exam stress management during covid 19 essay in english

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The impact of COVID-19 on students’ anxiety and its clarification: a systematic review

Mohamad najmi masri, abdulwali sabo, yee cheng kueh.

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Edited by: Jesus de la Fuente, University of Navarra, Spain

Reviewed by: Ismail Xodabande, Kharazmi University, Iran; Dong Yang, Krirk University, Thailand

*Correspondence: Garry Kuan, [email protected]

Yee Cheng Kueh, [email protected]

Received 2023 Apr 13; Accepted 2023 Jul 25; Collection date 2023.

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.

Introduction

Since the emergence of COVID-19 in 2019, every country in the world has been affected to varying degrees. Long-term psychological pressure and anxiety will inevitably damage the physical and mental health of students. This study aimed to examine the effects of the COVID-19 pandemic on students who experienced stress and anxiety and to clarify which intervention was more effective.

A comprehensive literature search was conducted between January 2020 and December 2022 using online databases such as PubMed, Web of Science, Scopus, and Google Scholar by using the following keywords in combination: “COVID-19,” “stress,” “anxiety,” “depression,” and “intervention.” The retrieved literature was screened and reviewed.

A total of 2,924 articles were retrieved using subject and keyword searches. After screening through the titles and abstracts, 18 related studies were retained. Their review revealed that: (1) most studies did not use medication to control stress and anxiety; (2) the standard methods used to reduce stress and anxiety were religion, psychological counseling, learning more about COVID-19 through the media, online mindfulness courses, improving sleep quality, and physical exercise; (3) the most effective interventions were physical activity and raising awareness about COVID-19 through the media and online mindfulness programs. However, some studies show that physical activity cannot directly relieve psychological stress and anxiety.

Limited interventions are effective, but learning more about COVID-19 and using active coping strategies may help reduce stress and anxiety. The implications of COVID-19 are also discussed.

Keywords: COVID-19, stress, anxiety, depression, coping

Since the COVID-19 outbreak in December 2019, the virus has maintained exceptionally high transmission rates, and countries around the world have been greatly affected. According to the World Health Organization’s (WHO) COVID-19 Dashboard (2022), the cumulative number of confirmed cases worldwide exceeded 600 million as of September of that same year. Due to the continuous mutation of COVID-19, the number of confirmed and suspected cases remains high, and people are forced to live with the virus for a long time, which creates a lot of psychological anxiety and stress and seriously affects the normal lives of people around the world ( Peteet, 2020 ).

Although the severity of COVID-19 has decreased over time and the current level of prevention and control of the epidemic in the world has also decreased, COVID-19 has not been eliminated and still poses a threat to humanity ( World Health Organization, 2023a , b ). As noted in the WHO’s most recent official COVID-19 policy brief, the pandemic appears to be in transition after more than 3 years. However, the COVID-19 pandemic remains an acute global emergency, with the risk of the emergence of new variants and future surges remaining real ( World Health Organization, 2023a , b ).

According to data released by the WHO COVID-19 Dashboard of 2023, as of 7 June, there had been 6,941,095 deaths and 767,750,853 confirmed cases of COVID-19 worldwide. Furthermore, according to the WHO Coronavirus (COVID-19) Dashboard, the COVID-19 outbreak has shown unpredictable volatility in terms of weekly changes in the number of confirmed cases worldwide every week since the outbreak began, with the most recent large-scale outbreak appearing in December 2022. In just 4 weeks, the outbreak increased the number of cases worldwide by 97,976,070 ( World Health Organization, 2022a , b ).

It is clear from these findings that COVID-19 remains a threat to humans. To deal with the possibility of a recurrence of the virus pandemic in the future, we need to understand the various effects of COVID-19 on people’s psychological states and develop effective responses.

Many psychological effects have been examined during the virus outbreak at the personal, national, and even international levels ( Fawaz et al., 2023 ). On a personal level, people are more likely to experience fear of getting sick or dying, feeling helpless, and being stereotyped by others ( Salari et al., 2020 ). Mental health can contribute to serious psychological crises. In fact, COVID-19 affected the mental health of medical workers and also the general population ( Chakraborty and Chatterjee, 2020 ; Khatatbeh et al., 2021 ; Chen et al., 2022 ). For healthcare workers, the sudden increase in workload has led to a surge in work stress ( Tabur et al., 2022 ), and the risk of infection at any time has had a negative impact on their psychology ( Wu et al., 2020 ). Witnessing the suffering and death of patients can also have a profound impact on their mental health ( Mosheva et al., 2021 ). In addition, the uncertainty and rapid change of the COVID-19 pandemic mean that they must constantly adapt to new job requirements, changing work processes, and protective measures, and the stress caused by this uncertainty may also increase their anxiety levels ( Deliktas Demirci et al., 2021 ). For the general population, COVID-19 may increase health anxiety and panic, and concern over the risk of infection may cause people to over-interpret common physiological responses ( Marra et al., 2020 ). Reduced human interaction due to fear of infection can also lead to depression and anxiety ( Haider et al., 2020 ). In addition, financial stress and work stress also contribute to a decline in mental health ( Halliburton et al., 2021 ). The WHO has also reported that the COVID-19 pandemic triggered a 25% increase in the prevalence of anxiety and depression worldwide ( World Health Organization, 2022a , b ).

University students face certain peculiarities compared to working adults. They will show emotional instability under pressure. Their psychological characteristics differ from those of the general public or even ordinary young people, and they are high-risk groups for psychological problems ( Kontoangelos et al., 2020 ; Fusar-Poli et al., 2021 ). Under the influence of an external environment, psychological problems such as anxiety, depression, and post-traumatic stress disorder (PTSD) are more likely to occur ( Bruffaerts et al., 2018 ). They face greater academic pressures and challenges, and their worries about academic performance and work prospects are more intense ( Son et al., 2020 ). Compared with adults, they are more susceptible to the adverse effects of distance learning due to their lack of experience in time management ( Singh et al., 2020 ). Most of the students social and interpersonal relationships exist on campus, and COVID-19 isolation has cut off most of their social ties, increased their loneliness, and led to a decline in mental health. This will last for a period of time and will not disappear quickly with the end of the epidemic ( Garris and Fleck, 2022 ). In addition, in terms of independence and social identity, COVID-19 can also have a negative impact on independence and social identity and last for a long time ( Sharaievska et al., 2022 ).

How to deal with the psychological problems faced by university students due to the COVID-19 epidemic has become a crucial research topic at this stage ( González-Sanguino et al., 2020 ). The purpose of this article is to review articles on the different interventions applied to reduce the psychological impact of COVID-19 and to discuss solutions among students. First of all, such research has a long-term and global impact. A large number of studies have confirmed that COVID-19 has broad psychological effects on university students worldwide. Understanding the long-term impact of COVID-19 on the mental health of university students and adaptation strategies can provide experience and lessons for similar emergencies in the future ( De Girolamo et al., 2020 ). Second, by evaluating the effectiveness of different mental health intervention strategies, we can determine which interventions have a positive impact on alleviating mental distress and improving the mental health of university students, which can help guide mental health professionals and policymakers in choosing appropriate intervention strategies to better support their mental health. In addition, by focusing on the mental health of college students, it is helpful to increase public awareness and attention to the mental health of college students and promote overall societal attention to mental health ( Hunt and Eisenberg, 2010 ). There are three problems to be solved in this study: (a) To summarize the effects of COVID-19 on the psychological status of students; (b) To compare the impact of different interventions; (c) To discuss the findings and recommendations for future research in this area.

Methodology

Search strategy.

A literature search was conducted using major computerized databases (e.g., PubMed, Web of Science, Scopus, and Google Scholar) and library holdings for English-language peer-reviewed articles and was reviewed by two additional co-authors. When searching the database, the selected studies were those published from the beginning of January 2020 to December 2022 (because the outbreak of COVID-19 began in December 2019, this study only looked at studies over a three-year period, from January 2020 to December 2022, when searching the databases). The keywords used in this review were “COVID-19,” “anxiety,” “stress,” “student,” and “intervention.” A manual search of the reference lists of relevant studies found in the computerized search was also performed.

Inclusion and exclusion criteria

The inclusion of articles followed a three-phase approach ( Figure 1 ) using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( Moher et al., 2015 ). In the first phase, a total of 3,101 records were initially obtained through an extensive database search. A total of 178 duplicates were identified and removed in this phase. In the second phase, the titles of 2,923 records were screened, and the following records were removed: (a) those that did not refer to the terms “COVID-19” or “anxiety” or “stress” or “student”; (b) all types of literature reviews and guidelines; and (c) those that were not written in English. This process resulted in the removal of 2,496 records. In the third phase, the abstracts or full texts of the remaining 427 records were examined. Records that met the inclusion criteria were studies with an interventional design. Only 18 studies met the inclusion criteria, and the authors and co-authors assessed the quality of these 18 studies and found them to be of good quality for a systematic review and were therefore included in this review.

Flow diagram from identification to inclusion of studies.

Categorization of studies

The impact of covid-19 on the psychological status of students, research on the psychological status of medical college students.

Early in the COVID-19 outbreak, the Association of American Medical Colleges recommended pausing all student clinical rotations while the in-person curriculum moved to virtual modalities. Medical students also reported higher levels of anxiety, stress, and exhaustion, with female students experiencing this more than male students ( Mittal et al., 2021 ). At the College of Medicine of King Saud University, Riyad, Saudi Arabia, a total of 234 medical students found that quarantine caused them to feel emotionally detached from family, colleagues, and friends and reduced their overall work performance and study time. The findings also showed that a quarter of the medical students who participated in the study felt disheartened during the quarantine period ( Meo et al., 2020 ). In a study of 217 undergraduate medical students at a medical college in Chennai, India, there was a significant increase in both the prevalence and level of anxiety and stress ( Saraswathi et al., 2020 ). In an Indonesian study of 1,027 medical students, 44.6% were found to be stressed, 47.8% had anxiety, and 18.6% had depression ( Natalia and Syakurah, 2021 ).

Research on the mental state of the general student population

The psychological state of the general student population has also been a focus of researchers during the COVID-19 pandemic. A study of Bangladesh university students aged 18 to 29 years (59.5% men; mean age 21.4 ± 2 years) revealed that the estimated prevalence of depression, anxiety, and stress was 76.1, 71.5, and 70.1% for at least mild symptoms, 62.9, 63.6, and 58.6% for at least moderate symptoms, 35.2, 40.3, and 37.7% for at least severe symptoms, and 19.7, 27.5, and 16.5% for at least very severe symptoms, respectively. These data are significantly higher than before the COVID-19 pandemic ( Islam et al., 2020 ). In a cross-sectional survey of different populations in Jordan, anxiety was highest among college students during the COVID-19 pandemic, at 21.5%, and college students were found to be at higher risk for depression ( Naser et al., 2020 ). In another study of 69,054 high school students in France, the prevalence of suicidal thoughts, severe distress, high levels of perceived stress, severe depression, and high levels of anxiety were 11.4% (7,891 students), 22.4% (15,463 students), 24.7% (17,093 students), 16.1% (11,133 students), and 27.5% (18,970 students), respectively ( Wathelet et al., 2020 ). Similarly, a study of 1,224 high school students in Brazil reported that the majority of undergraduates presented with symptoms of depression (60.5%), anxiety (52.5%), and stress (57.5%). These data indicated a high prevalence of symptoms of depression, anxiety, and stress in students ( Lopes and Nihei, 2021 ). In summary, numerous studies have reported on the mental health of students during the COVID-19 pandemic, and the results show that the pandemic has caused varying degrees of mental health problems among students, indicating that the presence of COVID-19 has indeed increased psychological stress and anxiety among the student population around the world.

