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Open Access

Peer-reviewed

Research Article

Persistent anxiety among high school students: Survey results from the second year of the COVID pandemic

Roles Conceptualization, Data curation, Formal analysis, Writing – original draft

Affiliation Irvington High School, Irvington, New York, United States of America

Roles Conceptualization, Writing – review & editing

Roles Investigation

Roles Formal analysis, Methodology, Writing – review & editing

Affiliation HIV Center for Clinical and Behavioral Studies, NY State Psychiatric Institute and Columbia University, New York, New York, United States of America

Roles Conceptualization, Formal analysis, Methodology, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

ORCID logo

  • Olivia Yin, 
  • Nadia Parikka, 
  • Amy Ma, 
  • Philip Kreniske, 
  • Claude A. Mellins

PLOS

  • Published: September 30, 2022
  • https://doi.org/10.1371/journal.pone.0275292
  • Reader Comments

Table 1

Introduction

National mental health surveys have demonstrated increased stress and depressive symptoms among high-school students during the first year of the COVID-19 pandemic, but objective measures of anxiety after the first year of the pandemic are lacking.

A 25-question survey including demographics, the Generalized Anxiety Disorder-7 scale (GAD-7) a validated self-administered tool to evaluate anxiety severity, and questions on achievement goals and future aspirations was designed by investigators. Over a 2-month period, all students from grade 9–12 in a single high-school (n = 546) were invited to complete an online survey after electronic parental consent and student assent. Bi-variate and chi-square analyses examined demographic differences in anxiety scores and the impact on outcomes; qualitative analyses examined related themes from open-ended questions.

In total, 155/546 (28%) completed the survey. Among students with binary gender classifications, 54/149 (36%) had GAD-7 scores in the moderate or severe anxiety range (scores≥10), with a greater proportion among females than males (47% vs 21%, P<0.001). Compared to students with GAD-7<10, those with ≥ 10 were more likely to strongly agree that the pandemic changed them significantly (51% vs 28%, p = 0.05), made them mature faster (44% vs 16%, p = 0.004), and affected their personal growth negatively (16% vs 6%, p = 0.004). Prominent themes that emerged from open-ended responses on regrets during the pandemic included missing out on school social or sports events, missing out being with friends, and attending family events or vacations.

In this survey of high school students conducted 2 years after the onset of COVID-19 in the United States, 47% of females and 21% of males reported moderate or severe anxiety symptoms as assessed by the GAD-7. Whether heightened anxiety results in functional deficits is still uncertain, but resources for assessment and treatment should be prioritized.

Citation: Yin O, Parikka N, Ma A, Kreniske P, Mellins CA (2022) Persistent anxiety among high school students: Survey results from the second year of the COVID pandemic. PLoS ONE 17(9): e0275292. https://doi.org/10.1371/journal.pone.0275292

Editor: Ravi Shankar Yerragonda Reddy, King Khalid University, SAUDI ARABIA

Received: June 27, 2022; Accepted: September 13, 2022; Published: September 30, 2022

Copyright: © 2022 Yin et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information file.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

The long-term impact of the COVID-19 pandemic on the mental health of adolescents is still under investigation. A meta-analysis of 136 studies from various populations affected by COVID-19 found that at least 15–16% of the general population experienced symptoms of anxiety or depression [ 1 ]. The Adolescent Behaviors and Experiences Survey (ABES) an online survey of a probability-based nationally representative sample of students in grades 9–12 (N = 7,705) collected from January-June of 2021 in the United States, found that 37% of students experienced poor mental health during the pandemic [ 2 ]. During the 12 months before the survey, 44% experienced persistent feelings of sadness or hopelessness, 19.9% had seriously considered attempting suicide, and 9.0% had attempted suicide [ 2 ].

Adolescence is a development stage characterized by profound physiological, psychological and social change that could make them particularly vulnerable to stressful events [ 3 , 4 ]. Although fears of infection, sadness related to loss, and overwhelming uncertainty was experienced by people of all ages, the widespread disruption of education had profound effects on the mental health of children and adolescents [ 5 ]. Remote learning, restrictions placed on social gathering, cancellation or modification of sports or clubs, and in-school activities and events present major challenges for the education and social growth of young people. The disruption of school routines and isolation, loss of support from peers and teachers, not only makes learning difficult but can heighten the anxiety that adolescents already feel about their education and career [ 6 ]. Even before the pandemic, there were reports of increases in anxiety, depression, substance use among adolescents faced with excessive pressures to excel in affluent settings [ 7 ]. Social support from other students and teachers, especially during stressful times, is critical for the social-emotional well-being of adolescents and for sustaining academic engagement and motivation [ 8 – 10 ]. The COVID Experiences Survey, a nationwide survey of 567 adolescents in grades 7–12 performed in 2020, found that adolescents receiving virtual instruction reported more mentally unhealthy days, more persistent symptoms of depression, and a greater likelihood of considering suicide than students in other modes of instruction [ 11 ].

The Adolescent Behaviors and Experiences Survey and COVID Experiences Survey both assessed level of stress, symptoms of depression and consideration of suicide among high school students but did not specifically include an evaluation of anxiety [ 2 , 11 ]. Several smaller published surveys of mental health among adolescent high school students in the United States included assessments of anxiety, although not all of them included validated measures of anxiety or examined the consequences of heightened anxiety [ 12 , 13 ]. In addition, all were performed in 2020, during the first wave of the infection. To our knowledge, few if any studies have examined longer-term consequences of the COVID-19 pandemic on adolescent anxiety using validated tools. The goal of this study was to evaluate the longer-term impact of the COVID-19 pandemic on generalized anxiety in high school students using the General Anxiety Disorder-7 (GAD-7), a validated self-report measure, at the end of 2021. Variations by gender and the impact of anxiety on achievement goals, future aspirations and outlook of students were also explored.

Materials and methods

Study design.

This study was conducted at a single public high school in Westchester County of the State of New York. New York was one of the epicenters during the first wave of the COVID-19 epidemic in the United States with a peak daily infection rate of over 9,000 cases/day in April 2020. In response to the New York State Education Department Executive Order, the high school was closed to in-person learning in March 2020 and transitioned to online classes (remote learning). The school remained closed to in-person learning for the remainder of the academic year. After summer break, the school re-opened with remote learning and provided the option for students to return to hybrid learning on October 7, 2020. Hybrid learning consisted of in-person school for half the week and remote learning for the other half of the week with half the capacity of students in the school at any given time. The school also allowed students to continue with full-time remote learning. This decision was made to balance the benefits of in-person learning with safety guidelines by reducing the total number students in school at any given time. On April 7, 2021, the school transitioned from hybrid learning to 100% in-person learning for the remainder of the academic year but still allowed students the option of remote learning. On September 7, 2021, the school re-opened after summer break to 100% in-person learning for all students without the remote learning option. The decision to transition to in-person learning for all students in September 2021 was based upon the low case rates of COVID and the availability of COVID vaccination. The FDA announced the emergency use authorization of the Pfizer-BioNTech COVID-19 vaccine for individuals 16 years of age and older on December 11, 2020 and for individuals 12 years of age and older on April 9, 2021.

Participants

A total of 521 students were enrolled in the high school, with the following numbers of students in each grade: 142 in 9 th ,130 in 10 th , 120 in 11 th and 128 in 12 th grade. The student body composed of 242 females and 279 males, with the following racial/ethnic distribution: 79% White, 13% Asian, 7% Black/African American, 1% American Indian/Native American. This non-selective public high school is the only high school in town. For context, the racial distribution of Westchester County was 73% White, 7% Asian, 17% Black in the 2019 census, with a median household income (in 2019 dollars) of $96,610 and 49% of the population over 25 years having a bachelor’s degree or higher. In the same period, the median household income in the United States was $68,703 with 22.5% of population age 25 and older having bachelor’s degree or higher.

The Irvington School Board approved the survey instruments and the overall study. All students attending the high school in 9 th -12 th grade were eligible to participate. Participation was voluntary, each survey question was optional, and there were no incentives for completion of survey. All participants completed an electronic parental consent and student assent prior to performing the online survey. A survey link was posted by the science teachers on the science classroom pages for all eligible students to complete on November 24, 2021. Science teachers continued to promote the survey until its closure on January 13, 2022.

Study instruments

The survey was conducted online via Google Forms software (version 2018) in English, and contained 25 questions, 23 of which were multiple choice. Participants took approximately 10–15 minutes to complete the survey. The Generalized Anxiety Disorder-7 scale (GAD-7), a validated 7-item self-administered tool to evaluate anxiety severity, was utilized to measure anxiety [ 14 ]. GAD-7 has been utilized in adolescents and demonstrates an acceptable specificity and sensitivity for detecting clinically significant anxiety symptoms in comparison to the Pediatric Anxiety Rating Scale [ 15 ]. Participants are asked how often they were bothered by each of the following symptoms during the last 2 weeks with a 4-point scale ranging from “not at all” (0 points) to “nearly every day” (3 points): feeling nervous, anxious or on edge; not being able to stop or control worrying; worrying too much about different things; trouble relaxing; being so restless that it is hard to sit still; becoming easily annoyed or irritable; feeling afraid as if something awful might happen. The total score indicates the level of anxious symptoms ranging from minimal/no anxiety (0–4), mild (5–9), moderate (10–14) and severe (≥15).

Demographic data were collected, including current grade (9–12), gender (female, male, transgender man, transgender woman, non-binary, other), race (American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino, Native Hawaiian or other Pacific Islander, other), whether attending school by hybrid or remote learning, and COVID-19 vaccination status (none, partial or full series).

Several questions were developed by the study team through an iterative process that included initial development of question by the student researcher, refinement of wording by all investigators including experts in adolescent development and cognition, and testing for comprehension and clarity through review by 2 additional students. Four questions on whether students had more anxiety upon return to in-person learning in April 2021 (after hybrid or remote learning) or September 2021 (after summer break), and factors associated with the anxiety associated with in-person learning were assessed. Thirteen questions were included to assess importance of relationships, safety, achievements and future aspirations (5-point Likert scale from very important to not important): having friends/socializing; perception by friends; making parents proud; maintaining family relationships; good health (not getting COVID); feeling safe; getting good grades; graduating high school; attending college; becoming famous; having adventure; having money/wealth; and having your own family. One additional question addressed outlook on future (5-point Likert scale from strongly agree to strongly disagree): “I think I will have more opportunities in life than my parents.” Three questions designed by the team assessed the impact of COVID-19 (5-point Likert scale from strongly agree to strongly disagree): “The COVID-19 pandemic has changed me significantly”; “The COVID-19 pandemic has made me mature faster”; Overall, the COVID-19 pandemic has affected my personal growth negatively.”

Two additional open-ended questions were included to allow students to reflect upon opportunities lost and gratitude experienced during COVID-19: “Share one moment that you regret missing out on during the COVID-19 pandemic,” and “Share one moment when you felt grateful during the COVID-19 pandemic”

Data analysis

Quantitative analysis..

Overall frequencies for demographics, GAD-7, and responses to questions on the importance of relationships, safety, achievements and opportunities were examined. Bivariate analyses by demographics characteristics (gender, grade, and learning type) were conducted with each response. Chi-square tests were conducted to determine whether responses differed by gender, grade, learning type, and severity of anxiety. All analyses were performed using SPSS Statistics for Mac, version 28.0 (SPSS Inc, Chicago, Ill, USA).

Qualitative analysis.

The answers to each open-ended question were evaluated for themes. The iterative process took the form of a data analysis spiral such that following data collection, the data was organized, read and notated for emerging ideas, described and classified by thematic codes, assessed and interpreted, and presented in this research report [ 16 ]. Author 1 read all the responses and compiled the data and created preliminary thematic codes. Author 2 reviewed the thematic codes and believed that thematic saturation had been reached. Author 1 then discussed all preliminary codes with all authors who provided additional memos. Representative excerpts for each theme are presented in Table 4 . Data saturation was defined using the grounded theory standpoint by Urquhart, that defined saturation as “the point in coding when you find that no new codes occur in the data. There are mounting instances of the same codes, but no new ones”[ 17 , 18 ].

Among the 546 students enrolled in the high school, 155/546 (28%) completed the survey, including 90 females, 59 males, and 6 students who did not identify as gender binary. Since the number of gender non-binary students was too small to include as a separate group in analyses looking at gender differences, results were presented only for students who self-identified as either female or male (n = 149) ( Table 1 ). The proportion of respondents was greater among females (90/262, 34%) than males (59/284, 21%). The response rates were much lower in 12 th grade (25/137, 18%) than in 9 th grade (61/139, 44%). The students were mostly White (69%), Asian (16%) or multi-racial (9%), predominantly engaged in hybrid learning (86%), and almost all (97%) fully or partially vaccinated against SARS-CoV-2 at the time of survey completion ( Table 1 ).

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Overall, 54/149 (36%) of the students had GAD-7 scores in the range for moderate or severe anxiety (scores≥10), with a greater proportion of the females than males experiencing moderate/severe anxiety (47% vs 21%, X 2 = 21.3984, P<0.001) ( Table 2 ). Among students who answered yes to any of the GAD-7 questions, 3% reported that anxiety made it extremely difficult and 12% reported that anxiety made it very difficult to do their work, take care of things at home, or get along with other people. More females than males (19% vs 7%, p<0.01) reported that anxiety made it very or extremely difficult to do their work, take care of things at home, or get along with other people ( Table 2 ). Severity of anxiety did not differ between students in the lower (9 th and 10 th ) versus the upper (11 th and 12 th ) grades. Severity of anxiety also did not differ between students engaged in hybrid versus remote learning ( Table 2 ).

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More females than males felt anxious returning to in-person school in April 2021 (52% vs 27%; X 2 = 9.3457, p = 0.002) ( Table 1 ). COVID-19 vaccinations were available for individuals 16 years of age or older by December 2020 with emergency use authorization for individuals 12 years of age and older only granted on April 9, 2021. All of the major factors contributing to anxiety measured were more frequently reported in females than males: fear of getting COVID-19 (26% vs 15%), anxiety toward social interactions (20% vs 8%), and schoolwork (10% vs 5%). By September 2021, 51% of females and 44% of males reported feeling less anxious for in-person school than in April 2021. The primary reasons reported for decreased anxiety were the receipt of COVID-19 vaccinations (38%) and normalization of social interactions with in-person school (16%) ( Table 1 ).

Overall, 34% of students strongly agreed that the COVID-19 pandemic “changed me significantly” and 24% strongly agreed that it “made me mature faster” ( Table 3A ). However, only 8% of students strongly agreed that the COVID-19 pandemic “has affected my personal growth negatively.” More females reported that COVID-19 affected their personal growth negatively, but it did not reach statistical significance (11% vs 5%, p = 0.15). In comparison to students with either mild anxiety or no anxiety (GAD-7<10), students with moderate to severe anxiety (GAD-7≥10) were more likely than students with either mild anxiety or no anxiety (GAD-7<10) to strongly agree that the COVID-19 pandemic changed them significantly (51% vs 28%, p = 0.05), made them mature faster (44% vs 16%, p = 0.004), and affected their personal growth negatively (16% vs 6%, p = 0.004) ( Table 3B ).

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We further explored whether moderate/severe anxiety affected students’ outlook on relationships, safety, achievements, aspirations and opportunities. Over half of students reported the following life factors as very important: having friends/socializing (53%), maintaining good health and not getting COVID-19 (53%), getting good grades (62%), graduating high school (82%), and attending college (74%) ( Table 4 ). Females were more likely than males to regard the following factors as very important: money/wealth (28% vs 12%, p<0.01) and having your own family (39% vs 29%, p = 0.02), but did not differ from boys in other reported factors. Students with moderate to severe anxiety (GAD-7≥10) were more likely than students with mild or no anxiety to regard the following as very important: attending college (81% vs 70%, p = 0.04), becoming famous (9% vs 1%, p = 0.04), and having your own family (44% vs 31%, p = 0.01). Only 23% of students reported that they strongly agree with the statement “I will have more opportunities in my life than my parents”, without apparent differences by anxiety status ( Table 4 ).

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In response to “share one moment that you regret missing out on during COVID-19 pandemic,” the following themes emerged, from most common to least common: missing out on school social events and sports; being with friends; family events and vacations, wasted new opportunities that were presented during COVID-19 pandemic, and celebrating milestones like bar mitzvahs, sweet-sixteens and birthdays. In response to “share one moment when you felt grateful during the COVID-19 pandemic,” the following themes emerged, from most common to least common: connecting with friends and family, health and safety, having time for personal development, moments during which there was a sense of return to normalcy, and the decreased stress of remote learning ( Table 5 ). Generally, the noted themes were similar in students with moderate-severe anxiety versus those with mild or no anxiety. However, in comparison to students with mild or no anxiety, more students with moderate-severe anxiety expressed that they regret missing out on being with friends, and less expressed regret for missing out on school-related social events such as the prom, school trips, or sports competitions. Notably, while all the students with moderate-severe anxiety reported missing out on something, 5% of students with either mild or no anxiety reported that they did not miss out on anything during the COVID-19 pandemic. Also, more students with moderate-severe anxiety expressed that they were grateful for health and safety and situations that provided a sense of normalcy.

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In one of the first reports on levels of anxiety in high school students during the second year of the COVID pandemic, this study found that 36% of the students reported moderate or severe anxiety, disproportionately affecting females. Although the GAD-7 is a screener for anxiety and meant to over detect, anxiety scores in this range are considered clinically meaningful and indications for further assessment and/or referral to a mental health professional for more definitive diagnoses. These surveys were completed in late 2021 at a point when over 95% of students had received partial or full vaccinations; therefore, our data suggest that the impact of COVID-19 on the generalized anxiety of high school students may be long-lasting.

Our findings are consistent with several large mental health surveys that included measures of anxiety were conducted on university students in 2020, earlier in the COVID-19 pandemic, and found that females were more likely to report moderate to severe general anxiety then males. The Healthy Minds Survey 2020, one of the largest studies of university students in the United States (N = 36,875), found that 32.2% of students reported moderate to severe anxiety, with a higher proportion in females than males (66.6% vs 28.6% of males) [ 19 ]. Similarly, a survey of over 69,000 university students in France found that females were more likely to report high levels of anxiety than males (30.8% vs 17.1%) [ 20 ].

As noted previously, the largest mental health surveys conducted among high school students in the United States did not specifically include an evaluation of anxiety [ 2 , 11 ], but anxiety was included in two smaller studies. Gazmararian et al. surveyed racial/ethnically and socioeconomically diverse students at 2 semi-rural public high schools in Georgia in 2020 and found that 25% of students were worried about the COVID-19 pandemic and a negative financial impact, with a similar gender difference in girls versus boys (29% vs 16%, p<0.0001) [ 13 ]. The Policy and Communication Evaluation (PACE) Vermont is an online cohort study of 212 adolescents (ages 12–17) and 662 young adults (ages 18–25) that completed questionnaires in the Fall of 2019 and 2020, before and after the onset of the COVID-19 pandemic [ 12 ]. The prevalence of anxiety symptoms measured by the GAD-2 increased from 24.3% to 28.4% among adolescents after COVID-19, similar to the increase from 35.3% to 42.3% observed among young adults [ 12 ].

In our study, 36% of high school students had moderate/severe anxiety by GAD-7, which is slightly higher than the prevalence in aforementioned high school studies, and similar to the prevalence among college students in the Healthy Minds Survey. Female high school students were more likely to report moderate or severe anxiety. Importantly, this study explored potential reasons for anxiety upon return to in-person learning in April 2021, informed by high school students (including lead author) and a greater proportion of females than males endorsed each category: COVID-19 (26% vs 15%), schoolwork (10% vs 5%) and social interactions (20% vs 8%). These data suggest that female high school students had higher anxiety levels not only because of fear of COVID, but also because of more normative stressors pre-COVID, such as school and social pressures. Furthermore, females reported more negative effects of their anxiety compared to boys, with 19% reporting that it is “extremely difficult to do their work, take care of things at home, or get along with other people” as compared to only 9% of males. Notably, severity of anxiety did not appear to differ between students in the lower (9 th and 10 th ) versus the upper (11 th and 12 th ) grades. This was unexpected given higher levels of stress associated with standardized testing and college applications in the upper grades. Severity of anxiety also did not differ between students engaged in hybrid versus remote learning ( Table 2 ). However, since most of the students were engaged in hybrid learning (87%), our power to detect differences was limited. Other investigators found no difference in risk for anxiety among students with remote versus in-person education [ 21 ]; however, the role of hybrid learning has never been adequately assessed.

Students who reported moderate/severe anxiety had very different responses than students with either mild or no anxiety regarding the impact of the COVID-19 pandemic. Students with moderate/severe anxiety were far more likely to strongly agree that the COVID pandemic changed them (51% vs 28%), made them mature faster (44% vs 16%), and affected their personal growth negatively (16% vs 6%). It is possible that COVID-19 had a greater negative impact on these students resulting in higher anxiety levels, or that students with higher anxiety levels before the pandemic were more susceptible to the negative effects of COVID-19. This question cannot be addressed without pre-pandemic data on these students. However, it is interesting that even though students with moderate/severe anxiety perceived a greater negative impact of COVID-19, they did not differ from other students in their hopes and aspirations for the future. In fact, more students with moderate to severe anxiety responded that attending college, becoming famous, and having their own family was very important ( Table 4 ). This may also reflect a greater underlying expectation for success and a desire for safety and security among students with greater anxiety. This is an important area for future study. While students reported being concerned about good health and “not getting COVID-19,” less than half of the students (45%) rated “feeling safe” as very important. While these data may reflect the higher risk tolerance of adolescents in general vs other age groups, the data also suggest that the heightened awareness of safety measures for COVID-19 did not translate into generalized fear affecting other aspects of their lives. Overall, these data suggest that despite the relatively high proportion of students reporting anxiety, the majority did not perceive negative effects and thus appeared to be coping with the stressors of COVID-19.

This study was not designed for formal qualitative research, but there were two open-ended questions on regrets and gratitude. Missing out on school social or sports events was the most common theme, followed by missing out being with friends or attending family events or vacations. Several students also articulated missed opportunities for growth presented by COVID-19 and shared regrets for not accomplishing more with the extra time. Students shared their gratitude mostly for connecting with friends and family and for health and safety. There were also appreciations written for having a time for personal growth, moments during COVID-19 that provided a sense of normalcy, and the decreased stress from school that remote learning offered ( Table 4 ). Based upon exploratory analyses, it appeared that students with moderate-severe anxiety were more likely to regret missing out on being with friends, less likely to regret missing out on school social or sports events, and more likely to be grateful for health and safety. Further work could examine how these constructs may be important for adolescents experiencing moderate-severe anxiety.

There are now several longitudinal studies of change in mental health measures among children and young adults before and during the COVID-19 pandemic [ 22 ]. Several comprehensive studies of college and university students in the United States include data on pre-pandemic mental health, analyses of predictors, and a focus on serious psychiatric and alcohol/drug use outcomes [ 23 , 24 ], but data are lacking for high school students. Stamatis et al found that the disruption due to the pandemic and limited confidence in the government response were the main predictors of depression among college students [ 24 ]. Bountress et al found that COVID-19 worry predicted post-traumatic stress disorder (PTSD), depression and anxiety even after adjusting for pre-pandemic symptom levels [ 23 ]. In addition, housing/food concerns predicted PTSD, anxiety and depression symptoms as well as suicidal ideation, after adjusting for pre-pandemic symptoms in college students [ 23 ]. Comprehensive longitudinal studies are necessary to assess the true impact of COVID on mental health in high school students. In particular, studies should assess whether symptoms are associated with serious clinical outcomes such as suicidal ideation, alcohol and substance misuse and missed milestones such as graduation from high school, admission to college, and employment.

Strengths and limitations

A strength of our study was the use of the well validated and extensively used GAD-7 to measure anxiety symptoms. There were no data on anxiety for the students prior to COVID-19 as a baseline for comparison nor measures of other indicator of mental health such as depression and suicidality. Other limitations of this study include the performance of the survey at a single high school—our sample size was limited and the analyses were performed on a convenience sample. While only 28% of the study body responded to the survey, this response rate was similar to the response rates of other high school surveys performed in the United States [ 12 , 13 , 25 ]. The lack of racial/ethnic diversity in the student population also limits generalizability to other populations of adolescents. We did not include potential risk factors elicited in other studies such as prior psychiatric history, financial hardship, or illness in family in our survey. We were also unable to evaluate the impact of hybrid versus remote learning on anxiety, since very few of our students chose remote learning. Lastly, the survey questions we created were done so because nothing specifically existed for this age group, the newness of COVID, and the need to implement questions quickly; therefore, we did not utilize a formal validation process.

In this survey of high school students performed almost 2 years after the onset of COVID-19 in the United States, a relatively high proportion reported moderate or severe anxiety symptoms as assessed by the GAD-7. Our data suggest that the negative impact of COVID-19 on the anxiety levels of high school students may be long-lasting. Whether the heightened anxiety results in functional deficits is still uncertain, but resources for assessment and treatment should be prioritized.

Supporting information

S1 dataset..

https://doi.org/10.1371/journal.pone.0275292.s001

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  • Research article
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  • Published: 26 October 2019

Stress among university students: factorial structure and measurement invariance of the Italian version of the Effort-Reward Imbalance student questionnaire

  • Igor Portoghese 1 ,
  • Maura Galletta   ORCID: orcid.org/0000-0002-0124-4248 1 ,
  • Fabio Porru 2 ,
  • Alex Burdorf 2 ,
  • Salvatore Sardo 1 ,
  • Ernesto D’Aloja 1 ,
  • Gabriele Finco 1 &
  • Marcello Campagna 1  

BMC Psychology volume  7 , Article number:  68 ( 2019 ) Cite this article

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In the last decade academic stress and its mental health implications amongst university students has become a global topic. The use of valid and theoretically-grounded measures of academic stress in university settings is crucial. The aim of this study was to examine the factorial structure, reliability and measurement invariance of the short student version of the effort-reward imbalance questionnaire (ERI-SQ).

