Мельничук М.Г. Migrants Psychosocial Maladjustment Scale (MPMS): Pilot Study

DOI: 10.17689/psy-2016.1.2
УДК 159.98:167

Background: One of the defining global issues of the XXI century is sharply increased world population mobility. Number of people who were forced or voluntarily left their homeland in search of better life, for the last 15 years has increased by 41%. Forced (and voluntary) immigrants are fully exposed to traumatic emotional experience of immigration where maladjustment is often an outcome.

Objective: The present study represents problem of psychosocial adaptation of temporary migrants in a new country. It gives psychometric characteristics of Migrants Psychosocial Maladjustment Scale (MPMS) in a pilot study.

Methods: The first stage of the pilot study of migrants’ psychosocial maladjustment comprised literature review. As a theoretical framework, we chose theory of cognitive adaptation, transactional model of adaptation to stress and cognitive-behavioral model of coping behavior. Methodological basis for creation of MPMS scale was diagnostics and treatment of psychosocial distress developed and described by American Psychiatric Association. The second stage of the pilot study was dedicated to formulation of MPMS statements, their revision and adjustment. Then, we analyzed the psychometric properties of the scale using a sample of international students, studying in Universities of Ukraine.

Results: We tested stability and internal consistency to determine the reliability of MPMS. Pearson correlation coefficient between the results of first and second test was 0.87, p < 0.05, and Cronbach's alpha coefficient — 0.91, that indicates a high test-retest reliability and internal consistency of the scale. MPMS content validity was provided by maximum conformity of test material content to the concept of individual’s maladjustment. MPMS construct validity was assessed by comparing the scale with instruments dealing with psychological adaptation problems.

Conclusion: MPMS scale sufficiently meets basic psychometric requirements for psycho diagnostic instruments, and can be recommended for use in practice. We also plan to study criterion validity of the scale, using second year migrants-students’ school successes as an objective validation criteria.

Keywords: temporary migrants; psychosocial adaptation; psychosocial maladjustment scale; psychometric characteristics.

Разработка шкалы психосоциальной дезадаптации мигрантов: предварительные результаты
© 2016 Мельничук Марина Геннадиевна*,
*старший преподаватель кафедры философии Харьковского национального университета радиоэлектроники (Харьков, Украина), m.g.melnichuk@gmail.com

История вопроса: Мобильность населения земного шара, резко возросшая по множеству причин, является одной из определяющих глобальных проблем XXI века. Число лиц, добровольно или вынужденно покинувших родину в поисках лучшей жизни (временно или навсегда), только за последние 15 лет выросло на 41%. Вынужденные и добровольные переселенцы в полной мере подвержены эмоциональному переживанию иммиграции, как травмирующего события, вызывающего психологический кризис. Одним из проявлений этого кризиса считается дезадаптация.

Цель: Изучить проблемы психосоциальной адаптации временных мигрантов на примере англоязычных студентов-иностранцев, обучающихся в высших учебных заведениях Украины. Представить психометрические характеристики шкалы психосоциальной дезадаптации мигрантов (Migrants Psychosocial Maladjustment Scale, MPMS), разработанной в рамках пилотного исследования.

Метод: На первом этапе разработки MPMS был проведен анализ литературы, позволивший в качестве теоретической концептуальной основы нового скрининг-инструмента выбрать теорию когнитивной адаптации, трансактную модель адаптации к стрессу и когнитивно-поведенческую модель копинг-поведения. Методической основой для создания MPMS послужили рекомендации относительно диагностики и терапии психосоциальных расстройств, разработанные Американской психиатрической ассоциацией. На втором этапе была проведена работа по формулированию пунктов (утверждений) MPMS, их экспертная оценка, а также последующая корректировка. Затем на выборке первокурсников-иностранцев был проведен анализ психометрических свойств шкалы.

Результаты: Для определения надежности MPMS проверялась ее устойчивость и внутренняя согласованность. Коэффициент корреляции Пирсона между результатами первого и второго тестирования составил 0,87 при р <0,05, а коэффициент альфа Кронбаха — 0,91, что свидетельствует о высокой ретестовой надежности и внутренней согласованности методики. Содержательная валидность MPMS обеспечивалась путем достижения максимального соответствия тестового материала современному пониманию концепта дезадаптации индивида. Конструктная валидность MPMS оценивалась сопоставлением показателей шкалы с данными методик, ориентированных на диагностику проблем психологической адаптации.

