Sage Journals: Discover world-class research

Abstract

Background

Students with foreign backgrounds can face challenges in the study environment linked to language, cultural roles, norms, and ethnicity. It is important to increase knowledge about students’ own health-promoting resources and social study factors, to optimize a good study environment.

Objective

This study aimed to describe and investigate changes in health-promoting resources and social study factors in, respectively, the first and final semesters, for students with and without foreign backgrounds, in nursing and social work programs in Sweden.

Methods

The study had a repeated cross-sectional multicentre design at the group level. Students at six Swedish universities answered a web-based questionnaire in the first (n = 665) and final semester (n = 296) of nursing and social work programs. The questionnaire measured health-promoting resources (SOC-13; SHIS; OBQ), and social study factors (QPSNordic). Statistics were conducted through descriptive, correlation, and multiple linear regression analyses.

Results

At baseline, students with foreign backgrounds reported significantly lower health-promoting resources, including SOC total (p < .004), SHIS (p < .004), and social study factors (p < .004), compared to other students. By the final semester, disparities between the two groups persisted in two items of social study factors. In the final semester, students’ relationships and the value of group work predicted health-promoting resources for the entire student cohort.

Conclusion

Social relationships were central to health-promoting resources for Swedish nursing and social work students. The results indicated the value of targeted actions, in the study environment, especially among students with foreign backgrounds.

Keywords

culture health promotion nursing occupational health psychological and social factors at the workplace work-life balance

Introduction

University education is an extensive activity that has increased in recent years.¹ In the autumn semester of 2022, 370,000 students registered at Swedish universities on bachelor's or master's degree programs.² Since the beginning of the 2000s, efforts have been made to broaden recruitment and participation, to reach underrepresented groups.^3–5 One of the goals of Swedish educational policy is that 50 percent of a cohort have applied for university studies before the age of 25.⁴ Globally, there are wide disparities in access to higher education, especially for vulnerable groups, in relation to issues such as disability, gender, and socioeconomic status.⁶ Research on ethnicity and race in this field remains limited.⁶ In Sweden, currently, there is no skewed distribution concerning students with foreign backgrounds. The group is represented in university studies in a proportion corresponding to that of the ethnic Swedish population.⁷ An exception is those who migrated to Sweden from the age of seven to 18 who apply to university to a lesser extent.⁸ Efforts are being made for broadened recruitment, and as a result, strategies for broadening participation need to be developed.⁹ The COVID-19 pandemic accelerated the development of more human-centered solutions and flexible pedagogical methods through improved digital solutions which can promote participation in higher education for underrepresented groups.¹⁰ Students with foreign backgrounds can face challenges linked to cultural roles, norms, and expectations, in relation to differences in ethnicity and culture.¹¹ Nursing education is still characterized by traditional patterns, where the white female student is the norm, and minority groups, such as foreign students, male students, older students, and students with disabilities are seen as nontraditional outsiders and are disadvantaged in clinical education evaluations.¹² Similar challenges are shown among sociology students, where students with foreign backgrounds belong to a group with a greater risk of failing in their studies.¹³ The importance of social and psychosocial factors in working environments has been investigated within working life^14–16 and, there is a need for more knowledge about minority groups’ experiences.¹⁷ The environment in higher education is less researched. Social factors affect academic outcomes, and friendship networks are important,^18,19 and stronger than work and learning networks.¹⁸ Students’ readiness for higher education affects academic outcomes, and research shows a lower degree of readiness for students with a foreign background compared to native students.²⁰ Language skills are important for success in university-level studies. Debrew et al.¹² show the risk that the nursing student with a foreign background can be misunderstood in the assessment if the language is not mastered and is at risk of failing the internship. Health-promoting resources include several components that impact life in a healthy direction. The World Health Organization (WHO) defines health promotion as “the process of enabling people to increase control over and to improve their health”.²¹ This definition is based on the Ottawa Charter,²² which determined that “Caring, holism and ecology are essential issues in developing strategies for health promotion”. It also emphasizes the importance of the involvement of all conceivable parties in society, both private and public, and that the responsibility for striving towards good public health cannot be placed solely on health and medical services. Nor is it a matter merely for the individual.²³ Previous research shows that students in higher education within health care and social work show good health and well-being.²⁴ It also indicates that health-promoting resources, such as physical activity, good sleep, and not smoking, are significant factors in promoting health.²⁴ This study investigates health-promoting resources and social study factors with internal significance for the student. Notably, research by Turk et al. (2025) showed that health is a fragile factor among students and that weight and sleep hygiene were affected negatively by the stressors of the pandemic.²⁵

The concept of health, although difficult to define, needs to be put into context, to illuminate the concept of health promotion.²⁶ It has many definitions, that come from different perspectives. According to WHO's definition, health is described as complete physical, mental, and social well-being.²⁷ The Ottawa Charter added social and personal resources,²² while other literature views health from a holistic perspective,²⁸ as something more than the “absence of disease”.²⁹ Another way of approaching the concept of health in research has been to combine it with other concepts, such as health and lifestyle³⁰ or health and capabilities.³¹ From a salutogenic perspective, health is described as a movement toward the health pole on the health ease/dis-ease continuum.³²

In Sweden, the proportion of students with foreign backgrounds has increased in line with demographic changes in the general population.^2,7 Ensuring students complete their studies successfully and have a positive educational experience is crucial. Previous research on health experiences among students with foreign backgrounds remains limited and this study aims to contribute with knowledge in the field.

Adopting a salutogenic perspective, this study aimed to describe and investigate improvements or disimprovements in health-promoting resources and social study factors among nursing and social work students with and without foreign backgrounds during their higher education in Sweden. We hypothesized that health-promoting resources and social study factors would develop differently between student groups across their education.

