Background
Physicians care not only for their patients’ health but also support their patients in coping with lifestyle problems. Health-care providers can act as role models by setting an example of healthy behaviour and a healthy lifestyle for their patients [
1]. Some studies have demonstrated a link between medical doctors’ physical activity levels and their motivation to encourage patients to undertake intensive physical exercise. Doctors with alcoholic problems underestimate the relevance and necessary frequency of alcohol counselling [
2]. Earlier studies found an association between medical students’ health behaviour and their plans for counselling activities [
3,
4]. Other findings indicate that patterns of health-related behaviour in medical students are created even before they enter higher education [
3‐
6].
Pre-existing unhealthy behavioural patterns may continue to develop during students’ medical training. Students in later academic years show a higher prevalence of drinking, smoking and substance abuse [
7] and their consumption of fruit and vegetables declines with every completed semester [
8]. The academic environment may affect the mental health of college students; for example, academic overload may lead to stress, anxiety and depression [
9]. Contact with patients in poor health can also be a unique stressor in medical school. The incidence of mental health problems among medical students may be as high as 30 %, but most students do not seek help [
10]. This may explain why students tend to use alternative methods—like alcohol consumption—to cope with stress.
Cultural background may also influence health risk behaviours and self-rated health status [
11]. Immigration flows are on the rise in most OECD countries and the number of migrant doctors working in these countries elevated with 60 % since 2004. There are some important variations among OECD countries in the proportion of health personnel born abroad. More than 30 % of practising medical doctors in the United Kingdom, Switzerland, Sweden and Canada are foreign-born but Norway, Belgium and the United States also exceed 20 %. The phenomenon can also be observed in Central-Eastern European countries as well: the share of foreign-born physicians exceeds 10 % in Slovenia and Hungary and is around 3 % in Poland and Slovakia [
12]. Some medical schools in the world are training doctors for their home country as well as for the international labour market [
13]. Learning experiences of international medical graduates must be individualized because residents come from very different cultures with different values [
14]. Studying abroad in a foreign language environment is a challenge that cannot be underestimated [
15]. Norwegian medical students studying abroad smoke more frequently and consume alcohol more excessively than their domestic peers [
16]. Comparisons of culturally different populations may help to explain factors related to health behaviours in students. Numerous studies have attempted to assess medical students’ lifestyle and health status, but only a few studies have compared samples from different cultures [
9,
16‐
18].
The aim of our study was to explore the health behaviour (i.e., nutrition, exercise, tobacco smoking and alcohol consumption) and certain aspects of mental health (i.e., role limitations because of emotional problems, energy/fatigue, emotional well-being and social functioning) of medical students in Hungary. Our study also aimed to compare foreign and Hungarian students in this regard.
Discussion
Previous studies have indicated that medical training is more stressful than other types of education [
25], although some recent research suggests that attending medical school is not associated with increased stress [
26]. However, stress at university may have a debilitating effect on studying [
27] and can even result in burnout [
28], suicidal thoughts and suicide among medical students [
29]. Understanding medical students’ lifestyle habits and mental health may be a first step to the stress prevention and the improvement of quality of life.
We found that only 15.3 % of our sample reported ‘healthy diet’ that meets dietary recommendations at least partially [
21,
30] and the majority (51.6 %) consumed fruit and vegetables only 3–4 times a week. These results are not surprising. Most of our sample was from European countries with insufficient vegetable consumption [
31]. Women were more likely to report ‘healthy diet’ than men, and this finding agrees with previous scientific results [
32‐
34]. Country of origin did not seem to be related to healthy dietary practices and we concluded that students from Mediterranean countries do not necessarily follow the Mediterranean diet. Previous studies have highlighted recent dietary changes in Mediterranean countries; namely, an increase in the intake of processed foods and saturated fat and a decrease in the intake of plant foods and monounsaturated fatty acids [
35,
36]. In our sample, 20.9 % of Scandinavian students reported good dietary practice. Based on personal communications from the students, we hypothesise that food availability could explain this pattern. In Hungary (where students live during their academic years), fruit and vegetables are much cheaper than in their home countries. Our participants were medical students and part of their training focused on the advantages of a healthy diet. As obesity is a modern worldwide epidemic, the dietary behaviour patterns found here need to be changed (and not only for the personal health of our medical students). Physicians who are healthy are more credible to patients who consult them about prevention of illness [
1] and their dietary habits may help to bring about desired changes in their patients.
The overall prevalence of smoking was 18.6 % in our sample and was highest in the Mediterranean subsample (30.4 %). All subsamples showed lower prevalence than the general age-matched population of their home country [
37‐
39] (the Mediterranean subsample showed an equal prevalence), which is promising. We assume this means that medical students understand the public health importance of not smoking, which will increase their credibility when advising smoking cessation for their future patients.