The effects of the different interventions

Since the outbreak of COVID-19, some research studies have tried various ways to reduce people’s stress and anxiety. By collating the existing literature, the primary approaches for reducing stress and anxiety include religious practice, psychological counseling, learning more about COVID-19 through the media, mindfulness online programs, increasing the quality of sleep, and physical activity. Some of the most effective interventions include watching brief Dialectical Behavior Therapy (DBT) skill videos, regular web-based physical education to increase students’ understanding of COVID-19 through social media, and about 2,500 METs of physical activity per week ( Deng et al., 2020 ; Zhang et al., 2020 ; Kheirallah et al., 2021 ; Rizvi et al., 2022 ). Although the effect of some intervention methods is not significant, they play a role as effective mediating factors. These methods include: middle- and long-distance running, boosting satisfaction with distance learning, strengthening psychological resilience, enhancing social support, improving sleep quality, reducing incorrect smartphone use, and catalyzing academic satisfaction ( Franzen et al., 2021 ; Li and Peng, 2021 ; Lin et al., 2021 ; Liu et al., 2021 ; Gabrovec et al., 2022 ; Song et al., 2022 ). The intervention had positive results, and effective alternatives to conventional psychotherapy included behavioral therapy and online mindfulness programs ( Liang et al., 2021 ; Simonsson et al., 2021 ). Some studies have suggested that positive approach coping strategies for COVID-19 are better than negative avoidance coping strategies in improving stress and anxiety ( Banstola et al., 2021 ; Chan et al., 2022 ). A review of the literature identified 18 articles related to COVID-19, anxiety, stress, and the effects of different interventions (all studies are summarized in Table 1 ).

Literature on different interventions evaluated in this study.

Of the 18 articles included, four showed significant effects on students’ stress and anxiety after the intervention ( Deng et al., 2020 ; Zhang et al., 2020 ; Kheirallah et al., 2021 ; Rizvi et al., 2022 ). In a randomized clinical trial, 153 undergraduate students from a large public university in the United States completed three phases of pre-assessment, intervention, and post-assessment over six weeks during the COVID-19 pandemic. During the intervention, participants were randomized to receive animated videos of DBT skills for 14 consecutive days. All participants received ecological momentary assessments of mood, emotion management self-efficacy, and emotional tolerance four times a day. The study found that negative emotions significantly decreased and positive emotions significantly increased before and after watching the videos. There was a significant interaction between time and conditions in the development of emotional tolerance. Compared to the first two weeks, participants in the control group rated their emotions as more intolerable in the third and fourth weeks, whereas participants in the intervention group did not rate their emotions as more intolerable ( Rizvi et al., 2022 ). This proved that DBT techniques can help college students avoid a decline in mental health and that this simple, highly scalable intervention could expand the scope of available mental health treatment.

In a Chinese study, 1,607 college students in Wuhan were asked about their mental health, exercise-related lifestyle, and other issues. The Depression, Anxiety, and Stress Scale (DASS-21) was used to evaluate their mental health. The results showed that lower DASS-21 scores were significantly associated with regular exercise, maintaining exercise habits during the COVID-19 pandemic, exercising more than 1–2 times per week, exercising for ≥1 h, and taking ≥2,000 steps ( Deng et al., 2020 ). This proved that mental status is significantly related to regular exercise and adequate exercise time. In a similar article, a longitudinal survey of 66 college students during the peak of the COVID-19 epidemic in China showed that COVID-19 had a direct negative impact on general sleep quality. In contrast, COVID-19 mediated general negative emotions, stress, anxiety, and sleep quality. In addition, physical activity directly alleviated general negative emotions, with the greatest effect when physical activity was approximately 2,500 METs per week ( Zhang et al., 2020 ).

In a study of all medical students in Jordan, participants self-reported increased levels of negative emotions, such as anxiety, and decreased levels of positive emotions. Nearly half of the participants reported that social media was the primary source of COVID-19 information, with a significant reduction in emotional distress after long-term use of social media for COVID-19 information ( Kheirallah et al., 2021 ). This was evidence that social media has a potentially positive effect on mitigating negative emotions.

Of the 18 included studies, three suggested that improving sleep quality could indirectly improve stress and anxiety in students during COVID-19 ( Zhang et al., 2020 ; Liu et al., 2021 ; Song et al., 2022 ). In a study examining the relationship between perceived stress and depression in medical students during the COVID-19 pandemic and the mediating role of insomnia in this relationship, researchers used the Perceived Stress Scale (PSS), Insomnia Severity Index (ISI), and Patient Health Questionnaire 9 (PHQ-9) to measure perceived stress, insomnia, and depression levels. Results showed that perceived stress was significantly associated with depression. Insomnia mediated the relationship between perceived stress and depression. The indirect effect of insomnia on perceived stress was significant ( Liu et al., 2021 ). This demonstrates that depression in medical students can be effectively reduced by improving sleep quality and relieving perceived stress. In a similar study of 666 medical students in China, anxiety was significantly associated with problematic smartphone use and sleep disturbances during the COVID-19 pandemic. Problematic smartphone use not only directly affected anxiety but also had a significant indirect effect on anxiety through sleep disturbance. Using sleep disturbance as a mediator, a significant reduction in the path coefficient of problematic smartphone use on anxiety was observed. The importance of promoting sleep health to reduce anxiety should be emphasized ( Song et al., 2022 ).

HP Lovecraft, in “Supernatural Horror in Literature” (1927), H.P. Lovecraft wrote: “The oldest and strongest emotion of mankind is fear, and the oldest and strongest kind of fear is fear of the unknown” ( Joshi and Schultz, 2001 ; p. 255). Therefore, among the 18 included studies, five were of the opinion that we should actively face COVID-19 and that increasing its understanding through various means would help reduce students’ stress and anxiety ( Banstola et al., 2021 ; Kheirallah et al., 2021 ; Simegn et al., 2021 ; Yildirim et al., 2021 ; Chan et al., 2022 ).

The study of 202 medical students in Hong Kong about their mental health status, stress coping strategies, and their relationship proved that respondents who adopted an approach strategy had higher Ryff scores than those with avoidant coping strategies, suggesting that approach strategies are more effective in stress management than the more dysfunctional avoidant strategies ( Chan et al., 2022 ). Similarly, Banstola et al. (2021) suggested that adopting adaptive coping strategies helps reduce pandemic-related mental health problems. Kheirallah et al. (2021) suggested that students’ use of social media to increase access to COVID-19 information had a significant effect on reducing emotional distress. Simegn et al. (2021) found that the mental health situation can be improved by the provision of adequate and accurate information and by increasing the self-efficacy of students. Yildirim et al. (2021) indicated that this would be an effective method to provide training to nursing students, to change their negative attitudes, increase their awareness of COVID-19-related death anxiety, improve their coping skills for dealing with death anxiety, and reduce the burden of anxiety. Table 2 provides a summary of the studies included in this review. Across all works, data were derived from assessments of 44,014 participants. Of these, 14,790 were men (33.60%), 26,547 were women (60.32%), and 2,677 were undetermined (6.08%). The number of participants ranged from 40 to 29,663. The studies included 32,973 medical students and 11,041 non-medical students.

Summary of this systematic review.

The research included in this review covers three years (01/2020–12/2022). The participants in these studies were college students. According to the country distribution of the participants, Asia (11), the Americas (2), Europe (4), Australia (0), and Africa (1). From the perspective of the interventions used, the most common effective interventions were sustained physical exercise at a certain intensity for a period of time, maintaining good sleep quality, improving understanding of COVID-19 through multimedia, and facing COVID-19 with more positive attitudes and behaviors. In addition, regular watching of DBT skill videos may help college students avoid mental health issues.

The COVID-19 pandemic has resulted in substantial global mental health challenges, such as increased levels of anxiety and depression symptoms ( Brooks et al., 2020 ; Holmes et al., 2020 ), along with significant variation in anxiety and depression symptoms among residents of different countries ( Ding et al., 2021a , b ). In this review, 18 studies on anxiety and stress levels among students during the COVID-19 pandemic were identified, while also listing the effects of different interventions. The 11 studies that did not explicitly report anxiety among participants all reported higher rates of anxiety among participants; in the seven studies where anxiety was explicitly reported, the average anxiety rate was 77.99%. Hence, this shows the high level of anxiety among students due to COVID-19.

Studies have shown that students’ anxiety about COVID-19 stems not only from concerns about their health but also from the health of those around them ( Al-Kumaim et al., 2021 ). In addition, academic pressure and employment prospects during this period are also major causes of anxiety for students ( Sundarasen et al., 2020 ). In particular, female, rural, low-income, and academically underperforming students are more likely to suffer from psychological distress ( Lee et al., 2021 ). These key findings are of great concern given that mental health is strongly linked to student well-being, academic performance, and employment rates. During the pandemic, student mental health is in crisis and necessitates increased attention and intervention.

The primary focus of this study was to identify more effective interventions. Four of the 18 included studies reported significant reductions in student stress and anxiety. The selected interventions included: (1) Watching DBT skill videos. The results of this study showed that the simple animated DBT skill videos were easily accepted by most of the participants; the intervention showed promising results in reducing negative emotions at the time and preventing students from experiencing increased distress (i.e., finding their emotions more unbearable) as the semester progressed. This intervention is also very easy to implement ( Rizvi et al., 2022 ). (2) 2,500 METs of physical activity per week. The results of this study showed that the persistence of COVID-19 may reduce people’s sleep quality, thereby significantly increasing their negative emotions; maintaining regular exercise can help alleviate this state of mind, and engaging in physical activity (PA) of 2,500 METs per week is the most effective optimal load ( Zhang et al., 2020 ). (3) Extending the use of social media to gain a better understanding of COVID-19 has been shown to reduce students’ fear of COVID-19 and improve their negative mental state ( Deng et al., 2020 ; Kheirallah et al., 2021 ).

Three of the 18 selected studies showed that due to the persistence of COVID-19, students have experienced sleep disturbance or insomnia, and the continuation of this phenomenon will lead to stress and anxiety. Improving sleep quality can indirectly help with these symptoms ( Zhang et al., 2020 ; Liu et al., 2021 ; Song et al., 2022 ). In addition, increasing physical activity is not only beneficial in improving stress and anxiety caused by COVID-19, but it also happens to be an effective way to improve sleep quality ( Piercy et al., 2018 Zhang et al., 2020 ). There is now a consensus that appropriately heightened physical activity can help relieve stress and anxiety, promote blood circulation, relax muscles, and improve sleep quality; multi-component exercise has a significant effect on improving people’s sleep quality and physical fitness ( Yang, 2019 Ai et al., 2022 ).

By synthesizing the results of previous studies, we have drawn a comprehensive summary that includes effective intervention methods and combined these with the current situation. Therefore, we have been able to clearly identify the most effective intervention measures. At this stage, COVID-19 is no longer an unfamiliar disease. As a result, simply getting more information about COVID-19 through social media no longer seems to be an effective way to reduce the resulting stress and anxiety. Although watching DBT skill videos is considered an effective intervention, due to the relatively small number of similar studies, it is not yet possible to provide sufficiently strong evidence. After a comprehensive comparison, it can be found that appropriate physical activity can not only directly reduce the stress and anxiety caused by COVID-19 but can also indirectly relieve these by improving sleep quality. Therefore, this can be regarded as the most effective means of intervention at this stage. Proper physical exercise can also help improve our body’s immune system, increase the speed of antibody production, and improve the ability to resist viral attacks ( Atzrodt et al., 2020 ). Therefore, more research in the future can address the need to improve sleep quality through physical activity to alleviate the perceived stress caused by COVID-19 and effectively reduce students’ anxiety.