Вывод: Шкала MPMS в достаточной мере удовлетворяет основным психометрическим требованиям, предъявляемым к психодиагностическим инструментам, и может быть рекомендована к применению на практике. В дальнейшем предполагается провести исследование критериальной валидности предложенной шкалы, используя в качестве объективных критериев валидизации показатели успешности освоения учебного плана иностранными студентами второго года обучения.

Ключевые слова: временные мигранты; психосоциальная адаптация; шкала психосоциальной дезадаптации; психометрические характеристики.

The XXI century is characterized by sharply increased world population mobility. For the last 15 years number of people who left their homeland (voluntarily or by force) in search of better life, has increased by 41%. According to UN statistics, the total number of international migrants in 1990 was 152 million, now we have a number of 244 million people. The percentage of migrants in the world population increased from 2.9% to 3.3% [UN, 2015].

Voluntary or forced migrants are fully exposed to traumatic emotional experience of immigration where maladjustment is often an outcome. Maladjustment is known as loss of life values, important for professional and personal success; failure to meet demands of society, such as coping with problems and social relationships that usually reflects in emotional instability. Thus, due to drastic change in social environment, lifestyle and activities of migrants (as "visitors" or permanent residence seekers), there is a strong need for their psychosocial adaptation. We see migrants’ psychosocial adaptation as a process and result of personal involvement in a new social environment, accepting immigration trauma and forming new social attitudes. We also have to consider that the adaptation process can be complicated by other life traumatic experiences [Essential Psychiatry, 2008; Konstantinov, 2007; Shaygerova, 2001; Soldatova, 2002].

Methods. In review of methods for psychological adaptation treatment, we noticed that international studies mostly use Q-Adjustment Score (QAS), Satisfaction with Life Scale (SWLS), Rosenberg Self-Esteem Scale (SES), Multidimensional Scale of Perceived Social Support (MSPSS), and General Health Questionnaire (GHQ). We would also like to use them in our study and give them a brief description. Q-Adjustment Score (QAS) (R.F. Diamond, 1954) is used for diagnosis of personal adaptation to changing environment within the system of interpersonal relations. QAS scale consists of 101 statements. 42 of them meet the criteria of social and psychological personal adaptation such as self-esteem and ability to respect others, openness to activities and relationships, own problems understanding and desire to deal with them, and so on. The following 42 statements meet the criteria of maladjustment (self-rejection and disconnection from others, protective "barriers"; virtual solving of problems; inflexibility of mental processes). There are also 8 neutral statements and 9 control statements (lie scale). As a measuring instrument, the present scale shows high differential ability to diagnose the state of adjustment-maladjustment. It represents a model of personal relationship with social environment as well as self-understanding, based on the concept of personal self-development and taking full responsibility process [Rogers, 1954].

Satisfaction with Life Scale (SWLS) (E. Diener, 1985) assesses satisfaction with people’s lives as a whole. Respondents have to mark answers according to the level of their agreement/disagreement with each of the five statements that make up the scale. They have a choice from "strongly agree – (7)" to "strongly disagree – (1)" [Diener, 1985; Pavot, 1993]. SWLS normative data shows good reliability and convergence with other types of assessment scales. Life satisfaction level on SWLS has relative temporal stability (e.g. 0.54 for 4 years). However, the scale showed sufficient sensitivity to potential changes in life satisfaction level in course of treatment. It also demonstrated the discriminatory validity in emotional state assessment. Results obtained using SWLS, correlate with mental health indicators and allow to predict possibility of future improper behavior, such as suicide attempts. As a valid and reliable instrument of life satisfaction assessment, SWLS can be used within a wide range of age groups and helps saving resources and time for the interview. SWLS scale is recommended as an addition to psychometric tests focused on psychopathology or emotional state of respondents.