A total of 6448 Italian university students participated in an online cross-sectional survey. The factorial structure was investigated using exploratory factor analysis and confirmatory factor analysis. Finally, the measurement invariance of the ERI-SQ was investigated.

Results from explorative and confirmatory factor analyses showed acceptable fits for the Italian version of the ERI-SQ. A modified version of 12 items showed the best fit to the data confirming the 3-factor model. Moreover, multigroup analyses showed metric invariance across gender and university course (health vs other courses).

Conclusions

In sum, our results suggest that the ERI-SQ is a valid, reliable and robust instrument for the measurement of stress among Italian university students.

Peer Review reports

In the last decade, there has been a growing attention in investigating stress risk factors and well-being consequences among university student’s population [ 1 , 2 ]. Stress and mental health of university students is a crucial public health subject as healthy students will be the healthier workers of the future. Attending university has the potential to become a positive and satisfying experience for students’ life. However, there is empirical evidence that being a student may become a stressful experience [ 1 , 3 , 4 , 5 , 6 ]. Stallman and Hurst [ 2 ] distinguished between eustress, important for student motivation and success at university, and distress, harmful for student’s well-being, as it exposes to a higher risk of psychological (for example, anxiety and burnout), behavioral (for example eating disorders), physical health problems (for example, ulcers, high blood pressure, and headaches), and suicidal ideation [ 7 , 8 , 9 , 10 ]. Furthermore, many scholars found that high stress was linked to reduced academic performance, low grade averages, and low rates of graduation and higher dropout [ 11 , 12 , 13 , 14 , 15 ].

Academic stressors have been identified as including high workload, attending lessons, respecting deadlines, balancing university and private life, and economic issues. Those stressors are linked to a greater risk of distress and reduced academic achievement [ 1 , 16 , 17 , 18 , 19 ].

Many authors adopted and extended original measures of stress, for example, by adapting work related stress measures to the university context [ 20 , 21 ]. Most of these measures were designed for medical students [ 22 ] or employed measures of stress not specifically developed for the academic context [ 20 , 21 , 22 ].

According to Hilger-Kolb, Diehl, Herr, and Loerbroks [ 23 ], the vast majority of these measures lack a stress theoretical model. It may represent an important limitation as, meausers based on a common tested stress model may be better help researchers to capture the links between stress and health among university students and to develop theory-based interventions [ 21 ]. Effort-Reward Imbalance (ERI) [ 24 ] is among the most common tested and valid models of stress. According to this model, when high efforts are balanced by low rewards, the resulting imbalance may generate negative emotions and sustained stress experiences. Originally developed to investigate stress risks among workers, this model has been the theorethical root of many studies investigating stress in non-working contexts.

Recently, Wege, Muth, Angerer, and Siegrist [ 25 ] extended the original ERI model to the context of university and adapted the ERI short questionnaire to the university setting, showing good psychometric properties. Thus, according to this theoretical approach, students’ stress was defined as the result of an imbalance between effort, such as high study load, and reward, such as being respected from supervisors.

A vast number of empirical studies measuring effort–reward imbalance in workplace context confirmed good psychometric qualities of the ERI short questionnaire [ 26 , 27 ]. Furthermore, psychometrically validated versions have been tested in 9 languages and in large European cohort studies, confirming the good psychometric qualities of the short ERI [ 28 , 29 ].

Concerning the student version of the ERI, there is limited psychometric information available. Given the importance of academic stress for understanding students’ mental health risk, the aim of this study was to investigate the psychometric properties of the Italian version of the ERI-student questionnaire [ 25 ]. To address this goal, we examined the factor structure of the Italian version of the ERI-SQ, assessed internal consistency for the dimensions of effort, reward, and over-commitment, and test the measurement invariance of the ERI-SQ.

Participants and procedure

The study population (convenience sample) was recruited through a public announcement at electronic learning platforms for students and university students’ associations’ network that contained an invitation for participating in a “Health Promoting University” survey. The online survey was implemented with Limesurvey from October 16th, 2017 to November 27th, 2017 and was restricted to enrolled university students (bachelor level and master level). The survey’s homepage reported the online informed consent form with specific information about study purpose, general description of the questionnaire, including information about risks and benefits of participation. Also, the time necessary to complete the survey (less than 10 min) and privacy policy information were reported. Specifically, to ensure anonimity, we did not register ip address neither requested any another sensitive data. The investigators and research team did not employ any active advertising to increase recruitment rates neither played any active role in selecting and/or targeting specific subpopulations of respondents. A total of 9883 students agreed to participate in the survey with 6448 (65.24%) completing the survey (target population: 1.654.680 Italian university students in 2017). The Italian version of the ERI-SQ (see Table 4 in Appendix ) was translated following the back-translation procedure [ 30 ].

Demographics

The sample for this research consisted of 75.5% females ( n  = 4869). Participants in this study ranged from 19 to 56 years of age, M = 22.97, SD = 3.01. 56.2% (3624) were enrolled in bachelor prrogrammes and 43.8% (2824) in master programmes. 39.6% (2551) were enrolled in health related courses (such as medicine, nursing, psychology, and biomedical science).

Stress was assessed with the ERI-SQ [ 25 ] that was developed for use in student samples. The version adopted in this study consists of 14 items that constitute three scales: Effort (EFF; 3 items; example: “I have constant time pressure due to a heavy study load”), Rewards (REW; 6 items; example: “I receive the respect I deserve from my supervisors/teachers”), and over-commitment (OC; 6 items; example: “As soon as I get up in the morning I start thinking about study problems”). All items are scored on a 4-point rating scale ranging from 1 (strongly disagree) to 4 (strongly agree). Average scores of items ratings for each subscale were calculated following appropriate recoding.

Statistical analyses

Statistical analyses were performed with R [ 31 ] and Rstudio [ 32 ]. The factorial structure was investigated using exploratory factor analysis (EFA; psych package) [ 33 ] and confirmatory factor analysis (CFA; lavaan package) [ 34 ]. The dataset was randomly split in half to allow for independent EFA (training set) and CFA (test set). A robust ML estimator was used for correcting violations of multivariate normality.

The analyses were conducted in two stages. Firstly, an EFA with principal axis factor (PAF) analysis was performed. Using Horn’s Parallel Analysis for factor retention. Internal consistency was assessed via Cronbach’s alpha coefficient.

The second stage of analysis involved investigating the factor structure of the Italian version of the ERI-SQ, a series of CFA were performed. As Mardia’s test of multivariate kurtosis (28.78, p  < .0001) showed multivariate non-normality, we investigated model fit with robust maximum likelihood (MLM) [ 35 ]. We compared alternative models: a 1-factor model, in which all 14 items were assessed as one common factor, a 3-factor model where items reflected the three subscales of the ERI-SQ, and a three-factor model with adjustments made according to error theory. We considered several fit indices: χ2(S-B χ2) [ 36 ], the robust root mean square error of approximation (RMSEA); the standardized root mean square residual (SRMR) and the robust comparative fit index (CFI). For CFI, score > .90 indicated acceptable model fit. For both RMSEA and SRMR, score ≤ .05 was considered a good fit, and ≥ .08 a fair fit [ 37 , 38 ].

Finally, the measurement invariance of the ERI-SQ was investigated. We performed a series of multi-group CFAs. We tested 5 nested models with progressive constrained parameters: Model 0 tested for configural invariance; Model 1 tested for metric invariance (constrained factor loadings); Model 2 tested for scalar invariance (constrained factor loadings and item intercepts); Model 3 tested for uniqueness invariance (constrained factor loadings, item intercepts, and residual item variances/covariances); Model 4 tested for structural invariance (constrained factor loadings, item intercepts, and factor variances/covariances). Models were compared by using the chi-square (χ2) [ 39 ]. In comparing nested models, we considered changes in CFI, RMSEA, and SRMR indices as follows: ΔCFI ≤ − 0.02 [ 40 , 41 ], ΔRMSEA ≤0.015, and ΔSRMR ≤0.03 for tests of factor loading invariance [ 40 , 42 ] and ΔCFI ≤-0.01, RMSEA ≤0.015, and SRMR ≤0.01 for test of scalar invariance [ 42 ].

Exploratory factor analysis

We split the dataset ( n  = 6448) into random training and test samples. EFA was performed on the training sample ( n  = 3879). Results from parallel analysis with 5000 parallel data sets using 95th percentile random eigenvalue showed that the eigenvalues for the first three factors exceeded those generated by the random data sets. Subsequently, a three-factor solution was inspected in a principal axis factor analysis with varimax rotation on the 14 items of the ERI-SQ (Table 1 ).

The EFA revealed that two items (EFF2 “I have many interruptions and disturbances while preparing for my exams” and REW4r “ I am not sure whether I can successfully accomplish my university trainings”) loaded on the same factor. An item analysis revealed that, probably, both items have a general and ambiguous formulation among student population. These items were therefore deleted from all analyses, as subsequent analyses were conducted with the remaining 12 items. We then re-conducted a principle axis factor analysis with varimax rotation. The three factors collectively explained 40.0% of the variance in the three facets. After rotation, the factors were interpreted as effort, reward and over-commitment.

Confirmatory factor analysis

Based on the results from the EFA, three models were tested on the test sample ( n  = 3879; Table  2 ).

Fit indices for the unidimensional model S-Bχ2(54) = 1833.95, rCFI = .78, rTLI = .73, RMSEA = .109, SRMR = .084 suggested that the model did not provide a good fit to the data. We next considered the three-factor model [ 21 ]. Fit indices suggested this model fits the data well, S-Bχ2(51) = 384.17, rCFI = .96, rTLI = .95, rRMSEA = .048, SRMR = .033. The χ2 difference test was significant, ΔS-Bχ2(3) = 1449.79, p  < .001. All standardized factor loadings were significant.

Internal consistency was .66 for reward, and .78 for overcommitment. Correlations between the three latent factors were as follows: −.30 between effort and reward, .52 between effort and over-commitment, −.33 between reward and over-commitment. Mean scores were: effort = 3.04 (SD = 0.59), reward = 2.67 (SD = 0.48) and over-commitment = 2.65 (SD = 0.63). The mean value of the effort-reward ratio was 1.20 (SD = 0.41).

Measurement invariance

Next, for testing measurement invariance, we conducted a series of multi-group CFAs across different groups: health (medicine, nursing, etc.) vs other courses (engineering, economy, etc.) and gender (male vs female).

First, a series of multi-group CFA (MGCFA) was conducted on the health and other university courses. Table  3 shows that configural invariance was supported (Model 0) as fit the data well across health courses ( n  = 2551) and other courses ( n  = 3897): S-Bχ2(102) = 398.06, CFI = .962, RMSEA = .045, SRMR = .032. All loadings were significant ( p  < .01). We found support for metric invariance (Model 1): ΔCFI = −.001, ΔRMSEA = −.001, and ΔSRMR = −.002. Next, we did not find support for scalar invariance (Model 2; ΔCFI = − .043; ΔRMSEA = .019, and ΔSRMR = .017). As full scalar invariance was not supported, we tested for partial invariance. Inspecting modification indices, we found that three items from the reward subscale (REW2 “I receive the respect I deserve from my fellow students”; REW3 “I am treated unfairly at university”; and REW6 “Considering all my efforts and achievements, my job promotion prospects are adequate”) and all items from the over-commitment subscale lacked invariance. However, as showed on Table 3 , partial scalar invariance (Model 2b) was not supported (ΔCF = −.021, ΔRMSEA = −.012, and ΔSRMR = .011).

Next, we performed a series of MGCFAs to test the invariance of the ERI-SQ between female and male students (Table 3 ). We found support for configural invariance (Model 0) across female ( n  = 4869) and male ( n  = 1579) groups: S-Bχ2(102) = 445.20, CFI = .956, RMSEA = .049, SRMR = .033. All loadings were significant ( p  < .01). Next, we found support for metric invariance (Model 1): ΔCFI = − .001, ΔRMSEA = −.002, and ΔSRMR = .003. Next we found support for scalar invariance (Model 2): ΔCFI = −.009, ΔRMSEA = .003, and ΔSRMR = .002. Next uniqueness invariance (Model 3) was supported: ΔCFI = −.005, ΔRMSEA = −.001, and ΔSRMR = .002. Finally, we found support for structural invariance (Model 4): ΔCFI = −.010, ΔRMSEA = .004, and ΔSRMR = .012.

The main objective of this study was to examine the factorial validity and invariance of the Italian version of the ERI-SQ among Italian university students. Overall, our results confirmed the factorial structure underlying the ERI-SQ, as theorized by Siegrist [ 25 ] and reported by Wege and colleagues [ 25 ] in the student version of the ERI. However, in light of the conclusions drawn from the EFA, to enhance the fit of the model, we had to delete two items with high cross loadings. The deleted items were problematic in the Wege and colleagues [ 25 ] study too. Specifically, both items (EFF2 and REW4) showed a low factor loading in the CFA.

In the Italian sample, using a modified and shortened version (12 items) of the ERI-SQ, we confirmed the three factors structure components of the model, showing a satisfactory fit of the data structure with the theoretical concept. In sum, the current findings show that the ERI-SQ is as a reliable instrument for measuring academic stress among students.

Finally, as expected, we found support for metric invariance across gender and university course, health (medicine, nursing, etc.) vs other courses (engineering, economy, etc.). Mainly, MCFAs confirmed that the three-factor structure of the ERI-QS is (mostly) invariant across different groups. More specifically, we found support for parameter equivalence across gender (structural invariance), but the ERI-SQ was significantly different in health vs other courses. In fact, we were not able to find scalar invariance, suggesting that items REW2, REW3, REW6 and all the over-commitment items vary by academic courses. However, the lack of scalar invariance is a negligible issue for the Italian version of the ERI-SQ.

Implications and limitations

Results from our study showed that the Italian version of the ERI-SQ-10 provides a psychometrically sound measure of stress as defined in the ERI theoretical framework. The ERI-SQ is a brief and easy to administer university student stress measure. In this sense, using valid and reliable measures of stress is crucial for Italian university counselling services to advance in monitoring and understanding the levels of stress affecting students and how to support them. In this manner it would be possible to offer appropriate mental health support [ 43 ] when students are exposed to lack of reciprocity between spending high efforts and receiving low rewards during their student career.

The present study has several limitations. First, data were obtained from a convenience sample offering reduced generalizability of our results. However, for the purpose of the study this sample was deemed appropriate. Second, the Effort dimension was composed of only two items. A factor with only two items leads to a CFA that cannot be estimated unless constraining the model. Future research would overcome this limitation by reevaluating a wider version of the ERI and adapting other items from the Effort factor as defined in the ERI questionnaire [ 24 ]. Third, further research is also recommended concerning construct and criterion validity [ 44 ]. Specifically, we are not able to provide evidence of convergent validity (how closely the ERI-SQ is related to other variables and other measures of the same construct), and discriminant (ERI-SQ does not correlate with other variables that are theoretically not related). Future research would consider to analyse it by employing a multitrait-multimethod [ 45 ]. Finally, as one of the anonymous reviewers correctly pointed out, our study does not offer any evidence of criterion validity, mainly concurrent validity (the degree to which a measure correlates concurrently to an external criterion in the same domain [ 44 ]. However, according to Wege and colleagues [ 25 ], no studies have provided estimates of these validities for the ERI-SQ. Future research would provide evidence of it by analyzing the correlation between the ERI-SQ and a theoretically similar measure of student stress. In this sense, concurrent validity is an important area of future research. Fourth, we did not test for test–retest reliability. Future research should address these issues. Despite these important limitations, the Italian version of the ERI-SQ showed satisfactory psychometric properties.

In the present study, we found that the Italian version of the ERI-QS partially confirms the original version from Wege and colleagues [ 25 ]. We were able to show satisfactory psychometric properties of the ERI-SQ. Considering a high prevalence of academic distress among University students and the limited interventions aimed to reduce stress [ 46 ], universities should employ preventive interventions by measuring and controlling for potentially harmful psychosocial risk. In this sense, the Italian version of the ERI-QS presents a valid instrument for measuring academic stress on Italian-speaking university students.

Availability of data and materials

Raw data pertaining to analyses performed in this study are available available from the authors upon reasonable request.

Abbreviations

Confirmatory Factor Analysis

Comparative Fit Index

Exploratory Factor Analysis

Effort-Reward Imbalance

Effort-Reward Imbalance Students Questionnaire

Multi-Group Confirmatory Factor Analysis

Maximum Likelihood

Robust Maximum Likelihood

Over-commitment

Principal Axis Factor

Root Mean Square Error of Approximation

Standard Deviation

Standardized Root Mean Square Residual

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Acknowledgements

The authors gratefully acknowledge Prof. Johannes Siegrist and Prof. Nico Dragano for their careful reading and constructive feedbacks on the final draft of the manuscript.

This study was not funded.

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Contributions

IP, MG, FB and MC contributed to the conception and design of the study. IP, FB and AB contributed to the development procedure of the Italian version of ERI-SQ, including forward translation and back translation review. IP and FP contributed to the acquisition of data. IP analyzed the data and wrote the first draft of the manuscript. MG, and AB supervised the analysis. SS, ED, GF and MC helped to draft and revise the manuscript. All authors read and approved the final manuscript.

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Portoghese, I., Galletta, M., Porru, F. et al. Stress among university students: factorial structure and measurement invariance of the Italian version of the Effort-Reward Imbalance student questionnaire. BMC Psychol 7 , 68 (2019). https://doi.org/10.1186/s40359-019-0343-7

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Stress and Coping Mechanisms Among College Students

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This is a sample student stress survey template that has questions and examples to understand the higher education experience of students, how they cope with stress and the entire experience as a student in high school. Stress takes a toll on students' mental health. Use this short example questionnaire to conduct a stress assessment study among students to find the sources of student stress. Ask questions about anxiety and create student stress statistics to take measures to overcome it. This sample survey template asks questions to gather feedback on increasing stress levels in high schools, colleges, and universities. It offers insights into the measures that educational institutions can take to cope with stress.

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Running a student stress survey can give insights into the mental wellbeing of students. Teenagers and young adults face a lot of stress from ongoing academic demands. One of the main concerns is the pressure to get good grades. Peer pressure to behave like others also creates a lot of anxiety, stress, depression and other mental health issues. Below are the benefits of using this template in your student surveys:

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  • Published: 24 February 2024

Physical activity improves stress load, recovery, and academic performance-related parameters among university students: a longitudinal study on daily level

  • Monika Teuber 1 ,
  • Daniel Leyhr 1 , 2 &
  • Gorden Sudeck 1 , 3  

BMC Public Health volume  24 , Article number:  598 ( 2024 ) Cite this article

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Physical activity has been proven to be beneficial for physical and psychological health as well as for academic achievement. However, especially university students are insufficiently physically active because of difficulties in time management regarding study, work, and social demands. As they are at a crucial life stage, it is of interest how physical activity affects university students' stress load and recovery as well as their academic performance.

Student´s behavior during home studying in times of COVID-19 was examined longitudinally on a daily basis during a ten-day study period ( N  = 57, aged M  = 23.5 years, SD  = 2.8, studying between the 1st to 13th semester ( M  = 5.8, SD  = 4.1)). Two-level regression models were conducted to predict daily variations in stress load, recovery and perceived academic performance depending on leisure-time physical activity and short physical activity breaks during studying periods. Parameters of the individual home studying behavior were also taken into account as covariates.

While physical activity breaks only positively affect stress load (functional stress b = 0.032, p  < 0.01) and perceived academic performance (b = 0.121, p  < 0.001), leisure-time physical activity affects parameters of stress load (functional stress: b = 0.003, p  < 0.001, dysfunctional stress: b = -0.002, p  < 0.01), recovery experience (b = -0.003, p  < 0.001) and perceived academic performance (b = 0.012, p  < 0.001). Home study behavior regarding the number of breaks and longest stretch of time also shows associations with recovery experience and perceived academic performance.

Conclusions

Study results confirm the importance of different physical activities for university students` stress load, recovery experience and perceived academic performance in home studying periods. Universities should promote physical activity to keep their students healthy and capable of performing well in academic study: On the one hand, they can offer opportunities to be physically active in leisure time. On the other hand, they can support physical activity breaks during the learning process and in the immediate location of study.

Peer Review reports

Introduction

Physical activity (PA) takes a particularly key position in health promotion and prevention. It reduces risks for several diseases, overweight, and all-cause mortality [ 1 ] and is beneficial for physical, psychological and social health [ 2 , 3 , 4 , 5 ] as well as for academic achievement [ 6 , 7 ]. However, PA levels decrease from childhood through adolescence and into adulthood [ 8 , 9 , 10 ]. Especially university students are insufficiently physically active according to health-oriented PA guidelines [ 11 ] because of academic workloads as well as difficulties in time management regarding study, work, and social demands [ 12 ]. Due to their independence and increasing self-responsibility, university students are at a crucial life stage. In this essential and still educational stage of the students´ development, it is important to study their PA behavior. Furthermore, PA as health behavior represents one influencing factor which is considered in the analytical framework of the impact of health and health behaviors on educational outcomes which was developed by the authors Suhrcke and de Paz Nieves [ 13 , 14 ]. In light of this, the present study examines how PA affects university students' academic situations.

Along with the promotion of PA, the reduction of sedentary behavior has also become a crucial part of modern health promotion and prevention strategies. Spending too much time sitting increases many health risks, including the risk of obesity [ 15 ], diabetes [ 16 ] and other chronic diseases [ 15 ], damage to muscular balances, bone metabolism and musculoskeletal system [ 17 ] and even early death [ 15 ]. University students are a population that has shown the greatest increase in sedentary behavior over the last two decades [ 18 ]. In Germany, they show the highest percentage of sitting time among all working professional groups [ 19 ]. Long times sitting in classes, self-study learning, and through smartphone use, all of which are connected to the university setting and its associated behaviors, might be the cause of this [ 20 , 21 ]. This goes along with technological advances which allow students to study in the comfort of their own homes without changing locations [ 22 ].

To counter a sedentary lifestyle, PA is crucial. In addition to its physical health advantages, PA is essential for coping with the intellectual and stress-related demands of academic life. PA shows positive associations with stress load and academic performance. It is positively associated with learning and educational success [ 6 ] and even shows stress-regulatory potential [ 23 ]. In contrast, sedentary behavior is associated with lower cognitive performance [ 24 ]. Moreover, theoretical derivations show that too much sitting could have a negative impact on brain health and diminish the positive effects of PA [ 16 ]. Given the theoretical background of the stressor detachment model [ 25 ] and the cybernetic approach to stress management in the workplace [ 26 ], PA can promote recovery experience, it can enhance academic performance, and it is a way to reduce the impact of study-related stressors on strain. Load-related stress response can be bilateral: On the one hand, it can be functional if it is beneficial to help cope with the study demands. On the other hand, it can be dysfunctional if it puts a strain on personal resources and can lead to load-related states of strain [ 27 ]. Thus, both, the promotion of PA and reduction of sedentary behavior are important for stress load, recovery, and performance in student life, which can be of particular importance for students in an academic context.

A simple but (presumably) effective way to integrate PA and reduce sedentary behavior in student life are short PA breaks. Due to the exercises' simplicity and short duration, students can perform them wherever they are — together in a lecture or alone at home. Short PA breaks could prevent an accumulation of negative stressors during the day and can help with prolonged sitting as well as inactivity. Especially in the university setting, evidence of the positive effects of PA breaks exists for self-perceived physical and psychological well-being of the university students [ 28 ]. PA breaks buffer university students’ perceived stress [ 29 ] and show positive impacts on recovery need [ 30 ] and better mood ratings [ 31 , 32 ]. In addition, there is evidence for reduction in tension [ 30 ], overall muscular discomfort [ 33 ], daytime sleepiness or fatigue [ 33 , 34 ] and increase in vigor [ 34 ] and experienced energy [ 30 ]. This is in line with cognitive, affective, behavioral, and biological effects of PA, all categorized as palliative-regenerative coping strategies, which addresses the consequences of stress-generating appraisal processes aiming to alleviate these consequences (palliative) or restore the baseline of the relevant reaction parameter (regenerative) [ 35 , 36 ]. This is achieved by, for example, reducing stress-induced cortisol release or tension through physical activity (reaction reduction) [ 35 ]. Such mechanisms are also in accordance with the previously mentioned stressor detachment model [ 25 ]. Lastly, there is a health-strengthening effect that impacts the entire stress-coping-health process, relying on the compensatory effects of PA which is in accordance to the stress-buffering effect of exercise [ 37 ]. Health, in turn, effects educational outcomes [ 13 , 14 ]. Therefore, stress regulating effects are also accompanied with the before mentioned analytical framework of the impact of health and health behaviors on educational outcomes [ 13 , 14 ].

Focusing on the effects of PA, this study is guided by an inquiry into how PA affects university students' stress load and recovery as well as their perceived academic performance. For that reason, the student´s behavior during home studying in times of COVID-19 is examined, a time in which reinforced prolonged sitting, inactivity, and a negative stress load response was at a high [ 38 , 39 , 40 , 41 , 42 ]. Looking separately on the relation of PA with different parameters based on the mentioned evidence, we assume that PA has a positive impact on stress load, recovery, and perceived academic performance-related parameters. Furthermore, a side effect of the home study behavior on the mentioned parameters is assumed regarding the accumulation of negative stressors during home studying. These associations are presented in Fig.  1 and summarized in the following hypotheses:

figure 1

Overview of the assumed effects and investigated hypotheses of physical activity (PA) behavior on variables of stress load and recovery and perceived academic performance-related parameters

Hypothesis 1 (path 1): Given that stress load always occurs as a duality—beneficial if it is functional for coping, or exhausting if it puts a strain on personal resources [ 27 ] – we consider two variables for stress load: functional stress and dysfunctional stress. In order to reduce the length of the daily surveys, we focused the measure of recovery only on the most obvious and accessible component of recovery experience, namely psychological detachment. PA (whether performed in leisure-time or during PA breaks) encourages functional stress and reduce dysfunctional stress (1.A) and has a positive effect on recovery experience through psychological detachment (1.B).

