_________ Lauren Terzis, PhD, MSW, Clinical Assistant Professor, School of Social Work, Tulane University, New Orleans, LA. Lauren Beasley, PhD, MS, LMSW, Assistant Professor of Sport Administration, Department of Kinesiology and Health, Georgia State University, Atlanta, GA. Copyright © 2022 Authors, Vol. 22 No. 3 (Fall 2022), 1116-1140, DOI: 10.18060/26266 This work is licensed under a Creative Commons Attribution 4.0 International License. International Student-Athletes' Psychological and Sociocultural Adjustment Experiences: A Qualitative Interpretive Meta-Synthesis Lauren Terzis Lauren Beasley Abstract: International college students face psychosocial adjustment challenges transitioning into college, which may be heightened for international student-athletes (ISAs) who also have to adjust to Division I (DI) athletics. Even so, there are limited articles that synthesize the research on this population. Thus, we sought to fill this gap by examining studies focused on the adjustment experiences of ISAs. A qualitative interpretive meta-synthesis is a method used in social work research to synthesize the findings of qualitative studies (Aguirre & Bolton, 2014). We used qualitative interpretive meta- synthesis to conduct an exhaustive search of the literature, construct themes, and synthesize themes of qualitative research regarding ISAs and their adjustment experiences. We identified 11 articles with three overarching themes: (a) acculturative stress, (b) adjustment to the college experience, and (c) adjustment to athletics in the United States. Findings suggest ISAs experience not only transitional stress related to their identities as a student and as an athlete but also from their acculturation experiences. Thus, we propose ISAs transitioning to college experience a ternary-or three way-role negotiation of student identity, athlete identity, and cultural identity. Social workers employed at Division I institutions and within Division I athletic departments have the opportunity to advocate for the needs of this population. Keywords: Collegiate athletes, student-athletes, international students, NCAA, social work practice, higher education The National Collegiate Athletic Association (NCAA) is the official governing body of university-level sports in the United States. Currently, the organization oversees nearly 500,000 student-athletes who participate in 24 NCAA-sanctioned sports across three divisions: Division I (DI), Division II (DII), and Division III (DIII; NCAA, 2021). Student- athletes experience both the stress of being a college student and the stress of athletic competition, which may put them at an increased risk for negative psychosocial outcomes. For instance, student-athletes experience high rates of depression (Wolanin et al., 2016); illicit substance use (NCAA, 2017); eating disorders (Power et al., 2020); and anxiety (Li et al., 2017), especially in light of the ongoing COVID-19 global pandemic and its impact on college sports (NCAA, 2022b). Thus, the NCAA has recently called for member institutions to address the mental health of their student-athletes, specifically citing licensed social workers as a key member of the student-athlete care team (NCAA Sports Science Institute, 2020). As such, social work literature has begun to explore social work practice with the student-athlete population. There is limited discussion, however, on practice specifically with the international student-athlete population, despite the population’s unique service needs. Therefore, the purpose of this qualitative meta-synthesis was to explore the psychosocial adjustment experiences of international student-athletes at about:blank Terzis & Beasley/INTERNATIONAL STUDENT ATHLETES 1117 DI NCAA member institutions in the United States in order to guide evidence-based social work practice. Literature Review DI sport is the most elite level of college sports and is a pathway to professional athletics for a small number of student-athletes. Students-athletes across all NCAA divisions face stressors of navigating the dual role as a college student and an athlete (Lu et al., 2018; Settles et al., 2002; Wendling et al., 2018); however, DI student-athletes may experience high rates of stress and associated negative consequences due to the pressure of competing in elite athletics (Brown et al., 2021). Interestingly, one study found that depression prevalence was significantly higher for current DI student-athletes compared to those who had recently graduated (Weigand et al., 2013), which further emphasizes the immense amount of mental stress that elite student-athletes experience while playing in college. Additionally, physical risk factors, such as concussions (Kontos et al., 2012; Vargas et al., 2015) and overtraining syndrome (Kreher & Schwartz, 2012) are linked to increased rates of depression. Due to disruption in athletic identity, injury can also increase the risk of a clinical mental health diagnosis (Bader, 2014; Putukian, 2016). Similarly, research has linked transition out of sport to negative mental health outcomes (Jewett et al., 2019; Smith & Hardin, 2018). In light of all the risk factors, student-athletes are at risk for anxiety, depression, drug and alcohol use, and eating disorders (Strohle, 2019). Research has found that more than 30% of student-athletes present with depressive symptoms (Cox et al., 2017), between 30 to 50% of student-athletes have experienced anxiety (Davoren & Hwang, 2014), and almost 60% of female student-athletes are at risk for an eating disorder (National Eating Disorders Association, 2022). Studies have also found that student-athletes participate in high-risk binge-drinking (Druckman et al., 2015; Ford, 2007) and drug use (Gill, 2009; Yusko et al., 2008). Furthermore, these statistics may be underestimated, perhaps due to the population’s overall low help-seeking behaviors (Drew & Matthews, 2019). Indeed, studies have suggested that student-athletes have high rates of mental health stigma (Bird et al., 2018), which acts as a barrier to seeking behavioral health services. International Student-Athletes One subset of the student-athlete population that experiences additional stressors are DI international student-athletes (ISAs). According to the NCAA (2022a), there are over 20,000 ISAs competing at NCAA member institutions from almost 200 different home countries, with the highest percentage of DI athletes recruited from Canada, the United Kingdom, Germany, Australia, and Spain (NCAA, 2022a). In DI sport specifically, ISAs make up approximately 12.5% of the total student-athlete population competing (NCAA, 2020). For both men’s and women’s DI sports, the majority of ISAs compete in tennis, ice hockey, soccer, and golf; however, the fastest growing sports between 2015 - 2020 for ISAs were men’s football and women’s water polo (NCAA, 2022a). Recruitment of ISAs often happens by word-of-mouth, when athletes hear about opportunities to play in the United States from friends, family members, and fellow athletes who had previously played ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 1118 in the United States university system. They may also be recruited from coaches or talent recruiters in the United States by way of a “talent pipeline,” connected to university coaches from their current coach