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Academic Stress and Mental Well-Being in College Students: Correlations, Affected Groups, and COVID-19

Affiliations.

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.
PMID: 35677139
PMCID: PMC9169886
DOI: 10.3389/fpsyg.2022.886344

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.

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

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SWEMWBS and PAS scores for all participants.

SWEMWBS and PAS scores according…

SWEMWBS and PAS scores according to gender (mean ± SEM). Different letters for…

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

SWEMWBS and PAS scores according to year in college (mean ± SEM). Different…

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Exploring the Link Between Academic Stress and Mental Health in College Students

College students have experienced unique challenges in adjusting to disruptions associated with the COVID-19 pandemic, such as displacement from the traditional university setting and the abrupt shift to remote learning. 1 Even before the pandemic, however, it was well-known that this population faces substantial stress related to the college experience, including the transition to independent living and changes in peer relationships. In addition, overwhelming academic demands represent a significant source of distress for many college students.

In a study published in Frontiers in Psychology , Barbayannis et al examined the relationship between perceived levels of academic stress and mental well-being among 843 college students (78.5% women; 66.4% White) in the United States. 2 Scores on the Perception of Academic Stress Scale (PAS) and the Short Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS) were significantly correlated (r=0.53; P <.001) and showed an association between worse academic stress and poor mental well-being in all students surveyed.

Based on SWEMWBS scores, nonbinary students demonstrated the highest levels of academic stress and worst mental health across the sample, while men showed the lowest academic stress levels and highest mental well-being. PAS scores revealed higher levels of both academic stress and COVID-related stress among women and nonbinary students compared to men.

Second-year college students demonstrated higher academic stress and worse psychological well-being compared to students in other years of study, which may be due in part to “this group taking advanced courses, managing heavier academic workloads, and exploring different majors,” the authors wrote.

According to study co-author Xue Ming, MD, PhD, professor of neurology at Rutgers New Jersey Medical School in Newark, the potential reasons for the observed impact of academic stress on college students’ mental health include “ranking systems, peer pressure, global competition in the job market, and parental and societal demands regarding grades,” among others. “Colleges are perceived by some as a competition stage and less of pure learning environment,” she said.

These findings align with those from other recent research, including a 2022 study showing that academic stress was a significant predictor of anxiety (β=0.247, t=5.462; P <.001) among college students in China. 3 Other studies have demonstrated links between various sources of stress and the risk for mental health disorders in college students.

In 2020, results of the World Health Organization World Mental Health Surveys International College Student Initiative showed a significant dose-response relationship between the degree of perceived stress in each of 6 life areas (health, finances, family relationships, romantic relationships, work and school relationships, and problems experienced by loved ones) and higher 12-month odds of at least 1 of 6 mental health disorders (major depressive disorder, generalized anxiety disorder, panic disorder, bipolar disorder, drug use disorder, and alcohol use disorder) in first-year college students (n=20,842) from 24 universities in 9 countries. 4

Additionally, estimates of population attributable risk proportions indicated that targeted stress prevention interventions may eliminate up to 80% of the prevalence of the disorders observed in the study. 4

“Awareness is paramount in implementing help for these students,” Dr Xue said. “For those at higher risk, individualized counseling and stress reduction strategies are needed.” Helpful strategies may include peer support groups and training in mindfulness skills. 5

Results of another study published in 2022 suggest that resources aimed at improving time management and self-regulation skills may reduce academic stress in college students , and findings from a 2018 study support the utility of a social-emotional program to improve psychological well-being in this population. 1,6

We interviewed clinical psychologist Jenny C. Yip, PsyD, ABPP, clinical assistant professor of psychiatry at the Keck School of Medicine of the University of Southern California and founder of the Renewed Freedom Center for the treatment of anxiety disorders, to learn more about the effects of academic stress on the mental health of college students and how clinicians, schools, and parents can best support these individuals.

What are believed to be the reasons why academic stress has such as significant impact on college students’ mental health, as found by Barbayannis et al and other researchers?

Dr Yip: Being a student has never been more difficult because of the increased demand for kids to be the most perfect that they can be. Many parents have the expectation that their kids will strive for perfection or will perform perfectly, and that’s just not realistic. Kids know that it’s much more difficult today to get into a university than it’s ever been. There’s more demand and less supply, and therefore, the competition is very anxiety-provoking. On top of that, a lot of kids go into freshman year feeling unprepared to be independent, which has a lot to do with how we’re parenting our children. With helicopter parenting, we’re not giving our children the same opportunities they had in the past to solve their own problems, to find their own solutions. Therefore, they don’t feel capable of doing that on their own when they enter college. Socially, our kids are also very underprepared to engage with others independently due to the dependence on digital devices to communicate.

What might be the reasons for the greater impact of this stress on nonbinary students and women in particular?

Dr Yip: We are living in a world today where everyone is adjusting to gender neutrality. Someone who is nonbinary will have a taller order of struggle to overcome. Women traditionally have had a glass ceiling. Research has demonstrated that teachers pay more attention to men than women. On top of that, young women who enter college also have the added concern of sexual harassment and assault on campus. For most female students, this is the first time they’re living in a co-ed environment without parental presence for more than just a week or 2 at summer camp. That presents new stressors for those who identify as women.

What are recommendations for mental health professionals to help reduce the impact of academic stress on the mental health of patients who are college students?

Dr Yip: As a mental health professional, I suggest helping the student adjust to independent living. Begin practicing assertive communication so that they can advocate for themselves and problem-solve for the challenges that will come up, whether it’s with their roommates, classmates, or professors. Too often kids today are not advocating for themselves. They’re responding passive-aggressively and avoiding uncomfortable situations. For mental health professionals, the number 1 priority is to help patients practice assertive communication skills to help them feel independent by having agency to speak up for themselves in a way that is conducive to problem solving.

What broader measures are needed to help minimize the effects of academic stress on college students?

Dr Yip: Number 1, parents and schools should start preparing college students for the demand and the transition to college before college even starts. I see a lot of high schools doing that now because of the high attrition rate of incoming freshmen. There are college campuses offering more mental health support than before, but we need to start much earlier than when a student becomes a freshman. Conversations need to be had even before a child starts elementary school. It’s a systemic adjustment. Mental health adjustments need to be incorporated in colleges, especially with incoming freshmen. It should be mandatory that each incoming student meets with a mental health professional on a regular, consistent basis to evaluate their emotional adjustment. It’s often required for a new college student to meet with a college counselor to be sure they’re taking the coursework that is conducive to them. Why is that not being done with each student’s mental health?

Jenny C. Yip, PsyD, ABPP is a clinical assistant professor of psychiatry at the Keck School of Medicine of the University of Southern California and founder of the Renewed Freedom Center. Resource http://www.renewedfreedomcenter.com

References:

von Keyserlingk L, Yamaguchi-Pedroza K, Arum R, Eccles JS. Stress of university students before and after campus closure in response to COVID-19 . J Community Psychol . 2022;50(1):285-301. doi:10.1002/jcop.22561
Barbayannis G, Bandari M, Zheng X, Baquerizo H, Pecor KW, Ming X. Academic stress and mental well-being in college students: correlations, affected groups, and COVID-19 . Front Psychol . 2022;13:886344. doi:10.3389/fpsyg.2022.886344
Yang Y, Yang P. Effect of college students’ academic stress on anxiety under the background of the normalization of COVID-19 pandemic: the mediating and moderating effects of psychological capital . Front Psychol . 2022;13:880179. doi:10.3389/fpsyg.2022.880179
Karyotaki E, Cuijpers P, Albor Y, et al. Sources of stress and their associations with mental disorders among college students: results of the World Health Organization World Mental Health Surveys International College Student Initiative . Front Psychol . 2020;11:1759. doi:10.3389/fpsyg.2020.01759
Smit B, Stavrulaki E. The efficacy of a mindfulness-based intervention for college students under extremely stressful conditions . 2021;12(12):3086-3100. doi:10.1007/s12671-021-01772-9
Stocker SL, Gallagher KM. Alleviating anxiety and altering appraisals: social-emotional learning in the college classroom. College Teaching . 2019;67(1):23-35. doi:10.1080/87567555.2018.1515722

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Published: 07 August 2024

Well-being among university students in the post-COVID-19 era: a cross-country survey

M. Bersia 1 ,
L. Charrier 1 ,
G. Zanaga 1 , 2 ,
T. Gaspar 3 ,
C. Moreno-Maldonado 4 ,
P. Grimaldi 1 , 2 ,
E. Koumantakis 1 , 2 ,
P. Dalmasso 1 &
R. I. Comoretto 1

Scientific Reports volume 14 , Article number: 18296 ( 2024 ) Cite this article

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University students have to handle crucial challenges for their future lives, such as succeeding in academic studies and finding attachment figures. These processes could potentially involve their well-being and mental health, with possible sociocultural differences based on the country of study. In order to explore such potential differences, a cross-sectional, multi-center survey was performed involving students from the University of Torino (Italy), Sevilla (Spain), and Lusòfona (Portugal). The survey, conducted from May to November 2023, investigated students’ demographic and educational details, socioeconomic status, social support, mental health, academic environment, perceived COVID-19 pandemic impact, and future plans. Demographic profiles showed a predominance of female participants and straight sexual orientation, followed by bisexuality. Italian students showed the lowest levels of mental well-being and the highest rates of mental problems (anxiety and depression) and suicidal risk across the three countries despite the relatively similar profiles of social support. The prevalence of the students’ confidence in their professional future is higher in Spain than in Italy and Portugal. This study provides a comprehensive examination of university students’ mental health and well-being in three Southern European countries, addressing the major mental health challenges among university students and offering valuable insights for public health purposes.

A repeated cross-sectional analysis assessing mental health conditions of adults as per student status during key periods of the COVID-19 epidemic in France

Mental health disorders among medical students during the COVID-19 pandemic in the area with no mandatory lockdown: a multicenter survey in Tanzania

Mental health prevalence and predictors among university students in nine countries during the COVID-19 pandemic: a cross-national study

Introduction.

The university years represent an intriguing life period with plenty of challenges, including academic issues, emotional delusions, and problems related to the transition between the end of adolescence and the beginning of adulthood 1 . The interplay of academic pressures, social dynamics, and developmental transitions provides a delicate balance in which mental vulnerabilities can easily thrive 2 , 3 , 4 . Furthermore, university experience can move the needle: indeed, college students are at higher risk of developing a mental condition compared to their non-college peers 5 , 6 . In particular, Beiter pinpointed three college-related individual concerns that may heighten mental risk: struggles with academic performance, intense pressure to succeed, and uncertainty about post-graduation life 7 . Furthermore, academic environments themselves, demanding high effort and commitment, could play a role in impairing the university experience 8 , 9 , 10 . All these elements could synergically stimulate the onset of both burnout and several mental conditions, such as anxiety, depression, and suicidality 8 , 9 , 10 , 11 . In this regard, a prevalence of about 30% % of depressive and anxiety symptoms among university students has been estimated 12 . In particular, the female gender, the pre-existing mental health conditions, and the lower socioeconomic status seem to be additional risk factors across multiple studies 13 , 14 , 15 . On the other hand, good social support can mitigate the above-mentioned risk factors for mental health, playing a crucial protective role as a source of motivation and promoting healthier lifestyles 16 . Further, the perceived social support could also represent a relevant individual background, capable of encouraging students’ resilience and having beneficial effects on academic performance 16 .

Beyond the well-known influential factors, the COVID-19 pandemic profoundly impacted students’ mental health worldwide in both the short- and long term. In the immediate phase after the COVID-19 pandemic eruption, the impairment was observed mainly in terms of difficulties concentrating, disruptions of sleep patterns, concerns about academic performance, and increased anxiety and depression 17 , 18 , 19 , 20 . Furthermore, several researchers assessed the impact of prolonged exposure to the pandemic on cognitive and affective processing among students, observing an increase in the prevalence and severity of conditions such as anxiety, depression, suicidality, chronic sleeping difficulties, appetite changes, and health-related anxiety 21 , 22 , 23 . More specifically, the pandemic could have contributed to impaired mental health also among college students through the implementation of distancing measures leading to distance learning modalities, social isolation, lack of access to traditional support services, and family financial difficulties 24 , 25 . Additionally, research suggests that female students and those residing in lower-quality housing during lockdowns displayed exacerbated declines in mental health 25 , 26 .

In May 2022, the WHO Director-General declared the global emergence related to the COVID-19 pandemic concluded 27 . However, the pandemic long-term consequences on youths’ mental health are still a relevant public concern, and they still deserve careful surveillance over time to address targeted mitigation policies. The still scarce literature on the topic mainly relies on data from national-level surveys, hampering the adoption of a transcultural approach 28 , 29 , 30 , 31 , 32 .

To our knowledge, literature still lacks studies assessing and comparing college students’ mental health and well-being across different environments in the delicate post-pandemic phase. In order to address these research gaps, the present study describes the main findings of an international project that explored university students' mental health and well-being in three universities in Italy, Spain, and Portugal. These Mediterranean countries share cultural and environmental similarities (e.g. dietary habits, natural environment, social bounds) 33 , 34 , 35 , despite the societal peculiarities (e.g. financial situation, physical activity habits) and the adoption of different pandemic-related measures potentially influencing mental health and well-being outcomes 36 , 37 , 38 , 39 . More specifically, the aim was to discern commonalities and differences in students’ characteristics and experiences across these countries through a comparative approach, trying to offer a more detailed understanding of well-being patterns among college students in the post-COVID-19 era.

Survey design

A cross-sectional and multi-center survey was conducted between May and November 2023 in three European universities, the University of Torino (Italy), Sevilla (Spain), and Lusòfona (Portugal).

Participants

Students were eligible for enrollment in the study if they were (1) between 18 and 35 years old and (2) attending a bachelor's or master’s degree program. Those who declined to provide informed consent were excluded from the study. All the eligible students (about 79,000 students in Italy, 60,000 in Spain, and 15,000 in Portugal) received an institutional email with a link to an anonymous online questionnaire. Students could agree to participate in the study by checking the box at the bottom of the personal data treatment information sheet on the first page of the online questionnaire. There was also a section explaining the study’s goals, clarifying that there was no obligation to complete the questionnaire and assuring confidentiality and anonymity of the collected data. Finally, the research team did not offer any incentives to increase recruitment nor played an active role in selecting and/or targeting specific subpopulations of students. Participation was entirely voluntary, with students having the option to opt-out at any stage. Informed consent was obtained from all subjects.

Ethical considerations

Data was collected anonymously, no personal identifiers were collected, and the IP address was not registered. Approval for this study has been obtained from the institutional ethics boards of the participating universities (Prot. no. 0059546 of 30 January 2023, for the University of Torino; approval no. 20/23 of 16 May 2023 obtained by the Comité de Ética en la Investigación de Sevilla; approval no. 9 of 8 March 2023 received by the Ethics and Deontology Commission For Scientific Research (CEDIC) for the Lusofona University). The study was conducted in accordance with the international guidelines and regulations and the Declaration of Helsinki.

Questionnaire

A multi-language online survey (i.e., in English, Italian, Spanish, and Portuguese) was implemented on the REDCap platform of the University of Torino 40 , 41 . Overall, we adopted standardized scales validated in English. When available, we used the validated versions of the scales in Italian, Spanish, and Portuguese; otherwise, the English scales underwent the forward–backward translation process. The specific process for each scale, with the relevant validation work, can be found in the Supplementary file, Table S1 . Respondents could choose the language in which they would fill out the questionnaire. The survey encompassed the following key components: demographic details (e.g., age, sex, sexual orientation), educational profile (course area, year of study, progress), socioeconomic status, social support, mental health and well-being, perceived COVID-19 impact, academic stress, and future perspectives information.

In particular, information related to sex at birth and sexual orientation was assessed following the GeniuSS Group guidelines 42 . Sexual orientation was asked as follows: ‘How do you identify yourself?’, adopting as possible answers: ‘straight’, ‘lesbian’, ‘gay’, ‘bisexual’, ‘queer’, ‘pansexual’, ‘asexual’, ‘unlabelled’, ‘questioning’, ‘other’.

Socioeconomic status (SES)

The students’ socioeconomic status was investigated using the MacArthur Scale of Subjective Social Status 43 . The scale visually represented a ladder in which steps were associated with numbers ranging from 1 (low perceived SES) to 10 (high perceived SES). Respondents were then asked to place themselves on the ladder compared to their peers. The personal financial situation was evaluated through one further question with four possible answers: ‘dependent on family’, ‘work’, ‘scholarship’, or ‘other’.

Social support

Social support was assessed using a well-known validated psychometric tool, the Multidimensional Scale of Perceived Social Support (MSPSS) 44 . The scale consists of 12 items exploring an individual's perceived social support distributed across three subscales: Family, Friends, and Significant Other Support. Individuals rated their agreement with each item on a 7-point Likert scale ranging from ’strongly disagree’ to ’strongly agree’. The scores for each subscale are added up and then divided by 4, while for the overall support, the sum score is divided by 12. Both the overall and subscales scores (ranging from 1 to 7) provide a measure of the individual’s perceived social support. Low, medium, and high social support are defined based on the overall score (i.e. 1–2.9, 3–5, and 5.1–7, respectively). An excellent internal consistency was found for the overall scale (α > 0.92), and the three subscales, consistently in the three countries.

