research questions on stress among students

• Research article
• Open access
• 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.

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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.

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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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DOI : https://doi.org/10.1186/s40359-019-0343-7

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• Philip Kreniske, 
• Claude A. Mellins

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

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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https://doi.org/10.1371/journal.pone.0275292.t001

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 ).

https://doi.org/10.1371/journal.pone.0275292.t002

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 ).

https://doi.org/10.1371/journal.pone.0275292.t003

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 ).

https://doi.org/10.1371/journal.pone.0275292.t004

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.

https://doi.org/10.1371/journal.pone.0275292.t005

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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Student mental health is in crisis. Campuses are rethinking their approach

Amid massive increases in demand for care, psychologists are helping colleges and universities embrace a broader culture of well-being and better equipping faculty to support students in need

Vol. 53 No. 7 Print version: page 60

• Mental Health

By nearly every metric, student mental health is worsening. During the 2020–2021 school year, more than 60% of college students met the criteria for at least one mental health problem, according to the Healthy Minds Study, which collects data from 373 campuses nationwide ( Lipson, S. K., et al., Journal of Affective Disorders , Vol. 306, 2022 ). In another national survey, almost three quarters of students reported moderate or severe psychological distress ( National College Health Assessment , American College Health Association, 2021).

Even before the pandemic, schools were facing a surge in demand for care that far outpaced capacity, and it has become increasingly clear that the traditional counseling center model is ill-equipped to solve the problem.

“Counseling centers have seen extraordinary increases in demand over the past decade,” said Michael Gerard Mason, PhD, associate dean of African American Affairs at the University of Virginia (UVA) and a longtime college counselor. “[At UVA], our counseling staff has almost tripled in size, but even if we continue hiring, I don’t think we could ever staff our way out of this challenge.”

Some of the reasons for that increase are positive. Compared with past generations, more students on campus today have accessed mental health treatment before college, suggesting that higher education is now an option for a larger segment of society, said Micky Sharma, PsyD, who directs student life’s counseling and consultation service at The Ohio State University (OSU). Stigma around mental health issues also continues to drop, leading more people to seek help instead of suffering in silence.

But college students today are also juggling a dizzying array of challenges, from coursework, relationships, and adjustment to campus life to economic strain, social injustice, mass violence, and various forms of loss related to Covid -19.

As a result, school leaders are starting to think outside the box about how to help. Institutions across the country are embracing approaches such as group therapy, peer counseling, and telehealth. They’re also better equipping faculty and staff to spot—and support—students in distress, and rethinking how to respond when a crisis occurs. And many schools are finding ways to incorporate a broader culture of wellness into their policies, systems, and day-to-day campus life.

“This increase in demand has challenged institutions to think holistically and take a multifaceted approach to supporting students,” said Kevin Shollenberger, the vice provost for student health and well-being at Johns Hopkins University. “It really has to be everyone’s responsibility at the university to create a culture of well-being.”

Higher caseloads, creative solutions

The number of students seeking help at campus counseling centers increased almost 40% between 2009 and 2015 and continued to rise until the pandemic began, according to data from Penn State University’s Center for Collegiate Mental Health (CCMH), a research-practice network of more than 700 college and university counseling centers ( CCMH Annual Report , 2015 ).

That rising demand hasn’t been matched by a corresponding rise in funding, which has led to higher caseloads. Nationwide, the average annual caseload for a typical full-time college counselor is about 120 students, with some centers averaging more than 300 students per counselor ( CCMH Annual Report , 2021 ).

“We find that high-caseload centers tend to provide less care to students experiencing a wide range of problems, including those with safety concerns and critical issues—such as suicidality and trauma—that are often prioritized by institutions,” said psychologist Brett Scofield, PhD, executive director of CCMH.

To minimize students slipping through the cracks, schools are dedicating more resources to rapid access and assessment, where students can walk in for a same-day intake or single counseling session, rather than languishing on a waitlist for weeks or months. Following an evaluation, many schools employ a stepped-care model, where the students who are most in need receive the most intensive care.

Given the wide range of concerns students are facing, experts say this approach makes more sense than offering traditional therapy to everyone.

“Early on, it was just about more, more, more clinicians,” said counseling psychologist Carla McCowan, PhD, director of the counseling center at the University of Illinois at Urbana-Champaign. “In the past few years, more centers are thinking creatively about how to meet the demand. Not every student needs individual therapy, but many need opportunities to increase their resilience, build new skills, and connect with one another.”

Students who are struggling with academic demands, for instance, may benefit from workshops on stress, sleep, time management, and goal-setting. Those who are mourning the loss of a typical college experience because of the pandemic—or facing adjustment issues such as loneliness, low self-esteem, or interpersonal conflict—are good candidates for peer counseling. Meanwhile, students with more acute concerns, including disordered eating, trauma following a sexual assault, or depression, can still access one-on-one sessions with professional counselors.

As they move away from a sole reliance on individual therapy, schools are also working to shift the narrative about what mental health care on campus looks like. Scofield said it’s crucial to manage expectations among students and their families, ideally shortly after (or even before) enrollment. For example, most counseling centers won’t be able to offer unlimited weekly sessions throughout a student’s college career—and those who require that level of support will likely be better served with a referral to a community provider.

“We really want to encourage institutions to be transparent about the services they can realistically provide based on the current staffing levels at a counseling center,” Scofield said.

The first line of defense

Faculty may be hired to teach, but schools are also starting to rely on them as “first responders” who can help identify students in distress, said psychologist Hideko Sera, PsyD, director of the Office of Equity, Inclusion, and Belonging at Morehouse College, a historically Black men’s college in Atlanta. During the pandemic, that trend accelerated.

“Throughout the remote learning phase of the pandemic, faculty really became students’ main points of contact with the university,” said Bridgette Hard, PhD, an associate professor and director of undergraduate studies in psychology and neuroscience at Duke University. “It became more important than ever for faculty to be able to detect when a student might be struggling.”

Many felt ill-equipped to do so, though, with some wondering if it was even in their scope of practice to approach students about their mental health without specialized training, Mason said.

Schools are using several approaches to clarify expectations of faculty and give them tools to help. About 900 faculty and staff at the University of North Carolina have received training in Mental Health First Aid , which provides basic skills for supporting people with mental health and substance use issues. Other institutions are offering workshops and materials that teach faculty to “recognize, respond, and refer,” including Penn State’s Red Folder campaign .

Faculty are taught that a sudden change in behavior—including a drop in attendance, failure to submit assignments, or a disheveled appearance—may indicate that a student is struggling. Staff across campus, including athletic coaches and academic advisers, can also monitor students for signs of distress. (At Penn State, eating disorder referrals can even come from staff working in food service, said counseling psychologist Natalie Hernandez DePalma, PhD, senior director of the school’s counseling and psychological services.) Responding can be as simple as reaching out and asking if everything is going OK.

Referral options vary but may include directing a student to a wellness seminar or calling the counseling center to make an appointment, which can help students access services that they may be less likely to seek on their own, Hernandez DePalma said. Many schools also offer reporting systems, such as DukeReach at Duke University , that allow anyone on campus to express concern about a student if they are unsure how to respond. Trained care providers can then follow up with a welfare check or offer other forms of support.

“Faculty aren’t expected to be counselors, just to show a sense of care that they notice something might be going on, and to know where to refer students,” Shollenberger said.

At Johns Hopkins, he and his team have also worked with faculty on ways to discuss difficult world events during class after hearing from students that it felt jarring when major incidents such as George Floyd’s murder or the war in Ukraine went unacknowledged during class.

Many schools also support faculty by embedding counselors within academic units, where they are more visible to students and can develop cultural expertise (the needs of students studying engineering may differ somewhat from those in fine arts, for instance).

When it comes to course policy, even small changes can make a big difference for students, said Diana Brecher, PhD, a clinical psychologist and scholar-in-residence for positive psychology at Toronto Metropolitan University (TMU), formerly Ryerson University. For example, instructors might allow students a 7-day window to submit assignments, giving them agency to coordinate with other coursework and obligations. Setting deadlines in the late afternoon or early evening, as opposed to at midnight, can also help promote student wellness.

At Moraine Valley Community College (MVCC) near Chicago, Shelita Shaw, an assistant professor of communications, devised new class policies and assignments when she noticed students struggling with mental health and motivation. Those included mental health days, mindful journaling, and a trip with family and friends to a Chicago landmark, such as Millennium Park or Navy Pier—where many MVCC students had never been.

Faculty in the psychology department may have a unique opportunity to leverage insights from their own discipline to improve student well-being. Hard, who teaches introductory psychology at Duke, weaves in messages about how students can apply research insights on emotion regulation, learning and memory, and a positive “stress mindset” to their lives ( Crum, A. J., et al., Anxiety, Stress, & Coping , Vol. 30, No. 4, 2017 ).

Along with her colleague Deena Kara Shaffer, PhD, Brecher cocreated TMU’s Thriving in Action curriculum, which is delivered through a 10-week in-person workshop series and via a for-credit elective course. The material is also freely available for students to explore online . The for-credit course includes lectures on gratitude, attention, healthy habits, and other topics informed by psychological research that are intended to set students up for success in studying, relationships, and campus life.

“We try to embed a healthy approach to studying in the way we teach the class,” Brecher said. “For example, we shift activities every 20 minutes or so to help students sustain attention and stamina throughout the lesson.”

Creative approaches to support

Given the crucial role of social connection in maintaining and restoring mental health, many schools have invested in group therapy. Groups can help students work through challenges such as social anxiety, eating disorders, sexual assault, racial trauma, grief and loss, chronic illness, and more—with the support of professional counselors and peers. Some cater to specific populations, including those who tend to engage less with traditional counseling services. At Florida Gulf Coast University (FGCU), for example, the “Bold Eagles” support group welcomes men who are exploring their emotions and gender roles.

The widespread popularity of group therapy highlights the decrease in stigma around mental health services on college campuses, said Jon Brunner, PhD, the senior director of counseling and wellness services at FGCU. At smaller schools, creating peer support groups that feel anonymous may be more challenging, but providing clear guidelines about group participation, including confidentiality, can help put students at ease, Brunner said.

Less formal groups, sometimes called “counselor chats,” meet in public spaces around campus and can be especially helpful for reaching underserved groups—such as international students, first-generation college students, and students of color—who may be less likely to seek services at a counseling center. At Johns Hopkins, a thriving international student support group holds weekly meetings in a café next to the library. Counselors typically facilitate such meetings, often through partnerships with campus centers or groups that support specific populations, such as LGBTQ students or student athletes.

“It’s important for students to see counselors out and about, engaging with the campus community,” McCowan said. “Otherwise, you’re only seeing the students who are comfortable coming in the door.”

Peer counseling is another means of leveraging social connectedness to help students stay well. At UVA, Mason and his colleagues found that about 75% of students reached out to a peer first when they were in distress, while only about 11% contacted faculty, staff, or administrators.

“What we started to understand was that in many ways, the people who had the least capacity to provide a professional level of help were the ones most likely to provide it,” he said.

Project Rise , a peer counseling service created by and for Black students at UVA, was one antidote to this. Mason also helped launch a two-part course, “Hoos Helping Hoos,” (a nod to UVA’s unofficial nickname, the Wahoos) to train students across the university on empathy, mentoring, and active listening skills.

At Washington University in St. Louis, Uncle Joe’s Peer Counseling and Resource Center offers confidential one-on-one sessions, in person and over the phone, to help fellow students manage anxiety, depression, academic stress, and other campus-life issues. Their peer counselors each receive more than 100 hours of training, including everything from basic counseling skills to handling suicidality.

Uncle Joe’s codirectors, Colleen Avila and Ruchika Kamojjala, say the service is popular because it’s run by students and doesn’t require a long-term investment the way traditional psychotherapy does.

“We can form a connection, but it doesn’t have to feel like a commitment,” said Avila, a senior studying studio art and philosophy-neuroscience-psychology. “It’s completely anonymous, one time per issue, and it’s there whenever you feel like you need it.”

As part of the shift toward rapid access, many schools also offer “Let’s Talk” programs , which allow students to drop in for an informal one-on-one session with a counselor. Some also contract with telehealth platforms, such as WellTrack and SilverCloud, to ensure that services are available whenever students need them. A range of additional resources—including sleep seminars, stress management workshops, wellness coaching, and free subscriptions to Calm, Headspace, and other apps—are also becoming increasingly available to students.

Those approaches can address many student concerns, but institutions also need to be prepared to aid students during a mental health crisis, and some are rethinking how best to do so. Penn State offers a crisis line, available anytime, staffed with counselors ready to talk or deploy on an active rescue. Johns Hopkins is piloting a behavioral health crisis support program, similar to one used by the New York City Police Department, that dispatches trained crisis clinicians alongside public safety officers to conduct wellness checks.

A culture of wellness

With mental health resources no longer confined to the counseling center, schools need a way to connect students to a range of available services. At OSU, Sharma was part of a group of students, staff, and administrators who visited Apple Park in Cupertino, California, to develop the Ohio State: Wellness App .

Students can use the app to create their own “wellness plan” and access timely content, such as advice for managing stress during final exams. They can also connect with friends to share articles and set goals—for instance, challenging a friend to attend two yoga classes every week for a month. OSU’s apps had more than 240,000 users last year.

At Johns Hopkins, administrators are exploring how to adapt school policies and procedures to better support student wellness, Shollenberger said. For example, they adapted their leave policy—including how refunds, grades, and health insurance are handled—so that students can take time off with fewer barriers. The university also launched an educational campaign this fall to help international students navigate student health insurance plans after noticing below average use by that group.

Students are a key part of the effort to improve mental health care, including at the systemic level. At Morehouse College, Sera serves as the adviser for Chill , a student-led advocacy and allyship organization that includes members from Spelman College and Clark Atlanta University, two other HBCUs in the area. The group, which received training on federal advocacy from APA’s Advocacy Office earlier this year, aims to lobby public officials—including U.S. Senator Raphael Warnock, a Morehouse College alumnus—to increase mental health resources for students of color.

“This work is very aligned with the spirit of HBCUs, which are often the ones raising voices at the national level to advocate for the betterment of Black and Brown communities,” Sera said.

Despite the creative approaches that students, faculty, staff, and administrators are employing, students continue to struggle, and most of those doing this work agree that more support is still urgently needed.

“The work we do is important, but it can also be exhausting,” said Kamojjala, of Uncle Joe’s peer counseling, which operates on a volunteer basis. “Students just need more support, and this work won’t be sustainable in the long run if that doesn’t arrive.”

Further reading

Overwhelmed: The real campus mental-health crisis and new models for well-being The Chronicle of Higher Education, 2022

Mental health in college populations: A multidisciplinary review of what works, evidence gaps, and paths forward Abelson, S., et al., Higher Education: Handbook of Theory and Research, 2022

Student mental health status report: Struggles, stressors, supports Ezarik, M., Inside Higher Ed, 2022

Before heading to college, make a mental health checklist Caron, C., The New York Times, 2022

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• Stress effects on the body

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ORIGINAL RESEARCH article

Academic stress and mental well-being in college students: correlations, affected groups, and covid-19.

• 1 Department of Neurology, Rutgers New Jersey Medical School, Newark, NJ, United States
• 2 Rutgers New Jersey Medical School, Newark, NJ, United States
• 3 Office for Diversity and Community Engagement, Rutgers New Jersey Medical School, Newark, NJ, United States
• 4 Department of Biology, The College of New Jersey, Ewing, NJ, United States

Academic stress may be the single most dominant stress factor that affects the mental well-being of college students. Some groups of students may experience more stress than others, and the coronavirus disease 19 (COVID-19) pandemic could further complicate the stress response. We surveyed 843 college students and evaluated whether academic stress levels affected their mental health, and if so, whether there were specific vulnerable groups by gender, race/ethnicity, year of study, and reaction to the pandemic. Using a combination of scores from the Perception of Academic Stress Scale (PAS) and the Short Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS), we found a significant correlation between worse academic stress and poor mental well-being in all the students, who also reported an exacerbation of stress in response to the pandemic. In addition, SWEMWBS scores revealed the lowest mental health and highest academic stress in non-binary individuals, and the opposite trend was observed for both the measures in men. Furthermore, women and non-binary students reported higher academic stress than men, as indicated by PAS scores. The same pattern held as a reaction to COVID-19-related stress. PAS scores and responses to the pandemic varied by the year of study, but no obvious patterns emerged. These results indicate that academic stress in college is significantly correlated to psychological well-being in the students who responded to this survey. In addition, some groups of college students are more affected by stress than others, and additional resources and support should be provided to them.

Introduction

Late adolescence and emerging adulthood are transitional periods marked by major physiological and psychological changes, including elevated stress ( Hogan and Astone, 1986 ; Arnett, 2000 ; Shanahan, 2000 ; Spear, 2000 ; Scales et al., 2015 ; Romeo et al., 2016 ; Barbayannis et al., 2017 ; Chiang et al., 2019 ; Lally and Valentine-French, 2019 ; Matud et al., 2020 ). This pattern is particularly true for college students. According to a 2015 American College Health Association-National College Health Assessment survey, three in four college students self-reported feeling stressed, while one in five college students reported stress-related suicidal ideation ( Liu, C. H., et al., 2019 ; American Psychological Association, 2020 ). Studies show that a stressor experienced in college may serve as a predictor of mental health diagnoses ( Pedrelli et al., 2015 ; Liu, C. H., et al., 2019 ; Karyotaki et al., 2020 ). Indeed, many mental health disorders, including depression, anxiety, and substance abuse disorder, begin during this period ( Blanco et al., 2008 ; Pedrelli et al., 2015 ; Saleh et al., 2017 ; Reddy et al., 2018 ; Liu, C. H., et al., 2019 ).

Stress experienced by college students is multi-factorial and can be attributed to a variety of contributing factors ( Reddy et al., 2018 ; Karyotaki et al., 2020 ). A growing body of evidence suggests that academic-related stress plays a significant role in college ( Misra and McKean, 2000 ; Dusselier et al., 2005 ; Elias et al., 2011 ; Bedewy and Gabriel, 2015 ; Hj Ramli et al., 2018 ; Reddy et al., 2018 ; Pascoe et al., 2020 ). For instance, as many as 87% of college students surveyed across the United States cited education as their primary source of stress ( American Psychological Association, 2020 ). College students are exposed to novel academic stressors, such as an extensive academic course load, substantial studying, time management, classroom competition, financial concerns, familial pressures, and adapting to a new environment ( Misra and Castillo, 2004 ; Byrd and McKinney, 2012 ; Ekpenyong et al., 2013 ; Bedewy and Gabriel, 2015 ; Ketchen Lipson et al., 2015 ; Pedrelli et al., 2015 ; Reddy et al., 2018 ; Liu, C. H., et al., 2019 ; Freire et al., 2020 ; Karyotaki et al., 2020 ). Academic stress can reduce motivation, hinder academic achievement, and lead to increased college dropout rates ( Pascoe et al., 2020 ).