or by personal research, or even through a sport recruitment service (Pierce et al., 2012). Studies suggest ISAs may face stressors before competing in the United States related to recruitment challenges, such as navigating the visa process (Turick et al., 2020) and differing amateurism rules (Abbey-Pinnegar, 2010). Once in the United States, these student-athletes not only face the stress of competing in elite athletics but also might experience the stressors of adjusting to a new culture (Ridinger & Pastore, 2000). To better understand the ISA experience, Ridinger and Pastore (2000) proposed a model of ISA adjustment that includes: (a) antecedents (e.g., interpersonal relationships), (b) adjustments (e.g., academic, athletic), and (c) outcomes (e.g., satisfaction). In this model, mostly qualitative research has suggested family considerations (Popp et al., 2010), cultural differences (Pierce et al., 2012), and discrimination (Lee & Opio, 2011) may increase the stress on ISAs, which may result in negative psychosocial and adjustment outcomes (Popp et al., 2011). Furthermore, another stressor that may now be impacting high profile ISAs are new name, image, and likeness (NIL) rules. Although NCAA student-athletes can now profit off of their NIL, ISAs cannot as it would conflict with student visa status (McCarthy, 2021). Despite these unique challenges, there are currently no reviews of the literature that explore the adjustment experiences of ISAs, even though research suggests international college students face psychosocial adjustment challenges transitioning into college in the United States (Mesidor & Sly, 2016; Zhang & Goodson, 2011). Systematic reviews (e.g., Brunsting et al., 2018; Zhang & Goodson, 2011) and meta- analyses (e.g., Bender et al., 2019) have focused on the adjustment experiences of international college students. Taken together, the findings of these reviews suggest social support, English language proficiency, and acculturation/acculturative stress all impact the adjustment of international students in the United States. Within student-athlete literature, systematic reviews have examined athletes’ adjustment to transition out of sport. For instance, Park et al. (2013) included 122 studies in their systemic review, of which 32 looked specifically at student-athletes’ transition out of sport. In their analysis of psychosocial outcomes, the study did not separate out findings by NCAA Division level, but 83 studies found transition had negative psychological adjustment outcomes (i.e., identity crisis). However, none of the studies included in the review focused specifically on ISAs in the United States and none considered the adjustment process of the transition into college. Therefore, a review of the psychological and sociocultural transition experiences of ISAs is missing both in the student-athlete literature and the broader college student literature. Social Work in College Sport Practice with athletes is a growing subspeciality of the social work profession (Dean & Rowan, 2014; Moore & Gummelt, 2019; Newman et al., 2021). As the NCAA in 2019 passed legislation that requires all member institutions to provide mental health care to student-athletes (Adelson, 2019), athletic departments have been one of the largest Terzis & Beasley/INTERNATIONAL STUDENT ATHLETES 1119 employers of social workers among sport organizations (Newman et al., 2022). Social workers add a unique perspective to the care of student-athletes. Scholars have specifically pointed to social work’s emphasis on social justice and advocacy (Moore & Gummelt, 2019), the biopsychosocial assessment (Beasley et al., 2022), the case management approach (McHenry et al., 2022), and the interdisciplinary nature of the profession (Newman et al., 2019) as aspects of social work that can add a unique perspective to the care of student-athletes. From a theoretical perspective, although clinical social workers may ground their work from a variety of paradigms (e.g., psychodynamic theory, cognitive behavioral theory, humanist theory, etc; Aron, 2022), social work’s ecological systems perspective distinguishes the social work profession from other behavioral health professions in sport (McHenry et al., 2022). Indeed, social workers in sport work at micro, meso, exo, and macro levels (Newman et al., 2019). As a systems approach to care takes into account the impact of cultural context on one’s well-being at the interpersonal and intrapersonal level, it may be an especially important approach for work with ISAs if they are struggling to adjust to a new social, academic, and athletic culture (Ridinger & Pastore, 2000). In an attempt to understand how social work practitioners in sport are translating theory to practice, a few recent qualitative studies have explored the perspectives of social workers embedded in athletic departments (Beasley et al., 2021, 2022; Newman et al., 2021). Social workers in these studies provided both case management and clinical services to NCAA DI student-athletes, including attention to the stressors of transition into elite collegiate sport. However, results across the studies consistently pointed to the need for increased training and empirical literature to guide evidence-based practice with the student-athlete population, suggesting the need for more empirical work as a foundation to evidence-based practice with the general student-athlete population and with specific subsets of the student-athlete population, such as ISAs. The Current Study The systems perspective that attends to the impact of culture on one’s well-being is a unique perspective social workers can bring to the care of student-athletes (Moore & Gummelt, 2019), specifically in work with ISAs. However, a review of the transition experiences of ISAs that may guide social work practice with this population is missing from the literature. Therefore, we sought to fill this gap by specifically examining studies focused on the adjustment experiences of ISAs. This qualitative interpretive meta-synthesis (QIMS) was guided by one primary research question: What are the psychosocial adjustment experiences of ISAs at DI NCAA member institutions in the United States? Methods A review of the literature found the majority of studies that look specifically at the psychosocial adjustment experiences of ISAs are qualitative in nature; thus, we determined a qualitative interpretive meta-synthesis (QIMS) would be an appropriate methodology to use for this study. QIMS synthesizes qualitative research to gain a deeper understanding of the phenomenon (Aguirre & Bolton, 2014). QIMS focuses on creating a synergy of ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 1120 qualitative findings and is interpretive, as opposed to focusing on the aggregate, which is common in systematic reviews and meta-analyses (Aguirre & Bolton, 2014). Watkins- Kagebein and colleagues (2019) suggest researchers can use QIMS instead of conducting one’s own qualitative study, where sample size may be low, to increase sample size by using previous qualitative research on the topic. Due to the low number of ISAs at our respective institutions, and the ability to increase the sample by using existing findings, we opted to utilize the QIMS approach to provide a deeper understanding of the phenomenon. Aguirre