Mental health

Mental health was evaluated using different validated tools based on the specific characteristics under investigation. Depression and anxiety were assessed through the Patient Health Questionnaire-2 (PHQ-2) 45 and the Generalized Anxiety Disorder-2 (GAD-2) 46 , respectively. These two brief self-report instruments derived from the longer Patient Health Questionnaire-9 (PHQ-9) 47 and the Generalized Anxiety Disorder-7 (GAD-7) 48 questionnaire, both commonly used tools in mental health assessments. Participants were asked to indicate the frequency of presentation of each symptom using a 4-point scale ranging from 0, ’not at all’, to 3, ‘nearly every day’. A total score ≥ 3 on the PHQ-2 assessment suggests the presence of anxiety symptoms, while a score ≥ 3 on the GAD-2 evaluation indicates the occurrence of depressive traits. The PHQ-2 and the GAD-2 scales showed good internal consistency (α = 0.80 and α = 0.85, respectively), consistently in the three countries.

Suicidal behaviors and ideation were evaluated with the Suicide Behaviors Questionnaire-Revised (SBQ-R) 49 . This self-report validated questionnaire includes four items inquiring about different aspects related to suicidal risk (suicidal ideation, past suicide attempts, and the likelihood of engaging in future suicidal behavior). SBQ-R can help identify individuals who may be at risk for suicidal behavior or who have a history of suicidal thoughts or attempts. Total scores (ranging from 3 to 18) have been categorized identifying groups with low (total score less than 7) and high risk (total score equal to or higher than 7) of suicidal behavior 49 . A good internal consistency was found in our sample (α = 0.82), independently by country. Before the SBQ-R questionnaire, participants were warned of questions about a particularly sensitive topic, and the section was optional.

Well-being was investigated through the Mental Health Continuum-Short Form (MHC-SF) 50 . The self-report validated scale consists of 14 items measuring the degree of several aspects of well-being: (a) Overall well-being (items 1–14); (b) Emotional well-being (items 1–3), defined in terms of positive affect and satisfaction with life; (c) Social well-being (items 4–8), as described in Keyes’ model of social well-being 51 ; and (d) Psychological well-being (items 9–14). The MHC–SF asks individuals how frequently they felt in a specific aptitude, from 0 (none of the time) to 5 (all of the time): the higher the overall score, the higher the level of well-being. In our sample, an excellent internal consistency (α > 0.90) was found referring to Overall and Emotional well-being, while a good internal consistency was shown for both Social, and Psychological well-being (α = 0.82, and α = 0.87, respectively), consistently in the three countries.

Perceived COVID-19 impact

A 10 items scale from the 2021/2022 Health Behavior in School-Aged Children was used to evaluate the subjective impact of COVID-19-related measures on various aspects of individuals’ lives: life in general, overall and mental health, relationships with family and friends, school performance, physical activity, eating behaviors, future expectations, financial situation 52 . Respondents were asked to assess the extent of the impact by selecting one of the following options on a five-point Likert scale: 1 = ‘’very negative’, 2 = ’somewhat negative’, 3 = ’neither positive nor negative’, 4 = somewhat positive’, or 5 = ’very positive’. Collapsing some response options, a three-level variable was obtained for each item, identifying negative (options 1 and 2), neutral (option 3), and positive (options 4 and 5) COVID-19 impact groups 53 .

Academic stress

The Academic stress was evaluated using the Effort-Reward Imbalance—Student Questionnaire (ERI-SQ) 54 , a self-reported validated questionnaire based on the Effort-Reward Imbalance (ERI) theoretical framework 55 . The tool includes three subscales: the Effort (from items 1 to 3), the Reward (from items 4 to 9), and the Overcommitment dimensions (from items 10 to 14). The Effort score identifies the intensity and amount of effort an individual perceives in academic activities. It is calculated based on participants' responses to items regarding the study load, time pressure, and interruptions in doing the academic tasks. The Reward score reflects the perceived level of rewards gained in exchange for the efforts made. Rewards encompass social recognition, career advancement, job security, or other positive outcomes associated with academic accomplishments. In addition, the ERI-SQ incorporates a measure of Overcommitment, which denotes a personality trait characterized by an excessive dedication to work or academic tasks, regardless of the balance between effort and reward. From the previous measures, the Effort-Reward Imbalance (ERI) ratio is computed by dividing the Effort score by the Reward score multiplied by a correction factor 54 , 56 . The ERI ratio suggests a possible imbalance between the effort and the reward. For ERI ratio equal to 1, the student reports equal levels of effort and reward, an ERI ratio < 1 indicates less effort than rewards, while an ERI ratio > 1 indicates that the perceived effort is greater than the rewards, suggesting a greater likelihood of negative health outcomes due to stressors in the academic environment. Similarly, a high overcommitment score implies a propensity to invest excessive effort, even when the corresponding rewards are perceived as inadequate. The 14-item scale showed good internal consistency (overall α = 0.83), in contrast, independently by country, lower internal consistency levels were registered for Effort, Reward, and Overcommitment scales (α = 0.66, α = 0.69, and α = 0.80, respectively).

Future perspectives

Some further questions were asked about students’ future professional perspectives: (1) Plans for the future after completing higher education (the possible answers were pursuing further studies (post-graduate, master's, or Ph.D.), getting a job, working in another country, starting a business, or not having a specific plan); (2) Professional future: two questions with response options ranging from 1 (‘strongly disagree’) to 5 (‘strongly agree’) were provided to explore the readiness to manage and build the professional future after completing higher education and confidence in professional future. Dichotomized variables were then created based on high (options 4 or 5) or medium/low (equal or lower than 3) agreement. Furthermore, one further question exploring overall future expectations was provided. In this regard, subjects were asked to rate their expectations for the future on a scale from 0 to 10, where 0 represents poor expectations and 10 excellent ones. This assessment reflects general optimism or pessimism about prospects.

Data analysis

Demographic information and psychometric measures were described with absolute frequencies and percentages for categorical variables and medians and interquartile ranges (IQRs) for continuous ones. Data was stratified by country, and the rate of missing values for each aforementioned variable was reported. Afterward, further stratification by sex was performed within each country, and d fferences by sex were tested with a chi-square test for categorical variables and a Wilcoxon test for continuous ones. All statistical tests were two-sided, and the level of statistical significance was set at 0.05. Data were analyzed using the R software version 4.3.0 57 . Radar plots were generated to visually represent specific results by country, using Flourish 58 , a data visualization platform, and InkScape 59 , a vector graphics editor, to enhance their quality and clarity.

Demographic and Educational profile of participants

Our sample comprised 8773 students in Italy, 612 in Spain, and 396 in Portugal. The response rates in the three universities were 11.1% (Italy), 2.6% (Portugal), and 1.0% (Spain). We then excluded all participants who waived informed consent (n = 90), those older than 35 (n = 1308) or younger than 18 (n = 3), and those with missing information about sex (n = 72) obtaining a final overall sample of 8380 students (7559 students in Italy, 469 in Spain, and 352 in Portugal).

Table 1 shows the demographic and educational characteristics of the sample. The median age of respondents was homogeneous in the three countries. The majority of the sample was composed of females (more than 65% in the three countries) and declared a straight sexual orientation (> 70%). The main reported non-straight sexual orientation was bisexual, declared by 8–20% of the participants across countries (Most respondents attended a program concerning “Humanities and Philosophy” and “Social and Economic Sciences” areas, although over 12% of participants did not provide such information. Most students were in the first three years of college in the three countries (71% in Italy, 62% in Spain, and 88% in Portugal). Less than 50% of students in Italy and Spain declared themselves on track (44% and 46%, respectively), compared to 73% of Portuguese students.

Socioeconomic status and social support

The MacArthur Scale registered slightly higher levels of Subjective Social Status in Italy (median score: 7.0; IQR: 5.0–7.0) than in Spain and Portugal (median score: 6.0; IQR: 5.0–7.0 in both countries). Participants declared that they mainly depend on their families for financial support (> 75%), with variations in rates of work and scholarships across the countries. Notably, fewer respondents in Italy and Portugal (11% and 16%, respectively) relied on scholarships compared to the Spanish sample (29%), while an inverse trend was found regarding rates of work (i.e., lower in Spain than in Italy and Portugal) (Fig. 1 , Table 2 , and Table S2 , Supplementary file).

Financial situation among university students in Italy, Spain, and Portugal. Radar plots with percentages of financial situation are presented across the three countries.

The social support profiles emerging from the MSPSS showed similar perceived support levels on the three subscales among the three countries. Significant other subscales represented the primary source of support (median scores of at least 6.0 across the three countries). Overall, most respondents reported high social support (> 60%), mainly from Significant other and Friends, without relevant cross-country differences. Some sex differences were found within countries concerning social support (Table S3 , Supplementary file). More specifically, females declared higher Friends and Significant others support scores in Italy and Spain than their male peers (p < 0.001). In Portugal, males declared higher scores of Family support than females (p = 0.007). Patterns are globally confirmed adopting the categorized variables.

Mental health and well-being

In Italy and Spain, about two out of three respondents showed a high GAD-2 score (67% and 64%, respectively), while in Portugal, this anxious trait was presented by 50% of the sample (Table 3 , Fig. 2 ). However, the percentages of high depressive scores on the PHQ-2 were below 50% in all countries (44% in Italy, 44% in Spain, and 34% in Portugal). While students in Italy and Spain exhibited a higher frequency of both anxious and depressive symptoms compared to the Portuguese sample, a quite homogeneous picture emerged exploring SBQ-R scores. More specifically, 30%, 26%, and 29% of respondents were classified in the high suicidal risk group in Italy, Spain, and Portugal, respectively. Concerning the MHC-SF questionnaire, Italian respondents exhibited lower overall scores (median score: 30.0; IQR: 21.0–40.0) than Spanish and Portuguese ones (median scores: 41.0 (IQR: 29.0–51.0) and 39.0 (IQR: 29.0–48.0), respectively) indicating lower mental well-being among Italian participants compared to the others. This pattern is consistent across the three domains of the MHC-SF questionnaire.

Radar plots showing rates of mental problems and confidence levels in the professional future among university students in Italy, Spain, and Portugal. Radar plots with percentages of anxiety symptoms (GAD-2), depressive symptoms (PHQ-2), suicidal risk (SBQ-R), and confidence in professional future are presented across the three countries.

In terms of sex differences across the mental domains, Italian and Portuguese females presented higher scores in both the GAD-2 (p < 0.001 in both countries) and the PHQ-2 scales (p = 0.011 and p = 0.023, respectively), while no substantial patterns were found regarding SBQ-R. In the three countries, lower levels of well–being could be observed in girls than in boys in all domains of the MHC-SF questionnaire, with significant differences between the two sexes in Italy and Portugal for the overall score and social and psychological domains (Table S3 , Supplementary file).

Perceived impact of the COVID-19 pandemic

Results about the perceived impact of the COVID-19 pandemic are shown in Fig. 3 and Table S4 (Supplementary file). University students were more likely to report a negative than a positive pandemic impact on several life domains (i.e., life as a whole, overall and mental health, physical activity, eating behaviors, family financial situation, and future expectations), especially in Italy. In particular, half of Italian students (50.2%) reported a negative impact of the pandemic on their mental health compared to 40.3% and 37.8% of Spanish and Portuguese ones. Conversely, the COVID-19 pandemic’s influence on relationships with family and friends and school performance seemed to have been perceived more positively than negatively. A missing rate of 16% was observed consistently throughout the items.

Prevalence of positive (in blue) and negative (in red) perceived COVID-19 impact on several life domains among university students in Italy, Spain, and Portugal. Radar plots with percentages of perceived COVID-19 pandemic impact on students’ overall health, life in general, family relationships, friends’ relationships, mental health, school performance, physical activity, eating behaviors, future perspectives, and financial situation are presented across the three countries.

Academic stress and future perspectives

The ERI-SQ scoring revealed a homogeneous pattern in perceived overcommitment levels and the ERI ratio across countries (Table 4 ). In all countries, the median ERI ratio was slightly greater than 1, indicating that 6–13% of the effort was not met by the received rewards. In all countries, females seemed to have a significantly higher ERI ratio than males (Table S3 , Supplementary file).

The expectations for the future were similar in the analyzed universities (median score: 7.0; IQR: 5.0–8.0), while perspectives after graduation showed a higher variability across countries (Table 4 ). More specifically, in Italy, most students declared their intention to find a job after graduation (35%), while in Spain and Portugal, most planned to continue their studies (46% and 40%, respectively). Overall, a decreasing prevalence of participant students declaring confidence in their own professional future was found in Spain, Italy, and Portugal (47%. 34%, and 20%, respectively). Furthermore, Italian and Spanish students felt more prepared for work than Portuguese ones (35% and 29% vs. 19%, respectively).

The present cross-country project primarily aimed to identify common and specific mental health and well-being traits among university students in Italy, Spain, and Portugal.

Respondents were primarily females with a median age of 21, currently attending the first three academic years. About three out of four students declared a straight sexual orientation, while bisexuality represented the second most common sexual orientation, ranging from 8% in Italy to 20% in Spain. The high levels of bisexuality compared to the previous studies (up to 10%) could be the result of undergoing changes in sexual norms and behaviors, leading to even more youths identifying as bisexual 60 , 61 . Italian students presented higher median socioeconomic status than Portuguese and Spanish ones, reflecting the different economic wealth situations observed by the World Bank in such countries 38 , 39 . Conversely, quite similar patterns in social support were registered across universities, confirming the expected cultural similarities in social bonds in these three Mediterranean countries 35 , 62 , 63 . Overall, students declared a relatively higher support from Friends and Significant other than Family, underlying their developmental transition from adolescent to young adult supportive networks 64 , 65 , 66 .

The PHQ-2 and GAD-2 assessments showed high levels of anxiety (> 50%) and depressive symptoms (> 30%) among students in the three countries, being exacerbated among females than males. Furthermore, these first insights suggest higher levels of such mental problems among Italian and Spanish students than Portuguese ones. The disparities in emotional, social, and psychological well-being captured by MHC-SF are also noteworthy, with Italian students reporting lower scores than their counterparts in Spain and Portugal.

These results suggested different cross-country trends based on the indicators explored, enforcing the validity of conceptualizing mental health as a multidimensional construct in which the various dimensions can have different correlated patterns 51 , 67 , 68 , 69 , 70 . More specifically, the present study found that Italian students showed the lowest levels of well-being and the highest rates of mental problems across the three countries. These findings align with those reported by recent works on nationally representative samples of adolescents in the same countries, suggesting shared underlying causes at a macro-level, even among contiguous age groups (adolescents and young adults) 36 , 71 . Several factors could be involved in the observed pattern, including pandemic-related measures duration and strictness, as confirmed by the higher levels of negative perceived impact of COVID-19 on mental health in Italy, observed in the present and other studies 36 , 71 . Moreover, cross-country differences in physical activity could have had a contributing role 37 . In particular, the high negative impact of pandemic-related measures on students’ physical activity in Italy could have exacerbated the pre-pandemic cross-cultural exercise differences 37 .

Furthermore, the observed cross-country pattern of mental problems in the university environment may also be attributed to the significant social and academic pressures that Italian university students experience 10 , 72 . Our analysis revealed a lower percentage of scholarship recipients and higher rates of working students in Italy than in the other explored countries. These elements suggest differences in university study support policies across countries, reflecting the different financial frameworks, which also have consequences for the well-being of university students 73 .

Among the mental health issues explored in this survey, results about suicidality deserve to be discussed separately, in light of the latest evidence on this sensitive topic.

Approximately one-third of students within the three countries exhibited characteristics placing them in the “high risk” category in the SBQ-R assessment, with substantially geographically homogeneous patterns across countries. Such prevalence is higher than that emerged from other surveys conducted before the COVID-19 pandemic 74 , 75 , 76 , in line with data collected during 2020 77 , and slightly lower than levels registered in 2021 77 . In particular, literature exploring long-term temporal trends of suicidality suggested an increase in the phenomenon since 2021, which was attributed to the impact of COVID-19 on students’ lives 21 , 78 , 79 , 80 . Furthermore, in our sample, high rates of negative perceived impact of the COVID-19 pandemic on mental health were observed across the three countries, enforcing such possible association. From this perspective, the long-term consequences of COVID-19 pandemic-related measures on youths’ mental health could have left prolonged traces, still detectable in 2023, during the so-called post-COVID-19 era. In this regard, literature is still lacking, and further exploration of the topic is needed to increase the knowledge of the phenomenon and to guide the policy agenda promoting youths’ mental health 81 , 82 .

COVID-19 perceived impact assessment showed a relatively homogeneous picture among students across countries. Specifically, pandemic-related measures seemed to have negatively impacted several domains (i.e., mental health, physical activity, future perspectives, and financial situation). Still, a prevailing positive impact was perceived regarding relationships with family, friends, and school performance. Overall, our findings are consistent with other studies adopting the same measurement tool on nationally representative samples of adolescents in the three countries, enlightening shared environmental exposures across age groups 53 , 83 . More specifically, results referring to the pandemic impact on family relationships are consistent with the findings by other authors, who observed tighter family bonds after the lockdown establishment 17 , 25 , 84 , 85 , 86 , 87 , 88 .