Rosenberg Self-Esteem Scale (SES) (M. Rosenberg, 1989) measures level of self-esteem of respondents as a combination of positive or negative self believes often referred to as self-esteem or global self-esteem. Self-esteem is one of the key components of "self-concept", along with self-efficacy and self-identity. Self-esteem affects social behavior and is associated with anxiety and depression [Rosenberg, 1989]. SES was created as a uni-dimensional scale, though factor analysis revealed two independent factors: self-confidence and self-depreciation. Self-confidence can be present without self-depreciation as well as along with it (protective function).

SES includes five positive and five negative statements about self-esteem. The respondent has to evaluate them on a 4-point Likert scale. The scale includes answers: 3 (strongly agree), 2 (disagree), 1 (do not agree) and 0 (strongly disagree) for statements number 1, 2, 4, 6, 7. Negative statements 3, 5, 8, 9, 10 have to be evaluated in reverse order. Global self-esteem index (self-esteem level) is equal to the sum of points. The questionnaire shows high reliability, internal consistency and constructs validity (retest correlation coefficient for different samples in the range of 0.82 to 0.88; Cronbach's alpha – from 0.77 to 0.88) [Baumeister, 2003]. Indicators assess depressed mood, anxiety and psychosomatic symptoms, communication activity, leadership, sense of interpersonal safety. During half-century history of Rosenberg scale (1965 – first SES version presentation) it was translated into 53 different languages and adapted in many countries. It is widely used for sociological, psychological and cross-cultural studies of all categories of respondents, starting from age 15.

Multidimensional Scale of Perceived Social Support (MSPSS) (G. Zimet et al., 1988) measures respondent’s perception of how much he or she receives outside social support and has been tested on people from different age groups and cultural backgrounds and found to be a reliable and valid instrument. MSPSS consists of three sub-scales: Family, Friends, and Significant Others. Social support acts as a buffer for psychological distress, therefore its absence could lead to a relapse of depression, emotional stress, and other adverse effects on mental health [Zimet, 1988].

MSPSS comprises 12 statements, ranked by a seven-point Likert scale from 1 (strongly disagree) to 7 (strongly agree). The questionnaire is divided into three subscale "Family Support" (statements 3, 4, 8, 11), "Friends Support" (statements 6, 7, 9, 12) and "Support of Significant Others" (statements 1, 2, 5, 10). To calculate the total score on the subscales, we have to sum up respondent’s answers within each subscale, and the result will show the level of social support obtained from each source. Results for all 12 statements are added together to obtain a global index of perceived social support. Measurement of each factor includes elements designed to assess the support functions (e.g. statement 4 "I get necessary emotional support from my family"), as well as perceived availability of support (e.g. statement 11 "My family is willing to help me in making decisions").

Since its first publication, MSPSS has been translated into 23 languages and has been tested on samples with different age groups and cultural traditions. MSPSS shows good internal consistency (Cronbach's alpha from 0.85 to 0.91), test-retest reliability (correlation coefficient from 0.72 to 0.85), and construct validity (significant correlations between the subscales MSPSS and HSCL), as well as stable factor structure. The three-factor MSPSS model was also successfully used on a sample of inpatient adolescents with diagnoses of behavioral disorders and maladjustment [Kazarian, 1991].

General Health Questionnaire (GHQ) (D.P. Goldberg, P. Williams, 1988) is used to assess general mental health condition of the respondents. GHQ helps to determine the risk of psychiatric disorders; assesses psychological well-being and emotional stability. The present questionnaire is used to evaluate the state of respondent within the concept of psychological distress. [Goldberg, 1988].

The questionnaire has five versions (GHQ-60, GHQ-30, GHQ-28, GHQ-20, GHQ-12), which differ in volume and consist of 60, 30, 28, 20 and 12 statements. GHQ-12 is one-dimensional screening tool, used to detect mental disorders providing psychological assistance and primary care. GHQ-28 is a multidimensional screening tool, used to consider mental health as part of more general construct – "quality of life" and has four subscales: somatic symptoms, anxiety and insomnia, social dysfunction and severe depression. GHQ-60 is a basic version, used for more intensive hospital study. GHQ-12 version gained the most popularity because of its conciseness. The reported Cronbach alpha coefficient for the GHQ is a range of 0.82 to 0.86. The questionnaire has been translated into 38 languages and is recommended for use in different circumstances and cultures. When correlated with the global quality of life scale, the GHQ showed negative correlation. This demonstrates the inverse relationship with an increase in distress leading to a decrease in quality of life.