and Bolton (2014) outline the steps for conducting QIMS for social work research, which include: formulation of a research question, sampling of studies to include, theme extraction, and synthesis of themes. Positionality of Authors The two authors were involved in each step of the review process, including constructing the research question, organizing search terms, conducting the search, reviewing abstracts, completing a full-text review, and performing an extraction and synthesis of themes. Below is a synopsis of each author to establish credibility and connect their personal experience to the research. First Author I have a PhD in Social Work and a Master of Social Work. My primary research agenda centers on immigrant experiences in the United States. I was an ISA at a DI mid-major university located in the Midwest competing in a non-revenue earning sport. Therefore, I have had personal experience with the adjustment process as an ISA. I am originally from a Western country and my first language is English, and while there was an adjustment, I do acknowledge that these factors provided an easier transition to college life and athletics in the United States. As a licensed social worker, I am interested in how athletic departments at universities can utilize social workers, particularly with ISAs that may be experiencing difficult adjustment experiences. I have experience in quantitative, qualitative, and mixed-methods research. Second Author I am a licensed master social worker and hold my PhD in sport management. My research centers on the intersection of social work and sport, specifically the professional role of social workers in athletic departments. In my work, I advocate for the hiring of social workers in athletic departments due to the unique systems perspective social workers can bring to the care of student-athletes--a belief I bring into this current project. Additionally, as both a social worker and an instructor for sport management courses where I teach international student-athletes and have seen many struggle in their academic adjustment, I am interested in how social workers and other university stakeholders can better meet the needs of this specific student-athlete population. As a researcher, I have experience in both qualitative and quantitative research. Terzis & Beasley/INTERNATIONAL STUDENT ATHLETES 1121 Sampling We conducted a comprehensive search of 14 scholarly databases commonly used for social work research and sport/athletic-related research to locate appropriate studies. These databases included: Applied Social Service Index and Abstracts, Health and Psychosocial Instruments, SocINDEX, Social Work Abstracts, ERIC, ProQuest Dissertations and Thesis, PubMed, PsychInfo, Conference Papers Index, Google Scholar, SPORTDiscus, Sports Medicine and Education Index, and SCOPUS. Only 10 of these databases yielded results based on our inclusion criteria. Search terms used during this process included: • international student-athlete OR international student OR international athlete OR international collegiate athlete OR student athlete AND • National Collegiate Athletic Association OR NCAA OR college athletics OR DI or Division I OR DI AND • Psychosocial adjustment OR behavior OR experiences OR adjustment OR psychological outcomes OR sociocultural adjustment OR institutional adjustment OR social adjustment OR academic adjustment OR personal adjustment OR emotional adjustment OR acculturated stress OR social support OR English language proficiency OR self-efficacy OR cultural distance OR interpersonal OR athletic adjustment OR transition AND satisfaction OR performance OR academic performance OR athletic performance OR anxiety OR depression OR mental health OR well-being In addition to search terms, the inclusion criteria were that studies must include (a) ISAs competing at the DI level in the United States and (b) variables related to psychosocial adjustment and experiences of the ISA. From the initial search, we identified 200 articles and dissertations that met the search criteria. However, this included quantitative, qualitative, and mixed-methods studies. When reviewing abstracts of the articles and dissertations further, those that used strictly quantitative methodology were eliminated from the review. There were 81 articles that were moved to the full text review phase. The two authors reviewed the articles for further information on the sample and methods. We included only qualitative articles that consisted of ISAs and their adjustment experiences for theme extraction. A final 11 articles were identified as meeting the inclusion criteria, consisting of a combined sample of 291 ISAs (see Table 1). We used covidence software for data management and to assist in streamlining the review process between the two researchers. If discrepancies occurred regarding whether to include or exclude an article, the two authors met to discuss and come to a consensus. This included both authors reviewing each article together, and discussing whether it fit the inclusion criteria. There were several instances where this occurred, and a discussion about each article and whether to include it in the analysis took place. Theme Extraction and Synthesis During the data extraction phase, all final studies that met the inclusion criteria were compiled into a table (see Table 1), and the main original themes, sample size, ISA country of origin, and sport from each study were extracted and recorded. Constructing Table 1 ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 1122 enabled us to visualize all original themes and engage in qualitative synthesis. The data synthesis phase included both researchers engaging in reviewing and organizing the textual data that were included in the 11 articles. We looked for similarities among concepts and original themes among all studies, and noted where there were common themes, even though there were different terms used across studies and authors (Aguirre & Bolton, 2014). This included translating each study into one another, while also ensuring that the integrity of each study was not compromised during the synthesis phase (Aguirre & Bolton, 2014). Translation refers to comparing concepts and themes in an account (such as each individual study), and how they interact with one another, while also considering the concepts and themes of other accounts (Noblit & Hare as cited by Aguirre & Bolton, 2014). Once original themes were compared and grouped, we discussed the new overarching themes that were constructed for our QIMS. We followed a similar process in identifying sub-themes that fell under each of our new overarching themes. We chose an interpretive synthesis approach to managing the textual data over an aggregate approach as the goal was to focus on the conceptual and theoretical development (Aguirre & Bolton, 2014). Coming to a synergistic understanding of the themes presented in the articles allowed us to delve into a deeper understanding of the phenomenon and experience of ISAs and their adjustment experiences. To ensure trustworthiness when conducting QIMS, it is imperative to use participant quotes from the original studies so their descriptions and experiences are not lost in the synthesis (Aguirre & Bolton, 2014). Direct quotes from participants are used to support overarching