Methods

Theoretical framework

Salutogenesis can be explained as the “origin of health” and is directed toward that which promotes health, rather than having a pathological orientation.^33,34 Aaron Antonovsky³³ developed the salutogenic concept of Sense of Coherence (SOC)^32,35 and a measuring instrument with the same name.³⁴ SOC describes how the individual, group, or organization handles stressors, and SOC consists of comprehensibility, manageability, and meaningfulness.³² Comprehensibility is the cognitive dimension, manageability is the experience of available and useful resources, and meaningfulness is about seeing meaning in life's challenges. These three dimensions form the basis of SOC.³³ Life is constantly affected by stressors. How these are handled depends on the individual's access to or lack of general resistance resources (GRRs), a key concept in the SOC model.³² Among students in urban areas, Mato and Tsukasaki³⁶ found SOC to be significantly related to GRRs, such as social capital, self-efficacy, and mental health. The salutogenic model highlights health-promoting factors. It can be employed at societal, organizational, group, and individual levels,³⁷ and is advantageously researched using more and different methods.³⁸

Study design

The study employed a repeated cross-sectional multicentre design to explore group-level health-promoting factors among nursing and social work students in the first and final semesters, with a particular focus on students with foreign backgrounds. The data in the study were collected as part of a larger research project conducted within the Swedish framework for Health Research in Collaboration.³⁹ The project participants were students in seven undergraduate programs within healthcare and social work at six universities in southwestern Sweden. The programs lead to the qualification of biomedical laboratory scientists, diagnostic radiology nurses, occupational therapists, physiotherapists, registered dental hygienists, registered nurses, and social workers.³⁹

Participants

This study included solely the nursing and social work programs. The rationale for their selection was that they represented the largest number of respondents in the project, and exhibited similarities in the distribution of students with foreign backgrounds, both within the two programs and as a proportion of the Swedish population.⁷ The programs were distributed differently across the six universities. The nursing program was offered at all six universities, with biannual admission, while the social work program was available at two universities, with annual admission. A web-based questionnaire was distributed to 1854 nursing and social work students. The participants responded to the questionnaire in, respectively, the first and final semesters of the program. In the first semester, 665 students responded (nursing n = 536 and social work n = 129), and in the final semester, 296 responded (nursing n = 212 and social work n = 84) (Table 1). Nursing and social work students form in the future one group. The respondents in the first and final semesters were, on the whole, not the same individuals, but they were in the same semester of their education. Students with foreign backgrounds formed one group (n = 138 first semester, n = 42 final semester) and other students another group (n = 527 first semester, n = 254 final semester). Foreign background was defined as both parents being born abroad and included foreign-born.⁴⁰ Exchange students were excluded. Students without foreign backgrounds are referred to as other students.

Table 1.

Participants’ characteristics, health-promoting resources, and social study factors. Students with foreign backgrounds (SFB), other students (OS).

	First semester				Last semester
	Total	SFB	OS		Total	SFB	OS
	n = 665	n = 138	n = 527	p-value	n = 296	n = 42	n = 254	p-value
Participants’ characteristics
Age (years) (SD)	26 (7)	27 (8)	26 (7)	.065*	30 (8)	31 (9)	29 (8)	.400*
Gender (% women)	89	88	88	.755*	91	88	92	.447*
Residential area (rural), n (%)	91 (14)	17(12)	74 (14)	***	58 (20)	5 (12)	53 (21)	***
Living alone, n (%)	109 (16)	18 (13)	91 (17)	***	61 (21)	7 (17)	54 (21)	***
Living with parents/siblings, n (%)	151 (23)	48 (35)	103 (20)	<.001**	22 (7)	9 (21)	13 (5)	***
Living with husband/wife/partner, n (%)	292 (44)	46 (33)	246 (47)	.005**	163 (55)	18 (43)	145 (57)	***
Living with other adults, n (%)	53 (8)	15 (11)	38 (7)	***	8 (3)	0	8 (3)	***
Living with children, n (%)	82 (12)	15 (11)	67 (13)	***	50 (17)	8 (19)	42 (16)	***
Health-promoting resources
SOC Total 13–91 (SD)	59.26 (11.73)	56.75 (11.65)	59.90 (11.67)	.004*	61.30(12.00)	59.23 (13.21)	61.63 (13.21)	.223*
SOC Comprehensibility 5–35 (SD)	20.83 (5.32)	20.58 (5.30)	20.89 (5.32)	.441*	21.64 (5.49)	20.83 (5.85)	21.77 (5.43)	.291*
SOC Meaningfulness 4–28 (SD)	20.67 (4.12)	19.73 (4.39)	20.91 (4.02)	.004*	20.93 (3.91)	20.71 (4.44)	20.97 (3.83)	.923*
SOC Manageability 4–28 (SD)	17.80 (4.44)	16.70 (4.69)	18.90 (4.33)	.002*	18.77 (4.39)	17.85 (4.33)	18.92 (4.39)	.088*
SHIS 11 11–66 (SD)	43.92 (9.49)	41.59 (10.03)	44.54 (9.26)	.004*	41.59(10.30)	41.07 (11.66)	41.68 (10.08)	.728*
OBQ 0–33 (IQR)	12 (10)	12 (10)	12 (11)	.896*	14 (11)	12.5 (12)	14 (11)	.748*
General health (Good), n (%)	592 (89.0)	117 (84.8)	475 (90.1)	.605**	183 (61.8)	25 (59.5)	148 (58.3)	.741**
Perceived well-being (Good), n (%)	591 (88.9)	120 (87.0)	471 (89.4)	.233**	173 (58.4)	25 (59.5)	158 (62.2)	.879**
Social study factors(QPSNordic), (yes), n (%)
Support from study mates	504 (76)	77 (56)	427 (81)	<.001*	222 (75)	27 (64)	195 (77)	.083*
Study mates listen	512 (77)	72 (52)	440 (83)	<.001*	236 (80)	25 (59)	211 (83)	<.001*
Good relationship with study mates	562 (84)	102 (74)	460 (87)	<.001*	227 (77)	29 (69)	198 (78)	.173*
Value group work	521 (78)	93 (67)	428 (81)	<.001*	172 (58)	23 (55)	149 (59)	.615*
Talk with friends about studies	518 (78)	91 (66)	427 (81)	<.001*	212 (72)	22 (52)	190 (75)	.004*

*Mann-Whitney U-test, **Chi-squared test, ***Too small sample size to perform statistical analysis.

