258	0.076	3.403	<.001	0.109	0.406
	Having financial	λ32	0.423	0.094	4.476	<.001	0.238	0.608
Stress due to discrimination	Discrimination	λ41	0.291	0.060	4.847	<.001	0.173	0.409
	Cultural/Language issues	λ42	0.336	0.084	3.998	<.001	0.171	0.500

For the Adaptation Stress factor, item loadings ranged from λ = 0.375 to λ = 0.403, indicating moderate relationships between the observed indicators and the latent variable. The Management Stress factor demonstrated smaller but statistically significant loadings for Inadequate support (λ = 0.258, 95% CI [0.109, 0.406]) and Financial difficulties (λ = 0.423, 95% CI [0.238, 0.608]). Similarly, the Discrimination Stress factor showed significant but lower loadings for Discrimination (λ = 0.291, 95% CI [0.173, 0.409]) and Cultural or language barriers (λ = 0.336, 95% CI [0.171, 0.500]).

Although all loadings were statistically significant, the relatively weaker indicators within the Management and Discrimination Stress factors suggest that these constructs may benefit from further refinement through the inclusion of additional or more specific indicators in future research.

Correlations among stress domains

The correlations among the latent factors indicated interrelationships between the main domains of stress experienced by medical students (Table 3). Study Stress was positively correlated with Adaptation Stress (r = 0.430, 95% CI [0.256, 0.603], p < 0.001), Management Stress (r = 0.373, 95% CI [0.105, 0.640], p = 0.006), and Discrimination Stress (r = 0.234, 95% CI [0.020, 0.448], p = 0.032), suggesting that academic demands are associated with adaptation difficulties, challenges in managing responsibilities, and experiences of discrimination.

Table 3.

Correlations among latent stress domains in the confirmatory factor analysis

			Estimate	Std. Error	z-value	p	95% Confidence Interval
							Lower	Upper
Study stress	↔	Stress due to adaptation	0.430	0.088	4.861	<.001	0.256	0.603
Study stress	↔	Management stress	0.373	0.136	2.731	0.006	0.105	0.640
Study stress	↔	Stress due to discrimination	0.234	0.109	2.146	0.032	0.020	0.448
Stress due to adaptation	↔	Management stress	0.973	0.192	5.067	<.001	0.596	1.349
Stress due to adaptation	↔	Stress due to discrimination	0.597	0.131	4.568	<.001	0.341	0.854
Management stress	↔	Stress due to discrimination	0.423	0.177	2.393	0.017	0.077	0.770

The correlation between Adaptation Stress and Management Stress was very strong (r = 0.973, 95% CI [0.596, 1.349], p < 0.001) indicating limited empirical distinctness between these two domains in this sample. The upper confidence bound slightly exceeded 1.0 due to sampling uncertainty around the standardized estimate. This suggests limited discriminant validity between these two factors in the present sample. Adaptation Stress also correlated with Discrimination Stress (r = 0.597, 95% CI [0.341, 0.854], p < 0.001), while Management Stress showed a moderate correlation with Discrimination Stress (r = 0.423, 95% CI [0.077, 0.770], p = 0.017), indicating that these types of stress tend to co-occur.

Discussion

This study examined the multidimensional nature of stress among international medical students and supported a four-factor structure encompassing academic, adaptation, management, and discrimination-related stress domains. The confirmatory factor analysis demonstrated satisfactory model fit, supporting the conceptualization of stress as an interrelated and multidimensional construct rather than a single, uniform experience [11]. However, acceptable model fit alone does not establish construct validity, particularly given the weaker loadings observed for some indicators. This finding reinforces the Transactional Model of Stress and Coping [43], which posits that stress results from the dynamic interaction between environmental demands and the individual’s appraisal of available coping resources [45]. By empirically substantiating the distinct yet interrelated domains of stress, the study contributes to a more nuanced understanding of how multiple stressors jointly shape the well-being of international medical students.

Consistent with existing research, academic stress emerged as the most salient factor, characterized by examination pressure, workload intensity, and time-management difficulties [13, 16]. These stressors are inherent to medical education, yet their intensity is magnified for international students who must simultaneously navigate linguistic challenges, unfamiliar pedagogical systems, and varying academic expectations [6]. The significant association between academic and adaptation stress underscores the interdependence of these domains: difficulties in adjusting to new cultural and academic contexts appear to heighten vulnerability to academic strain. This finding aligns with previous evidence that cultural adjustment challenges can exacerbate learning difficulties and emotional exhaustion among globally mobile students [4, 57].