The academic stress assessment pointed out similar trends among countries: the median ERI ratio was higher than one among students regardless of the country, indicating perceived rewards lower than expected, especially among girls. These findings align with results from previous works that showed unbalanced ERI ratios toward effort among university students 10 , 54 .

Finally, a quite heterogeneous geographical pattern was found regarding future professional perspectives: 20–30% of students in our sample felt prepared for work, and confidence in the professional future showed a decreasing pattern from Spain to Italy and Portugal. This presumably reflects the cross-country economic wealth differences and the widespread uncertainty about the future among youths 38 , 39 , 89 , 90 .

Limitations and strengths

The observed findings should be interpreted cautiously due to several limitations of the study. While our sample included over 8000 students, it only represented a small percentage of the target population (approximately 150,000 students in the academic year 2022–2023). This issue could potentially hinder the generalizability of our findings. Additionally, most students responded in Italy, resulting in an unbalanced sample and few participants in Spain and Portugal. These methodological issues could lead to analytical constraints regarding statistical comparisons between countries, making it possible to analyze differences only within each country. The unbalanced sample and the low sample size in 2 out of 3 countries also limited the exploration of the factors associated with well-being in a cross-country framework. Furthermore, the self-reported nature of the data and the cross-sectional design of the study also represented additional weaknesses.

Despite these limitations, the present work is one of the first cross-country surveys exploring academic stress, mental health, and well-being among university students in the post-COVID-19 era. This international research stands out for its rigorous methodology, using validated tools and a consistent protocol to assess the well-being of university students in Italy, Spain, and Portugal. The comparative approach adopted across countries allowed us to explore the complexities of three Southern European countries sharing cultural similarities and to study their influence on university students' well-being. In particular, we found cross-university patterns consistent with the existing studies on the topic despite a high level of heterogeneity recognized in the literature in psychometric instruments and target student populations. Finally, using validated tools like PHQ-2, GAD-2, SBQ-R, and MHC-SF allowed us to simultaneously capture different mental health and well-being dimensions among university students, providing a more comprehensive and holistic framework.

Conclusions

This cross-sectional survey explores the well-being levels and mental health patterns in three Southern European countries in the post-COVID-19 phase in light of their cultural similarities and peculiarities.

Overall, Italian students showed the lowest levels of mental well-being and the highest rates of mental problems (i.e., anxiety and depression) and suicidal risk across the three countries despite the relatively similar profiles of social support. The prevalence of the students’ confidence in their professional future is higher in Spain than in Italy and Portugal. The emerging picture offers valuable insights into this public health topic and paves the way for further exploration of the relationships between students' environmental factors (e.g., social support and academic stress) and various aspects of their well-being.

Data availability

Data is available from the corresponding author upon reasonable request.

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Acknowledgements

We would like to thank the students who participated in the study and the university staff who assisted us in sending the links for participation.

The present study was funded by the University of Torino (COMR_GFI_22_01_F, COMR_RILO_23_01_F, COMR_RILO_24_01).

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PD and RIC designed the research. MB, RIC, TG, CMM, EK conducted the research. MB, GZ and RIC analyzed data. MB, LC, TG, CMM, PG, EK, RIC interpreted the results. MB, GZ, PG mainly wrote the manuscript. PD and RIC supervised the research team. All of the authors read and approved the final manuscript.

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Bersia, M., Charrier, L., Zanaga, G. et al. Well-being among university students in the post-COVID-19 era: a cross-country survey. Sci Rep 14 , 18296 (2024). https://doi.org/10.1038/s41598-024-69141-9

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ORIGINAL RESEARCH article

Perceived academic stress and depression: the mediation role of mobile phone addiction and sleep quality.

$\nXin Zhang&#x;$

1 Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, Harbin, China
2 Institute of Food Safety and School Health, Heilongjiang Center for Disease Control and Prevention, Harbin, China
3 Department of Educational Administration, Ningbo College of Health Sciences, Ningbo, China
4 Department of Elderly Healthcare and Management, School of Health Services and Management, Ningbo College of Health Sciences, Ningbo, China

Background: Although academic stress is a well-known risk factor for students' depression, little is known about the possible psychological mechanisms underlying this association. In this study, we investigated the prevalence of depression and sleep disturbance among Chinese students, examined the relationship between perceived academic stress and depression, considered if mobile phone addiction and sleep quality is a mediator of this relationship, and tested if mobile phone addiction and sleep quality together play a serial mediating role in the influence of perceived academic stress on depression.

Method: A cross-sectional survey was conducted among students from September to December 2018 in Heilongjiang Province, China. The final analysis included 5,109 students. Mobile phone addiction, sleep quality, and depressive symptoms were assessed using the Mobile Phone Addiction Index, Pittsburgh Sleep Quality Index, and Center for Epidemiologic Studies-Depression scales, respectively. The serial mediation model was used to analyse the relationship between perceived academic stress, mobile phone addiction, sleep quality, and depression.

Results: Among all participants, the prevalence of depressive symptoms and sleep disturbance was 28.69 and 27.95%, respectively. High school students showed the highest scores of perceived academic stress (2.68 ± 1.06), and the highest prevalence of depressive symptoms (33.14%) and sleep disturbance (36.47%). The serial mediation model indicated that perceived academic stress was a significant predictor of depression (B = 0.10, SE = 0.02, 95% CI = 0.06 – 0.13). Additionally, mobile phone addiction (B = 0.08, 95% boot CI = 0.06–0.11) and sleep quality (B = 0.27, 95% boot CI = 0.22–0.33) played a mediating role between perceived academic stress and depression. Mobile phone addiction and sleep quality together played a serial mediating role in the influence of perceived academic stress on depression (B = 0.11, 95% boot CI = 0.08–0.14). Furthermore, the indirect effect (i.e., the mediating effect of mobile phone addiction and sleep quality) was significant and accounted for 64.01% of the total effect.

Conclusions: Our research results underscore the need for stakeholders—including family members, educators, and policy makers—to take preventative intervention measures to address depression among Chinese students, especially high school students.

- Perceived academic stress significantly predicts depression.

- Sleep quality mediates perceived academic stress and depression.

- Mobile phone addiction mediates perceived academic stress and depression.

- Mobile phone addiction and sleep quality together play a serially mediating role in the influence of PAS on depression.

Introduction

Depression (major depressive disorder) is a widespread chronic medical illness that can influence mood, thoughts, and physical health ( 1 ), and is a severe problem faced by students worldwide. A meta-analysis that included 183 studies from 43 countries shows that the overall pooled crude prevalence of depression was 27.2% among medical students ( 2 ). Previous studies demonstrated that the prevalence of depression was 51.3, 38.3, 28.4, and 30.6% among Indian students ( 3 ), Japanese adolescents ( 4 ), Chinese university students ( 5 ), and Cameroon medical students ( 6 ), respectively. It is important to evaluate the prevalence of depressive symptoms and explore the effect mechanism of depressive symptoms to protect students from the harmful effects of depression. Studies related to students' depressive symptoms often focus on a particular group of students, such as medical ( 2 ), college ( 7 ), and university students ( 8 ), and scant research exists about depressive symptoms among students at different levels of education. Many risk factors have been associated with depression, including being female ( 9 , 10 ), life stressors ( 9 , 10 ), physical and mental factors, social media addiction ( 11 ), and parental factors, including parental psychopathology and parenting attachment ( 12 ). Stress has been shown to be one of the most important risk factors of depression, and numerous studies have demonstrated that stress plays an important role in the emergence of depression ( 13 – 15 ). For example, Torres-Berrío et al. supposed that depression is caused by a combination of genetic predisposition and life events ( 16 ). Stress often leads to adverse consequences—such as depression and anxiety ( 17 – 19 ), mobile phone addiction (MPA) ( 20 , 21 ), poor sleep quality (PSQ) ( 22 , 23 ), changes in legal drug consumption ( 24 ), cardiovascular disease ( 25 ), and worsens the outcomes of many medical illnesses ( 26 ), potentially even leading to suicide ( 27 , 28 ). Additionally, various physical and mental factors influence the prevalence of depressive symptoms, such as PSQ ( 29 ), bodily pain ( 30 ), and poor cognitive and physical functioning ( 31 ). Scholars have noted that there is a remarkable association between alterations in sleep patterns and depression ( 32 ). Furthermore, in the internet age, studies show that individuals who experience depressive symptoms often suffer from social media addictions, such as Facebook ( 33 , 34 ), mobile phone ( 35 ), and internet addictions ( 8 ). For instance, Ivanova found that MPA was positively related to both depression and loneliness in Ukrainian students ( 36 ).

In China, the school environment and parental practices contribute to the extraordinarily high expectations of students' academic performance ( 37 ). Chinese students experience high levels of academic stress throughout their academic careers, including numerous, intense examinations—such as end-of-term tests and the standardized senior high school and university entrance examinations—and a heavy homework burden ( 37 ). Scholars have demonstrated that Chinese students experience sleep deprivation owing to this culture of academic achievement. A study of 9,392 Chinese students in primary education through university levels showed that 35.6% of participants slept <7 h a day ( 38 ). In addition to the threat of academic stress and sleep deprivation, MPA is a risk factor affecting Chinese students' physical and mental health. Mobile phones have become an integral part of students' quotidian lives—Meng's survey from December 2016 to January 2017 found that 100% of the college students had mobile phones ( 39 )—and the prevalence of problematic mobile phone use has been found to be 28.2% among Chinese college students ( 40 ). Our study explored the correlations between perceived academic stress (PAS), MPA, sleep quality, and depression among Chinese students in middle school through college levels. Based on previous literature, our study proposed research hypotheses, and tested hypothesis by using survey data on Chinese students. To our knowledge, this was the first study to investigate relations between these variables among Chinese students by using the serial mediation model.

Literature Review and Research Hypotheses

Academic stress.

Academic concerns are the most important sources of chronic and sporadic stress for young people in both Western and Asian countries ( 41 ). Academic stress is defined as a student's psychological state resulting from continuous social and self-imposed pressure in a school environment that depletes the student's psychological reserves ( 42 , 43 ). Students experience academic stress throughout their secondary school ( 41 ), high school ( 44 ), and university ( 45 , 46 ), educational careers. Studies have shown that academic stress has been positively associated with depression ( 41 ), PSQ ( 24 , 47 ), and MPA ( 48 ) among students. Jayanthi observed that, compared to adolescents who do not experience academic stress, adolescents who experienced academic stress were 2.4 times more likely to have depressive symptoms ( 41 ). Other studies have found that there is a relationship between high academic stress and PSQ ( 47 , 49 ). However, scholars have not adequately addressed the adverse consequences (e.g., depression, PSQ, and MPA) of Chinese students' academic stress. Hence, we propose the following hypotheses:

H1 : PAS is positively associated with depression.

H2 : PAS is positively associated with MPA.

H3 : PAS is positively associated with PSQ.

MPA is one of the most common behavioral (i.e., non-drug) addictions ( 48 ), and is accompanied by negative effects, such as PSQ ( 50 ), depression ( 35 ), and impaired academic performance ( 51 ). The positive relationship between MPA and PSQ has been proved in previous studies, including a longitudinal study conducted among Korean adolescents ( 52 ) and a one-year prospective study among Chinese college students ( 50 ). Zhang found that among Chinese university students, there is a significant positive relationship between smartphone addiction and bedtime procrastination, which is one of the indicators of PSQ ( 53 ). Hence, we propose the following hypothesis:

H4 : MPA is positively associated with PSQ.

Similarly, the positive relationship between MPA and depression has been proved in previous studies, including a cross-sectional study conducted among Saudi university students ( 35 ), a cross-sectional study among Ukrainian college students ( 36 ), and a systematic review of relations between problematic smartphone use, anxiety and depression psychopathology ( 54 ). Furthermore, another study based on three cohorts of Korean children and adolescents confirmed the bidirectional relationship between MPA and depression ( 55 ). Hence, we propose the following hypothesis:

H5 : MPA is positively associated with depression.

Researchers have documented that stress is associated with MPA, and that MPA is associated with depression. For example, according to Wan et al., smartphone addictions are significantly positively associated with both depression and stress among Malaysian public university students ( 56 ). However, it is unclear if MPA mediates the relationship between PAS and depression. Hence, we propose the following hypothesis:

H6 : MPA mediates the relationship between PAS and depression.

Sleep Quality

Sleep disturbance has complex associations with depression (major depressive disorder) ( 31 ), and is a common physical symptom of depression. Numerous studies have confirmed the remarkable association between PSQ and depression ( 29 , 57 , 58 ). For example, Okun et al. found that PSQ is positively related to depression symptoms in postpartum women ( 29 ). Hence, we propose the following hypothesis:

H7 : PSQ is positively associated with depression.

Scholars have also demonstrated that there are relationships between stress, PSQ, and depression. A prospective birth cohort study showed that PSQ is associated with stress and depression symptoms among Chinese pregnant women ( 58 ). Zhang et al. found that perceived stress is associated with sleep quality and depressive symptoms among Chinese nursing students ( 59 ). However, it has not been documented if sleep quality mediates the relationship between PAS and depression among Chinese students. Hence, we propose the following hypothesis:

H8: Sleep quality mediates the relationship between PAS and depression.

Mobile Phone Addiction and Sleep Quality and the Relationship Between Perceived Academic Stress and Depression

Scholars have posited that there are significant associations between MPA, depression levels, and sleep quality. Demirci found that there were positive correlations between MPA, depression levels, and sleep quality ( 60 ). The results of Kaya's multivariate regression analysis showed a relationship between smartphone usage, PSQ, and depression in university students ( 57 ). A recent meta-analysis also found that there are positive correlations between MPA, depression, and sleep quality ( 61 ). Another literature review and case study found that depressive symptoms are associated with screen time-induced poor sleep, digital device night use, and mobile phone dependency ( 62 ). Although these studies explored the correlations between MPA, sleep quality, and depression among students, several scholars have added academic stress into the relationship—for example, a review found that sleep disturbance, anxiety, stress, and depression have been associated with problematic mobile phone use ( 63 ). There still exist gaps in the literature on how PAS influences depression. First, few scholars have focused on PAS, MPA, sleep quality, and depression among Chinese students. Second, the underlying mediating mechanisms that account for this association have been disregarded partly. Based on H6 and H8, it remains unclear if MPA and sleep quality serially mediate the relationship between PAS and depression. Therefore, we propose the following hypothesis:

H9: MPA and sleep quality serially mediate the relationship between PAS and depression.

Study Objectives

In this study, our primary aim was to investigate the prevalence of depression and sleep disturbance among Chinese students. Our secondary aim was to test if there were relationships between PAS, MPA, sleep quality, and depression. First, we tested if there was a relationship between PAS and depression among Chinese students (H1: PAS is positively associated with depression). Second, we tested if MPA was a mediator of the relationship between PAS and depression (H2: PAS is positively associated with MPA, H5: MPA is positively associated with depression, and H6: MPA mediates the relationship between PAS and depression). Third, we tested if sleep quality was a mediator of the relationship between PAS and MPA (H3: PAS is positively associated with PSQ, H7: PSQ is positively associated with depression, and H8: Sleep quality mediates the relationship between PAS and depression). Finally, we also tested if MPA and sleep quality together played a serial mediating role in the influence of PAS on depression (H4: MPA is positively associated with PSQ and H9: MPA and sleep quality serially mediate the relationship between PAS and depression).

Data were collected from a cross-sectional questionnaire survey that was conducted from September to December 2018 in Heilongjiang Province, China, by the Heilongjiang Center for Disease Control and Prevention. A multistage cluster sampling method was used. In the first stage, three cities of Heilongjiang province were randomly selected by economic characteristics. In the second stage, one urban district and one rural township were chosen at random. In the third stage, two middle schools were randomly selected in each urban district and rural township; Since nine-year compulsory education was implemented in China, high school education is not included in the nine-year compulsory education, high schools are more in urban districts than in rural townships, two high schools and one high school were randomly selected in urban district and rural township, respectively; Since vocational high schools and universities are scarce in rural townships, one vocational high school and one college were randomly selected from the urban district. In the fourth stage, two classes were randomly selected from each grade of middle school, high school, vocational high school, and from grades 1, 2, and 3 in college. Since senior students may have been looking for a job or working as an intern, some of them were not on campus, they were not been investigated. Finally, four middle schools, three high schools, one vocational high school, and one college were randomly selected within each city (Harbin, Jiamusi, and Jixi) of Heilongjiang Province. Data were collected through a self-administered questionnaire distributed in class. Students completed the survey within 1 h, while a well-trained member of the research group supervised. All the students were informed of the purpose of the study and assured that their identities would remain confidential. Students and their parents provided written informed assent to participate in the study.