Academic stress has also been shown to negatively impact mental health in students ( Li and Lin, 2003 ; Eisenberg et al., 2009 ; Green et al., 2021 ). Mental, or psychological, well-being is one of the components of positive mental health, and it includes happiness, life satisfaction, stress management, and psychological functioning ( Ryan and Deci, 2001 ; Tennant et al., 2007 ; Galderisi et al., 2015 ; Trout and Alsandor, 2020 ; Defeyter et al., 2021 ; Green et al., 2021 ). Positive mental health is an understudied but important area that helps paint a more comprehensive picture of overall mental health ( Tennant et al., 2007 ; Margraf et al., 2020 ). Moreover, positive mental health has been shown to be predictive of both negative and positive mental health indicators over time ( Margraf et al., 2020 ). Further exploring the relationship between academic stress and mental well-being is important because poor mental well-being has been shown to affect academic performance in college ( Tennant et al., 2007 ; Eisenberg et al., 2009 ; Freire et al., 2016 ).

Perception of academic stress varies among different groups of college students ( Lee et al., 2021 ). For instance, female college students report experiencing increased stress than their male counterparts ( Misra et al., 2000 ; Eisenberg et al., 2007 ; Evans et al., 2018 ; Lee et al., 2021 ). Male and female students also respond differently to stressors ( Misra et al., 2000 ; Verma et al., 2011 ). Moreover, compared to their cisgender peers, non-binary students report increased stressors and mental health issues ( Budge et al., 2020 ). The academic year of study of the college students has also been shown to impact academic stress levels ( Misra and McKean, 2000 ; Elias et al., 2011 ; Wyatt et al., 2017 ; Liu, C. H., et al., 2019 ; Defeyter et al., 2021 ). While several studies indicate that racial/ethnic minority groups of students, including Black/African American, Hispanic/Latino, and Asian American students, are more likely to experience anxiety, depression, and suicidality than their white peers ( Lesure-Lester and King, 2004 ; Lipson et al., 2018 ; Liu, C. H., et al., 2019 ; Kodish et al., 2022 ), these studies are limited and often report mixed or inconclusive findings ( Liu, C. H., et al., 2019 ; Kodish et al., 2022 ). Therefore, more studies should be conducted to address this gap in research to help identify subgroups that may be disproportionately impacted by academic stress and lower well-being.

The coronavirus disease 19 (COVID-19) pandemic is a major stressor that has led to a mental health crisis ( American Psychological Association, 2020 ; Dong and Bouey, 2020 ). For college students, the COVID-19 pandemic has resulted in significant changes and disruptions to daily life, elevated stress levels, and mental and physical health deterioration ( American Psychological Association, 2020 ; Husky et al., 2020 ; Patsali et al., 2020 ; Son et al., 2020 ; Clabaugh et al., 2021 ; Lee et al., 2021 ; Lopes and Nihei, 2021 ; Yang et al., 2021 ). While any college student is vulnerable to these stressors, these concerns are amplified for members of minority groups ( Salerno et al., 2020 ; Clabaugh et al., 2021 ; McQuaid et al., 2021 ; Prowse et al., 2021 ; Kodish et al., 2022 ). Identifying students at greatest risk provides opportunities to offer support, resources, and mental health services to specific subgroups.

The overall aim of this study was to assess academic stress and mental well-being in a sample of college students. Within this umbrella, we had several goals. First, to determine whether a relationship exists between the two constructs of perceived academic stress, measured by the Perception of Academic Stress Scale (PAS), and mental well-being, measured by the Short Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS), in college students. Second, to identify groups that could experience differential levels of academic stress and mental health. Third, to explore how the perception of the ongoing COVID-19 pandemic affected stress levels. We hypothesized that students who experienced more academic stress would have worse psychological well-being and that certain groups of students would be more impacted by academic- and COVID-19-related stress.

Materials and Methods

Survey instrument.

A survey was developed that included all questions from the Short Warwick-Edinburgh Mental Well-Being ( Tennant et al., 2007 ; Stewart-Brown and Janmohamed, 2008 ) and from the Perception of Academic Stress Scale ( Bedewy and Gabriel, 2015 ). The Short Warwick-Edinburgh Mental Well-Being Scale is a seven-item scale designed to measure mental well-being and positive mental health ( Tennant et al., 2007 ; Fung, 2019 ; Shah et al., 2021 ). The Perception of Academic Stress Scale is an 18-item scale designed to assess sources of academic stress perceived by individuals and measures three main academic stressors: academic expectations, workload and examinations, and academic self-perceptions of students ( Bedewy and Gabriel, 2015 ). These shorter scales were chosen to increase our response and study completion rates ( Kost and de Rosa, 2018 ). Both tools have been shown to be valid and reliable in college students with Likert scale responses ( Tennant et al., 2007 ; Bedewy and Gabriel, 2015 ; Ringdal et al., 2018 ; Fung, 2019 ; Koushede et al., 2019 ). Both the SWEMWBS and PAS scores are a summation of responses to the individual questions in the instruments. For the SWEMWBS questions, a higher score indicates better mental health, and scores range from 7 to 35. Similarly, the PAS questions are phrased such that a higher score indicates lower levels of stress, and scores range from 18 to 90. We augmented the survey with demographic questions (e.g., age, gender, and race/ethnicity) at the beginning of the survey and two yes/no questions and one Likert scale question about the impact of the COVID-19 pandemic at the end of our survey.

Participants for the study were self-reported college students between the ages of 18 and 30 years who resided in the United States, were fluent in English, and had Internet access. Participants were solicited through Prolific ( https://prolific.co ) in October 2021. A total of 1,023 individuals enrolled in the survey. Three individuals did not agree to participate after beginning the survey. Two were not fluent in English. Thirteen individuals indicated that they were not college students. Two were not in the 18–30 age range, and one was located outside of the United States. Of the remaining individuals, 906 were full-time students and 96 were part-time students. Given the skew of the data and potential differences in these populations, we removed the part-time students. Of the 906 full-time students, 58 indicated that they were in their fifth year of college or higher. We understand that not every student completes their undergraduate studies in 4 years, but we did not want to have a mixture of undergraduate and graduate students with no way to differentiate them. Finally, one individual reported their age as a non-number, and four individuals did not answer a question about their response to the COVID-19 pandemic. This yielded a final sample of 843 college students.

Data Analyses

After reviewing the dataset, some variables were removed from consideration due to a lack of consistency (e.g., some students reported annual income for themselves and others reported family income) or heterogeneity that prevented easy categorization (e.g., field of study). We settled on four variables of interest: gender, race/ethnicity, year in school, and response to the COVID-19 pandemic ( Table 1 ). Gender was coded as female, male, or non-binary. Race/ethnicity was coded as white or Caucasian; Black or African American; East Asian; Hispanic, Latino, or of Spanish origin; or other. Other was used for groups that were not well-represented in the sample and included individuals who identified themselves as Middle Eastern, Native American or Alaskan Native, and South Asian, as well as individuals who chose “other” or “prefer not to answer” on the survey. The year of study was coded as one through four, and COVID-19 stress was coded as two groups, no change/neutral response/reduced stress or increased stress.

Table 1 . Characteristics of the participants in the study.

Our first goal was to determine whether there was a relationship between self-reported academic stress and mental health, and we found a significant correlation (see Results section). Given the positive correlation, a multivariate analysis of variance (MANOVA) with a model testing the main effects of gender, race/ethnicity, and year of study was run in SPSS v 26.0. A factorial MANOVA would have been ideal, but our data were drawn from a convenience sample, which did not give equal representation to all groupings, and some combinations of gender, race/ethnicity, and year of study were poorly represented (e.g., a single individual). As such, we determined that it would be better to have a lack of interaction terms as a limitation to the study than to provide potentially spurious results. Finally, we used chi-square analyses to assess the effect of potential differences in the perception of the COVID-19 pandemic on stress levels in general among the groups in each category (gender, race/ethnicity, and year of study).

In terms of internal consistency, Cronbach's alpha was 0.82 for the SMEMWBS and 0.86 for the PAS. A variety of descriptors have been applied to Cronbach's alpha values. That said, 0.7 is often considered a threshold value in terms of acceptable internal consistency, and our values could be considered “high” or “good” ( Taber, 2018 ).

The participants in our study were primarily women (78.5% of respondents; Table 1 ). Participants were not equally distributed among races/ethnicities, with the majority of students selecting white or Caucasian (66.4% of responders; Table 1 ), or years of study, with fewer first-year students than other groups ( Table 1 ).

Students who reported higher academic stress also reported worse mental well-being in general, irrespective of age, gender, race/ethnicity, or year of study. PAS and SWEMWBS scores were significantly correlated ( r = 0.53, p < 0.001; Figure 1 ), indicating that a higher level of perceived academic stress is associated with worse mental well-being in college students within the United States.

Figure 1 . SWEMWBS and PAS scores for all participants.

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 ( Table 2 ). However, as measured by partial eta squared, the effect sizes were relatively small, given the convention of 0.01 = small, 0.06 = medium, and 0.14 = large differences ( Lakens, 2013 ). As such, there were only two instances in which Tukey's post-hoc tests revealed more than one statistical grouping ( Figures 2 – 4 ). For SWEMWBS score by gender, women were intermediate between men (high) and non-binary individuals (low) and not significantly different from either group ( Figure 2 ). Second-year students had the lowest PAS scores for the year of study, and first-year students had the highest scores. Third- and fourth-year students were intermediate and not statistically different from the other two groups ( Figure 4 ). There were no pairwise differences in academic stress levels or mental well-being among racial/ethnic groups.

Table 2 . Results of the MANOVA.

Figure 2 . SWEMWBS and PAS scores according to gender (mean ± SEM). Different letters for SWEMWBS scores indicate different statistical groupings ( p < 0.05).

Figure 3 . SWEMWBS and PAS scores according to race/ethnicity (mean ± SEM).

Figure 4 . SWEMWBS and PAS scores according to year in college (mean ± SEM). Different letters for PAS scores indicate different statistical groupings ( p < 0.05).

The findings varied among categories in terms of stress responses due to the COVID-19 pandemic ( Table 3 ). For gender, men were less likely than women or non-binary individuals to report increased stress from COVID-19 (χ 2 = 27.98, df = 2, p < 0.001). All racial/ethnic groups responded similarly to the pandemic (χ 2 = 3.41, df = 4, p < 0.49). For the year of study, first-year students were less likely than other cohorts to report increased stress from COVID-19 (χ 2 = 9.38, df = 3, p < 0.03).

Table 3 . Impact of COVID-19 on stress level by gender, race/ethnicity, and year of study.

Our primary findings showed a positive correlation between perceived academic stress and mental well-being in United States college students, suggesting that academic stressors, including academic expectations, workload and grading, and students' academic self-perceptions, are equally important as psychological well-being. Overall, irrespective of gender, race/ethnicity, or year of study, students who reported higher academic stress levels experienced diminished mental well-being. The utilization of well-established scales and a large sample size are strengths of this study. Our results extend and contribute to the existing literature on stress by confirming findings from past studies that reported higher academic stress and lower psychological well-being in college students utilizing the same two scales ( Green et al., 2021 ; Syed, 2021 ). To our knowledge, the majority of other prior studies with similar findings examined different components of stress, studied negative mental health indicators, used different scales or methods, employed smaller sample sizes, or were conducted in different countries ( Li and Lin, 2003 ; American Psychological Association, 2020 ; Husky et al., 2020 ; Pascoe et al., 2020 ; Patsali et al., 2020 ; Clabaugh et al., 2021 ; Lee et al., 2021 ; Lopes and Nihei, 2021 ; Yang et al., 2021 ).

This study also demonstrated that college students are not uniformly impacted by academic stress or pandemic-related stress and that there are significant group-level differences in mental well-being. Specifically, non-binary individuals and second-year students were disproportionately impacted by academic stress. When considering the effects of gender, non-binary students, in comparison to gender-conforming students, reported the highest stress levels and worst psychological well-being. Although there is a paucity of research examining the impact of academic stress in non-binary college students, prior studies have indicated that non-binary adults face adverse mental health outcomes when compared to male and female-identifying individuals ( Thorne et al., 2018 ; Jones et al., 2019 ; Budge et al., 2020 ). Alarmingly, Lipson et al. (2019) found that gender non-conforming college students were two to four times more likely to experience mental health struggles than cisgender students ( Lipson et al., 2019 ). With a growing number of college students in the United States identifying as as non-binary, additional studies could offer invaluable insight into how academic stress affects this population ( Budge et al., 2020 ).

In addition, we found that second-year students reported the most academic-related distress and lowest psychological well-being relative to students in other years of study. We surmise this may be due to this group taking advanced courses, managing heavier academic workloads, and exploring different majors. Other studies support our findings and suggest higher stress levels could be attributed to increased studying and difficulties with time management, as well as having less well-established social support networks and coping mechanisms compared to upperclassmen ( Allen and Hiebert, 1991 ; Misra and McKean, 2000 ; Liu, X et al., 2019 ). Benefiting from their additional experience, upperclassmen may have developed more sophisticated studying skills, formed peer support groups, and identified approaches to better manage their academic stress ( Allen and Hiebert, 1991 ; Misra and McKean, 2000 ). Our findings suggest that colleges should consider offering tailored mental health resources, such as time management and study skill workshops, based on the year of study to improve students' stress levels and psychological well-being ( Liu, X et al., 2019 ).

Although this study reported no significant differences regarding race or ethnicity, this does not indicate that minority groups experienced less academic stress or better mental well-being ( Lee et al., 2021 ). Instead, our results may reflect the low sample size of non-white races/ethnicities, which may not have given enough statistical power to corroborate. In addition, since coping and resilience are important mediators of subjective stress experiences ( Freire et al., 2020 ), we speculate that the lower ratios of stress reported in non-white participants in our study (75 vs. 81) may be because they are more accustomed to adversity and thereby more resilient ( Brown, 2008 ; Acheampong et al., 2019 ). Furthermore, ethnic minority students may face stigma when reporting mental health struggles ( Liu, C. H., et al., 2019 ; Lee et al., 2021 ). For instance, studies showed that Black/African American, Hispanic/Latino, and Asian American students disclose fewer mental health issues than white students ( Liu, C. H., et al., 2019 ; Lee et al., 2021 ). Moreover, the ability to identify stressors and mental health problems may manifest differently culturally for some minority groups ( Huang and Zane, 2016 ; Liu, C. H., et al., 2019 ). Contrary to our findings, other studies cited racial disparities in academic stress levels and mental well-being of students. More specifically, Negga et al. (2007) concluded that African American college students were more susceptible to higher academic stress levels than their white classmates ( Negga et al., 2007 ). Another study reported that minority students experienced greater distress and worse mental health outcomes compared to non-minority students ( Smith et al., 2014 ). Since there may be racial disparities in access to mental health services at the college level, universities, professors, and counselors should offer additional resources to support these students while closely monitoring their psychological well-being ( Lipson et al., 2018 ; Liu, C. H., et al., 2019 ).

While the COVID-19 pandemic increased stress levels in all the students included in our study, women, non-binary students, and upperclassmen were disproportionately affected. An overwhelming body of evidence suggests that the majority of college students experienced increased stress levels and worsening mental health as a result of the pandemic ( Allen and Hiebert, 1991 ; American Psychological Association, 2020 ; Husky et al., 2020 ; Patsali et al., 2020 ; Son et al., 2020 ; Clabaugh et al., 2021 ; Lee et al., 2021 ; Yang et al., 2021 ). Our results also align with prior studies that found similar subgroups of students experience disproportionate pandemic-related distress ( Gao et al., 2020 ; Clabaugh et al., 2021 ; Hunt et al., 2021 ; Jarrett et al., 2021 ; Lee et al., 2021 ; Chen and Lucock, 2022 ). In particular, the differences between female students and their male peers may be the result of different psychological and physiological responses to stress reactivity, which in turn may contribute to different coping mechanisms to stress and the higher rates of stress-related disorders experienced by women ( Misra et al., 2000 ; Kajantie and Phillips, 2006 ; Verma et al., 2011 ; Gao et al., 2020 ; Graves et al., 2021 ). COVID-19 was a secondary consideration in our study and survey design, so the conclusions drawn here are necessarily limited.

The implications of this study are that college students facing increased stress and struggling with mental health issues should receive personalized and specific mental health services, resources, and support. This is particularly true for groups that have been disproportionately impacted by academic stress and stress due to the pandemic. Many students who experience mental health struggles underutilize college services due to cost, stigma, or lack of information ( Cage et al., 2020 ; Lee et al., 2021 ). To raise awareness and destigmatize mental health, colleges can consider distributing confidential validated assessments, such as the PAS and SWEMWBS, in class and teach students to self-score ( Lee et al., 2021 ). These results can be used to understand how academic stress and mental well-being change over time and allow for specific and targeted interventions for vulnerable groups. In addition, teaching students healthy stress management techniques has been shown to improve psychological well-being ( Alborzkouh et al., 2015 ). Moreover, adaptive coping strategies, including social and emotional support, have been found to improve the mental well-being of students, and stress-reduction peer support groups and workshops on campus could be beneficial in reducing stress and improving the self-efficacy of students ( Ruthig et al., 2009 ; Baqutayan, 2011 ; Bedewy and Gabriel, 2015 ; Freire et al., 2020 ; Green et al., 2021 ; Suresh et al., 2021 ). Other interventions that have been effective in improving the coping skills of college students include cognitive-behavioral therapy, mindfulness mediation, and online coping tools ( Kang et al., 2009 ; Regehr et al., 2013 ; Molla Jafar et al., 2015 ; Phang et al., 2015 ; Houston et al., 2017 ; Yusufov et al., 2019 ; Freire et al., 2020 ). Given that resilience has also been shown to help mediate stress and improve mental well-being during the COVID-19 pandemic, interventions focusing on enhancing resilience should be considered ( Surzykiewicz et al., 2021 ; Skalski et al., 2022 ). Telemental health resources across colleges can also be implemented to reduce stigma and improve at-risk students' access to care ( Toscos et al., 2018 ; Hadler et al., 2021 ). University campuses, professors, and counselors should consider focusing on fostering a more equitable and inclusive environment to encourage marginalized students to seek mental health support ( Budge et al., 2020 ).