The strong correlation between adaptation and management stress highlights the central role of institutional support systems in the stress–coping process. In this sample, the magnitude of this association suggests that adaptation difficulties and perceptions of institutional management function as closely intertwined experiences rather than as clearly separable stress domains. This overlap may partly reflect the broad operationalisation of the Management Stress factor, which combines indicators related to financial strain and perceived institutional support. Rather than suggesting a need to merge these domains conceptually, this pattern indicates that institutional management may represent a primary contextual barrier to successful adaptation within this educational setting. Effective orientation programs, the availability of a dedicated international student ombudsperson, standardized administrative feedback and grievance procedures, and mandatory cultural competency training for administrative staff can facilitate smoother adaptation and strengthen perceived coping resources [32, 36]. Conversely, bureaucratic inefficiency, unclear procedures, or inadequate mentorship may function as secondary stressors, compounding the psychological burden of adjustment [28]. Similar institutional barriers, including limited mentorship and unclear academic guidance structures, have also been reported in recent medical education research, reinforcing the importance of institutional support systems for student functioning and well-being [48]. These findings echo the core propositions of the Transactional Model, which emphasizes that coping effectiveness depends not only on personal resilience but also on contextual affordances that shape how students appraise and respond to stressors. Similar patterns have also been reported among nursing students, where academic, institutional, and contextual stressors interact and are shaped by available coping resources and institutional support [8]. Related work has also linked faculty support and curriculum quality to student outcomes in health education settings [25].

Although discrimination-related stress exhibited lower individual loadings, its significant correlations with all other domains emphasize its pervasive and indirect influence on students’ overall stress experience. Several indicators (particularly within the Management and Discrimination factors) showed low standardized loadings (e.g., < 0.30), suggesting limited convergent validity for parts of the measurement model. Perceived discrimination, whether overt or subtle, can erode a sense of belonging, diminish motivation, and impede coping efficacy [54]. Even mild or ambiguous instances of exclusion and stereotyping can accumulate over time, producing chronic psychological strain and disengagement from academic and social environments [1, 14]. The relatively modest loadings observed for discrimination and management indicators suggest that these forms of stress may be more diffuse and context-dependent, underscoring the need for refined and context-sensitive measurement approaches in future research.

The pattern of associations observed in this study indicates that stress among international medical students is shaped by multiple, interrelated demands rather than by isolated sources of pressure. Academic, cultural, institutional, and social stressors appear to reinforce one another, suggesting that interventions targeting a single domain are unlikely to be sufficient. Strategies that combine academic support, cultural mentoring, financial guidance, and efforts to address discrimination may therefore be better suited to the realities of international medical education. Interpreted within the Transactional Model of Stress and Coping, these findings emphasize the need to strengthen both individual coping resources and the institutional environments in which stress appraisal and coping occur.

Importantly, the data were collected in 2019, prior to the COVID-19 pandemic. Since then, the educational environment and the experience of internationally mobile students have evolved, including shifts in teaching modalities, mobility restrictions, financial uncertainty, and reduced opportunities for social integration. For this reason, the present findings should be interpreted as pre-pandemic baseline evidence rather than as a direct representation of current conditions.

This study contributes to the literature by extending multidimensional stress models to a culturally and institutionally distinct context, namely international medical education in Eastern Europe. The support for a four-factor structure supports the multidimensional nature of student stress while drawing attention to the close relationship between adaptation and institutional management stressors. These domains are often underrepresented in models developed within Western academic settings, underscoring the value of cross-cultural validation and contextually grounded theory testing in higher education research.

Implications

The findings of this study have several implications for universities, medical educators, and policymakers involved in international medical education. These implications should be interpreted in light of the pre-COVID timing of the dataset and complemented by updated institutional assessments reflecting post-pandemic realities. The supported four-factor structure provides a diagnostic framework for identifying key areas of vulnerability among international medical students, spanning academic, adaptation, management, and discrimination-related stress.