The main focus of this paper is to examine the effects of various intervention methods applied during the COVID-19 pandemic. However, there are still some limitations. Firstly, many of the included studies in the literature were cross-sectional studies, meaning that a temporal causal relationship between mental health and stress-coping strategies could not be established. The reason for this is that, although there is a large amount of research on psychological problems caused by COVID-19 at this stage, fewer articles can be retrieved with the inclusion of the keywords “student” and “intervention.” Therefore, future research should focus more on the impact of COVID-19 on students’ mental states and potential solutions. Second, all included studies used self-report methods to assess anxiety and depression scores, and mental health counselors were not asked to evaluate the psychological status of the participants as a form of third-party verification. Although this method simplifies the difficulty of obtaining data on the mental state of subjects, it is highly subjective and may be affected by social desirability bias. However, since all papers considered found a higher rate of anxiety in the study groups, the results are generally reliable. In addition, the participants included in the literature are all college students, so it is impossible to conclude whether the interventions applicable to college students are also applicable to students in other age groups. Similarly, the research subjects included in the literature are mostly medical students. Since these students have medical knowledge and skills, in addition to certain characteristics, it is impossible to conclude whether the interventions applicable to medical students are also applicable to non-medical students.

This study provides a comprehensive look at solutions to student anxiety during COVID-19. By comparing different interventions, we found that appropriate physical activity has unique benefits that not only directly reduce the stress and anxiety caused by COVID-19 but also further alleviate these feelings by improving sleep quality. Currently, the persistence and impact of COVID-19 on daily life present students with unprecedented psychological challenges. Appropriate physical activity, as a comprehensive intervention that provides both a physical and mental health response, was found to be the most effective intervention for students. Of course, we must also acknowledge the limitations of this study and recognize that physical activity, while effective, is not the only solution. A combination of other interventions is also critical when dealing with the stress and anxiety of COVID-19. Therefore, in the future response to the epidemic, we should continue to explore, research, and promote the combination of more targeted physical activities and other interventions to better help students cope with the challenges they may face during COVID-19.

Data availability statement

The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/supplementary material.

Author contributions

JW, GK, HL, and YK conceptualized and designed the original study, from which the data for the analyses presented here were obtained. JW, GK, and YK completed data collection, data analysis, and initial writing. JW, GK, HL, XH, MM, AS, and YK participated in writing and commenting on the manuscript and drafted, edited, and approved its final version. All authors read and agreed to the published version of the manuscript.

This research was supported by the Ministry of Higher Education Malaysia for the Fundamental Research Grant Scheme (FRGS) with project code: FRGS/1/2020/SKK06/USM/03/13.

Conflict of interest

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

Publisher’s note

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

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ORIGINAL RESEARCH article

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

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

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

Introduction

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

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

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

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

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

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

Materials and Methods

Survey instrument.

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

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

Data Analyses

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

Table 1 . Characteristics of the participants in the study.

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

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

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

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

Figure 1 . SWEMWBS and PAS scores for all participants.

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

Table 2 . Results of the MANOVA.

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

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

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

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

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

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

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

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

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

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

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

Limitations

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

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

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

Future Studies

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

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

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

Data Availability Statement

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

Ethics Statement

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

Author Contributions

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

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

Conflict of Interest

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

Publisher's Note

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

Acknowledgments

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

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

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

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

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Copyright © 2022 Barbayannis, Bandari, Zheng, Baquerizo, Pecor and Ming. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Keith W. Pecor, pecor@tcnj.edu

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

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University students’ strategies of coping with stress during the coronavirus pandemic: Data from Poland

Anna babicka-wirkus, lukasz wirkus, krzysztof stasiak, paweł kozłowski.

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

* E-mail: [email protected]

Contributed equally.

Received 2021 Mar 24; Accepted 2021 Jul 9; Collection date 2021.

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

The COVID-19 pandemic has changed the functioning of universities worldwide. In Poland, the transfer to online teaching was announced without prior warning, which radically changed students’ daily functioning. This situation clearly showed the students’ helplessness and difficulties with coping with this new, stressful situation, highlighted in many previous studies. A sudden and far-reaching change in daily functioning caused anxiety, depression, and stress in this group. Thus, from a pedagogical and psychological point of view, it is pertinent to examine the students’ strategies of coping with stress caused by the COVID-19 pandemic. To this end, in 2020, a sample of Polish students was anonymously measured using the Mini-COPE questionnaire. Data was gathered from 577 students from 17 universities. The statistical analysis showed that during the coronavirus pandemic, Polish students most often used the coping strategies of: acceptance, planning, and seeking emotional support. Such factors as age, gender, and place of residence influenced the choice of specific strategies of coping with stress during the COVID-19 pandemic. The results also showed that the youngest students had the lowest coping skills. The results allow for concluding that the students’ maladaptive strategies of coping with stress, especially during the pandemic, may result in long-term consequences for their psychophysiological health and academic achievements. Thus, based on the current results and on the participatory model of intervention, a support program for students is proposed which would involve psychological, organizational, and instrumental support.

Introduction

University studies are a stressful period as they mean the transition to independent, adult life. Beginning studies can be stressful to many students, since it means the necessity to establish new relationships, develop new studying habits related to the chosen program, cope with overwork, learn time management, and often also change one’s place of residence [ 1 , 2 ]. In its later stages, university education is related to new, further stressors, such as concern over being able to find employment after graduation. Studies thus far show that many students struggle to cope with these stressors and that the incidence of stress among students is increasing [ 3 , 4 ]. Among other consequences, it has a negative impact on mental health [ 2 , 5 ]. In the US, around 10% of university students reported suffering from depression [ 2 ], and this proportion has increased to 15% since 2000 [ 6 – 9 ]. A significant causal factor behind this increase is the stress related to studying.

Stress is undoubtedly a part of students’ lives and it may impact their ways of coping with the demands of university life. Their daily responsibilities involve numerous challenges which lead to stress [ 10 ]. Results from various studies carried out thus far show a clear increase in mental health problems among students [ 11 ]. As some of them indicate, there is also an urgent need to assess the impact of the current pandemic on students’ mental health and wellbeing [ 12 ], which legitimizes carrying out such studies in various countries, including Poland.

In 2020, a new situation appeared which necessitates a different approach to stress and its causal factors–the SARS-CoV-2 virus. Data published by the Johns Hopkins University indicates that thus far, over 100 million people have become infected with COVID-19, and around 2.5 million have died [ 13 ]. The COVID-19 disease affects everyone, including students [ 14 , 15 ], since even those who have not been infected are subject to various restrictions which many countries have implemented to limit the spread of the disease. The reality of the pandemic has also negatively impacted the students’ quality of social life. Studying at a university is also a period of establishing new relationships and intense social life. This is facilitated by the fact that young people exhibit greater levels of extraversion and openness to experience than do older people [ 16 ]. Studies show that contacts with others positively influence quality of life [ 17 ]. Lack of regular contact with friends throughout all phases of the coronavirus pandemic, results in loneliness, which might not be fully mitigated by regular contacts via telephone or other means [ 18 ]. These conclusions are supported by evidence from studies carried out in Great Britain (with participants aged between 13 and 25 years), in which young people reported having lost support, daily routine, social ties, and experiencing anxiety, loneliness, and loss of motivation and aim. Higher incidence of depression and anxiety, both during as well as after periods of social isolation, was also confirmed [ 19 , 20 ]. This may lead to harmful social and psychological consequences [ 21 – 23 ].

In response to the pandemic, most countries have implemented severe restrictions in societal functioning which comprise many spheres of life: social, economic, cultural, and educational. They led to limited interpersonal contacts, changes in the mode of education (online teaching), and reduced economic activity. As a result, an economic recession has affected nearly all countries (including Poland) [ 24 ], which worsened the material conditions of many people (increased unemployment). This significantly impacts students, as it intensifies their concerns about being able to find or retain a job and thus support themselves during their studies and after graduation. Essen and Owusu showed that work and studies are the most frequent causes of stress for students [ 25 ]. Historical data shows that previous pandemics have negatively impacted young people’s material conditions, which had long-term consequences for their physical and mental health as well as academic achievement [ 26 ]. For many students, COVID-19 has additionally complicated their current plans and changed their mode of functioning.

More recently, Matthew H. E. M. Browning et al. identified a range of psychological consequences of the COVID-19 pandemic on students’ psychosocial functioning. All students in the sample indicated that the pandemic impacted them negatively, with 59% reporting a high level of psychological impact [ 27 ]. Other studies on the effects of the pandemic on student mental health also show greater stress, anxiety, depression symptoms, concerns for own and one’s family’s health, reduced social interactions, and increased concerns over academic achievements. Students try to cope with stress, seek support from others, and prefer either negative or positive coping strategies [ 11 , 28 ].

The COVID-19 situation, its rapid spread, insufficient preparation, and significant changes in everyday functioning, including university culture, may contribute to increased stress among students. When not managed properly, chronic stress leads to emotional and psychosomatic consequences which manifest through physical, cognitive, and emotional exhaustion as well as depersonalization and lowered professional–in case of students, academic–efficiency [ 29 ]. The consequences of stress lower efficiency, productivity, and engagement in life activities as well as the satisfaction with their results [ 30 , 31 ]. As Adler and Park point out, effective coping with stress might buffer the impact of stressful events on the physical and mental health, and individuals differ with regards to the coping strategies they use [ 32 ]. Therefore, the aims of the study were: identifying the students’ dominant strategies of coping with stress in the pandemic situation, assessing the influence of sociodemographic factors on the dominant coping strategies, and diagnosing differences in the students’ coping strategies depending on expected social support and its sources.

The stress and coping concept is the most popular study approach, also explaining the mechanisms mediating between personality and disease. Currently, the transactional model of stress by Lazarus and Folkman [ 33 ] is employed increasingly frequently. It posits mutual interactions between people and their environment. This model served as the theoretical basis of the current study. The perception of stress is a subjective and variable phenomenon. Particular attention is paid to the processes of coping with stress, which decide the positive and negative impact of stress on the individual. Using different strategies of coping with stress involves mobilizing cognitive and behavioral resources to meet the demands which are subjectively perceived as surpassing personal capabilities. The course of the coping process depends on personal resources and social support. It can also lead to various behaviors which have negative health effects (substance use) or are maladaptive [ 34 ]. Also, according to Lazarus and Folkman, coping with stress might be related to negative health behaviors [ 35 ]. Metzger et al. analyzed the frequency of negative health behaviors among students. They found that increased alcohol consumption and risky sexual behaviors are typical for people at risk for significant stress [ 36 ]. Styles of coping with stress are determined by gender, education, age, health, well-being, the nature of the stressful situation, personality factors, and others [ 20 ]. Efficient use of emotions allows for more effective problem solving, while venting anger and frustration and denial of reality are potentially destructive reactions to stress [ 37 ]. Expressing emotions might also lead to lower depression and hostility levels in stressful situations [ 38 ]. Some authors distinguish between emotion-focused and problem-focused coping styles, while others distinguish active and avoidant coping or identify maladaptive coping strategies (denial, substance use, venting of negative emotions) which allow for lowering subjectively experienced stress [ 39 – 41 ].

Research questions

The study concerned students’ strategies of coping with stress during the pandemic. The following research questions were put forward:

What strategies of coping with stress are most often used by students during the coronavirus pandemic?

What is the relationship between sociodemographic variables and the dominant coping strategies among students?

How does anticipated support differentiate the coping strategies used by students?

Study population and procedure

In 2019, 1.230 million students studied at around 400 universities in Poland. Sixty-five percent were full-time students. Seventy-three percent studied at public (national) universities. The number of foreign students is relatively low in Poland, being only 61 thousand in 2019. Moreover, a decisive majority—around 60%—of students in Poland are women [ 42 , 43 ]. This proportion reaches 65% for MA studies. Meanwhile, in the EU in general, women comprise around 54% of students [ 44 ].

In early spring of 2020, soon after online teaching was instituted, the questionnaire was distributed to students of four randomly chosen Polish universities. Those students who filled out the online questionnaire were also asked to share it with their acquaintances from other universities. Using snowball sampling method was determined by difficulties in reaching students directly, as well as by their reluctance, especially in the first phase of the pandemic in Poland, to take part in studies and fill out online questionnaires. Having students to invite their acquaintances to also take part in the study allowed for gathering a relatively large sample in a short time. There were no missing data, since the online platform did not allow for submitting incomplete questionnaires.