Hypothesis 2 (path 2): The academic performance-related parameters attention difficulties and study ability are positively influenced by PA (whether done in leisure-time or during PA breaks). We have chosen to assess attention difficulties for a cognitive parameter because poor control over the stream of occurring stimuli have been associated with impairment in executive functions or academic failure [ 43 , 44 , 45 , 46 ]. Furthermore, we have assessed the study ability to refer to the self-perceived feeling of functionality regarding the demands of students. PA reduces self-reported attention difficulties (2.A) and improves perceived study ability, indicating that a student feels capable of performing well in academic study (2.B).

Hypothesis 3: We assume that a longer time spent on studying at home (so called home studying) could result in higher accumulation of stressors throughout the day which could elicit immediate stress responses, while breaks in general could reduce the influence of work-related stressors on strain and well-being [ 47 , 48 ]. Therefore, the following covariates are considered for secondary effects:

the daily longest stretch of time without a break spent on home studying

the daily number of breaks during home studying

Study setting

The study was carried out during the COVID-19 pandemic containment phase. It took place in the middle of the lecture period between 25th of November and 4th of December 2020. Student life was characterized by home studying and digital learning. A so called “digital semester” was in effect at the University of Tübingen when the study took place. Hence, courses were mainly taught online (e.g., live or via a recorded lecture). Other events and actions at the university were not permitted. As such, the university sports department closed in-person sports activities. For leisure time in general, there were contact restrictions (social distancing), the performance of sports activities in groups was not permitted, and sports facilities were closed.

Thus, the university sports department of the University of Tübingen launched various online sports courses and the student health management introduced an opportunity for a new digital form of PA breaks. This opportunity provided PA breaks via videos with guided physical exercises and health-promoting explanations for a PA break for everyday home studying: the so called “Bewegungssnack digital” [in English “exercise snack digital” (ESD)] [ 49 ]. The ESD videos took 5–7 min and were categorized into three thematic foci: activation, relaxation, and coordination. Exercises were demonstrated by one or two student exercise leaders, accompanied by textual descriptions of the relevant execution features of each exercise.

Participants

Participants were recruited within the framework of an intervention study, which was conducted to investigate whether a digital nudging intervention has a beneficial effect on taking PA breaks during home study periods [ 49 ]. Students at the University of Tübingen which counts 27,532 enrolled students were approached for participation through a variety of digital means: via an email sent to those who registered for ESD course on the homepage of the university sports department and to all students via the university email distribution list; via advertisement on social media of the university sports department (Facebook, Instagram, YouTube, homepage). Five tablets, two smart watches, and one iPad were raffled off to participants who engaged actively during the full study period in an effort to motivate them to stick with it to the end. In any case, participants knew that the study was voluntary and that they would not suffer any personal disadvantages should they opt out. There was a written informed consent prompt together with a prompt for the approval of the data protection regulations immediately within the first questionnaire (T0) presented in a mandatory selection field. Positive ethical approval for the study was given by the first author´s institution´s ethics committee of the faculty of the University of Tübingen.

Participants ( N  = 57) who completed the daily surveys on at least half of the days of the study period, were included in the sample (male = 6, female = 47, diverse = 1, not stated = 3). As not all subjects provided data on all ten study days, the total number of observations was between 468 and 540, depending on the variable under study (see Table  1 ). The average number of observations per subject was around eight. Their age was between 18 and 32 years ( M  = 23.52, SD  = 2.81) and they were studying between the 1st to 13th semester ( M  = 5.76, SD  = 4.11) within the following major courses of study: mathematical-scientific majors (34.0%), social science majors (22.6%), philosophical majors (18.9%), medicine (13.2%), theology (5.7%), economics (3.8%), or law (1.9%). 20.4% of the students had on-site classroom teaching on university campus for at least one day a week despite the mandated digital semester, as there were exceptions for special forms of teaching.

Design and procedures

To examine these hypothesized associations, a longitudinal study design with daily surveys was chosen following the suggestion of the day-level study of Feuerhahn et al. (2014) and also of Sonnentag (2001) measuring recovery potential of (exercise) activities during leisure time [ 50 , 51 ]. Considering that there are also differences between people at the beginning of the study period, initial base-line value variables respective to the outcomes measured before the study period were considered as independent covariates. Therefore, the well-being at baseline serves as a control for stress load (2.A), the psychological detachment at baseline serves as a control for daily psychological detachment (2.B), the perception of study demands serves as a control for self-reported attention difficulties (1.A), and the perceived study ability at baseline serves as a control for daily study ability (2.B).

Subjects were asked to continue with their normal home study routine and additionally perform ESD at any time in their daily routine. Data were collected one to two days before (T0) as well as daily during the ten-day study period (Wednesday to Friday). The daily surveys (t 1 -t 10 ) were sent by email at 7 p.m. every evening. Each day, subjects were asked to answer questions about their home studying behavior, study related requirements, recovery experience from study tasks, attention, and PA, including ESD participation. The surveys were conducted online using the UNIPARK software and were recorded and analyzed anonymously.

Measures and covariates

In total, five outcome variables, two independent variables, and seven covariates were included in different analyses: three variables were used for stress load and recovery parameters, two variables for academic performance-related parameters, two variables for PA behavior, two variables for study behavior, four variables for outcome specific baseline values and one variable for age.

Outcome variables

Stress load & recovery parameters (hypothesis 1).

Stress load was included in the analysis with two variables: functional stress and dysfunctional stress. Followingly, a questionnaire containing a word list of adjectives for the recording of emotions and stress during work (called “Erfassung von Emotionen und Beanspruchung “ in German, also known as EEB [ 52 ]) was used. It is an instrument which were developed and validated in the context of occupational health promotion. The items are based on mental-workload research and the assessment of the stress potential of work organization [ 52 ]. Within the questionnaire, four mental and motivational stress items were combined to form a functional stress scale (energetic, willing to perform, attentive, focused) (α = 0.89) and four negative emotional and physical stress items were combined to form dysfunctional stress scale (nervous, physically tensioned, excited, physically unwell) (α = 0.71). Participants rated the items according to how they felt about home studying in general on the following scale (adjustment from “work” to “home studying”): hardly, somewhat, to some extent, fairly, strongly, very strongly, exceptionally.

Recovery experience was measured via psychological detachment. Therefore, the dimension “detachment” of the Recovery Experience Questionnaire (RECQ [ 53 ]) was adjusted to home studying. The introductory question was "How did you experience your free time (including short breaks between learning) during home studying today?". Students responded to four statements based on the extent to which they agreed or disagreed (not at all true, somewhat true, moderately true, mostly true, completely true). The statements covered subjects such as forgetting about studying, not thinking about studying, detachment from studying, and keeping a distance from student tasks. The four items were combined into a score for psychological detachment (α = 0.94).

Academic performance-related parameters (hypothesis 2)

Attention was assessed via the subscale “difficulty maintaining focused attention performance” of the “Attention and Performance Self-Assessment” (ASPA, AP-F2 [ 54 ]). It contains nine items with statements about disturbing situations regarding concentration (e.g. “Even a small noise from the environment could disturb me while reading.”). Participants had to answer how often such situations happened to them on a given day on the following scale: never, rarely, sometimes, often, always. The nine items were combined into the AP-F2 score (α = 0.87).

The perceived study ability was assessed using the study ability index (SAI [ 55 ]). The study ability index captures the current state of perceived functioning in studying. It is based on the Work Ability Index by Hasselhorn and Freude ([ 56 ]) and consists of an adjusted short scale of three adapted items in the context of studying. Firstly, (a) the perceived academic performance was asked after in comparison to the best study-related academic performance ever achieved (from 0 = completely unable to function to 10 = currently best functioning). Secondly, the other two items were aimed at assessing current study-related performance in relation to (b) study tasks that have to be mastered cognitively and (c) the psychological demands of studying. Both items were answered on a five-point Likert scale (1 = very poor, 2 = rather poor, 3 = moderate, 4 = rather good, 5 = very good). A sum index, the SAI, was formed which can indicate values between 2 and 20, with higher values corresponding to higher assessed functioning in studies (α = 0.86). In a previous study it already showed satisfying reliability (α = 0.72) [ 55 ].

Independent variables

Pa behavior.

Two indicators for PA behavior were included via self-reports: the time spent on ESD and the time spent on leisure-time PA (LTPA). Participants were asked the following overarching question daily: “How much time did you spend on physical activity today and in what context”. For the independent variable time spent on PA breaks, participants could answer the option “I participated in the Bewegungssnack digital” with the amount of time they spent on it (in minutes). To assess the time spent on LTPA besides PA breaks, participants could report their time for four different contexts of PA which comprised two forms: Firstly, structured supervised exercise was reported via time spent on (a) university sports courses and (b) other organized sports activities. Secondly, self-organized PA was indicated via (c) independent PA at home, such as a workout or other physically demanding activity such as cleaning or tidying up, as well as via (d) independent PA outside, like walking, cycling, jogging, a workout or something similar. Referring to the different domains of health enhancing PA [ 57 ], the reported minutes of these four types of PA were summed up to a total LTPA value. The total LTPA value was included in the analysis as a metric variable in minutes.

Covariates (hypothesis 3)

Regarding hypothesis 3 and home study behavior, the longest daily stretch of time without a break spent on home studying (in hours) and the daily number of breaks during home studying was assessed. Therein, participants had to answer the overarching question “How much time did you spend on your home studying today?” and give responses to the items: (1) longest stretch of time for home studying (without a break), and (2) number of short and long breaks you took during home studying.

In principle, efforts were made to control for potential confounders at the individual level (level 2) either by including the baseline measure (T0) of the respective variable or by including variables assessing related trait-like characteristics for respective outcomes. The reason why related trait-like characteristics were used for the outcomes was because brief assessments were used for daily surveys that were not concurrently employed in the baseline assessment. To enable the continued use of controlling for person-specific baseline characteristics in the analysis of daily associations, trait-like characteristics available from the baseline assessment were utilized as the best possible approximation.To sum up, four outcome specific baseline value variables were measured before the study period (at T0). The psychological detachment with the RECQ (α = 0.87) [ 53 ] was assessed at the beginning to monitor daily psychological detachment. Further, the SAI [ 55 ] was assessed at the beginning of the study period to monitor daily study ability. To monitor daily stress load, which in part measures mental stress aspects and negative emotional stress aspects, the well-being was assessed at the beginning using the WHO-Five Well-being Index (WHO-5 [ 58 ]). It is a one-dimensional self-report measure with five items. The index value is the sum of all items, with higher values indicating better well-being. As the well-being and stress load tolerance may linked with each other, this variable was assumed to be a good fit with the daily stress load indicating mental and emotional stress aspects. With respect to student life, daily academic performance-related attention was monitored with an instrument for the perception of study demands and resources (termed “Berliner Anforderungen Ressourcen-Inventar – Studierende” in German, the so-called BARI-S [ 59 ]). It contains eight items which capture overwork in studies, time pressure during studies, and the incompatibility of studies and private life. All together they form the BARI-S demand scale (α = 0.85) which was included in the analysis. As overwork and time pressure may result in attention difficulties (e.g. Elfering et al., 2013), this variable was assumed to have a good fit with academic performance-related attention [ 60 ]. Additionally, age in years at T0 was considered as a sociodemographic factor.

Statistical analysis

Since the study design provided ten measurement points for various people, the hierarchical structure of the nested data called for two-level analyses. Pre-analyses of Random-Intercept-Only models for each of the outcome variables (hypothesis 1 to 3) revealed an Intra-Class-Correlation ( ICC ) of at least 0.10 (range 0.26 – 0.64) and confirmed the necessity to perform multilevel analyses [ 61 ]. Specifically, the day-level variables belong to Level 1 (ESD time, LTPA time, longest stretch of time without a break spent on home studying, daily number of breaks during home studying). To analyze day-specific effects within the person, these variables were centered on the person mean (cw = centered within) [ 50 , 62 , 63 , 64 ]. This means that the analyses’ findings are based on a person’s deviations from their average values. The variables assessed at T0 belong to Level 2, which describe the person level (psychological detachment baseline, SAI baseline, well-being, study demands scale, age). These covariates on person level were centered around the grand mean [ 50 ] indicating that the analyses’ findings are based how far an individual deviates from the sample's mean values. As a result, the models’ intercept reflects the outcome value of an average student in the sample at his/her daily average behavior in PA and home study when all parameters are zero. For descriptive statistics SPSS 28.0.1.1 (IBM) and for inferential statistics R (version 4.1.2) were used. The hierarchical models were calculated using the package lme4 with the lmer-function in R in the following steps [ 65 ]. The Null Model was analyzed for all models first, with the corresponding intercept as the only predictor. Afterwards, all variables were entered. The regression coefficient estimates (”b”) were considered for statistical significance for the models and the respective BIC was provided.

In total, five regression models with ‘PA break time’ and ‘LTPA time’ as independent variables were computed due to the five measured outcomes of the present study. Three models belonged to hypothesis 1 and two models to hypothesis 2.

Hypothesis 1: To test hypothesis 1.A two outcome variables were chosen for two separate models: ‘functional stress’ and ‘dysfunctional stress’. Besides the PA behavior variables, the ‘number of breaks’, the ‘longest stretch of time without a break spent on home studying’, ‘age’, and the ‘well-being’ at the beginning of the study as corresponding baseline variable to the output variable were also included as independent variables in both models. The outcome variable ‘psychological detachment’ was utilized in conjunction with the aforementioned independent variables to test hypotheses 1.B, with one exception: psychological detachment at the start of the study was chosen as the corresponding baseline variable.

Hypothesis 2: To investigate hypothesis 2.A the outcome variable ‘attention difficulties’ was selected. Hypothesis 2.B was tested with the outcome variables ‘study ability’. Both models included both PA behavior variables as well as the ‘number of breaks’, the ‘longest stretch of time without a break spent on home studying’, ‘age’ and one corresponding baseline variable each: the ‘study demand scale’ at the start of the study for ‘attention difficulties’ and the ‘SAI’ at the beginning of the study for the daily ‘study ability’.

Hypothesis 3: In addition to both PA behavior variables, age and one baseline variable that matched the outcome variable, the covariates ‘daily longest stretch of time spent on home studying’ and ‘daily number of breaks during home studying’ were included in the models for all five outcome variables.

Handling missing data

The dataset had up to 18% missing values (most exhibit the variables ‘daily longest stretch of time without a break spent on home studying’ with 17.89% followed by ‘daily number of breaks during homes studying’ with 16.67%, and ‘functional / dysfunctional stress’ with 12.45%). Therefore, a sensitivity analysis was performed using the multiple imputation mice-package in the statistical program R [ 66 ], the package howManyImputation based on Von Hippel (2020, [ 67 ]), and the additional broom package [ 68 ]. The results of the models remained the same, with one exception for the Attention Difficulties Model: The daily longest stretch of time without a break spent on home studying showed a significant association (Table  1 in supplement). Due to this almost perfect consistency of results between analyses based on the dataset with missing data and those with imputed data alongside the lack of information provided by the packages for imputed datasets, we decided to stick with the main analysis including the missing data. Thus, in the following the results of the main analysis without imputations are presented.

Table 1 shows the descriptive statistics of the variables used in the analysis. An overview of the analysed models is presented in Table  2 .

Effects on stress load and recovery (hypothesis 1)

Hypothesis 1.A: The Model Functional Stress explained 13% of the variance by fixed factors (marginal R 2  = 0.13), and 52% by both fixed and random factors (conditional R 2  = 0.52). The time spent on ESD as well as the time spent on PA in leisure showed a positive significant influence on functional stress (b = 0.032, p  < 0.01). The same applied to LTPA (b = 0.003, p  < 0.001). The Model Dysfunctional Stress (marginal R 2  = 0.027, conditional R 2  = 0.647) showed only one significant result. The dysfunctional stress was only significantly negatively influenced by the time spent on LTPA (b = 0.002, p  < 0.01).

Hypothesis 1.B: With the Model Detachment, fixed factors contributed 18% of the explained variance and fixed and random factors 46% of the explained variance for psychological detachment. Only the amount of time spent on LTPA revealed a positive impact on psychological detachment (b = 0.003, p  < 0.001).

Effects on academic performance-related parameters (hypothesis 2)

Hypothesis 2.A: The Model Attention Difficulties showed 13% of the variance explained by fixed factors, and 51% explained by both fixed and random factors. It showed a significant negative association only for the time spent on LTPA (b = 0.003, p  < 0.001).

Hypothesis 2.B: The Model SAI showed 18% of the variance explained by fixed factors, and 39% explained by both fixed and random factors. There were significant positive associations for time spent on ESD (b = 0.121, p  < 0.001) and time spent on LTPA (b = 0.012, p  < 0.001). The same applied to LTPA (b = 0.012, p  < 0.001).

Effects of home study behavior (hypothesis 3)

Regarding the independent covariates for the outcome variables functional and dysfunctional stress, there were no significant results for the number of breaks during homes studying or the longest stretch of time without a break spent on home studying. Considering the outcome variable ‘psychological detachment’, there were significant results with negative impact for both study behavior variables: breaks during home studying (b = 0.058, p  < 0.01) and daily longest stretch of time without a break (b = 0.120, p  < 0.01). Evaluating the outcome variables ‘attention difficulties’, there were no significant results for the number of breaks during home studying or the longest stretch of time without a break spent on home studying. Testing the independent study behavior variables for the SAI, it increased with increasing number in daily breaks during homes studying relative to the person´s mean (b = 0.183, p  < 0.05). No significant effect was found for the longest stretch of time without a break spent on home studying ( p  = 0.07).

The baseline covariates of the models showed expected associations and thus confirmed their inclusion. The baseline variables well-being showed a significant impact on functional stress (b = 0.089, p  < 0.001), psychological detachment showed a positive effect on the daily output variables psychological detachment (b = 0.471, p  < 0.001), study demand scale showed a positive association on difficulties in attention (b = 0.240, p  < 0.01), and baseline SAI had a positive effect on the daily SAI (b = 0.335, p  < 0.001).

The present study theorized that PA breaks and LTPA positively influence the academic situation of university students. Therefore, impact on stress load (‘functional stress’ and ‘dysfunctional stress’) and ‘psychological detachment’ as well as academic performance-related parameters ‘self-reported attention difficulties’ and ‘perceived study ability’ was taken into account. The first and second hypotheses assumed that both PA breaks and LTPA are positively associated with the aforementioned parameters and were confirmed for LTPA for all parameters and for PA breaks for functional stress and perceived study ability. The third hypothesis assumed that home study behavior regarding the daily number of breaks during home studying and longest stretch of time without a break spent on home studying has side effects. Detected negative effects for both covariates on psychological detachment and positive effects for the daily number of breaks on perceived study ability were partly unexpected in their direction. These results emphasize the key position of PA in the context of modern health promotion especially for students in an academic context.

Regarding hypothesis 1 and the detected positive associations for stress load and recovery parameters with PA, the results are in accordance with the stress-regulatory potential of PA from the state of research [ 23 ]. For hypothesis 1.A, there is a positive influence of PA breaks and LTPA on functional stress and a negative influence of LTPA on dysfunctional stress. Given the bilateral role of stress load, the results indicate that PA breaks and LTPA are beneficial for coping with study demands, and may help to promote feelings of joy, pride, and learning progress [ 27 ]. This is in line with previous evidence that PA breaks in lectures can buffer university students’ perceived stress [ 29 ], lead to better mood ratings [ 29 , 31 ], and increase in motivation [ 28 , 69 ], vigor [ 34 ], energy [ 30 ], and self-perceived physical and psychological well-being [ 28 ]. Looking at dysfunctional stress, the result point that LTPA counteract load-related states of strain such as inner tension, irritability and nervous restlessness or feelings of boredom [ 27 ]. In contrast, short PA breaks during the day could not have enough impact in countering dysfunctional stress at the end of the day regarding the accumulation of negative stressors during home studying which might have occurred after the participant took PA breaks. Other studies have been able to show a reduction in tension [ 30 ] and general muscular discomfort [ 33 ] after PA breaks. However, this was measured as an immediate effect of PA breaks and not with general evening surveys. Blasche and colleagues [ 34 ] measured effects immediately and 20 min after different kind of breaks and found that PA breaks led to an additional short‐ and medium‐term increase in vigor while the relaxation break lead to an additional medium‐term decrease in fatigue compared to an unstructured open break. This is consistent with the results of the present study that an effect of PA breaks is only observed for functional stress and not for dysfunctional stress. Furthermore, there is evidence that long sitting during lectures leads to increased fatigue and lower concentration [ 31 , 70 ], which could be counteracted by PA breaks. For both types of stress loads, functional and dysfunctional stress, there is an influence of students´ well-being in this study. This shows that the stress load is affected by the way students have mentally felt over the last two weeks. The relevance of monitoring this seems important especially in the time of COVID-19 as, for example, 65.3% of the students of a cross-sectional online survey at an Australian university reported low to very low well-being during that time [ 71 ]. However, since PA and well-being can support functional stress load, they should be of the highest priority—not only as regards the pandemic, but also in general.

Looking at hypothesis 1.B; while there is a positive influence of LTPA on experienced psychological detachment, no significant influence for PA breaks was detected. The fact that only LTPA has a positive effect can be explained by the voluntary character of the activity [ 50 ]. The voluntary character ensures that stressors no longer affect the student and, thus, recovery as detachment can take place. Home studying is not present in leisure times, and thus detachment from study is easier. The PA break videos, on the other hand, were shot in a university setting, which would have made it more difficult to detach from study. In order to further understand how PA breaks affect recovery and whether there is a distinction between PA breaks and LTPA, future research should also consider other types of recovery (e.g. relaxation, mastery, and control). Additionally, different types of PA breaks, such as group PA breaks taken on-site versus video-based PA breaks, should be taken into account.

Considering the confirmed positive associations for academic performance-related parameters of hypothesis 2, the results are in accordance with the evidence of positive associations between PA and learning and educational success [ 6 ], as well as between PA breaks and better cognitive functioning [ 28 ]. Looking at the self-reported attention difficulties of hypothesis 2.A, only LTPA can counteract it. PA breaks showed no effects, contrary to the results of a study of Löffler and collegues (2011, [ 31 ]), in which acute effects of PA breaks could be found for higher attention and cognitive performance. Furthermore, the perception of study demands before the study periods has a positive impact on difficulties in attention. That means that overload in studies, time pressure during studies, and incompatibility of studies and private life leads to higher difficulties with attention in home studying. In these conditions, PA breaks might have been seen as interfering, resulting in the expected beneficial effects of exercise on attention and task-related participation behavior [ 72 , 73 ] therefore remaining undetected. With respect to the COVID-19 pandemic, accompanying education changes, and an increase in student´s worries [ 74 , 75 ], the perception of study demands could be affected. This suggests that especially in times of constraint and changes, it is important to promote PA in order to counteract attention difficulties. This also applies to post-pandemic phase.

Regarding the perceived academic performance of hypothesis 2.B, both PA breaks and LTPA have a positive effect on perceived study ability. This result confirms the positive short-term effects on cognition tasks [ 76 ]. It is also in line with the positive function of PA breaks in interrupting sedentary behavior and therefore counteracting the negative association between sitting behavior and lower cognitive performance [ 24 ]. Additionally, this result also fits with the previously mentioned positive relationship between LTPA and functional stress and between PA breaks and functional stress.

According to hypothesis 3, in relation to the mentioned stress load and recovery parameters, there are negative effects of the daily number of breaks during home studying and the longest stretch of time without a break spent on home studying on psychological detachment. As stressors result in negative activation, which impede psychological detachment from study during non-studying time [ 25 ], it was expected and confirmed that the longest stretch of time without a break spent on home studying has a negative effect on detachment. Initially unexpected, the number of breaks has a negative influence on psychological detachment, as breaks could prevent the accumulation of strain reactions. However, if the breaks had no recovery effect through successful detachment, the number might not have any influence on recovery via detachment. This is indicated by the PA breaks, which had no impact on psychological detachment. Since there are other ways to recover from stress besides psychological detachment, such as relaxation, mastery, and control [ 53 ], PA breaks must have had an additional impact in relation to the positive results for functional stress.

In relation to the mentioned academic performance-related parameters, only the number of breaks has a positive influence on the perceived study ability. This indicates that not only PA breaks but also breaks in general lead to better perceived functionality in studying. Paulus and colleagues (2021) found out that an increase in cognitive skills is not only attributed to PA breaks and standing breaks, but also to open breaks with no special instructions [ 28 ]. Either way, they found better improvement in self-perceived physical and psychological well-being of the university students with PA breaks than with open breaks. This is also reflected in the present study with the aforementioned positive effects of PA breaks on functional stress, which does not apply to the number of breaks.

Overall, it must be considered that the there is a more complex network of associations between the examined parameters. The hypothesized separate relation of PA with different parameters do not consider associations between parameters of stress load / recovery and academic performance although there might be a interdependency. Furthermore, moderation aspects were not examined. For example, PA could be a moderator which buffer negative effects of stress on the study ability [ 55 ]. Moreover, perceived study ability might moderate stress levels and academic performance. Further studies should try to approach and understand the different relationships between the parameters in its complexity.