At the program level, medical schools can use this model to design data-informed interventions such as structured orientation programs, culturally responsive mentoring, and workload monitoring systems that target academic and adaptation stress. Integrating stress management modules and resilience training into the curriculum may also enhance students’ coping efficacy and academic persistence. Structured peer feedback and peer-support approaches may further strengthen academic adjustment and coping resources among international students in demanding educational contexts [60].

At the institutional level, the findings underscore the importance of transparent administrative communication, accessible financial guidance, and fair policies addressing discrimination or bias. Establishing cross-cultural student advisory councils or wellness task forces could ensure that international students’ needs are systematically represented in policy design.

At the policy level, ministries of education and accreditation bodies can encourage universities to include international student well-being indicators in quality assurance frameworks, promoting more equitable learning environments across transnational medical programs.

By adopting a comprehensive, systems-oriented approach grounded in the interdependence of stress domains, universities can move from reactive to preventive mental health strategies, ultimately improving not only student well-being but also retention, performance, and future workforce sustainability in global health education.

Limitations and future directions

While the findings provide valuable insights, several limitations must be acknowledged. The cross-sectional design precludes causal inferences regarding relationships among the stress domains, and limits conclusions about how stress appraisal and coping processes unfold over time [21]. The present analysis therefore represents a necessary first step in validating the proposed multidimensional stress structure, while longitudinal research is needed to examine the transactional processes implied by the theoretical framework, including changes in appraisal, coping, and stress responses across stages of medical training. The sample’s confinement to a single institution may limit generalizability to other cultural or educational contexts [15]. Additionally, reliance on self-reported measures introduces the potential for response bias, as participants may underreport or exaggerate their stress experiences due to social desirability or self-perception factors [42]. Self-report data may also be influenced by recall bias, particularly when participants are asked to reflect on stressors experienced over time. Because all variables were measured using self-report questionnaires at a single time point, common method variance cannot be excluded and may have inflated observed associations among constructs [55]. Future studies should incorporate multi-source data and longitudinal designs to reduce common method bias. Data were collected in 2019, prior to the COVID-19 pandemic. While the multidimensional structure of stress may remain broadly relevant, the post-pandemic context may affect the intensity and expression of stressors in international student cohorts. The findings should therefore be interpreted as baseline evidence, and future studies should examine whether these patterns replicate in post-pandemic samples.

Future research should employ longitudinal and multi-institutional designs to track changes in stress trajectories over time and across diverse educational systems. Examining contextual variables such as country of origin, gender, socioeconomic status, and prior academic experience may clarify individual differences in stress appraisal and coping. Extending the model to include coping strategies, social support, and resilience indicators would allow for a more direct examination of the mechanisms proposed by the Transactional Model of Stress and Coping.

Despite these limitations, this study represents an important empirical step in validating a multidimensional, construct-based model of stress among international medical students. It lays the groundwork for comparative and intervention-based research that can inform institutional policies and promote equitable, supportive learning environments across global medical education contexts.

Conclusion

This study advances understanding of the complex and multidimensional nature of stress among international medical students by supporting a four-factor model encompassing academic, adaptation, management, and discrimination-related domains. Grounded in Lazarus and Folkman’s Transactional Model of Stress and Coping, the findings underscore that stress arises from the dynamic interaction between environmental demands and individual coping resources. The study confirms that these domains are interrelated, reflecting overlapping yet distinct sources of pressure that collectively shape students’ academic engagement, psychological well-being, and sense of belonging.

By situating the analysis within the lived realities of international medical education, the study contributes both theoretically and practically to the field of student mental health. It provides an empirically supported framework for designing institutional interventions that are preventive, integrative, and culturally responsive, helping universities better support diverse student populations. Future research building on this model can further clarify how coping processes and contextual supports mediate stress outcomes, offering new pathways for promoting resilience and academic success in global medical education.

Authors’ contributions

S.P.N. conceived and designed the study, performed the data analyses, and led the interpretation and discussion of the findings. M.S.V. and M.A.I. coordinated participant recruitment and data collection. E.S. contributed to the conceptual framing, drafted the Introduction, and critically revised the manuscript. S.C. and K.S.L. reviewed and edited the manuscript for important intellectual content. All authors read and approved the final manuscript and consented to its submission for publication.

Data availability

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Approved by the Ethics Committee of the Medical University of Varna (Protocol No. 74/3.05.2018). Written informed consent was obtained from all participants. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee and the 1964 Helsinki Declaration and its later amendments.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.