Participation in the study was voluntary. Informed written consent was obtained from every participant. Before participants started to fill out the online study questionnaire, they had to read the information about the project and its aims and checked the option ’I agree to take part in the study’. The data were analyzed anonymously. The research project and its procedure were approved by the Commission of Bioethics and Human Rights.

Using the snowball sampling method, data from 17 Polish institutions was obtained: universities, technical universities, medical universities, and higher vocational schools. This allowed for measuring coping strategies during the pandemic among students from various universities in various regions of Poland. However, it has to be noted that snowball sampling does not allow for generalizing the results to the entire student population in Poland. Nevertheless, based on the obtained data, certain trends in coping strategies among social sciences students can be shown.

The study took place in April-May 2020. Five hundred and seventy-seven complete questionnaires were collected. Table 1 shows the demographic characteristics of the sample divided by universities.

Table 1. Sociodemographic characteristics of the sample.

The data was divided into six groups based on the number of students from each given university who took part in the study. The largest group were the students from the University of Gdańsk (UG). Next, the sample comprised students from: Adam Mickiewicz University in Poznań (UAM) - 22.2%, University of Warsaw (UW) - 17.2%, Jan Kochanowski University of Kielce (UJK- 13.7%, and Pomeranian University in Słupsk (5.9%). Due to a low number of students from other universities, an additional group (different universities—DU) was created, which comprised 6.0% of the total sample.

Polish universities vary with respect to their size and educational profile. There are relatively few large universities with over 20 thousand people (roughly 20 out of 400). Most universities are of medium or small size. The largest university in Poland is the University of Warsaw. It also has one of the broadest selections of programs. A characteristic aspect of Polish universities is that they offer specific educational profiles, for example, universities focusing on medical education. Another example is the Pomeranian University, which specializes in teaching education. Table 2 shows basic characteristics of universities which were widely represented in the research sample [ 45 – 50 ].

Table 2. Characteristics of the universities most widely represented in the current sample.

In the current study, women represented 89.6% of the sample. Participants between 21 and 24 years of age and those living in large cities represented the largest group (59.5% and 36.7%, respectively) Over 80% of the participants were full-time students, which reflected the general population distribution of students in Poland [ 51 ]. Undergraduate students also represented a larger group.

The multidimensional COPE inventory by Carver et al [ 52 , 53 ] is one of the most popular measures of strategies of coping with stress. It can be used to measure dispositional (typical) and situational coping. The Mini-COPE inventory in a Polish adaptation by Juczyński and Ogińska-Bulik [ 54 ] was used in the current study. The internal consistency of the Polish version of the Mini-COPE was estimated based on a sample of 200 people aged between 25 and 60. The split-half reliability was 0.86 (Guttman’s coefficient = 0.87). The repeatability was satisfactory for the majority of the scales. The Polish version of the Mini-COPE comprises 28 items, which form 14 coping strategies. It is used to measure typical reactions in situations of intense stress. The main question is: What do you usually do when you are stressed by a problem? The coping strategies are described in statements such as “I work or do other things in order not to think about the problem.” Each statement is graded on a four-point Likert scale: 1 = very seldom, 2 = fairly seldom, 3 = fairly often, 4 = very often. Each of the 14 coping strategies is measured by two items.

The Mini-COPE inventory was supplemented with two other semi-open questions. The first concerned the type of support the students expected during the pandemic. The available answers were: psychological, emotional, financial, organizational support, no support needed, and other (to be filled out by the students if necessary). The second supplemental question concerned the sources from which the students expected support during the pandemic. In this case, the students could select the closest appropriate answer from among: family, friends, the university, the government, and other (to be filled out by the students if necessary). Fig 1 shows the distribution of the students’ answers to the supplementary questions about support.

Fig 1. Support expected during the pandemic: Type and source.

Regarding the source of support, 5.0% of the students chose “other.” This category comprised the following answers: significant other (0.9%), nobody (1.2%), psychologist/therapist (0.5%), myself (1.4%), all of the above (0.3%), and other combinations indicating two sources, for example, family and the government (0.7%).

Statistical analyses were carried out using the IBM SPSS Statistics 25.0 software. The program was used to calculate basic descriptive statistics together with the Kolmogorov-Smirnov test of normality. Additionally, the Cronbach’s α coefficient was used to calculate the reliability of the Mini-COPE scales. To compare coping strategies between two groups, Mann-Whitney’s U test was used. To compare a higher number of groups, a one-way analysis of variance (ANOVA) was used, and if variance was not equal between the groups, Welch’s correction was additionally applied. Tukey’s HSD test (if variance was homogenous) or Dunnett’s T3 test (if variance was heterogenous) was used for post hoc analyses. To estimate intergroup differences in coping strategies, Pearson’s r correlation analysis was carried out. The significance level was set at α = 0.05. In order to distinguish the groups of participants in terms of coping strategies, a two-step cluster analysis was carried out.

Students’ dominant strategies of coping with stress during the pandemic

Based on the descriptive statistics and the results of the Kolmogorov-Smirnov test of normality, it was concluded that neither of the analyzed variables assumed a distribution close to the Gaussian curve. Skewness values were within the <-2;2> range, which means that it was not significant [ 55 ]. Additionally, the Cronbach’s α coefficient was used to calculate the reliability of the Mini-COPE scales. The analysis showed satisfactory reliability for most of the scales. Relatively low reliability was obtained for the scales of acceptance, humor, self-distraction, and venting of emotions. Detailed results are shown in Table 3 .

Table 3. Basic descriptive statistics with the Kolmogorov-Smirnov test of normality and reliability (Cronbach’s α).

The dominant coping strategies among Polish students were: acceptance, planning, and seeking emotional support. The least frequent strategies were: substance use, denial, behavioral disengagement, and religious coping.

Pearson’s correlation analysis was used to examine the relationships between individual coping strategies in the current sample ( Table 4 ). Active coping was positively correlated with the following coping strategies: planning (strong correlation), positive reframing, religious coping, emotional support seeking, instrumental support seeking, self-distraction, venting of emotions, and self-blame (weak correlations). The higher the frequency of active coping, the higher the frequencies of the above strategies as well. Active coping was moderately and negatively correlated with behavioral disengagement, which means that the higher the frequency of active coping, the lower the frequency of behavioral disengagement.

Table 4. Pearson’s correlation coefficients between the strategies of coping with stress.

* p < 0.05;

** p < 0.01.

Another coping strategy—planning—was positively and weakly-to-moderately correlated with positive reframing, acceptance, religious coping, emotional support seeking, instrumental support seeking, self-distraction, and self-blame. A weak, negative correlation occurred between planning and denial, and a moderate one between behavioral activation—the higher the frequency of planning, the lower the frequency of denial and behavioral disengagement.

Positive reframing was positively and weakly-to-moderately correlated with acceptance, humor, religious coping, emotional support seeking, instrumental support seeking, and self-distraction. This coping strategy was also weakly and negatively correlated with behavioral disengagement and self-blame.

Acceptance was weakly and positively correlated with humor and negatively with denial, behavioral disengagement, and self-blame. In turn, humor was weakly and positively correlated with emotional support seeking, self-distraction, and substance use. A weak and positive correlation also occurred between religious coping and emotional support seeking, instrumental support seeking, and venting of emotions. Religious coping was also weakly and negatively correlated with substance use.

Another strategy—emotional support seeking—was strongly and positively correlated with instrumental support seeking. A weak and positive correlation occurred between the following coping strategies: self-distraction and venting of emotions. Emotional support seeking was weakly and negatively correlated with behavioral disengagement.

On the other hand, seeking instrumental support was weakly-to-moderately and positively correlated with self-distraction, venting of emotions, and self-blame.

Self-distraction was weakly-to-moderately and positively correlated with denial, venting of emotions, substance use, behavioral disengagement, and self-blame.

Denial, venting of emotions, substance use, behavioral disengagement, and self-blame were positively correlated with each other on a weak-to-moderate level (the relationship between behavioral disengagement and self-blame).

The remaining correlations between the coping strategies were not statistically significant.

Students’ strategies of coping with stress–cluster analysis

To distinguish groups of participants based on their coping strategies, a two-step cluster analysis was carried out. It allowed for distinguishing two clusters ( Fig 2 ) for which the silhouette value was 0.2, indicating a satisfactory quality of clustering. From among the coping strategies included in the model, the most important ones were: seeking instrumental support, seeking emotional support, and planning. These strategies differentiated the two clusters to the highest degree. The least important strategies were substance use, denial, and self-blame.

Fig 2. Cluster analysis for strategies of coping with stress.

Table 5 shows the comparison of the clusters with regard to the analyzed strategies. The analysis showed no statistically significant differences for denial, substance use, and self-blame. Differences for other coping strategies were statistically significant, with Cluster 1 participants scoring higher on active coping, planning, positive reframing, humor, religious coping, seeking emotional and instrumental support, self-distraction, and venting of emotions, and lower on behavioral disengagement compared to Cluster 2 participants.

Table 5. Comparisons of coping strategies between the clusters.

Sociodemographic factors and strategies of coping with stress.

To estimate the gender differences in coping strategies, Mann-Whitney’s U test was used. The analysis showed statistically significant gender differences for humor, emotional support seeking, instrumental support seeking, self-distraction, denial, and venting of emotions. Men in the current sample reported using humor significantly more often than women, but they reported using religious coping, emotional support seeking, instrumental support seeking, self-distraction, and denial less frequently. The results of the analysis are shown in Table 6 .

Table 6. Gender differences in strategies of coping with stress.

Gender differences could result from differences in gender role socialization [ 56 , 57 ]. Women are socialized to be more emotional and seek support in interpersonal relationships. On the other hand, men are socialized to cope with their problems on their own or use humor.

Using a one-way analysis of variance (ANOVA), coping strategy use was compared between age groups ( Table 7 ). The analysis showed statistically significant differences for six strategies: active coping, planning, positive reframing, venting of emotions, behavioral disengagement, and self-blame. To estimate the character of the intergroup differences, an additional post hoc analysis using Tukey’s HSD test was carried out when the variance was equal between the groups, and Dunnett’s T3 test, when the variance was unequal. This type of post hoc analysis was used due to the disproportions in the size of the compared groups. In the case of unequal variances, the Welch correction was also applied.

Table 7. One-way analysis of variance of differences in strategies of coping with stress between age groups.

*—Welch’s correction was applied.

18-20-year-olds reported statistically significantly less frequent active coping than did 25-30-year-olds ( p = 0.032) and those 31 and over ( p = 0.032). The youngest participants also reported less frequent planning than did 25-30-year-olds ( p = 0.039) and those 31 and over ( p = 0.045), while 21-24-year-olds reported significantly less frequent planning than 25-30-year-olds ( p = 0.015) and those 31 and over ( p = 0.030). The coping strategy of positive reframing was more frequent in the oldest group compared to the younger groups (p ≤ 0.013). Those 31 and over also reported significantly less frequent venting of emotions compared to 18-20-year-olds ( p = 0.007) and 21-24-year-olds ( p = 0.002). Behavioral disengagement differed significantly between the youngest and the oldest group ( p = 0.014), with the higher frequency of this strategy being reported in the 18-20-year-olds group. Those 31 and over reported less frequent self-blame than did 18-20-year-olds ( p = 0.036) and 25-30-year-olds ( p = 0.019).

The current data show that the oldest students used active coping strategies more often during the pandemic than did the younger students. The aim of these strategies is to solve the problem causing difficult internal tension rather than to avoid the situation altogether. This effect may be related to the older students having greater life experience, including academic experience, at 31 years of age.

In the next step, differences in coping strategy use depending on the place of residence were examined ( Table 8 ). To this end, a one-factor ANOVA was carried out. It showed significant intergroup differences for the following coping strategies: active coping, planning, humor, religious coping, denial, and substance use. Participants living in cities with over 100 thousand residents reported using planning significantly more often than those living in villages ( p < 0.001) or towns up to 20 thousand residents ( p = 0.006).

Table 8. One-factor analysis of variance of differences in strategies of coping with stress depending on place of residence.