GHQ includes both positive and negative statements, pointing out mental health level or state of distress of the respondent. The structure of all the questions is always the same, regardless of version. The respondent is asked to evaluate the changes in his/her mood, feelings and behavior for the past four weeks. Respondent has to choose from 0 – "not at all" to 3 – "much more often than usual." All versions of this questionnaire are used in clinical practice to measure the degree of distress. They show high validity and reliability for different age, gender and professional groups [Hardy, 1999].

Data analysis. As we can see from the analysis of listed instruments, we still do not have a valid psycho-diagnostic instrument reflecting specificity of psychosocial adaptation of migrants. It gives us a possibility to create a diagnostic method for the study of migrants’ psychosocial adaptation problems, taking into account possible previous traumatic experience as well as trauma of migration.

The first stage of the pilot study of psychosocial maladjustment scale for migrants comprised literature review. As a theoretical framework for our study we chose theory of cognitive adaptation [Taylor, 1983], transactional model of adaptation to stress [Lazarus, 1984] and cognitive-behavioral model of coping behavior [Ababkov, 2004]. Methodological basis for creation of Migrants Psychosocial Maladjustment Scale (MPMS) was diagnostics and treatment of psychosocial distress developed and described by American Psychiatric Association [DSM-V, 2013].

The second stage of the pilot study was dedicated to formulation of MPMS statements, their revision and adjustment. Then, we analyzed the psychometric properties of the scale, using a sample of 115 first-year international students (86 boys, 29 girls; M = 21.6; SD = 2.03), studying in Universities of Ukraine. The pilot study involved temporary migrants from Afghanistan (3.5%), Egypt (2.8%), Iraq (19.6%), Iran (12.3%), Cameroon (17.2%), Libya (4.9%), Nigeria (27.7%), Sudan (9.9%), and Tunisia (2.1%).

Two months later, 79 of these students (67 boys, 12 girls; M 21.9; SD = 2.02) were re-interviewed to verify the test-retest reliability of the tested instrument. This time, it was students from Iraq (22.4%), Iran (13.7%), Cameroon (19.3%), Libya (7.1%), Nigeria (31.2%), and Sudan (6.3%).

Results. The present psychological diagnostic tool allows you to estimate the degree of psychosocial maladjustment of migrants. MPMS scale is suitable for work with both genders groups, starting from age 18. The twenty-five items of the MPMS and a brief screener on a wide range of mental health outcomes are presented in the Appendix.

Respondents have to choose their answers on a 5-point Likert scale, ranging from (never) to 4 (always) for statements 2, 3, 6, 8, 9, 11 – 25. Positive statements (1, 4, 5, 7, and 10) are ranged in reverse order.

Index of psychosocial maladjustment obtained as a total score divided by 100, ranges from 0 to 1 as follows:

0.00 – 0.49 — normal (adaptation);

0.50 – 0.66 — slight maladjustment, situational or neurotic genesis;

0.67 – 0.82 — moderate maladjustment;

0.83 – 1.00 — severe maladjustment.

MPMS can be used in groups or individually; form-filling time is not limited.

In order to prove efficiency of a new psycho-diagnostic instrument, we studied psychometric characteristics of the scale; tested stability and internal consistency to determine the reliability of MPMS. Pearson correlation coefficient between the results of first and second test was 0.87, p < 0.05, and Cronbach's alpha coefficient – 0.91, that indicates a high test-retest reliability and internal consistency of the scale.

MPMS content validity was provided by maximum conformity of test material content to the concept of individual’s maladjustment. MPMS construct validity was assessed by comparing the scale with instruments dealing with psychological adaptation problems: QAS, SWLS, SES, MSPSS, and GHQ. Correlation coefficients (-0.56; -0.43; -0.18; -0.22; -0.47; p < 0.01) indicate statistical dependence between MPMS diagnostic indicators and listed instruments.