Limitations

While our study has numerous strengths, including using standardized instruments and a large sample size, this study also has several limitations due to both the methodology and sample. First, the correlational study design precludes making any causal relationships ( Misra and McKean, 2000 ). Thereby, our findings should be taken in the context of academic stress and mental well-being, and recognize that mental health could be caused by other non-academic factors. Second, the PAS comprised only the perception of responses to academic stress, but stress is a multi-factorial response that encompasses both perceptions and coping mechanisms to different stressors, and the magnitude of stress varies with the perception of the degree of uncontrollability, unpredictability, or threat to self ( Miller, 1981 ; Hobfoll and Walfisch, 1984 ; Lazarus and Folkman, 1984 ; Wheaton, 1985 ; Perrewé and Zellars, 1999 ; Schneiderman et al., 2005 ; Bedewy and Gabriel, 2015 ; Schönfeld et al., 2016 ; Reddy et al., 2018 ; Freire et al., 2020 ; Karyotaki et al., 2020 ). Third, the SWEMSBS used in our study and the data only measured positive mental health. Mental health pathways are numerous and complex, and are composed of distinct and interdependent negative and positive indicators that should be considered together ( Margraf et al., 2020 ). Fourth, due to the small effect sizes and unequal representation for different combinations of variables, our analysis for both the PAS and SWEMSBS included only summed-up scales and did not examine group differences in response to the type of academic stressors or individual mental health questions.

An additional limitation is that the participants in our study were a convenience sample. The testing service we used, prolific.co, self-reports a sample bias toward young women of high levels of education (i.e., WEIRD bias) ( Team Prolific, 2018 ). The skew toward this population was observed in our data, as 80% of our participants were women. While we controlled for these factors, the possibility remains that the conclusions we draw for certain groups, such as nonbinary students, ethnic/racial minorities, and men, may not be as statistically powerful as they should be. Moreover, our pre-screening was designed to recruit undergraduate level, English-speaking, 18–30-year-olds who resided in the United States. This resulted in our participant demographics being skewed toward the WEIRD bias that was already inherent in the testing service we used. Future research will aim to be more inclusive of diverse races/ethnicities, sexual orientations, languages, educational backgrounds, socioeconomic backgrounds, and first-generation college students.

Another limitation of our study is the nature of satisficing. Satisficing is a response strategy in which a participant answers a question to satisfy its condition with little regard to the quality or accuracy of the answer ( Roberts et al., 2019 ). Anonymous participants are more likely to satisfice than respondents who answer the question face-to-face ( Krosnick et al., 2002 ). We sought to mitigate satisficing by offering financial incentives to increase response rates and decrease straight-lining, item skipping, total missing items, and non-completion ( Cole et al., 2015 ). Concerns of poor data quality due to surveys offering financial incentives found little evidence to support that claim and may do the opposite ( Cole et al., 2015 ). On the other hand, social desirability bias may have influenced the participant's self-reported responses, although our anonymous survey design aimed to reduce this bias ( Joinson, 1999 ; Kecojevic et al., 2020 ).

Future Studies

Future studies should replicate our study to validate our results, conduct longitudinal cohort studies to examine well-being and perceived academic stress over time, and aim for a more representative student sample that includes various groups, including diverse races/ethnicities, sexual orientations, socioeconomic backgrounds, languages, educational levels, and first-generation college students. Additionally, these studies should consider examining other non-academic stressors and students' coping mechanisms, both of which contribute to mental health and well-being ( Lazarus and Folkman, 1984 ; Freire et al., 2020 ). Further explorations of negative and other positive indicators of mental health may offer a broader perspective ( Margraf et al., 2020 ). Moreover, future research should consider extending our work by exploring group differences in relation to each factor in the PAS (i.e., academic expectations, workload and examinations, and self-perception of students) and SWEMBS to determine which aspects of academic stress and mental health were most affected and allow for the devising of targeted stress-reduction approaches. Ultimately, we hope our research spurs readers into advocating for greater academic support and access to group-specific mental health resources to reduce the stress levels of college students and improve their mental well-being.

Utilizing two well-established scales, our research found a statistically significant correlation between the perceived academic stress of university students and their mental well-being (i.e., the higher the stress, the worse the well-being). This relationship was most apparent among gender and grade levels. More specifically, non-binary and second-year students experienced greater academic burden and lower psychological well-being. Moreover, women, non-binary students, and upper-level students were disproportionately impacted by stress related to the COVID-19 pandemic.

Studies regarding broad concepts of stress and well-being using a questionnaire are limited, but our study adds value to the understanding of academic stress as a contributor to the overall well-being of college students during this specific point in time (i.e., the COVID-19 pandemic). Competition both for admission to college ( Bound et al., 2009 ) and during college ( Posselt and Lipson, 2016 ) has increased over time. Further, selective American colleges and universities draw applicants from a global pool. As such, it is important to document the dynamics of academic stress with renewed focus. We hope that our study sparks interest in both exploring and funding in-depth and well-designed psychological studies related to stress in colleges in the future.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Institutional Review Board at Rutgers University. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GB and MB contributed to conceptualization, study design, IRB application, manuscript drafting, and revision. XZ participated in the conceptualization and design of the questionnaires. HB participated in subject recruitment and questionnaire collection. KP contributed to data analysis, table and figure preparation, manuscript drafting, and revision. XM contributed to conceptualization, study design, IRB application, supervision of the project, manuscript drafting, and revision. All authors contributed to the article and approved the submitted version.

This study was made possible by a generous donation from the Knights of Columbus East Hanover Chapter in New Jersey.

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.

Acknowledgments

The authors wish to thank Shivani Mehta and Varsha Garla for their assistance with the study. We also thank all the participants for their efforts in the completion of the study.

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Keywords: academic stress, well-being, college students, Perception of Academic Stress, Short Warwick-Edinburgh Mental Well-Being Scale, COVID-19

Citation: Barbayannis G, Bandari M, Zheng X, Baquerizo H, Pecor KW and Ming X (2022) Academic Stress and Mental Well-Being in College Students: Correlations, Affected Groups, and COVID-19. Front. Psychol. 13:886344. doi: 10.3389/fpsyg.2022.886344

Received: 28 February 2022; Accepted: 20 April 2022; Published: 23 May 2022.

Reviewed by:

Copyright © 2022 Barbayannis, Bandari, Zheng, Baquerizo, Pecor and Ming. 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: Keith W. Pecor, pecor@tcnj.edu

† These authors have contributed equally to this work and share first authorship

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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Variables linked to academic stress related to the psychological well-being of college students inside and outside the context of the covid-19 pandemic.

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Wong Aitken, H.G.; Rabanal-León, H.C.; Saldaña-Bocanegra, J.C.; Carranza-Yuncor, N.R.; Rondon-Eusebio, R.F. Variables Linked to Academic Stress Related to the Psychological Well-Being of College Students Inside and Outside the Context of the COVID-19 Pandemic. Educ. Sci. 2024 , 14 , 739. https://doi.org/10.3390/educsci14070739

Wong Aitken HG, Rabanal-León HC, Saldaña-Bocanegra JC, Carranza-Yuncor NR, Rondon-Eusebio RF. Variables Linked to Academic Stress Related to the Psychological Well-Being of College Students Inside and Outside the Context of the COVID-19 Pandemic. Education Sciences . 2024; 14(7):739. https://doi.org/10.3390/educsci14070739

Wong Aitken, Higinio Guillermo, Helen Catalina Rabanal-León, Jesús Catherine Saldaña-Bocanegra, Nelly Roxana Carranza-Yuncor, and Rafael Fernando Rondon-Eusebio. 2024. "Variables Linked to Academic Stress Related to the Psychological Well-Being of College Students Inside and Outside the Context of the COVID-19 Pandemic" Education Sciences 14, no. 7: 739. https://doi.org/10.3390/educsci14070739

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Stressors and resources related to academic studies and improvements suggested by medical students: a qualitative study

• Jeannette Weber 1 ,
• Stefanie Skodda 1 ,
• Thomas Muth 1 ,
• Peter Angerer   ORCID: orcid.org/0000-0002-9602-7405 1 &
• Adrian Loerbroks 1 , 2  

BMC Medical Education volume  19 , Article number:  312 ( 2019 ) Cite this article

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Prior evidence suggests that medical students’ mental health is poor and deteriorates during the course of academic studies. This qualitative study therefore aims to improve our understanding of medical students’ perceptions of i) stressors related to their academic studies, ii) resources that may facilitate coping with those stressors and iii) suggestions to potentially reduce stress.

Eight focus groups were conducted with medical students enrolled at a medical school in Germany until thematic saturation was reached. A topic guide was used to facilitate the discussion. Subsequently, focus group discussions were transcribed and content-analyzed using MaxQDA.

Organizational factors especially related to inadequate information flow as well as exams (e.g. repeat exams, scheduling, perceived unfair grading), poor theoretical and practical teaching quality, time and performance pressure, social interactions and individual characteristics (e.g. self-expectations, fear of failure) emerged as major contributors to stress. Resources perceived to facilitate coping with those stressors pertained to some other organizational aspects (e.g. flexibility, availability of contact persons), career prospects, practical training, social support, personal characteristics (e.g. knowledge base, past experience) and leisure time. Suggestions for improvement related primarily to organizational measures rather than individual-level measures.

Conclusions

Besides well-known stressors (e.g. exams and high performance pressure), some new aspects emerged from our study including stress related to organizational factors and repeat exams. Accordingly, students’ wishes for organizational-level interventions, including better information systems and better interweaving of practical and theoretical education, could be first target areas for improvement.

Peer Review reports

Medical studies are perceived as very stressful, e.g., due to the associated high workload, emotional demands and exposure to death and ill-health [ 1 ]. It is therefore not surprising that previous research has observed a decline of mental health in medical students throughout the course of their academic studies, finally reaching levels which are lower than among the general population of similar age [ 1 , 2 , 3 , 4 ]. In a significant number of studies, distress and poor mental well-being were further associated with suicidal ideation and exit from medical schools [ 5 , 6 , 7 ]. Furthermore, concerns regarding implications for adequate patient care during and even after practical medical training were raised [ 8 , 9 ]. Therefore, interventions to improve study conditions and strengthen students’ abilities to cope with them are urgently needed.

In quantitative research (e.g. surveys), academic factors were identified as main stressors for medical students including exams, time management, a high workload, dissatisfaction with lectures as well as selection and performance pressure [ 10 , 11 , 12 , 13 ]. Psychosocial resources are factors that have an intrinsic value or are useful to pursue goals and cope with demands and stress in everyday life [ 14 ]. They may include self-esteem, health, skills, knowledge, social support or other factors and may decrease students’ stress. During medical education, resources such as joy, optimism, social support and self-care (e.g. adequate nutrition, physical activity, social relationships) have been found to be associated with reduced perceived stress and to buffer against potentially negative effects of stress on mental health [ 4 , 15 , 16 ]. Further, several intervention studies have demonstrated the effectiveness of mindfulness-based training to reduce stress in medical students [ 17 ].

Those quantitative studies have provided important data that helps to identify stressors related to medical studies (i.e. observational studies) and to test approaches to reduce students’ distress (i.e. experimental studies). However, quantitative studies usually rely on pre-conceived notions regarding relevant stressors or resources. Therefore, stressors, resources and starting points for interventions which may be specifically important for medical students themselves might have been overlooked by using standardized data collection tools [ 18 ]. Starting points for interventions and health promotion may include the enhancement of resources that are perceived to be useful by medical students themselves. Furthermore, only interventions that are considered useful by medical students will be accepted and utilized by members of this population. Qualitative research, by contrast, offers the opportunity to gain such in-depth information without prior pre-conceived notions regarding stressors, resources and intervention needs due to its focus on the experience of individuals in everyday life [ 18 , 19 ]. In particular focus groups constitute a highly exploratory approach and are well suited to study common experiences [ 20 ]. Focus groups are likely highly effective in investigating potential strategies for intervention because a broad consensus can emerge from participants discussing and reflecting upon each other’s suggestions and wishes.

So far, several qualitative studies have addressed specific stressors during practical as well as theoretical medical education in Europe. Using individual in-depth interviews, two studies have revealed an overload of routine activities, lack of skills and knowledge to perform certain tasks, role conflicts, the feeling of having to prove oneself, and loneliness as specific stressors during practical training [ 21 , 22 ]. Two further studies have also examined theoretical medical education and suggested further stressors including a high workload due to studying for exams and acquisition of new knowledge and skills, transition from school to university as well as regulations about absence [ 23 , 24 ]. Also several types of psychosocial resources and suggestions for improvement regarding the practical year have been identified [ 22 ]. However and to the best of our knowledge, only one study has explored suggestions for improvement and psychosocial resources to cope with stress during earlier parts of medical education [ 24 ]. In that study, data collection included only two focus groups with one of them lacking a complete transcript [ 24 ]. Therefore, data saturation is questionable (i.e. the point when no more information is expected by conducting further data collection), which represents a quality criterion of qualitative research [ 25 ]. We therefore aim to expand those preliminary findings based on a more in-depth inquiry building on data collection through focus groups until data saturation is reasonably achieved. Doing so, we will explore medical students’ perceptions of i) stressors related to their academic studies, ii) resources that help to handle those stressors and iii) suggestions for improvements that may potentially reduce the stress experienced during medical studies.

Study participants

Study participants were recruited from the Medical School at the University of Düsseldorf in Germany. Each year, approximately 400 students embark on their studies at our medical school. In 2013, a new competence-oriented curriculum was introduced. That new curriculum builds on an interdisciplinary approach and emphasizes hands-on training (i.e. earlier in the curriculum and to a larger extent). Furthermore, internships with a total duration of four months in hospitals, family practices and outpatient care are mandatory in all German medical schools. Moreover, before graduation a full practical year in medical care has to be completed. Study participants were approached via social media or recruited through personal contacts of doctoral students (Stefanie Skodda (SS), Christin Bergmann (CB; see acknowledgements)) of the research team. Regretfully, we do not know how many students were exposed to the recruitment materials and therefore participation rates cannot be calculated. In order to facilitate engagement of all study participants in the discussions, each focus group was comprised of participants who studied in the same academic year, due to pre-existing familiarity with each other and their common experiences. Six to eleven students participated in each focus group, except for one small focus group with only two participants. Inclusion criterion was enrollment in human medical studies. No further selection criteria were applied. Participants were compensated for their time with a cinema or bookshop voucher.

In total, eight focus groups were conducted with 68 participants. Four focus groups were conducted with students in the fifth year, two with students in the second year and two with students in the last month of the first academic year of education. We also gathered additional information regarding age and sex from participants of the last six of our eight focus groups (respectively three focus groups with students in the fifth year, one with students in the second year and two with student in the first year of medical education). The mean age of those participants was 24 years (range 18–34 years) and 77% were female and 23% were male. The first two focus groups were conducted following exactly the methods as described below, but with the aim to simply learn about students’ experiences in their medical studies. For this reason, sociodemographic data was not gathered from the first two focus groups.

Study design

Focus groups were conducted between November 2013 and July 2015 until data saturation was reached. Prior to the study, a topic guide was developed by Adrian Loerbroks (AL) and Thomas Muth (TM) and two medical students (SS and CB) to facilitate focus group discussions (the topic guide can be found in Additional file  1 ). AL and TM have a vast knowledge of the current stress literature, are experienced in qualitative research [ 26 , 27 ], and are teaching staff of the medical school. Furthermore, TM has close contact with medical students in his role as coordinator and contact person for elective courses at our institute. We can further assume that most study participants were aware that TM’s main research focus pertains to medical students’ health. Focus groups were held at a conference room at our institute and were facilitated by TM while SS and CB took field notes. Focus groups were conducted and content-analyzed in German. Relevant quotes were translated into English by a certified translator after data analysis (see acknowledgements). An open introductory question was used to initiate discussions amongst study participants, asking them to reflect on their studies, how they had experienced them so far, what had been difficult and what had helped them to cope with their studies. All participants were encouraged to contribute to discussions early. Whenever appropriate, the facilitator explored a topic in greater depth during the course of each focus group to direct the discussion to underlying causes of perceived stress, resources used to cope with this stress, balance between private and academic life Footnote 1 and finally to suggestions for improvement. Each focus group lasted for about 90 min.

Data analysis

All focus groups were digitally recorded and transcribed. Subsequently, the material was analyzed by Jeannette Weber (JW) following established approaches to qualitative content analysis [ 28 , 29 ] using the MaxQDA 12 software package. JW has an educational background in public health and experience in occupational health research. In a first step, our research questions as specified in the topic guide were included as main categories (i.e. deductive coding): “stressors”, “resources” and “suggestions for improvement”. During analysis, those categories were further broken down into sub-categories by inductive category formation. After coding of the first four focus groups was completed, those sub-categories were revised and when appropriate corresponding text passages were reanalyzed. Then, the final four focus groups were analyzed and, if needed, additional sub-categories were created. Subsequently, the coding scheme was reviewed by AL and some further adaptations were discussed. Finally, a second coding round was conducted by JW. However, this second coding round entailed only few adaptations. Therefore, two coding rounds were considered to be sufficient. Corrections and feedback on transcripts and research findings were not obtained from study participants due to logistic constraints.

The completed checklist of consolidated criteria for reporting qualitative research (COREQ; [ 30 ]) can be found in Additional file  2 .

The coding system including clustering of main- and sub-categories at first and second level can be found in Fig.  1 . Additional quotes that are not cited in the text can be found in Additional file  3 .

Coding system with main- and sub-categories. Only sub-categories at first and second level are shown

Organizational stressors

Students perceived an insufficient information flow from administration and teaching staff which was characterized by missing information, inadequate feedback of results, delayed provision and updating of schedules, a lack of contact persons and conflicting information depending on which staff were asked. Furthermore, students criticized that there was no single standardized source of information, but reported that information about courses and examinations is spread across various online portals and web pages. Furthermore, some students felt stressed by the varying types of teaching materials (e.g. books, scripts, PowerPoint presentations) and lack of information regarding which of those materials ought to be used to prepare best for exams. This insufficient information flow resulted in rumors and hearsay, uncertainty of what is expected and fear of missing out on important information. Furthermore, mandatory attendance and regulation of absenteeism were perceived as burdensome.

“I think [… ] , that it’s always somewhat unclear what’s going on. One asks about something and gets 10,000 different answers. Everyone says something else, and when you google it or check it on the website you don’t find anything. For example, not being able to attend, there are different regulations for each subject. How many times are you allowed to be absent. OK, 15% is allowed in general, but there are subjects where they’re calculating 15% per module. Then there are subjects where they’re calculating 15% for all 12 modules. In this case one can check for oneself, how often do I have to attend here and there and how many times can I be absent. Of course, you don’t know exactly, because we don’t have the schedules for all 12 modules yet [… ] . ” (Focus group (FG) 4 - Study year (Y) 1).

The timetable was perceived as an additional stressor due to a large number of teaching events in short periods of time or even simultaneous events.

“Well my group had a module with an internship in a practice and my impression was that I miss out on a lot of things during that week. I was in the practice every day until 7 p.m. and [… ] I somehow felt that I don’t have enough time to work through everything during that week. I also had to do a sonography exam during that week. I think it’s totally crazy to organize it in a way that it’s scheduled for the middle of the semester.” (FG 5-Y2).

Study participants also highlighted issues regarding repeat exams, which were usually scheduled at inconvenient times during the academic year. Some students criticized that the schedule changes on a weekly basis. Particularly those students who commute between university and their home town felt stressed when only one event was scheduled on a day or when unnecessary and long breaks were scheduled between different events (Quote (Q) 1, see Additional file 3 ). Furthermore, students believed that subjects were unstructured in terms of content and time and perceived a gap between theory and practice.