Participants living in towns up to 20 thousand residents reported using humor significantly less frequently than those living in cities with over 100 thousand residents ( p = 0.021). Participants living in villages reported using religious coping significantly more often than those living in cities with over 100 thousand residents ( p = 0.004). This is related to a more traditional upbringing and culture in Polish rural regions, where religious rituals play a significant role. Participants living in cities with over 100 thousand residents reported using denial significantly less frequently than those living in villages ( p = 0.002) and in towns with between 20 and 100 thousand residents ( p = 0.034). Substance use was reported more frequently among participants living in biggest cities compared to participants living in villages ( p = 0.002). This is because various psychoactive substances are more easily available in large cities.

After the correction for multiple comparisons was applied, a post hoc analysis using Tukey’s HSD test did not reveal statistically significant intergroup differences in active coping.

To compare full-time and extramural students’ use of coping strategies, Mann-Whitney’s U test was used. It showed that extramural students reported using active coping and positive reframing more frequently, and humor, instrumental support seeking, self-distraction, venting of emotions, substance use, and self-blame less frequently compared to full-time students. The results of the analysis are presented in Table 9 .

Table 9. Comparison of coping strategy use between full-time and extramural students.

Using a one-factor ANOVA, coping strategies were compared between students in different program years. The analysis showed significant differences for four strategies: active coping ( Fig 3 ), planning ( Fig 4 ), positive reframing ( Fig 5 ), and behavioral disengagement ( Fig 6 ).

Fig 3. The coping strategy of active coping (mean) among students in individual program years (F = 5.72, p<0.001, eta = 0.06).

I U–I Undergraduate (n = 142), II U–II Undergraduate (n = 100), III U–III Undergraduate (n = 104), I G–I Graduate (n = 66), II G–II Graduate (n = 70), I-III M–I-III uniform Master’s studies (n = 64), IV-V M–IV-V uniform Master’s studies (n = 31).

Fig 4. The coping strategy of planning (mean) among students in individual program years (F = 4.87, p<0.001, eta = 0.05).

Fig 5. The coping strategy of positive reframing (mean) among students in individual program years (F = 2.51 a , p = 0.023, eta = 0.01).

* Welch’s correction was applied.

Fig 6. The coping strategy of behavioral disengagement (mean) among students in individual program years (F = 3.06, p = 0.006, eta = 0.03).

A detailed post hoc analysis showed that first year undergraduate students reported using active coping less frequently compared to second year graduate students ( p = 0.048), first-third year uniform Master’s students ( p = 0.009), and fourth-fifth year uniform Master’s students ( p < 0.001). Second year undergraduate students also reported using active coping less frequently than did fourth-fifth year uniform Master’s students ( p = 0.001), similar to third year undergraduate students ( p = 0.004). First year undergraduate students reported using planning less frequently compared to second year graduate students ( p = 0.006) and fourth-fifth year uniform Master’s students ( p < 0.001). Fourth-fifth year uniform Master’s students reported using planning more frequently than second year ( p = 0.018) and third year ( p = 0.007) undergraduate students. A significant difference in the frequency of using behavioral disengagement occurred between first year undergraduate students and fourth-fifth year uniform Master’s students ( p = 0.015). First year undergraduate students reported using behavioral disengagement more frequently than did fourth-fifth year uniform Master’s students. For positive reframing, after applying the correction for multiple comparisons, Dunnett’s T3 test did not show statistically significant intergroup differences. A statistical trend ( p = 0.053) was observed between third year undergraduate students and first year graduate students—first year graduate students reported a slightly higher frequency of using positive reframing than did third year undergraduate students.

Students’ strategies of coping with stress and the type and source of needed social support

A one-way ANOVA was used to estimate the differences in coping strategy use depending on the need for a given type of social support ( Table 10 ). The post hoc analysis showed that participants who indicated a need for psychological support reported using the coping strategy of positive reframing less frequently than those who did not indicate any need for support ( p = 0.027). Also, those who indicated a need for financial support reported using positive reframing less frequently than those who did not indicate any need for support ( p = 0.034). Those who did not indicate any need for support used the coping strategy of acceptance more frequently than those who indicated a need for psychological ( p = 0.013) and emotional ( p = 0.002) support. This is due to the fact that these individuals cope with the pandemic-related difficulties on their own. Those who indicated a need for financial support also used religious coping less frequently than those who indicated a need for emotional support ( p = 0.007). Participants who indicated a need for emotional support reported using the coping strategy of emotional support seeking more frequently than those who indicated a need for financial support ( p = 0.004) and those who did not indicate any need for support ( p = 0.034). Analogous differences were observed for instrumental support seeking. Participants who indicated a need for emotional support reported using this coping strategy more often than did those who indicated a need for financial support ( p < 0.001) and those who did not indicate any need for support ( p = 0.001). Those who did not indicate any need for support reported using self-distraction less frequently than those who indicated needing psychological ( p = 0.014) and emotional ( p = 0.003) support. Also, participants who did not indicate any need for support reported using the coping strategy of denial less frequently than did those who indicated a need for psychological ( p = 0.002) or emotional ( p = 0.002) support. Participants who did not indicate any need for support reported using venting of emotions less frequently than did those who indicated a need for psychological ( p < 0.001) and emotional ( p < 0.001) support, whereas participants who indicated a need for financial support reported using venting of emotions less frequently than did those who indicated a need for emotional support ( p = 0.003). Participants who indicated a need for psychological support reported more frequent substance use than did those who did not indicate any need for support ( p = 0.002). Participants also used behavioral disengagement more often than did those who indicated a need for financial ( p = 0.001) and organizational support ( p = 0.001), or did not indicate any need for support ( p < 0.001). In turn, those participants who indicated a need for emotional support reported using behavioral disengagement more frequently than those who did not indicate any need for support at all ( p = 0.006).

Table 10. One-factor analysis of variance of differences in coping strategy use depending on the type of support needed.

Participants who indicated a need for psychological support and emotional support reported using self-blame more often than did those who indicated a need for financial ( p < 0.001, p = 0.003 respectively). Self-blame is a cognitive judgment related to a belief that not making mistakes is extremely important. However, self-blame causes withdrawal from interpersonal relationships and prevents learning from one’s mistakes. Thus, normal sadness and guilt becomes transformed into depressive disorders [ 58 ]. In this case, seeking psychological support seems warranted. People seek to relieve their suffering and solve their problems through utilizing psychological consultations or therapy. However, in contrast to seeking emotional support from significant others within close relationships, individuals seeking psychological support may discount their own agency, responsibility for their decisions, and independent solution-seeking to a greater extent. Additionally, when describing the pandemic situation, it is worth to consider another context of self-blame, namely, the phenomenon of guiltless guilt, that is, guilt without any specific influence on a given situation which is the source of self-blame. This creates a vicious circle which depends psychological suffering [ 59 ].

A one-factor ANOVA also revealed significant differences between the groups distinguished by the source of expected support. These differences were significant for three coping strategies: religious coping ( Fig 7 ), substance use ( Fig 8 ), and self-blame ( Fig 9 ). A detailed post hoc analysis revealed that those participants who expected support from the government used religious coping less frequently than those who expected support from their families ( p = 0.043) or their universities ( p = 0.026). Participants who expected support from their families reported using the coping strategy of substance abuse significantly less frequently than those who expected support from their friends ( p = 0.013). In turn, participants who expected support from their friends reported using self-blame significantly more often than did those who expected support from the government ( p = 0.027).

Fig 7. Students’ use of religious coping (mean) and sources of expected support during the COVID-19 pandemic (F = 3.99, p = 0.007, η 2 = 0.02).

Fig 8. Students’ substance use (mean) and sources of expected support during the COVID-19 pandemic (F = 4.12 a , p = 0.007, η 2 = 0.02).

Fig 9. Students’ use of self-blame (mean) and sources of expected support during the COVID-19 pandemic (F = 3.14, p = 0.024, η 2 = 0.02).

The aim of the current study was to examine the strategies of coping with stress among Polish university students during the coronavirus pandemic, as well as to assess the type of support they expected. An analysis of the empirical results allows for drawing conclusions on this topic.

The transactional model of stress [ 33 ] allowed for identifying a specific relation formed between an individual and their surroundings. The participants in the currents study found themselves in a stressful transaction in which they experienced a real risk in the form of the pandemic situation. Coping is a specific adaptative reaction chosen during the secondary appraisal. It emerges when an individual appraises the situation in terms of harm or risk, that is, as a difficulty. Students differed with respect to their tendency to use specific coping strategies, which does not mean that a given individual’s coping strategies are the same in every situation. Emotion-oriented coping strategies seek to reduce tension and unpleasant emotions which arise in reaction to stressful situations. They are unavoidable particularly when the individual has no influence on the external events. Problem-focused coping involves cognitive and behavioral efforts to reduce stress by trying to solve the problem [ 33 ]. Thus, the main condition for appropriate functioning is to develop optimal strategies of coping with stress.

The results of the current study showed that during the stressful situation of the pandemic, which can cause feelings of uncertainty and crisis [ 60 ], Polish students mainly chose such coping strategies as acceptance, planning, and seeking emotional support. The current studies showed that students more often use coping strategies which, according to Lazarus and Folkman’s theory [ 33 ] are emotion-focused (acceptance, seeking emotional support). On the other hand, planning is a problem-focused coping strategy. These three main strategies seem constructive as they direct people towards a future temporal perspective and might facilitate a reorganization of the values–goals–life plans triad driving the dynamic character of the personality [ 61 ], especially in decisive periods of personal crises [ 62 ]. It is also related to reframing one’s own life situation. Substance use, denial, behavioral disengagement, and religious coping were used the least frequently by Polish students to cope with stress during the pandemic.

Among all groups of people in education, students exhibited higher levels of emotional problems and pressure related to the changes in the educational and social situation during the pandemic than did primary and high school students [ 63 , 64 ]. Thus, it was important to assess their need for support and the sources they expect this support from. The results showed that 78% of the students needed support, while 22% did not express such needs. The greatest proportion of students—25%—needed emotional support. This type of support was mainly sought from family (38%) and friends (26%). Participants who expected emotional support simultaneously chose strategies of support seeking and religious coping. Their search for personal resources which would facilitate coping was oriented at close interpersonal relationships. They most likely allowed for conversations which supported another coping strategy preferred by this group, namely, venting and self-blame. Students seeking emotional support–in contrast to those seeking psychological support–likely maintained closer and deeper interpersonal relationships. On the other hand, psychological support was expected by 16% of the participants. They scored the lowest on the strategy of positive reframing. However, they scored higher on substance use, denial, and venting, as well as self-blame. Such a pattern of coping strategies suggests that use of professional psychological help is warranted. These participants showed such difficulties in coping with the pandemic situation that they concluded they should seek professional help from a psychologist.

Those students who expected organizational (18%) and financial (17%) support reported using different coping strategies than did those who expected emotional and psychological support. Such coping strategies as religious coping, support seeking, venting, substance use, behavioral disengagement, and self-blame were lower in this group. Rather, these participants were oriented at gaining concrete material support and support related to organizing their life in the city where they studied, and sometimes also worked to support themselves financially.

Further analyses showed that those students who indicated a need for emotional and social support reported using the coping strategies of positive reframing and acceptance of the pandemic situation less frequently. Need for emotional, organizational, and psychological support was related to typical stressors (studying, pressure to achieve high grades, pass exams, and qualify for scholarships) [ 65 , 66 ], which remained at similar levels during online teaching. However, it was also related to additional limitations stemming from the digitalization of the teaching process [ 67 ]. Moreover, the need for support was also increased by isolation, limitations in social relationships with peers, and limited possibilities for establishing new relationships and realizing affiliative needs [ 68 , 69 ]. Importantly, these needs concern direct relationships rather than telephone or online contact, as these do not fully mitigate loneliness and do not provide the same amount of support [ 18 ]. Seeking real, direct support, the students expressed a perspective of building psychological resilience and improving their emotional state, which corresponds with the results of Bernabé and Botia [ 70 ]. Students mainly expressed a need for emotional, organizational, and psychological support from their families and friends in order to maintain a high level of functioning, which might be explained through the perspective of the resilience theory [ 71 , 72 ]. This is because resilience is strongly related to, among others, perceived emotional support and close, safe relationships with one’s family and friends [ 73 , 74 ], which create networks of emotional and social support [ 75 , 76 ]. The ability to use support serves as a buffer for stress and its negative consequences. It can also prevent the deepening of the problems by providing resources for coping when stress occurs. Studies confirm that people with access to support show less reactivity to stress factors and enjoy higher mental health [ 77 ].