themes and subthemes and are included in the results section of this paper. Table 1. Studies Included in QIMS and Original Themes (n = 11) Source Sample Size ISA Country of Origin Sport Original Themes Extracted Bentzinger (2016) 7 North America, South America, northwestern Europe, western Europe, Asia, Africa Soccer, individual sport (not disclosed) • Opportunity • Process • Adjustment Garret et al. (2020) 11 (8 DI, 2 DII, 1 DIII) England Golf, soccer, track & field, basketball, tennis, squash • Migrating • Influencing factors in athletic development in the U.S. Hong (2018) 9 Germany, China, Japan, the Netherlands, Malaysia, Columbia Rowing, tennis, soccer, field hockey, fencing, swimming, diving • Motivations • Recruitment process • Adjustment & integration • Development of ISAs • Areas of improvement from participants’ perspectives Jean-Noel (2020) 8 (3 DI, 5 DII) Argentina, Belgium, China, England, France, Sweden, Turkmenistan Basketball, track & field, football, tennis • Professional-like atmosphere • ISA adjustment to U.S. culture • Time needed for adjustment • Importance of relationships • Influence of host community’s effort & attitude about acculturation laid • Microaggressions • Availability & helpfulness of academic & international support services Terzis & Beasley/INTERNATIONAL STUDENT ATHLETES 1123 Source Sample Size ISA Country of Origin Sport Original Themes Extracted Kontaxakis (2011) 6 Greece, France, Russia Basketball, track & field, tennis • U.S. vs. home country education system • Factors that influence decision making • Steps to transition • Challenges • Opportunities after graduation Lee & Opio (2011) 16 Kenya, Nigeria, South Africa, Burundi, Uganda, Zambia, Morocco Cross country running, track & field, swimming, basketball • Burden of ignorance • Negative stereotypes (neo-racism) • Discrimination Lopes (2015) 15 Poland, Croatia, Brazil, Italy, Saudi Arabia, Slovakia, Germany, Malaysia, China Cross country running, volleyball, golf, soccer, swimming • International dislocation among young students • Acculturation & integration on campus • Academic challenges • Cultural shock • Plans after graduation Pierce et al. (2012) 192 57 countries represented (top countries: Canada, England, Puerto Rico) Team & individual sports • Homesickness • Adjustment to the U.S. culture • Strong support system from teammates & coaches, friends & family from home country Popp et al. (2010) 13 Australia, Brazil, Canada, Congo, England, Romania, Serbia, Slovakia, Spain Basketball, diving, golf, softball, tennis, volleyball • Personal dimension • Sense of adventure & previous international travel experience • Interpersonal dimension • Perceptual dimension • Family influence Rankine (2014) 11 Jamaica Track & field • Acculturation adjustment • Success from guidance & support of other Jamaicans • Failure/difficulty due to racial acts/discriminations Veselinovic (2020) 3 Italy, Greece, Israel Golf, rowing, track & field • Academic adjustment • Personal-emotional adjustment • Athletic adjustment • Social adjustment • Institutional attachment Results Three overarching themes were constructed with 10 subthemes: 1) acculturative stress: a) discrimination/racism, b) homesickness, and c) culture; 2) adjustment to the college experience: a) social and b) academic; and 3) adjustment to athletics: a) relationships with coaches and staff, b) relationships with teammates, c) training. Theme 1: Acculturative Stress New college students experience acculturative stress due to being away from their home and family for the first time, experiencing newfound independence, and recognizing increases in responsibility, which is particularly exacerbated for international students (Sullivan & Kashubeck-West, 2015). In our synthesis of themes from the qualitative ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 1124 studies, we noted several compounding stressors that added to the ISA’s experience with adjustment to their time in the United States. Discrimination and Racism Articles explicitly discussed themes related to the discrimination, racism, and negative stereotypes ISAs experienced once in the United States (Jean-Noel, 2020; Lee & Opio, 2011; Rankine, 2014). ISAs experienced discrimination from other students, their professors, and their athletic coaches (Rankine, 2014). An African student-athlete discussed the challenges and barriers experienced and how negative stereotypes and racism were everyday occurrences for them in the United States (Lee & Opio, 2011). As one athlete commented, “A lot of people here have a very limited knowledge about Africa. Most of what they know is from the National Geographic channel and those late TV infomercials about starving kids in Africa with lots of flies around them” (Lee & Opio, 2011, p. 638). Experiences of racism and discrimination were particularly prevalent in interviews that were conducted with ISAs who identified as Black. A Jamaican student-athlete described how they felt they were racially discriminated against because of the color of their skin and felt people “looked down on you, like you’re less than them” (Rankine, 2014, p. 98) at their college. The Jamaican student-athlete also shared an experience they perceived as “racist” (Rankine, 2014, p. 98) where White students were not stopped to ask for their ID on campus, but Black students, such as themselves, were stopped. Although there were participants who experienced overt acts of racism, there were ISAs who reported incidences of microaggressions, which are considered not as overt as racism yet still have devastating impacts on the student experiences (Jean-Noel, 2020). After receiving All-American status, an ISA reported a U.S. native teammate stated, “That's funny that you are an All-American and you're not even American” (Jean-Noel, 2020, p. 75). Feelings of jealousy that ISAs had better scholarship offers was discussed as potential motivation for the comment. Homesickness Being away from one’s home country and family and not being able to travel home as much as one would like was also a prominent subtheme throughout the original studies. Participants discussed ways they kept in touch with their family and friends from home, such as using phone calls, the internet, and Skype video conferencing (Bentzinger, 2016). However, time zone changes between countries often made it hard to call and connect with family and friends whenever they wanted (Bentzinger, 2016). The difficulty in connecting led to feelings of isolation and homesickness among ISAs. One ISA discussed their adjustment experience to being away from home: “You feel lonely and you just want to go back, but as time goes by, you meet new people, you kind of get a new family, and you adjust to the new environment” (Kontaxakis, 2011, p. 105). Although these feelings may be similar to that of any athlete transitioning to college, the lack of ease in communication with family (i.e., time zones) and the inability to take quick trips home confounded these Terzis & Beasley/INTERNATIONAL STUDENT ATHLETES 1125 issues. Additionally, due to the busy schedule of student-athletes (academics, practice, travel, etc.) during their athletic season, often being busy was found to be helpful in alleviating some homesickness. One ISA stated there was so much going on during the season that “I didn’t