“One thing that continues to annoy me [… ] is the separation of practice from theory within the modules. That they are not connected at all is something that I find irritating again and again, [… ] Then you have a module about the head and afterwards you practice in, I don’t know, nephrology, radiotherapy, orthopaedics, and psychiatry, yes psychiatry would also be useful. But that there are no connections, I always find that annoying, also because then you’re often in a situation where you have to say, sorry, I haven’t learned that yet, I can’t say anything about it. Personally, I always find this very inconvenient and it doesn’t help me at all for getting in-depth knowledge on something I studied for three weeks.” (FG2-Y5).

In addition, registration to events and cancellations of events, especially when students were not informed beforehand, were mentioned as further stressors. Some students believed that those organizational deficits were associated with the conversion of the standard curriculum to a new curriculum.

Difficult exams, the German first state examination (“Physikum”), feelings of being unprepared, errors in the phrasing of exam questions as well as a high quantity of exams emerged as further stressors. In addition, cumulative exams (i.e., a number of exams that add up to a final grade) seemed to increase pressure because students had to wait until the end of the study block to know whether they passed the exam (Q2). The feeling of an imbalance between one’s efforts and rewards was often expressed as large amounts of time spent learning did not necessarily correspond with equivalent grades or passing exams.

“Before each final exam of a module you’ll go to your limit. I have never attended a module without someone crying because they had a nervous breakdown. It becomes, I don’t know, quite emotional. […] And compared to this I think the results aren’t great either. I mean people go to their limits and still there are so many who fail.” (FG4-Y1).

Furthermore, unfair grading systems - i.e. the grade being partly contingent upon the specific examiner - were perceived to increase stress.

“I mean, I have already begun to wonder who will be in charge of my oral equivalency exam next year. Because no one can tell me that there are equal opportunities. Well, it makes a big difference who sits in front of you and asks questions, and these are things that create more stress than the preparation itself.” (FG5-Y2).

A disproportion between subject matter and number of exam questions was also alluded to. Furthermore, study participants felt highly stressed due to repeat exams because a) they were scheduled at inconvenient times, b) one has to learn for them again simultaneously with other regular exams, which increases time pressure (Q3), and c) of the option to repeat exams only twice. After failing the same exam for the third time, students are excluded from medical studies at any medical school in Germany.

“This is simply the pressure one feels, that you know that if you fail three times, something that happens really, really quickly, then you will never be able to do it again. If I failed three times, I have no idea what I would do then.” (FG8-Y2).

Poor quality of teaching, including lectures, lecture slides and scripts, as well as lack of guidance and supervision was often perceived as demotivating (Q4). Furthermore, study participants felt that they were not well prepared for exams (Q5). Some educational content was experienced to be inadequate. Specifically, according to participants’ views, unimportant and easy topics are frequently and strongly emphasized whereas important and more complex issues remain unaddressed.

“Yes, and honestly, it’s unbelievably discouraging when you’re told that you don’t really need this for practicing, then I ask myself, why don’t we learn the things that are really important for practicing.” (FG6-Y1).

Due to the perceived frequent emphasis on supposedly unimportant topics a feeling of time waste was often mentioned, especially in association with mandatory attendance. Furthermore, some students expressed that they are bored and not intellectually challenged due to the requirement of learning a lot of content simply by heart (Q6). Many participants pointed to poor supervision during practical tasks.

“Well, I find it annoying that we have no supervision and that we have to take care of everything by ourselves, you have to realize, it’s not always their fault, perhaps they would like to help but they just don’t have enough time. That’s annoying.” (FG1-Y5).

Some students also expressed that some physicians are unfriendly, demotivating and that they give them a feeling of being bothersome during their practical tasks.

“When you’re looking for a physician for three weeks who just makes you feel that you’re a burden (,) I do find this extremely discouraging.” (FG1-Y5).

Furthermore, some students felt that the mandatory internship at the general practitioner is ineffective. They complained about a lack of responsibility and the inability to adequately perform their tasks for university. If they were allowed to perform some medical examinations, they felt uncomfortable due to a lack of experience and permission to discuss their diagnoses with the patient.

“Sometimes it was really inconvenient to go to a patient and say, OK, I’m a student and I will examine you. And then they ask me, what do you think. Well, I am not allowed to express an opinion. What. No. Well I sometimes found this very inconvenient to sit there with my partial knowledge and to pretend that I could do a perfect examination, but I am not allowed to diagnose them.” (FG5-Y2).

In addition, the nursing internship of three months was experienced as time-consuming and some students reported that responsibilities during the internship were not clearly communicated beforehand.

“For example, in my case I divided the [nursing] internship into three parts and in one case they wanted me to work thirty days in a row for eight hours per day without a break. Not even two days off in between, although as I know now I would have had a right to them. I basically had no idea what I was allowed to do and what I wasn’t allowed to do. In the end [… ] nurses sometimes forced me to do things I wasn’t allowed to do, e.g. giving injections to prevent thrombosis.” (FG8-Y2).

Time and performance pressure

The feeling of time pressure caused by competing events, own rescheduling of learning, elective courses and a heavy workload due to a high amount of subjects as well as very comprehensive single subjects was often expressed (Q7). This seemed to result in a lack of time for private life and to learn guided by one’s own interests (Q8), in a lack of motivation (Q9), and in learning on short-term memory.

“I think here we really bring ‘bulimic studying’ to perfection. During the three weeks before the written exam I stuff myself with everything. Study all night. I try to find time for everything. I can’t tell you anything anymore about locomotor system or TB1 or TB3. I can’t tell you what I learned last week because I’ve already forgotten it. We try to learn so much in such a short period of time. And we have to concentrate on a new subject immediately afterwards. That there’s no chance to remember what you learned in the last modules or to enhance it.” (FG4-Y1).

Many students also alluded to a lack of recreational time due to courses, internships and exams during non-lecture periods and emphasized that they feel exhausted at the end of the academic term. Furthermore, they expressed the feeling of performance pressure, which occurred due to the scheduling of repeat exams and simultaneous scheduling of lecture periods, exams and internships. They further expressed the thought that this performance pressure is deliberately built up by the medical school to test students’ stamina and to thereby initiate selection according to stamina.

“The impression is that there’s pressure to simply select and I really find this (,) to be quite honest I have come to find this a bit annoying.” (FG8-Y2).

Social stressors

Interactions with administrative staff were heavily criticized and unfriendliness as well as a lack of appreciation, respect and support was experienced.

“Well you’re not really appreciated here. They rush you through it and, uh, when you don’t function you’ll be punished.” (FG8-Y2).

Additionally, a bad atmosphere between teaching staff and between students and teaching staff was reported (Q10). Furthermore, fellow students were identified as additional stressors. First, stress seemed to develop due to one’s own comparison with fellow students in terms of time spent for learning and learning progress.

“In the week before the exam I have at least one nervous breakdown per day, because I sit there and start crying, because when I talk to friends who are more advanced I see that there are so many things I still have to do. You have no idea what they’re talking about [… ] ” (FG4-Y1).

Second, most social contacts involve other medical students and therefore conversations always addressed medical studies even in private life.

Internal stressors

Internal stressors seemed to involve a guilty conscience when taking a break from learning due to high performance pressure, high self-expectations regarding one’s performance during medical studies (Q11), inability to relax and fear of failure regarding exams (Q12) and as a physician in the future.

“You always think about it, OK, you didn’t study for two hours. Now you have a bad conscience and having a bad conscience when you spent ten hours studying and did something else for two hours, somehow that’s sick.” (FG7-Y5).

“When I meet with friends or do something with my family, then I always think in the back of my mind that I could just as well study. You can’t enjoy it.” (FG6-Y1).

Additional stressors

Finally some additional stressors were highlighted including the financial situation (Q13), commuting between university and one’s home town, transition from high school to university, writing a doctoral thesis (Q14), which in Germany is often performed during medical studies, and feeling unprepared for future work life.

“Somehow, I think that (,) for me it’s really sad, because after a very short time I will be a physician and I think OK, concerning the eyes, for example, there’s a knowledge gap. I find it very embarrassing because if you ask me about it or I have to say something about it, then I don’t know anything about it and because of all the organizational stuff this went wrong a bit.” (FG3-Y5).

Organizational aspects

A well-structured curriculum, combining practical and theoretical training and having a block by block structure, was appreciated by study participants. They argued that this helped them to deepen their knowledge, to really concentrate on one subject and to feel certain on what to expect at exams.

“What you said is quite right, these eight-week modules, I found it so relaxing to study there [… ] . That’s great. That’s so nice because it’s a combination of both. There are good modules for practicing, because they do a great job organizing, and you have theory, but it’s not too much and you can repeat in between.” (FG3-Y5).

Flexibility regarding optional attendance of lectures (Q15), the possibility of repeat exams (Q16) and having a contact person for each subject were named as additional organizational resources.

“Yes. Basically, I have to say that I found it really great that in the beginning professor X stood there and said ‘I am in charge of this module and if you have any questions please contact me’. In the other modules, it was not clear (other participants: agreement – yes) who you could contact. But basically, you simply have someone of whom you knew you could contact them. And I must say this module was the first one where this happened. I found this extremely helpful.” (FG5-Y2).

Practical training and career prospects

Practical training and internships were viewed as opportunities to practice what has been learnt. It seemed to help to remember and to better understand content covered in teaching. Furthermore, practical training, internships and side jobs seemed to motivate study participants to proceed further with their education because it reinforced their career choice (Q17). Good career prospects in the medical field were also repeatedly named as important motivation to proceed further with studies despite increased stress and workload.

“I believe I simply know that it’s the right thing and that you look forward to it, and I think being a physician is stressful and perhaps frustrating and all kinds of things, but it’s a great job. I really look forward to it because it’s not a job that involves moving piles of pallets from A to B, or checking if some part for cars arrived, it’s a job where I will rush home at night and I will say you did not change the world but you made a certain difference for a patient and I think this is (,) this will be a great feeling. And we have this with small things, during part-time jobs all of us (,) or in a practical module, or during a clinical elective or something like this, but it’s very satisfying and this is what helps you to get through with your studies.” (FG2-Y5).

In addition, prospects on easier and more interesting parts of the curriculum seemed to help some participants to carry on (Q18).

Social aspects

Contact with relatives and friends seemed to help study participants to cope with increased stress due to their studies (Q19). Additionally, also social interactions with students from higher years and fellow students were named as important resources. They assured social contact and exchange of important information (Q20–21). Furthermore, students felt less lonely and were able to share their stress, anger and fears regarding medical studies with like-minded persons.

“What really helped me is that I wasn’t the only one who suffered. I always think that sharing suffering, that’s what (,) while studying medicine it becomes very obvious that it’s extremely helpful when others are in the same boat and also rant.” (FG3-Y5).

Conversely, some participants believed that distance from fellow students helped them to cope with and get away from stress due to medical studies.

“But it was the most important thing, I completely isolated myself from my fellow students, I really didn’t want to meet them because I knew they are also stressed out by studying and they are all afraid and I didn’t want to catch their panic. And this really worked out.” (FG7-Y5).

Personal characteristics

A relaxed attitude involving lower self-expectations, acceptance when things are not going so well (Q22) and less comparison with other students was believed to decrease stress. Also past experiences seemed to help students cope with high demands related to medical studies (Q23). Furthermore, a good knowledge base, interest in the medical field, partial control of learning content according to one’s own interests, ability to learn easily by heart and rewarding oneself were named as further resources.

Hobbies, physical activity, meeting friends, holidays, recreational time and breaks during learning phases were thought to be important by the majority of study participants.

Additional resources

Committed teaching staff and medical doctors who mentor during practical training seem to motivate study participants to carry on and help them with learning content (Q24).

“I always find when I meet a physician who is very motivated and who is able to explain things very well, then I really enjoy it and I think wow, that’s a great kind of studies. And I look forward to becoming a physician one day.” (FG7-Y5).

Personal feedback from teaching staff was also regarded to be helpful. Furthermore, preliminary tests (Q25) and mock exams were regarded as opportunities to practice and to prepare for major exams.

“[… ] uploaded an exam for preparation, twenty questions were assigned by chance and you could answer them, and finally you could see the right and wrong answers and who failed. I think that prior to the locomotor system exam I did this 38 times. I felt so incredibly safe, I was not afraid of the exam at all.” (FG6-Y1).

Suggestions for improvement

The study participants made a broad range and to some extent also very specific suggestions for improvement. The reproduction of all suggestions would by far exceed the scope of this article and thus the presentation is limited to the most salient findings.

Organizational factors

Regarding timetables, study participants wished for earlier announcement of examination dates, more flexibility (Q26) and less mandatory events (Q27). In addition, temporal equalization in placing subjects from time-consuming terms into more relaxed terms and increasing lecture periods and study blocks was suggested (Q28). However, some participants also wished that no further events should be scheduled for non-lecture periods (Q29). Furthermore, parallel scheduling of corresponding theoretical and practical training was requested. A group size of less than 15 students during bedside teaching was regarded to increase opportunities for learning (Q30). Furthermore, some participants wished to be taken on daily work routines of medical doctors and to have more guidance during practical tasks (Q31). They further wished that the teaching staff of different subjects would discuss and coordinate their content to ensure that topics between subjects are complementary and non-overlapping. Furthermore, to improve information flow students suggested that there should be i) one single online portal which comprises all important information (Q32) and ii) a single designated contact person for organizational issues.

Several suggestions were expressed regarding repeat exams including a larger number of attempts, prompt scheduling after the first exam and the possibility to unsubscribe from exams. Furthermore, a wish was stated that exams should assess understanding and more relevant topics rather than rote recall. Further suggestions included a smaller number or less importance of mid-term exams (Q33).

To increase the quality of teaching, better pedagogical education of teaching staff, inspection of teaching clinics, higher appreciation of teaching and exemption of medical doctors from day-to-day business for bedside teaching was proposed. Students also wished that their evaluations of study courses are incorporated in continuous development of the curriculum. Some students suggested to reduce the nursing internship to one month and to inform nurses about learning objectives and range of authority to decrease strain on medical students. Furthermore, some students wished for more consultation with teaching staff including opportunities to pose questions after lectures. In addition, suggestions pertaining to more basic teaching (Q34), soft skills and medical skills (e.g. thoracic drainage or sonography, Q35) as well as tutorials and practical training to deepen and discuss learning content were made.

“Could it perhaps be useful if there were regular seminars for the different subjects, by simply (.) [… ] I think oral presentations don’t make sense because no one listens, but mid-term tests, one prepares for them, one deals with them, then you do the test. Then we could simply discuss them afterwards or exchange ideas or talk about them, so that it’s sustainable. Step by step. Building in-depth knowledge by repetition throughout the curriculum. [… ] To be quite honest, when you discuss a subject with other people, then it consolidates.” (FG4-Y1).

Support services

Some students asked for information events, especially in the beginning of the academic term, to increase information flow about inter alia upcoming subjects, exams or elective courses.

“Just a simple suggestion (,) if one could simply say at the beginning of the semester perhaps the dean will attend in this case, will spend two hours of time and come to the lecture hall. He will give an introductory lecture, just like at the beginning of the first semester, but that we simply are told this semester encompasses these subjects, these are the dates of the written exams. Then you also have the chance to ask questions if anything is unclear.” (FG8-Y2).

Furthermore, students wished for guidelines about upcoming subjects and learning objectives, a tutorial for stress management, support for families, mentoring and student advisory services (Q36).

“OK, well, yes, that you receive a kind of schedule in the beginning, after each semester this is what you should be able to tick off and this is what you should have done. ”  (FG3-Y5). “What I think another issue is, I don’t know if this could be put into practice because of the large number of students. It would be great if every student could have a physician as a mentor [… ] That would be awesome, then you would have access. Then you would have a person to provide stability and who says, this and that is what you need to know. Someone who looks over your shoulder. Who, I don’t know. Then it would be easier for us to transition between theory and practice. We could better fulfil the expectations.” (FG7-Y5).

A large number and large variety of stressors, resources and resultant suggestions for improvement were identified based on eight focus groups. Most stressors involved organizational structures. Furthermore, exams, poor quality of teaching and lack of guidance during practical training, time and performance pressure due to a high workload, social stressors due to interactions with administration, teaching staff and fellow students and some internal stressors (e.g. high self-expectations, fear of failure, inability to relax) emerged. In contrast, organizational aspects such as flexibility and a combination of theoretical and practical training were perceived as important resources. Additionally, career prospects often conveyed by internships or side jobs, social support by family members, friends and fellow students, personal characteristics and recovery through hobbies, physical activity and meeting friends were perceived as helpful to cope with stress. Accordingly, suggestions for improvement often involved organizational aspects, exams and teaching quality, but also included requests for support services.

Our results are in line with previous qualitative studies on this research topic [ 23 , 24 , 31 , 32 ], which implies that identified stressors and resources generally apply to students at various medical schools in and outside of Germany. Furthermore, some new themes emerged related to organizational structures especially regarding information flow, repeat exams, perceived effort-reward imbalance and challenges due to commuting. The fact that we found a larger scope of themes may indicate that a particularly thorough thematic saturation was achieved based on our eight focus groups. Alternatively, one may speculate that additional themes are of contextual nature and thus specific for the medical school where this study was carried out. For example, daily commuting between one’s home town and the university is very common in the area where our medical school is located (i.e. the Rhine-Ruhr area in Germany) and may be less of a salient issue in other university cities outside this area. Furthermore, some of our participants were in the first year of a new study curriculum at this particular university. Therefore and as acknowledged by some study participants, challenges and stress related to organizational structures may have partly been caused by this recent re-design of the curriculum.

Not surprisingly, exams have often been identified as major stressors in higher education and our study is not an exception [ 23 , 24 , 31 , 33 ]. However, not only the high quantity and difficulty of exams were perceived as stressful, but we also identified some new aspects on how exams contribute to stress, in particular among medical students. Those new aspects were mainly associated with organizational factors that pertain to repeat exams and grading systems that were perceived to be unfair. On the one hand, the option to repeat failed exams was referred to as a resource by several students. On the other hand, the fact that only three attempts are granted was heavily criticized. This issue may have been aggravated by the fact that students were not able to decide by themselves on when to repeat exams, but were automatically registered if they had not passed the first exam. Furthermore, medical certificates were needed when students did not feel well enough to participate in exams. To reduce this pressure, it was recently decided by this particular medical school that students should register for exams by themselves. Furthermore, supposedly unfair grading and an imbalance between time and effort that was put into the preparation of exams and subsequent results were highly criticized. This corresponds to the effort-reward imbalance (ERI) model, a well-established stress model in occupational contexts, which assumes that the combination of high effort and low reward results in emotional distress [ 34 ]. The ERI model has recently been adapted to academic settings and has shown its utility to capture stress in medical students [ 35 ].