SOC (Sense Of Coherence), SHIS (Salutogenic Health Indicator Scale), OBQ (Occupational Balance Questionnaire), QPSNordic (The General Nordic Questionnaire for Psychological and Social Factors at Work).

Data collection

Data were collected from spring/autumn 2018 (first semester) to autumn 2020/spring 2021 (final semester),³⁹ depending on whether the program started in the autumn or spring semester. The survey was a self-reported, web-based questionnaire (esMaker NX3 software), sent to all students on the relevant programs at the included universities,³⁹ along with information about the study. The students were informed about their right to terminate their participation in the study. Three digital reminders were sent. The study received ethical approval from the Linköping Regional Research Ethics Committee (no. 2017/211-31) and the Swedish Ethical Review Authority (no. 2021-04851). The study followed the recommendations in the Declaration of Helsinki.⁴¹

Measures and analysis

The web-based questionnaire³⁹ contained questions about demographic characteristics, health-promoting resources—as measured by three validated instruments, the Sense of Coherence Scale 13-items (SOC-13), the Salutogenic Health Indicator Scale (SHIS), and the Occupational Balance Questionnaire (OBQ))—and social study factors, measured by five questions from the General Nordic Questionnaire for Psychological and Social Factors at Work (QPSNordic), and general health and well-being. In addition, there were questions about program selection, working life, health, and lifestyle. These questions were omitted from the current study.

SOC-13 measured health-promoting resources.³² There were thirteen questions, scored from 1 to 7, ranging from 13 to 91 points.³⁴ It consisted of the components: comprehensibility, manageability, and meaningfulness. These three components were examined individually and in total and were linked to each other. SHIS illuminated health from a salutogenic and holistic perspective, including cognitive, physical, and psychometric health.⁴² The SHIS scale contained 12 questions, rated from 1 to 6. One item was missing by mistake (‘having energy’), and the total score ranged from 11 to 66. OBQ measured occupational balance and contained 11 items, scored from 0 to 3, ranging from 0 to 33 points.^43,44 It was proven to be a part of life balance⁴⁵ and involved having variety and the right number of tasks in life.^43,46 The higher the values indicated on the scales, the better the health-promoting resources. Social study factors were investigated by five items from QPS Nordic,^47,48 measuring social interaction and teamwork, and adapted to the student context, focusing on social study factors, such as relationships with study mates and other friends. The questions were dichotomized; the two lowest answers corresponded to “no”, while the other two or three options corresponded to “yes”.

In the first and final semesters, reported values from students with foreign backgrounds were compared with values from other students, regarding health-promoting resources, social study factors, and demographic data. Descriptive analyses were used to describe the background characteristics. The Chi-squared test, t-test, and Mann-Whitney U test were used to describe diversity in health-promoting resources, social study factors, general health, and perceived well-being. SOC-13, SHIS, OBQ, and social study factors were reported respectively. In the final semester, items related to social study factors that significantly correlated with SHIS and SOC were included in a multiple linear regression analysis. There were too few respondents with foreign backgrounds in the final semester for the regression analysis. Therefore, the analysis was carried out with the total number of students, 296 (n = 42 students with foreign backgrounds and n = 254 other students). A p-value <0.05 was considered significant. All data were analyzed using SPSS Statistics 27. The data were described in both measurement cases independently of each other.

Results

Students’ characteristics

A total of 665 students completed the survey in the first semester. Of these, 138 (21%) were students with foreign backgrounds (Table 1). In the final semester, 296 students responded and 42 (14%) had foreign backgrounds. The mean age in the first semester was 27 years for students with foreign backgrounds and 26 years for other students. The overall gender distribution varied from 88% women in the first semester to 91% women in the final semester, with a slightly higher proportion of women for other students in the final semester (Table 1). In the first semester, students with foreign backgrounds lived with their parents and siblings to a greater extent (35%) than other students (20%), which represented a significant difference (p < .001) (Table 1). This also applied to the final semester group, but the number of participants was small, and the results were not statistically significant. When it came to living with a partner, there was a significant difference in the first semester (p < .005), where students with foreign backgrounds lived with a partner to a lesser extent (33%) than other students (47%). The final semester showed no significant differences.

Health-promoting resources

In the first semester, students with foreign backgrounds reported significantly lower total SOC-13 (p < .004), meaningfulness (p < .004), and manageability (p < .002) than other students. However, this was not the case for comprehensibility (Table 1). For SHIS in the first semester, students with foreign backgrounds reported significantly lower than other students (p < .004) (Table 1). In the final semester, there were no significant differences in SOC-13 or SHIS between students with foreign backgrounds and other students, and the total group of students reported lower SHIS, compared to the first semester (Table 1). OBQ showed no significant differences in the first or final semester between students with foreign backgrounds and other students (Table 1). Further, self-reported general health and perceived well-being showed no significant differences between students with foreign backgrounds and other students in either the first or final semesters. Both students with foreign backgrounds and other students reported lower values in the final semester than in the first semester.