Participants

Finally, we recruited 6,480 students in our investigation; 6,430 (99.23%) valid questionnaires were analyzed after excluding those with incomplete information. Participants were included in the sample if they had one constant internet-accessible mobile phone, which is similar with previous studies ( 64 – 68 ). A total of 5,109 (79.46%) participants reported having one constant internet-accessible mobile phone at the time of the survey. The final sample comprised 1,904 middle school students from grades 1, 2, and 3, respectively; 1,859 high school students from grades 1, 2, and 3, respectively; 660 vocational high school students from grades 1, 2, and 3, respectively; and 686 college students from grades 1, 2 and 3, respectively. Of these participants, there were 2,422 (47.41%) boys and 2,687 (52.59%) girls; on average, the mean age of participants was 15.53 years, with a standard deviation of 2.22, ranging from 11 to 25 years. Approval was obtained from the Medical Research Ethics Committee of Harbin Medical University and the principals of the participating schools.

Perceived Academic Stress

Consistent with previous studies ( 69 – 71 ), PAS was measured using one self-report item “How much academic stress did you feel in the study during the past month?” using a 5-point Likert scale where 1 = “No,” 2 = “relatively low,” 3 = “average/general,” 4 =“relatively high” and 5 = “extremely heavy,” with a higher score indicating more PAS.

Center for Epidemiologic Studies-Depression Scale. The 20-item CES-D developed by Radloff ( 72 ) is a self-report measure that has been widely used to assess depressive symptoms in different populations ( 73 ). The reliability and validity of the CES-D have been tested among Chinese populations ( 74 ). The CES-D, when used in Chinese adolescents and university students, has shown good reliability ( 75 – 78 ), as well as good validity ( 77 , 78 ). There are four components of CES-D, namely somatic and retarded activity, depressed affect, positive affect, and interpersonal relationships. Among the 20 items, four (items 4, 8, 12, and 16) are reversed scores. All items are evaluated on a 4-point Likert scale in relation to their incidence during the previous week, and are scored from 0 to 3 (0 = not at all, 1 = a little, 2 = some, 3 = a lot); total possible scores thus range from 0 to 60, with higher scores indicating greater number of symptoms ( 79 ).

For the original CES-D scale, a total score of 16 or greater is considered as indicative of subthreshold depression ( 72 ). Many studies have evaluated the diagnostic accuracy of the CES-D to detect depression among the general population and proposed a variety of cut-off scores, such as a cut-off score of 21 for Chinese patients with type 2 diabetes ( 80 ), and a cut-off score of 22 for the older Chinese population ( 81 ). However, the cut-off score of 16 has been widely used for Chinese adolescents and university students ( 7 , 76 , 82 – 84 ). Therefore, the same cut-off score has been used in our study too. Students with CES-D scores between 16 and 21 were defined as “mildly depressed,” between 21 and 24 as “moderately depressed,” and ≥ 25 as “severely depressed” ( 83 ). The CFA on the four-factor model showed a good model fit, with χ 2 = 16.54, df = 1, P < 0.000, RMSEA = 0.06, SRMR = 0.01, CFI = 0.99, TLI = 0.98. Additionally, the Cronbach's alpha coefficient was 0.84 for the total scale, all four dimensions had acceptable reliability with Cronbach's alpha coefficient of 0.70, 0.83, 0.78, and 0.62.

Mobile Phone Use Situation and Mobile Phone Addiction

Mobile phone use situation was assessed by three items. First, “How many hours do you use your mobile phone every day?” to which participants answered with one of four options: “less than a half hour,” “a half hour to one hour,” “one to two hours,” or “more than two hours.” Second, “How long have you had a mobile phone?” to which participants answered “ <1 year,” “1–2 years,” “2–3 years,” or “more than 3 years.” Third, “How much do you spend on mobile phone charges every month?” to which participants answered “less 30 yuan,” “30–50 yuan,” “50–100 yuan,” or “more than 100 yuan.”

The Mobile Phone Addiction Index (MPAI) was used in our study ( 85 ). Participants rated the 17 items on a 5-point Likert scale ranging from 1 (not at all) to 5 (always). Higher scores indicated greater addiction to mobile phones ( 86 ). There are four components of MPAI, namely inability to control craving, feeling of anxiety and being lost, withdrawal or escape, and productivity loss. The Confirmatory Factor Analysis (CFA) on the four-factor model showed a good model fit, with χ 2 = 6.44, df = 1, p < 0.05, RMSEA = 0.03, SRMR = 0.004, CFI = 0.99, TLI = 0.99. Additionally, the Cronbach's alpha coefficient was 0.90 for the total scale. All four dimensions had satisfactory reliability with Cronbach's alpha coefficient of 0.76, 0.81, 0.85, and 0.75.

The Pittsburgh Sleep Quality Index (PSQI) was used in our study ( 87 ). PSQI scale contains 19 items covering seven components: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. Each component was scored from 0 (no difficulty) to 3 (severe difficulty). The total score was calculated from the seven component scores, ranging from 0 to 21. A score of more than 5 implied poor sleep ( 87 ). The CFA on the seven-factor model showed a good model fit, with χ 2 = 79.49, df = 11, P < 0.000, RMSEA = 0.04, SRMR = 0.02, CFI = 0.99, TLI = 0.98. Additionally, Cronbach's alpha coefficient was 0.624 for the PSQI scale in our study.

Data Analyses

SPSS version 19.0. and Mplus 7.0 were used to analyse data in our study. Descriptive analyses were first conducted of participants' characteristics, participants' mobile phone use and the prevalence of sleep disturbance, MPA, and depression. We tested the reliability and validity of the MPAI scale, PSQI scale and CES-D scale by examining their Cronbach's alpha coefficient and performing a CFA. Spearman's correlation analysis was performed to examine the general relationships among the four variables—PAS, MPA, sleep quality, and depression. A structural equation model (SEM) was built to examine hypotheses. We tested the mediating role of MPA and sleep quality; the constructed serial mediation model included three latent variables (MPA, sleep quality and depression) and one manifest variable (PAS), PAS was the independent variable, depression was the dependent variable, and MPA and sleep quality were the mediating variables ( 88 ). The bootstrapping analyses used 5,000 samples at the 95% confidence interval (CI) to indicate significance.

To determine whether the model fits the data well, multiple indices were tested, including (1) the model χ 2 and its p value, in which non-significance is desirable for good fit. With increasing sample size and a fixed degree of freedom, the χ 2 value increases. It is difficult to get a nonsignificant chi-square (indicative of good fit) when sample sizes are over 200 ( 89 ). This can lead to a problem where plausible models might be rejected. Because this statistic is sensitive to the sample size, inspection of the other fit indices is recommended ( 90 ). (2) The root mean square error of approximation (RMSEA) in which values ranging from 0.05 to 0.08 represent adequate fit, and values <0.05 indicate good fit. (3) The standardized root mean square residual (SRMR) in which values are ≤0.08 indicate good fit. (4) The comparative fit index (CFI), in which values range from 0.90 to 0.95 indicate an adequate fit and values ≥0.95 indicate a good fit, and (5) the Tacker-Lewis index (TLI) in which values >0.90 indicate a good fit.

Descriptive Statistics

The mean scores of PAS were 2.61 ± 1.03, 2.68 ± 1.06, 2.13 ± 0.98, and 2.29 ±0.96 for middle school students, high school students, vocational high school students, and college school students, respectively.

Among the participants, 45.55% used their mobile phone more than 2 h daily; 39.5% of the participants had a mobile phone for more than 3 years; 53.24% of the participants spent more than or equal to 30 yuan on mobile phone charges every month ( Table 1 ). The mean MPAI score of all the participants was 30.62 ± 11.92.

Table 1 . Participants' mobile phone use.

The prevalence of depressive symptoms was 28.69% ( n = 1,466) with a mean CES-D score of 12.52 ± 8.86. Prevalence of depression at a mild level (CES-D ≥ 16 and CES-D < 21), moderate level (CES-D ≥ 21 and CES-D < 25), and severe level (CES-D ≥ 25) was 12.62, 6.95, and 9.12%, respectively. The prevalence of depressive symptoms among high school students (33.14%) was the highest, while the prevalence of depressive symptoms among college students (21.43%) was the lowest ( Table 2 ).

Table 2 . Depression classifications of participants.

The prevalence of sleep disturbance was 27.95% ( n = 1,428) with a mean global PSQI score of 4.29 ± 2.59. The prevalence of sleep disturbance among high school students (36.47%) was the highest, while the prevalence of sleep disturbance among middle school students (20.75%) was the lowest. The average sleep time and sleep latency were 7.40 ± 1.28 h and 15.81 ± 12.48 min, respectively. Among the participants, 14.50% reported that they had bad or very bad sleep quality; 36.29% reported that their sleep latency was more than 15 min; 50.89% reported that they slept ≤7 h a day; 12.62% reported that their sleep efficiency was ≤85%; 67.59% reported that they experienced sleep disturbances; 2.90% of them reported that they used sleep medication; and 78.80% reported that they had daytime dysfunction ( Table 3 ).

Table 3 . Prevalence of sleep disturbance for participants at different education levels.

Means, Standard Deviation (SD) and correlations of the main variables in the mediation model are shown in Table 4 . The results, indicating that the variables were significantly and positively correlated, provide initial support for the hypotheses of this study, and act as a foundation of the serial mediation model.

Table 4 . Means, SD, Pearson's correlation coefficient of variables.

Test for Serial Mediation Model

SEM was used to provide the fit indexes of the serial mediation model. A model was constructed with MPA (M1) as a mediator and sleep quality (M2) as another mediator. In this model, PAS was set as the predictor (X) and depression as the outcome (Y). Results of the serial mediation model indicated that the constructed model exhibited a satisfactory fit with the data: χ 2 = 1,196.50, df = 95, P < 0.000, SRMR = 0.04, RMSEA = 0.05, CFI = 0.95, and TLI = 0.94.

First, PAS was positively associated with depression (B = 0.10, SE = 0.02, 95% CI = 0.06–0.13). Higher levels of PAS were related to higher levels of depression, and thus H1 was supported. Second, PAS positively predicted MPA (B = 0.18, SE = 0.02, 95% CI = 0.15–0.21). Higher levels of PAS were related to higher levels of MPA, and thus H2 was supported. Third, PAS was positively associated with PSQ (B = 0.23, SE = 0.02, 95% CI = 0.19–0.26). Higher levels of PAS were related to poorer sleep quality, and thus H3 was supported. Fourth, MPA was positively associated with PSQ (B = 0.51, SE = 0.02, 95% CI = 0.47–0.54). Higher levels of MPA were related to poorer sleep quality, and thus H4 was supported. Fifth, MPA was positively associated with depression (B = 0.17, SE = 0.02, 95% CI = 0.13–0.22). Higher levels of MPA were related to higher levels of depression, and thus H5 was supported. Last, PSQ was positively associated with depression (B = 0.44, SE = 0.03, 95% CI = 0.39–0.49). PSQ was related to higher levels of depression, and thus H7 was supported.

Total, Direct, and Indirect Effects

Table 5 shows all possible indirect effects of the mediation model. First, the indirect effect of PAS on depression through MPA was significant (B = 0.08, 95% boot CI = 0.06–0.11), and thus H6 was supported. Second, the indirect effect of PAS on depression through sleep quality was significant (B = 0.27, 95% boot CI = 0.22–0.33), and thus H8 was supported. Third, the indirect effect of PAS on depression through MPA and sleep quality was also significant (B = 0.11, 95% boot CI = 0.08–0.14), and thus H9 was also supported. The total indirect effect was B = 0.46, 95% boot CI = 0.40–0.53, and the mediating effect of MPA and sleep quality were significant ( P < 0.001), accounting for 64.01% (total indirect effect/total effect) of the total effect. The indirect effect related to sleep quality accounted for 82.61% of the total indirect effect, that is, (indirect effect 2 + indirect effect 3)/total indirect effect ( Table 5 ).

Table 5 . Total, direct, and indirect effects.

Although academic stress is a well-known risk factor for depression in students, little is known about the possible psychological mechanisms underlying this association, or how MPA and PSQ—which also are risk factors of depression—operate to have an impact on it. The main aim of our study was to test if there is a relationship between PAS and depression and if MPA and sleep quality together play a serial mediating role in the influence of PAS on depression among Chinese students. To the best of our knowledge, this was the first study to investigate the relationship between the variables using SEM. As expected, the serial mediation model showed that PAS was a significant predictor of depression. MPA and sleep quality played a mediating role between PAS and depression. Furthermore, MPA and sleep quality together played a serial mediating role in the influence of PAS on depression. In our study, the indirect effect (i.e., the mediating effect of MPA and sleep quality) was significant and accounted for 64.01% of the total effect. Thus, apart from the direct effect of PAS on depression, the indirect effect of PAS on depression should be emphasized. Our findings provide significant insights into the risk factors for depressive symptoms in students.

Depression Among Students

According to studies that have focused on depression among Chinese students, the prevalence of depression varies from 22.0 to 68.5% ( 5 , 91 – 95 ). In our study, the prevalence of depressive symptoms was 28.69%. The differences across these studies may have resulted from temporal or regional disparities or variations in depression definitions and assessment methods. Depressive symptoms are related to many negative consequences, such as increased suicide risk among students ( 96 ) and increased college withdrawal rates ( 97 ). Controlling depressive symptoms among students can both protect human capital value from the societal perspective and maintain students' physical and mental health from the individual perspective. In our study, the most stressed, depressed, and sleep-deprived students were high school students. Thus, Chinese high school students' physical and mental health requires attention. In China, high school students are admitted to colleges and universities based on gaokao , the standardized National College Entrance Examination ( 98 ). These admission decisions are extremely important, as they impact high school students' future educational opportunities, career paths, and life experiences. Our research results prove that Chinese students experience the most stressful and competitive academic environment of their academic careers when they are in high school.

Mediating Role of Mobile Phone Addiction

Chinese students spend considerable time on mobile phones−45.55% of the participants spent more than 2 h daily on their mobile devices. 39.5% of participants had had a mobile phone for more than 3 years, while the mean age of participants was 15.53 years. Using the mediation model, we illustrated the mediating role of MPA in line with our hypothesis. As H6 predicted, MPA played a role in the path from PAS to depression. MPA could partially explain the association between PAS and depression among Chinese students—hence, MPA was not only an outcome of PAS, but also a catalyst of depression. First, we found that high levels of PAS were associated with high levels of MPA. This finding is consistent with previous research results ( 48 ) and suggests that PAS may be a significant trigger for students' negative behaviors—such as MPA. Scholars have posited that young people's digital distraction activities—including playing computer games and online surfing—may be interpreted as a way to avoid problems, reality, and stress ( 99 , 100 ). High levels of PAS were associated with high levels of MPA, which may be due to students' use of mobile phones to escape from academic stress. Second, we found that high levels of MPA were associated with high levels of depression, which is in line with existing research results ( 35 , 36 , 101 ). Students who experience MPA may neglect real-world social engagement ( 102 ) resulting in academic underperformance ( 103 ), clinical health symptoms ( 68 ), which are related to negative emotions—such as depression. Our findings add to the existing research that suggests that when students are facing academic stress, they may be addicted to their mobile phones to escape from academic stress, and thus the negative consequences of MPA may lead to depression in students.

Mediating Role of Sleep Quality

As H8 predicted, sleep quality is not only an outcome of academic pressure—it is also a catalyst of depression. Moreover, the indirect effect related to sleep quality accounted for 82.61% of the total indirect effect. Thus, compared to MPA, sleep quality played a more important role in the path from PAS to depression. We found that higher levels of PAS were associated with poorer sleep quality. This finding is consistent with previous research findings ( 24 , 47 ). For example, Waqas et al. demonstrated that perceived stress is a significant predictor of PSQ ( 47 ). In China, students exist in a prolonged competitive learning environment and experience unrelenting academic stress. To achieve better academic performance and meet the extraordinarily high expectations of parents and educators, Chinese students have heavy homework burdens and learning burdens, resulting in sleep deprivation. Furthermore, academic stress decreases sleep quality. According to Almojali et al., students who are not suffering from academic stress are less likely to experience PSQ ( 104 ). Previous studies have proved that sleep deficiency and sleep health problems are common among Chinese students ( 105 ). Our research results may explain why higher levels of PAS were related to poorer sleep quality.

We also found that high levels of PSQ were associated with high levels of depression, which is consistent with prior research findings ( 31 , 50 , 57 ). Scholars have proved that PSQ is related to multiple negative consequences that may lead to depression—including daytime dysfunction, poor academic performance, and fatigue ( 106 , 107 ). Our findings add to the existing research that suggests that sleep quality is a mediator between PAS and depression among students, which means that higher levels of PAS were related to poorer sleep quality—such as sleep deficiency and daytime dysfunction—which was related to higher levels of depression.