Additionally, the emphasis on poor teaching quality is worrisome. In accordance with another qualitative study with medical students in Germany, students criticized a strong focus on topics that are perceived to be unimportant and asked for prioritization on basic knowledge, skills and clinical relevance [ 24 ]. However, it may be questionable whether students are able to fully grasp the relevance of specific content and a first step may include better communication of their practical relevance. Introduction of re-designed curricula represents an approach taken by an increasing number of German universities to exert a stronger focus on practical training and to combine preclinical and clinical education. Practical training seems to motivate students and has been shown to promote clinical thinking and learning [ 36 ]. In this context side jobs and internships were alluded to as important resources during our focus groups. However, it seems that the implementation of the new curriculum at this particular university has been challenging and stressful to students. Students still wished that topics between subjects and the scheduling of courses are better matched to effectively combine preclinical and clinical education as well as theoretical education with corresponding tutorials and practical courses. Furthermore, a perceived lack of support and guidance during practical training has been expressed and has partially been attributed to contextual problems involving the shortage of health care professionals in Germany.

Clinical settings involve strong hierarchies and especially physicians in lower positions frequently report exposure to workplace bullying [ 37 ]. The mistreatment of medical students is not a new problem and is accompanied by a widespread attitude among the medical professional society that a rough educational climate is an effective and acceptable teaching strategy [ 38 , 39 ]. Our study expands the current knowledge by highlighting that this unfavorable atmosphere is already perceived to be established during undergraduate medical education through unfair treatment, allegedly unfair grading, inconvenient scheduling of exams, unclear regulations regarding absenteeism and a lack of support. Furthermore, performance pressure has also been identified as a major stressor in previous quantitative research [ 11 ]. Such selection pressure was also experienced by our study participants, who felt that a high workload was utilized to test students’ stamina and to select students based on their stamina. By contrast, committed and supportive teaching staff and physicians were mentioned as a resource to cope with medical studies.

Students expressed that those stressors had several sequelae including lack of motivation, distress, fear, exhaustion, learning and recalling content only for the short-term, inability to relax after high effort and feeling unprepared for examinations and working life. This is alarming because it might have an impact on students’ health by increasing the risk of depression, burnout and substance abuse [ 1 , 40 ]. Consequently the quality of patient care during practical training might be reduced due to decreased empathy and unprofessional behavior [ 8 , 9 , 41 , 42 ]. Furthermore, it might reduce academic performance and increase the risk of exiting from medical studies [ 6 , 43 ]. However, most students in our study still seemed motivated and were looking forward to become physicians, which was mainly due to positive experiences during internships and side jobs and due to support by family and friends.

Strengths and limitations

Strengths of this study include the rich and comprehensive data, which was collected from 68 medical students in 8 focus groups until thematic saturation was reached. Furthermore, participants of different academic years, age and sex were included to ensure that a broad range of potential opinions and experiences are taken into account. It needs mentioning though that the proportion of female participants was 77%, which is higher than the actual proportion at this particular medical school (i.e. 62 to 63% female students during the period of data collection). Therefore, perspectives of female students may be somewhat overrepresented in our study. Furthermore, the scope of information may be limited by the fact that students of only one university were included. Some themes might therefore relate to conditions specifically linked to our university (e.g. stressors like commuting and organizational factors), whereas others might have been overlooked. However, findings from previous qualitative research and from our study are similar (e.g. stressors like exams and time and performance pressure) and are consistent with established stress models (e.g. effort-reward imbalance model), which may suggest partial transferability of our study results to students at other medical schools. In addition, our study allows for a local view on the study conditions and may thereby help to identify setting-specific intervention needs and means for effective improvement. Furthermore, only students who experienced increased stress may have participated due to higher interest in the research question. Alternatively, it may also be possible that especially students who do not experience major stress have participated due to larger perceived time resources. However, we assume that the likelihood of selection of particularly stressed or non-stressed individuals was minimized by randomly approaching whole course groups to participate in the study.

The fact that participants knew each other, followed the same courses and that a teaching staff member (TM) acted as focus group facilitator may be further limitations of this study. For example, study participants might have felt uncomfortable to raise and share certain topics due to reduced anonymity within focus groups. However, protection and confidentiality of participants’ identity was assured by addressing participants only by numbers instead of names. Furthermore, we experienced that even sensitive topics, such as fear of failure or views about particular medical staff members, were openly discussed. In addition, familiarity within the group ensured that every study participant was actively involved in the discussion. Furthermore, most themes were brought up without any guidance through the facilitator, which reduces the potential influence of the facilitator on study participants.

Due to a high numerus clausus in Germany (i.e. a grade cut-off that governs admission to medical studies), most students accepted for medical studies have graduated from high school with top grades and thereby likely have high confidence in their academic abilities. At medical schools however, a considerable number will for the first time experience average grades or even failure on exams despite high effort. The high confidence in one’s academic skills is likely perceived incompatible with the fact that one failed an exam and may induce an unpleasant state of cognitive dissonance [ 44 ]. Attributing one’s failure to external aspects could be one approach to reduce such dissonance. This may explain why the medical students in our study rather discuss organizational aspects of their studies instead of personal characteristics. In addition, students may have preferably come up with suggestions for organizational improvements, because consideration of individual-level interventions may imply that individual deficiencies are discussed, which is socially undesirable, especially when surrounded by other top-grade high school graduates.

Due to considerations regarding time and costs, complete coding was only performed by one person (JW). This approach may be criticized in terms of reliability. However and in line with previous suggestions, the coding scheme and some selected parts of the data material were reviewed by a second researcher (AL) with profound experience in the field of qualitative research [ 45 ]. As only minor adaptations were proposed during this review process, multiple coding of the complete data material was deemed unnecessary.

Implications

Interventions will only be successful when they are perceived to be useful by medical students themselves. We have therefore explored their suggestions for improvement and received a wide range of recommendations. Most of those suggestions highlighted the wish for organizational-level interventions instead of individually focused prevention. Regarding the significant contribution of organizational factors to students’ distress and the fact that most of these organizational stressors seemed modifiable, we propose that organizational structures should be the first target for adaptations. As suggested by some of our study participants, lack of information may easily be reduced by the availability of one single online portal which includes all relevant information as well as information sessions and earlier announcement of exam dates. Furthermore, the presentation of specific learning objectives may be another straightforward approach to reduce students’ uncertainty of what is expected. This is in line with findings from another qualitative study [ 24 ]. Furthermore, stronger interweaving of practical and theoretical training as well as preclinical and clinical education may further reduce students’ distress and increase learning effects. Such approaches are already being implemented in new curricula by an increasing number of German medical schools. Insights into the potential positive effects of those new curricula on students’ health are of interest. Also in light of previous qualitative and quantitative research [ 37 , 38 , 39 ], reflection on the social climate in medical schools and within the medical society as a whole seems justified. A respectful and supportive climate including better supervision of medical students during practical training might contribute to improved learning environments and subsequently to enhanced patient care in the future.

To develop tailored interventions, separate consideration of students in the old and new curriculum might be of interest due to the possibility that stressors, resources and suggestions for improvement differ between those groups. However, separate analyses were beyond the scope of this report and might be carried out in the future.

Even though our results are in line with previous research findings on this topic, we acknowledge that some of our findings may be less relevant to other universities. Our study shows that focus groups are an efficient research tool to identify stressors, resources and suggestions for improvement in educational contexts. This approach may be useful for other universities to determine specific intervention needs and to thereby reduce students’ distress. At our university, a new project relating to health management for medical students was recently initiated. This project aims to improve study conditions through the development and implementation of support services for students who are in need. In addition, organizational-level (e.g. curriculum, communication) and individual-level (e.g. stress management, relaxation and learning techniques) preventive measures are currently being devised in a participatory approach involving medical students and other relevant stakeholders. The results of this study are thereby a first step to identify promising starting points for interventions.

In light of evidence documenting medical students’ poor mental health, insights into specific stressors, resources and starting points for interventions are highly relevant. In this qualitative study, previously identified stressors and resources to cope with increased stress during medical studies were confirmed. This implies that these factors are generally important for students at various medical schools in different countries. Furthermore, some new themes emerged such as a burden due to organizational factors and repeat exams. According to students’ perspectives, approaches to reduce students’ distress should predominately involve organizational-level interventions.

Availability of data and materials

Full transcripts of focus groups are not publicly available to protect the privacy of our study participants.

the balance between private and academic life was beyond the scope of this article and is addressed in a separate report (Bergmann C, Muth T, Loerbroks A. Medical students’ perceptions of stress due to academic studies and its interrelationships with other domains of life: a qualitative study. Med Educ Online. 2019;24 (1):1603526.27)

Abbreviations

Adrian Loerbroks

Christin Bergmann

Consolidated criteria for reporting qualitative research

Effort-reward imbalance

Focus group

Jeannette Weber

Peter Angerer

Stefanie Skodda

Thomas Muth

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Acknowledgments

We thank Ms. Christin Bergmann for her contribution to the development of the topic guide, support during data collection and transcription of large segments of our recordings. For her translation of quotes we are also grateful to Ms. Ursula Goldberger, a certified translator from the Mannheim Institute of Public Health, Social and Preventive Medicine, Mannheim Medical Faculty, Heidelberg University, Mannheim, Germany.

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Jeannette Weber, Stefanie Skodda, Thomas Muth, Peter Angerer & Adrian Loerbroks

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Contributions

JW analyzed the transcripts and wrote the initial draft of this manuscript. SS contributed to topic guide development, recruitment of study participants, data collection and transcription of recordings. TM designed the study and was the major contributor during data collection. PA contributed to the study design and to the draft of the manuscript. AL designed the study, reviewed the coding scheme and contributed to the initial draft of this manuscript. All authors revised the draft for important intellectual content and approved the final version of the paper.

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Correspondence to Peter Angerer .

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Ethical approval was obtained by the ethics committee of the medical faculty of the Heinrich-Heine-University of Düsseldorf. All study participants gave their written informed consent to participate in the study.

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The authors declare that they attempted to present a well-balanced account of the findings. However, being employed (JW, TM, PA, AL), a member of the teaching staff (TM, PA, AL) or a medical student (SS) at the medical faculty of the Heinrich-Heine-University of Düsseldorf may have induced some bias which we are not aware of.

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Focus group guide. (PDF 463 kb)

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Completed checklist of the consolidated criteria for reporting qualitative research (COREQ). (PDF 310 kb)

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Additional quotes of participants related to stressors, resources and suggestions for improvement. (PDF 258 kb)

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Weber, J., Skodda, S., Muth, T. et al. Stressors and resources related to academic studies and improvements suggested by medical students: a qualitative study. BMC Med Educ 19 , 312 (2019). https://doi.org/10.1186/s12909-019-1747-z

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StudyCorgi . "268 Stress Topics & Research Questions." September 9, 2021. https://studycorgi.com/ideas/stress-essay-topics/.

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This essay topic collection was updated on June 24, 2024 .

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• 50+ Stress survey questions to ask students

Şeyma Beyazçiçek

Stress has a significant impact on students, just like everybody. Because of feeling stressed, students' success is affected to a large extent. There are lots of sources of stress that trigger stress, and school might be one of them. To help students with their mental health wellness, schools should present their students with survey questions about stress to collect necessary feedback.

Once schools want to raise awareness of stress and give a hand to them in this issue, it is necessary for them to share stress-related survey questions with their students . If schools attempt to reduce the stress level of the students, asking students stress survey questions will be an excellent start. 

In this article, you will learn about what is a stress survey , why you need to measure it regularly , the best 50+ stress survey questions to ask students, and finally, how to make one !

• What is a stress survey?

A stress survey is a document that collects feedback from people to look for the root of the stress affecting their work, school, etc. A stress survey can quickly assess and analyze anxiety levels and reasons. After the survey, some ways outs for stress management can be discovered according to the survey result.

The definition of a stress survey

A stress survey questionnaire can include kind of questions that measures how stress affects work or school. For that reason, especially stress survey for students is an excellent way to show students that they care about and are working hard to reduce the stress (no matter the source) in their lives. 

• Why do you need to measure student stress regularly?

Undeniably, stress is a considerable factor affecting the lives of students. There are already lots of things in the students’ lives that stress them out, so collecting data regularly by asking them stress questions and trying to find a way out will relieve their stress, needless to say. 

Pew Research Center points out that  anxiety is a major problem for 70% of U.S. teens . In addition, another statistic proves that in high school,  45%  of pupils report feeling stressed out nearly daily. 

As unlucky as it is, this rate shows the seriousness of the situation. So, measuring students' stress regularly and following the process closely will help you collect better data and create better solutions for them. 

• 50+ question examples for your student stress survey

Finding the right questions to ask students about stress might confuse you since there are many ways to measure stress. For this reason, we have divided the questions about stress according to their category. 

Initially, starting by asking general questions about stress would be an excellent choice. Later, you can ask more detailed questions about teachers , friendships , and family . According to your aim of collecting feedback, here are the most essential 50+ stress survey questions for students: 

General questions about student stress

Asking some basic questions to measure their stress would be a good beginning. Also, asking them a rating or “ yes/no ” questions will be easy for them to fill in. In this way, they will be more comfortable since the students will not have to give details. You can see 20 basic questions about general questions for your stress survey below:

1 . What grade are you level in?

2 . How often do you feel stress in your life?

3 . Do you feel overwhelmed because of school?

4 . Do you get mental support?

5 . Do you use social media? If so, how does it affect your mental health?

6 . Do the assignments stress you out?

7 . Is stress a powerful aspect of your success?

8 . Do you get enough pocket money?

9 . Do you have a separate room in your house?

10 . Do you attend classes regularly? 

11 . I often feel depressed.

12 . I feel insecure about my physical appearance. 

13 . I have regular sleep hours. 

14 . I have a health condition that affects my life. 

16 . I use pills for my mental health. 

17 . I know how to deal with stress. 

18 . I can control my thoughts.

19 . Nobody puts pressure on me to perform well on tests.

20 . I am happy with who I am.

Stress survey questions related to student-teacher relationship

Teachers have a powerful impact on the lives of students, needless to say. This impact might be both good and harmful. To measure the teachers’ approaches to the students and test the methods of teachers, you should ask the students stress survey questions about their relationship with teachers. Here are the essential stress survey questions about student and teacher relationships:

21 . I feel my teachers understand me.

22 . I can share my opinions with my teachers easily. 

23 . I have a favorite teacher.

24 . My teachers appreciate my success.

25 . My teachers shout in class.

26 . I think my teachers are well-equipped enough. 

27 . I can ask questions to my teacher comfortably.

28 . My teachers are not a source of stress for me.

29 . My teachers are concerned with my success. 

30 . My teachers are making my anxiety worse.

Stress survey questions related to friendships

Friendships give directions in our lives in many areas; however, young people's friendships might be more complicated and fragile than it is. They might take it more seriously and deeply, so their relationship with friends might affect their stress levels. You can find some rating questions about friendship below: 

31 . I have enough friends.

32 . I am good at making friends.

33 . I have never been bullied.

34 . My classmates have never assaulted me.

35 . Classmates are not a source of stress for me.

36 . Relationship with my friends decreases my anxiety.

37 . I believe I have good social skills.

38 . Relationship with my friends increases my anxiety. 

39 . My friends motivate me.

40 . I also meet my friends after school.

41 . I have witnessed bullying before.

42 . Spending time with my friends reduces my stress.

43 . I have been outcasted before.

Stress survey questions related to family

Especially in the teenage era, students might have difficulty communicating with their family members, which enormously influences their stress levels . Asking some questions about their relationship with the family might help you understand how they affect the student’s stress. The most crucial stress survey questions about family are listed here:

44 . Does your family pressure you to succeed?

45 . Does your family have an impact on your stress?

46 . Do your parents allow time for you?

47 . Do your parents reflect on their job stress or any negativity in their work life?

48 . From 1 to 10, how would you rate your relationship with your family?

49 . How does your relationship with your family affect your stress level?

50 . Do your parents attend parent meetings?

• How to create an online stress questionnaire for students

You are now prepared to design your stress survey using an online survey tool, like forms.app, since you have an idea of the questions to include. Utilizing an online survey is crucial for gathering free, need-based input. You may simply complete the following steps if you want to make your stress survey or access survey templates:

1 - Choose a template, start from scratch, or generate with AI

To begin with, you have two options: either start from scratch or choose a template .  Starting from scratch will let you choose the specifics of the survey. Nevertheless, you may have a positive effect after selecting a ready-to-use survey template. You may also immediately take advantage of the simplicity of creation using AI .

Choose a starting point to start creating your survey

2 - Add your stress questions

You may add your questions to your stress survey based on your requirements and preferences. You should choose the appropriate questions for your survey from the titles, which include general questions, family, teacher, and friends.

Add your stress survey questions

3 - Change how your form looks

You need not worry if you have made headway in creating your online survey but still want to make modifications since you can alter the survey’s visual look . You might change the colors, background, font style and size, etc.

Customize your school stress survey

4 - Test and share

The most satisfying step of the survey-creation process is checking and sharing it with others since you will see that your efforts are genuinely appreciated, and you will be pleased to learn how near you are to helping your students! 

Share your survey with teachers and students

• To wrap it up

To wrap it all up, stress surveys are fantastic tools to gauge how stressed out your students are, needless to say. When used properly, these surveys can find the reason behind the students' stress, and you can help them cope with it. 

With this article, you can learn the must-ask 50+ stress survey questions and how to create an online survey . Act now if you want to help your students to study in a stress-free environment!

Şeyma is a content writer at forms.app. She loves art and traveling. She is passionate about reading and writing. Şeyma has expertise in surveys, survey questions, giveaways, statistics, and online forms.

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Student Stress and the Research Consultation: The Effect of the Research Consultation on Project Stress and Overall Stress and Applications for Student Wellness

LuMarie Guth and Bradford Dennis *

Academic libraries have conducted studies on the importance of the library research consultation (LRC) regarding student learning and the impact on academic success. While there is a robust literature examining library anxiety, no study has been designed to measure the impact of the library research consultation on stress. Researchers at a mid-sized midwestern Carnegie Research 2 institution analyzed 108 surveys administered before and after the consultation. Findings confirm the LRC improves perceived stress levels at the project and overall level. The overall stress change and project stress levels were lower during the COVID phase of the study.