Social study factors

In the first semester, students with foreign backgrounds rated the five questions about social study factors significantly lower than other students. The percentage of students with foreign backgrounds and other students who rated the following elements as yes were: Support from study mates (56%/ 81%) (p < .001), Study-mates listen (52%/83%) (p < .001), Good relationship with study mates (74%/87%) (p < .001), Value group work (67% /81%) (p < .001) and Talk with friends about studies (66%/81%) (p < .001) (Table 1). In the final semester, students with foreign backgrounds reported significantly lower values for two of the five questions than other students: Study mates listen (59%/83%) (p < .001) and Talk with friends about studies (52%/75%) (p < .004) (Table 1). The other three questions indicated no significant differences between the groups.

Associations between health-promoting resources and social study factors

From the first to the final semester, the differences in the groups of students with foreign backgrounds and other students were evened out when it came to health-promoting resources (SOC total and SHIS). In social study factors, a difference remained in two of the five items: Study mates listen and Talk with friends about studies. Furthermore, the association between health-promoting resources reported by SOC and SHIS and the items of social study factors was investigated (Table 2). In the group of other students, there were consistently significant—albeit weak—correlations. In the group of students with foreign backgrounds, two significant correlations for SHIS correlated moderately. These were SHIS and Good relationships with study mates (r = 0,419, p = 0007) and SHIS and Value group work (r = 0,375, p = 0017).

Table 2.

Correlations for health-promoting resources (Sense of Coherence (SOC) total and Salutogenic Health Indicator Scale (SHIS)) and social study factors in the final semester for undergraduate nursing and social work students. Students with foreign backgrounds (SFB), other students (OS).

	Support from study mates		Study mates listen		Good relationship with study mates		Value group work		Talk with friends about studies
	SFB n = 42	OS n = 254	SFB n = 42	OS n = 254	SFB n = 42	OS n = 254	SFB n = 42	OS n = 254	SFB n = 42	OS n = 254
SOC total	−0400	0235	−0017	0224	0285	0307	0202	0287	0188	0276
	NS	p < .001	NS	p < .001	NS	p < .001	NS	p < .001	NS	p < .001

SHIS	−0163	0254	0080	0207	0419	0316	0375	0213	0267	0235
	NS	p < .001	NS	p < .001	p = .007	p < .001	p = .017	p < .001	NS	p < .001

Data are presented as Pearson's Correlation coefficients. Not significant (NS).

When significantly associated factors were entered, based on multiple linear regression, Good relationships with study mates were found to be a significant predictor for SHIS (β 0759; 95% CI: 1,26- 4,25, p < 0001), while the other four variables in social study factors were not (Table 3). With SOC as a dependent variable, Good relationships with study mates (β .921; 95% CI: = .31–3.94, p = 0.022), and Value group work (β 0.753; 95% CI: 0,02–3,92, p = 0.048) were significant predictors (Table 4). These findings indicated that social study factors were associated with health-promoting resources for students in nursing and social work programs at the group level.

Table 3.

Multiple linear regression analysis of social study factors predictive items of Salutogenic Health Indicator Scale (SHIS) in the final semester of nursing and social work programs (total cohort).

VariablesN = 296	Dependent variable SHIS
VariablesN = 296	Beta	Standard error (Beta)	95% CI	p-value
Support from study mates	.745	1.125	−1.469–2.959	.508
Study mates listen	−.015	1.221	−2.418–2.388	.990
Value group work	.867	.625	−.363–2.097	.167
Talk with friends about studies	.098	.732	−1.342–1.539	.894
Good relationship with study mates	2.753	.759	1.259–4.246	<.001

CI Confidence interval, R2 = 0.127; ANOVA; F = 8.27, p = <.001.

Table 4.

Multiple linear regression analysis of social study factors predictive items of Sense of Coherence (SOC) in the final semester of nursing and social work programs (total cohort).

VariablesN = 296	Dependent variable SOC
VariablesN = 296	Beta	Standard error (Beta)	95% CI	p-value
Support from study mates	1196	1386	−1532–3924	.389
Study mates listen	−.405	1512	−3381–2570	.789
Value group work	1499	.753	.016–2982	.048
Talk with friends about studies	.829	.881	−.905–2563	.347
Good relationship with study mates	2123	.921	.311–3936	.022

CI Confidence interval, R2 = 0.124; ANOVA; F = 7.72, p = <.001.

Discussion

This study investigated health-promoting resources and social study factors among students in nursing and social work programs in a Swedish context, at the group level. The study took a salutogenic perspective and compared values from students with foreign backgrounds with those of other students. The principal findings showed, firstly, that differences in reported values for health-promoting resources and social study factors among the groups evened out from the first to the final semester (Table 1). Secondly, in the final semester, there was a correlation between health-promoting resources and social study factors that was weak but pronounced for the group of other students, and moderate and scarce for students with foreign backgrounds (Table 2). Third, for the entire student group, taken as a whole, in the final semester, social study factors, measured by Good relations with study mates and the Value of group work, were predictive of health-promoting resources, as measured by SOC and SHIS, (Table 3 and Table 4).