Serial Mediating Effect of Mobile Phone Addiction and Sleep Quality

As per H9, MPA and sleep quality together play a serial mediating role in the influence of PAS on depression. The results of our study showed that higher levels of PAS were related to higher levels of MPA, which was associated with poorer sleep quality, which was associated with higher levels of depression. Numerous studies have documented that there is a positive relationship between MPA and PSQ ( 50 , 52 ). For example, Kang et al. found that there were bidirectional longitudinal relationships between MPA and PSQ ( 50 ). Scholars have posited that the more screen time young people use, the less sleep time they have ( 108 ). Moreover, young people often use their mobile phone in the bedroom—bedtime mobile phone use is related to higher insomnia scores and increased fatigue ( 109 ), and both insomnia and fatigue are related to depression ( 110 , 111 ). This may explain why MPA and PSQ together play a serial mediating role in the influence of PAS on depression. Our findings suggests that Chinese students are likely to distract themselves from PAS by using their mobile phones, and thus shortening their sleep duration, decreasing their sleep quality, leading to PSQ, and resulting in depressive symptoms.

Measures to Reduce Depressive Symptoms Among Chinese Students

To reduce depressive symptoms among students, their PAS should be managed. Given the multiple, negative consequences (MPA, PSQ, and depression) of PAS, stakeholders—family members, educators (including teachers, school administrators, and school health professionals), and policy makers—should take preventative measures to help students manage and relieve academic stress, such as provide counseling services ( 112 ), foster their psychological resilience ( 113 ), and increase social support ( 19 ) to improve their overall well-being. Second, students' sleep quality should be ensured to reduce depressive symptoms. Stakeholders should actively promote counseling and intervention for students experiencing sleep disturbances. Third, given that higher levels of MPA are associated with poorer sleep quality and higher levels of depression, stakeholders should develop mitigating strategies to manage mobile phone use to ensure students' sleep quality and to relieve their depressive symptoms. Rational and normative mobile phone use should be advocated and classroom management strategies enforced to ensure that students use their mobile phones at restricted times and places for positive purposes, such as online learning. Fourth, regular psychological assessment of depression, MPA, and PSQ will help stakeholders detect and manage students' health problems. Last, parents and family members, educators, and policy makers should encourage students to exercise more to alleviate MPA ( 114 ), improve sleep quality ( 115 ), and reduce depression ( 116 ).

Limitations

This study has several limitations. First, although we conducted our research based on previous studies, due to the cross-sectional design of our study, we could not confirm causal relationships among the study variables. Second, the study period was September to December 2018, which was more than 2 years ago. However, we believe that the results of our study are valuable for understanding the mechanisms of how PAS influences students' depression through MPA and sleep quality, and our study can provide a basis for future research. Third, the study measured the participants' perceived academic stress using a single item, which may not have captured various other relevant stressors, such as parental learning expectations. Future studies should use a multiple-item scale to assess the participants' perceived academic stress. Forth, this study was limited to middle school, high school, vocational high school, and college students. Future research on Chinese students at all education levels from primary school to postgraduate levels is necessary. Fifth, perceived academic stress can increase during stressful conditions ( 117 ), such as during exams or major change in life (e.g., from high-school student to freshman). While our study was conducted in 27 schools in three cities, it is impossible that we conducted the survey when the participants had no examinations or changes. Future studies can control for stressful academic conditions in the analyses to enhance their accuracy. Last, gender, age, and other factors are important influencing factors of PAS, MPA, sleep quality, and depression. Since the main aim of this study was to test if there was a relationship between PAS and depression and if MPA and sleep quality together play a serial mediating role in the influence of PAS on depression, the aforementioned factors were not considered in this study. Future studies should consider these factors and test the relationships between PAS, MPA, sleep quality, depression, and other health indicators.

Conclusions

Our study's results showed that Chinese students face the risk of depression and sleep disturbance, and the most stressed, depressed, and sleep-disturbed students are those in high school. Second, the results of the serial mediation model indicated that PAS predicted depression, and MPA and sleep quality played a mediating role between PAS and depression. Furthermore, MPA and sleep quality together play a serial mediating role in the influence of PAS on depression. Our study extends the understanding of how PAS is associated with depression among Chinese students. Considering the harmful effects of depression, stakeholders—including parents and family members, educators, and policy makers—should take preventative measures to alleviate Chinese students' depression and depressive symptoms.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. Requests to access these datasets should be directed to wuqunhong@163.com .

Author Contributions

XZ, FG, ZK, and QW: conceptualization. XZ, HZ, JW, and HL: formal analysis. FG, JZ, JL, JY, HZ, and BL: investigation. XZ, FG, ZK, and BL: data curation. XZ, FG, and ZK: writing—original draft preparation. QW and BL: writing—review and editing. All authors have read and agreed to the published version of the manuscript.

This research was funded by QW of The National Key Social Science Fund of China (Grant No.19AZD013).

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 would like to express our appreciation to all of the individuals for their involvement in the study, including each of students and teachers for their support during the data collection.

Abbreviations

PAS, Perceived Academic Stress; MPA, Mobile Phone Addiction; MPAI, Mobile Phone Addiction Index; CES-D, Center for Epidemiologic Studies-Depression; PSQ, Poor Sleep Quality; PSQI, Pittsburgh Sleep Quality Index; SEM, Structural Equation Model.

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Keywords: perceived academic stress, mobile phone addiction (MPA), sleep quality, depression, depressive symptoms, Chinese students

Citation: Zhang X, Gao F, Kang Z, Zhou H, Zhang J, Li J, Yan J, Wang J, Liu H, Wu Q and Liu B (2022) Perceived Academic Stress and Depression: The Mediation Role of Mobile Phone Addiction and Sleep Quality. Front. Public Health 10:760387. doi: 10.3389/fpubh.2022.760387

Received: 18 August 2021; Accepted: 07 January 2022; Published: 25 January 2022.

Reviewed by:

Copyright © 2022 Zhang, Gao, Kang, Zhou, Zhang, Li, Yan, Wang, Liu, Wu and Liu. 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: Qunhong Wu, wuqunhong@163.com ; Baohua Liu, liubaohuawoshi@163.com

† These authors have contributed equally to this work

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.

Understanding Academic Stress in College

How can you tell if your college stress is unhealthy, signs you may need professional support, get more academic stress tips.

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If you’re like most college students, you experience school-related stress. Stress isn’t always a bad thing. At manageable levels, it’s necessary and healthy because it keeps you motivated and pushes you to stay on track with studying and classwork.

But when stress, worry, and anxiety start to overwhelm you, it makes it harder to focus and get things done. National studies of college students have repeatedly found that the biggest stumbling blocks to academic success are emotional health challenges including:

Not getting enough sleep
Depression

Many things can create stress in college. Maybe you’re on a scholarship and you need to maintain certain grades to stay eligible. Maybe you’re worried about the financial burden of college on your family. You may even be the first person in your family to attend college, and it can be a lot of pressure to carry the weight of those expectations.

Stress seems like it should be typical, so it’s easy to dismiss it. You may even get down on yourself because you feel like you should handle it better. But research shows that feeling overwhelming school-related stress actually reduces your motivation to do the work, impacts your overall academic achievement, and increases your odds of dropping out.

Stress can also cause health problems such as depression, poor sleep, substance abuse, and anxiety.

For all those reasons—and just because you deserve as much balance in your life as possible—it’s important to figure out if your stress is making things harder than they need to be, affecting your health, or getting in the way of your life.

Then you can get help and learn ways to reduce the impact of stress on your life.

First identify what’s causing your stress.

Is it a particular class or type of work?
Is it an issue of time management and prioritization?
Do you have too much on your plate?
Is it due to family expectations or financial obligations?

Next think about how college stress affects you overall.

Does it prevent you from sleeping?
Does it make it take longer to do your work or paralyze you from even starting?
Does it cause you to feel anxious, unwell, or depressed?

If any of that feels familiar, it’s time to find support to ease your stress and help you feel better. Check out these tips to figure out the best support and approach for you.

It’s important to be able to recognize when stress starts to become all-encompassing, affecting your overall mental health and well-being. Here are some signs you might need to get help:

Insomnia or chronic trouble sleeping
Inability to motivate
Anxiety that results in physical symptoms such as hair loss, nail biting, or losing weight
Depression, which may manifest as not wanting to spend time with friends, making excuses, or sleeping excessively
Mood swings, such as bursting into tears or bouts of anger

Learn how to find professional mental health support at your school or elsewhere.

If you need help right now, text HOME to 741-741 for a free, confidential conversation with a trained counselor any time of day, or text or call 988 or use the chat function at 988lifeline.org .

If this is a medical emergency or there is immediate danger of harm, call 911 and explain that you need support for a mental health crisis.

Tips for Managing Academic Stress in College

How to Reduce Stress by Prioritizing and Getting Organized

5 Ways to Stay Calm When You’re Stressed About School

6 Ways to Take Care of Yourself During Exam Time

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Tips for stressful election conversations, what i wish i knew before coming out, 3 steps to make it easier to ask for mental health support, search resource center.

If you or someone you know needs to talk to someone right now, text, call, or chat 988 for a free confidential conversation with a trained counselor 24/7.

You can also contact the Crisis Text Line by texting HOME to 741-741.

If this is a medical emergency or if there is immediate danger of harm, call 911 and explain that you need support for a mental health crisis.

College Student Stress Crisis: Alarming Statistics and Solutions

Drowning in textbooks and term papers, today’s college students are silently screaming for help as an unprecedented wave of stress threatens to wash away their dreams and well-being. The college experience, once heralded as a time of growth, exploration, and self-discovery, has increasingly become a pressure cooker of anxiety and overwhelm for many students. As we delve into the alarming statistics surrounding college student stress, it becomes clear that this issue demands immediate attention and action from educators, institutions, and society at large.

The prevalence of stress among college students has reached epidemic proportions, with recent studies painting a grim picture of the mental health landscape on campuses across the nation. According to a 2020 survey by the American College Health Association, a staggering 87% of college students reported feeling overwhelmed by all they had to do, while 66% experienced overwhelming anxiety within the past year. These numbers represent a significant increase from just a decade ago, highlighting the growing crisis facing our young adults in higher education.

The Stress Epidemic: A Closer Look at the Numbers

To truly understand the magnitude of the stress crisis in college students, we need to examine the statistics in greater detail. A comprehensive study conducted by the Anxiety and Depression Association of America found that 80% of college students report feeling stressed on a daily basis. This pervasive stress is not limited to any particular group of students but spans across all academic years and demographics.

When comparing stress levels between different academic years, a clear pattern emerges. Freshmen often experience high levels of stress as they adjust to the demands of college life, with 75% reporting significant stress during their first year. However, contrary to what one might expect, stress levels do not necessarily decrease as students progress through their academic careers. In fact, seniors often report the highest levels of stress, with 87% experiencing severe stress as they face the pressures of graduation, job hunting, and transitioning into the “real world.”

Gender differences in reported stress levels are also noteworthy. Studies consistently show that female college students report higher levels of stress than their male counterparts. A recent survey found that 91% of female students reported feeling overwhelmed by all they had to do, compared to 76% of male students. This disparity may be attributed to a variety of factors, including societal expectations, academic pressures, and differences in stress coping mechanisms.

The trends in college stress statistics over the past decade are particularly alarming. A longitudinal study tracking stress levels from 2010 to 2020 revealed a 30% increase in the number of students reporting “extreme stress” during their college years. This upward trend shows no signs of slowing down, especially in light of recent global events such as the COVID-19 pandemic, which has added new layers of uncertainty and anxiety to the college experience.

Unraveling the Sources of Student Stress

To effectively address the stress crisis among college students, it’s crucial to understand the major stressors contributing to this epidemic. While the sources of stress can vary from student to student, several common themes emerge consistently in research and surveys.

Academic pressure and workload top the list of stressors for most college students. The relentless cycle of exams, assignments, and projects can leave students feeling overwhelmed and exhausted. A study by the National College Health Assessment found that 45% of students reported academics as their top source of stress. The pressure to maintain high GPAs, meet scholarship requirements, and stand out in an increasingly competitive job market only adds to this academic burden.

Financial concerns and student debt are another significant source of stress for many college students. With the rising costs of tuition and living expenses, many students find themselves juggling part-time jobs with their studies or taking on substantial loans to finance their education. The Hidden Cost of Education: How Student Debt Impacts Mental Health reveals that the average student loan debt for the Class of 2020 was $37,584, a figure that can cast a long shadow over students’ mental well-being and future prospects.

Social and relationship challenges also contribute significantly to student stress. The college years are a time of intense personal growth and social exploration, but navigating new friendships, romantic relationships, and social expectations can be daunting. A survey by the Jed Foundation found that 63% of college students felt very lonely in the past year, highlighting the social pressures and isolation that many students experience.

Career and future uncertainty loom large in the minds of many college students. The pressure to choose the right major, secure internships, and land a job after graduation can be overwhelming. A study by the National Association of Colleges and Employers found that 76% of seniors reported feeling anxious about their career prospects, a statistic that underscores the weight of future-oriented stress on students.

Time management and balancing responsibilities round out the major stressors for college students. With academics, social life, extracurricular activities, and often part-time jobs competing for their attention, many students struggle to find equilibrium. A survey by the American Institute of Stress found that 60% of college students reported that their stress levels made it difficult to get work done, highlighting the impact of poor time management on academic performance.

The Far-Reaching Impact of College Stress

The consequences of chronic stress on college students extend far beyond temporary discomfort or anxiety. The impact can be profound and long-lasting, affecting various aspects of students’ lives and potentially shaping their future trajectories.

Mental health consequences are perhaps the most immediate and visible effects of college stress. Anxiety and depression rates among college students have skyrocketed in recent years, with the American Psychological Association reporting that 41.6% of college students suffer from anxiety and 36.4% from depression. These mental health challenges can severely impact a student’s quality of life, academic performance, and overall well-being.

Physical health effects of chronic stress should not be underestimated. Prolonged exposure to high levels of stress can lead to a range of physical symptoms and conditions, including headaches, insomnia, weakened immune system, and digestive issues. A study published in the Journal of American College Health found that 32% of college students reported that stress had negatively impacted their physical health in the past year.

Academic performance and dropout rates are significantly affected by high levels of stress. The Alarming Reality: What Percent of Students Are Stressed by Homework? reveals that excessive stress can lead to decreased motivation, poor concentration, and lower grades. In severe cases, stress can contribute to academic burnout and even dropout. The National Student Clearinghouse Research Center reports that the overall six-year completion rate for students who started college in 2014 was only 60%, with stress being cited as a major factor in many cases of non-completion.

The long-term implications of college stress on future career and personal life cannot be overlooked. Chronic stress during the formative college years can shape students’ coping mechanisms, career choices, and overall life satisfaction well into adulthood. A longitudinal study by the American Psychological Association found that individuals who experienced high levels of stress in college were more likely to report job dissatisfaction and lower overall life satisfaction in their 30s and 40s.

Coping Strategies and Support Systems

In the face of these daunting statistics, it’s crucial to examine the coping mechanisms and support systems available to college students. Understanding how students manage stress and the effectiveness of various support structures can provide valuable insights for developing more robust stress-reduction strategies.

Common stress management techniques used by students vary widely, but some popular methods include exercise, meditation, time management strategies, and social support. 10 Effective Stress Relief Activities for College Students: Balancing Academic Success and Mental Well-being offers a comprehensive guide to stress management techniques specifically tailored for college students. A survey by the American College Health Association found that 65% of students reported using exercise as a stress management technique, while 45% practiced mindfulness or meditation.

The effectiveness of college counseling services plays a crucial role in addressing student stress. However, the utilization and perception of these services vary widely. A study by the Center for Collegiate Mental Health found that while 87% of college counseling centers reported an increase in students seeking services, only about 10-15% of students actually use these services. This discrepancy highlights the need for improved outreach and destigmatization of mental health support on college campuses.

The role of peer support and student organizations in managing stress should not be underestimated. Many students find solace and support in campus clubs, study groups, and peer mentoring programs. A study published in the Journal of American College Health found that students who reported strong social connections and involvement in campus activities had lower levels of perceived stress and better overall well-being.

Institutional initiatives to address student stress have become increasingly common as awareness of the issue grows. Many colleges and universities now offer stress management workshops, wellness programs, and even courses on mindfulness and resilience. For example, Stanford University’s “Resilience Project” aims to help students develop skills to manage stress and adversity, while the University of Pennsylvania’s “Penn Resiliency Program” teaches cognitive-behavioral and positive psychology skills to reduce stress and promote well-being.

Charting a Path Forward: Strategies for Reducing College Stress

As we confront the alarming statistics of stress in college students, it’s clear that a multi-faceted approach is needed to address this growing crisis. Implementing effective strategies to reduce stress levels requires collaboration between students, educators, institutions, and policymakers.

Implementing stress management programs in curricula is a proactive step that many institutions are considering. By integrating stress management techniques and mental health education into core coursework, colleges can equip students with valuable life skills while normalizing conversations about mental health. Effective Stress Relief Techniques for College Students: A UoPeople Guide provides an excellent framework for such programs, offering practical strategies that can be easily incorporated into academic settings.

Improving access to mental health resources is crucial in addressing the stress crisis. This includes not only expanding counseling services but also reducing barriers to access, such as long wait times, stigma, and lack of awareness. Some innovative approaches include teletherapy options, peer counseling programs, and mental health apps specifically designed for college students. A study by the American Psychological Association found that colleges that implemented comprehensive mental health programs saw a 13% reduction in student stress levels and a 15% improvement in academic performance.