have time to think about how much I miss home and stuff” (Veselinovic, 2020, p. 94). However, feelings changed once the off-season started, and “I had more time to myself and then suddenly I’m like, oh I would want to go home now” (Veselinovic, 2020, p. 94). Culture Another adjustment experience that was constructed was the intense cultural shock ISAs experienced when they moved to the United States. This shock can lead to negative outcomes that students may face during the acculturation phase. Cultural shocks international students experienced and discussed in the studies included: language, food, weather, and the need to convert distances from the metric to the U.S. customary system. Students-athletes across the studies discussed the difficulties and stress associated with the language barrier between their native language and having to attend an English- speaking university in the United States (Hong, 2018; Popp et al., 2010). The language barrier appeared to be more prominent and of issue in the classroom as opposed to the sporting environment. For example, ISAs discussed having to “spend more time on readings and writings” (Hong, 2018, p. 113) of their assignments due to English not being their primary language. Spending additional time on understanding class content and assignments that were impeded by the language barrier was a challenge due to ISAs’ competing interests, such as going to practice and traveling for competitions and meets. University classes place a heavy emphasis on class participation, and one student found her GPA suffering due to the language barrier: Like in my first semester, I didn’t really speak in class or anything. Because I didn’t want anybody to be like, “Can you please repeat that?” You know, so I just didn’t speak; so that first semester, I remember we had to like go to our professors’ office hours; they’d always say you have to participate—20% of the grade is participation. I just did not speak, so . . . it did, ’cause that’s my lowest GPA ever. (Rankine, 2014, p. 100) Conversely, there were some ISAs who came from English-speaking countries or had previous experience speaking English who tended to have an easier adjustment experience to college life in the United States compared to their non-English speaking peers (Jean-Noel, 2020). Another important part of one’s culture is food and cuisine, and ISAs expressed difficulties in adapting to not only the different cuisine in the United States but also to the food at their college’s dining center. An ISA reported eating only pasta and cereal for the entire year due to limited food choices (Popp et al., 2010). Further, Lopes (2015) found ISAs had troubles with the availability of healthy food provided at the dining center. Another ISA discussed the food at the college: “It’s unhealthy; they always fry everything with bad oil, something like that. I would like to eat something light and healthy and I can ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 1126 choose only between pizza and burger, or burrito” (Lopes, 2015, p. 60). Another student who was a native of an African country reported being chronically sick due to the different foods and indicated there was “a lot more fast food” (Bentzinger, 2016, p. 98) she had to consume at the campus cafeteria, which impacted her ability to attend practice and compete. Depending on the location of the university in the United States, weather and climate can be a major adjustment for international students (Popp et al., 2010). In particular, harsh winters in some locations, such as the Midwest, meant some ISAs were struggling to adjust to the differences in weather from their home country (Bentzinger, 2016, p. 81). ISAs reported not being prepared for the intensity of the winter weather and it taking a while to get used to the new climate. Another ISA reported not being prepared for the weather differences and they “didn’t have enough warm clothes.” Thankfully, other teammates were able to help by providing the ISA with extra jackets to get through the winter (Bentzinger, 2016, p. 125). The United States is unique in that it is one of the remaining countries to continue to use the imperial system of measurement (now known as the U.S. customary system) as opposed to the metric system. ISAs reported needing to get used to this difference and had trouble initially understanding workouts, distances for practice, and gauging performance based on the different systems of measurement in the United States compared to their home country (Bentzinger, 2016). Further, ISAs also had to adapt to the different terminology used in the United States with their specific sport (Jean-Noel, 2020). An ISA shared that he “did not understand the workouts his coaches prepared during practice, and he was confused if he was performing well because of the different measuring system in the United States versus the metric system used in his native country” (Bentzinger, 2016, p. 143). Theme 2: Adjustment to the College Experience Adjusting to the college experience can be an overwhelming experience for students, and ISAs need to navigate both adjusting to the a) social and the b) academic experience, on top of also participating in athletics. ISAs also shared that the international student office on campus was a resource in their college adjustment experience. Social Adjustment Experiences Student-athletes are often at an advantage socially as they automatically become teammates, roommates, and travel together for competitions throughout the semester (Lopes, 2015). Being part of a social group immediately via the team and athletics program can be beneficial to the ISA’s adjustment to their new life in the United States (Lopes, 2015; Popp et al., 2010). An ISA discussed the benefits of being on a team and having the built-in support system: It was actually really great to have a team because this is such a big school. It’s harder to make friends . . . the fact that I had the team that I could go straight into they had to take care of me . . . especially being with the Americans, talking with them made me a better English speaker. (Bentzinger, 2016, p. 90) Terzis & Beasley/INTERNATIONAL STUDENT ATHLETES 1127 However, not all ISAs found they had an automatic membership to a social group and found it harder to adjust, particularly if their native language was not English: I didn’t know how much people like accents here. I would have, maybe, involved myself a little bit more. Because my first semester, I kept to myself. I didn’t want to talk to anyone. It was like don’t approach me, I don’t want to talk. (Bentzinger, 2016, p. 72) Having a strong support system and social connections with teammates was found to decrease the acculturative stress for ISAs, whereas having a poor connection to teammates increased their stress (Jean-Noel, 2020). ISAs also reported they often relied on other ISAs (from either the same team or other teams) who were able to give them advice on the “transition” (Popp et al., 2010, p. 174) from their home country to college life in the United States (Rankine, 2014). As one Jamaican athlete said, “Having other Jamaicans here before, so when I was a freshman, we had a senior on the team at the time from Jamaica, and I feel like there’s kinda of a community where once you’re international people, like all of the