The findings enabled reflections on possible reasons for the reported values. SOC has a salutogenic orientation and predicts and explains the movement toward health,³⁴ and salutogenesis is also the dominant perspective in SHIS.⁴² The study was conducted at a group level, and cautious conclusions about the development of health-promoting resources can be drawn, but the cross-sectional design means that causality cannot be claimed. Those who reported low values in the first semester may have dropped out or not answered in the final semester. Drop-out is a well-known phenomenon in higher education and has several causes, such as engagement and the choice of studies,⁴⁹ lack of supervision at the right placement level, personal reasons⁵⁰ or economic reasons.⁵¹ Lack of language proficiency has been identified as another contributing factor, placing non-native students at greater risk of lower academic achievement.²⁰ Moreover, students’ backgrounds may involve hidden cultural and linguistic challenges that negatively affect their educational experience.⁵ These difficulties are further compounded in clinical education, where students from minority groups often face additional barriers.⁵² On the other hand, the study period and the university environment may positively affect health-promoting values. Olsson et al.⁵³ have shown that initiatives implemented by universities to enhance a health-promoting learning environment can involve action on inclusion and diversity, physical environment, health-related skills, and pedagogical practicies.⁵³ The healthy university is described by Newton et al.⁵⁴ as an environment where all parts of the system are taken into account, from the organizational to the interpersonal, and similar aspects of higher education from a salutogenic perspective are described by Dooris et al.⁵⁵ The results of the current study also showed that, in the first semester, students with foreign backgrounds to a significantly lesser extent answered “yes” to the five questions about social study factors, than did other students. In the final semester, the differences had evened out, but two questions were still answered “yes” to an affirmatively lesser extent, Study mates listen and Talk to friends about studies by students with foreign backgrounds. Research shows the importance of having study mates and social networks in higher education,¹⁸ and that readiness affects the study outcome.²⁰ The literature shows the importance of social relationships—that they can help students get through some of the more difficult situations they experience.⁵⁶

In the final semester, there was a significant correlation between health-promoting resources and social study factors. It was weak but pronounced for the group of other students and appeared in both SOC and SHIS. For students with foreign backgrounds, it was moderate and associated with two correlations in SHIS (Value group work and Good relationship with study mates). The current study is based on a small number of participants, specifically students with foreign backgrounds, especially in the final semester, so conclusions are drawn with caution. To investigate the correlation further, a multiple linear regression analysis was conducted for the entire student group in the final semester. SOC and SHIS, respectively, constituted dependent variables for social study factors. The findings were that Value group work and Good relationship with study mates predict SOC, and Good relationship with study mates predict SHIS. These associations should be interpreted with caution due to the low response rate among students in the final semester. However, the results indicate the importance of students’ social relationships for their development of health-promoting resources, which is in line with previous studies.^18,56 There is also reason to investigate the organization of education and how universities support students in a health-promoting way.^18,53,54 The teaching staff is important for students’ transition into higher education.⁵⁷ Students’ development of social networks and groups is complex and influenced by, among other things, gender and language background. Such networks are often present in the educational context differently than what teaching staff expect and plan for.¹⁸ Groups formed by teachers have proven to be more sustainable and well-functioning than if the students themselves form the groups.⁵⁸

The present study did not reveal significant differences between the student groups in occupational balance, general health, and perceived well-being. Previous research shows that occupational balance is a complex concept when it comes to measuring individual satisfaction with life.⁵⁹ It is important to be careful about equating student life with working life. Research among occupational students reveals the difficulty of using function as an adequate measure of occupational balance.⁶⁰ Living conditions differed between the two groups in the first semester, and partly in the final semester. On the one hand, living with parents and siblings can be interpreted as positive for students with foreign backgrounds and contribute to increased SOC in the final semester. One of the components of GRR is social support.³² Resilience in higher education is important.⁶¹ Academic resilience shows that a meaningful relationship with one's family is an essential factor.⁶² Family resilience, with warm and strong bonds,⁶³ can help people to master difficult situations and develop their character. A well-functioning family and resilience can contribute to increased psychological well-being.⁶⁴ On the other hand, close family ties may be interpreted as the maintenance of traditional gender roles, which can harm female emancipation.⁶⁵ This has been debated in Sweden in the context of honour-based violence and opression.⁶⁶ However, the student's family relations were not further explored in the current study, and no conclusions in any direction can be made.

The area needs further investigation to optimize sustainable, high-quality higher education.

Strengths and limitations

This study has both strengths and limitations. A strength of the study is the use of validated instruments in the web-based questionnaire. Furthermore, the statistical analysis was conducted in a structured manner, beginning with descriptive and comparative tests, followed by correlations and regression analyses, which contribute to the robustness of the results. Finally, a strength is that the study has secured ethical permissions and follows ethical guidelines.

The limitations largely relate to the number of participants in the study. Achieving a satisfactory response rate is a challenge in survey research. The number of participants in the group of students with foreign backgrounds was small, and only a subset of respondents completed the survey at both time points (the initial and final semesters). Therefore, the respondents were not the same individuals at both time points, and the two time points were compared at the group level rather than the individual level. In the final semester, the group of students with a foreign background consisted of only 42 students. For the results to be generalizable to the population, a power calculation is often recommended for statistical analysis. The total population of this study consisted of nursing and social work students at six universities. The results can therefore only be generalized to this population. Furthermore, there were dropouts from the first to the final semester, but no dropout analysis has been conducted. In this case, it is unclear whether the students dropped out of the program or chose not to respond to the survey. The questionnaire was in Swedish, and its linguistic design, with many questions that were to be answered, may have presented a limitation for students whose mother tongue was not Swedish. These factors are limitations and must be considered when evaluating the results.

The study period coincided with the unexpected COVID-19 pandemic. As this global event was unforeseen, the study design didn’t include specific measures to assess its impact on participants. Emerging post-pandemic research documents significant transformations in higher education, including positive developments, such as enhanced virtual learning, which has been shown to improve teacher-student interactions in some contexts.⁶⁷ However, these changes also brought health-related consequences, such as increased sedentary behavior and screen time, leading to musculoskeletal complaints among both students and educators.⁶⁸ Relevant for our study population is the fact that young healthcare professionals proved to be vulnerable to pandemic-related challenges, experiencing moral distress, heightened stress levels, and career uncertainty.⁶⁹ These findings likely extend to nursing and social work students undergoing practice-based training. While we cannot determine the exact impact of the pandemic on our results regarding students’ health-promoting factors, this uncertainty represents a validity limitation that should be considered when interpreting the findings.