Limitations

Certain limitations must be taken into account. Regarding the imbalanced design toward more female students in the sample (47 female versus 6 male), possible sampling bias cannot be excluded. Gender research on students' emotional states during COVID-19, when this study took place, or students´ acceptance of PA breaks is diverse and only partially supplied with inconsistent findings. For example, during the COVID-19 pandemic, some studies reported that female students were associated with lower well-being [ 71 ] or worse mental health trajectories [ 75 , 77 ]. Another study with a large sample of students from 62 countries reported that male students were more strongly affected by the pandemic because they were significantly less satisfied with their academic life [ 74 ]. However, Keating and colleges (2020) discovered that, despite the COVID-19 pandemic, females rated some aspects of PA breaks during lectures more positively than male students did. However, this was also based on a female slanted sample [ 78 ]. Further studies are needed to get more insights into gender bias.

Furthermore, the small sample size combined with up to 16% missing values comprises a significant short-coming. There were a lot of possibilities which could cause such missing data, like refused, forgotten or missed participation, technical problems, or deviation of the personal code for the questionnaire between survey times. Although the effects could be excluded by sensitive analysis due to missing data, the sample is still small. To generalize the findings, future replication studies are needed.

Additionally, PA breaks were only captured through participation in the ESD, the specially instructed PA break via video. Effects of other short PA breaks were not include in the study. However, participants were called to participate in ESD whenever possible, so the likelihood that they did take part in PA breaks in addition to the ESD could be ignored.

With respect to the baseline variables, it must be considered that two variables (stress load, attention difficulties) were adjusted not with their identical variable in T0, but with other conceptually associated variables (well-being index, BARI-S). Indeed, contrary to the assumption the well-being index does only show an association with functional stress, indicating that it does not control dysfunctional stress. Although the other three assumed associations were confirmed there might be a discrepancy between the daily measured variables and the variables measured in T0. Further studies should either proof the association between these used variables or measure the same variables in T0 for control the daily value of these variables.

Moreover, the measuring instruments comprised the self-assessed perception of the students and thus do not provide an objective information. This must be considered, especially for measuring cognitive and academic-performance-related measures. Here, existing objective tests, such as multiple choice exams after a video-taped lecture [ 72 ] might have also been used. Nevertheless, such methods were mostly used in a lab setting and do not reflect reality. Due to economic reasons and the natural learning environment, such procedures were not applied in this study. However, the circumstances of COVID-19 pandemic allowed a kind of lab setting in real life, as there were a lot of restrictions in daily life which limited the influence of other covariates. The study design provides a real natural home studying environment, producing results that are applicable to the healthy way that students learn in the real world. As this study took place under the conditions of COVID-19, new transformations in studying were also taken into account, as home studying and digital learning are increasingly part of everyday study.

However, the restrictions during the COVID-19 pandemic could result in a greater extent of leisure time per se. As the available leisure time in general was not measured on daily level, it is not possible to distinguish if the examined effects on the outcomes are purely attributable to PA. It is possible that being more physical active is the result of having a greater extent of leisure time and not that PA but the leisure time itself effected the examined outcomes. To address this issue in future studies, it is necessary to measure the proportion of PA in relation to the leisure time available.

Furthermore, due to the retrospective nature of the daily assessments of the variables, there may be overstated associations which must be taken into account. Anyway, the daily level of the study design provides advantages regarding the ability to observe changes in an individual's characteristics over the period of the study. This design made it possible to find out the necessity to analyze the hierarchical structure of the intraindividual data nested within the interindividual data. The performed multilevel analyses made it possible to reflect the outcome of an average student in the sample at his/her daily average behavior in PA and home study.

Conclusion and practical implications

The current findings confirm the importance of PA for university students` stress load, recovery experience, and academic performance-related parameters in home studying. Briefly summarized, it can be concluded that PA breaks positively affect stress load and perceived study ability. LTPA has a positive impact on stress load, recovery experience, and academic performance-related parameters regarding attention difficulties and perceived study ability. Following these results, universities should promote PA in both fashions in order to keep their students healthy and functioning: On the one hand, they should offer opportunities to be physically active in leisure time. This includes time, environment, and structural aspects. The university sport department, which offers sport courses and provides sport facilities on university campuses for students´ leisure time, is one good example. On the other hand, they should support PA breaks during the learning process and in the immediate location of study. This includes, for example, providing instructor videos for PA breaks to use while home studying, and furthermore having instructors to lead in-person PA breaks in on-site learning settings like universities´ libraries or even lectures and seminars. This not only promotes PA, but also reduces sedentary behavior and thereby reduces many other health risks. Further research should focus not only on the effect of PA behavior but also of sedentary behavior as well as the amount of leisure time per se. They should also try to implement objective measures for example on academic performance parameters and investigate different effect directions and possible moderation effects to get a deeper understanding of the complex network of associations in which PA plays a crucial role.

Availability of data and materials

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

Abbreviations

Attention and Performance Self-Assessment

"Berliner Anforderungen Ressourcen-Inventar – Studierende" (instrument for the perception of study demands and resources)

Centered within

Grand centered

“Erfassung von Emotionen und Beanspruchung “ (questionnaire containing a word list of adjectives for the recording of emotions and stress during work)

Exercise snack digital (special physical activity break offer)

Intra-Class-Correlation

Leisure time physical activity

  • Physical activity

Recovery Experience Questionnaire

Study ability index

World Health Organization-Five Well-being index

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Acknowledgements

We would like to thank Juliane Moll, research associate of the Student Health Management of University of Tübingen, for the support in the coordination and realization study. We would like to express our thanks also to Ingrid Arzberger, Head of University Sports at the University of Tübingen, for providing the resources and co-applying for the funding. We acknowledge support by Open Access Publishing Fund of University of Tübingen.

Open Access funding enabled and organized by Projekt DEAL. This research regarding the conduction of the study was funded by the Techniker Krankenkasse, health insurance fund.

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Authors and affiliations.

Institute of Sports Science, Faculty of Economics and Social Sciences, University of Tübingen, Tübingen, Germany

Monika Teuber, Daniel Leyhr & Gorden Sudeck

Methods Center, Faculty of Economics and Social Sciences, University of Tübingen, Tübingen, Germany

Daniel Leyhr

Interfaculty Research Institute for Sports and Physical Activity, University of Tübingen, Tübingen, Germany

Gorden Sudeck

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M.T. and G.S. designed the study. M.T. coordinated and carried out participant recruitment and data collection. M.T. analyzed the data and M.T. and D.L. interpreted the data. M.T. drafted the initial version of the manuscript and prepared the figure and all tables. All authors contributed to reviewing and editing the manuscript and have read and agreed to the final version of the manuscript.

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Teuber, M., Leyhr, D. & Sudeck, G. Physical activity improves stress load, recovery, and academic performance-related parameters among university students: a longitudinal study on daily level. BMC Public Health 24 , 598 (2024). https://doi.org/10.1186/s12889-024-18082-z

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Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates

  • Jacqueline Maria Dias 1 ,
  • Muhammad Arsyad Subu 1 ,
  • Nabeel Al-Yateem 1 ,
  • Fatma Refaat Ahmed 1 ,
  • Syed Azizur Rahman 1 , 2 ,
  • Mini Sara Abraham 1 ,
  • Sareh Mirza Forootan 1 ,
  • Farzaneh Ahmad Sarkhosh 1 &
  • Fatemeh Javanbakh 1  

BMC Nursing volume  23 , Article number:  322 ( 2024 ) Cite this article

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Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses’ sources of stress and coping styles in the Arab region, there is limited understanding of these stressors and coping strategies of nursing students within the UAE context thereby, highlighting the novelty and significance of the study.

A qualitative study was conducted using semi-structured interviews. Overall 30 students who were undergoing their first clinical placement in Year 2 at the University of Sharjah between May and June 2022 were recruited. All interviews were recorded and transcribed verbatim and analyzed for themes.

During their first clinical training, nursing students are exposed to stress from different sources, including the clinical environment, unfriendly clinical tutors, feelings of disconnection, multiple expectations of clinical staff and patients, and gaps between the curriculum of theory classes and labatories skills and students’ clinical experiences. We extracted three main themes that described students’ stress and use of coping strategies during clinical training: (1) managing expectations; (2) theory-practice gap; and (3) learning to cope. Learning to cope, included two subthemes: positive coping strategies and negative coping strategies.

Conclusions

This qualitative study sheds light from the students viewpoint about the intricate interplay between managing expectations, theory practice gap and learning to cope. Therefore, it is imperative for nursing faculty, clinical agencies and curriculum planners to ensure maximum learning in the clinical by recognizing the significance of the stressors encountered and help students develop positive coping strategies to manage the clinical stressors encountered. Further research is required look at the perspective of clinical stressors from clinical tutors who supervise students during their first clinical practicum.

Peer Review reports

Nursing education programmes aim to provide students with high-quality clinical learning experiences to ensure that nurses can provide safe, direct care to patients [ 1 ]. The nursing baccalaureate programme at the University of Sharjah is a four year program with 137 credits. The programmes has both theoretical and clinical components withs nine clinical courses spread over the four years The first clinical practicum which forms the basis of the study takes place in year 2 semester 2.

Clinical practice experience is an indispensable component of nursing education and links what students learn in the classroom and in skills laboratories to real-life clinical settings [ 2 , 3 , 4 ]. However, a gap exists between theory and practice as the curriculum in the classroom differs from nursing students’ experiences in the clinical nursing practicum [ 5 ]. Clinical nursing training places (or practicums, as they are commonly referred to), provide students with the necessary experiences to ensure that they become proficient in the delivery of patient care [ 6 ]. The clinical practicum takes place in an environment that combines numerous structural, psychological, emotional and organizational elements that influence student learning [ 7 ] and may affect the development of professional nursing competencies, such as compassion, communication and professional identity [ 8 ]. While clinical training is a major component of nursing education curricula, stress related to clinical training is common among students [ 9 ]. Furthermore, the nursing literature indicates that the first exposure to clinical learning is one of the most stressful experiences during undergraduate studies [ 8 , 10 ]. Thus, the clinical component of nursing education is considered more stressful than the theoretical component. Students often view clinical learning, where most learning takes place, as an unsupportive environment [ 11 ]. In addition, they note strained relationships between themselves and clinical preceptors and perceive that the negative attitudes of clinical staff produce stress [ 12 ].

The effects of stress on nursing students often involve a sense of uncertainty, uneasiness, or anxiety. The literature is replete with evidence that nursing students experience a variety of stressors during their clinical practicum, beginning with the first clinical rotation. Nursing is a complex profession that requires continuous interaction with a variety of individuals in a high-stress environment. Stress during clinical learning can have multiple negative consequences, including low academic achievement, elevated levels of burnout, and diminished personal well-being [ 13 , 14 ]. In addition, both theoretical and practical research has demonstrated that increased, continual exposure to stress leads to cognitive deficits, inability to concentrate, lack of memory or recall, misinterpretation of speech, and decreased learning capacity [ 15 ]. Furthermore, stress has been identified as a cause of attrition among nursing students [ 16 ].

Most sources of stress have been categorized as academic, clinical or personal. Each person copes with stress differently [ 17 ], and utilizes deliberate, planned, and psychological efforts to manage stressful demands [ 18 ]. Coping mechanisms are commonly termed adaptation strategies or coping skills. Labrague et al. [ 19 ] noted that students used critical coping strategies to handle stress and suggested that problem solving was the most common coping or adaptation mechanism used by nursing students. Nursing students’ coping strategies affect their physical and psychological well-being and the quality of nursing care they offer. Therefore, identifying the coping strategies that students use to manage stressors is important for early intervention [ 20 ].

Studies on nursing students’ coping strategies have been conducted in various countries. For example, Israeli nursing students were found to adopt a range of coping mechanisms, including talking to friends, engaging in sports, avoiding stress and sadness/misery, and consuming alcohol [ 21 ]. Other studies have examined stress levels among medical students in the Arab region. Chaabane et al. [ 15 ], conducted a systematic review of sudies in Arab countries, including Saudi Arabia, Egypt, Jordan, Iraq, Pakistan, Oman, Palestine and Bahrain, and reported that stress during clinical practicums was prevalent, although it could not be determined whether this was limited to the initial clinical course or occurred throughout clinical training. Stressors highlighted during the clinical period in the systematic review included assignments and workload during clinical practice, a feeling that the requirements of clinical practice exceeded students’ physical and emotional endurance and that their involvement in patient care was limited due to lack of experience. Furthermore, stress can have a direct effect on clinical performance, leading to mental disorders. Tung et al. [ 22 ], reported that the prevalence of depression among nursing students in Arab countries is 28%, which is almost six times greater than the rest of the world [ 22 ]. On the other hand, Saifan et al. [ 5 ], explored the theory-practice gap in the United Arab Emirates and found that clinical stressors could be decreased by preparing students better for clinical education with qualified clinical faculty and supportive preceptors.

The purpose of this study was to identify the stressors experienced by undergraduate nursing students in the United Arab Emirates during their first clinical training and the basic adaptation approaches or coping strategies they used. Recognizing or understanding different coping processes can inform the implementation of corrective measures when students experience clinical stress. The findings of this study may provide valuable information for nursing programmes, nurse educators, and clinical administrators to establish adaptive strategies to reduce stress among students going clinical practicums, particularly stressors from their first clinical training in different healthcare settings.

A qualitative approach was adopted to understand clinical stressors and coping strategies from the perspective of nurses’ lived experience. Qualitative content analysis was employed to obtain rich and detailed information from our qualitative data. Qualitative approaches seek to understand the phenomenon under study from the perspectives of individuals with lived experience [ 23 ]. Qualitative content analysis is an interpretive technique that examines the similarities and differences between and within different areas of text while focusing on the subject [ 24 ]. It is used to examine communication patterns in a repeatable and systematic way [ 25 ] and yields rich and detailed information on the topic under investigation [ 23 ]. It is a method of systematically coding and categorizing information and comprises a process of comprehending, interpreting, and conceptualizing the key meanings from qualitative data [ 26 ].

Setting and participants

This study was conducted after the clinical rotations ended in April 2022, between May and June in the nursing programme at the College of Health Sciences, University of Sharjah, in the United Arab Emirates. The study population comprised undergraduate nursing students who were undergoing their first clinical training and were recruited using purposive sampling. The inclusion criteria for this study were second-year nursing students in the first semester of clinical training who could speak English, were willing to participate in this research, and had no previous clinical work experience. The final sample consisted of 30 students.

Research instrument

The research instrument was a semi structured interview guide. The interview questions were based on an in-depth review of related literature. An intensive search included key words in Google Scholar, PubMed like the terms “nursing clinical stressors”, “nursing students”, and “coping mechanisms”. Once the questions were created, they were validated by two other faculty members who had relevant experience in mental health. A pilot test was conducted with five students and based on their feedback the following research questions, which were addressed in the study.

How would you describe your clinical experiences during your first clinical rotations?

In what ways did you find the first clinical rotation to be stressful?

What factors hindered your clinical training?

How did you cope with the stressors you encountered in clinical training?

Which strategies helped you cope with the clinical stressors you encountered?

Data collection

Semi-structured interviews were chosen as the method for data collection. Semi structured interviews are a well-established approach for gathering data in qualitative research and allow participants to discuss their views, experiences, attitudes, and beliefs in a positive environment [ 27 ]. This approach allows for flexibility in questioning thereby ensuring that key topics related to clinical learning stressors and coping strategies would be explored. Participants were given the opportunity to express their views, experiences, attitudes, and beliefs in a positive environment, encouraging open communication. These semi structured interviews were conducted by one member of the research team (MAS) who had a mental health background, and another member of the research team who attended the interviews as an observer (JMD). Neither of these researchers were involved in teaching the students during their clinical practicum, which helped to minimize bias. The interviews took place at the University of Sharjah, specifically in building M23, providing a familiar and comfortable environment for the participant. Before the interviews were all students who agreed to participate were provided with an explanation of the study’s purpose. The time and location of each interview were arranged. Before the interviews were conducted, all students who provided consent to participate received an explanation of the purpose of the study, and the time and place of each interview were arranged to accommodate the participants’ schedules and preferences. The interviews were conducted after the clinical rotation had ended in April, and after the final grades had been submitted to the coordinator. The timings of the interviews included the month of May and June which ensured that participants have completed their practicum experience and could reflect on the stressors more comprehensively. The interviews were audio-recorded with the participants’ consent, and each interview lasted 25–40 min. The data were collected until saturation was reached for 30 students. Memos and field notes were also recorded as part of the data collection process. These additional data allowed for triangulation to improve the credibility of the interpretations of the data [ 28 ]. Memos included the interviewers’ thoughts and interpretations about the interviews, the research process (including questions and gaps), and the analytic progress used for the research. Field notes were used to record the interviewers’ observations and reflections on the data. These additional data collection methods were important to guide the researchers in the interpretation of the data on the participants’ feelings, perspectives, experiences, attitudes, and beliefs. Finally, member checking was performed to ensure conformability.

Data analysis

The study used the content analysis method proposed by Graneheim and Lundman [ 24 ]. According to Graneheim and Lundman [ 24 ], content analysis is an interpretive technique that examines the similarities and differences between distinct parts of a text. This method allows researchers to determine exact theoretical and operational definitions of words, phrases, and symbols by elucidating their constituent properties [ 29 ]. First, we read the interview transcripts several times to reach an overall understanding of the data. All verbatim transcripts were read several times and discussed among all authors. We merged and used line-by-line coding of words, sentences, and paragraphs relevant to each other in terms of both the content and context of stressors and coping mechanisms. Next, we used data reduction to assess the relationships among themes using tables and diagrams to indicate conceptual patterns. Content related to stress encountered by students was extracted from the transcripts. In a separate document, we integrated and categorized all words and sentences that were related to each other in terms of both content and context. We analyzed all codes and units of meaning and compared them for similarities and differences in the context of this study. Furthermore, the emerging findings were discussed with other members of the researcher team. The final abstractions of meaningful subthemes into themes were discussed and agreed upon by the entire research team. This process resulted in the extraction of three main themes in addition to two subthemes related to stress and coping strategies.

Ethical considerations

The University of Sharjah Research Ethics Committee provided approval to conduct this study (Reference Number: REC 19-12-03-01-S). Before each interview, the goal and study procedures were explained to each participant, and written informed consent was obtained. The participants were informed that participation in the study was voluntary and that they could withdraw from the study at any time. In the event they wanted to withdraw from the study, all information related to the participant would be removed. No participant withdrew from the study. Furthermore, they were informed that their clinical practicum grade would not be affected by their participation in this study. We chose interview locations in Building M23that were private and quiet to ensure that the participants felt at ease and confident in verbalizing their opinions. No participant was paid directly for involvement in this study. In addition, participants were assured that their data would remain anonymous and confidential. Confidentiality means that the information provided by participants was kept private with restrictions on how and when data can be shared with others. The participants were informed that their information would not be duplicated or disseminated without their permission. Anonymity refers to the act of keeping people anonymous with respect to their participation in a research endeavor. No personal identifiers were used in this study, and each participant was assigned a random alpha-numeric code (e.g., P1 for participant 1). All digitally recorded interviews were downloaded to a secure computer protected by the principal investigator with a password. The researchers were the only people with access to the interview material (recordings and transcripts). All sensitive information and materials were kept secure in the principal researcher’s office at the University of Sharjah. The data will be maintained for five years after the study is completed, after which the material will be destroyed (the transcripts will be shredded, and the tapes will be demagnetized).

In total, 30 nursing students who were enrolled in the nursing programme at the Department of Nursing, College of Health Sciences, University of Sharjah, and who were undergoing their first clinical practicum participated in the study. Demographically, 80% ( n  = 24) were females and 20% ( n  = 6) were male participants. The majority (83%) of study participants ranged in age from 18 to 22 years. 20% ( n  = 6) were UAE nationals, 53% ( n  = 16) were from Gulf Cooperation Council countries, while 20% ( n  = 6) hailed from Africa and 7% ( n  = 2) were of South Asian descent. 67% of the respondents lived with their families while 33% lived in the hostel. (Table  1 )

Following the content analysis, we identified three main themes: (1) managing expectations, (2) theory-practice gap and 3)learning to cope. Learning to cope had two subthemes: positive coping strategies and negative coping strategies. An account of each theme is presented along with supporting excerpts for the identified themes. The identified themes provide valuable insight into the stressors encountered by students during their first clinical practicum. These themes will lead to targeted interventions and supportive mechanisms that can be built into the clinical training curriculum to support students during clinical practice.

Theme 1: managing expectations

In our examination of the stressors experienced by nursing students during their first clinical practicum and the coping strategies they employed, we identified the first theme as managing expectations.

The students encountered expectations from various parties, such as clinical staff, patients and patients’ relatives which they had to navigate. They attempted to fulfil their expectations as they progressed through training, which presented a source of stress. The students noted that the hospital staff and patients expected them to know how to perform a variety of tasks upon request, which made the students feel stressed and out of place if they did not know how to perform these tasks. Some participants noted that other nurses in the clinical unit did not allow them to participate in nursing procedures, which was considered an enormous impediment to clinical learning, as noted in the excerpt below:

“…Sometimes the nurses… They will not allow us to do some procedures or things during clinical. And sometimes the patients themselves don’t allow us to do procedures” (P5).

Some of the students noted that they felt they did not belong and felt like foreigners in the clinical unit. Excerpts from the students are presented in the following quotes;

“The clinical environment is so stressful. I don’t feel like I belong. There is too little time to build a rapport with hospital staff or the patient” (P22).

“… you ask the hospital staff for some guidance or the location of equipment, and they tell us to ask our clinical tutor …but she is not around … what should I do? It appears like we do not belong, and the sooner the shift is over, the better” (P18).

“The staff are unfriendly and expect too much from us students… I feel like I don’t belong, or I am wasting their (the hospital staff’s) time. I want to ask questions, but they have loads to do” (P26).

Other students were concerned about potential failure when working with patients during clinical training, which impacted their confidence. They were particularly afraid of failure when performing any clinical procedures.

“At the beginning, I was afraid to do procedures. I thought that maybe the patient would be hurt and that I would not be successful in doing it. I have low self-confidence in doing procedures” (P13).

The call bell rings, and I am told to answer Room No. XXX. The patient wants help to go to the toilet, but she has two IV lines. I don’t know how to transport the patient… should I take her on the wheelchair? My eyes glance around the room for a wheelchair. I am so confused …I tell the patient I will inform the sister at the nursing station. The relative in the room glares at me angrily … “you better hurry up”…Oh, I feel like I don’t belong, as I am not able to help the patient… how will I face the same patient again?” (P12).

Another major stressor mentioned in the narratives was related to communication and interactions with patients who spoke another language, so it was difficult to communicate.

“There was a challenge with my communication with the patients. Sometimes I have communication barriers because they (the patients) are of other nationalities. I had an experience with a patient [who was] Indian, and he couldn’t speak my language. I did not understand his language” (P9).

Thus, a variety of expectations from patients, relatives, hospital staff, and preceptors acted as sources of stress for students during their clinical training.

Theme 2: theory-practice gap

Theory-practice gaps have been identified in previous studies. In our study, there was complete dissonance between theory and actual clinical practice. The clinical procedures or practices nursing students were expected to perform differed from the theory they had covered in their university classes and skills lab. This was described as a theory–practice gap and often resulted in stress and confusion.

“For example …the procedures in the hospital are different. They are different from what we learned or from theory on campus. Or… the preceptors have different techniques than what we learned on campus. So, I was stress[ed] and confused about it” (P11).

Furthermore, some students reported that they did not feel that they received adequate briefing before going to clinical training. A related source of stress was overload because of the volume of clinical coursework and assignments in addition to clinical expectations. Additionally, the students reported that a lack of time and time management were major sources of stress in their first clinical training and impacted their ability to complete the required paperwork and assignments:

“…There is not enough time…also, time management at the hospital…for example, we start at seven a.m., and the handover takes 1 hour to finish. They (the nurses at the hospital) are very slow…They start with bed making and morning care like at 9.45 a.m. Then, we must fill [out] our assessment tool and the NCP (nursing care plan) at 10 a.m. So, 15 only minutes before going to our break. We (the students) cannot manage this time. This condition makes me and my friends very stressed out. -I cannot do my paperwork or assignments; no time, right?” (P10).

“Stressful. There is a lot of work to do in clinical. My experiences are not really good with this course. We have a lot of things to do, so many assignments and clinical procedures to complete” (P16).

The participants noted that the amount of required coursework and number of assignments also presented a challenge during their first clinical training and especially affected their opportunity to learn.

“I need to read the file, know about my patient’s condition and pathophysiology and the rationale for the medications the patient is receiving…These are big stressors for my learning. I think about assignments often. Like, we are just focusing on so many assignments and papers. We need to submit assessments and care plans for clinical cases. We focus our time to complete and finish the papers rather than doing the real clinical procedures, so we lose [the] chance to learn” (P25).

Another participant commented in a similar vein that there was not enough time to perform tasks related to clinical requirements during clinical placement.

“…there is a challenge because we do not have enough time. Always no time for us to submit papers, to complete assessment tools, and some nurses, they don’t help us. I think we need more time to get more experiences and do more procedures, reduce the paperwork that we have to submit. These are challenges …” (P14).

There were expectations that the students should be able to carry out their nursing duties without becoming ill or adversely affected. In addition, many students reported that the clinical environment was completely different from the skills laboratory at the college. Exposure to the clinical setting added to the theory-practice gap, and in some instances, the students fell ill.

One student made the following comment:

“I was assisting a doctor with a dressing, and the sight and smell from the oozing wound was too much for me. I was nauseated. As soon as the dressing was done, I ran to the bathroom and threw up. I asked myself… how will I survive the next 3 years of nursing?” (P14).

Theme 3: learning to cope

The study participants indicated that they used coping mechanisms (both positive and negative) to adapt to and manage the stressors in their first clinical practicum. Important strategies that were reportedly used to cope with stress were time management, good preparation for clinical practice, and positive thinking as well as engaging in physical activity and self-motivation.