Next, it was showed that the chosen strategies of coping with stress were related to sociodemographic variables such as gender, age, and place of residence, which was confirmed by Cantor [ 61 ]. A detailed analysis revealed gender differences in the use of some specific coping strategies, which is also supported by other studies [ 78 – 80 ]. Women used the strategies of emotional and instrumental support seeking statistically significantly more often than did men. On the other hand, men used humor as a coping strategy more often than did women.

Regarding age, it was shown that younger people who began studying (18-20-year-olds) reported using active coping and planning statistically significantly less frequently than older students (21-24-year-olds, 25-30-year-olds, and those 31 and above). In turn, the higher frequency of using positive reframing and the lowest frequency of using venting of emotions was reported by the oldest students (31 and above). These age-related differences are difficult to relate to previous studies due to methodological differences [ 81 – 83 ]. The strategy of active coping, characteristic for older students, was positively correlated with planning (strong relationship), positive reframing, religious coping, and emotional and instrumental support seeking, which was confirmed by the cluster analysis. Cluster 1 results (statistically significantly higher active coping, planning, positive reframing, humor, religious coping, emotional and instrumental support seeking, self-distraction, and venting, and lower behavioral disengagement) correspond to this profile of active coping.

The youngest students (18–20 years old) did not choose active (adaptive) coping strategies, in contrast to the older students. It is worth noting that, as the youngest persons in the academic community, they have less life and experience and less environmental resources due to the fact that they did not yet develop close and deep social and emotional relationships. This is related to identity development [ 84 , 85 ]. Additionally, the university is a new setting for such students, which makes it more difficult for them to perceive it as a source of instrumental and organizational support. Thus, the youngest students in particular should be the recipients of complex (psychological, instrumental, possibly also spiritual) support from the university intended to shape appropriate adaptive conditions.

Comparing the full-time and extramural students with respect to their coping strategies, it was found that extramural students scored higher on active coping and positive reframing, and lower on humor, instrumental support seeking, self-distraction, venting, substance use, and self-blame compared to full-time students. It is worth noting that extramural students are usually older than full-time students. Thus, they are at a different developmental period in their lives. They often live with their own families, including their children. They attend classes only during the weekends and are most often employed and financially independent Thus, they have different areas of life activities and exhibit different strategies of coping with stress.

Analyzing the variable of place of residence, it was found that students living in cities with over 100 thousand residents used the coping strategies of planning, humor, and substance use more frequently than did students from smaller towns and villages. These results can be interpreter with reference to Bronfebrenner’s [ 86 ] ecological theory. Larger cities have more (both on the mesosystem and the exosystem levels) infrastructural resources, opportunities related to social life, and institutional offers (even during the periods of pandemic-related restrictions). Thus, people living in large cities were subjected to less social isolation during the pandemic than were the people living in rural areas. However, they used religious coping and denial less frequently, which was used more often by students living in villages. Studies on Polish students carried out before the pandemic using the Mini-COPE did not show differences in coping strategies related to place of residence.

The results of the current study allowed for the identification of coping strategies among students. This is important for the process of designing support strategies at universities. Our study also identified the mechanisms of active (adaptive) and passive (maladaptive) coping and directions of support seeking.

Taking into account the current results, future empirical studies can focus on more detailed examinations of the relationships between specific coping strategies used by students. Additional studies on the influence of the later stages of the pandemic on students’ mental health are necessary, as the consequences of this difficult situation may last for a long time, beyond the most intense period of the pandemic.

Strengths and limitations

The strengths of the current study include an examination of students’ strategies of coping with stress during the pandemic as a global situation which, to some extent, warrants the introduction of monitoring and prevention of the “post-COVID syndrome” in the context of students’ coping with stress and rebuilding social and emotional relationships.

The current results might also serve as a point of reference and comparison for further studies on coping strategies among students in other countries. In turn, this could support the development of local strategies of supporting students in organizing their academic careers and personal lives. This is especially important considering the fact that the occurrence of subsequent pandemics is only a matter of time, as was cautioned by the Director General of the World Health Organization, Tedros Adhanom Ghebreyesus. The UN resolution naming December 27 as the International Day of Epidemic Preparedness acknowledges the disproportional harm they cause in people’s lives and highlights the need for increased awareness, exchange of scientific knowledge, and searching for the best solutions on both the local and national levels. This message finds direct expression in the topic of the current study.

A limitation of the current study is the high proportion of female students of social sciences and humanities in the current sample. In Poland, these programs are more often chosen by women (73%) than men (27%) [ 87 ]. This resulted in a high gender imbalance in the current sample.

Recommendations for universities

The results of the current study lead to formulating several recommendations for universities regarding the organization of teaching in ways that consider the students’ psychosocial functioning to a greater extent. These suggestions include: implementing assessments of students’ psychosocial functioning in order to determine the potential need for emotional, social, and psychological support, and establishing psychological consultation points for students requiring such support.

It also seems warranted to introduce interpersonal training and stress coping workshops for individual student groups. Regarding organizational support, the current results are an argument for providing material support and career counseling in part-time employment for students.

The current results serve as a basis for designing a model of support and-self support solutions for students during the pandemic. The participatory model of intervention development [ 88 ] may be particularly useful in this regard. The Participatory Intervention Model (PIM), rooted in participatory action research, provides aa mechanism for integrating theory, research and practice and for promoting involvement of stakeholders in intervention efforts [ 88 ]. Based on this model, it seems pertinent to revise the role of the year mentor ( opiekun roku ; in Polish universities, students at each year of their academic program are assigned an academic teacher who meets with the students, acquaints them with the university’s structure and the program, etc.) by including screening assessments of the students’ expected sources of support. Additionally, the role of the university counselor should be created. It is worth noting that the youngest students in particular should be incorporated in the design process for such solutions. This is because the presented study shows that the youngest full-time students showed passive and maladaptive coping strategies. Support solutions designed through the participatory model of intervention should be useful for students, should address their specific needs, and should consider the students’ cultural, organizational, and social contexts, including the context of the pandemic and its consequences. Efforts towards designing adequate interventions may prove insufficient if no attempts are made to understand the students’ beliefs, motivations, practices, language, and culture. Such practices can help universities offer more comprehensive support to students of specific populations. Thus, the particular attention should be draw to the notion of acceptability within PIM, which reflects the perception of the beneficiaries (mainly the university inn this context) as partners in identifying problems and developing the offer of psychological, organizational, and instrumental support solutions created through the process of researching the specificity of the pandemic situation and post-pandemic adaptation. Identifying problems, as well as the scope and range of partnership between the university and its personal and infrastructural resources in planning psychological, organizational, and infrastructural support for students requires an evidence base.

The necessity of carrying out research that would lead to effective practical solutions through PIM is also underscored by Nastasi (et. al.) [ 89 ]. The study presented in this article fits this proposal. The current study results showed also that 10% of the sample expecting support from the university. This situation indicates that the current support offer could be insufficient in the context of the pandemic. Thus far, support given to students has been limited mainly to material support–financial support and academic scholarships. Verifying its role as a source of support and an important social environment for its students is also a significant new challenge for universities in the pandemic and post-pandemic reality.

Conclusions

Studies in this direction should continue in order to examine how students cope with subsequent stages of studying both during the pandemic as well as after its end.

Despite the limitations indicated above, the current results contribute to understanding the social and emotional changes related to the coronavirus pandemic, especially in the area of higher education. Studies on stress and coping among students carried out thus far have not sufficiently considered a range of factors such as the study system (paid vs. free), sources of institutional support (scholarships, student loans, material support), unemployment, or job prospects after graduation. Additionally, similarities and differences in the experience of stress and coping strategies between students in various countries (ethnic and cultural differences) have not been researched to an appropriate degree.

The current study indicates, among others, that younger students who are in the beginning stages of their academic careers cope with stress less effectively. This is largely a consequence of the fact that they do not yet possess appropriate life experience, and thus do not have sufficient competences in coping with difficult situations. This suggests that university administrations should pay particular attention to this group. An obligatory course on coping skills should be recommended for the first year curriculum. This could improve students’ competences, wellbeing, and resilience.

Supporting information

Data availability.

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

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

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• Published: 28 March 2024

Medical student wellbeing during COVID-19: a qualitative study of challenges, coping strategies, and sources of support

• Helen M West   ORCID: orcid.org/0000-0001-8712-5890 1 ,
• Luke Flain   ORCID: orcid.org/0000-0001-7296-6304 2 ,
• Rowan M Davies 3 , 4 ,
• Benjamin Shelley 3 , 5 &
• Oscar T Edginton   ORCID: orcid.org/0000-0001-5298-9402 3 , 6  

BMC Psychology volume  12 , Article number:  179 ( 2024 ) Cite this article

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A Publisher Correction to this article was published on 26 June 2024

This article has been updated

Medical students face challenges to their mental wellbeing and have a high prevalence of mental health problems. During training, they are expected to develop strategies for dealing with stress. This study investigated factors medical students perceived as draining and replenishing during COVID-19, using the ‘coping reservoir’ model of wellbeing.

In synchronous interactive pre-recorded webinars, 78 fourth-year medical students in the UK responded to reflective prompts. Participants wrote open-text comments on a Padlet site. Responses were analysed using reflexive thematic analysis.

Analysis identified five themes. COVID-19 exacerbated academic pressures, while reducing the strategies available to cope with stress. Relational connections with family and friends were affected by the pandemic, leading to isolation and reliance on housemates for informal support. Relationships with patients were adversely affected by masks and telephone consultations, however attending placement was protective for some students’ wellbeing. Experiences of formal support were generally positive, but some students experienced attitudinal and practical barriers.

Conclusions

This study used a novel methodology to elicit medical students’ reflections on their mental wellbeing during COVID-19. Our findings reinforce and extend the ‘coping reservoir’ model, increasing our understanding of factors that contribute to resilience or burnout. Many stressors that medical students typically face were exacerbated during COVID-19, and their access to coping strategies and support were restricted. The changes to relationships with family, friends, patients, and staff resulted in reduced support and isolation. Recognising the importance of relational connections upon medical students’ mental wellbeing can inform future support.

Peer Review reports

Medical students are known to experience high levels of stress, anxiety, depression and burnout due to the nature, intensity and length of their course [ 1 ]. Medical students are apprehensive about seeking support for their mental wellbeing due to perceived stigma and concerns about facing fitness to practise proceedings [ 2 ], increasing their vulnerability to poor mental health.

Research has identified that the stressors medical students experience include a demanding workload, maintaining work–life balance, relationships, personal life events, pressure to succeed, finances, administrative issues, career uncertainty, pressure around assessments, ethical concerns, and exposure to patient death [ 3 , 4 ]. In March 2020, the COVID-19 pandemic introduced additional stressors into medical students’ lives. These included sudden alterations to clinical placements, the delivery of online teaching, uncertainty around exams and progression, ambiguity regarding adequate Personal Protective Equipment (PPE), fear of infection, and increased exposure to death and dying [ 5 , 6 ]. Systematic reviews have reported elevated levels of anxiety, depression and stress among medical students during COVID-19 [ 7 ] and that the prevalence of depression and anxiety during COVID-19 was higher among medical students than in the general population or healthcare workers [ 8 ].