Introduction

Faculty reported that—two years into the pandemic—students continued to face heightened stress and burnout. 1 Gen Z (born 1997 and later) 2 students are present at all levels of the undergraduate curriculum. According to the American Psychological Association (APA) 2018 Stress in America survey—in its report introducing Gen Z—91 percent of Gen Z respondents claimed to have experienced physical or emotional symptoms due to stress, compared to 74 percent of adults overall. Gen Z adults were also more likely than other generations at similar life stages to report that they have been diagnosed with an anxiety disorder (18 percent of Gen Z) and/or depression (23 percent of Gen Z). 3 Several studies indicate that college student mental health is a contributor to student retention and academic success. 4 Therefore it is in the best interest of the student and the university to address mental wellness. Faculty knowledge of mental health disorders, 5 along with direct expressions of concern and support, 6 can have a positive impact on student mental health and academic success. Likewise, it has been the experience of this study’s researchers that students express a sense of relief upon finishing a research consultation with academic librarians. However, is this just anecdotal? Is it possible to demonstrate that librarians leading the research consultation can have a positive impact on student stress reduction? In summer 2019 early results were being filtered out from a campus-wide survey and series of listening sessions indicating that students on campus wanted additional mental wellness support. Early discussions centered around building a campus referral system to a “wellness wheel” of services, such as tutoring, recreation, and counseling. The researchers saw an opportunity to investigate their anecdotal experiences to see if the research consultation could serve as an effective option, among others, for triaging academic stress. The library—as an academic service on campus—has a mission to contribute to student success by providing the resources and services they need for their academic research. One such service is the library research consultation, which students can schedule to get individual assistance for their project(s). The consultation differs from the reference interview in that it is pre-scheduled versus conducted at a drop-in point-of-service. Since there is dedicated time allotted for the consultation, there is more flexibility to guide the patron through the research process and to impart information literacy skills. In the consultation, the librarian typically works with the student to develop their topic, determine the best research strategy, conduct initial searches to find sources, and evaluate the sources found for relevancy.

The researchers began their investigation in the fall of 2019 and paused collecting data when the university announced a move to fully remote instruction in March 2020. When it was evident that the pandemic would be long term, the researchers recognized the opportunity to include analysis of pre- and post-COVID data to measure its effect, if any. They conducted a second round of data collection from October 2020 to March 2021 while most classes were online and library research consultations were exclusively offered virtually.

Literature Review

Students and faculty believe the research consultation is helpful in learning library research skills 7 and is an important factor in academic success. 8 However, research linking the consultation with academic success metrics has been mixed. A University of Minnesota study on library use and academic success did not find any significant differences in GPA or retention between those who scheduled a peer research consultation and those who did not. 9 A similar study at University of Wisconsin—Eau Claire found that students who used reference consultations earned marginally higher grade point averages than non-library users. 10 Researchers at the University of Northern Iowa examined the effect of the research consultation on course performance and found that students who had research consultations had higher course grades than those who had not. However, they also found that students seeking consultations were more likely to live on campus and be full-time students, introducing the prospect of sampling bias in analysis of the effect of research consultations on academic success since students who are already more likely to succeed academically may be more likely to seek out a research consultation. 11

Kuhlthau’s ISP model offers an early examination of emotions experienced during the research process. In the origin study at Rutgers, Kuhlthau surveyed and interviewed high school seniors in AP English classes on their research process, and developed a new model for the information search process (ISP) which mapped each stage to a series of emotions. 12 Kuhlthau’s ISP model argues that feelings of uncertainty increase after the initial optimism of the topic selection stage as students begin searching for sources. However, as the topic becomes more focused and students gather more pertinent information—as typically happens during the research consultation—feelings of clarity and confidence emerge, followed by relief at the end of the information gathering process, and then final satisfaction or dissatisfaction with the commencement of the writing of the paper. Further testing of this model on users from a range of libraries found that academic participants showed the largest growth in confidence from the initiation to closure of the search project. 13 An advantage of the research consultation is that it expedites the information gathering process to move students more quickly to clarity and confidence.

Mellon constructed a grounded theory of “library anxiety” drawing on data collected from 6000 students over two years by 20 English professors. Three concepts emerged from these descriptions: 1. students generally feel that their own library-use skills are inadequate while the skills of other students are adequate; 2. the inadequacy is shameful and should be hidden; and 3. the inadequacy would be revealed by asking questions. 14 Bostick developed the Library Anxiety Scale 15 and researchers administered it to 493 students at two US universities; they found that library-anxious students tend to experience negative emotions such as fear, apprehension, and mental disorganization, therefore limiting their ability to use the library effectively. 16 Frustration associated with the search for information resources in libraries or information systems is one of the most prevalent forms of academic anxiety because most students are required to conduct research as a part of their academic program. 17 Researchers at Kent State found that 50 percent of respondents in first-year writing classes were, “mostly sure about how to begin a general search for information,” but 48 percent agreed or strongly agreed they were, “unsure about how to begin research;” 63 percent of respondents felt “uncomfortable searching for information,” and 67 percent did “not want to learn how to do their own research.” 18 These numbers reflect a persistent need to work with students to make them more comfortable and confident in their research. Library anxiety and research performance are inversely related, and library anxiety represents a negative experience for the student. 19 Experiencing a successful search could lead to a reduction in search anxiety. 20

Recent studies have shown that course instructors can play a role in recognizing and supporting students with mental health disorders by referring them to resources on campus. 21 As instructors, librarians can help minimize the effect of research anxiety, or “library anxiety.” 22 Kracker developed and administered a Research Process Survey based on Kuhlthau’s ISP model along with a standard anxiety test to a writing course at the University of Tennessee—Knoxville. The study found a significant decrease in anxiety about the research paper assignment in the test group after a 30-minute presentation on the ISP model, compared to the control. This finding indicates that instruction on the research process and on the expected emotions of that process, can mitigate negative emotions. 23 Students are less anxious when they know what they are experiencing is normal.

Student perceive the research consultation as a learning experience that extends beyond information literacy in the classroom. 24 Students undergoing the research consultation view the librarian as a teacher, and agree that the consultation helps improve their skills in conducting a literature search. A particular benefit of the consultation is modelling how to address the natural challenges of the research process. 25 The research consultation is an important service because it occurs at a point of need. Students often seek out the research consultation after already attempting research and meeting with challenges, 26 and frequently cite time savings as a benefit. 27 Reinsfelder 28 describes the unique advantages of the consultation: “the method of instruction can be quite effective and is used frequently by on-campus tutors and writing centers because these personal meetings allow for greater attention to detail and the ability to address unique concerns of each student in a way that is not possible in larger groups.”

Several studies have found that students report increased research confidence after the consultation 29 and this confidence can have lasting effects beyond the project at hand. 30 Fewer studies investigate the effect of the research consultation on stress and anxiety and, when they do, it is not the central focus of the study. In a small study at Colorado State University—Pueblo undergraduate participants exhibited mild decreases in library anxiety over the course of one semester. However, the study included both instruction and consultation and it was not determined which had a greater impact on anxiety, if any. 31 In a study conducted at Utah State University, 80 percent of students who expressed library anxiety prior to the consultation were comforted by the professional knowledge of the librarian. 32 Although the central focus of their research was not stress, Magi and Mardeusz 33 —in their qualitative study at the University of Vermont—found, after coding the open ended comments, that students reported increased confidence and reduced stress after the consultation. Of the 52 students in the study, more than one-third said they felt overwhelmed before the consultation and about 20 percent referenced a feeling of stress or anxiety in their comments. After the consultation all but one remarked on a positive change. Responses in the appendix show 40 percent of the students mentioned feelings of confidence/readiness/preparedness, and about 20 percent mentioned feelings of relief or relaxation after the consultation.

The observation of heightened stress for Gen Z in the beginning of the COVID-19 pandemic is supported by the findings in the APA 2020 Stress and America report. Gen Z adults (aged 18–23 in 2020) reported high levels of stress with a 6.1 rating on a 10-point scale, compared to 5.0 for all adults. Eighty-two percent of Gen Z adults in college said that the uncertainty going into the 2020–21 school year would likely result in stress. 34 However, in the 2021 study Gen Z stress levels had lowered to 5.6, the second highest cohort after Millennials. Several studies have found that COVID-19 directly affected student stress levels. Active Minds surveyed undergraduate students in September 2020 and found that 89 percent reported that COVID-19 has had an impact on their stress/anxiety levels. When asked what the most stressful factor was, college students ranked having troubles focusing on studies and/or work as the third highest stress factor at 14 percent. 35 In interviews of undergraduates at Texas A&M in April 2020, 71 percent of respondents reported that their stress and anxiety had increased due to COVID-19, 89 percent of respondents reported difficulty concentrating, and 82 percent were concerned about their academic performance. 36 In contrast, a study comparing measurements before and after the University of Vermont moved all instruction online due to COVID-19 did not find significant changes in stress levels in their study. They hypothesized that the lack of stress changes could be attributed to moving back home, or to the additional pandemic-related accommodations instructors provided. 37

Methodology and Demographics

Students who scheduled a research consultation with four of the nine instruction liaison librarians at Western Michigan University were invited to participate in the study, which was reviewed and approved through the IRB process. These four librarians served the areas of fine arts, business, health sciences, and education and were selected because of their breadth of disciplines, as well as their history of having a high volume of research consultations. Study participants were not asked why they sought the consultation, but there are a variety of incentives at the university. In some classes it is required. In others the instructor recommends the service, particularly when a student is struggling, or offers extra credit for using the service. Students in the business college can use the research consultation as an option for obtaining a badge in a microlearning credentials program. Multiple librarians at the university have reported that students seek consultations for individual assistance after an instruction session was delivered to their class. There were 209 students eligible for participation and 108 opted into the study resulting in a response rate of 52 percent. The pre- and post- questionnaires were on the same Qualtrics web-based survey with a page in between asking students to keep the tab open and pause to resume the session. Prior to the study students were asked to self-report their feelings related to their project with the question: “How much stress do you feel about this project?” (possible responses were: None at all (1), A little (2), A moderate amount (3), A lot (4), A great deal (5)); and were asked about their overall stress via the question: “How much overall stress do you feel this semester?” (possible responses were: None at all (1), A little (2), A moderate amount (3), A lot (4), A great deal (5)). Definitions of project and overall stress were not provided, leaving interpretation to the students. Immediately after the consultation students were asked to report how their project and overall stress levels had changed with the questions: “How is your project stress after the research consultation?” (possible responses were: Much better (5), Somewhat better (4), About the same (3), Somewhat worse (2), Much worse (1)), and “How is your overall stress after the research consultation?” (possible responses were: Much better (5), Somewhat better (4), About the same (3), Somewhat worse (2), Much worse (1)). The study launched in week six of the fall 2019 semester and was suspended in week ten of the spring 2020 semester when it was announced that the following week campus would move to virtual services because of the COVID-19 pandemic. The study resumed in week six of the fall 2020 semester and ended in week ten of the spring 2021 semester to measure changes in reported project and overall stress before and during the COVID-19 pandemic. The weeks correspond to late October and early March. During the study period prior to the pandemic, the four librarians collecting responses for the study conducted 92 percent of their consultations in-person and none via web conferencing; while during the pandemic none of their consultations were in-person and 93 percent were via web conference. Other mediums for consultations included IM/Chat and phone.

SPSS version 27 was used in analysis of the data. The researchers consulted with the Associate Director of the Office of Institutional Research on the appropriate statistical tests, following up to verify the validity of the findings. Three of the factors were condensed in order to increase within-group sample size. Class standing was reduced from five categories (first year, sophomore, junior, senior, and graduate student) to three categories (first year/sophomore, junior/senior, and graduate student). Project stress and overall stress were reduced from five categories to two categories: low (none at all/a little/a moderate amount) and high (a lot/a great deal). Additionally, project stress change and overall stress change were transformed from much worse, somewhat worse, about the same, somewhat better, and much better to –2, –1, 0, 1, and 2 respectively to quantify the magnitude and direction of change of respondents from their previous state.

Of the 108 respondents, 43 percent (n=46) took the survey before the COVID-19 closures in Michigan and 57 percent (n=62) of respondents took the survey during the COVID-19 pandemic when library services and most courses were offered virtually. Eighty-five respondents gave their age. The ages of respondents ranged from a minimum of 17 to a maximum of 50 with a mean of 22.2 and standard deviation of 4.6. The ages and dates of participation were used to sort students into generations. Seventy-nine percent (n=67) of respondents who gave their age were from Gen Z, 19 percent (n=16) were Millennials, and 2 percent (n=2) were from Gen X.

Class Standing

Twelve percent (n=13) of respondents were first years/sophomores, 76 percent (n=82) were juniors/seniors, and 12 percent (n=13) were graduate students. This indicates that the primary audience for the research consultation service, at least among librarians in the study, is juniors/seniors.

There was a significant association between COVID and class standing (x 2 (2)=10.306, p =.006), as exhibited in table 1. More respondents than expected were graduate students before COVID (late October 2019 through early March 2020), and there were more first years/sophomores than expected during the COVID phase of the study (late October 2020 through early March 2021). Examining LibAnswers consultation reporting statistics of librarians in the study, there were many more undergraduate consultations (178 versus 78) and slightly more graduate consultations (18 versus 16) during the COVID phase. While the researchers do not have an explanation for the change in graduate students, there was a first-year class that was strongly encouraged to meet with one of the librarians in the study during the COVID phase.

Stress Change

The primary interest of the study was to observe whether or not students reported an improvement in perceived stress after the research consultation. Thirty-seven percent (n=40) of respondents reported high levels of project stress and 64 percent (n=69) reported high levels of overall stress before the consultation. Respondents reported an improvement in both project stress and overall stress after the research consultation. Frequencies can be seen in figures 1 and 2. Respondents in the study experienced a mean positive change in project stress of 1.5 units and a mean positive change in overall stress of 1.2 units.

Chi-square Goodness of Fit Test Analysis

Using crosstabs, the researchers performed a chi-square goodness of fit test to explore associations between the variables and found significant associations between: 1. Project Stress and Covid; 2. Overall Stress Change and COVID; 3. Project Stress and Overall Stress; and 4. Project Stress Change and Overall Stress Change. One area of interest was whether participants in the study demonstrated higher levels of stress during the COVID phase of the study than in the pre-COVID phase.

There was a significant association between COVID and project stress before the consultation (x 2 (1)=10.297, p =.001), but the data showed there were more respondents than expected reporting high project stress before COVID (late October 2019 through early March 2020). Likewise, more respondents than expected reported low project stress during COVID (late October 2020 through early March 2021) as shown in table 2. A similar analysis on overall stress before the consultation did not show a significant association with COVID.

There was a significant association between COVID and overall stress change (x 2 (2)=6.725, p =.035). There were more respondents than expected reporting a positive overall stress change by two units before COVID, and more than expected reporting no overall stress change, or a positive stress change by one unit during COVID (see table 3). No students reported a negative overall stress change. In general, improvements in overall stress were higher before COVID. A similar analysis on project stress change did not show a significant association with COVID.

In addition to the difference between initial project stress and COVID, there was a significant association between project stress and overall stress (x 2 (1)=5.101, p =.024). There were more respondents than expected with both low project and overall stress, and likewise more than expected with both high project and overall stress (see table 4). In general, students with low project stress also had low overall stress and students with high project stress also had high overall stress.

There was also a significant association between project stress change and overall stress change (x 2 (6)=35.181, p <.001). In general, students that showed large positive changes in project stress were more likely to show large positive changes in overall stress (see table 5).

Regression Analysis of Project and Overall Stress Change

An ordinal regression model using the Cauchit link function in SPSS was used to estimate the relationships between changes in stress and possible explanatory variables including: COVID, Millennial, Gen Z, class standing, and initial project/overall stress respectively. The use of this model was affirmed by the model fitting, Pearson, and Deviance tests.

The ordinal regression model for project stress change found two explanatory variables that were statistically significant (see table 6). Students in the pre-COVID portion of the study reported stronger positive changes in project stress on average than students in the COVID portion (beta = 1.817, se = 0.885, p = 0.040). Students with low project stress prior to consultation reported stronger positive changes in project stress on average than students with high initial project stress (beta = 1.986, se = 0.876, p = 0.023).

A cross tab analysis shows the responses to these questions and illustrates the difference between the estimated and reported values (see table 7). Respondents before COVID reported a higher-than-expected project stress change of two units and a lower than expected change of one unit while those during COVID reported a lower than expected project stress change of two units and higher than expected change of one unit. In general, respondents reported lower levels of project stress change during COVID than they did before.

Table 8 shows that respondents who reported high project stress (4–5) reported lower-than-expected results for a positive project stress change factor of two and higher than expected results for zero project stress change and a positive project stress change factor of one. In general, participants reported lower levels of project stress change when they had high initial project stress than when they had low initial project stress.

Similarly, the overall stress change regression found overall stress and COVID to be the two significant explanatory variables (see table 9). Students in the pre-COVID portion of the study reported stronger positive changes in overall stress on average than students in the COVID portion (beta = 2.252, se = 0.837, p = 0.007). Students with low overall stress prior to consultation reported stronger positive changes in overall stress on average than students with high initial overall stress (beta = 1.594, se = 0.646, p = 0.014).

Respondents before COVID had a higher-than-expected overall stress change for two units and lower than expected change for zero and one units (see table 10). Respondents during COVID had a lower-than-expected overall stress change of two units and a higher-than-expected change for zero and one units. In general, respondents reported lower levels of overall stress change during COVID than they did before and when they had high initial overall stress.

Respondents who reported high overall stress (4–5) reported lower than expected results for a positive overall stress change factor of two and higher than expected results for zero overall stress change and a positive overall stress change factor of one (see table 11). In general, respondents who reported higher overall stress had lower levels of stress change than people with lower overall stress.

The most impactful finding of this study is the consistent positive change in reported student stress after the research consultation. While the researchers were expecting to see a positive change in project stress, the researchers were very encouraged to see a corresponding positive change in overall stress. The overall stress change was lower in magnitude during the COVID phase of the study. This study did not ask students to describe the factors contributing to their overall stress and stress factors may have been more persistent during COVID times than prior. In their study of 243,694 students seeking counseling support, the Center for Collegiate Mental health found that levels of distress related to academics, eating, and family were heightened in 2020. 38 The finding that project stress levels were lower during the COVID period of our study was surprising. Anderson, Fisher, and Walker 39 analyzed 3,331 reference encounters at Georgia State University from the fall 2019 and spring 2020 semesters, coding them for level of difficulty, and found that transactions during COVID were more difficult than those before COVID. However, as the Vermont study speculated, accommodations from instructors during the COVID period of change may explain reduced stress. 40 Western Michigan University faculty may have improved communication and support—many faculty went through professional development when transitioning their courses online in the spring and summer of 2020. Additionally, the registrar offered students the opportunity to change their grading structure to pass/fail during the COVID lockdown with no penalty. In Texas A&M’s study students reported increased stress due to COVID. 41 There was no significant difference in reported overall stress before and during COVID in our study or Vermont’s, 42 but it’s possible that students saw the project as a lower weighted stress factor in comparison to factors that arose from the context of the pandemic. The regression analysis found that, similarly to overall stress change, project stress change had a lower magnitude during the COVID phase of the study.