“Time management. Yes, it is important. I was encouraging myself. I used time management and prepared myself before going to the clinical site. Also, eating good food like cereal…it helps me very much in the clinic” (P28).

“Oh yeah, for sure positive thinking. In the hospital, I always think positively. Then, after coming home, I get [to] rest and think about positive things that I can do. So, I will think something good [about] these things, and then I will be relieved of stress” (P21).

Other strategies commonly reported by the participants were managing their breathing (e.g., taking deep breaths, breathing slowly), taking breaks to relax, and talking with friends about the problems they encountered.

“I prefer to take deep breaths and breathe slowly and to have a cup of coffee and to talk to my friends about the case or the clinical preceptor and what made me sad so I will feel more relaxed” (P16).

“Maybe I will take my break so I feel relaxed and feel better. After clinical training, I go directly home and take a long shower, going over the day. I will not think about anything bad that happened that day. I just try to think about good things so that I forget the stress” (P27).

“Yes, my first clinical training was not easy. It was difficult and made me stressed out…. I felt that it was a very difficult time for me. I thought about leaving nursing” (P7).

I was not able to offer my prayers. For me, this was distressing because as a Muslim, I pray regularly. Now, my prayer time is pushed to the end of the shift” (P11).

“When I feel stress, I talk to my friends about the case and what made me stressed. Then I will feel more relaxed” (P26).

Self-support or self-motivation through positive self-talk was also used by the students to cope with stress.

“Yes, it is difficult in the first clinical training. When I am stress[ed], I go to the bathroom and stand in the front of the mirror; I talk to myself, and I say, “You can do it,” “you are a great student.” I motivate myself: “You can do it”… Then, I just take breaths slowly several times. This is better than shouting or crying because it makes me tired” (P11).

Other participants used physical activity to manage their stress.

“How do I cope with my stress? Actually, when I get stressed, I will go for a walk on campus” (P4).

“At home, I will go to my room and close the door and start doing my exercises. After that, I feel the negative energy goes out, then I start to calm down… and begin my clinical assignments” (P21).

Both positive and negative coping strategies were utilized by the students. Some participants described using negative coping strategies when they encountered stress during their clinical practice. These negative coping strategies included becoming irritable and angry, eating too much food, drinking too much coffee, and smoking cigarettes.

“…Negative adaptation? Maybe coping. If I am stressed, I get so angry easily. I am irritable all day also…It is negative energy, right? Then, at home, I am also angry. After that, it is good to be alone to think about my problems” (P12).

“Yeah, if I…feel stress or depressed, I will eat a lot of food. Yeah, ineffective, like I will be eating a lot, drinking coffee. Like I said, effective, like I will prepare myself and do breathing, ineffective, I will eat a lot of snacks in between my free time. This is the bad side” (P16).

“…During the first clinical practice? Yes, it was a difficult experience for us…not only me. When stressed, during a break at the hospital, I will drink two or three cups of coffee… Also, I smoke cigarettes… A lot. I can drink six cups [of coffee] a day when I am stressed. After drinking coffee, I feel more relaxed, I finish everything (food) in the refrigerator or whatever I have in the pantry, like chocolates, chips, etc” (P23).

These supporting excerpts for each theme and the analysis offers valuable insights into the specific stressors faced by nursing students during their first clinical practicum. These insights will form the basis for the development of targeted interventions and supportive mechanisms within the clinical training curriculum to better support students’ adjustment and well-being during clinical practice.

Our study identified the stressors students encounter in their first clinical practicum and the coping strategies, both positive and negative, that they employed. Although this study emphasizes the importance of clinical training to prepare nursing students to practice as nurses, it also demonstrates the correlation between stressors and coping strategies.The content analysis of the first theme, managing expectations, paves the way for clinical agencies to realize that the students of today will be the nurses of tomorrow. It is important to provide a welcoming environment where students can develop their identities and learn effectively. Additionally, clinical staff should foster an environment of individualized learning while also assisting students in gaining confidence and competence in their repertoire of nursing skills, including critical thinking, problem solving and communication skills [ 8 , 15 , 19 , 30 ]. Another challenge encountered by the students in our study was that they were prevented from participating in clinical procedures by some nurses or patients. This finding is consistent with previous studies reporting that key challenges for students in clinical learning include a lack of clinical support and poor attitudes among clinical staff and instructors [ 31 ]. Clinical staff with positive attitudes have a positive impact on students’ learning in clinical settings [ 32 ]. The presence, supervision, and guidance of clinical instructors and the assistance of clinical staff are essential motivating components in the clinical learning process and offer positive reinforcement [ 30 , 33 , 34 ]. Conversely, an unsupportive learning environment combined with unwelcoming clinical staff and a lack of sense of belonging negatively impact students’ clinical learning [ 35 ].

The sources of stress identified in this study were consistent with common sources of stress in clinical training reported in previous studies, including the attitudes of some staff, students’ status in their clinical placement and educational factors. Nursing students’ inexperience in the clinical setting and lack of social and emotional experience also resulted in stress and psychological difficulties [ 36 ]. Bhurtun et al. [ 33 ] noted that nursing staff are a major source of stress for students because the students feel like they are constantly being watched and evaluated.

We also found that students were concerned about potential failure when working with patients during their clinical training. Their fear of failure when performing clinical procedures may be attributable to low self-confidence. Previous studies have noted that students were concerned about injuring patients, being blamed or chastised, and failing examinations [ 37 , 38 ]. This was described as feeling “powerless” in a previous study [ 7 , 12 ]. In addition, patients’ attitudes towards “rejecting” nursing students or patients’ refusal of their help were sources of stress among the students in our study and affected their self-confidence. Self-confidence and a sense of belonging are important for nurses’ personal and professional identity, and low self-confidence is a problem for nursing students in clinical learning [ 8 , 39 , 40 ]. Our findings are consistent with a previous study that reported that a lack of self-confidence was a primary source of worry and anxiety for nursing students and affected their communication and intention to leave nursing [ 41 ].

In the second theme, our study suggests that students encounter a theory-practice gap in clinical settings, which creates confusion and presents an additional stressors. Theoretical and clinical training are complementary elements of nursing education [ 40 ], and this combination enables students to gain the knowledge, skills, and attitudes necessary to provide nursing care. This is consistent with the findings of a previous study that reported that inconsistencies between theoretical knowledge and practical experience presented a primary obstacle to the learning process in the clinical context [ 42 ], causing students to lose confidence and become anxious [ 43 ]. Additionally, the second theme, the theory-practice gap, authenticates Safian et al.’s [ 5 ] study of the theory-practice gap that exists United Arab Emirates among nursing students as well as the need for more supportive clinical faculty and the extension of clinical hours. The need for better time availability and time management to complete clinical tasks were also reported by the students in the study. Students indicated that they had insufficient time to complete clinical activities because of the volume of coursework and assignments. Our findings support those of Chaabane et al. [ 15 ]. A study conducted in Saudi Arabia [ 44 ] found that assignments and workload were among the greatest sources of stress for students in clinical settings. Effective time management skills have been linked to academic achievement, stress reduction, increased creativity [ 45 ], and student satisfaction [ 46 ]. Our findings are also consistent with previous studies that reported that a common source of stress among first-year students was the increased classroom workload [ 19 , 47 ]. As clinical assignments and workloads are major stressors for nursing students, it is important to promote activities to help them manage these assignments [ 48 ].

Another major challenge reported by the participants was related to communicating and interacting with other nurses and patients. The UAE nursing workforce and population are largely expatriate and diverse and have different cultural and linguistic backgrounds. Therefore, student nurses encounter difficulty in communication [ 49 ]. This cultural diversity that students encounter in communication with patients during clinical training needs to be addressed by curriculum planners through the offering of language courses and courses on cultural diversity [ 50 ].

Regarding the third and final theme, nursing students in clinical training are unable to avoid stressors and must learn to cope with or adapt to them. Previous research has reported a link between stressors and the coping mechanisms used by nursing students [ 51 , 52 , 53 ]. In particular, the inability to manage stress influences nurses’ performance, physical and mental health, attitude, and role satisfaction [ 54 ]. One such study suggested that nursing students commonly use problem-focused (dealing with the problem), emotion-focused (regulating emotion), and dysfunctional (e.g., venting emotions) stress coping mechanisms to alleviate stress during clinical training [ 15 ]. Labrague et al. [ 51 ] highlighted that nursing students use both active and passive coping techniques to manage stress. The pattern of clinical stress has been observed in several countries worldwide. The current study found that first-year students experienced stress during their first clinical training [ 35 , 41 , 55 ]. The stressors they encountered impacted their overall health and disrupted their clinical learning. Chaabane et al. [ 15 ] reported moderate and high stress levels among nursing students in Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. Another study from Bahrain reported that all nursing students experienced moderate to severe stress in their first clinical placement [ 56 ]. Similarly, nursing students in Spain experienced a moderate level of stress, and this stress was significantly correlated with anxiety [ 30 ]. Therefore, it is imperative that pastoral systems at the university address students’ stress and mental health so that it does not affect their clinical performance. Faculty need to utilize evidence-based interventions to support students so that anxiety-producing situations and attrition are minimized.

In our study, students reported a variety of positive and negative coping mechanisms and strategies they used when they experienced stress during their clinical practice. Positive coping strategies included time management, positive thinking, self-support/motivation, breathing, taking breaks, talking with friends, and physical activity. These findings are consistent with those of a previous study in which healthy coping mechanisms used by students included effective time management, social support, positive reappraisal, and participation in leisure activities [ 57 ]. Our study found that relaxing and talking with friends were stress management strategies commonly used by students. Communication with friends to cope with stress may be considered social support. A previous study also reported that people seek social support to cope with stress [ 58 ]. Some students in our study used physical activity to cope with stress, consistent with the findings of previous research. Stretching exercises can be used to counteract the poor posture and positioning associated with stress and to assist in reducing physical tension. Promoting such exercise among nursing students may assist them in coping with stress in their clinical training [ 59 ].

Our study also showed that when students felt stressed, some adopted negative coping strategies, such as showing anger/irritability, engaging in unhealthy eating habits (e.g., consumption of too much food or coffee), or smoking cigarettes. Previous studies have reported that high levels of perceived stress affect eating habits [ 60 ] and are linked to poor diet quality, increased snacking, and low fruit intake [ 61 ]. Stress in clinical settings has also been linked to sleep problems, substance misuse, and high-risk behaviors’ and plays a major role in student’s decision to continue in their programme.

Implications of the study

The implications of the study results can be grouped at multiple levels including; clinical, educational, and organizational level. A comprehensive approach to addressing the stressors encountered by nursing students during their clinical practicum can be overcome by offering some practical strategies to address the stressors faced by nursing students during their clinical practicum. By integrating study findings into curriculum planning, mentorship programs, and organizational support structures, a supportive and nurturing environment that enhances students’ learning, resilience, and overall success can be envisioned.

Clinical level

Introducing simulation in the skills lab with standardized patients and the use of moulage to demonstrate wounds, ostomies, and purulent dressings enhances students’ practical skills and prepares them for real-world clinical scenarios. Organizing orientation days at clinical facilities helps familiarize students with the clinical environment, identify potential stressors, and introduce interventions to enhance professionalism, social skills, and coping abilities Furthermore, creating a WhatsApp group facilitates communication and collaboration among hospital staff, clinical tutors, nursing faculty, and students, enabling immediate support and problem-solving for clinical situations as they arise, Moreover, involving chief nursing officers of clinical facilities in the Nursing Advisory Group at the Department of Nursing promotes collaboration between academia and clinical practice, ensuring alignment between educational objectives and the needs of the clinical setting [ 62 ].

Educational level

Sharing study findings at conferences (we presented the results of this study at Sigma Theta Tau International in July 2023 in Abu Dhabi, UAE) and journal clubs disseminates knowledge and best practices among educators and clinicians, promoting awareness and implementation of measures to improve students’ learning experiences. Additionally we hold mentorship training sessions annually in January and so we shared with the clinical mentors and preceptors the findings of this study so that they proactively they are equipped with strategies to support students’ coping with stressors during clinical placements.

Organizational level

At the organizational we relooked at the available student support structures, including counseling, faculty advising, and career advice, throughout the nursing program emphasizing the importance of holistic support for students’ well-being and academic success as well as retention in the nursing program. Also, offering language courses as electives recognizes the value of communication skills in nursing practice and provides opportunities for personal and professional development.

For first-year nursing students, clinical stressors are inevitable and must be given proper attention. Recognizing nursing students’ perspectives on the challenges and stressors experienced in clinical training is the first step in overcoming these challenges. In nursing schools, providing an optimal clinical environment as well as increasing supervision and evaluation of students’ practices should be emphasized. Our findings demonstrate that first-year nursing students are exposed to a variety of different stressors. Identifying the stressors, pressures, and obstacles that first-year students encounter in the clinical setting can assist nursing educators in resolving these issues and can contribute to students’ professional development and survival to allow them to remain in the profession. To overcome stressors, students frequently employ problem-solving approaches or coping mechanisms. The majority of nursing students report stress at different levels and use a variety of positive and negative coping techniques to manage stress.

The present results may not be generalizable to other nursing institutions because this study used a purposive sample along with a qualitative approach and was limited to one university in the Middle East. Furthermore, the students self-reported their stress and its causes, which may have introduced reporting bias. The students may also have over or underreported stress or coping mechanisms because of fear of repercussions or personal reasons, even though the confidentiality of their data was ensured. Further studies are needed to evaluate student stressors and coping now that measures have been introduced to support students. Time will tell if these strategies are being used effectively by both students and clinical personnel or if they need to be readdressed. Finally, we need to explore the perceptions of clinical faculty towards supervising students in their first clinical practicum so that clinical stressors can be handled effectively.

Data availability

The data sets are available with the corresponding author upon reasonable request.

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The authors are grateful to all second year nursing students who voluntarily participated in the study.

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Jacqueline Maria Dias, Muhammad Arsyad Subu, Nabeel Al-Yateem, Fatma Refaat Ahmed, Syed Azizur Rahman, Mini Sara Abraham, Sareh Mirza Forootan, Farzaneh Ahmad Sarkhosh & Fatemeh Javanbakh

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JMD conceptualized the idea and designed the methodology, formal analysis, writing original draft and project supervision and mentoring. MAS prepared the methodology and conducted the qualitative interviews and analyzed the methodology and writing of original draft and project supervision. NY, FRA, SAR, MSA writing review and revising the draft. SMF, FAS, FJ worked with MAS on the formal analysis and prepared the first draft.All authors reviewed the final manuscipt of the article.

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Dias, J.M., Subu, M.A., Al-Yateem, N. et al. Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates. BMC Nurs 23 , 322 (2024). https://doi.org/10.1186/s12912-024-01962-5

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Are We Talking Too Much About Mental Health?

Recent studies cast doubt on whether large-scale mental health interventions are making young people better. Some even suggest they can have a negative effect.

A portrait of Lucy Foulkes, who wears a gray sweater and black pants and sits on a bench in a garden area outside a building.

By Ellen Barry

In recent years, mental health has become a central subject in childhood and adolescence. Teenagers narrate their psychiatric diagnosis and treatment on TikTok and Instagram. School systems, alarmed by rising levels of distress and self-harm, are introducing preventive coursework in emotional self-regulation and mindfulness.

Now, some researchers warn that we are in danger of overdoing it. Mental health awareness campaigns, they argue, help some young people identify disorders that badly need treatment — but they have a negative effect on others, leading them to over-interpret their symptoms and see themselves as more troubled than they are.

The researchers point to unexpected results in trials of school-based mental health interventions in the United Kingdom and Australia: Students who underwent training in the basics of mindfulness , cognitive behavioral therapy and dialectical behavior therapy did not emerge healthier than peers who did not participate, and some were worse off, at least for a while.

And new research from the United States shows that among young people, “self-labeling” as having depression or anxiety is associated with poor coping skills, like avoidance or rumination.

In a paper published last year , two research psychologists at the University of Oxford, Lucy Foulkes and Jack Andrews, coined the term “prevalence inflation” — driven by the reporting of mild or transient symptoms as mental health disorders — and suggested that awareness campaigns were contributing to it.

“It’s creating this message that teenagers are vulnerable, they’re likely to have problems, and the solution is to outsource them to a professional,” said Dr. Foulkes, a Prudence Trust Research Fellow in Oxford’s department of experimental psychology, who has written two books on mental health and adolescence.

Until high-quality research has clarified these unexpected negative effects, they argue, school systems should proceed cautiously with large-scale mental health interventions.

“It’s not that we need to go back to square one, but it’s that we need to press pause and reroute potentially,” Dr. Foulkes said. “It’s possible that something very well-intended has overshot a bit and needs to be brought back in.”

This remains a minority view among specialists in adolescent mental health, who mostly agree that the far more urgent problem is lack of access to treatment.

About 60 percent of young Americans with severe depression receive no treatment, according to Mental Health America, a nonprofit research group. In crisis, desperate families fall back on emergency rooms, where teens often remain for days before a psychiatric bed opens up. There is good reason to embrace a preventive approach, teaching schoolchildren basic skills that might forestall crises later, experts say.

Dr. Foulkes said she understood that her argument runs counter to that consensus, and when she began to present it, she braced for a backlash. To her surprise, she said, many educators reached out to express quiet agreement.

“There’s definitely a fear about being the one to say it,” she said.

A deflating result

In the summer of 2022, the results of a landmark study on mindfulness training in British classrooms landed — like a lead balloon.

The trial, My Resilience in Adolescence, or MYRIAD, was ambitious, meticulous and expansive, following about 28,000 teenagers over eight years. It had been launched in a glow of optimism that the practice would pay off, improving the students’ mental health outcomes in later years.

Half of the teenagers were trained by their teachers to direct their attention to the present moment — breathing, physical sensations or everyday activities — in 10 lessons of 30 to 50 minutes apiece.

The results were disappointing . The authors reported “no support for our hypothesis” that mindfulness training would improve students’ mental health. In fact, students at highest risk for mental health problems did somewhat worse after receiving the training, the authors concluded.

But by the end of the eight-year project, “mindfulness is already embedded in a lot of schools, and there are already organizations making money from selling this program to schools,” said Dr. Foulkes, who had assisted on the study as a postdoctoral research associate. “And it’s very difficult to get the scientific message out there.”

Why, one might ask, would a mental health program do harm?

Researchers in the study speculated that the training programs “bring awareness to upsetting thoughts,” encouraging students to sit with darker feelings, but without providing solutions, especially for societal problems like racism or poverty. They also found that the students didn’t enjoy the sessions and didn’t practice at home.

Another explanation is that mindfulness training could encourage “co-rumination,” the kind of long, unresolved group discussion that churns up problems without finding solutions.

As the MYRIAD results were being analyzed, Dr. Andrews led an evaluation of Climate Schools, an Australian intervention based on the principles of cognitive behavioral therapy, in which students observed cartoon characters navigating mental health concerns and then answered questions about practices to improve mental health.

Here, too, he found negative effects. Students who had taken the course reported higher levels of depression and anxiety symptoms six months and 12 months later.

Co-rumination appears to be higher in girls, who tend to come into the program more distressed, as well as more attuned to their friends, he said. “It might be,” he said, “that they kind of get together and make things a little bit worse for each other.”

Dr. Andrews, a Wellcome Trust research fellow, has since joined an effort to improve Climate Schools by addressing negative effects. And he has concluded that schools should slow down until “we know the evidence base a bit more.” Sometimes, he said, “doing nothing is better than doing something.”

The awareness paradox

One problem with mental health awareness, some research suggests, is that it may not help to put a label to your symptoms.

Isaac Ahuvia, a doctoral candidate at Stony Brook University, recently tested this in a study of 1,423 college students . Twenty-two percent “self-labeled” as having depression, telling researchers “I am depressed” or “I have depression,” but 39 percent met the diagnostic criteria for depression.

He found that the students who self-labeled felt that they had less control over depression and were more likely to catastrophize and less likely to respond to distress by putting their difficulties in perspective, compared with peers who had similar depression symptoms.

Jessica L. Schleider, a co-author of the self-labeling study, said this was no surprise. People who self-label “appear to be viewing depression as a biological inevitability,” she said. “People who don’t view emotions as malleable, view them as set and stuck and uncontrollable, tend to cope less well because they don’t see a point to trying.”

But Dr. Schleider, an associate professor of medical social sciences at Northwestern University and the director of the university’s Lab for Scalable Mental Health, pushed back on the prevalence inflation hypothesis. She disagreed with the claim that students are overdiagnosing themselves, noting that Mr. Ahuvia’s findings suggest otherwise.

Awareness campaigns are bound to have multiple effects, helping some students and not others. And ultimately, she argued, the priority for public health should be reaching young people in the most distress.

“The urgency of the mental health crisis is so clear,” she said. “In the partnerships that I have, the emphasis is on the kids truly struggling right now who have nothing — we need to help them — more so than a possible risk for a subset of kids who aren’t really struggling.”

Maybe, she said, we need to look beyond the “universal, school-assembly-style approach,” to targeted, light-touch interventions, which research has shown can be effective at decreasing anxiety and conduct disorders, especially in younger children.

“There is a risk of throwing the baby out with the bathwater,” Dr. Schleider said. “The response can’t be ‘Forget all of it.’ It should be ‘What about this intervention was unhelpful?’”

Other researchers echoed her concern, pointing to studies that show that on average, students benefit from social and emotional learning courses.

One of the largest, a 2023 meta-analysis of 252 classroom programs in 53 countries, found that students who participated performed better academically, displayed better social skills and had lower levels of emotional distress or behavioral problems. In that context, negative effects in a handful of trials appear modest, the researchers said.

“We clearly have not figured out how to do them yet, but I can’t imagine any population-based intervention that the field got right the first time,” said Dr. Andrew J. Gerber, the president and medical director of Silver Hill Hospital and a practicing child and adolescent psychiatrist.

“Really, if you think about almost everything we do in schools, we don’t have great evidence for it working,” he added. “That doesn’t mean we don’t do it. It just means that we’re constantly thinking about ways to improve it.”

‘We want everyone to have it’

These debates are taking place a long way away from classrooms, where mental health curriculums are increasingly commonplace.

Allyson Kangisser, a counselor at Woodsdale Elementary School in Wheeling, W.Va., said the focus in her school is on basic coping skills. In the early grades, students are asked, “What things can you do to take care of yourself when you’re having big feelings?”

Starting in third grade, they take on more complex material, such as watching cartoon characters to distinguish transient stress from chronic conditions like depression. “We’re not trying to have them diagnose themselves,” Ms. Kangisser said. “We are saying, what do you feel — this one? Or this one?”

At the school’s sixth annual mental health fair last month, Woodsdale students walked through a giant inflatable brain, its lobes neatly labeled. They did yoga stretches and talked about regulating their emotions. Ms. Kangisser said the event is valuable precisely because it is universal, so troubled children are not singled out.

“The mental health fair, everybody does it,” she said. “It’s not ‘You need it, and you don’t.’ We want everyone to have it, because you just never know.”

By the time the students reach college, they will have absorbed enormous amounts of information about mental health — from school, but also from social media and from one another.

Dr. Jessica Gold, chief wellness officer for the University of Tennessee system, said the college students she sees are recognizably different — more comfortable speaking about their emotions and more willing to be vulnerable. They also overuse diagnostic terms and have the self-assurance to question a psychiatrist’s judgment.

“It’s sort of a double-edged sword,” she said. “We want people to talk about this more, but we don’t want that to lead to overdiagnosis or incorrect diagnosis or overtreatment. We want it to lead to normalizing of having feelings.”

Lucy Kim, a Yale senior who has lobbied for better mental health support on campus, described the prevalence inflation hypothesis as “disheartening, dismissive and potentially dangerous,” providing another way to discount the experiences of young people.

“As a college student, I see a generation of young people around me impacted by a depth and breadth of loneliness, exhaustion and disillusionment suggestive of a malaise that goes deeper than the general vicissitudes of life,” said Ms. Kim, 23.

Overdiagnosis does happen, she said, and so does glorification of mental health disorders. But stigma and barriers to treatment remain the bigger problem. “I can confidently say I have never heard anyone respond to disclosures of depression with ‘That’s so cool, I wish I had that, too,’” she said.

Ellen Barry is a reporter covering mental health for The Times. More about Ellen Barry

Managing Anxiety and Stress

Stay balanced in the face of stress and anxiety with our collection of tools and advice..

How are you, really? This self-guided check-in will help you take stock of your emotional well-being — and learn how to make changes .

These simple and proven strategies will help you manage stress , support your mental health and find meaning in the new year.

First, bring calm and clarity into your life with these 10 tips . Next, identify what you are dealing with: Is it worry, anxiety or stress ?

Persistent depressive disorder is underdiagnosed, and many who suffer from it have never heard of it. Here is what to know .

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How much anxiety is too much? Here is how to establish whether you should see a professional about it .

ORIGINAL RESEARCH article

Living in fear at the unpredictability of mental health issues in the classroom: a phenomenological study of secondary school teachers in encountering students with mental health issues.

Mining Liang,,*

  • 1 School of Nursing, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
  • 2 Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, China
  • 3 The Interdisciplinary Centre for Qualitative Research, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China

Background: The prevalence of mental health issues among secondary school students is on the rise. Secondary school teachers, outside the home environment, are often in a prime position to identify adolescents facing mental health challenges. Limited knowledge regarding the experiences and perspectives of secondary school teachers when encountering this particular group of students, particularly in Asian countries.

Objectives: This study aimed to describe the lived experiences of secondary school teachers exposed to students with mental health issues in the classroom in a Chinese context.

Methods: A descriptive phenomenological approach within the tradition of Husserl was used. A purposive sampling method was used to collect the participants in Changsha, Hunan, China. Sixteen secondary school teachers participated in this study. Individual, face-to-face interviews were conducted, tape-recorded, and transcripted. Colaizzi’s seven-step descriptive phenomenological method was used to do the data analysis.