While training, medical students are expected to develop awareness of personal mental wellbeing and learn healthy coping strategies for dealing with stress [ 9 ]. Developing adaptive methods of self-care and stress reduction is beneficial both while studying medicine, and in a doctor’s future career. Protecting and promoting psychological wellbeing has the potential to improve medical students’ academic attainment, as well as their physical and mental wellbeing [ 10 ], and it is therefore important for medical educators to consider how mental wellbeing is fostered. Feeling emotionally supported while at medical school reduces the risk of psychological distress and burnout, and is related to whether students contemplate dropping out of medical training [ 11 ]. In their systematic narrative review of support systems for medical students during COVID-19, Ardekani et al. [ 12 ] propose a framework incorporating four levels: policies that promote a supportive culture and environment, active support for students at higher risk of mental health problems, screening for support needs, and provision for students wishing to access support. This emphasis on preventative strategies aligns with discussions of trauma-informed approaches to medical education, which aim to support student learning and prevent harm to mental wellbeing [ 13 ]. Dunn et al. [ 14 ] proposed a ‘coping reservoir’ model to conceptualise the factors that deplete and restore medical students’ mental wellbeing (Fig.  1 ). This reservoir is drained and filled repeatedly, as a student faces demands for their time, energy, and cognitive and emotional resources. This dynamic process leads to positive or negative outcomes such as resilience or burnout.

Coping reservoir model– adapted from Dunn et al. [ 14 ], with permission from the authors and Springer Nature

At present we have limited evidence to indicate why medical students’ mental wellbeing was so profoundly affected by COVID-19 and whether students developed coping strategies that enhanced their resilience, as suggested by Kelly et al. [ 15 ]. This study therefore sought to conceptualise the challenges medical students experienced during COVID-19, the coping strategies they developed in response to these stressors, and the supportive measures they valued. The ‘coping reservoir’ model [ 14 ] was chosen as the conceptual framework for this study because it includes both restorative and depleting influences. Understanding the factors that mediate medical students’ mental wellbeing will enable the development of interventions and support that are effective during crises such as the pandemic and more generally.

Methodology

This research study is based on a critical realist paradigm, recognising that our experience of reality is socially located [ 16 ]. Participant responses were understood to represent a shared understanding of that reality, acknowledging the social constructivist position that subjective meanings are formed through social norms and interactions with others, including while participating in this study. It also draws on hermeneutic phenomenology in aiming to interpret everyday experienced meanings for medical students during COVID-19 [ 17 ]. The use of an e-learning environment demonstrates an application of connectivism [ 18 ], a learning theory in which students participate in technological enabled networks. We recognise that meaning is co-constructed by the webinar content, prompts, ‘coping reservoir’ framework and through the process of analysis.

The multidisciplinary research team included a psychologist working in medical education, two medical students, and two Foundation level doctors. The team’s direct experience of the phenomenon studied was an important resource throughout the research process, and the researchers regularly reflected on how their subjective experiences and beliefs informed their interpretation of the data. Reflexive thematic analysis was chosen because it provides access to a socially contextualised reality, encompasses both deductive and inductive orientations so that analysis could be informed by the ‘coping reservoir’ while also generating unanticipated insights, and enables actionable outcomes to be produced [ 19 ].

Ethical approval

Approval was granted by the University of Liverpool Institute of Population Health Research Ethics Committee (Reference: 8365).

Participants

Fourth-year medical students at the University of Liverpool were invited to participate in the study during an online webinar in their Palliative Medicine placement. During six webinars between November 2020 and June 2021, 78 out of 113 eligible students participated, giving a response rate of 69%. This was a convenience sample of medical students who had a timetabled session on mental wellbeing. At the time, these medical students were attending clinical placements, however COVID-19 measures in the United Kingdom meant that academic teaching and support was conducted online, travel was limited, and contact with family and friends was restricted.

Students were informed about the study prior to the synchronous interactive pre-recorded webinar and had an opportunity to ask questions. Those who consented to participate accessed a Padlet ( www.padlet.com ) site during the webinar that provided teaching on mental wellbeing, self-care and resilience in the context of palliative medicine. Padlet is a collaborative online platform that hosts customisable virtual bulletin boards. During this recording, participants were asked to write anonymous open-text responses to reflective prompts developed from reviewing the literature (Appendix 1 ), and post these on Padlet. The Padlet board contained an Introduction to the webinar, sections for each prompt, links to references, and signposting to relevant support services. Data files were downloaded to Excel and stored securely, in line with the University of Liverpool Research Data Management Policy.

The research team used the six steps of reflexive thematic analysis to analyse the dataset. This process is described in Table  1 , and the four criteria for trustworthiness in qualitative research proposed by Lincoln and Guba [ 20 ] are outlined in Table  2 . We have used the purposeful approach to reporting thematic analysis recommended by Nowell et al. [ 21 ] and SRQR reporting standards [ 22 ] (Appendix 2 ).

Five themes were identified from the analysis:

COVID-19 exacerbated academic pressures.

COVID-19 affected students’ lifestyles and reduced their ability to cope with stress.

COVID-19 changed relationships with family and friends, which affected mental wellbeing.

COVID-19 changed interactions with patients, with positive and negative effects.

Formal support was valued but seeking it was perceived as more difficult during COVID-19.

COVID-19 exacerbated academic pressures

‘Every day feels the same, it’s hard to find motivation to do anything.’

Many participants reported feeling under chronic academic pressure due to studying medicine. Specific stressors reported were exams, revision, deadlines, workload, specific course requirements, timetables, online learning, placement, and communication from University. Some participants also reported negative effects on their mental wellbeing from feelings of comparison and competition, feeling unproductive, and overthinking.

Massive amounts of work load that feels unachievable.

COVID-19 exacerbated these academic stresses, with online learning and monotony identified as particularly draining. However, other students found online learning beneficial, due to reduced travelling.

I miss being able to see people face to face and zoom is becoming exhausting. My mental wellbeing hasn’t been great recently and I think the effects of the pandemic are slowly beginning to affect me.

I also prefer zoom as it is less tiring than travelling to campus/placement.

Clinical placements provided routine and social interaction. However, with few social interactions outside placement, this became monotonous. A reduction in other commitments helped some students to focus on their academic requirements.

‘Most social activity only taking place on placement has made every day feel the same’.

Some students placed high value on continuing to be productive and achieve academically despite the disruption of a pandemic, potentially to the detriment of their mental wellbeing. Time that felt unproductive was frustrating and draining.

‘Having a productive day i.e. going for a run and a good amount of work completed in the day’.

‘Unproductive days of revision or on placement’.

COVID-19 affected students’ lifestyles and reduced their ability to cope with stress

‘Everyone’s mental well-being decreased as things they used for mental health were no longer available’.

Students often found it difficult to sustain motivation for academic work without the respite of their usual restorative activities challenging.

‘Not being able to balance work and social life to the same extent makes you resent work and placement more’.

The competing demands medical students encounter for their time and energy were repeatedly reported by participants.

‘Sometimes having to go to placement + travel + study + look after myself is really tough to juggle!’

However, removing some of the boundaries around academic contact and structure of extracurricular activities heightened the impact of stressors. Many participants focused on organising and managing their time to cope with this. Students were aware that setting time aside for relaxation, enjoyment, creativity, and entertainment would be beneficial for their wellbeing.

‘Taking time off on the weekends to watch movies’.

However, they found it difficult to prioritise these without feeling guilty or believing they needed to ‘earn’ them, and academic commitments were prioritised over mental wellbeing.

‘Try to stop feeling guilty for doing something that isn’t medicine’. ‘Would like to say I’d do more to increase my mental wellbeing but finals are approaching and that will probably have to take priority for the next few months’.

Medical students were generally aware that multiple factors such as physical activity, time with loved ones, spiritual care, nourishment and hobbies had a positive impact on their mental wellbeing. During COVID-19, many of the coping strategies that students had previously found helpful were unavailable.

‘Initially it improved my mental well-being as I found time to care for myself, but with time I think everyone’s mental well-being decreased as things they used for mental health were no longer available e.g. gym, counselling, seeing friends’.

Participants adapted to use coping strategies that remained available during the pandemic. These included walks and time spent outdoors, exercise, journaling, reflection, nutrition, and sleep.

‘Running’. ‘Yoga’. ‘Fresh air and walks’.

A few students also reported that they tried to avoid unhelpful coping strategies, such as social media and alcohol.

‘Not reading the news, not using social media’.

‘Avoiding alcohol as it leads to poor sleep and time wasted’.

Many participants commented on increased loneliness, anxiety, low mood, frustration, and somatic symptoms.

‘Everyone is worn out and demotivated’. ‘Feel that as I am feeling low I don’t want to bring others down’. ‘Feel a lot more anxious than is normal and also easily annoyed and irritable.’

However, not all students reported that COVID-19 had a negative effect on wellbeing. A small minority responded that their wellbeing had improved in some way.

‘I think covid-19 has actually helped me become more self reliant in terms of well-being’.

COVID-19 changed relationships with family and friends, which affected mental wellbeing

‘Family are a huge support for me and I miss seeing them and the lack of human contact.’

Feeling emotionally supported by family and friends was important for medical students to maintain good mental wellbeing. However, COVID-19 predominantly had a negative impact on these relationships. Restrictions, such as being unable to socialise or travel during lockdowns, led to isolation and poor mental wellbeing.

‘Not being able to see friends or travel back home to see friends/family there’.

Participants frequently reported that spending too much time with people, feeling socially isolated, being unable to see people, or having negative social experiences had an adverse effect on their mental wellbeing. Relationships with housemates were a key source of support for some students. However, the increased intensity in housemate relationships caused tension in some cases, which had a particularly negative effect.

‘Much more difficult to have relationships with peers and began feeling very isolated’. ‘Talk about some of the experiences I’ve had on placement with my housemates’. ‘Added strain on my housemates to be the only ones to support me’.

Knowing that their peers were experiencing similar stressors helped to normalise common difficulties. The awareness that personal contacts were also struggling sometimes curtailed seeking informal support to avoid being a burden.

‘Actually discussing difficulties with friends has been most helpful, as it can sometimes feel like you’re the only one struggling, when actually most people are finding this year really difficult’. ‘Family and friends, but also don’t want to burden them as I know I can feel overwhelmed if people are always coming to me for negative conversations’.

COVID-19 changed interactions with patients, with positive and negative effects

‘With patients there has been limited contact and I miss speaking to patients.’

Some students reported positive effects on relationships with patients, and feeling a sense of purpose in talking to patients when their families were not allowed to visit. Medical students felt a moral responsibility to protect patients and other vulnerable people from infection, which contributed to a reduction in socialising even when not constrained by lockdown.

‘Talking to patients who can’t get visitors has actually made me feel more useful’. ‘Anxiety over giving COVID-19 to patients or elderly relatives’.

Students occasionally reported that wearing PPE made interactions with patients more challenging. Students’ contact with patients changed on some placements due to COVID-19, for example replacing in-person appointments with telephone consultations, and they found this challenging and disappointing.

‘Masks are an impediment to meaningful connections with new people’. ‘GP block when I saw no patients due to it all being on the telephone’.

Formal support was valued but seeking it was perceived as more difficult during COVID-19

‘Feel a burden on academic and clinical staff/in the way/annoying so tend to just keep to myself.’

Many participants emphasised the primary importance of support from family and friends, and their responses indicated that most had not sought formal support. While staff remained available and created opportunities for students to seek support, factors such as online learning and increased clinical workloads meant that some students found it harder to build supportive relationships with academic and placement staff and felt disconnected from them, which was detrimental for wellbeing and engagement.

‘Staff have been really helpful on placement but it was clear that in some cases, staff were overwhelmed with the workload created by COVID’. ‘Even though academic staff are available having to arrange meetings over zoom rather than face to face to discuss any problem is off putting’.

A few students described difficulty knowing what support was available, and identifying when they needed it.

‘It’s difficult to access support when you’re not sure what is available. Also you may feel your problems aren’t as serious as other people’s so hold off on seeking support’.