Promoting work-life balance and self-care should be a priority for both students and institutions. This can involve encouraging students to set realistic goals, practice time management, and engage in regular self-care activities. Navigating the Stress Semester: A Comprehensive Guide to Managing End-of-Term Pressure offers valuable insights into maintaining balance during particularly stressful periods of the academic year.

Addressing systemic issues contributing to student stress is perhaps the most challenging but potentially impactful strategy. This may involve reevaluating academic policies, addressing the student debt crisis, and creating more supportive campus environments. For example, some institutions are experimenting with grade-free first years, flexible deadlines, and reduced course loads to alleviate academic pressure.

Conclusion: A Call to Action

As we reflect on the alarming stress statistics in college students, it’s clear that we are facing a crisis that demands immediate and sustained attention. The numbers paint a stark picture: 87% of students feeling overwhelmed, 80% experiencing daily stress, and a 30% increase in “extreme stress” over the past decade. These figures are not just statistics; they represent the lived experiences of millions of young adults struggling to navigate the challenges of higher education.

The importance of continued research and intervention in this area cannot be overstated. As the landscape of higher education continues to evolve, so too must our understanding of student stress and our approaches to addressing it. Comprehensive Guide to Student Stress Surveys: Understanding, Conducting, and Addressing Academic Pressure underscores the value of ongoing assessment and data-driven interventions in tackling this issue.

This article serves as a call to action for students, educators, and institutions alike. Students must prioritize their mental health and well-being, seeking help when needed and advocating for supportive policies. Educators have a responsibility to create learning environments that challenge students without overwhelming them, incorporating stress management techniques into their teaching practices. Institutions must take a holistic approach to student well-being, investing in comprehensive mental health services, implementing stress-reduction programs, and addressing systemic issues that contribute to student stress.

While the current statistics are alarming, there is hope for a less stressful future in higher education. By acknowledging the problem, implementing evidence-based solutions, and fostering a culture of well-being on college campuses, we can work towards a future where students can thrive academically, socially, and emotionally. The college years should be a time of growth, discovery, and preparation for the future – not a period of chronic stress and anxiety.

As we move forward, let us remember that behind every statistic is a student with dreams, potential, and a future to shape. By addressing the stress crisis in our colleges and universities, we are not just improving individual lives; we are investing in the future of our society. The time for action is now – let us rise to the challenge and create a healthier, more balanced higher education experience for all.

References:

1. American College Health Association. (2020). National College Health Assessment.

2. Anxiety and Depression Association of America. (2021). College Student Anxiety and Depression Study.

3. National College Health Assessment. (2021). Stress in College Students Report.

4. Jed Foundation. (2020). Survey on College Student Mental Health and Well-being.

5. National Association of Colleges and Employers. (2021). Job Outlook Survey.

6. American Institute of Stress. (2020). College Students and Stress: A National Survey.

7. American Psychological Association. (2021). Stress in America: Generation Z Report.

8. Journal of American College Health. (2020). Physical Health Effects of Stress in College Students.

9. National Student Clearinghouse Research Center. (2021). Completing College: National and State Reports.

10. Center for Collegiate Mental Health. (2021). Annual Report on College Counseling Center Utilization.

11. Stanford University. (2021). The Resilience Project. https://resilience.stanford.edu/

12. University of Pennsylvania. (2021). Penn Resiliency Program. https://ppc.sas.upenn.edu/research/resilience-children

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

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Cite this article

Authors Yousif MA , Arbab AH , Yousef BA

Received 21 November 2021

Accepted for publication 23 February 2022

Published 28 February 2022 Volume 2022:13 Pages 189—197

DOI https://doi.org/10.2147/AMEP.S350562

Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 3

Editor who approved publication: Prof. Dr. Balakrishnan Nair

Mariam A Yousif, 1 Ahmed H Arbab, 2 Bashir A Yousef 3 1 Faculty of Pharmacy, University of Khartoum, Al-Qasr Ave, 11111, Khartoum, Sudan; 2 Department of Pharmacognosy, Faculty of Pharmacy, University of Khartoum, Al-Qasr Ave, 11111, Khartoum, Sudan; 3 Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Al-Qasr Ave, 11111, Khartoum, Sudan Correspondence: Ahmed H Arbab, Tel +24991893200, Email [email protected] Background: Academic stress is a common problem among medical students, and the COVID-19 health crisis lockdown further worsened it. High academic stress has a negative impact on students learning and overall performance. Objective: To assess perceived academic stress, causes, and coping strategies among undergraduate pharmacy students during the COVID-19 pandemic. Methods: A descriptive cross-sectional study was conducted among undergraduate pharmacy students at the University of Khartoum. Data were collected from randomly selected participants using three validated self-administered questionnaires; perceived stress scale, study habits inventory, and mental health inventory. Data were analyzed using SPSS software, and descriptive statistics and chi-square were employed. Results: The response rate in our study was 99.6% (251/252). About 87% of the participants were females. The majority of participants (92%) experience academic stress, with a mean score (24.99 ± 5.159), the level of academic stress ranging from low (4.3%), moderate (73.2%), to high (22.5%). Approximately 80% of the percipients reported academic stress during all exam times with a mean score (25.33 ± 4.976). The level of academic stress was significantly associated with participants’ gender (P-value: 0.042), and living conditions (P-value: 0.001). The most common factors that were significantly associated with academic stress were difficulty in remembering all that is studied (66.7%, P=0.006) and worrying about the exams (54.1%, P=0.011). Moreover, the most frequent strategies used to cope with academic stress were praying (84.4%) and maintaining some control over the situation (61.9%). Conclusion: The study revealed a high prevalence of academic stress among percipients. Academic counseling, monitoring of mental status, and implementation of stress reduction programs are highly recommended. Keywords: academic stress, exam stress, COVID-19, pharmacy students, Sudan

Introduction

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

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

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

Materials and Methods

Study design and setting.

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

Study Population

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

Sample Size and Sampling

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

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

Data Collection Tool

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

Data Management and Analysis

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

Ethical Consideration

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

Socio-Demographic Characteristics of Participants

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

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

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

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

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

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

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

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

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

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

Acknowledgment

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

All authors report no conflicts of interest in this work.

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From academia to addiction: understanding the mechanism behind how academic stress fuels social media addiction in PhD students

Published: 16 August 2024

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Along He 1 &
Lili Zhu 1

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PhD life is a challenging phase and often faced with heavy academic stress. Indulging in social media may be one of the coping styles to relieve this stress. However, the underlying mechanisms by which academic stress affects social media addiction among PhD students are not fully understood. In this study, 431 PhD students (male: n = 243, 56.38%; female: n = 188, 43.62%; mean age = 27.34 years, SD = 2.70 years) completed online self-report measures of academic stress, anxiety, desire thinking, loneliness, and social media addiction. Grounded in general strain theory and the Interaction of Person-Affect-Cognition-Execution (I-PACE) model, we conducted mediation and moderated mediation model analysis to examine the associations among these variables. The results indicated that academic stress was positively associated with social media addiction and this association was sequentially mediated by anxiety and desire thinking. Furthermore, loneliness moderated and strengthened the positive association between academic stress and social media addiction. We provided empirical support for the feasibility of integrating desire thinking into the I-PACE model. Our research also calls on society to pay attention to the mental health issues affecting these populations and encouraging them to actively participate in offline activities, seek social support, reduce their dependence on social media, and improve stress management and psychological adjustment.

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Interpersonal relationships moderate the relation between academic stress and mobile phone addiction via depression among Chinese adolescents: A three-wave longitudinal study

Different Roles of Academic Stress and Academic Expectation Stress in Emotional Problems and Internet Gaming Disorder Among Chinese Adolescents: Application of the General Strain Theory

Social Media Addiction and Its Impact on College Students' Academic Performance: The Mediating Role of Stress

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The data underlying this article will be shared on reasonable request to the corresponding author.

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Examining perceptions of academic stress and its sources among university students: The Perception of Academic Stress Scale

Dalia bedewy.

1 Tanta University, Egypt

Adel Gabriel

2 University of Calgary, Canada

The development of a scale to measure perceived sources of academic stress among university students. Based on empirical evidence and recent literature review, we developed an 18-item scale to measure perceptions of academic stress and its sources. Experts ( n = 12) participated in the content validation process of the instrument before it was administered to ( n = 100) students. The developed instrument has internal consistency reliability of 0.7 (Cronbach’s alpha), there was evidence for content validity, and factor analysis resulted in four correlated and theoretically meaningful factors. We developed and tested a scale to measure academic stress and its sources. This scale takes 5 minutes to complete.

Introduction

Stress among undergraduate and graduate students is multifactorial, arising from both academic and non-academic factors, including socio-cultural, environmental, and psychological attributes ( Brand and Schoonheim-Klein, 2009 ). Stress levels may escalate to significant proportions in some students, to present with symptoms of anxiety especially during tests and examination periods. In fact, previous research suggested a modest prevalence rate of 10 to 35 percent of college students experience functionally impairing levels of test anxiety ( Chapell et al., 2005 ; Naveh-Benjamin et al., 1997 ). However, not all students experience anxiety with the same severity. In the Social Survey of the German Student Union, it was estimated that approximately 15–20 percent of student’s functioning become impaired by exam nerves in a “modest” to “high” degree ( Neuderth et al., 2009 ). Also, it was demonstrated that the delay and the drop-out in university students occur significantly more often in students with test anxiety and is associated with psychiatric morbidity including suicidal behavior and high economic costs ( Schaefer et al., 2007 ). Also, it was demonstrated that 10 percent of dental students suffered from severe emotional exhaustion, 17 percent complained about a severe lack of accomplishment, and 28 percent reported severe depersonalization symptoms ( Pohlmann et al., 2005 ). Academic factors were the predominant cause of stress in most students, followed by physical, social, and emotional. Majority of students with stress reported high scores of poor self-esteem, and about half scored high on depression scales ( Baste and Gadkari, 2014 ). Results from the literature suggest that higher level of stress to be associated with poor academic performance ( Sohail, 2013 ).

Perceived stress was reported in some research, to vary among different sociodemographic groups ( Acharya, 2003 ; Pau et al., 2007 ; Polychronopoulou and Divaris, 2005 ). For example, it was found that females, younger students, those without a previous higher education qualification, and those not satisfied with their decision to study dentistry were significantly more likely to report perceived stress levels when compared to their counterparts ( Morse and Dravo, 2007 ; Pau et al., 2007 ). However, in other studies, men showed more stress (62.9%) than women. However, females perceived more stress in the interpersonal domain score more significantly than males ( Saxena et al., 2014 ; Tangade et al., 2011 ). In a recent study, it was demonstrated that the most common sources of stress among medical students ( n = 161) were related to both academic and psychosocial pressures. These included high parental expectations, frequency of examinations, vastness of the academic curriculum, sleeping difficulties, worrying about the future, and about becoming a doctor. From reviewing the literature, stress among dental and medical students in different cultures is well documented and was associated with significant psychiatric morbidity in the literature ( Al-Omari, 2005 ; Naidu et al., 2002 ; Pohlmann et al., 2005 ; Rajab, 2001 ; Shah et al., 2010 ; Tuisuva and Morse, 2003 ). For example, it was demonstrated recently that more than half of the respondents were affected by depression, and over two-thirds by anxiety and stress, and females consistently reported higher score of stress as compared to their male counterparts ( Iqbal et al., 2015 ; Kumar et al., 2014 ).

Literature search summary

Workload and test difficulty and exam format.

In a number of studies, authors found that the most frequently reported factors contributing to stress and anxiety around the examination periods were extensive course loads, lack of physical exercise, and long duration of exams, reported by the students ( Harikiran et al., 2012 ; Hashmat et al., 2008 ; Sansgiry and Sail, 2006 ; Shah et al., 2010 ). The perception of extensive course load and long duration of examinations were found to be the most important sources of test anxiety in a number of research studies. For example, in a cross-sectional study, Hashmat et al. (2008) examined factors contributing to exam anxiety among the final medical students ( n = 120), using structured self-administered questionnaire including questions about lifestyle, study style, psychological problems, and examination system. Authors found that the most frequently reported factors by the students, contributing to exam anxiety, were extensive course loads (90.8%), lack of physical exercise (90%), and long duration of exams (77.5%). Authors also reported that most students had poor knowledge of exam-taking and anxiety-reduction ( Hashmat et al., 2008 ). Medical students’ performance in periodic examinations was the most frequently and severely occurring sources of stress ( Shah et al., 2010 ).

It was demonstrated in both laboratory and in self-report questionnaires that students report and experience higher levels of anxiety from the objective structured clinical examination (OSCE) than from the written examinations ( Furlong et al., 2005 ). Also, Omigbodun et al. (2006) and Polychronopoulou and Divaris (2005) found that excessive school work, congested classrooms, strikes by faculty, and lack of laboratory equipment were identified as a source of stress. The fear of course failure, uncertainty about future, clinical training difficulties, and work overload were among the perceived sources of stress among dental students ( Acharya, 2003 ; Polychronopoulou and Divaris, 2005 ). In a recent study, it was reported that 16.2 percent of the variance accounted for the excessive cognitive, somatic, and emotional responses on the Examination Anxiety Scale scores ( Bedewy and Gabriel, 2013 ). Based on a self-administered survey, it was demonstrated that test anxiety among pharmacology students ( n = 198) was positively correlated with students’ perceptions of course load and negatively related to their ability to manage time with course work ( Sansgiry and Sail, 2006 ).

Morse and Dravo (2007) utilized a modified version of the Dental Environment Stress questionnaire (41 items) to assess levels of stress among undergraduate students ( n = 115). Authors reported that there was slight to moderate stress. However, sources of stress were more prominent among female students and with the following items: full loaded day, followed by criticism from clinical supervisors in front of patients, amount of assigned work, fear of failing a course or year, examination and grades, financial resources, fear of employment after graduation, and fear of facing parents after failure ( Morse and Dravo, 2007 ).

Factors related to academic expectations and pressures to perform

It was demonstrated in a number of studies that parental pressures and teachers’ expectations were associated with stress around the time of examinations or about choosing particular academic study or a future career. For example, students who joined dentistry due to parental pressure, with associated fear of facing parents after failure, described greater stress than those who joined of their accord ( Acharya, 2003 ; Tangade et al., 2011 ). Authors recommended that parents need to be counseled against forcing their children to join an educational program, not of their choice ( Tangade et al., 2011 ). Also, receiving criticism from supervisors about academic or clinical work was one of the sources associated with significant stress among dental students ( Kumar et al., 2009 ). Other authors suggested that parental pressure predicted a higher degree of test anxiety, as the threat of negative evaluation from others is increased. Conversely, it was theorized that parental support would predict a lower degree of stress and test anxiety, as the threat of negative evaluation is reduced ( Putwain et al., 2010 ). Also, a higher than expected levels of emotional exhaustion were found in a large sample of first-year undergraduate students, and among entry-level students dental students in seven European dental schools ( Polychronopoulou and Divaris, 2005 ), and recently, Tangade et al. (2011) found that final year students presented with higher stress scores. Using a descriptive cross-sectional design, Wang and Yeh (2005) examined the perceptions and sources of entrance exam stress among third-year nursing students ( n = 441) and its effect on coping behavior. Authors concluded that the five main stressors of entrance exam stress, in descending order, included taking tests, the student’s own aspirations, learning tasks, teacher’s aspirations, and parent’s aspirations ( Wang and Yeh, 2005 ).

Factors related to students’ academic self-perceptions

Other sources which are commonly related to students’ academic self-perceptions involve such scores especially those related to their personality characteristics, intelligence, their past academic achievements, and other academic environmental and psychosocial sources.

Hancock (2001) and Hembree (1988) reported that negative cognitions related to examinations, when such students underestimate their own abilities, or overestimation of the consequences related to their failure, are often accompanied by higher anxiety levels and poor performance. It was demonstrated that in a number of studies, among dental and medical students, stress was high enough to present with psychiatric disorders in substantial proportions of students. The experience of severe stress and anxiety among dental school students is well documented. Students often report stress-related symptoms that may range from mild anxiety to sleep and eating disorders, as well as resulting in reduced performance, inability to concentrate, hostility, depression, and other debilitating effects ( Stewart et al., 2006 ; Westerman et al., 1993 ). In a cross-sectional survey examining the level of perceived academic stress among medical, dental, psychology, and sports students, it was demonstrated that sports and psychology students had a lower perceived stress risk compared with medicine students ( Neveu et al., 2012 ).

The relationship between personality traits and stress and anxiety related to taking examinations was also examined in a number of studies. For example, Liu et al. (2006) argued that test anxiety should be related to the personality and self-esteem, and that the prevalence of test anxiety should be higher in introversive, unstable emotional, apparent psychoticism or low self-esteem students. Xu et al. (2005) examined the effects of self-concept on the test anxiety among medical college students, using the test anxiety questionnaire and the English-learning self-concept scale. Authors found that all the dimensions of self-concept were significantly related to test anxiety, among which are the general self-concept and the academic self-concept. Others claimed that perceived academic competence was related to worry and tension ( Putwain et al., 2010 ).

Objectives of the study

If we are to develop programs to assist students in their scholastic activities and to minimize their anxiety and decrease their distress, one should develop a reliable tool to measure the sources of their stress and its associated causes.