internationals who were here before you, they like look out for you” (Rankine, 2014, p. 94). Some ISAs mentioned becoming friends and making connections with other students on campus who were not athletes was also beneficial in their adjustment experience, particularly if they shared a similar culture: I met my first friend when I was a freshman, and we were both in the same class. . . and after I met her, I came to her a lot, and we did spend time together, hang out, and go to some Chinese restaurant, and then I know I got to know more Chinese students . . . It was pretty . . . it was . . . yeah, I would say it was a . . . kind of a turning point for me ‘cause, finally, I know someone that I feel comfortable staying with. (Jean-Noel, 2020, p. 70) Academic Adjustment Experiences A large part of the adjustment experience also has to do with how the ISA can successfully engage in the academic portion of their college experience in the United States. On the surface, universities and athletic departments emphasize the importance of being successful in both athletics and academics, such that individuals should be able to manage the balance between both. However, in addition to sport-related activities, which the NCAA (2020b) estimates is on average 34 hours a week for DI-athletes despite the 20- hour rule, student-athletes also balance attending a full course schedule and maintaining a healthy social life; thus, ISAs are tasked with using their time management skills. As one ISA stated: I feel like the main thing that was hard was just time management. Especially with the sports, and practice, and traveling, there’s a lot going on and you need to be very diligent about what you need to do and give it the time. Because we travel usually during the week, so you need to work ahead for next week and already do those assignments, so that when you’re at the tournament you don’t have to think ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 1128 about it. It’s just getting into a system and knowing what you need to do. Just like knowing how much time to dedicate to everything. (Veselinovic, 2020, p. 102) In relation to the cultural and language barrier, ISAs reported needing to spend more time on assignments, readings, and in the classroom due to the language barrier (Hong, 2018; Veselinovic, 2020). This meant spending more time than their U.S.-born peers when it came to preparing and studying for class: “You have to listen to what they say, then look at the screen, and the slides. And then you need to also take notes, all at the same time in another language that you are not comfortable with” (Veselinovic, 2020, p. 83). In the studies reviewed, ISAs felt relatively supported in their academics due to the support services available to help student-athletes at their university. This included professors who were helpful in adjusting assignments so ISAs could balance athletics and school and having tutors on hand if they were struggling with a course (Jean-Noel, 2020; Rankine, 2014). A resource on campus that helped ISAs adjust to both the social and academic experience included the international student office. The international office on campus provided ISAs with helpful information and support during their time on campus, with participants noting the office’s importance in the adjustment process (Jean-Noel, 2020). The international student office could be helpful for both the social and academic adjustment of ISAs. International offices provide social activities, academic services, student visa concerns, international tax requirements, and a place where ISAs can meet other international students. One ISA stated, “I go a lot to the international student office and sometimes I ask them if they know other people from my country” (Bentzinger, 2016, p. 82). However, there was a small number of students who did not have positive interactions with the international office and did not feel the international office supported ISAs in adjusting to the new culture (Kontaxakis, 2011). One student shared the international office at their school made “international students feel like a minority” and that “they don’t have the experience with international students” (Kontaxakis, 2011, p. 106). Theme 3: Adjustment to Athletics in the United States One of the primary reasons ISAs come to the United States is to take advantage of and participate in college athletics, which is structured unlike anywhere else in the world. Three distinct sub-themes were constructed with respect to the athletic adjustment that ISAs face, their a) relationships with coaches and staff, b) relationships with teammates; and c) their training and development as an athlete. Relationships with Coaches and Staff ISAs tended to view their relationship with their coaches positively, especially when it came to adjusting to life and athletics in the United States. Coaches were usually the first point of contact for the ISA, starting from the recruiting process, to picking them up at the airport once they arrived, and helping the ISA quickly adjust (Hong, 2018). ISAs felt a great deal of support from their coaches and claimed their coaches were not only concerned Terzis & Beasley/INTERNATIONAL STUDENT ATHLETES 1129 with their athletic well-being but also their personal well-being (Popp et al., 2010). ISAs felt their coaches were always there if they had questions or needed help. One ISA appreciated their coach as their focus was developing athletes as individuals, not just in their sport (Veselinovic, 2020). These positive experiences and relationships with coaches were beneficial to the ISA’s adjustment and were even more helpful if the coach was previously an ISA or spoke the language of the ISA (Jean-Noel, 2020). However, not all ISAs had positive experiences and relationships with their coaches. Some ISAs reported negative experiences and not feeling supported by their coaches, which led to their adjustment experience being more challenging than the experiences of their peers who had positive experiences with their coaches (Jean-Noel, 2020). An ISA claimed, “I did not think that coaches or schools themselves had the mechanisms to support international students with their transition” (Kontaxakis, 2011, p. 63). Other key figures included the athletic academic coordinators and athletic trainers who also played a vital role in ISA’s adjustment (Veselinovic, 2020). An ISA stated her athletic academic coordinator was “amazing” and said, “I don’t think I could figure out my life without her” (Veselinovic, 2020, p. 149). These coordinators helped with regular check- ins, study strategies, time management, and ongoing support. They served as someone else the ISA could talk to and connect with at the university. Relationships With Teammates Relationships with teammates helped ISAs socially adjust and adapt to their new life in the United States, as they allowed ISAs to immediately experience part of a team atmosphere. Spending so much time with teammates led to friendships that often became the ISA’s “primary social circle” (Veselinovic, 2020, p. 129): We are a very tight-knit group and I think that’s why we are one of the best groups within athletics. Other coaches actually want their groups to look more like our group because we’re all friends, not just teammates. I think that being a