The findings in the regression analysis that respondents with lower initial project stress, or lower initial overall stress, experienced greater change is unexpected because there was less opportunity for change—if stress is already low, you wouldn’t expect it to have as much room for improvement. However, it is easier to remove a small amount of stress than a large amount, and students going from some stress to none could see this as a great improvement. Researchers at Rutgers University studied subjective factors—such as happiness and confidence—before and after six web search tasks; they found that those who were happy before the search, and who thought the search task would be easy, felt better after the search. 43 In the same study, subjects who felt unhappy before the search did feel happier, as well as more confident and satisfied with the results if the results found were complete and relevant. So, it may be that patrons going into the consultation with low project stress are likely to report improvement afterward regardless of the relevancy of the sources found, but patrons with high initial project stress are more reliant on relevancy for perceived improvement. These findings emphasize the importance of the librarian considering the research question fully and making connections between the information found in the consultation and the research question clear to the patron.

While the study gathered sufficient responses from Gen Z and Millennials to run a comparison, they were too close in age to represent the breadth of their generations. Additionally, there were only two Gen Xers in the study. Over the span of the study from October 2019 through March 2021, the mean age was 22.2 and the standard deviation was 4.6. Sixty-seven percent of respondents who gave their age were between 20 and 23 years old. Our finding of no difference in stress levels by generation is also in line with the APA Stress in America 2021 study where Gen Z and Millennials report the most similar stress levels of any generation, at 5.6 and 5.7 out of 10 respectively. The researchers theorized there would be a stress difference by class standing—that as students gained experience in their programs, they would gain research and coping skills. However, this may be offset by the increased difficulty of the assignments in the upper levels.

The research coincided with a movement toward personal wellness at the Western Michigan University campus due to groundswell support from students during a series of educational innovation town halls held in 2018 and 2019. In pursuing this goal, the campus adopted the Wellness Wheel model derived from Hettler’s Dimensions of Wellness. 44 The wheel adopted included eight dimensions: social, emotional, physical, environmental, financial, purpose/spiritual, occupational, and intellectual. Selected campus services were assigned a dimension and provided to students seeking education on campus wellness options. Through this study the researchers were able to get the research consultation service included on the menu of services for the dimension of intellectual wellness in spring 2020, joining others such as the tutoring and the writing center. Additionally, the library sought out mental health first aid professional development opportunities offered to all employees and invited the Assistant Director of Mental Health Outreach to present at a library all staff meeting.

Limitations and Opportunities for Future Research

The study gathered a sample of 108 completed responses which may limit generalizability to the larger student population at the university. The study did not collect demographic factors beyond class standing and age. Additionally, responses were self-selected and reported on perceived stress, which increases subjectivity. The mode of delivery of the consultation (virtual meeting vs in-person) may have influenced stress levels; this was not explored because the shift in delivery due to COVID was unexpected at the initiation of the study and thus was not included on the survey instrument.

Future opportunities for research include analyzing changes and perceived stress by comparing students who sought the research consultation intervention to a control of students who did not seek a consultation. This would likely have the additional advantage of gathering a larger sample size. While the study focused on having a short survey in order to increase responses and to decrease consultation time dedicated to the survey, additional demographic questions could be included to analyze differences by gender, race, ethnicity, GPA, and first-generation status, among others. The post-test was administered immediately following the consultation. Future studies could investigate persistence of the effects further into the semester. One of the librarians in the study does collect Project Outcome data on the research consultation at the end of the semester and received 26 responses during the period of the study. Ninety-six percent reported using the resources for their assignment and 81 percent reported they applied what they learned to another research task; however, these responses do not touch on stress. Overall and Project Stress also could be further segmented. Future studies could include the incorporation of assessment metrics, such as the Perceived Stress Scale (PSS) or Bostick’s Library Anxiety Scale. Another opportunity would be to conduct a study incorporating factors of confidence, happiness, stress, and library anxiety, which are frequently studied separately.

Findings of the study confirm the researchers’ hypothesis that the library research consultation improves perceived stress levels at the project and overall level in the population surveyed. While the researchers want to affirm their belief that the consultation is not in any way a replacement for professional counseling services, the results show that it is a wellness-focused student service that can help students to reduce academic stress. Therefore, they argue it could be included with other campus services promoted to students seeking wellness triage, particularly for students who seek intellectual wellness. The researchers hope this is just the beginning of librarianship interest in utilizing the research consultation to its fullest potential not only in student learning but also as one of several academic services contributing to student wellness.

Acknowledgements

The authors would like to acknowledge the work of Will Stutz, Data Scientist and Associate Director at the Western Michigan University Office of Institutional Research for advising the authors on appropriate statistical tests and interpretation of the data.

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* LuMarie Guth is an Associate Professor and Business Librarian at Western Michigan University, email: [email protected] ; Bradford Dennis is an Associate Professor and Education and Human Development Librarian at Western Michigan University, email: [email protected] . ©2024 LuMarie Guth and Bradford Dennis, Attribution-NonCommercial ( https://creativecommons.org/licenses/by-nc/4.0/ ) CC BY-NC.

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COVID-19 Student Stress Questionnaire: Development and Validation of a Questionnaire to Evaluate Students’ Stressors Related to the Coronavirus Pandemic Lockdown

Maria clelia zurlo.

1 Dynamic Psychology Laboratory, Department of Political Sciences, University of Naples Federico II, Naples, Italy

Maria Francesca Cattaneo Della Volta

2 Department of Humanities, University of Naples Federico II, Naples, Italy

Federica Vallone

Associated data.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Clinical observations suggest that during times of COVID-19 pandemic lockdown university students exhibit stress-related responses to fear of contagion and to limitations of personal and relational life. The study aims to describe the development and validation of the 7-item COVID-19 Student Stress Questionnaire (CSSQ), a measurement tool to assess COVID-19-related sources of stress among university students. The CSSQ was developed and validated with 514 Italian university students. Exploratory Factor Analysis (EFA) was conducted with one split-half sub-sample to investigate the underlining dimensional structure, suggesting a three-component solution, which was confirmed by the Confirmatory Factor Analysis (CFA) with the second one split-half sub-sample (CFI = 0.95; TLI = 0.95; RMSEA = 0.06). The CSSQ three subscales measure COVID-19 students’ stressors related to (1) Relationships and Academic Life (i.e., relationships with relatives, colleagues, professors, and academic studying); (2) Isolation (i.e., social isolation and couple’s relationship, intimacy and sexual life); (3) Fear of Contagion. A Global Stress score was also provided. The questionnaire revealed a satisfactory internal consistency (Cronbach’s alpha = 0.71; McDonald’s omega = 0.71). Evidence was also provided for convergent and discriminant validity. The study provided a brief, valid and reliable measure to assess perceived stress to be used for understanding the impact of the COVID-19 pandemic lockdown among university students and for developing tailored interventions fostering their wellbeing.

Introduction

The Coronavirus Disease 2019 (COVID-19) has been defined as an extreme health, economic and social emergency and it was declared a global pandemic by the World Health Organization on March 2020 ( World Health Organization, 2020 ), resulting in lockdown and life restrictions in Italy as worldwide in the attempt to prevent and slow the spread of the virus.

Comparable previous emergencies, such as the SARS outbreak, were strongly demonstrated as spreading stress and inducing psychological disease in terms of depression, anxiety but also panic attacks, and even psychotic symptoms, delirium, and increased rates of suicidal ( Xiang et al., 2020 ). These results have been recently confirmed with respect to the current COVID-19 pandemic ( Brooks et al., 2020 ; Zandifar and Badrfam, 2020 ), particularly in terms of high levels of psychological distress ( Qiu et al., 2020 ), depression ( Wang et al., 2020 ), anxiety ( Horesh and Brown, 2020 ; Lima et al., 2020 ; Rajkumar, 2020 ), fear and panic behaviors ( Shigemura et al., 2020 ).

In this perspective, a review conducted by Brooks et al. (2020) on the psychological impact of quarantine periods and outbreak confinements in last decades (e.g., the SARS outbreak, the 2009 and 2010 H1N1 influenza pandemic) identified specific common experiences such as fear of contagion, fear and frustration related to inadequate supplies (e.g., basic necessities and medical supplies), sense of confusion due to inadequate quality of information from public health authorities, sense of isolation, frustration and boredom due to loss of usual routine and to reduced social contacts ( Brooks et al., 2020 ).

Furthermore, the COVID-19-related containment measures imposed massive work and school closures, segregation and social distancing, deeply impacting on personal and relational life and exposing people to experience uncertainty, feelings of isolation, and sense of “losses” in terms of motivation, meaning, and self-worth ( Williams et al., 2020 ).

In view of that, research made several efforts to better explore the psychological impact of the ongoing Coronavirus global outbreak, developing and validating specific tools.

In particular, the Fear of COVID-19 Scale (FCV-19S; Ahorsu et al., 2020 ; Soraci et al., 2020 ) and the Coronavirus Anxiety Scale (CAS; Lee, 2020a ) were developed to assess, respectively, perceived COVID-related fear and anxiety. Moreover, the COVID-19 Peritraumatic Distress Index (CPDI; Costantini and Mazzotti, 2020 ; Qiu et al., 2020 ) was developed to assess the frequency of anxiety, depression, specific phobias, cognitive change, avoidance and compulsive behavior, physical symptoms and loss of social functioning.

Finally, the COVID-19 Stress Scales (CSS; Taylor et al., 2020 ) was developed to measure the psychological impact of COVID-19 in terms of danger and contamination fears, fears about economic consequences, xenophobia, compulsive checking and reassurance seeking, and traumatic stress symptoms.

Overall, the instruments reported above specifically addressed the impact of the COVID-19 outbreak in terms of psychological outcomes, without addressing and identifying specific sources of stress related to relational and daily life changes induced by the COVID-19 pandemic lockdown. Indeed, the COVID-19 pandemic-related experiences induced not only fears of contagion and social isolation but also significant modifications in several aspects of daily routine, mainly influencing (hindering or intensifying) all relationships, such as those with relatives, with the partner, with friends, with colleagues. Consequently, it emerged the need to develop instruments able to address not only the potential effects of isolation and fear of contagion but also of modifications of all significant relationships in daily life, so considering all potentially perceived sources of stress featuring the experience of pandemic lockdown.

Furthermore, in line with the transactional perspective ( Lazarus and Folkman, 1984 ), stress is considered a dynamic relational process, which depends on the constant interplay between individual factors (e.g., age, gender) and situational factors, so requiring to take into account specificities of target populations when defining tools to evaluate perceived sources of pressure.

From this perspective, the academic context was deeply affected by the lockdown restrictions worldwide. Indeed, due to the massive closure of colleges and universities ( United Nations Educational, Scientific and Cultural Organization, 2020 ), all the scheduled activities and events were postponed/annulled, campuses and students’ accommodations were forced to evacuations, all the formal and informal interactions were shifted to online platforms, leading to a substantial change in students’ customary life.

Different studies exploring factors associated to COVID-19 outbreak among university students highlighted high levels of anxiety and worries about academic delays and influence of the epidemic on daily life, due to the disruption in students’ daily routine, in terms of activities, objectives and social relationships ( Cao et al., 2020 ; Chen et al., 2020 ; Lee, 2020b ; Sahu, 2020 ). Indeed, the quarantine hindered the possibility to experience the university life, impacting on academic studying (i.e., uncertainties related to annulment/delays of activities, difficulties in employment of online platforms for the distance learning), but also impairing the possibility to benefit from the relationships that may represent anchor in students’ life, such as those with peers, colleagues, and professors ( Lee, 2020b ; Sahu, 2020 ). In addition, also considering the increasingly key role played by romantic relationships in the young population ( Anniko et al., 2019 ), research also outlined the potential changes in couple’ relationship, intimacy, and sexual life due to the COVID-19 pandemic ( Li et al., 2020 ; Rosenberg et al., 2020 ).

Moreover, whether, on the one hand, the abovementioned relationships with partner, friends, peers, colleagues, and professors were subject to a radical reduction and standstill, on the one other hand, in most of the cases, relationships with relatives were deeply intensified. Indeed, the majority of students were forced to return back home, also resulting from the campus dormitory evacuations, inducing an increased exclusivity of interaction with relatives, potentially exacerbating frustration and conflicts. This particularly when considering students living in already disadvantaged conditions and/or suffering from abusive home experiences ( Lee, 2020b ).

Overall, whether it’s clear that university students’ life was subject to broad modifications, up to date, there are no specific tools to understand, comprehensively identify and assess specific sources of stress featuring university students’ COVID-19-related experiences. This, however, could help in early recognize those students at higher risk for developing a significant psychological disease related to the pandemic lockdown, and, accordingly, provide timely and tailored interventions fostering their wellbeing.

Responding to this need, the present study aimed at proposing and validating a newly developed measurement tool to specifically assess sources of stress related to the COVID-19 pandemic lockdown among university students, namely the COVID-19 Student Stress Questionnaire (CSSQ).

Seven potential sources of stress have been hypothesized and operationalized. These sources have been defined as connected not only to fear of contagion and to experience of isolation but also to the potential abovementioned changes in students’ daily life and routine. 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 validity and reliability of the COVID-19 Student Stress Questionnaire (CSSQ) are listed in Table 1 .

Research questions and hypotheses of the validation study.

Materials and Methods

Participants and sampling.

Online survey data were collected from 15 April to 15 May 2020 with students from the University of Naples Federico II. This period fully corresponded to the pandemic lockdown due to COVID-19 in Italy, and students were experiencing the consequences of university closures, with massive social restrictions. The participants were recruited through Microsoft Teams. Students were contacted and given all the information about the study, and they were asked their participation on a voluntary basis. All the participants were fully informed about the aims of the study and about the confidentiality of the data, and they were also assured that the data would be used only for the purpose of the research and refusal to participate would not affect their current and future course of study in any way. The study was approved by the Ethical Committee of Psychological Research of the University where the study took place (IRB:12/2020). Research was performed in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from each student prior to participating in the study. Every precaution was taken to protect the privacy of research subjects and the confidentiality of their personal information. Overall, 514 university students voluntarily enrolled in the study and completed online Microsoft Teams forms.

The questionnaire included a section dealing with background information (i.e., Gender, Age, Degree Program, Year of study), the proposed 7-item COVID-19 Student Stress Questionnaire, and a measure for psychophysical health conditions.

COVID-19 Related Sources of Stress Among University Students

The COVID-19 Student Stress Questionnaire (CSSQ) was specifically developed to assess university students’ perceived stress during the COVID-19 pandemic lockdown. It consists of 7 items on a 5-point Likert scale ranging from zero (“Not at all stressful”) to four (“Extremely stressful”). For the purpose of instrument design, perceived stress was operationalized based on transactional models of stress ( Lazarus and Folkman, 1984 ). Each item was developed to cover different domains that could have been subject to variations due to the COVID-19 pandemic lockdown, and, therefore, that may be potentially perceived as sources of stress (i.e., risk of contagion; social isolation; relationship with relatives; relationship with colleagues; relationship with professors; academic studying; couple’s relationship, intimacy and sexual life). The scale provides a Global Stress score ranging from 0 to 28.

Psychophysical Health Conditions

The Symptom Checklist-90-Revised (SCL-90-R; Derogatis, 1994 ; Prunas et al., 2010 ) was used to assess self-reported psychophysical health conditions. The scale comprises 90 items on a 5-point Likert scale ranging from zero (“Not at all”) to four (“Extremely”) and divided into nine subscales: Anxiety (10 items, Cronbach’s α = 0.84), Depression (13 items, Cronbach’s α = 0.87), Somatization (12 items, Cronbach’s α = 0.83), Interpersonal Sensitivity (9 items, Cronbach’s α = 0.83), Hostility (6 items, Cronbach’s α = 0.80), Obsessive-Compulsive (10 items, Cronbach’s α = 0.82), Phobic Anxiety (7 items, Cronbach’s α = 0.68), Psychoticism (10 items, Cronbach’s α = 0.77), and Paranoid Ideation (6 items, Cronbach’s α = 0.76). Participants were asked to indicate how much these problems have affected them during the past 4 weeks (e.g., Anxiety subscale: “Tense or keyed up”, “Fearful”; Depression subscale: “Hopeless about future”, “No interest in things”). The scale also provides a global index, namely the Global Severity Index (GSI). GSI is the sum of all responses divided by 90, and it indicates both the number of symptoms and the intensity of the disease (GSI Cronbach’s α = 0.97).

Data Analysis

For the validity testing of the CSSQ we used the European Federation of Psychologists’ Association’s (EFPA) standards and guidelines ( Evers et al., 2013 ), which describe the standard method for validity testing by the following levels of evidence: 1) Construct validity; 2) Criterion validity: (a) Post-dictive or retrospective validity; (b) Convergent validity; (c) Discriminant validity. In the present study, validity evidence was examined in relation to Construct validity, Convergent validity, and Discriminant validity.

Evidence Based on Construct Validity

Evidence based on construct validity was examined to answer research questions 1 and 2 and to test hypotheses 1 and 2 ( Table 1 ). To examine the validity of the COVID-19 Student Stress Questionnaire (CSSQ) we used a two-step analytic strategy. First, the entire study sample ( N = 514) was split using a computer-generated random seed. According to the rules of thumb for sample size in factor analysis, the sample size for each sub-sample ( n = 257) was considered adequate to explore the structure of the 7-item CSSQ ( Comrey and Lee, 1992 ; Costello and Osborne, 2005 ; DeVellis, 2017 ). Construct validity was analyzed using Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA).

EFA was performed in the first split-half (Sub-sample A, n = 257) to explore the latent dimensional structure (R1 and R2) and to identify significant and coherent factors (H1). Principal Components Analysis (PCA) with oblique promax rotation was used. The choice of non-orthogonal rotation was justified on the hypothesis that the factors would be correlated. The factorability of the correlation matrix of the scale was evaluated by Kaiser–Meyer–Olkin (KMO) measure and Barlett test of sphericity. Criteria for extraction and interpretation of factors were as follows: eigenvalues > 1.0, Cattell’s scree test and inspection of scree plot, communality ≥ 0.30 for each item and factor loading > 0.32 for each item loading on each factor ( Costello and Osborne, 2005 ).

CFA was performed in the second split-half sub-sample (Sub-sample B, n = 257) to determine the goodness-of-fit of the extracted factor model (H2). Standard goodness-of-fit indices were selected a priori to assess the measurement models: χ 2 non-significant ( p > 0.05), Tucker-Lewis Index (TLI > 0.95), Root Mean Square Error of Approximation (RMSEA < 0.08) and Comparative Fit Index (CFI > 0.95) ( Hu and Bentler, 1998 ).

Evidence Based on Convergent Validity

Evidence based on convergent validity was explored to test hypotheses 3 and 4 ( Table 1 ). Convergent validity was tested, first, by calculating standardized factor loadings, composite reliability (CR), and average variance extracted (AVE) of factors (H3). If the standardized factor loadings of a questionnaire are > 0.5 and statistically significant, and the values of CR and AVE of each factor are higher than 0.7 and 0.5, respectively, the questionnaire is considered as having a satisfactory convergent validity ( Fornell and Larcker, 1981 ; Hair et al., 2010 ). Moreover, convergent validity was assessed by correlational analyses (Pearson’s correlation coefficient) between the scales scores of the newly developed COVID-19 Student Stress Questionnaire and the standardized scales scores of the SCL-90-R (nine subscales and Global Severity Index) (H4). The effects size were interpreted following Cohen’s thresholds ( r < 0.30 represents a weak or small correlation; 0.30 < r < 0.50 represents a moderate or medium correlation; r > 0.50 represents a strong or large correlation) ( Cohen, 1988 ).