The objective of this study is to develop and psychometrically assess an instrument with demonstrated evidence of validity, to measure academic stress among university students, the Perception of Academic Stress Scale (PAS).

Participants

There were 100 students, both men and women, ranging from 19 to 26 years of age (mean = 20.5 years) who participated. The proportion of male to female participants was 30/10 (75%/25%). All the participating students were from the third-year, Educational Psychology class at Tanta University Egypt. Students were included if they were planning to sit their third-year final course examinations in Educational Psychology. All students who participated in this study did not have a history of diagnosed psychiatric disorders, and all provided their consent to be included in the study.

The examination process involved taking a 3-hour written essay paper and an oral examination on the same day, which followed the written examination almost immediately. The written examination carried 75 percent of the total mark, and the oral examination carried the rest (25%). Students did not receive any credits for any assignments, or any homework, which they did during the whole year. Students, therefore, have to memorize a large amount of knowledge, for the two main semesters that they attended throughout the year.

Education experts

Both male and female experts (defined as more than 15 years of experience as a faculty in the area of Education and or Educational Psychology) were invited to participate in this study. Participated in the formal validation process were 12 experts from the Faculties of Psychology and Educational Psychology at Tanta University. There were female/male = 3/9, mean age = 54 years, standard deviation (SD) = 8.7 years, and mean years of experience as independent Psychology Consultants = 24, SD = 6.8. Letters of invitations were delivered face to face inviting experts to participate in the validation process. There was also one-on-one discussion and feedback about each item of the scale with regard to its relevancy to sample sources of academic stress among undergraduate students. Among experts, there were seven at the rank of professor, two at the associate professor, and three PhD lecturers. Initially, experts provided opinion about the overall content of the instrument. Each expert reviewed and provided comments on the relevance of the scale to be developed before testing the instruments with students.

The design involved the development and the psychometric assessment of a scale to measure the perceived sources of academic stress among undergraduate university students. Following extensive literature review, a table of specification with the initial items was created to guide item construction for developing the scale. We were able to identify a list of specification with three main components to characterize sources of academic stress among university students: (1) the academic expectations subscale (four items), (2) workload and examinations subscale (eight items), and (3) students’ academic self-perceptions subscale (six items). The items related to these academic stresses were converted into an 18-item, 5-point Likert-type questionnaire, resulting in the PAS.

Table 2 displays the PAS three main subscales: (1) the academic expectations subscale (four items), (2) workload and examinations subscale (eight items), and (3) students’ academic self-perceptions subscale (six items).

Table of specification and students’ and experts’ ratings of the PAS scale.

Items of specifications and the subscale items	Experts ratings for relevancy of items, min–max (mean ± SD)		Students responses, min–max (mean ± SD)
Stresses related to academic expectations
Competition with my peers for grades is quite intense	3–5	4.5 (0.67)	1–5	2.9 (1.2)
My teachers are critical of my academic performance	4–5	4.1 (0.38)	1–5	3.3 (1.2)
Teachers have unrealistic expectations of me	3–5	4.1 (0.71)	1–5	2.6 (1.1)
The unrealistic expectations of my parents stresses me out	3–5	4.5 (0.67)	1–5	2.3 (1.3)
Stresses related to faculty work and examinations
The time allocated to classes and academic work is enough	4–5	4.5 (0.51)	1–5	2.0 (1.0)
The size of the curriculum (workload) is excessive	3–5	4.7 (0.62)	1–5	1.2 (0.58)
I believe that the amount of work assignment is too much	3–5	4.7 (0.62)	1–5	1.3 (0.86)
Am unable to catch up if getting behind my work	4–5	4.5 (0.52)	1–5	2.5 (1.2)
I have enough time to relax after work	3–5	4.4 (0.66)	1–5	2.1 (1.2)
The examination questions are usually difficult	4–5	4.8 (0.38)	1–5	2.5 (0.90)
Examination time is short to complete the answers	3–5	4.8 (0.57)	1–5	2.2 (1.0)
Examination times are very stressful to me	4–5	4.8 (0.38)	1–5	1.7 (0.95)
Stresses related to students’ academic self-perceptions
Am confident that I will be a successful student	3–5	3.8 (0.57)	1–5	4.2 (0.76)
Am confident that I will be successful in my future career	3–5	3.8 (0.57)	1–5	3.9 (0.76)
I can make academic decisions easily	4–5	4.7 (0.45)	1–5	3.8 (0.98)
I fear failing courses this year	4–5	4.6 (0.49)	1–5	2.1 (1.4)
I think that my worry about examinations is weakness of character	3–5	4.2 (0.62)	1–5	2.6 (1.3)
Even if I pass my exams, am worried about getting a job	4–5	4.5 (0.51)	1–5	1.8 (1.1)
Mean scores (%)	4.4 (89%)		2.5 (50%)

The volunteer panel of experts discussed and reviewed the items to examine the appropriateness and clarity of each item and to ensure that each item assessed students’ sources of academic stress as perceived by students in faculty sittings. Experts were invited to rate each item formally for its relevance in measuring academic stresses, on a five-point Likert-type scale (1 = extremely irrelevant, 2 = irrelevant, 3 = slightly relevant, 4 = relevant, and 5 = strongly relevant). The objective of the consultation with experts was to provide both face and content validity by providing their agreement about the relevance of each item separately as a measure of students’ academic stress. For the purpose of developing the PAS, it was agreed to include only items receiving a mean score of 3.5 or above rating from experts, as relevant to develop the scale. This process resulted in selecting the PAS (18 items).

Format, layout, and language review of instruments

All items were reviewed for clarity and grammatical corrections. After the scale had been written, the Microsoft Word computer program was used to assess the grammar, in order to ensure that students could easily understand and interpret each item.

Administration to students

The scale was pilot tested with four students. Student’s concerns and feedback were sought in the following aspects of the scale:

Clarity of items, identifying and reporting any ambiguous items, and items difficult to interpret.
Difficulties with language, technical jargon, or any offending language.
Reactions and responses to the format and layout of each item.
Time needed to complete the scale.

After a slight modification based on experts’ and students’ input, the Perception of Academic Stress Scale (PAS = 18 items), was distributed by e mail to a heterogeneous group of undergraduate and postgraduate students from educational psychology specialization, from all four classes of education (Class 1 to Class 4) class of Educational Psychology ( n = 160). Hundred students (100/160, 62%) returned the completed PAS. Students were asked to rate on a 5-point Likert-type scale (from 1 = strongly disagree to 5 = strongly agree) their perceptions and experiences about each item in measuring sources of academic stress.

Appendix 1 displays the final version of the administered scale. Five items scoring were reversed to avoid response patterns ( Appendix 1 ). Completed responses and consent were returned via e-mail or regular mail to the investigator at the Department of Educational Psychology, Faculty of Education, Tanta University. All students provided their consent to participate in this project.

At the same time, students were also asked to provide demographics including age, sex, academic year, their faculty, and university affiliation, and if they had a history of academic failure. All students were also asked to rate their satisfaction with their learning environment and their overall physical and psychiatric health.

Data collection and analysis

Responses from educational and psychology experts were used to provide evidence for content validity for the instrument, while students’ responses and performances on the instrument were utilized to provide evidence for internal consistency reliability, and convergent validity as adduced in correlation analysis of the students’ responses on the subscales of the instrument. Students needed on average 5 minutes to complete the PAS.

Table 1 describes the demographics.

Demographics of participating students ( n = 100).

Non-continuous variables	Frequency	Percentage (%)
Male/female	06/94	06/94
Marital status
Single	69	69
Married	30	30
Divorced	01	01
Academic year
Undergraduate	18	18
Postgraduate	82	82
Faculty
Education	95	95
History of academic class failure
Never	72	72
Once or twice	24	24
Three or four	04	04
Satisfaction with the learning environment
Very satisfying	3	3.0
Satisfying	31	31.0
Not very	39	39.0
Not at all	27	27.0
Satisfaction with home environment
Yes	73	73.0
No	27	27.0
Continuous variables	Min/max	Mean ± SD
Age	19/43	23.34 ± 4.29

SD: standard deviation.

The results of students’ responses are summarized in Table 2 . The internal consistency reliability (Cronbach’s alpha) was 0.7 for the 18 items of the PAS. Analyses of variance (ANOVAs) indicated that there were no significant differences in the mean PAS score, between sexes, and age groups in the severity scores of anxiety symptoms.

Experts’ responses

There were no significant differences in ratings of experts based on their length of experience ( p < 0.08). Expert’s ratings for all items on the scale ranged from a minimum of 3.8 to a maximum of 4.8 and an average rating for all the instrument items of 4.4. Experts’ responses yield an overall agreement of 89 percent among experts about the 18 items to measure academic stress ( Table 2 ).

Students’ responses

A close inspection of Table 2 will show that the level of academic sources of stress, as reported by students, was in the low range for most of the scales’ items. Overall, students reported confidence in their academic performance and in their ability to succeed. In this study, moderate-to-severe stress items were “My teachers are critical to my academic performance” and “Competition with my peers for grades is quite intense.” Also, the positively reported items were “Am confident that I will be a successful student, “Am confident that I will be a successful in my future career,” and “I can make academic decisions easily.”

Factor analysis

Several exploratory principal component analyses were conducted on the 18-item scale. Based on the Kaiser rule (eigenvalues > 1.0), the percentage of variance accounted for, and the cohesiveness of the factors (i.e. patterns of loadings), a four-factor solution appeared optimum. The four factors accounted for 43 percent of the variance in responses related to students’ experiences of academic-related stresses, and the varimax rotation converged in four iterations. Table 3 contains the factor loadings, the internal consistency reliability analysis, and the proportion of the observed variance for each factor.

Rotated component matrix * for the Perception of Academic Stress (PAS) scale.

	Factor loading
	1	2	3	4
The competition with my peers for grades is quite intense	0.75
The unrealistic expectations of my parents stress me out	0.72
Examination times are very stressful to me	0.50
I think that my worry about examinations is weakness of character	0.44			0.42
My teachers are critical of my academic performance	0.41		0.42
I believe that the amount of work assignment is too much		0.79
The size of the curriculum (workload) is excessive		0.78
Even if I pass my exams, am worried about getting a job		0.52
The examination questions are usually difficult		0.47
Am confident that I will be successful in my future career			0.71
Am confident that I will be a successful student			0.67
I fear failing courses this year			0.48
I can make academic decisions easily			0.45
I have enough time to relax after work				0.63
The time allocated to classes and academic work is enough				0.59
Teachers have unrealistic expectations of me				0.52
Examination time is short to complete the answers				0.47
Am unable to catch up if getting behind the work				0.46

Factor 1: pressures to perform.

Factor 2: perceptions of workload.

Factor 3: academic self-perceptions.

Factor 4: time restraints .

Factor 1: pressures to perform

This component consists of five items, has an internal consistency of 0.6, and explains 18 percent of the observed variance. It refers to the excessive stresses from the competitive peer pressures, parents’ expectations, and teachers’ critical comments on students’ performance.

Factor 2: perceptions of workload and examinations

This component consists of four items, has an internal consistency of 0.6, and explains 10 percent of the observed variance. The factor refers to stresses relating excessive workload, lengthy assignments, and worried about failing examinations.

Factor 3: self-perceptions

This component consists of five items having an internal consistency of 0.5 and explains 9 percent of the observed variance. It refers to academic self-confidence and confidence for success as a student, in future career and confidence in making the right academic decisions.

Factor 4: time restraints

This component consists of six items having an internal consistency of 0.6 and explains 8 percent of the observed variance. It refers to stresses as a result of limited time allocated to classes, inability to finish homework, the difficulty to catch up if behind, and the limited time to wind up or relax.

There were significant positive correlations ( p > 0.001) between factor scores and between the Pearson product moment correlations. A close inspection of Table 4 reveals the significant correlation between the three factors of the PAS. There were no significant differences between males and females, or across age groups, in the mean scores of the scale’s factors.

Pearson product moment correlations between PAS factors and subscale scores.

Subscale	Factor 1	Factor 2	Factor 3	Factor 4	Subscale 1	Subscale 2	Subscale 3
	1	0.27	0.42	0.40	0.47	0.70	0.41
		1	0.20	0.27	0.46	0.13	0.64
			1	0.20	0.77	0.41	0.34
				1	0.45	0.56	0.81
Subscale 1					1	0.29	0.50
Subscale 2						1	0.46
Subscale 3							1

In this study, the perceptions of sources of stress among the psychology students were included in an 18-Likert-type item scale that had an overall internal consistency reliability of 0.7. There was 89 percent overall agreement among experts about the relevance of its contents to measure students’ sources of academic stress. Students’ experience of academic sources of stress was rated as mild to moderate, and most students reported confidence about their academic skills and confidence in their ability to succeed.

There were no differences between male and female students in their perceptions of academic stress, and factor analysis revealed four factors that explained 43 percent of the variance for this scale. The results from this study demonstrated that the scale’s items, related to academic stress clustered into four constructs (i.e. factors), which resulted in four components. The factors are theoretically meaningful and cohesive, as it was demonstrated by the significant correlations between their scores, supporting evidence for convergent validity. The four extracted factors—Factor 1, “ Pressures to perform,” Factor 2, “ Perceptions of workload,” Factor 3, “ Academic Self-Perception,” and Factor 4, “ Time restraints”—are in concordance with previous research, are theoretically meaningful, and cohesive within the framework of test anxiety.

In this study, Factor 1 “ Pressures to perform ,” which accounts for 18 percent of the variance, represents the experience of academic stress, related to teachers’ and parents’ high expectations and to peer pressures to perform and compete. In this study, however, students who completed the PAS reported mild level of stress for most items administered, despite the fact that the scale was administered around the time of taking a high stakes final examination, which is considered a major source of stress. In this study, moderate-to-severe stress sources were associated with teachers’ criticism of students’ academic performance and associated with the intense competition with peers. Results from this study support the fact that there were positively reported scores reflecting that students were significantly confident about the success in their academic performance and their future career and were confident in making academic decisions. These findings replicate the findings from other studies, which were conducted among medical and dental undergraduate students ( Morse and Dravo, 2007 ).

Evidence for content validity

The considerable effort to carefully develop a table of specifications with items for the present scale plus the systematic input from education experts enhanced the content and face validity of the scale. The follow-up by the experts further enhanced the content validity because of their high agreement on the relevance of the items.

Evidence for convergent validity

From the correlations between the four factors’ scores, there is evidence to support convergent validity for this scale. Convergent validity was demonstrated by the positive significant correlations between the three factors, especially by the significant positive correlation between the scores of Factor 1, “ Pressures to perform ,” and the scores of the other three factors.

Limitations of the study

The sample size was not large, and all patients were recruited from one class.

Notwithstanding the limitations of this study, a brief self-report scale to measure student’s perceptions of academic stress sources was developed. There is acceptable internal consistency reliability, and there is evidence for face, content, and convergent validity of this instrument. In future research, the scale should be administered to a larger, heterogeneous sample of students, and in different educational and cultural settings. Also, future research should examine the relationship between academic stresses and psychiatric disorders especially depression and anxiety disorders, which is lacking in the literature. Last but not least, prophylactic measures were suggested to manage stress among students, to include early identification of individuals who may be more prone to it, and implementation of stress management workshops can be effective. It is believed that implementing a positive student-centered environment is associated with full awareness of what is expected of them and can discuss perceived skills and weaknesses ( Burk and Bender, 2005 ). Others suggested improving the academic environment ( Neveu et al., 2012 ), problem-focused and emotion-focused strategies are the preferred choice to alleviate stress, the use of the student counseling services ( Iqbal et al., 2015 ), and curricular and policy changes aiming at assisting students in coping with identified stressors ( Harikiran et al., 2012 ).

Acknowledgments

The authors would like to extend sincere thanks to all Tanta University faculties who participated in the validity assessments of this instrument. This research project was presented at the 66th Institute on Psychiatric Services (2014), San Francisco, California, USA.

Appendix 1.

The final version of the Perceptions of Academic Stress (PAS) scale.

Please rate your perception about the following statements in contributing to academic stresses
Am confident that I will be a successful student
Am confident that I will be a successful in my future career
I can make academic decisions easily
The time allocated to classes and academic work is enough
I have enough time to relax after work
Please rate your perception about the following statements contributing to Academic Stresses
My teachers are critical of my academic performance
I fear failing courses this year
I think that my worry about examinations is weakness of character
Teachers have unrealistic expectations of me
The size of the curriculum (workload) is excessive
I believe that the amount of work assignment is too much
Am unable to catch up if getting behind the work
The unrealistic expectations of my parents stresses me out
competition with my peers for grades is quite intense
The examination questions are usually difficult
Examination time is short to complete the answers
Examination times are very stressful to me out
Even if I pass my exams, am worried about getting a job

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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

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Exploring Student Stress And How To Cope As A Stressed Student

School can be a challenging time for both college and high school students. With coursework, relationships, extracurricular activities, and family pressure, you may face a wide range of stressors at different stages of your academic career. While occasional stress may not be a problem, stress can become an issue when it interferes with your mental or physical well-being. Let’s take a closer look at how stress may manifest in students, as well as some coping strategies for managing stress during school.