student- athlete you’re automatically given friends within your team. (Veselinovic, 2020, p. 129) Although having domestic teammates was helpful in the adjustment to college life and athletics, some participants also found being the only ISA on the team meant they struggled to connect with their teammates from the United States; thus, they sought friendships with other international students, which helped reduce acculturative stress (Hong, 2018; Jean- Noel, 2020). An ISA discussed their troubles with being accepted by teammates: “I was the only foreigner on the track team. And being the only foreigner on the team it was hard for the others on the team to accept me, not for me to accept them” (Kontaxakis, 2011, p. 105). Training and Development as an Athlete The U.S. intercollegiate system is unique in that it combines education and athletics and supports students to excel at both. ISAs have to adjust to the culture of the collegiate athletic system in the United States and how different athletics in college is perceived in ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 1130 their home country (Hong, 2018). In the United States, even an individual sport (e.g., swimming, tennis, track and field) is perceived as a team sport, which is different from the nature of individual sports in the ISA’s home country, where they may be focusing on competing for themselves (Jean-Noel, 2020; Veselinovic, 2020): Now it’s not only about me, it’s the team that needs to grow. So it’s my responsibility to give everything to the team and not only to myself. So that was kind of like a mind shift I needed to do. (Veselinovic, 2020, p. 117) In addition, ISAs also found the intensity of training was different in the United States, with higher training volume, more hours spent on strength and conditioning, and a greater overall general competitiveness (Garret et al., 2020; Hong, 2018; Jean-Noel, 2020). ISAs see another draw of the U.S. collegiate system is the abundance of resources for athlete development and the strong links to a professional sports career after college: “The culture in the U.S. [was] the right way for people to improve in sport, to get a degree, play a college sport and then become a professional” (Garret et al., 2020, p. 26), which is unlike the college and sporting experience in any other country. Discussion The purpose of this QIMS was to explore the psychological and sociocultural adjustment experiences of ISAs. Overall, our findings suggest ISAs in this study faced adjustment challenges not only to life as both a student and an athlete but also to United States culture, both generally (i.e., culture shock) and sport-specific (i.e., use of the customary measurement system). These findings provide support for the importance of social work’s systems perspective in service provision for ISAs and offer insights for evidence-based social work practice with this population. There is a large body of work in the sport management and sport sociology literature that explores the experiences of student-athletes, which focuses on the stressors of the dual role of being a student and an athlete (e.g., Coakley, 1990; Steele et al., 2020. For example, Killeya-Jones (2005) found the more integrated the identity of student and athlete, the higher a student-athlete’s well-being, whereas if there is role discrepancy between the identity of student and athlete, student-athletes are less well adjusted. Similarly, Barger and Seward (2018) found when the identities of student and athlete were merged, student- athletes were more likely to be motivated in both school and sport, perhaps leading to both better academic and performance outcomes. Conversely, when student-athletes over- identify as an athlete, they are more likely to experience negative outcomes related both to lower academic achievement in school (Lumpkin, 2017) and depression when transitioning out of sport (Menke & Germany, 2019). Overall, the body of literature consistently points to the importance of identity integration between student and athlete identity. The overarching implication is any professional, including social workers, working with student-athletes needs to be attuned to both roles and understand the identity negotiation that takes place between being a student and an athlete. The experiences of the ISAs in this QIMS suggest similar tensions in this dual role. For example, participants spoke about the importance of time management to balance Terzis & Beasley/INTERNATIONAL STUDENT ATHLETES 1131 academic and athletic demands. Some even mentioned the importance of academic support counselors in making this transition. Therefore, programming and services focused on how to manage the transition into elite collegiate athletics, specifically related to negotiating both the student and athlete identity, may be effective for both international and domestic student-athletes. However, the results of this QIMS also support the need for culturally competent programming as the ISAs in this study also experienced acculturative stress related to discrimination and racism, feeling homesick, and adjusting to cultural factors, such as language, food, weather, and converting to the metric system. Other literature supports the importance of addressing acculturative stress, as such stress in international college students in the United States can lead to negative outcomes, including increased binge drinking (Kim & Cronley, 2020), depression and other mental health concerns (Shadowen et al., 2019), and challenges in academics (Behl et al., 2017). For participants in this study, similar negative impacts of acculturative stress included academic challenges and lower GPAs, illness due to nutritional changes, loneliness, and diminished relationships with teammates, peers, professors, and coaches. However, ISAs in this study also spoke to the benefits of their international status and their status as an athlete. For instance, participants addressed the benefit of having a pre-established social circle with their teammates and immediate support of their coach, which may not be readily available to international students not competing in athletics. Participants especially seemed to lean on other ISAs and the international student center on campus for support. Thus, it is evident that ISAs are influenced by a multitude of factors and relationships that impact their adjustment experiences, both positively and negatively. From a systems perspective, the interpersonal, intrapersonal, organizational, and cultural factors that encompass an individual’s environment all influence well-being (Bronfrenbrenner, 1994). In sport, scholars have acknowledged the importance of understanding care of athletes from a systems perspective (e.g., Araujo & Davids, 2009; Bader & Martin, 2019; Barkley et al., 2018). For example, Barkley and colleagues (2018) suggest that solely individual-focused approaches to athlete care neglects the need to integrate campus-wide services available to student athletes resulting in siloed services and neglects efforts to promote health equity. Further, they argue a systems perspective sensitizes practitioners to the political impact of college sport, which can lead to care interventions such as working with student-athletes to build skills to navigate what the authors term racialized