Migrants Psychosocial Maladjustment Scale (MPMS) sufficiently meets basic psychometric requirements for psycho-diagnostic instruments, and can be recommended for use in practice. We also plan to study criterion validity of the scale, using second year migrants-students’ school successes as an objective validation criteria.

References:

1. Ababkov V.A. Adaptatsiya k stressu. Osnovyi teorii, diagnostiki, terapii / V.A. Ababkov, M. Perre. – Sankt Petersburg: Rech, 2004. – 166 p.

2. Baumeister R.F. Does high self-esteem cause better performance, interpersonal success, happiness, or healthier lifestyles? / R.F. Baumeister, J.D. Campbell, J.I. Krueger, K.D. Vohs // Psychological Science in the Public Interest. – 2003. – №4. – Р. 1 – 44.

3. Diagnostic and statistical manual of mental disorders: DSM-V / eds. D.J. Kupfer, D.A. Regier, S.K. Schultz et al. – 5th ed. – Arlington, VA: American Psychiatric Publishing, 2013. – 947 р.

4. Diener E. The satisfaction with life scale / E. Diener, R.A. Emmons, R.J. Larsen, S. Griffin // Journal of Personality Assessment. – 1985. – №49 (1). – Р. 71 – 75.

5. Essential Psychiatry / eds. R.M. Murray, K.S. Kendler, P. McGuffin et al. – 4th ed. – Cambridge: University Press, 2008. – 735 р.

6. Goldberg D.P. A user's guide to the General Health Questionnaire / D.P. Goldberg, P. Williams. – Windsor, Berks.: NFER-Nelson, 1988. – 129 р.

7. Hardy G.E. Validation of the General Health Questionnaire-12: Using a sample of employees from England’s health care services / G.E. Hardy, D.A. Shapiro, C.E. Haynes, J.E. Rick // Psychological Assessment. – 1999. – №11. – Р. 159 – 165.

8. Kazarian S.S. Dimensions of support in the MSPSS: Factorial structure, reliability, and theoretical implications / S.S. Kazarian, S.B. McCabe // Journal of Community Psychology. – 1991. – №19. – Р. 150 – 160.

9. Konstantinov V.V. Social'no-psihologicheskie harakteristiki adaptacii migrantov v sovremennyh usloviyah / V.V. Konstantinov. – Penza: Izd-vo PGPU im. V.G. Belinskogo, 2007. – 187 р.

10. Lazarus R.S. Stress, appraisal, and coping / R.S. Lazarus, S. Folkman. – New York, NY: Springer Publishing Company, 1984. – 465 р.

11. Pavot W.G. Review of the Satisfaction with Life Scale / W.G. Pavot, E. Diener // Psychological Assessment. – 1993. – №5. – Р. 164 – 172.

12. Psihologicheskaya pomosch migrantam: travma, smena kulturyi, krizis identichnosti / Pod red. G.U. Soldatovoy. – Мoskva: Smyisl, 2002. – 479 p.

13. Rogers C.R. Psychotherapy and personality change: Co-ordinated research studies in the client-centered approach / C.R. Rogers, R.F. Dymond, eds. – Chicago, IL: The University of Chicago Press, 1954. – 447 р.

14. Rosenberg M. Society and the adolescent self-image. Revised edition / M. Rosenberg. – Middletown, CT: Wesleyan University Press, 1989. – 370 р.

15. Shaygerova L.A. Krizis identichnosti v situatsii vyinuzhdennoy migratsii / L.A. Shaygerova // Psihologi o migrantah i migratsii v Rossii : Inform.-analitich. byulleten ROKK. – 2001. – №2. – P. 132 – 151.

16. Taylor S.E. Adjustment to threatening events: A theory of cognitive adaptation / S.E. Taylor // American Psychologist. – 1983. – №38. – Р. 1161 – 1173.

17. United Nations, Department of Economic and Social Affairs, Population Division (2015). Trends in International Migrant Stock: The 2015 revision (United Nations database, POP/DB/MIG/Stock/Rev.2015).