Conclusions

This study explored health-promoting resources for undergraduate nursing and social work students, focusing on students with foreign backgrounds. Initially, students with foreign backgrounds rated lower values for health-promoting resources than did other students, but this gap closed by the final semester. The results showed that social relationships were central to health-promoting resources. Further, in the final semester, health-promoting resources were associated with social study factors for the total student group. That may contribute to a shift toward the health pole on the salutogenic ease/disease continuum. The results show the complexity of the area and underscore the importance of students’ social relations in higher education. Strategies for health-promoting learning environments need to be developed. This is important for students in general, but for students with foreign backgrounds, measures such as language support centers, peer-mentorship programs, cultural competency training, and student-led networking opportunities can be examples of promotional proposals at the organizational level. In the interactions with students, the teaching staff play an important role in practically facilitating diversity in teaching, especially regarding group formation and reducing language and cultural barriers. The study was conducted at a group level, and the sample was small. Therefore, the conclusions should be interpreted with caution.

Further research is needed to better understand the experiences of students with foreign backgrounds and how social and health-promoting factors can enhance their study experience and preparation for working life.

Footnotes

Acknowledgments

Thanks to the students who responded to the survey. Without their responses, the study would not have been possible. We are also thankful to the Swedish Framework for Health Research in Collaboration board for access to the collected data.

ORCID iDs

Annika Jensen

Ingrid Larsson

Elenita Forsberg

Ethical approval

Ethics approval was obtained from the Linköping Regional Research Ethics Committee (no. 2017/211-31) and the Swedish Ethical Review Authority (no. 2021-04851). The study followed the recommendations in the Declaration of Helsinki (World Medical Association, 2013).

Informed consent

All participants were informed of the purpose of the study, that participation was voluntary, that they could leave the study at any time, and that all data would be handled confidentially. Written informed consent was obtained from all participants; the information letter attached to the questionnaire stated that by submitting the completed questionnaire, consent to participate in the study was given.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research received funding to cover project management costs from the Swedish Framework for Health Research in Collaboration. The first author (AJ) is employed as a doctoral student at Halmstad University, and all the authors receive regular research support from their respective universities.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

Björklund

Magnusson

Fernström

. Lärares perspektiv på breddat deltagande i högre utbildning: mångfald, omsorg och merarbete. Högre utbildning 2023; 13: 58–71.

UKÄ . Universitet och högskolor årsrapport 2022. [University and Colleges Annual Report 2022]. Universitetskanslerämbetet, UKÄ [University chancellor’s office]; 2022, Stockholm. https://www.uka.se/download/18.3024c77018b37fb62411ac19/1697549856232/2022-UKAP-005-arsrapport2022.pdf. 2022.

Universitets- och högskolerådet, UHR. [University and Higher Education Council] . Från breddad rekrytering till breddat deltagande - en analys av hur lärosäten presenterar sitt arbete med lika möjligheter till studier. [From broadened recruitment to broadened participation – analysis of how higher education institutions present their work with equal opportunities for studies.]; 2014, Stockholm. https://www.uhr.se/globalassets/_uhr.se/publikationer/2014/uhr-rapport—fran-breddad-rekrytering-till-breddat-deltagande—-docx.pdf.

Flodgren

. Mångfald i högskolan - reflektioner och förslag om social och etnisk mångfald i högskolan. [Diversity in higher education – reflections and suggestions on social and ethnic diversity in higher education.] Report no. SOU 2000: 47, 2000. https://data.riksdagen.se/fil/940F0164-B7F8-4E91-A187-7B9FA1034DCC.

Hort

. Studieframgång inom högre utbildning: en utforskande undersökning av sambanden mellan högskolestudenters studieresultat och ålder, kön, språkbakgrund samt socioekonomisk bakgrund. Högre utbildning 2024; 14: 12–27.

Salmi

D’Addio

. Policies for achieving inclusion in higher education. Policy Reviews in Higher Education 2021; 5: 47–72.

UKÄ, 2023 . Universitet och högskolor Årsrapport 2023. [University and Colleges Annual Report 2023]. Universitetskanslerämbetet, UKÄ [University chancellor’s office]; 2023, Stockholm. https://www.uka.se/download/18.a6121fb188ba2cd92434ce/1687415665158/UKA%CC%88%20a%CC%8Arsrapport%202023.pdf.

Fröborg

Svensson

Dryler

, et al. Universitets och högskolors arbete med att främja och bredda rekryteringen till högre utbildning. Tematisk utvärdering, del 1. [Universities’ and colleges’ work to promote and broaden recruitment to higher education. Thematic evaluation, part 1.] 2022. https://www.uka.se/download/18.72ddc32918529b363f9d774/1675168187189/Slutrapport%20del%201_%20Universitets%20och%20h%C3%B6gskolors%20arbete%20med%20att%20fr%C3%A4mja%20och%20bredda%20rekryteringen%20till%20h%C3%B6gre%20utbildning.%20Tematisk%20utv%C3%A4rdering%20del%201.pdf.

Kottmann

Vossensteyn

Kolster

, et al. Social Inclusion Policies in Higher Education: Evidence from the EU. Overview of major widening participation policies applied in the EU 28. Publications Office of the European Union, 2019. file:///C:/Users/annj/Downloads/jrc_117257_social_inclusion_policies_in_higher_education_evidence_from_the_eu%20(4).pdf.

10.

Rainford

. Moving widening participation outreach online: challenge or opportunity? Perspectives: Policy and Practice in Higher Education 2021; 25: –6.

11.

Merry

Vissandjee

Verville-Provencher

. Challenges, coping responses and supportive interventions for international and migrant students in academic nursing programs in major host countries: a scoping review with a gender lens. BMC Nurs 2021; 20: 74.

12.

DeBrew

Lewallen

Chun

. Outsiders in nursing education: cultural sensitivity in clinical education. J Prof Nurs 2014; 30: 149–154.

13.

Liu

B-p

. Intersectional impact of multiple identities on social work education in the UK. J Soc Work 2017; 17: 226–242.