Seventy-five per cent of our sample engaged in regular vigorous exercise (males more often than females). These findings support previous findings [
33,
34]. Our results suggest that Mediterranean and Iranian students are the least physically active. Iranian researchers have found the same low levels of exercise in their homeland population [
40,
41]. It is recommended that everyone should perform daily exercise; such activity helps future medical doctors to promote physical activity to their patients [
3].
The overall prevalence of alcohol overconsumption was 13.8 %. There was a strong link between being Scandinavian and alcohol overconsumption for both genders. According to the World Economic Forum’s Global Gender Gap Report, 2013, Norway and Sweden were ranked third and fourth in terms of general gender equality (in comparison, Hungary ranked 87th on the same list). Unfortunately, there may be equality in bad habits too: women’s alcohol consumption patterns differ only a little from men’s in these countries. In addition, lifestyle may change when leaving the domestic cultural environment. A relevant former study indicated that Norwegian students behave differently in the domestic higher education system than abroad: in other countries, they seem to adopt the lifestyle of the host environment—particularly regarding alcohol-related behaviour [
16]. Hungarian alcohol legislation is very permissive: people aged over 18 years may buy all kinds of alcoholic beverages without any restrictions; therefore, these products are available daily from the smallest grocery shops to the largest supermarkets. Additionally, alcoholic drinks are much cheaper in Hungary than in the Scandinavian countries. Informal communication with Scandinavian students (mostly Norwegians) revealed that, at the beginning of their studies, they arranged parties for social integration that involved frequent alcohol consumption.
Concerning mental health, the mean score of the ‘Vitality’ subscale of the four SF-36 subscales was the lowest in all subsamples. The lower scores on the ‘Vitality’ subscale may be a sign of fatigue in the fourth-year students’ population [
28]. Normative data for the SF-36 are available for many countries so we could compare some of our results with previous findings (unfortunately, we could not find any normative data for Israel). For the Mediterranean subsample, we used the Greek data for comparison because this proportion was the highest. Scandinavian [
42] and Iranian students’ [
43] scores were about the same as those of their peers in their home country; Mediterranean students’ scores were a little lower [
44], and Hungarian students’ scores much lower than their age-matched peers [
45]. We can conclude that the self-reported mental health of our subsamples is better (or at least not worse) than reference values, excepting the Hungarian subsample. We should note that the last available normative data for the Hungarian population is from 1999 and there have been negative economic changes in Hungary since then. Therefore, the mental health of medical students (and the general population) in Hungary may have declined since 1999. Analysis of this phenomenon is beyond the scope of this paper.
Probably our most important finding is that the country of origin may affect mental health. Hungarian students rated their mental health significantly lower than the foreign student groups (with the best outcomes for Scandinavian and Israeli students). Country of origin was significantly associated with mental health even after adjusting for potential confounding variables (gender, age) and health (risk) behaviours. Although the association is significant it should be noted that the effect of the country of origin might be modest as only 5.5–9.5 % of the variance was explained by our models.
Our analysis of the potential predictors of mental health showed that regular, vigorous exercise predicted better mental health status. Regular physical activity has many health-related benefits, as it reduces the risk of cardiovascular diseases, certain cancers and diabetes and increases general well-being, generates positive mood and reduces symptoms of depression and anxiety [
46]. The positive association between exercise and mental health is well known among young health-care professionals [
47]. Motivating medical students to adopt an active lifestyle not only helps prevent ill-health, but also supports them in maintaining or improving their physical and mental health status.
As mental health may influence career options [
48], it is crucial to improve medical students’ mental well-being so that they can begin their professional life without avoidable setbacks. There are several examples, even in Hungary, that demonstrate that self-development groups may facilitate coping with stress during academic training [
49,
50].
There were some limitations of our study. Cross-sectional designs do not allow one to draw conclusions about cause–effect relationships. Voluntary participation might also result in bias. The size of some subsamples was small and reduced the power of certain statistical tests. Regarding the measures, we did not include a question about other forms of tobacco consumption (e.g., moist powder tobacco products, snus or water-pipe use). Additionally, the Simple Lifestyle Indicator Questionnaire contains only three questions about diet, which may not be enough to describe individuals’ dietary patterns. However we agree with the creators of this scale, who claimed that ‘people who have good dietary practices related to salads, fruit, and fibre also have good dietary practices around eating fish, not eating junk food, and choosing food low in saturated fat’ [
19]. An additional limitation was that the purchase power of the students was not taken into consideration. Finally, there are four medical schools in our country, but we collected data only from a single school (although this was the largest); thus, we have to be cautious about generalizing from our results.
Despite limitations, we believe the study has some strength. We still do not have sufficient knowledge about the lifestyle and stamina of future medical doctors and the factors that may have a significant impact on these. To our knowledge, only a few prior studies have compared medical students by their country of origin. Our results indicated that country of origin could be a contributing factor to medical students’ mental health and health (risk) behaviours. These findings may add a small, yet important piece to the puzzle of understanding the factors underlying medical students’ well-being.
Acknowledgement
The authors would like to thank the administrative staff of the Department of Public Health for their help with recording the data from the questionnaires.