18. Zimet G.D. The Multidimensional Scale of Perceived Social Support / G.D. Zimet, N.W. Dahlem, S.G. Zimet, G.K. Farley // Journal of Personality Assessment. – 1988. – №52. – Р. 30 – 41.

Литература:

1. Абабков В.А. Адаптация к стрессу. Основы теории, диагностики, терапии / В.А. Абабков, М. Перре. – Санкт-Петербург: Речь, 2004. – 166 с.

2. Константинов В.В. Социально-психологические характеристики адаптации мигрантов в современных условиях / В.В. Константинов. – Пенза: Изд-во ПГПУ им. В.Г. Белинского, 2007. – 187 с.

3. Психологическая помощь мигрантам: травма, смена культуры, кризис идентичности / Под ред. Г.У. Солдатовой. – Москва: Смысл, 2002. – 479 с.

4. Шайгерова Л.А. Кризис идентичности в ситуации вынужденной миграции / Л.А. Шайгерова // Психологи о мигрантах и миграции в России : Информ.-аналитич. бюллетень РОКК. – 2001. – №2. – С. 132 – 151.

5. Baumeister R.F. Does high self-esteem cause better performance, interpersonal success, happiness, or healthier lifestyles? / R.F. Baumeister, J.D. Campbell, J.I. Krueger, K.D. Vohs // Psychological Science in the Public Interest. – 2003. – №4. – Р. 1 – 44.

6. Diagnostic and statistical manual of mental disorders: DSM-V / eds. D.J. Kupfer, D.A. Regier, S.K. Schultz et al. – 5th ed. – Arlington, VA: American Psychiatric Publishing, 2013. – 947 р.

7. Diener E. The satisfaction with life scale / E. Diener, R.A. Emmons, R.J. Larsen, S. Griffin // Journal of Personality Assessment. – 1985. – №49 (1). – Р. 71 – 75.

8. Essential Psychiatry / eds. R.M. Murray, K.S. Kendler, P. McGuffin et al. – 4th ed. – Cambridge: University Press, 2008. – 735 р.

9. Goldberg D.P. A user's guide to the General Health Questionnaire / D.P. Goldberg, P. Williams. – Windsor, Berks.: NFER-Nelson, 1988. – 129 р.

10. Hardy G.E. Validation of the General Health Questionnaire-12: Using a sample of employees from England’s health care services / G.E. Hardy, D.A. Shapiro, C.E. Haynes, J.E. Rick // Psychological Assessment. – 1999. – №11. – Р. 159 – 165.

11. Kazarian S.S. Dimensions of support in the MSPSS: Factorial structure, reliability, and theoretical implications / S.S. Kazarian, S.B. McCabe // Journal of Community Psychology. – 1991. – №19. – Р. 150 – 160.

12. Lazarus R.S. Stress, appraisal, and coping / R.S. Lazarus, S. Folkman. – New York, NY: Springer Publishing Company, 1984. – 465 р.

13. Pavot W.G. Review of the Satisfaction with Life Scale / W.G. Pavot, E. Diener // Psychological Assessment. – 1993. – №5. – Р. 164 – 172.

14. Rogers C.R. Psychotherapy and personality change: Co-ordinated research studies in the client-centered approach / C.R. Rogers, R.F. Dymond, eds. – Chicago, IL: The University of Chicago Press, 1954. – 447 р.

15. Rosenberg M. Society and the adolescent self-image. Revised edition / M. Rosenberg. – Middletown, CT: Wesleyan University Press, 1989. – 370 р.

16. Taylor S.E. Adjustment to threatening events: A theory of cognitive adaptation / S.E. Taylor // American Psychologist. – 1983. – №38. – Р. 1161 – 1173.

18. Zimet G.D. The Multidimensional Scale of Perceived Social Support / G.D. Zimet, N.W. Dahlem, S.G. Zimet, G.K. Farley // Journal of Personality Assessment. – 1988. – №52. – Р. 30 – 41.