settings. In light of the findings of this current study, this systems approach to care can be an important approach for work with ISAs. For example, considering the legalities of gaining a student visa and the complexities of moving to a new country (i.e., phone plans), coordination of care at the organizational level can help ease stressors of relocation to the United States. At the macro level, for instance, practitioners should consider the added stress ISAs have of navigating the new NIL laws, and the impact of microaggressions and racism many ISAs experience. At the micro and meso levels, feeling a connection, or lack of connection, with teammates and coaching staff can be either positive or detrimental to the ISA, and can impact whether they experience challenges or thrive in the social, athletic, and academic environment. Thus, interventions can be focused on working with ISAs to build skills around positive relationship development, as well as with coaches to promote positive team-building from a culturally competent perspective. Although these are just a ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 1132 few examples, utilizing a systems perspective enables practitioners to gain a better understanding of how to effectively work with ISAs in meeting both their individual adjustment needs, as well as illuminates interventions at the meso, exo, and macro levels that can create a more positive environment. Overall, the findings of this study suggest that ISAs, similar to domestic student- athletes, do experience the stress of the role negotiation between student and athlete; however, they also must negotiate a new culture that impacts both their student and athlete identity. Extending Ridinger and Pastore’s (2000) model of ISA adjustment, the results of this study show the adjustment experiences of ISAs are dependent upon the role negotiation and integration of student, athlete, and cultural identity. Therefore, we suggest ISAs experience ternary-or three way-role negotiation, rather than a dual role negotiation, of student identity, athlete identity, and cultural identity. Practitioners must consider all three of these roles in understanding ISAs’ transition experiences and in providing culturally competent services to support ISAs in their transition to DI athletics. Implications for the Social Work Profession The findings of this QIMS have several implications for social work practice. First, in line with the call for more empirical evidence to guide social work practice within sport contexts (Beasley et al., 2022; Newman et al., 2021), findings offer key insights for providers working with ISAs. Specifically, participants in this study describe adjustment experiences that are comparable to both domestic student-athletes, who struggle being a student and an athlete (Steele et al., 2020), and international college students, who experience varying degrees of acculturative stress (Koo et al., 2021). However, their adjustment as student-athletes is dependent on their acculturation experience, and their adjustment as an international student is dependent on their athletic identity. Social workers and other professionals working with student-athletes need to approach work from this holistic perspective and take a biopsychosocial approach to care, considering the physical, emotional, spiritual, social, mental, and cultural health of student-athletes, a shift from the traditional medical model of care historically persuasive in sport medicine (Waller et al., 2016). Thus, aspects of cultural adjustment, including the impact on both athletics and academics, should be addressed in any programming offered to ISAs focused on their transition into DI athletics. Furthermore, social workers, specifically those working in collegiate athletics, can use this information to advocate for organizational changes that can improve the experiences of ISAs. For example, social workers could advocate for athletic departments to set up a winter clothing bank to prepare ISAs for winter weather and to provide training in the U.S. customary measurement system to ease the adjustment to U.S. sport. Additionally, it seemed the most positive transition experiences occurred when there was integration among student, athlete, and cultural identity, thus preserving important aspects of their home culture. For example, having strong connections with other ISAs and teammates form the United States, having a positive supportive experience with the international student office on campus, and developing relationships with peers in classes who were not athletes all diminished acculturative stress. Therefore, social workers can advocate for and Terzis & Beasley/INTERNATIONAL STUDENT ATHLETES 1133 develop more intentional efforts within athletic departments to maintain cultural connections for ISAs and provide experiences for domestic student-athletes to gain cultural competence in their teammates’ cultural practices, such as celebrating important cultural holidays or providing opportunities for teams to cook specific foods. In these ways, the specific training and perspective social workers bring, with attention to case management and cultural competence, can add to the care of ISAs. Limitations Although this study was able to explore the lived adjustment experiences of ISAs, there were several limitations to note. Despite initially identifying a wide range of appropriate articles (see Table 1), only 11 studies met the inclusion criteria and were included in the synthesis. Bondas and Hall (2007) suggest that the ideal number of studies to include in a qualitative meta-synthesis are between 10 (Sandelowski et al., 1997) and 12 studies (Patterson et al., 2001). In addition, the majority of these studies are considered grey literature because they are graduate theses or dissertations. This points to the lack of qualitative research that exists for ISAs’ adjustment experience in peer review articles. Another limitation is that this study focuses specifically on DI ISAs and does not include an analysis of ISAs who compete at other levels or divisions, such as DII, DIII, National Association of Intercollegiate Athletics, and National Junior College Athletic Association. ISAs are recruited and choose to compete in other divisions due to scholarship opportunities, academic opportunities, more playing time, and better aligned competitive nature of each division for the individual athlete. Thus, these findings are limited in their scope, given the large proportion of ISAs who compete outside of the D1 system may have different adjustment experiences. Due to the large number of quantitative studies identified, future research could include a systematic review of quantitative studies examining ISA’s adjustment experiences. Conclusion Student-athlete transition literature places much attention on the stress of the negotiation between the dual identity of student and athlete. Findings of this QIMS suggest ISAs experience transitional stress related to not only their identities as a student and as an athlete but also from their acculturation experiences. Thus, we suggest ISAs transitioning to DI sport in the United States experience a ternary role negotiation of student identity, athlete identity, and cultural identity. 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