What is stress?

Stress is a physical and mental response to demanding situations. When you’re stressed, you may notice symptoms in your body, such as tense muscles or fluttering in your stomach. You may also notice mental and emotional symptoms, such as irritability and trouble concentrating. These symptoms are your body’s way of preparing you to respond to a threat or challenge.

There are two types of stress: acute stress and chronic stress. Acute stress is stress that comes on quickly (for example, when you get into an argument or are running late to a meeting) and goes away once the situation passes. Chronic stress is often due to ongoing challenges like work or relationship concerns. As a student, you may experience both acute stress and chronic stress during your time in school.

Common causes of stress among high school and college students

Student stress can have a wide range of causes, including schoolwork, social dynamics, and worries about the future. Reasons you might experience stress as a student include:

Pressure to get good grades
Overwhelming amounts of homework or classwork
Trouble balancing schoolwork, your social life, and extracurricular activities
Pressure to get into a good college or graduate school
Standardized tests like the SAT, ACT, or GRE
Bullying or hazing
Challenges in friendships or romantic relationships
Concerns about tuition or student loans
The transition to adulthood

From anxiety to depression: Effects of stress on mental health

Occasional stress may not always be a problem. However, too much stress can have negative mental health effects. Some of the most common include:

Generalized anxiety disorder

Anxiety is a sense of ongoing worry or dread about future events. People with generalized anxiety disorder may experience anxiety about a wide range of concerns, to the extent that it interferes with their daily lives . Generalized anxiety disorder may also cause:

Restlessness or irritability
Feelings of worry that are hard to control
Unexplained muscle pains, headaches, or stomachaches
Trouble sleeping

Panic attacks

Panic attacks are sudden episodes of intense fear. These episodes typically last 5 to 20 minutes, often peaking at about 10 minutes, and may not always have an obvious trigger. When you have a panic attack, you might experience symptoms like:

A rapid heartbeat
Trouble breathing
Nausea or dizziness
An intense fear of dying
Feelings of overwhelming dread

Depression can cause ongoing feelings of sadness, hopelessness, or low energy. Episodes of depression typically last at least two weeks and:

Persistent feelings of sadness or emptiness
Feelings of anger, guilt, or restlessness
A loss of interest in hobbies and relationships
An ongoing lack of energy
Changes in eating and sleeping habits
Negative feelings about oneself

Substance use

When you have trouble controlling your urges to consume something and these challenges are interfering with your life, you may have a substance use disorder. Substance use disorders can develop from using alcohol, drugs, or other habit-forming substances. Symptoms of a substance use disorder may include:

An intense, overwhelming desire to use the substance
Unsuccessful attempts to stop using the substance
Symptoms of withdrawal that can be relieved by using the substance
Challenges in your life or relationships due to using the substance

High blood pressure, muscle pain, and more: Effects of stress on physical health

Beyond mental health, stress—especially chronic stress— can also have negative effects on physical health . Some examples include:

Trouble sleeping

Elevated stress levels can sometimes lead to insomnia. People with insomnia may struggle to fall asleep or stay asleep, or they may wake up at improper times. Not getting enough sleep can lead to daytime sleepiness and trouble concentrating, which may make it harder for students to focus during class, negatively affecting academic performance.

High blood pressure

When you experience stress, your body releases hormones like adrenaline and cortisol. These stress hormones can increase your heartbeat and constrict your blood vessels , leading to a spike in blood pressure. Over time, high blood pressure may contribute to vision loss, heart disease, stroke, and kidney disease .

Aches and pains

When you’re stressed, you may also experience physical pain in your body. While this symptom usually passes when the source of the stress goes away, ongoing stress may lead to your muscles staying in a state of tension. As a result, you may experience effects like tension headaches, migraines, and back and shoulder pain.

Signs you might be a stressed student

Understanding what stress can look like may help you take action to manage it before it can negatively affect your mental and physical health. Signs of stress can look different in different people, but you may be a stressed student if:

You often feel restless, irritable, or “on edge.”
You feel overwhelmed by your responsibilities or assignments.
You experience unexplained stomachaches, headaches, or pain.
You’re having trouble sleeping, or you’re sleeping more than usual.
You’re getting sick more often than usual.
You often struggle to concentrate, make decisions, or remember information.
You’re withdrawing from your relationships.
Other people have noticed changes in your mood or behavior.

How to manage stress in school

Not all stress can be avoided, but by being proactive, you may be able to better manage stress and reduce its effects on your well-being. If you’re a student, the strategies in this section may be helpful, whether you’re currently experiencing stress or you want to protect yourself from stress in the future.

How to manage stress and support your mental health as a high school student

Stress in high school can be especially challenging due to the added uncertainty students may experience about college, work, and standardized tests like the SAT and ACT. If you’re experiencing stress in high school, consider the following tips:

Prioritize your assignments based on their importance, difficulty, and due dates.
Find study techniques that work for you, such as flashcards, gamification, or mnemonic devices.
Turn off your phone before each class to ensure you’re fully present and engaged.
Build a block of free time into your schedule each day, even if you have a busy schedule.
Consider using a planner or other organization tool to manage your schoolwork.
Make time for regular exercise, especially if you aren’t taking any physical education classes.
Get as much quality sleep as you can by following a consistent bedtime schedule and avoiding screens before bed.
Seek support from your friends, family, and teachers if you’re feeling overwhelmed.

Stress management tips for college students

College students may also face unique stressors, such as the transition to independent living, tuition, and specialized coursework. Coping with these stressors may be easier with the following strategies:

Take advantage of campus tutoring, your student success center, and other resources offered by your school.
Build chores like laundry and cooking into your weekly routine.
Surround yourself with a social group that can offer advice and emotional support when you’re stressed.
Keep your workspace tidy and well-organized.
Take advantage of your professors’ office hours if you’re having difficulty with class material.
Create a simple budget for tuition, living expenses, and entertainment.
Break larger assignments into smaller, more manageable chunks and do a little each day.
Join a club, study group, or campus organization where you can connect with others and decompress from your schoolwork.
Avoid overscheduling yourself, especially if you also have an internship or part-time job.

Mental health and stress management resources for students

In addition to the coping strategies mentioned above, students facing high levels of stress may benefit from mental health support. Below, you can find a list of resources for getting advice, managing school-related stress, and connecting with mental health professionals in high school and college:

School psychologists: Many U.S. high schools have at least one psychologist on campus. Your school psychologist may be able to identify mental health concerns and connect you with appropriate mental health resources.
Guidance counselors: Guidance counselors don’t typically offer direct mental health support. However, your school counselor may be able to help you balance your schedule and find academic support like tutoring.
Campus mental health centers: Colleges often provide mental health counseling through their student health centers. Note that during busy academic seasons, you may want to make an appointment in advance to avoid long wait times.
Academic advising: Like high school guidance counselors, academic advisors may be able to help college students build a sustainable course load and manage academic stress.
Helplines: Mental health hotlines like the Crisis Text Line and 988 Suicide & Crisis Lifeline can provide students with quick, short-term support.

Online therapy for stress

You may find it harder to make time to get mental health support if you’re feeling overwhelmed by coursework. Online therapy lets you see a licensed therapist on your own schedule without having to leave the house. You can communicate with a therapist via voice call, video call, or live chat. This flexibility may make it easier to get stress management help when you need it. With online therapy, you can also contact your therapist any time through in-app messaging, and they’ll respond as soon as they can.

Studies show that online therapy can be effective for reducing stress. In a 2022 paper, researchers reviewed data from 13 studies of internet-based therapy for people with elevated stress levels. They found that online therapy effectively reduced symptoms of stress and stress-related disorders .

High school and college students may experience stress for a variety of academic, social, and financial reasons. Stress is a natural physical and mental response to challenging situations, but when stress becomes chronic, it can negatively affect mental and physical health. For this reason, students may benefit from becoming aware of common stress symptoms like muscle pain, irritability, and trouble concentrating. If you are a student experiencing stress, you may benefit from strategies like breaking tasks down, getting plenty of exercise, and taking advantage of school resources to get help. Online therapy is another option for additional mental health support. You can take the first step toward getting help with stress by reaching out to a licensed therapist.

Staying Close With College Friends: How To Maintain Your Friendships After Graduation Medically reviewed by Julie Dodson , MA
How To Study With ADHD: Tips For College Students Medically reviewed by April Justice , LICSW
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Magnolin alleviates cyclophosphamide-induced oxidative stress, inflammation, and apoptosis via Nrf2/HO-1 signaling pathway

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Sinan Ince, Hasan Huseyin Demirel, Ezgi Nur Demirkapi, Ismail Kucukkurt, Abdullah Eryavuz, Damla Arslan-Acaroz, Ulas Acaroz, Ali Tureyen, Magnolin alleviates cyclophosphamide-induced oxidative stress, inflammation, and apoptosis via Nrf2/HO-1 signaling pathway, Toxicology Research , Volume 13, Issue 4, August 2024, tfae129, https://doi.org/10.1093/toxres/tfae129

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In the present study, we investigated the protective effect of magnolin (MAG) against oxidative stress induced by cyclophosphamide (CP) and its role in the Nrf2/HO-1 signaling pathway. Rats were administered MAG (1 mg/kg, i.p.) for 14 days and CP (75 mg/kg, i.p.) on the 14th day. CP administration increased tissue damage, as evidenced by elevated levels of transaminases (aspartate and alanine), alkaline phosphatase, and renal parameters (blood urea nitrogen and creatinine). Additionally, 8-hydroxy-2′-deoxyguanosine and malondialdehyde levels were increased, whereas glutathione levels, along with catalase and superoxide dismutase activities, decreased in CP-treated rats. CP also down-regulated the expression of Bcl-2, HO-1, Nrf2, and NQO-1 , while up-regulating Bax, Cas-3, TNF- α , Cox-2, iNOS, IL-6, IL-1β, and NFκB in liver and kidney tissues. In addition, CP treatment caused histopathological changes in heart, lung, liver, kidney, brain, and testis tissues. Treatment with MAG improved biochemical and oxidative stress parameters and prevented histopathological changes in CP-treated rats. Moreover, MAG suppressed the expression of inflammatory cytokines and apoptosis markers. In conclusion, MAG effectively prevented CP-induced toxicity by reducing oxidative stress, inflammation, and apoptosis, with its protective efficacy associated with the up-regulation of Nrf2/HO-1 signaling.

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IMAGES

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Academic Stress and Mental Well-Being in College Students: Correlations, Affected Groups, and COVID-19
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Therefore, the current research investigates stress among students from family and academic perspectives using Lazaru's theory which describes stress as a relation between an individual and his environment and examines how it impacts students' depression level, leading to their academic performance.
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Academic stress is defined as the transient experience of pressure, anxiety, or distress related to achieving academic goals [].Theoretically, students experience academic stress when they are concerned about their capacity to cope with academic challenges [].Test anxiety, which originally was narrowly defined as the fear of taking tests or exams [], has been shown to strongly overlap with ...
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Previous research has largely failed to separate the between- and within-person effects in the longitudinal associations between academic stress, academic self-efficacy, and psychological distress (symptoms of anxiety and depression). Filling this research gap, this study investigated if academic self-efficacy mediated the relationship between academic stress and psychological distress at the ...
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Academic stress has been described as the mental distress that is associated with the anticipated frustration of an academic failure ... (Donnelly et al. 2009) and encourage the use of a positive outlet for stress reduction. Further, research shows that students having positive relationships with teachers can serve as a protective factor ...
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Although the association from mastery climate to academic stress was relatively weak, it supports the notion that focus on learning is likely to promote a balance between resources for learning and academic demands and thus experience less academic stress. As previous research indicates a positive association between performance climate and ...
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Depression, anxiety, and stress are. interrelated (Adu, 2023). Shared sy mptoms of depression, stress, and anxiety can contribute to. a variety of academic problems that ne gatively impact ...
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These findings align with those from other recent research, including a 2022 study showing that academic stress was a significant predictor of anxiety (β=0.247, t=5.462; P <.001) among college ...
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Frontiers
Academic stress is defined as a student's psychological state resulting from continuous social and self-imposed pressure in a school environment that depletes the student's psychological reserves (42, 43). Students experience academic stress throughout their secondary school , high school , and university (45, 46), educational careers.
Student Stress 101: Understanding Academic Stress
But research shows that feeling overwhelming school-related stress actually reduces your motivation to do the work, impacts your overall academic achievement, and increases your odds of dropping out. Stress can also cause health problems such as depression, poor sleep, substance abuse, and anxiety. For all those reasons—and just because you ...
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While the sources of stress can vary from student to student, several common themes emerge consistently in research and surveys. Academic pressure and workload top the list of stressors for most college students. The relentless cycle of exams, assignments, and projects can leave students feeling overwhelmed and exhausted.
Academic Stress and its Sources Among University Students
The mean of the sample on the total academic stress score was 53.46 (SD=25.70) as reflected in table 1. Using the mean as cut-off for preliminary analysis and interpretation, it was found that 48.80% of students fall under the category of having average to high stress levels.
Perceived academic stress, causes, and coping strategies
The current research focused on undergraduate university students' psychological well-being during the global COVID-19 pandemic, and accessed the prevalence and various variables contributing to academic stress, as well as exploring coping strategies used by students. ... Academic stress and emotional well-being in United States college ...
Anxiety in college: What we know and how to cope
Academic factors like school stress and disengagement from studies are also associated with psychological distress among college ... in Sweden showed that anxiety levels have increased in recent years, especially among young adults. In the US, some research shows a decrease in psychological well-being among adolescents over the past several ...
Perceived Academic Stress, Causes, and Coping Strategies Among
Introduction. Stress is a prevalent mental health disorder among university students. 1 College student stress is mostly attributed to many factors such as academic pressures, social issues, and financial problems. 2, 3 College-related factors contributing to student's stress include, the transition from school to the college environment, the curriculum load, and summative assessments, 4 ...
Student-Athlete Perceptions of Stress, Support, and Seeking Mental
This Original Research is brought to you by the Hospitality, Retail and Sports Management, College of at Scholar Commons. It has been accepted for inclusion in Journal of Issues in Intercollegiate Athletics by an authorized ... and academic stress on illness and injury in Division 1 college football players. The Journal of Strength ...
From academia to addiction: understanding the mechanism ...
Measures Academic stress. Academic stress was measured with a three-item scale that was designed to identify the level of self-perceived academic stress in Chinese PhD students (Zhang et al., 2013).The three items were as follows: "I am worried about how to complete academic/scientific research tasks," "I feel a lot of stress from academic/scientific research work," and "I feel ...
Examining perceptions of academic stress and its sources among
Introduction. Stress among undergraduate and graduate students is multifactorial, arising from both academic and non-academic factors, including socio-cultural, environmental, and psychological attributes (Brand and Schoonheim-Klein, 2009).Stress levels may escalate to significant proportions in some students, to present with symptoms of anxiety especially during tests and examination periods.
Impact of Stress on Students' Academic Performance in ...
The key findings revealed that, long course work is the leading factor which gives academic stress to higher learning Institution students as majority 49 (49.0%) of respondents, on the other hand ...
Exploring Student Stress And How To Cope As A Stressed Student
Academic advising: Like high school guidance counselors, academic advisors may be able to help college students build a sustainable course load and manage academic stress. Helplines: Mental health hotlines like the Crisis Text Line and 988 Suicide & Crisis Lifeline can provide students with quick, short-term support.
Magnolin alleviates cyclophosphamide-induced oxidative stress
Abstract. In the present study, we investigated the protective effect of magnolin (MAG) against oxidative stress induced by cyclophosphamide (CP) and its role in the Nrf2/HO-1 signaling pathway. Rats were administered MAG (1 mg/kg, i.p.) for 14 days and CP (75 mg/kg, i.p.) on the 14th day.

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Academic Stress and Mental Well-Being in College Students: Correlations, Affected Groups, and COVID-19

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Survey design

Participants

Ethical considerations

Questionnaire

Socioeconomic status (SES)

Social support

Mental health

Perceived COVID-19 impact

Future perspectives

Data analysis

Demographic and Educational profile of participants

Socioeconomic status and social support

Mental health and well-being

Perceived impact of the COVID-19 pandemic

Academic stress and future perspectives

Limitations and strengths

Conclusions

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ORIGINAL RESEARCH article

Introduction

Literature Review and Research Hypotheses

Sleep Quality

Mobile Phone Addiction and Sleep Quality and the Relationship Between Perceived Academic Stress and Depression

Study Objectives

Participants

Perceived Academic Stress

Mobile Phone Use Situation and Mobile Phone Addiction

Data Analyses

Descriptive Statistics

Test for Serial Mediation Model

Total, Direct, and Indirect Effects

Depression Among Students

Mediating Role of Mobile Phone Addiction

Mediating Role of Sleep Quality

Serial Mediating Effect of Mobile Phone Addiction and Sleep Quality

Measures to Reduce Depressive Symptoms Among Chinese Students

Limitations

Conclusions

Data Availability Statement

Author Contributions

Conflict of Interest

Publisher's Note

Acknowledgments

Abbreviations

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