Results: One Central theme: Living in fear at the unpredictability of mental health issues in the classroom and four sub-themes emerged: (1) Worried and anxious by the uncertainty of student mental health issues; (2) Scared and afraid by students’ unpredictable behaviors; (3) Afraid of students’ failure and its potential outcome; (4) Students having mental health issues are dangerous.

Conclusions and implications: The teachers in this study found managing the unpredictability of mental health issues in the classroom deeply distressing and challenging. A comprehensive approach to address the cultural, social, and educational factors influencing secondary school teachers’ experiences is encouraged.

1 Introduction

Over the past few years, there has been a growing global concern regarding the increasing prevalence of mental health issues among secondary school students. This rising trend not only has an impact on the academic performance of students but also affects their general well-being and long-term life outcomes ( 1 ). Abundant research suggests that approximately 20% of adolescents experience a diagnosable mental disorder, and around 50% of all lifetime cases of mental illness commence before the age of 14 ( 2 ). The intricate interaction of biological, psychological, and social factors during the adolescent developmental stage makes teenagers especially susceptible to mental health difficulties. Furthermore, the present-day environment, marked by heightened academic demands, cyberbullying, and societal expectations, has additionally contributed to the escalation of mental health issues among young individuals ( 3 ).

Based on Bronfenbrenner’s ecological systems theory, schools (along with other microsystems, including the family) are the most immediate developmental context for adolescents ( 4 ). Teachers are expected to play a significant role in school mental health. However, previous studies found that secondary school teachers experience the challenges by observing students with mental health issues ( 5 – 7 ). Secondary school teachers mostly rely on their prior training or judgment to identify students with mental health issues ( 8 ). In addition, criteria reported by secondary school teachers in China, such as “tired of learning”, “rebellious”, and “falling in love” at a young age, none of these would be considered to be a symptoms of mental illness by mental health professionals, however, some established signs of mental illness appeared to be normalized by some teachers, such as “self-harm” ( 9 ). Indeed, secondary school teachers were just trying their best to identify students with mental health issues despite not knowing what they were doing. Therefore, it is vital to explore their lived experience when encountering adolescents with mental health issues.

Although Western scholars have used a variety of qualitative research methods to examine teachers’ experiences from different perspectives, limited studies have been conducted in the Asian context. The Chinese government has recognized the importance of mental health in schools and has implemented various policies to promote mental health well-being. However, the school mental health system in China faces several challenges: There is often a shortage of trained mental health professionals in schools, the quality and availability of mental health services can vary significantly between different regions and schools. Moreover, as there is a difference in the education system and culture in the Chinese context, the secondary school teachers’ experience of encountering students’ mental health in China could be very different. Therefore, this study aims to understand secondary school teachers’ lived experiences of encountering students with mental health issues in a Chinese context.

2.1 Research question

What is the experience of encountering students with mental health issues in the classroom?

Based on Husserlian descriptive phenomenology ( 10 ), this study aims to understand the essence of encountering students with mental health issues based on the lived experience of secondary school teachers. This study was conducted in Changsha City, Hunan, China. China is a country where public education is the mainstay, with approximately 82% of students enrolled in public institutions. Therefore, secondary school teachers interviewed for this study all come from public schools in Changsha City.

2.3 Data collection and sampling

To select the participants for this study, purposive sampling was used. The inclusion criterion for this study was individuals who were particularly familiar with or experienced in a relevant phenomenon. In this context, the relevant phenomenon refers to secondary school teachers who had supported students with psychological issues ( 11 ). Sixteen secondary school teachers voluntarily participated in the study. Each participant was invited for a 45–60 minute face-to-face interview, which was audio-recorded. Subsequently, the recorded interviews were transcribed verbatim, and the accuracy of the transcripts was verified by comparing them with the original audio recordings. The interview had been completed when data saturation is achieved. Saturation means there was a sufficient understanding of the phenomenon. The interviews were conducted by the first author, who used to work as a psychiatric nurse in a public hospital. The study received ethical approval from the Hong Kong Polytechnic University’s Human Research Ethics Committee (HSEARS20221215002).

2.4 Data analysis

The transcripts underwent an initial reading using Colazzi’s seven-step analysis method to gain a comprehensive understanding of the data ( 12 ). Phenomenological reduction was employed during this stage to ensure that the author’s personal experiences did not influence the interpretation of the data. Following Whitting’s approach, meaningful units within the transcripts were identified, leading to the development of significant statements ( 13 ). These statements were then formulated into meaningful themes, which were further organized into theme clusters. Ultimately, a central theme emerged from the analysis. Throughout this process, reflection was crucial in ensuring that the formulated meanings, sub-themes, and central themes accurately reflected the phenomenon being investigated (refer to Appendix Table 1 for further details).

3.1 Participants’ socio-demographic characteristics

The mean age of secondary school teachers was 40.06 years old, and the mean teaching period in secondary school was 16.63 years. There were 11 female teachers and 5 male teachers. The teaching subjects were Math, English, Biology, Physics, Chemistry, Geograph, Computer, Political, etc. ( Appendix Table 2 ).

3.2 Findings regarding secondary school teachers’ experiences

One central theme was formed: living in fear at the unpredictability of mental health issues in the classroom. Four sub-theme were: “Worried and anxious by the uncertainty of student mental health issues”; “ Scared and afraid by students’ unpredictable behaviors”; “ Afraid of students’ failure and its potential outcome”; “Students having mental health issues are dangerous”.

3.2.1 Worried and anxious by the uncertainty of student mental health issues

The participant highlighted the uncertainty of when these students may face problems. Many of them acknowledged that initially, they may not be aware of the students’ mental health issues. Some of the participants further explained that under normal circumstances, students with mental health issues tended to exhibit reserved behavior in the classroom. The participant described those students as a “transparent” presence in the classroom, meaning that they were easily overlooked or blended into the background. This can be challenging for teachers as they may not be fully aware of the specific challenges these students face or how their mental health issues may manifest. As a result, it became difficult for teachers to anticipate or predict the situations that may arise when these students were dealing with mental health problems. As Guoa and Luo stated:

You never know when they might encounter problems. Therefore, you must constantly pay attention to them. Initially, we may not be aware that these children have mental health issues. (Guo) In regular circumstances, due to his classroom behavior, he tends to be introverted. However, his behavior does not significantly impact the overall pace of the class or the teacher’s instruction. In the classroom , he is not the type to actively participate in answering questions, but he also does not disrupt the order of the class. Therefore, in the classroom, he somewhat resembles a ‘transparent’ presence. (Luo)

The teacher also expressed surprise and a sense of disbelief because the unwell student did not exhibit any previous indications or signs of mental health issues. They acknowledged that educators may not possess the professional expertise to fully comprehend what was happening inside a student’s mind. Additionally, they noted that another challenging part was that issues could only be identified after they had already happened. As Liao said:

I was surprised because the student did not show any signs of this situation before. I genuinely thought he was a normal person. Usually, whether he was interacting with teachers, other children, or classmates, he appeared very normal and behaved in a typical manner. (Liao)

Moreover, the participant expressed a genuine feeling of being overwhelmed and inadequate in handling the situation when students had suicidal thoughts. They mentioned that the suicide attempt signs were extremely subtle, especially given the heavy workload of being a teacher. They felt that the sheer volume of tasks makes it difficult to effectively address the subtle signs exhibited by students. Additionally, they highlighted that students did not directly seek help in an obvious manner but instead hint at their issues indirectly. As a result, the participant found it particularly challenging to navigate the complexities of the situation. As Chen mensioned:

I genuinely feel that I am unable to handle it because it’s simply impossible to find out, right? Some signs are subtle, especially with the workload of being a head teacher being so heavy. There are various tedious tasks, constant complaints, numerous activities, meetings to attend, and still the need to teach classes. There are just too many things to handle. It is really difficult to effectively address these subtle signs because the students won’t directly seek help in an obvious manner. They will only hint at the issue indirectly. So, it becomes quite challenging, I believe it is quite challenging. (Chen)

3.2.2 Scared and afraid by students’ unpredictable behaviors

The participants like Hu, expressed her lack of comprehension and confusion regarding self-harm. She stated that she did not understand why this particular emotion and behavior had emerged. She questioned the motive behind self-harm, as she believed that hurting oneself would naturally cause pain. The participant further expressed her inability to grasp why some students would resort to cutting their wrists as a form of self-harm.

I don’t understand. I don’t know why this emotion arises. I mean, why? Doesn’t hurting oneself cause pain? Why would someone resort to self-harm? I don’t understand why someone would want to cut their wrists. (Hu)

Xie also described being greatly scared by the severity of the situation when she received a letter written in blood. Xie was concerned about the student’s health and mental state, recognizing that the act of writing such a letter may indicate significant distress and a cry for help. Additionally, the sight of blood and the disturbing nature of the situation evoked feelings of disgust and nausea in Xie. As she said:

I was scared. There was one time when I received a letter written in blood. She said she wanted to go home and handed it to someone else. When I saw that blood, I couldn’t even dare to open my eyes. It was truly nauseating to see it. (Xie)

Others like Yang expressed profound shock and disbelief at how the students reached a state where they took their own lives. The participant was left with a deep sense of confusion, questioning what thoughts might have been going through the students’ minds and how they arrived at such a drastic decision. Yang struggled to understand the complex factors that led to such a tragic outcome and the lasting impact it had on them. As he said:

I am deeply shocked by how this young person ended up in such a state (commit suicide). He had a promising future ahead, yet he didn’t seem to value his own life. How could a person become like this? What thoughts were going through his mind? How did he come to make such a drastic decision? This profound shock lingers in my heart. (Yang)

3.2.3 Afraid of students’ failure and its potential outcome

Participants believed that mental health issues had an impact on students’ learning abilities. They observed that students with mental health problems tended to be introverted and face challenges in their studies. At the same time, participants agreed with parents’ perspectives that lower expectations for students’ academic performance. Others expressed the belief that the child previously had the potential to be admitted to a more prestigious school, but their mental health issues hindered their academic progress. As Peng stated:

Because he has mental health issues, his learning abilities are naturally affected. From what I observed, including one very introverted student in the class, his learning abilities have always been in this state since childhood. His parents also don’t have high expectations for him. (Peng)

Some participants indicated a concern about the student’s ability to cope with adversity and negative feedback. They expressed their observation that the psychological resilience of the students they teach was relatively low. The students tended to attribute setbacks solely to external factors, such as difficult exam questions, instead of their understanding and mastery of the knowledge. The participants further highlighted that these students were more responsive to praise and encouragement, but they found it difficult to effectively handle criticism. Indeed, some participants observed that the students displayed weaker psychological resilience in urban cities and lots of students lacked any significant personal responsibilities for their families’ tasks or chores. As Li said:

Some students may have difficulty accepting setbacks and failures. I feel that the psychological resilience of the students we teach is quite low, which may be closely related to their experiences in junior high school. They are only receptive to praise and encouragement, but they struggle to handle criticism. If you try to criticize or provide feedback, they tend to have significant stress reactions. (Li)

Other participants expressed their concern about a prevalent trend within the education system. The participants expressed a sense of frustration and acknowledged the existence of a general atmosphere among educators characterized by fear of potential issues and a reluctance to address students’ weaknesses. This atmosphere resulted in a lack of constructive criticism and hesitancy in providing feedback that could contribute to students’ growth and improvement. The teacher also noted a shift in the perspectives of the student’s parents, who now prioritize encouragement above all else. As Yangmensioned:

We all have become only focused on discussing the strengths of students and dare not talk about their weaknesses. This situation exists throughout the entire education system, including what I have observed in other schools and our school. It seems that there is a general atmosphere among teachers where they are afraid of potential issues and hesitant to criticize or talk about students’ shortcomings. (Yang)

3.2.4 Students having mental health issues are dangerous

Some teachers highlighted that when students with mental health issues were faced with triggering events or circumstances, their ability to regulate their emotions becomes greatly compromised. This can manifest as intense emotional outbursts, difficulty managing anger or frustration, feeling overwhelmed by sadness or anxiety, and even self-harm or suicide. Others noted that students facing mental health challenges displayed reluctance to share their problems with others. This hesitance can create a situation where emotions and experiences were suppressed over an extended period, potentially resulting in a dangerous build-up, comparable to a hidden time bomb. Some participants worried about their safety and were afraid that the student might physically assault them or engage in other aggressive behaviors. As Wang and Zhu described:

Students with mental health issues are similar to normal individuals when nothing has triggered their emotions. However, if something happens that triggers an emotional explosion, their emotional control becomes extremely poor. (Wang) I believe this is a mental health issue. Many people are reluctant to share their mental health problems, experiences, and thoughts with others to have effective communication. As a result, this problem remains like a time bomb. (Zhu)

The majority of the participants felt they were concerned about the safety of students both during school hours and beyond. For example, some participants mentioned that they had noticed an increase in her phone usage, both at school and at home. On the other hand, Luo also expressed concern about a student’s absence from the classroom and the potential risks or dangers that the student may face outside of the school environment. Some of the participants expressed their genuine fear regarding the possibility of their students engaging in self-harm unexpectedly. Others, like Chen, also spoke of her fear and worry when a student openly expressed thoughts of self-harm or suicide in front of her.

The first time he disappeared was during our orientation program when he just entered the first year of middle school. He went missing for the whole afternoon, and that was the first time I faced his situation of being absent. At that moment, I felt very worried, and my mind was filled with thoughts of news stories about such incidents. I was afraid that something bad might have happened, and I felt a sense of fear. (Luo) He sat there and said, “The teacher wants me to stay, but I might just jump from here.” He said it right in front of me, and I was quite scared at that moment because I was genuinely afraid that he might be unstable and do such a thing. (Chen)

Some participants expressed concerns about the potential consequences that may arise if safety issues occur. Participants were genuinely concerned that their reputation and professional image would be damaged as a result. Others recognized that the loss of a student’s life affected the entire school community. Some explained that since they were all located on the same floor if a student from an adjacent class experiences a mental health problem or difficulty, it would inevitably have an impact on the students in the neighboring class. As Peng shared:

If a serious issue arises, particularly involving personal harm, it would greatly impact me in terms of my reputation. Since I will be staying in this institution for many years, should I prioritize the preservation of my professional image? (Peng) I feel a bit worried myself. I’m afraid that the student might engage in more intense behaviors towards me in the future. Because he is a boy, I perceive him as having significant physical strength and height, which added to my apprehension. I was afraid that he might strike me or engage in other aggressive behaviors towards me. (Peng)

Having taught students with mental health problems, teachers were inclined to amplify the students’ problems. For example, when they noticed that a student was exhibiting some unusual behavior or phenomena, they became overly concerned about the problem and tended to amplify it. Other participants felt anxious and concerned about the prospect of having a student with mental health issues appear in their classroom again. They anticipated that it could be a challenging experience, causing them distress and making it difficult to manage the student’s behavior or academic performance. As Yang and Liao articulated:

As soon as you see that the student has some abnormal behavior, you will think in that way, that is, it is easy to expand this matter. It is easy to cause sensitivity and hypersensitivity. (Yang) I don’t know if the student (with mental health issues) will be assigned to my class next semester. If they are, I feel it would still be tormenting. If they are not in my class, perhaps they would be a torment for another teacher. (Liao)

4 Discussion

Mental health issues in the classroom for the secondary school teachers in this study were unpredictable — something they were unaware and students usually did not show any signs. They did not know what signs or symptoms they should be looking for, especially for the signs of attempting suicide. Besides being unaware of the mental health issues, factors such as class size and the subject matter of the course seemed to affect faculty members’ capacity to identify and assist students with mental health illnesses. For instance, due to the class size ranging from 50 to 60 students, participants in our study tend to pay more attention to students at the top, who excel in various aspects such as academic performance, or students at the bottom, who struggle with poor grades and disciplinary issues. However, students who fall in the middle receive comparatively less attention from teachers, making it even more challenging to predict whether this group of students may have mental health issues. The participants in Kalkbrenner’s study also highlighted the challenges of recognizing students facing mental health illness in a large lecture hall (150 students) compared to a smaller classroom setting (10–15 students) ( 14 ). Like Buchanan, secondary school teachers decided to assume that every student in the school might be experiencing some form of crisis due to the impossibility of accurately identifying all at-risk students ( 15 ). Due to the uncertainty of students’ mental health issues, teachers in our study felt astonished when they aware certain students had mental health issues. Buchanan also found that secondary school teachers expressed shock and surprise upon being informed about the attempted suicide, particularly because they did not expect such an incident to occur and did not know the student even had emotional problems or issues at all ( 15 ).

Despite the difficulty in identifying students with mental health issues, teachers were afraid of unwell students’ failure and its potential impact on the classroom. Teachers observed the psychological resilience of the students was relatively low, students tended to attribute setbacks solely to external factors and had difficulty in handling criticism, they behaved indifferently and broke the school regulations and rules without any sense of concern, and they even lacked responsibility for the home chores and tasks in their family, especially for the students in the urban Changsha city. Therefore, teachers concerned about unwell students impacted other students, and worried about their ability to adjust and overcome challenges as they transition into society in the future. There was also a perception that university students today are less resilient compared to previous generations ( 16 ). Furthermore, if children’s social, emotional, and behavioral challenges were left unaddressed, it could hindered their ability to learn and thrive academically ( 17 ).

Despite their fear of student failure and the adverse effects on the classroom and school environment, teachers harbored fear towards students with mental health issues due to concerns for their safety and the potential negative impact on their professional reputation. On the one hand, they expressed apprehension that the student’s behavior might escalate and become more severe. The teachers were particularly concerned about their own safety and harbored fears of potential physical assault or other aggressive actions from the students. Some college teachers in Allie White’s study also justified their reluctance to initiate conversations about university students’ mental health, as they harbored concerns that such discussions could potentially trigger violent behavior from the students ( 18 ). They feared that addressing a university student’s mental health could lead to aggression towards the faculty member, themselves, or others—both during and after the conversation initiated by the teacher ( 18 ). On the other hand, teachers expressed apprehension regarding the potential ramifications that could arise from significant incidents, especially those related to students’ safety. Therefore, they were genuinely concerned that their reputation and professional image would be negatively impacted as a result. In addition, three adolescents in Tally Moses’s study also reported that teachers were afraid of adolescents because of their emotional or behavioral volatility ( 19 ).

One special facet of this theme, different from the participants in Buchanan’s study, experience with student suicide seemed to make secondary school teachers less shocked and more realistically address the subsequent occurrences of suicide ( 15 ). For secondary school teachers in our study, they were concerned about teaching students with mental health issues in the future. The teacher experienced anxiety and apprehension regarding the potential arrival of a new student with mental health issues in their classroom. They anticipated that this situation could present significant challenges, leading to personal distress and making it difficult to effectively handle the student’s behavior and academic performance.

The lived experiences of secondary school teachers encountering students with mental health issues in China were influenced by various cultural, social, and educational factors. In China, there is a social stigma attached to mental health issues, and many teachers fear admitting their struggles due to concerns about professional image and social perception ( 20 ). The “zero-COVID” policy in China has also been noted to contribute to increased pressure on teachers and students, impacting mental well-being. Moreover, the traditional exam-oriented education system in some parts of China has been identified as a factor contributing to the mental health challenges faced by both students and teachers ( 21 ). On the other hand, the reasons for increasing mental health issues in adolescents in China were exam-oriented education system, parental expectations, and cultural and societal stressors, stigma and misconceptions, which were different from Western countries, such as social media and technology, adverse childhood experiences, access to mental health services ( 22 , 23 ). Therefore, those differences highlight the need for a comprehensive approach to address the cultural, social, and educational factors influencing secondary school teachers’ experiences in facing students with mental health issues. Our study provide the evidence for future study and interventions.

4.1 Implications

The secondary school teachers in this study found managing the unpredictability of mental health issues in the classroom deeply distressing and challenging. The worry about student safety calls for a dual approach: improving teacher preparedness through specific training in crisis management and enhancing proactive measures within schools to identify and support students at risk before crises occur. Such training should include simulation-based learning, which could help reduce the shock factor by providing realistic scenarios for teachers to engage with in a controlled environment. Future research should explore the effectiveness of proactive mental health programs in reducing both student incidents and teacher anxiety.

4.2 Strength and limitations

There are some limitations to interpreting our study findings. The secondary school teachers all came from Changsha City in China, making the findings inapplicable to secondary school teachers in other cultures. However, the strength is that our study is the first study to use a descriptive phenomenological design to explore the lived experience of secondary school teachers in encountering students with mental health issues in a Chinese context.

5 Conclusion

The participants in our study described their feelings of uncertainty about whether students had mental health issues and found it challenging to identify students who may have such issues, leading to the potential overlooking of students with mental health problems. They also notice a decreased psychological resilience among current students. Over time, teachers begin to develop an understanding of students’ mental health issues and their impact on the classroom, they grow increasingly concerned that mental health issues as dangerous. Our recommendation is for adolescents to enroll in at least one course per semester that has a small class size, typically consisting of approximately 25 students or fewer. This approach can foster more frequent interactions between secondary school teachers and students. Additionally, the finding of our study that teachers’ experience of living in fear when encountering students with mental health issues encourages secondary school nurses to develop questionnaires and interventions for future studies.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving humans were approved by Hong Kong Polytechnic University’s Human Research Ethics Committee. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

ML: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. GH: Conceptualization, Supervision, Writing – review & editing. MC: Conceptualization, Formal analysis, Methodology, Supervision, Validation, Writing – review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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20. Fan Y, Chen J. In 2022, China’s Students are Struggling to Cope. So Are their Teachers. Sixth Tone. Fresh Voices from Today’s China(2022). Available online at: https://www.sixthtone.com/news/1011185/in-2022%2C-Chinas-students-are-struggling-to-cope.-so-are-their-teachers (Accessed 1(20), 2023).

21. Yang R, You X, Zhang Y, Lian L, Feng W. Teachers’ mental health becoming worse: the case of China. Int J Educ Dev . (2019) 70:102077. doi: 10.1016/j.ijedudev.2019.102077

22. Kingrey R. Addressing Student Mental Health: Strategies for Teachers(2022). Available online at: https://www.aypf.org/blog/addressing-student-mental-health-strategies-for-teachers/ .

23. Lee M. Mental Health Awareness in Chinese Schools(2023). Available online at: https://www.pacificprime.cn/blog/mental-health-awareness-chinese-schools/ .

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Table 1 Living in fear at the unpredictability of mental illness in the Classroom – From Formulated Meaning to Central Theme.

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Table 2 The demography of the secondary school teachers participated in the interviews.

Keywords: secondary school, mental health issues, phenomenology, qualitative study, teachers

Citation: Liang M, Ho GWK and Christensen M (2024) Living in fear at the unpredictability of mental health issues in the classroom: a phenomenological study of secondary school teachers in encountering students with mental health issues. Front. Psychiatry 15:1367660. doi: 10.3389/fpsyt.2024.1367660

Received: 09 January 2024; Accepted: 30 April 2024; Published: 15 May 2024.

Reviewed by:

Copyright © 2024 Liang, Ho and Christensen. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Mining Liang, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Stress, Anxiety, and Depression Among Undergraduate Students during the COVID-19 Pandemic and their Use of Mental Health Services

  • Published: 23 April 2021
  • Volume 46 , pages 519–538, ( 2021 )

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research questions on stress among students

  • Jungmin Lee 1 ,
  • Hyun Ju Jeong 2 &
  • Sujin Kim 3  

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The coronavirus 2019 (COVID-19) has brought significant changes to college students, but there is a lack of empirical studies regarding how the pandemic has affected student mental health among college students in the U.S. To fill the gap in the literature, this study describes stress, anxiety, and depression symptoms for students in a public research university in Kentucky during an early phase of COVID-19 and their usage of mental health services. Results show that about 88% of students experienced moderate to severe stress, with 44% of students showing moderate to severe anxiety and 36% of students having moderate to severe depression. In particular, female, rural, low-income, and academically underperforming students were more vulnerable to these mental health issues. However, a majority of students with moderate or severe mental health symptoms never used mental health services. Our results call for proactively reaching out to students, identifying students at risk of mental health issues, and providing accessible care.

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The coronavirus 2019 (COVID-19) has brought significant and sudden changes to college students. To protect and prevent students, faculty, and staff members from the disease, higher education institutions closed their campus in the spring of 2020 and made a quick transition to online classes. Students were asked to evacuate on a short notice, adjust to new online learning environments, and lose their paid jobs in the middle of the semester. The pandemic has also raised concerns among college students about the health of their family and friends (Brown & Kafka, 2020 ). Because all these changes were unprecedented and intensive, they caused psychological distress among students, especially during the first few months of the pandemic. There is abundant anecdotal evidence describing students’ stress and emotional difficulties as impacted by COVID-19, but there are only a few empirical studies available that directly measure college student mental health since the outbreak (e.g., Huckins et al., 2020 ; Kecojevic et al., 2020 ; Son et al., 2020 ). Most existing studies focus on mental health for general populations (e.g., Gao et al., 2020 ) or health care workers (e.g., Chen et al., 2020 ), whose results may not be applicable to college students. Given that college students are particularly vulnerable to mental health issues (e.g., Kitzrow, 2003 ), it is important to explore their mental health during this unprecedented crisis.

In this study, we describe the prevalence of stress, anxiety, and depression for undergraduate students in a public research university during the six weeks after the COVID-19 outbreak alongside their usage of mental health services. Using a self-administered online survey, we measured stress, anxiety, and depression levels with well-established clinical tools and asked the extent to which college students used on-campus and off-campus mental health services for the academic year. Our results revealed that more than eight out of ten students surveyed experienced modest or severe stress, and approximately 36–44% of respondents showed moderate or severe anxiety and depression. However, more than 60% of students with moderate or severe stress, anxiety, or depression had never utilized mental health services on- or off-campus. Although focusing on a single institution, this paper is one of the few studies that empirically examine mental health of college students in the U.S. during the early phase of the pandemic. Findings from this paper reassure the seriousness of student mental health during the pandemic and call for a proactive mental health assessment and increased support for college students.