14.

Taheri

Jami Pour

Asarian

. An exploratory study of subjective well-being in organizations–A mixed method research approach. J Hum Behav Soc Environ 2019; 29: 435–454.

15.

Nunstedt

Eriksson

Obeid

, et al. Salutary factors and hospital work environments: a qualitative descriptive study of nurses in Sweden. BMC Nurs 2020; 19: 11.

16.

Nagel

Westergren

Persson

, et al. Nurses’ work environment during the COVID-19 pandemic in a person-centred practice—A systematic review. Sustainability 2022; 14: 5785.

17.

Platts

Scott

Griffiths

, et al. Attitudes to and perceptions of workplace health promotion amongst employees from ethnic minorities in the UK: a scoping review. WORK 2024; 79: 289–305.

18.

Fjelkner-Pihl

. The constructive overlap: a study of Multiplex ties in Students’ study-related networks and academic performance. Innov High Educ 2022; 47: 273–295. 20210909.

19.

Hommes

Rienties

de Grave

, et al. Visualising the invisible: a network approach to reveal the informal social side of student learning. Adv Health Sci Educ Theory Pract 2012; 17: 743–757.

20.

Fjelkner

. Business students’ perceptions of their readiness for higher education studies and its correlation to academic outcome. J Adv Bus Educ 2020; 2: 74–92.

21.

World Health Organization, WHO . Health Promotion. World Health Organization Western Pacific Region. 2025. Accessed 05-22-2025. www.who.int/westernpacific/about/how-we-work/programmes/health-promotion.

22.

World Health Organization, WHO . Ottawa charter for health promotion. World Health Organization;1987. Accessed 05-22-2025. https://www.who.int/publications/i/item/WH-1987.

23.

Kickbusch

. The contribution of the World Health Organization to a new public health and health promotion. Am J Public Health 2003; 93: 383–388.

24.

Ahlstrand

Larsson

, et al. Health-promoting factors among students in higher education within health care and social work: a cross-sectional analysis of baseline data in a multicentre longitudinal study. BMC Public Health 2022; 22: 1314. 20220709. DOI: 10.1186/s12889-022-13690-z.

25.

Turk Dudukcu

Keser

Unusan

. Understanding the impact of the pandemic on university students: changes in sleep, eating patterns, and psychological well-being. WORK 2025; 80: 670–679.

26.

Huber

Knottnerus

Green

, et al.

How should we define health?

Br Med J 2011; 343: d4163. 20110726.

27.

World Health Organization, WHO . World Health Organization (WHO) Definition Of Health. Accessed 05-22-2025 https://www.publichealth.com.ng/world-health-organizationwho-definition-of-health.

28.

Bringsén

Andersson

Ejlertsson

, et al. Exploring workplace related health resources from a salutogenic perspective: results from a focus group study among healthcare workers in Sweden. Work 2012; 42: 403–414.

29.

Fagerstöm

. Caring, health, holism and person-centred ethos - common denominators for health science? Scand J Caring Sci 2019; 33: 253–254.

30.

Cockerham

. Health lifestyle theory and the convergence of agency and structure. J Health Soc Behav 2005; 46: 51–67.

31.

Tengland

. Health and capabilities: a conceptual clarification. Med Health Care Philos 2020; 23: 25–33.

32.

Antonovsky

. Unraveling the Mystery of Health. San Francisco and London: Jossey-Bass, 1987.

33.

Antonovsky

. The salutogenic model as a theory to guide health promotion. Health Promot Int 1996; 11: 11–18.

34.

Antonovsky

. The structure and properties of the sense of coherence scale. Soc Sci Med 1993; 36: 725–733.

35.

Antonovsky

. Health, stress and coping. San Francisco and London: Jossey-Bass, 1979.

36.

Mato

Tsukasaki

. Factors promoting sense of coherence among university students in urban areas of Japan: individual-level social capital, self-efficacy, and mental health. Glob Health Promot 2019; 26: 60–68. 20170406.

37.

Eriksson

. Teorin om hälsans ursprung - en systematisk forskningsöversikt. I M Eriksson (red). Salutogenes - om hälsans ursprung. Från forskning till praktisk tillämpning. [The theory of the origin of health – a systematic research review. In: Eriksson

(ed.) Salutogenesis – on the origin of health. From research to practical application.]. Stockholm: Liber, 2015, pp.14–46.

38.

Bauer

Roy

Bakibinga

, et al. Future directions for the concept of salutogenesis: a position article. Health Promot Int 2020; 35: 187–195.

39.

Lindmark

Ahlstrand

Ekman

, et al. Health-promoting factors in higher education for a sustainable working life - protocol for a multicenter longitudinal study. BMC Public Health 2020; 20: 233. 20200214.

40.

Statistiska centralbyrån, SCB . [Central Statistical Office]. Reports on Statistical Co-ordination for the Official Statistics of Sweden 2002:3. Statistics on persons with foreign background. Guidelines and recommendations. 2002. Accessed 05-13-2025. www.scb.se/contentassets/60768c27d88c434a8036d1fdb595bf65/mis-2002-3.pdf.

41.

World Medical Association, WMA . Declaration of Helsinki - ethical principles for medical research involving human subjects. Accessed 05-22-2025. https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects.

42.

Bringsen

Andersson

Ejlertsson

. Development and quality analysis of the Salutogenic Health Indicator Scale (SHIS). Scand J Public Health 2009; 37: 13–19.

43.

Wagman

Hakansson

. Introducing the occupational balance questionnaire (OBQ). Scand J Occup Ther 2014; 21: 227–231. 20140321.

44.

Wagman

Håkansson

Björklund

. Occupational balance as used in occupational therapy: a concept analysis. Scand J Occup Ther 2012; 19: 322–327.

45.