Evidence Based on Discriminant Validity

Evidence based on discriminant validity was explored to test hypotheses 5 and 6 ( Table 1 ). Discriminant validity was evaluated by comparing the square root of the average variance extracted (SQRT AVE) with the correlations between latent constructs (H5). When the SQRT AVE is above the correlations among factors, a questionnaire is considered as having an acceptable discriminant validity ( Fornell and Larcker, 1981 ). Furthermore, discriminant validity was also tested basing on the correlations between the CSSQ subscales and the Global Stress scores using the Pearson’s correlation coefficient (H6).

Evidence Based on Internal Consistency

Evidence based on internal consistency was explored to test hypothesis 7 ( Table 1 ). Item means, standard deviations, and mean inter-item correlation (between 0.15 and 0.50) were evaluated ( Clark and Watson, 1995 ). Moreover, for the reliability test, Cronbach’s Alpha ( Cronbach, 1951 ) and McDonald’s Omega ( McDonald, 1999 ) were used to assess the internal consistency of the questionnaire, considering α ≥ 0.70 ( Santos, 1999 ) and ω ≥ 0.70 ( McDonald, 1999 ) as indices of satisfactory internal consistency reliability (H7).

Finally, means, standard deviations, and ranges of the newly developed COVID-19 Student Stress Questionnaire (CSSQ) scales were calculated.

Characteristics of Participants

Characteristics of the total sample ( N = 514) as well as of each sub-sample (A and B) are shown in Table 2 . The total sample consisted of 372 women and 142 men, with a combined mean age of 19.92 ( SD = 1.50) years. The sample was composed of students enrolled in Philosophy ( n = 10, 1.9%), Modern Languages and Literature ( n = 44, 8.6%) and Psychology ( n = 460, 89.5%) degree programs; the majority of them were 1st year students (1st year n = 400, 77.8%; 2nd year n = 46, 8.9%; 3rd year n = 68, 13.3%).

Characteristics of study participants.

Construct Validity

Construct validity (research question 1) was examined by conducting EFA and CFA.

Exploratory Factor Analysis

Exploratory Factor Analysis (EFA) using Principal Components Analysis (PCA) with oblique promax rotation was carried out to investigate the underlining dimensional structure of the CSSQ. The assessment of factorability showed that the Kaiser–Meyer–Olkin measure was 0.73 and Bartlett’s test of sphericity was significant (χ 2 = 332.26, df = 21, p < 0.001) indicating that the data were adequate for the factor analysis, supporting hypothesis 1. The examination of the scree plot produced a departure from linearity corresponding to a three-component result; the scree-test also confirmed that our data should be analyzed for three components, responding to research question two. The first three eigenvalues were 2.61, 1.20, and 1.00. The three-component solution explained a variance of 67.09% from a total of 7 items.

The first component (4 items, explained variance = 37.23%) was loaded by items referred to perceived stress related to relationships with relatives, relationships with colleagues, relationships with professors, and academic studying. We labeled this scale Relationships and Academic Life.

The second component (2 items, explained variance = 17.20%) was loaded by items referred to perceived stress related to social isolation and changes in couples’ relationship, intimacy and sexual life due to the social isolation. We labeled this scale Isolation.

The third component (1 item, explained variance = 12.66%) was loaded by a single item referred to perceived stress related to the risk of infection, hence it was labeled as Fear of Contagion ( Table 3 ).

COVID-19 Student Stress Questionnaire (CSSQ) exploratory factor analysis on first random split-half sample ( n = 257).

Confirmatory Factor Analysis

Confirmatory Factors Analysis (CFA) was run to test hypothesis 2. The results supported the PCA findings ( Figure 1 ) by demonstrating that the three-factors model (χ 2 = 4.52, p = 0.79), comprising all the 7 items proposed, yielded good fit for all of indices (χ 2 /df ratio = 0.56; CFI = 0.95; TLI = 0.95; RMSEA = 0.06).

Path diagram and estimates for the three-factor COVID-19 Student Stress Questionnaire on second random split-half sample ( n = 257).

Convergent and Discriminant Validity

Concerning Convergent validity, the standardized factor loadings of CSSQ items were all > 0.5 (see Figure 1 ) and statistically significant ( p < 0.001). Moreover, the CR values were all > 0.7 (i.e., Relationships and Academic Life CR = 0.924; Isolation CR = 0.809; Fear of Contagion CR = 0.769). The values of AVE of all factors were > 0.5 (i.e., Relationships and Academic Life AVE = 0.637; Isolation AVE = 0.549; Fear of Contagion AVE = 0.649). Therefore, the standardized factor loadings, CR and AVE of factors were united to suggest that the CSSQ had strong convergent validity, confirming hypothesis 3.

Moreover, correlations with measures of psychophysical disease (SCL-90-R subscales and GSI) were carried out to further test convergent validity, showing that COVID-19 Student Stress Questionnaire scales and Global Stress scores revealed moderate to strong correlations with the SCL-90-R scales scores in the expected directions, and confirming hypothesis 4 ( Table 4 ).

Correlations of the COVID-19 Student Stress Questionnaire (CSSQ) scales with SCL-90-R scales.

Concerning Discriminant validity, the square root of AVE values were compared with the correlations among factors. All the square root of AVE values (i.e., Relationships and Academic Life, SQRT AVE = 0.798; Isolation SQRT AVE = 0.741; Fear of Contagion SQRT AVE = 0.805) were above the correlation values (i.e., correlation between Relationships and Academic Life and Isolation, r = 0.645; correlation between Relationships and Academic Life and Fear of Contagion, r = 0.621; correlation between Isolation and Fear of Contagion, r = 0.660; see Figure 1 ), indicating suitable discriminant validity, and supporting hypothesis 5.

Furthermore, still concerning discriminant validity, intercorrelations between the three COVID-19 Student Stress Questionnaire scales and the Global Stress scores were also calculated. Intercorrelations ranged from 0.30 to 0.42, showing medium levels of correlation, while correlations of all COVID-19 Student Stress Questionnaire scales with Global Stress scores were high in size and significant, indicating that the questionnaire assessed different but related dimensions, and confirming hypothesis 6 ( Table 5 ).

Intercorrelations between the COVID-19 Student Stress Questionnaire (CSSQ) scales.

Item Analysis and Reliability

Mean scores for the single items varied from a maximum score of 2.01 (Item 2: “How do you perceive the condition of social isolation imposed during this period of COVID-19 pandemic?”) to a minimum of 0.44 (Item 4: “How do you perceive the relationships with your university colleagues during this period of COVID-19 pandemic?”). SDs for the single items varied from 1.36 (Item 7: “How do you perceive the changes in your sexual life due to the social isolation during this period of COVID-19 pandemic?”) to 0.75 (Item 4: “How do you perceive the relationships with your university colleagues during this period of COVID-19 pandemic?”). The mean inter-item correlation was 0.26, therefore it was satisfactory. Cronbach’s alpha of the total scale was 0.71, while McDonald’s omega coefficient was 0.71, confirming that the CSSQ had satisfactory internal consistency (hypothesis 7).

All the items of the CSSQ were presented in Table 6 .

The COVID-19 Student Stress Questionnaire.

Table 7 displays items, means, standard deviations, and ranges of the CSSQ scales (Relationships and Academic Life, Isolation, Fear of Contagion) and the total score (Global Stress). Considering that high levels of COVID-19-related stress can be indicated by scores that are 1 SD above the mean (e.g., the 84th percentile) and low levels of stress can be indicated by scores that are 1 SD below the mean (e.g., the 16th percentile) of the distribution of the CSSQ scores, we can affirm that scores of 6 or below indicate low levels of perceived COVID-19-related Global stress, scores of 7–15 indicate average levels of perceived COVID-19-related Global stress, and scores of 16 or more indicate high levels of perceived COVID-19-related Global stress among university students.

Items, mean, SD and range scores of the COVID-19 Student Stress Questionnaire scales.

The aim of the present study was to develop, validate and evaluate the psychometric properties of the 7-item COVID-19 Student Stress Questionnaire (CSSQ), a brief measure to assess sources of stress related to the COVID-19 pandemic lockdown among university students. Indeed, addressing specific sources of stress tailored to target populations foster efficacy in preventive efforts and interventions ( Zurlo et al., 2013 , 2017 ; Anniko et al., 2019 ).

Accordingly, responding to the widespread need for developing specific tools to understand the impact of the COVID-19 global pandemic among students ( Cao et al., 2020 ; Lee, 2020b ; Sahu, 2020 ), it was hoped this instrument could foster a timely identification of those students at higher risk for developing a significant disease related to the ongoing unique situation, and to deliver evidence-based and tailored interventions to promote their adjustment and wellbeing.

Findings highlighted that the proposed CSSQ possessed adequate factor validity, tapping three meaningful factors.

The first factor, labeled Relationships and Academic Life, comprised four items covering perceived stress related to relationships with relatives, relationships with colleagues, relationships with professors, and academic studying. Indeed, considering that students’ daily routine have been subject to specific changes ( Cao et al., 2020 ; Chen et al., 2020 ; Lee, 2020b ), this first factor fostered a greater understanding of the dimensions characterizing these modifications among university students in terms of relationships and academic life.

From this perspective, the relationships with relatives should be carefully focused, considering the forced full-time cohabitation, with almost exclusive sharing time and spaces throughout all days. This also as a consequence of the closures of the campus and students accommodations, which forced several students to return back home, but also considering the great number of students already living with their parents, however under completely changed conditions.

In the same direction, since restrictions drastically impaired the possibilities to benefit from living the university life, university students may report growing disease connected to changes in relationships with colleagues and professors (that, during the COVID-19 pandemic, are only allowed through online platforms), but also increased suffering related to the academic studying (e.g., fear of delays, difficulties in finding appropriate spaces to concentrate) ( Cao et al., 2020 ; Lee, 2020b ; Sahu, 2020 ).

The second factor, labeled Isolation, comprised two items exploring perceived stress related to social isolation and changes in sexual life due to the containment measures. From this perspective, in line with research emphasizing the strong weight of containment measures such as quarantine and social distancing on individuals’ psychological health and wellbeing ( Brooks et al., 2020 ; Horesh and Brown, 2020 ; Lee, 2020a ; Williams et al., 2020 ), the second factor also captured the perceived disease and sense of loneliness derived from living this condition, often far from the loved ones ( Sahu, 2020 ; Zhai and Du, 2020 ).

From this perspective, considering the specificity of the target population, it’s not surprising that the confinement in itself and sexual life belonged to the same factor. Indeed, since students were more likely to still live with their families or they returned back home due to the pandemic, it’s more probable that their couple’ relationship, intimacy and sexual life were subject to significant restrictions due to the lockdown. However, these findings may be also due to the specific European context, considering that the average age of young people leaving the parental house is 25.9 ( Eurostat, 2020 ), while in several other countries students use to leave home around 18 years for starting the college ( Aassve et al., 2002 ; Crocetti and Meeus, 2014 ).

The third factor, labeled Fear of Contagion, comprised one item assessing perceived stress related to the risk of infection. The relevance of the latter dimension is, indeed, in line with previous studies on the key role played by the fear to be infected, the fear for others (e.g., relatives, friends) to become ill, as well as the fear to be a source of contagion for the others ( Ahorsu et al., 2020 ; Brooks et al., 2020 ; Taylor et al., 2020 ).

Concerning convergent validity, the standardized factor loadings, and the values of AVE and CR were well above the threshold suggested by Hair et al. (2010) , indicating that the variances were more explained by each factor and all of the items of each factor were consistent for measuring the same latent construct.

Furthermore, data revealed significant associations of all CSSQ scales scores with all the SCL-90-R standardized scales scores as well as with the Global Severity Index. This revealed how the specific sources of stress we have identified, covering changes in Relationships and Academic Life, perceived Isolation and Fear of Contagion, could have significant negative effects on perceived psychophysical health conditions among students. These results suggested the meaningfulness to adopt the proposed instrument also to foster the development of early interventions supporting students’ adjustment and promoting their psychophysical health during and after the COVID-19 pandemic lockdown.

Concerning discriminant validity, the square root of AVE values were greater than the correlations coefficients between the factors, indicating that the three factors could extract more variance than the sharing among factors, so revealing a satisfactory discriminant validity. Moreover, intercorrelations between COVID-19 Student Stress Questionnaire scales (moderate in size) and correlations between the three scales and the Global Stress score (high in size) confirmed that the CSSQ assessed different but connected dimensions, so giving further support about the validity of the proposed tool to evaluate both perceived Global Stress and different sources of stress related to the COVID-19 pandemic. Therefore, both perceived levels of Global Stress and specific stressors should be carefully considered when defining interventions fostering students’ wellbeing during the current COVID-19 crisis.

Finally, the evaluation of mean inter-item correlation, Cronbach’s alpha and McDonald’s omega confirmed that the CSSQ had satisfactory internal consistency.

In conclusion, this study demonstrated that the COVID-19 Student Stress Questionnaire is a 7-item multidimensional scale with satisfactory psychometric properties. Moreover, it is a good instrument to be used in assessing and allaying perceived COVID-19-related stress among university students.

Implications for Clinical Practice

The study sought to address the growing concerns arising from the challenges that students around the world are facing due to the COVID-19 pandemic and from its potential negative effects on their psychophysical health conditions, by providing a brief, valid and meaningful tool, namely the COVID-19 Student Stress Questionnaire (CSSQ).

The CSSQ presented here is a brief multidimensional tool, conceived to be helpfully used by members from different areas within universities (e.g., human resources, health units, student affairs) to promote a deeper understanding of the nature of COVID-19-related stressors perceived by students, in order to define tailored policies and support interventions.

In line with this, the CSSQ could be useful to early identify those students in need of psychological support. Indeed, due to the perceived risk of contagion, the consequent modifications of all significant relationships in daily life may induce, among university students, loss of contact with formal and informal support networks and growing risk of isolation. Therefore, it becomes pivotal to make all the possible efforts to assure careful monitoring of their perceived levels of stress and psychological wellbeing.

Finally, the adoption of the CSSQ in the clinical practice can significantly help social and health practitioners, serving as a monitoring and evaluation tool to define more tailored evidence-based counseling interventions. Indeed, since tapping different stressors that could have been experienced due to the COVID-19 outbreak (i.e., stressors related to Relationships and Academic Life, Isolation, and Fear of Contagion), the adoption of this tool can help to underline those areas requiring more attention within counseling interventions and to assess the effectiveness of the interventions by evaluating potential changes over time.

Limitations and Future Research

Despite these strengthens, some limitations need to be underlined. Firstly, the administering of the questionnaire was online, potentially limiting the enrollment in the study of those without Internet access. However, since the target population of Italian university students (taking into account both the age and the provision of distance learning during the COVID-19 pandemic), we consider this limitation could have influenced our results to a little extent. Secondly, the participant pool comprised a self-selected sample of students enrolled only in one university (i.e., students enrolled in Philosophy, Modern Languages and Literature, and Psychology degree courses) with a majority being female (and therefore, tests for gender differences were not possible). Further investigation on bigger and more representative samples is needed to confirm the results provided by the present study (e.g., a nationally representative sample with more male participants). Thirdly, the study relies on participants’ self-reports, and, therefore, findings could be affected by the risk of social desirability bias. Future research could, hence, include a broader range of sources of data. Furthermore, future studies could also consider the meaningfulness to adopt newly developed COVID-19-related instruments (e.g., FCV-19S) to test concurrent validity. Indeed, at the time of study design and data collection, the Italian versions of these specific measurement tools were not available yet. Another limitation is the lack of available data for a more robust examination of reliability beyond internal consistency, such as test-retest. Consequently, future studies could be designed with the aim to also conduct test-retest analysis. Finally, cultural and social variables may have potentially influenced the construct of the questionnaire as well as it’s convergent and discriminant validity. Consequently, further applications of this instrument in other countries are needed to allow gaining further information about sources of stress influencing students’ wellbeing according to different countries worldwide.

Notwithstanding these limitations, this study provided researchers and practitioners with a brief, easily administered, valid and reliable measure to assess perceived stress among university students, so supporting efforts to understand the impact of this unique global crisis and develop tailored interventions fostering students’ wellbeing.

Data Availability Statement

Ethics statement.

The studies involving human participants were reviewed and approved by Ethical Committee of Psychological Research of the University of Naples Federico II. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

MCZ: study conception and design, interpretation of data, drafting of manuscript, critical revision. MFCDV: analysis and interpretation of data, and drafting of manuscript. FV: acquisition of data, analysis and interpretation of data, and drafting of manuscript. All authors read and approved the final manuscript.

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.

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Knowledge, perception, and attitude toward premarital screening among university students in Kurdistan region- Iraq.

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Background Premarital screening programs are essential for identifying and providing counseling to couples at risk of transmitting genetic diseases or sexually transmitted infections. Despite their importance, university students' awareness and knowledge of premarital screening programs remain inadequate. This study aimed to evaluate the knowledge, perceptions, and attitudes of university students in the Kurdistan Region of Iraq regarding premarital screening programs. Methods A cross-sectional survey involving 960 students was conducted from December 2023 to February 2024. The survey assessed participants' demographics, knowledge, perception, and attitudes toward PMSP using a structured questionnaire. Results Findings revealed that a significant portion of participants (39.4%) had poor knowledge of premarital screening programs, 35.9% had fair knowledge, and only 24.7% had good knowledge. Despite limited knowledge, there was strong support for premarital screening programs, with 83.1% agreeing on its importance and 78.8% recognizing the need for premarital awareness. Most participants (65.8%) believed premarital screening programs could reduce genetic diseases, and 65.6% thought it could lower sexually transmitted diseases' prevalence. Cultural acceptance of marrying relatives was notable, with 59.7% disagreeing with the preference for not marrying relatives. Married participants showed significantly higher knowledge and attitude scores compared to single participants. Gender differences were observed, with males having higher knowledge scores. There were no significant differences in perception and attitude scores based on gender or residential area. Conclusion The study underscores the need for enhanced educational campaigns to improve premarital screening programs awareness and positively influence attitudes, especially targeting cultural aspects like accepting relative marriages. Comprehensive education and fostering positive attitudes toward premarital screening programs are vital for their broader acceptance and implementation.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

The author(s) received no specific funding for this work.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Not Applicable

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

This study was conducted in accordance with the principles outlined in the Declaration of Helsinki. The research protocol was reviewed and approved by the faculty of Medicine in Koya University, Ethics Committee, 2145/7/2023.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Data Availability

The data is available

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