Literature Review

Covid-19 and student mental health.

Empirical studies reported a high prevalence of college mental health issues during the early phase of COVID-19 around the world (Cao et al., 2020 ; Chang et al., 2020 ; Liu et al., 2020 , Rajkumar, 2020 ; Saddik et al., 2020 ). In the U.S. a few, but a growing number of empirical surveys and studies were conducted to assess college students’ mental health during the pandemic. Three nationwide surveys conducted across the U.S. conclude that college student mental health became worse during the pandemic. According to an online survey administered by Active Minds in mid-April of 2020, 80% of college students across the country reported that COVID-19 negatively affected their mental health, with 20% reporting that their mental health had significantly worsened (Horn, 2020 ). It is also concerning that 56% of students did not know where to go if they had immediate needs for professional mental health services (Horn, 2020 ). Another nationwide survey conducted from late-May to early-June also revealed that 85% of college students felt increased anxiety and stress during the pandemic, but only 21% of respondents sought a licensed counselor or a professional (Timely MD, n.d. ) According to the Healthy Minds Network’s survey (2020), which collected data from 14 college campuses across the country between March and May of 2020, the percentage of students with depression increased by 5.2% compared to the year before. However, 58.2% of respondents never tried mental health care and about 60% of students felt that it became more difficult to access to mental health care since the pandemic. These survey results clearly illustrate that an overwhelming majority of college students in the U.S. have experienced mental health problems during the early phase of COVID-19, but far fewer students utilized professional help. Despite the timely and valuable information, only Healthy Minds Network ( 2020 ) used clinical tools to measure student mental health, and none of them explored whether student characteristics were associated with mental health symptoms.

To date, only a few scholarly research studies focus on college student mental health in the U.S. since the COVID-19 outbreak. Huckins et al. ( 2020 ) have longitudinally tracked 178 undergraduate students at Dartmouth University for the 2020 winter term (from early-January to late-March of 2020) and found elevated anxiety and depression scores during mid-March when students were asked to leave the campus due to the pandemic. The evacuation decision coincided with the final week, which could have intensified student anxiety and depression. The anxiety and depression scores gradually decreased once the academic term was over, but they were still significantly higher than those measured during academic breaks in previous years. Conducting semi-structured interviews with 195 students at a large public university in Texas, Son et al. ( 2020 ) found that 71% of students surveyed reported increased stress and anxiety due to the pandemic, but only 5% of them used counseling services. The rest of the students explained that they did not use counseling services because they assumed that others would have similar levels of stress and anxiety, they did not feel comfortable talking with unfamiliar people or over the phone, or they did not trust counseling services in general. Common stressors included concerns about their own health or their loved ones’, sleep disruption, reduced social interactions, and difficulty in concentration. Based on a survey from 162 undergraduate students in New Jersey, Kecojevic et al. ( 2020 ) found that female students had a significantly higher level of stress than male students and that upper-class undergraduate students showed a higher level of anxiety than first-year students. Having difficulties in focusing on academic work led to increased levels of stress, anxiety, and depression (Kecojevic et al., 2020 ).

College Student Mental Health and Usage of Mental Health Services Before COVID-19

College student mental health has long been studied in education, psychology, and medicine even before the pandemic. The general consensus of the literature is that college student mental health is in crisis, worsening in number and severity over time. Before the pandemic in the academic year of 2020, more than one-third of college students across the country were diagnosed by mental health professionals for having at least one mental health symptom (American College Health Association, 2020 ). Anxiety (27.7%) and depression (22.5%) were most frequently diagnosed. The proportion of students with mental health problems is on the rise as well. Between 2009 and 2015, the proportion of students with anxiety or depression increased by 5.9% and 3.2%, respectively (Oswalt et al., 2020 ). Similarly, between 2012 and 2020, scores for depression, general anxiety, and social anxiety have constantly increased among those who visited counseling centers on college campuses (Center for College Mental Health [CCMH], 2021 ).

Some groups are more vulnerable to mental health problems than others. For example, female and LGBTQ students tend to report a higher prevalence of mental health issues than male students (Eisenberg et al., 2007b ; Evans et al., 2018 ; Wyatt et al., 2017 ). However, there is less conclusive evidence on the difference across race or ethnicity. It is well-supported that Asian students and international students report fewer mental health problems than White students and domestic students, but there are mixed results regarding the difference between underrepresented racial minority students (i.e., African-American, Hispanic, and other races) and White students (Hyun et al., 2006 ; Hyun et al., 2007 ). Many researchers find either insignificant differences (e.g., Eisenberg et al., 2007b ) or fewer mental health issues reported for underrepresented minority students compared to White students (e.g., Wyatt et al., 2017 ). This may not necessarily mean that racial minority students tend to have fewer mental health problems, but it may reflect their cultural tendency against disclosing one’s mental health issues to others (Hyun et al., 2007 ; Wyatt & Oswalt, 2013 ). In terms of age, some studies (e.g., Eisenberg et al., 2007b ) reveal that students who are 25 years or older tend to have fewer mental health issues than younger students, while others find it getting worse throughout college (Wyatt et al., 2017 ). Lastly, financial stress significantly increases depression, anxiety, and suicidal thoughts among college students (Eisenberg et al., 2007b ).

Despite the high prevalence of mental health issues, college students tend to underutilize mental health services (Cage et al., 2018 ; Hunt & Eisenberg, 2010 ; Lipson et al., 2019 ; Oswalt et al., 2020 ). The Healthy Minds Study 2018–2019, which collected data from 62,171 college students across the country, reports that 57% of students with positive anxiety or depression screens have not used counseling or therapy, and 64% of them have not taken any psychotropic medications within the past 12 months (Healthy Minds, 2019 ). Even when students had visited a counseling center, about one-fourth of them did not return for a scheduled appointment, and another 14.1% of students declined further services (CCMH, 2021 ). When asked the barriers that prevented them from seeking mental health services, students reported a lack of perceived needs for help (41%), preference to deal with mental health issues on their own or with families and friends (27%), a lack of time (23%), financial difficulty (15%), and a lack of information about where to go (10%). Students who never used mental health services were not sure if their insurance covered mental health treatment or were more skeptical about the effectiveness of treatment (Eisenberg et al., 2007a ). Stigma, students’ view about getting psychological help for themselves, is another significant barrier in seeking help and utilizing mental health services (Cage et al., 2018 ).

Current Study

While previous studies have advanced our understanding of student mental health and their usage of mental health services, we find a lack of empirical studies on these matters, particularly in the context of COVID-19. The goal of this study is to fill the gap with specific investigations into the prevalence and pattern of U.S. college student mental health with regard to counseling service use during the early phase of COVID-19. First, very few studies focus on college students and their mental health during the pandemic, and most nationwide surveys conducted in the U.S. did not use clinically validated tools to measure student mental health. In this study, we have employed the three clinical measures to assess stress, anxiety, and depression, which are the most prevalent mental health problems among college student populations (Leviness et al., 2017 ). Secondly, it should be noted that while empirical research conducted in U.S. institutions clearly demonstrate that college students were under serious mental distress during the pandemic (Huckins et al., 2020 ; Son et al., 2020 ; Kecojevic et al., 2020 ), such studies have relatively small sample sizes and rarely examined whether particular groups were more vulnerable than others during the pandemic. To overcome such limitations, the present study has recruited a relatively large number of students from all degree-seeking students enrolled at the study institution. Further, given the high prevalence of mental health issues, we have identified vulnerable student groups and provided suggestions regarding necessary support for these students in an effort to reduce mental health disparity. Lastly, previous studies (e.g., Healthy Minds, 2019 ) show that college students, even those with mental health issues, tended to underutilize counseling services before the pandemic. Yet, there is limited evidence regarding whether this continued to be the case during COVID-19. Our study provides empirical evidence regarding the utilization of mental health services during the early phase of the pandemic and identifies its predictors. Based on the preceding discussions, we address the following research questions in this study:

First, how prevalent were stress, anxiety, and depression among college students during the early phase of the pandemic? Second, to what extent have students utilized mental health services on- and off-campus? Third, what are the predictors of mental health symptoms and the usage of mental health services?

We collected data via a self-administered online survey. This survey was designed to measure student mental health, the usage of mental health services, and demographics. The survey was sent to all degree-seeking students enrolled in a public research university in Kentucky for the spring of 2020. An invitation email was first sent on March 23, which was two days after the university announced campus closure, and two more reminder emails were sent in mid-April and late-April. The survey was available until May 8th, which was the last day of the semester.

A total of 2691 students (out of 24,146 qualified undergraduate and graduate degree-seeking students enrolled for the semester) responded to the survey. The response rate was 11.14%, but this is acceptable as it is within the range of Internet survey response rates, which is anywhere from 1 to 30% (Wimmer & Dominick, 2006 ). We deleted responses from 632 students who did not answer any mental health questions, which left 2059 valid students for the analysis. In this study, we focused on undergraduate students because they are significantly different from graduate students in terms of demographics (e.g., racial composition, age, and income) and major stressors (Wyatt & Oswalt, 2013 ). As a result, 1412 undergraduate students are included in our sample. 90% of these students had complete data. The rest of students skipped a couple of questions (usually related to their residency) but answered most of the question. Thus, we conducted multiple imputation, created ten imputed data sets, and ran regression models using these imputed data (Allison, 2002 ). Our regression results using imputed data are qualitatively similar to the estimates using original data; however, for comparison, we also provided the regression estimates using original data in Appendix Tables  6 and 7 . Please note that we still used original data for descriptive research questions (presented in Tables  1 , 2 , and 4 ) to accurately describe the prevalence of mental health symptoms and use of counseling services.

Table  1 provides descriptive statistics for students in our data. Female (73%), White (86%), and students who are below 25 years old (95%) are the vast majority of our sample. About one in four students are rural students and/or students from Appalachian areas (27%) and first-generation students (23%). Wealthier students (whose family income was $100,000 or more) make up about 44% of the sample (44%). Compared to the undergraduate student population at the study site, female students (56.3% at the study site) are overrepresented in our study. The proportion of White students is slightly higher in our sample (86%) than the study population (84%), and that of first-generation students is slightly lower in our sample (23%) than that in the study population (26%).

There are five key outcome variables for this study. The first three outcome variables are stress, anxiety, and depression, and the other two variables are the extent to which students used on-campus and off-campus mental health services for the academic year, respectively. Our mental health measures are well-established and widely used in a clinical setting. For stress, we used the Perceived Stress Scale (PSS) that includes ten items asking students’ feelings and perceived stress measured on a 5-point Likert scale from 0 (strongly disagree) to 4 (strongly agree) (Cohen et al., 1983 ). Using the sum of scores from the ten items, the cut-off score for low, moderate, and high stress is 13, 26, and 40, respectively. PSS scale was used in hundreds of studies and validated in many languages (Samaha & Hawi, 2016 ). PSS also has a high internal consistency reliability. Of the recent studies that used the instrument to measure mental health of U.S. college students, Cronbach’s alpha was around 0.83 to 0.87, which exceeded the commonly used cut-off of 0.70 (Adams et al., 2016 ; Burke et al., 2016 ; Samaha & Hawi, 2016 ).

We used the General Anxiety Disorder 7-item (GAD-7) scale to measure anxiety. This is a brief self-report scale to identify probable cases of anxiety disorders (Spitzer et al., 2006 ). The GAD scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate, and severe anxiety, respectively. In a clinical setting, anyone with a score of 10 or above are recommended for further evaluation. GAD is moderately good at screening three other common anxiety disorders - panic disorder (sensitivity 74%, specificity 81%), social anxiety disorder (sensitivity 72%, specificity 80%), and post-traumatic stress disorder (sensitivity 66%, specificity 81%) (Spitzer et al., 2006 ) In their recent study, Johnson, et al. ( 2019 ) validated that “the GAD-7 has excellent internal consistency, and the one-factor structure in a heterogeneous clinical population was supported” (p. 1).

Lastly, depression was assessed with the eight-item Patient-Reported Outcomes Measurement Information System (PROMIS) Depression Short Form (Pilkonis et al., 2014 ). A score less than 17 is considered as none to slight depression, a score between 17 and 21 is considered as mild depression, a score between 22 and 32 is considered as moderate depression, and a score of 33 or above is considered as severe depression. PROMIS depression scale is a universal, rather than a disease-specific, measure that was developed using item response theory to promote greater precision and reduce respondent burden (Shensa et al., 2018 ). The scale has been correlated and validated with other commonly used depression instruments, including the Center for Epidemiological Studies Depression Scale (CES-D), the Beck Depression Inventory (BDI-II), and the Patient Health Questionnaire (PHQ-9) (Lin et al., 2016 ).

When it comes to the usage of psychological and counseling services, we asked students to indicate the extent to which they used free on-campus resources (e.g., counseling center) and off-campus paid health professional services (e.g., psychiatrists) anytime during the academic year on a scale of 1 (never) to 5 (very often), respectively. These questions do not specifically ask if students utilized these services after the COVID-19 outbreak, but responses for these questions indicate whether and how often students had used any of these services for the academic year until they responded to our survey.

We also collected data about student demographics and characteristics including student gender, race or ethnicity, age, class levels (freshman, sophomore, junior, and senior), first generation student status (1 = neither parent has a bachelor’s degree, 0 = at least one parent with a bachelor’s degree), family income, residency (rural and/or Appalachian students, international students), GPAs, and perceived stigma about seeking counseling or therapy (i.e., “I am afraid of what my family and friends will say or think of me if I seek counseling/therapy”) measured on a 5-point Likert scale. We used these variables to see if they were associated with a high level of stress, anxiety, and depression and the usage of mental health services.

We used descriptive statistics, ordinal logistic regression, and logistic regression models in this study. To address the first and second research questions, we used descriptive statistics and presented the prevalence of stress, anxiety, and depression as well as the frequency of using mental health services. For the third research question, we adopted ordinal logistic regression and logistic regression models depending on outcome variables. We used ordinal logistic regression models to identify correlates of different levels of stress, anxiety, and depression, which were measured in ordinal variables (e.g., mild, moderate, and severe). For the usage of mental health service outcomes, we employed logistic regression models. Because more than two-thirds of students in the sample never utilized either type of mental health services, we re-coded the usage variables into binary variables (1 = used services, 0 = never used services) and ran logistic regression models.

Limitations

Our study is not without limitations. First, we do not claim a causal relationship in this study, but we describe the state of mental health for students soon after the COVID-19 outbreak. We acknowledge that many students may have suffered from mental health problems before the pandemic, with some experiencing escalation after the outbreak (e.g., Horn, 2020 ). Even if our study does not provide a causal relationship, we believe that it is important to measure and document student mental health during the pandemic so that practitioners can be aware of the seriousness of this issue and consider ways to better serve students. Secondly, our study results may not be applicable to students in other institutions or states. We collected data from a public research university in Kentucky where the number of confirmed cases and deaths were relatively lower than other states such as New York. The study site mainly serves traditional college students who attend college right after high school, who live on campus, and who do not have dependents. Therefore, mental health for students at other types of institutions or in other states could be different from what is presented in our study.

Prevalence of Stress, Anxiety, and Depression

Table  2 shows the prevalence of stress, anxiety, and depression. Overall, a majority of students experienced psychological distress during the early phase of the pandemic. When it comes to stress, about 63% of students had a moderate level of stress, and another 24.61% of students fell into a severe stress category. Only 12% of students had a low level of stress. In other words, more than eight in ten students in the survey experienced moderate to severe stress during the pandemic. This result is comparable to the Active Minds’ survey results that report 91% of college students reported experiencing feelings of stress and anxiety since the pandemic (Horn, 2020 ).

In terms of anxiety, approximately 24% and 21% of students in our study had moderate and severe anxiety disorders, respectively. Given that those who scored 10 or above on the GAD-7 scale (moderate to severe category) are recommended to meet with professionals (Spitzer et al., 2006 ), this finding implies that nearly half of students in this study needed to get professional help. This proportion of students with moderate to severe anxiety is almost double that for university students in China (e.g., Chang et al., 2020 ) or the United Arab Emirates soon after the COVID-19 outbreak (Saddik et al., 2020 ). Lastly, approximately 30% and 6% of students suffered from moderate and severe depression, respectively. These proportions are far higher than college students in China measured during the pandemic (Chang et al., 2020 ) but slightly higher than a nationwide sample of U.S. college students assessed before the pandemic (Healthy Minds, 2019 ). Given that our study measured these mental health symptoms for the first six weeks of the pandemic, we speculate that the proportion of students with moderate or severe depression would increase over time.

In order to explore predictors of a higher level of stress, anxiety, and depression, we ran ordinal logistic regression models as presented in Table  3 . Overall, it is clear and consistent that the odds of experiencing a higher level of stress, anxiety, and depression (e.g., severe than moderate, moderate than mild, etc.) were significantly greater for female students by a factor of 1.489, 1.723, and 1.246 than the odds for male students when other things were held constant. This gender difference in mental health symptoms is quite consistent with other studies before and during the pandemic (Eisenberg et al., 2007a ; Kecojevic et al., 2020 ). When it comes to race or ethnicity, the odds of experiencing a higher level of stress, anxiety, and depression for African-American students were almost as half as the odds for White students. However, there was no significant difference in the odds for Hispanic and Asian students compared to White students. Student class level was significantly related to stress and anxiety levels: The odds were greater for upper-class students than lower class students. This result is consistent with Kecojevic et al. ( 2020 ), which reported significantly higher levels of anxiety among upper-class students compared to freshman students. It may reflect that one of major stressors for college students during the pandemic is the uncertain future of their education and job prospects, which would be a bigger concern for upper-class students (Timely MD, n.d.).

One’s rurality, family income, and GPA were significantly associated with the severity of mental health symptoms. The odds of experiencing a severe level of anxiety and depression were 1.325 and 1.270 times higher among rural students than urban and suburban students. With every one unit increase in family income or students’ GPAs, the odds of experiencing a more severe stress, anxiety, and depression significantly decreased. This result suggests that students from disadvantaged backgrounds were even more vulnerable to psychological distress during the early phase of the pandemic. The negative association between GPAs and mental distress levels was consistent with previous studies that showed that college students were very concerned about their academic performances and had difficulty in concentration during the early phase of the pandemic (Kecojevic et al., 2020 ; Son et al., 2020 ).

Usage of Mental Health Services

In Table  4 , we first describe the extent to which students with moderate to severe symptoms of stress, anxiety, or depression used mental health services on- and off-campus during the academic year. The university in this study has provided free counseling services for students, and the counseling services have continued to be available for students in the state via phone or Internet even after the university was closed after the outbreak. Table 4 presents the frequency of students using on-campus mental health services (Panel A) and off-campus paid mental health services (Panel B) on a five-point scale. For this table, we limited the sample to students with moderate to severe symptoms of stress, anxiety, or depression to focus on students who were in need of these services. Surprisingly, a majority of these students never used mental health services on- and off-campus even when their stress, anxiety, or depression scores indicated that they needed professional help. More than 60% of students with moderate to severe symptoms never used on-campus services, and more than two-thirds of students never used off-campus mental health services. This underutilization of mental health resources is concerning but not surprising given that college students tended not to use counseling services before and during the pandemic as presented in previous studies (e.g., CCMH, 2021 ; Healthy minds, 2019 ; Son et al., 2020 ).

In order to explore predictors of the usage of mental health services, we ran logistic regression models as shown in Table  5 . We included all students in these regression models to see whether a severity of mental health symptoms was related to the usage of mental health services. Table 5 presents the results for the usage of any mental health services, on-campus mental health services, and off-campus mental health services, respectively. Overall, stress, anxiety, and depression levels were positively associated with using mental health services on- and off-campus: With every one unit increase in each of these mental health symptoms, the odds of using on- and off-campus mental health services significantly increased. This result is relieving as it suggests that students who were in great need of these services actually used them. Other than mental health symptoms, there were different predictors for utilizing on-campus and off-campus services. African-American and Hispanic students were significantly more likely to use on-campus services than White students. The odds of using on-campus mental health services were 3.916 times higher for African-American students and 2.032 times higher for Hispanic students than White students. This result is interesting given that the odds of having severe mental distress were significantly lower for African-American students than White students, according to Table 3 . It may suggest that African-American students reported relatively lower levels of mental health symptoms as they had been using on-campus mental health services at higher rates. The odds of using on-campus mental health services were 2.269 times higher for international students than domestic students, but there was no significant difference in the odds of using off-campus services between the two groups. Students’ age was significantly associated with the usage of on-campus and off-campus mental health services: The odds of using on-campus services were significantly lower for older students, while the odds of utilizing off-campus services were significantly higher for older students compared to younger students. When it comes to using off-campus mental health services, the odds were significantly higher for female students, older students, and upper-class students than male students, younger students, and lower classman students. Students who were concerned with stigma associated with getting counseling and therapy were less likely to utilize off-campus mental health services.

Discussions

Our paper describes the prevalence of stress, anxiety, and depression among a sample of undergraduate students in a public research university during an early phase of the COVID-19 outbreak. Using well-established clinical tools, we find that stress, anxiety, and depression were the pervasive problems for college student population during the pandemic. In particular, female, rural, low-income, and academically low-performing students were more vulnerable to psychological distress. Despite its prevalence, about two-thirds of students with moderate to severe symptoms had not utilized mental health services on- and off-campus. These key findings are very concerning considering that mental health is strongly associated with student well-being, academic outcomes, and retention (Bruffaerts et al., 2018 ; Wyatt et al., 2017 ).

Above all, we reiterate that college student mental health is in crisis during the pandemic and call for increased attention and interventions on this issue. More than eight in ten students in our study had moderate to severe stress, and more than one thirds of students experienced moderate to severe anxiety and/or depression. This is much worse than American college students before the COVID-19 (e.g., American College Health Association, 2020 ) and postsecondary students in other countries during the pandemic (e.g., Chang et al., 2020 ; Saddik et al., 2020 ). In particular, rural students, low-income students, and students with low GPAs were more vulnerable to psychological distress. These students have already faced multiple barriers in pursuing higher education (e.g., Adelman, 2006 ; Byun et al., 2012 ), and additional mental health issues would put them at a high risk of dropping out of college. Lastly, although they were dropped from the main analysis due to the small sample size ( n  = 17), it is still noteworthy that a significantly higher proportion of LGBTQ students in our sample experienced severe stress, anxiety, and depression, which calls for significant attention and care for these students.

Despite the high prevalence of mental health problems, a majority of students with moderate to severe symptoms never used mental health services during the academic year, even though the university provided free counseling services. This result could be partially explained by the fact that the university’s counseling center switched to virtual counseling since the COVID-19 outbreak, which was available only for students who stayed within the state due to the license restriction across state boarders. This transition could limit access to necessary care for out-of-state students, international students, or students in remote areas where telecommunications or the internet connection is not very stable. Even worse, these students may also have limited access to off-campus health professionals due to the geographic restrictions (rural students), limited insurance coverage (international students), or a lack of financial means. Our results support that international students relied significantly more on on-campus resources than domestic students. We urge practitioners and policy makers to provide additional mental health resources that are accessible, affordable, and available for students regardless of their locations, insurance, and financial means, such as informal peer conversation groups or regular check-ins via phone calls or texts.

It is also important to point out that the overall usage of both on-campus and off-campus mental health services was generally low even before the COVID-19 outbreak. Previous studies consistently report that college students underutilize mental health services not only because of a lack of information, financial means, or available seats but also because of a paucity of perceived needs or stigma related to revealing one’s mental health issues to others (Cage et al., 2018 ; Eisenberg et al., 2007a ; Son et al., 2020 ). Our results support this finding by demonstrating that stigma one associated with getting counseling or therapy negatively influenced their utilization of off-campus mental health services. Considering these barriers, practitioners should deliver a clear message publicly that mental health problems are very common among college students and that it is natural and desirable to seek professional help if students feel stressed out, anxious, or depressed. In order to identify students with mental health needs and raise awareness among students, it can be also considered to administer a short and validated assessment in classes that enroll a large number of students (e.g., in a freshman seminar course), inform the entire class of how to interpret their scores on their own, and provide a list of available resources for those who may be interested. This would give students a chance to self-check their mental health without revealing their identities and seek help, if necessary.

We recommend that future researchers longitudinally track students and see whether the prevalence of mental health problems changes over time. Longitudinal studies are generally scarce in student mental health literature, but the timing of assessment can influence mental health symptoms reported (Huckins et al., 2020 ). The survey for our study was sent out right after the university of this study was closed due to the pandemic. It is possible that students may adjust to the outbreak over time and feel better, or that their stress may add up as the disease progresses. Tracking students over time can illustrate whether and how their mental health changes, especially depending on the way the pandemic unfolds combined with the cycle of an academic year. Secondly, there should be more studies that evaluate the effect of an intervention program on student mental health. Hunt and Eisenberg ( 2010 ) point out that little has been known about the efficacy of intervention programs while almost every higher education institution offers multiple mental health resources and counseling programs. During this pandemic, it can be a unique opportunity to implement virtual mental health interventions and evaluate their efficacy. Future research on virtual counseling and mental health interventions would guide practices to accommodate mental health needs for students who exclusively take online courses or part-time students who spend most of their time off campus. Lastly, we recommend future research investigate the extent of mental health service utilization among students with mental health needs. Existing surveys and studies on this topic usually rely on responses from those who visit a counseling center or students who respond to their surveys. Neither of these groups accurately represents those who are in need of professional help because there may be a number of students who are not aware of their mental health issues or do not want to reveal it. An effective treatment should first start with identifying those in need.