Wagman

Håkansson

Jacobsson

, et al. What is considered important for life balance? Similarities and differences among some working adults. Scand J Occup Ther 2012; 19: 377–384.

46.

Hakansson

Wagman

Hagell

. Construct validity of a revised version of the occupational balance questionnaire. Scand J Occup Ther 2020; 27: 441–449. 20190914.

47.

Lindström

Elo

A-L

Skogstad

, et al. User's guide for the QPSNordic. General Nordic Questionnaire for Psychological and Social Factors at Work. Stockholm, Helsingfors, Bergen, Oslo and Köpenhamn: Nordic Council of Ministers. TemaNord, 2000, 603. file:///C:/Users/annj/Downloads/SND%200837%20-%20user%20guide%20QPSNordic%20eng%20(1).pdf.

48.

Dallner

Lindström

Elo

A-L

, et al. Användarmanual för QPSNordic. Frågeformulär om psykologiska och sociala faktorer i arbetslivet utprovat i Danmark, Finland, Norge och Sverige. [User's guide for the QPSNordic. General Nordic Questionnaire for Psychological and Social Factors at Work tested in Denmark, Finland, Norway and Sweden.] Arbetslivsrapport [Working life report]. 2000:19. http://nile.lub.lu.se/arbarch/arb/2000/arb2000_19.pdf.

49.

Álvarez-Pérez

López-Aguilar

González-Morales

, et al. Academic engagement and dropout intention in undergraduate university students. J Coll Stud Retent Res Theory Pract 2024; 26: 108–125.

50.

Bakker

Verhaegh

Kox

, et al. Late dropout from nursing education: an interview study of nursing students’ experiences and reasons. Nurse Educ Pract 2019; 39: 17–25.

51.

Nurmalitasari, Awang Long

Faizuddin Mohd Noor

. Factors influencing dropout students in higher education. Education Research International 2023; 2023: 7704142.

52.

Graham

Phillips

Newman

, et al. Baccalaureate minority nursing students perceived barriers and facilitators to clinical education practices: an integrative review. Nurs Educ Perspect 2016; 37: 130–137.

53.

Olsson

Broberg

Frisk

, et al. Health-promoting learning environments in higher education: a scoping review of structural interventions to protect student mental health. European Journal of Education 2024; 59: e12772.

54.

Newton

Dooris

Wills

. Healthy universities: an example of a whole-system health-promoting setting. Glob Health Promot 2016; 23: 57–65.

55.

Dooris

Doherty

Orme

, et al. Applying salutogenesis in higher education. In: Mittelmark

Bauer

Vaandrager

(eds) The handbook of salutogenesis. 2nd ed. Cham, CH: Springer International Publishing, 2022, pp.307–319.

56.

Fjelkner

Roxå

Warfvinge

. “It has worked well despite the circumstances”–a study on student social relations and well-being during the pandemic. Högre Utbildning 2021; 11: 9–25.

57.

Leese

. Bridging the gap: supporting student transitions into higher education. J Furth High Educ 2010; 34: 239–251.

58.

Maguire

Keceli

. The impact of formation and diversity on student team conflict. Active Learning in Higher Education 2024; 25: 409–423.

59.

Anaby

Backman

Jarus

. Measuring occupational balance: a theoretical exploration of two approaches. Can J Occup Ther 2010; 77: 280–288.

60.

Bonsaksen

Lindstad

Hakansson

, et al. Rasch analysis of the Norwegian version of the occupational balance questionnaire in a sample of occupational therapy students. Occup Ther Int 2021; 2021: 8863453. 20210424.

61.

Price

. A review of resilience in higher education: toward the emerging concept of designer resilience. Stud High Educ 2023; 48: 83–99.

62.

Ang

WHD

Shorey

Hoo

MXY

, et al. The role of resilience in higher education: a meta-ethnographic analysis of students’ experiences. J Prof Nurs 2021; 37: 1092–1109. 20210828.

63.

Black

Lobo

. A conceptual review of family resilience factors. J Fam Nurs 2008; 14: 33–55.

64.

Desrianty

Hassan

Zakaria

, et al. Resilience, family functioning, and psychological well-being: findings from a cross-sectional survey of high-school students. Asian Soc Sci 2021; 17: 1–77.

65.

Okin

Nussbaum

Al-Hibri

, et al. Is multiculturalism bad for women?. In: Cohen

Howard

Nussbaum

(eds) Is multiculturalism bad for women?. Princeton, New Jersey: Princeton University Press, 1999, pp.7–24.

66.

Ouis

Högdin

. Hedersrelaterat våld och förtryck: Professionellas uppdrag och utmaningar. Stockholm: Liber, 2024.

67.

Alam

Abbasi

Han

, et al. Online teaching experience of the healthcare faculty during the pandemic: a cross sectional analysis. WORK 2024; 79: 613–621.

68.

Macedo

Costa de Assis

Pereira

NKF

, et al. Consequences of social distancing during the COVID-19 pandemic on the increase in perceived pain of students and professors from higher education institutions: a cross-sectional study. Work 2022; 73: 761–768.

69.

Cruise

Celis

Lashewicz

. I haven’t really gone through things like this”: young long-term care workers’ experiences of working during the COVID-19 pandemic. Work 2024; 78: 931–948.

Health-promoting resources and social study factors among students with and without foreign backgrounds in nursing and social work programs at six Swedish universities

Abstract

Background

Objective

Methods

Results

Conclusion

Keywords

Introduction

Methods

Theoretical framework

Study design

Participants

Data collection

Measures and analysis

Results

Students’ characteristics

Health-promoting resources

Social study factors

Associations between health-promoting resources and social study factors

Discussion

Strengths and limitations

Conclusions

Footnotes

Acknowledgments

ORCID iDs

Ethical approval

Informed consent

Funding

Declaration of conflicting interests

References