Appendix

Migrants Psychosocial Maladjustment Scale

Male/Female

Name ________________________

Age __________________________

Country_______________________

Occupation____________________

Religion ______________________

The reason of your visit to the country_______________________________

Do you have any physical, emotional or social problems that bother you? Yes/No

What are they? ___________________________________________

During your life, did you experience any traumatic life events? Yes/No

What are they? ____________________________________________

Have you ever received a psychiatric diagnosis or have you ever been treated for psychological problems? Yes/No

Instructions: Read carefully the statements. Circle the answer that best describes your feelings.

1.	It is easy for me to communicate with new people and make friends in this country.	Never	Seldom	Sometimes	Mostly	Always
2.	From the moment of my arrival I feel homesick, miss my friends and relatives and it makes me feel empty, blue, hopeless.	Never	Seldom	Sometimes	Mostly	Always
3.	In this country, I feel more comfortable in my ethnic community, than with local population.	Never	Seldom	Sometimes	Mostly	Always
4.	I feel comfortable surrounded by unknown people (on the street, in transport, in a cafe).	Never	Seldom	Sometimes	Mostly	Always
5.	I easily accept new culture, new traditions and customs.	Never	Seldom	Sometimes	Mostly	Always
6.	I feel growing anxiety when I have to address a stranger or a new colleague.	Never	Seldom	Sometimes	Mostly	Always
7.	In this country, I can easily ask local people for help with my everyday routine, medical or law assistance.	Never	Seldom	Sometimes	Mostly	Always
8.	It is difficult to be socially active in a new country. I think that my self-esteem decreases because of it.	Never	Seldom	Sometimes	Mostly	Always
9.	Since my arrival, my interest in entertainment has diminished. It is hard to get pleasure out of almost all activities. I feel loss of energy.	Never	Seldom	Sometimes	Mostly	Always
10.	If I need social assistance, I may easily find it in special work/school centers or among colleagues/teachers and staff.	Never	Seldom	Sometimes	Mostly	Always
11.	I get involved in activities that have a high potential for painful consequences because I am afraid that if I refuse I might lose my new friends and trust of people in general.	Never	Seldom	Sometimes	Mostly	Always
12.	It is hard to make friends in a new country. I feel shut out and excluded by others.	Never	Seldom	Sometimes	Mostly	Always
13.	When someone addresses me, I have exaggerated startle response because I am afraid that I might not understand what people say.	Never	Seldom	Sometimes	Mostly	Always
14.	I have irritable behavior and angry outbursts, which are difficult to control (with little or no provocation) and I am afraid it might scare people away.	Never	Seldom	Sometimes	Mostly	Always
15.	In this country, I have to share my room and I feel irritated/bored by my roommates.	Never	Seldom	Sometimes	Mostly	Always
16.	I think that being a foreigner, I have to work twice harder and always show my best. It makes me feel stressed and tense all day.	Never	Seldom	Sometimes	Mostly	Always
17.	I am afraid to do something wrong (at my new job/class) and have difficulty concentrating because of worry.	Never	Seldom	Sometimes	Mostly	Always
18.	I am over-excited, over-agitated during my working day/study in a new country and I have sleep disturbance because of it (difficulty falling or staying asleep, restless sleep, nightmares).	Never	Seldom	Sometimes	Mostly	Always
19.	I feel hypervigilance because I am trying to control everything and worry to fail.	Never	Seldom	Sometimes	Mostly	Always
20.	Due to constant stress feeling, I notice significant weight loss/weight gain, decreased/increased appetite.	Never	Seldom	Sometimes	Mostly	Always
21.	I try to avoid external reminders (people, places, conversations, activities, objects, situations) that remind me about my native country, city, friends and relatives.	Never	Seldom	Sometimes	Mostly	Always
22.	It is hard to get used to the change in climate that makes me feel weak, dizzy and faint.	Never	Seldom	Sometimes	Mostly	Always
23.	It is difficult to express my religious feelings in a new country (going to church, execute rituals). It makes me feel lonely, abandoned.	Never	Seldom	Sometimes	Mostly	Always
24.	I have thoughts of death (suicide attempts, specific plan for committing suicide) because I feel like I do not belong here.	Never	Seldom	Sometimes	Mostly	Always
25.	Because of problems related to a new country’s adjustment I smoke, use alcohol, drugs or medication to reduce tensions.	Never	Seldom	Sometimes	Mostly	Always

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