Our study highlights that college students are stressed, anxious, and depressed in the wake of COVID-19. Although college students have constantly reported mental health issues (e.g., American College Health Association, 2020 ), it is remarkable to note that the broad spectrum of COVID-19-related challenges may mitigate the overall quality of their psychological wellbeing. This is particularly the case for at-risk students (rural, international, low-income, and low-achieving students) who have already faced multiple challenges. We also present that a majority of students with mental health needs have never utilized on- and off-campus services possibly due to the limited access or potential stigma associated with mental health care. Systematic efforts with policy makers and practitioners are requested in this research to overcome the potential barriers. All these findings, based on the clinical assessment of student mental health during the early phase of the pandemic, will benefit scholars and practitioners alike. As many colleges and universities across the country have re-opened their campus for the 2020–2021 academic year, students, especially those who take in-person classes, would be concerned about the disease and continuing their study in this unprecedented time. On top of protecting students from the disease by promoting wearing masks and social distancing, it is imperative to pay attention to their mental health and make sure that they feel safe and healthy. To this end, higher education institutions should proactively reach out to all student populations, identify students at risk of mental health issues, and provide accessible and affordable care.

Data Availability

Not applicable.

Code Availability

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Lee, J., Jeong, H.J. & Kim, S. Stress, Anxiety, and Depression Among Undergraduate Students during the COVID-19 Pandemic and their Use of Mental Health Services. Innov High Educ 46 , 519–538 (2021). https://doi.org/10.1007/s10755-021-09552-y

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Perceived Academic Stress, Causes, and Coping Strategies Among Undergraduate Pharmacy Students During the COVID-19 Pandemic

Mariam a yousif.

1 Faculty of Pharmacy, University of Khartoum, Al-Qasr Ave, 11111, Khartoum, Sudan

Ahmed H Arbab

2 Department of Pharmacognosy, Faculty of Pharmacy, University of Khartoum, Al-Qasr Ave, 11111, Khartoum, Sudan

Bashir A Yousef

3 Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Al-Qasr Ave, 11111, Khartoum, Sudan

Academic stress is a common problem among medical students, and the COVID-19 health crisis lockdown further worsened it. High academic stress has a negative impact on students learning and overall performance.

To assess perceived academic stress, causes, and coping strategies among undergraduate pharmacy students during the COVID-19 pandemic.

A descriptive cross-sectional study was conducted among undergraduate pharmacy students at the University of Khartoum. Data were collected from randomly selected participants using three validated self-administered questionnaires; perceived stress scale, study habits inventory, and mental health inventory. Data were analyzed using SPSS software, and descriptive statistics and chi-square were employed.

The response rate in our study was 99.6% (251/252). About 87% of the participants were females. The majority of participants (92%) experience academic stress, with a mean score (24.99 ± 5.159), the level of academic stress ranging from low (4.3%), moderate (73.2%), to high (22.5%). Approximately 80% of the percipients reported academic stress during all exam times with a mean score (25.33 ± 4.976). The level of academic stress was significantly associated with participants’ gender (P-value: 0.042), and living conditions (P-value: 0.001). The most common factors that were significantly associated with academic stress were difficulty in remembering all that is studied (66.7%, P=0.006) and worrying about the exams (54.1%, P=0.011). Moreover, the most frequent strategies used to cope with academic stress were praying (84.4%) and maintaining some control over the situation (61.9%).

The study revealed a high prevalence of academic stress among percipients. Academic counseling, monitoring of mental status, and implementation of stress reduction programs are highly recommended.

Introduction

Stress is a prevalent mental health disorder among university students. 1 College student stress is mostly attributed to many factors such as academic pressures, social issues, and financial problems. 2 , 3 College-related factors contributing to student’s stress include, the transition from school to the college environment, the curriculum load, and summative assessments, 4 previous studies reported academia-related factors as the most common stressors among undergraduate pharmacy students. 5 Student’s stress may be further exacerbated by the COVID-19 health crisis, and its implications in education.

The World Health Organization (WHO) announced the COVID-19 (SARS-CoV-2) outbreak of a global pandemic on March 2020, 6 and about two months later, Sudan government adopted preventive measures to limit the spread of SARS-CoV-2 infection. The government imposed partial lockdown, closed universities, and suspended prayers in mosques and churches, particularly in the Khartoum state. 7 With the movement restrictions and banning direct contact, universities were either postponed or switched to asynchronous online learning. Implementation of online learning, especially with the limited resources and poor technical infrastructure, is a challenge, 8 and can induce stress for students. 9 Unfortunately, no interventions were conducted to study the psychological impact and provide guidance to students. Furthermore, since December 2018, there has been instability in high education in Sudan; governmental universities were suspended for about ten months due to political unrest.

Academic stress has a negative physiological and social impact on students and may affect their learning and overall performance. 10 Understanding prevalence, contributing factors, and coping strategies will facilitate organizing effective counseling strategies to facilitate students’ development and academic and professional success. Although many studies addressed academic stress during COVID-19 pandemic in economically developed countries. 11 , 12 However, there is a lack of studies exploring academic stress and coping strategies in low-income counties with limited digital infrastructure and inadequate mental health support, such as Sudan. Therefore, the current study aimed to assess perceived academic stress and coping strategies among undergraduate Pharmacy students at the University of Khartoum during the COVID-19 pandemic.

Materials and Methods

Study design and setting.

A descriptive cross-sectional study was conducted among undergraduate pharmacy students at the University of Khartoum, Khartoum, Sudan. In Sudan, undergraduate pharmacy education lasts for 5 years, and the student acquires a Bachelor of Pharmacy (B. Pharm) degree upon satisfactory completion. The Faculty of Pharmacy, University of Khartoum, was established in 1964 and remained the only one in Sudan for about three decades. Currently, the total number of enrolled students is about 750 students. 13 , 14 The study was conducted from March 21 to May 29, 2021, and data were collected during a blended learning environment that combines asynchronous online learning with limited face-to-face educational activities.

Study Population

Study participants were undergraduate pharmacy students from the first to the fifth year of both genders. The study excluded students who were not registered and undertook courses during the study period, and also students with a history of diagnosed psychiatric disorders were excluded.

Sample Size and Sampling

The sample size was calculated using “Survey systems”, a sample size calculation software, 15 with 95% confidence level and a 5% margin of error. Based on the accessible study population (n=733), The minimum sample size required for this study is 252 students.

Stratified and systematic sampling probability sampling methods were used to select the participants. The study population was divided into five strata according to the academic year of study (First year to the fifth year), and then a sample size appropriate to stratum size was obtained separately from each stratum by systematic sampling using students list in each academic year as a sample frame. The first unit of each stratum was selected by simple random sampling using Microsoft Excel.

Data Collection Tool

A pretested self-administered questionnaire was used for data collection. Google form was used to create and submit the questionnaire to the pre-selected study participants. The questionnaire consisted of four sections; the first section explored the socio-demographic characteristics of the participants. The second section contained the validated Perceived Stress Scale (PSS-10) with minor modifications. 16 The PSS-10 was originally developed by Cohen et al in 1983 to evaluate the degree to which situations in participant’s life are judged as stress. PSS-10 is widely used to measure the degree to which situations in one’s life are appraised as stressful, and it has been proven for reliability and validity among university students in similar conditions, for example, analysis of psychometric properties of PSS-10 showed that it has an acceptable convergent and divergent validity, and internal consistency among university students in Saudi Arabia, 17 and Ethiopia. 18 PSS-10 consists of 10 questions about the feelings and thoughts of the respondents during the last month. The five-point Likert scale ranging from never to very often was used to rate the participants’ responses. Individual scores on the PSS-10 inventory can range from 0 to 40, with higher scores indicating higher perceived stress, and the recommended cut-off scores: 0–13 low stress; 14–26 moderate stress; 27–40 high stress. 16 The last two sections of the questionnaire were adapted from two instruments designed by Rao (2012); study habits inventory and mental health inventory. These two instruments were pre-validated and showed good levels of test-retest reliability coefficients (0.8–0.9). 19 The study habits inventory consisted of 23 statements about factors most related to cause academic stress arranged into four categories; factors related to study habits and exams, factors related to sleep and living conditions, factors related to attitude, and factors related to class and teaching. Participants were asked to choose statements that they agreed with mental health inventory contained data about coping strategies, and it consisted of 24 items. Participants were asked to choose items they were using to cope with academic stress.

Data Management and Analysis

Data were downloaded from “Google drive” as a Microsoft Excel spreadsheet and imported to SPSS, version 22 (IBM SPSS Inc., Chicago, IL) for analysis. Descriptive statistics were used to present the results, and data were illustrated as tables. A Chi-square test was used to examine the significant association between independent socio-demographic variables and dependent variables. Data with a p-value of 0.05 or less was considered statistically significant.

Ethical Consideration

The study was conducted agreeing with the recommendations of the Declaration of Helsinki. The study proposal was approved by the Research Ethics Committee of the Faculty of Pharmacy, University of Khartoum (FPEC-07-2021). Written informed consent was obtained from each participant after explaining the purpose of the study, and the students were informed that their participation was voluntary. The students were given assurances about the confidentiality of information.

The response rate in the study was 99.6% (251/252). The mean age of the participants was 20.86 ± 1.751, and most of them were females (n=202, 87.4%). Almost 147 (63.6%) participants live with their families, and 73 (29%) students live in the university dormitory. Regarding the weekly budget, about 129 (58.8%) of respondents had more than 3000 Sudanese pound/week. Detailed results of socio-demographic characteristics are shown in Table 1 .

Socio-Demographic Characteristics of Participants

Abbreviation : SDG, Sudanese pound.

The overall prevalence of academic stress among participants was 92%, with a mean score (24.99 ± 5.159), and the levels of academic stress were ranged from low (4.3%), moderate (73.2%), to high (22.5%). Approximately 80% of the percipients reported academic stress during all exam times with a mean score (25.33 ± 4.976).

As shown in Table 2 , data analysis revealed a statistically significant association of the level of academic stress with the participants gender (p= 0.042), and living condition (P= 0.001). Furthermore, the major factors related to study habits and exams that are significantly associated with the level of academic stress were difficulty in remembering all that is studied (66.7%, P=0.006), worrying about the exams (54.1%, P=0.011), exam papers are tough and do not value well (23.8%, P=0.001), and the exams are too difficult, regardless of my personal hard work (21.6%, P= 0.031). Among factors related to sleep and living conditions, not having good sleep hours before the exam was significantly associated with the level of academic stress (46.3%, P=0.010). In addition, among factors related to attitude, lack of self-confidence, and thinking to pass anyway were significantly associated with the level of academic stress (22.9%, P=0.004). Finally, among factors related to class and teaching, teachers lacking interest in students (30.3%, P=0.001), and dislike of certain courses that affect student desire to study it (34.6%, P=0.003) were significantly associated with the level of academic stress ( Table 3 ).

Association Between Independent Socio-Demographic Characteristics and the Mean Score and Level of Academic Stress

Abbreviations : SD, standard deviation; SDG, Sudanese pound.

The Relationship Between Common Factors Associated with Academic Stress and the Mean Score and Level of Academic Stress

Abbreviation : SD, standard deviation.

As summarized in Table 4 , students had used several strategies to cope with academic stress. The most frequent positive strategies were praying (84.4%), trying to maintain some control over the situation (61.9%), and thinking through different ways to handle the situation (47.2%). Moreover, no significant associations were observed between the level of academic stress and coping strategies ( Table 4 ).

The Relationship Between the Coping Strategies Used and the Mean Score and Level of Academic Stress

The current research focused on undergraduate university students’ psychological well-being during the global COVID-19 pandemic, and accessed the prevalence and various variables contributing to academic stress, as well as exploring coping strategies used by students. The study revealed a high prevalence of academic stress among respondents (92%). The majority of the respondents were identified as expressing a moderate level of academic stress. This finding was in agreement with the results of the study conducted among public health and preventive medicine students in Vietnam, where 90% of participants showed high to moderate stress during the COVID-19 pandemic. 11 On the other hand, the level of academic stress in this study was higher than those reported in other studies conducted in Ethiopia, 20 Saudi Arabia, 21 Jordan, 22 and Ireland, 23 where academic stress was approximately reported in 50% to 64% of the respondents. The high prevalence of academic stress might be attributed to the to the fact that governmental universities including the University of Khartoum were closed for a few months prior to COVID-19 pandemic for political reasons, and students were fear of any further extended lockdown due to the COVID-19 pandemic. In addition, the poor infrastructure, lack of good training and preparation for online learning could negatively impact a student’s mental health.

In agreement with the results of studies conducted in Ireland, 23 and Saudi Arabia, 21 the prevalence of academic stress was higher among females than males (P= 0.013). Concerning the duration of academic stress, approximately three-quarters of respondents exhibited academic stress all the exams duration. Out of socio-demographic characteristics (gender, year of study, living conditions, weekly budget), and in agreement with studies conducted in Ireland, 23 and Saudi Arabia, 21 data analyses revealed significant associations between the prevalence and the level of academic stress and gender with P values; 0.013 and 0.042, respectively. Moreover, a significant association was also noted between participant living conditions and the level of academic stress (P-value: 0.001). However, changes in the academic year were insignificantly associated with the level of academic stress, which contrasts to the Saudi study that indicated a significant difference between students with high-stress occurrence for the 3rd year medical students. 21 This difference could be attributed to the difference in curriculum model, In the Saudi medical college curriculum, the 3rd year is a transition year from pre-clinical to clinical study level, while in our case, there is no “transition year”, the curriculum is based on the spiral model in many courses, where students re-visit material at increasing complexity as they progress.

Study habits inventory and mental health inventory were utilized to assess factors that cause stress. 19 Factors causing academic stress are broadly arranged into four categories: study habits and exams, sleep and living conditions, factors related to attitude, and factors related to class and teaching. Among study habits and exam-related factors, difficulty remembering all that is studied was ranked as the most academic stress-causing factor, followed by worrying about the exams and lack of concentration during study hours. Moreover, physical and psychological disturbances are related to the development of serious psychological disorders such as stress and depression. 20 , 24 In this study, physical factors such as not having good sleep hours before the exam and being tired sleepy to study efficiently were highly related to academic stress development in the participants. Regarding attitude-related factors, waiting for the mood to start reading and mood changes momentarily and affecting study were selected as the top inducers of academic stress. Boring teaching style was selected by about half of the participants as a most class and teaching-related academic stress-inducing factor. In agreement with our findings, an cross-sectional study conducted among undergraduate medical students at Taibah University reported that studying all night before the exam and extensive course load were the major confounding factors. 25

Stress Coping Strategies are a collection of actions or a way of thinking used to cope with or adjust one’s response to a stressful event. Problem-oriented and emotion-oriented coping techniques are the two types of coping strategies. 26 In the current study, participants used various stress coping strategies, including positive and negative strategies. The most frequently used positive strategy was religious practice “prying, trusting god”, then trying to maintain some control over the situation, and thinking in different ways to solve the situation. Similarly, religious activities were the most adopted coping strategy in a study conducted among King Saud University medical students. 21 On the other hand, the most negative activities adopted by participants to cope with academic stress were crying and getting depressed. The current study showed no significant relationship between coping strategies and the level of stress, which in contrast, previous literature showed a relationship between the stress coping strategies and developed anxiety or depression for undergraduate students. 27 Moreover, some participant relaxation methods and to overcome academic stress, the most commonly used relaxation strategies were drinking coffee/tea, and listening to music. Coping strategies can divided into three main types; proactive strategies that used manage or solve the problem, emotional strategies that focus on regulating or reducing the emotional arousal associated with the stress, and avoidance strategies designed to avoid the stressful conditions. 28 Although different types of coping strategies can be used, they may vary in their effectiveness. Some studies reported that personality variables, influence the coping strategies adopted as well as the outcomes. 29 Further studies may be required to access the determinants of choice, and the effectiveness of coping strategies.

Limitations of this study are that it was conducted among pharmacy students in one university so, it cannot be generalized to students in other universities. Another limitation is that it’s a cross-sectional study, administered to the students at one point in time. However, students’ academic stress status may change daily during the pandemic; repeating the survey may enable evaluation of the consistency of findings. In addition, in the questionnaire, the duration of academic stress was reported only about the exam, not at other times.

The present study highlighted the impact of the COVID-19 crisis on pharmacy student mental health. The study showed a high prevalence of academic stress, the level of academic stress was significantly associated with participants’ gender and living conditions. The major factors associated with academic stress among participants were difficulty in remembering all that is studied, worrying about the exams, and lack of concentration during study hours. The study’s findings revealed an alarming increase in mental health morbidity among study participants, which strongly recommend immediate treatment through academic counseling, mental status monitoring, and stress reduction programs.

Acknowledgment

We gratefully acknowledge the University of Khartoum, Faculty of pharmacy for providing information. Also, we would like to thank undergraduate pharmacy students who participated in the study.

All authors report no conflicts of interest in this work.

IMAGES

  1. (PDF) Stress and Burnout Questionnaire

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  2. (PDF) Stress among students: An emerging issue

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  3. Questionnaire measuring the stress in college students

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  5. Sources of stress identified by medical students.

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  6. Conceptual framework for academic stress

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COMMENTS

  1. Full article: The impact of stress on students in secondary school and

    Methods. A single author (MP) searched PubMed and Google Scholar for peer-reviewed articles published at any time in English. Search terms included academic, school, university, stress, mental health, depression, anxiety, youth, young people, resilience, stress management, stress education, substance use, sleep, drop-out, physical health with a combination of any and/or all of the preceding terms.

  2. (PDF) Stress among students: An emerging issue

    original definition of stress formulated by Selye (1983) was, "Stress is a non-specific response of the body". Stress is an. unavoidable phenomenon in all aspects of human life. Stress. is an ...

  3. Academic Stress and Mental Well-Being in College Students: Correlations

    A survey was developed that included all questions from the Short Warwick-Edinburgh Mental Well-Being (Tennant et al., ... anxiety, and stress among college students: a longitudinal study from China. J. Affect. Disord. 263, 292-300. 10.1016/j.jad.2019.11.121 ... Research synthesis: Satisficing in surveys: a systematic review of the literature.

  4. Stress, Anxiety, and Depression Among Undergraduate Students during the

    To address the first and second research questions, we used descriptive statistics and presented the prevalence of stress, anxiety, and depression as well as the frequency of using mental health services. For the third research question, we adopted ordinal logistic regression and logistic regression models depending on outcome variables.

  5. Key questions: research priorities for student mental health

    For example, there is strong evidence of relationships between mental health problems and financial stress, 30, 31 drug and alcohol consumption, 32, 33 isolation and loneliness, 34 and sleep disruption 35, 36 among students, as well as experiences of adverse events before and during university. 37 Although studies have increasingly explored the ...

  6. Frontiers

    Among the subgroups of students, women, non-binary students, and second-year students reported higher academic stress levels and worse mental well-being (Table 2; Figures 2-4).In addition, the combined measures differed significantly between the groups in each category ().However, as measured by partial eta squared, the effect sizes were relatively small, given the convention of 0.01 = small ...

  7. PDF Are Students Stressed?: A Study of the Impact of Student ...

    Of the 103 female students who participated in the study, 46% experienced a. clinically significant daytime sleepiness and 61 % experienced a clinically significant. fatigue severity. Participants experienced moderate symptoms of depression. Only three. students experienced no physical symptoms, and the other students experienced on.

  8. (PDF) Perceived Academic Stress among Students

    Academic stress is a student's perception of the pressure. they face, time constraints to comple te assignments, academic. workload, and their ac ademic self-perception (Bedewy &. Gabriel, 2015 ...

  9. Persistent anxiety among high school students: Survey results ...

    Introduction National mental health surveys have demonstrated increased stress and depressive symptoms among high-school students during the first year of the COVID-19 pandemic, but objective measures of anxiety after the first year of the pandemic are lacking. Methods A 25-question survey including demographics, the Generalized Anxiety Disorder-7 scale (GAD-7) a validated self-administered ...

  10. Stress among university students: factorial structure and measurement

    Background In the last decade academic stress and its mental health implications amongst university students has become a global topic. The use of valid and theoretically-grounded measures of academic stress in university settings is crucial. The aim of this study was to examine the factorial structure, reliability and measurement invariance of the short student version of the effort-reward ...

  11. Better emotion regulation mediates gratitude and increased stress in

    It is well established that university students are vulnerable to poor mental health. Although increased gratitude has been shown to reduce stress among students, a clearer understanding of key mechanisms underpinning this relationship are needed to better inform theoretical models and potential interventions targeted at improving well-being in university students.

  12. Social Sciences

    Stress is a defining trait of our modern societies. The correlations between economic and social developments and the state of ill-being of populations have long been demonstrated. Today, negative environmental factors such as climate change, war and health crises have consequences on populations. Regardless of gender or age, more and more people are suffering from stress, of which there are ...

  13. Stress and Coping Mechanisms Among College Students

    This research pursued the following question: Is there a relationship between self-compassion and coping mechanisms for stress among college students? Stress is something that college students face throughout their academic journey; however, this stress can be mitigated by coping skills implemented by students.

  14. A Qualitative Study of Stressors, Stress Symptoms, and Coping

    The Student-Life Stress Inventory, designed for students, was validated by Gardzella (1994) for reliability and validity. Other studies have utilized author- generated questionnaires based on traditional inventories and coping mechanisms (Hicks & Heastie, 2008). Nonetheless, measuring stress in college students remains a challenge, and

  15. (PDF) Impact of Academic Stress on Secondary School Student's

    Depression, anxiety, and stress are. interrelated (Adu, 2023). Shared sy mptoms of depression, stress, and anxiety can contribute to. a variety of academic problems that ne gatively impact ...

  16. How stress-related factors affect mental wellbeing of university students

    A cross-sectional survey design was used among students of an University of Applied Sciences and conducted between November 16, 2020, and January 18, 2021. ... An example question is ... The association of personality traits and coping styles according to stress level. Journal of research in medical sciences: the official journal of Isfahan ...

  17. Assessment of academic stress and its coping mechanisms among medical

    Academic stress is the most common mental state that medical students experience during their training period. To assess academic stress, to find out its determinants, to assess other sources of stress and to explore the various coping styles against academic stress adopted by students. Methods: It was a cross sectional study done among medical students from first to fourth year. Standard self ...

  18. Student stress survey questions

    20+ Student Stress Survey Questions for Questionnaire + Template. This is a sample student stress survey template that has questions and examples to understand the higher education experience of students, how they cope with stress and the entire experience as a student in high school. Stress takes a toll on students' mental health.

  19. How Stress and Burnout Impact the Quality of Life ...

    The current analysis also demonstrates that there is a critical need in the scientific literature for research on stress and burnout among healthcare students in Italy or, more broadly, in Europe. As a result, the findings are based on a global study of the data and are relevant to nations that differ from Europe in terms of their demographics.

  20. Physical activity improves stress load, recovery, and academic

    Hypothesis 1 (path 1): Given that stress load always occurs as a duality—beneficial if it is functional for coping, or exhausting if it puts a strain on personal resources [] - we consider two variables for stress load: functional stress and dysfunctional stress.In order to reduce the length of the daily surveys, we focused the measure of recovery only on the most obvious and accessible ...

  21. The longitudinal mediating role of sleep in associations between COVID

    The current study tested a longitudinal mediation model throughout the COVID-19 pandemic focused on whether students' housing instability stress and food/financial instability stress at the beginning of the pandemic in spring 2020 (T1) informed sleep dissatisfaction and duration in fall 2020 (T2) and, in turn, physical and mental health in spring 2021 (T3).

  22. (PDF) STRESS COPING MECHANISMS AMONG COLLEGE STUDENT ...

    O'Brien (2014) says that stress have a positive impact to a person that feels motivated and must able to. accomplish the situatio ns. Shared methods of coping employed by students include crying ...

  23. COVID-19 Student Stress Questionnaire: Development and Validation of a

    In particular, it was hypothesized that induced changes in academic studying and relationships with friends, partner, university colleagues, professors and relatives could constitute significant perceived COVID-19 pandemic lockdown-related sources of stress among university students. Hypotheses and research questions to rigorously check the ...

  24. Nursing students' stressors and coping strategies during their first

    Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses' sources of stress and coping styles ...

  25. Frontiers

    In particular, it was hypothesized that induced changes in academic studying and relationships with friends, partner, university colleagues, professors and relatives could constitute significant perceived COVID-19 pandemic lockdown-related sources of stress among university students. Hypotheses and research questions to rigorously check the ...

  26. Are Schools Too Focused on Mental Health?

    May 6, 2024. In recent years, mental health has become a central subject in childhood and adolescence. Teenagers narrate their psychiatric diagnosis and treatment on TikTok and Instagram. School ...

  27. Frontiers

    1 School of Nursing, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China; 2 Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, China; 3 The Interdisciplinary Centre for Qualitative Research, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China; Background: The prevalence of mental health issues ...

  28. Do childhood experiences influence associations between posttraumatic

    Results . Path analyses showed more PTSD symptom severity was significantly associated with less positive autobiographical memory vividness (β = −0.26, p = .019, R 2 = 0.06). Further, the number of ACEs moderated the relationship between PTSD symptom severity and positive autobiographical memory accessibility (β = −0.25, p = .023, R 2 = 0.10) and vividness (β = −0.20, p = .024, R 2 ...

  29. Stress, Anxiety, and Depression Among Undergraduate Students during the

    The coronavirus 2019 (COVID-19) has brought significant changes to college students, but there is a lack of empirical studies regarding how the pandemic has affected student mental health among college students in the U.S. To fill the gap in the literature, this study describes stress, anxiety, and depression symptoms for students in a public research university in Kentucky during an early ...

  30. Perceived Academic Stress, Causes, and Coping Strategies Among

    Introduction. Stress is a prevalent mental health disorder among university students. 1 College student stress is mostly attributed to many factors such as academic pressures, social issues, and financial problems. 2, 3 College-related factors contributing to student's stress include, the transition from school to the college environment, the curriculum load, and summative assessments, 4 ...