Formal support provided within the University included meetings with Academic Advisors, the School of Medicine wellbeing team, and University counselling service and mental health advisory team. It was also available from NHS services, such as GPs and psychological therapies. Those who had accessed formal support mostly described positive experiences with services. However, barriers to seeking formal support, such as perceived stigma, practicalities, waiting times for certain services, and concern that it may impact their future career were reported by some participants.

‘It is good that some services offer appointments that are after 5pm- this makes it more accessible to healthcare students’. ‘Had good experience with GPs about mental health personally’. ‘Admitting you need help or asking for help would make you look weak’. ‘Reassurance should be provided to medical students that accessing the wellbeing team is not detrimental to their degree. If anything it should be marketed as a professional and responsible thing to do’.

Some students preferred the convenience of remote access, others found phone or video impersonal and preferred in-person contact.

Students expressed that it was helpful when wellbeing support was integrated with academic systems, for example Academic Advisors or placement supervisors.

‘My CCT [primary-care led small group teaching] makes sure to ask how we are getting on and how our placements are going, so I think small groups of people with more contact with someone are more useful then large groups over zoom’. ‘Someone to speak to on palliative care placement, individual time with supervisor to check how we are doing (wellbeing, mental health) - would be a nice quick checkup’.

Participants typically felt able to share openly in an anonymous forum. Reading peers’ comments helped them to see that other students were having similar experiences and challenged unhealthy comparisons.

‘I definitely shared more than I would have done on a zoom call’. ‘I loved this session as it makes you feel like you’re not alone’. ‘Reassuring to know that there are others going through similar things as you’.

Our findings demonstrate that the COVID-19 pandemic exacerbated the stressors medical students experience, and removed some rewarding elements of learning, while reducing access to pre-existing coping strategies. The results support many aspects of the ‘coping reservoir’ framework [ 14 ]. Findings corroborate the restorative effects of psychosocial support and social/healthy activities such as sleep and physical activity, and the depletion of wellbeing due to time and energy demands, stress, and disruptions relating to the pandemic such as online teaching and limited social interaction. Feeling a sense of purpose, from continuing studying or interactions with patients for example, was restorative for wellbeing. Mentorship and intellectual stimulation were present in the responses, but received less attention than psychosocial support and social/healthy activities. Internal conflict is primarily characterised by Dunn et al. [ 14 ] as ambivalence about pursuing a career in medicine, which was not expressed by participants during the study. However, participants identified that their wellbeing was reduced by feeling unproductive and lacking purpose, feeling guilty about taking time for self-care, competing priorities, and comparison with peers, all of which could be described as forms of internal conflict. Different restorative and draining factors appeared to not be equally weighted by the participants responding to the prompts: some appear to be valued more highly, or rely on other needs being met. Possible explanations are that students may be less likely to find intellectual stimulation and mentorship beneficial if they are experiencing reduced social support or having difficulty sleeping, and internal conflict about pursuing a career in medicine might be overshadowed by more immediate concerns, for example about the pandemic. This prioritisation resembles the relationship between physiological and psychological needs being met and academic success [ 23 ], based on Maslow’s hierarchy of needs [ 24 ]. A revised ‘coping reservoir’ model is shown in Fig.  2 .

Coping reservoir model - the effects of COVID-19 on restorative and depleting factors for medical students, adapted from Dunn et al. [ 14 ], with permission from the authors and Springer Nature

Relational connections with family, friends, patients, and staff were protective factors for mental wellbeing. Feeling emotionally supported by family and friends is considered especially important for medical students to maintain good mental wellbeing [ 11 ]. These relationships usually mitigate the challenges of medical education [ 25 ], however they were fundamentally affected by the pandemic. Restrictions affecting support from family and friends, and changes to contact with patients on placement, had a negative effect on many participants’ mental wellbeing. Wellbeing support changed during the pandemic, with in-person support temporarily replaced by online consultations due to Government guidelines. Barriers to seeking formal support, such as perceived stigma, practicalities, and concern that it may impact their future career were reported by participants, reflecting previous research [ 26 ]. Despite initiatives to increase and publicise formal support, some students perceived that this was less available and accessible during COVID-19, due to online learning and awareness of the increased workload of clinicians, as described by Rich et al. [ 27 ]. These findings provide further support for the job demand-resources theory [ 28 , 29 ] where key relationships and support provide a protective buffer against the negative effects of challenging work.

In line with previous research, many participants reported feeling under chronic academic pressure while studying medicine [ 3 ]. Our findings indicate that medical students often continued to focus on achievement, productivity and competitiveness, despite the additional pressures of the pandemic. Remaining productive in their studies might have protected some students’ mental wellbeing by providing structure and purpose, however students’ responses primarily reflected the adverse effect this mindset had upon their wellbeing. Some students felt guilty taking time away from studying to relax, which contributes to burnout [ 30 ] , and explicitly prioritised academic achievement over their mental wellbeing.

Students were aware of the factors that have a positive impact on their mental wellbeing, such as physical activity, time with loved ones, spiritual care, nourishment and hobbies [ 31 ]. However, COVID-19 restrictions affected many replenishing factors, such as socialising, team sports, and gyms, and intensified draining factors, such as academic stressors. Students found ways to adapt to the removal of most coping strategies, for example doing home workouts instead of going to the gym, showing how they developed coping strategies that enhanced their resilience [ 15 ]. However, they found it more difficult to mitigate the effect of restrictions on relational connections with peers, patients and staff, and this appears to have had a particularly negative impact on mental wellbeing. While clinical placements provided helpful routine, social interaction and a sense of purpose, some students reported that having few social interactions outside placement became monotonous.

Our findings show that medical students often felt disconnected from peers and academic staff, and reported loneliness, isolation and decreased wellbeing during COVID-19. This corresponds with evidence that many medical students felt isolated [ 32 ], and students in general were at higher risk of loneliness than the general population during COVID-19 lockdowns [ 33 ]. Just as ‘belongingness’ mediates subjective wellbeing among University students [ 34 ], feeling connected and supported acts as a protective buffer for medical students’ psychological wellbeing [ 25 ].

Translation into practice

Based on the themes identified in this study, specific interventions can be recommended to support medical students’ mental wellbeing, summarised in Table  3 . This study provides evidence to support the development of interventions that increase relational connections between medical students, as a method of promoting mental wellbeing and preventing burnout. Our findings highlight the importance of interpersonal relationships and informal support mechanisms, and indicate that medical student wellbeing could be improved by strengthening these. Possible ways to do this include encouraging collaboration over competition, providing sufficient time off to visit family, having a peer mentor network, events that encourage students to meet each other, and wellbeing sessions that combine socialising with learning relaxation and mindfulness techniques. Students could be supported in their interactions with patients and peers by embedding reflective practice such as placement debrief sessions, Schwartz rounds [ 35 ] or Balint groups [ 36 ], and simulated communication workshops for difficult situations.

Experiencing guilt [ 30 ] and competition [ 4 ] while studying medicine are consistently recognised as contributing to distress and burnout, so interventions targeting these could improve mental wellbeing. Based on the responses from students, curriculum-based measures to protect mental wellbeing include manageable workloads, supportive learning environments, cultivating students’ sense of purpose, and encouraging taking breaks from studying without guilt. Normalising sharing of difficulties and regularly including content within the curriculum on self-care and stress reduction would improve mental wellbeing.

In aiming to reduce psychological distress among medical students, it is important that promotion of individual self-care is accompanied by reducing institutional stressors [ 11 , 29 ]. While the exploration of individual factors is important, such as promoting healthy lifestyle habits, reflection, time management, and mindset changes, this should not detract from addressing factors within the culture, learning and work environment that diminish mental wellbeing [ 37 ]. Heath et al. [ 38 ] propose a pro-active, multi-faceted approach, incorporating preventative strategies, organisational justice, individual strategies and organisational strategies to support resilience in healthcare workers. Similarly, trauma-informed medical education practices [ 13 ] involve individual and institutional strategies to promote student wellbeing.

Students favoured formal support that was responsive, individualised, and accessible. For example, integrating conversations about wellbeing into routine academic systems, and accommodating in-person and remote access to support. There has been increased awareness of the wellbeing needs of medical students in recent years, especially since the start of the pandemic, which has led to improvements in many of these areas, as reported in reviews by Ardekani et al. [ 12 ] and Klein and McCarthy [ 39 ]. Continuing to address stigma around mental health difficulties and embedding discussions around wellbeing in the curriculum are crucial for medical students to be able to seek appropriate support.

Strengths & limitations

By using qualitative open-text responses, rather than enforcing preconceived categories, this study captured students’ lived experience and priorities [ 4 , 31 ]. This increased the salience and depth of responses and generated categories of responses beyond the existing evidence, which is particularly important given the unprecedented experiences of COVID-19. Several strategies were used to establish rigour and trustworthiness, based on the four criteria proposed by Lincoln and Guba [ 20 ] (Table  2 ). These included the active involvement of medical students and recent medical graduates in data analysis and the development of themes, increasing the credibility of the research findings.

Potential limitations of the study are that participants may have been primed to think about certain aspects of wellbeing due to data being collected during a webinar delivered by medical educators including the lead author at the start of their palliative medicine placement, and the choice of prompts. Data was collected during the COVID-19 pandemic, and therefore represents fourth year medical students’ views in specific and unusual circumstances. Information on this context is provided to enable the reader to evaluate whether the findings have transferability to their setting. Responses were visible to others in the group, so participants may have influenced each other to give socially acceptable responses. This process of forming subjective meanings through social interactions is recognised as part of the construction of a shared understanding of reality, and we therefore view it as an inherent feature of this methodology rather than a hindrance. Feedback on the webinar indicated that students benefitted from this process of collective meaning-making. Similarly, researcher subjectivity is viewed as a contextual resource for knowledge generation in reflexive thematic analysis, rather than a limitation to be managed [ 19 ]. The study design meant that different demographic groups could not be compared.

Padlet provided a novel and acceptable method of data collection, offering researchers and educators the potential benefits of an anonymous forum in which students can see their peers’ responses. The use of an interactive webinar demonstrated a potential application of connectivist pedagogical principles [ 18 ]. Researchers are increasingly using content from online forums for qualitative research [ 40 ], and Padlet has been extensively used as an educational tool. However, to the authors’ knowledge, Padlet has not previously been used as a data collection platform for qualitative research. Allowing anonymity carried the risk of students posting comments that were inappropriate or unprofessional. However, with appropriate guidance it appeared to engender honesty and reflection, provided a safe and collaborative learning environment, and student feedback was overwhelmingly positive. It would be useful to evaluate the effects of this reflective webinar on medical students’ mental wellbeing, given that it acted as an intervention in addition to a teaching session and research study.

Students were prompted to plan what they would do following the webinar to improve their mental wellbeing. A longitudinal study to determine how students enacted these plans would allow a more detailed investigation of students’ self-care behaviour.

While we hope that the stressors of COVID-19 will not be repeated, this study provides valuable insight into medical students’ mental wellbeing, which can inform support beyond this exceptional time. The lasting impact of the pandemic upon medical education and mental wellbeing remains to be seen. Nevertheless, our findings reinforce and extend the coping reservoir model proposed by Dunn et al. [ 14 ], adding to our understanding of the factors that contribute to resilience or burnout. In particular, it provides evidence for the development of interventions that increase experiences of relational connectedness and belonging, which are likely to act as a buffer against emotional distress among medical students.

Data availability

The datasets generated and analysed during the study are available from the corresponding author on reasonable request.

Change history

26 june 2024.

A Correction to this paper has been published: https://doi.org/10.1186/s40359-024-01813-7

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Acknowledgements

We would like to thank Dr P Byrne for providing guidance, Mrs A Threlfall and Professor VCT Goddard-Fuller for commenting on drafts, and the medical students who participated in the webinars.

This study was unfunded.

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Helen M West

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School of Medicine, University of Liverpool, Liverpool, UK

Rowan M Davies, Benjamin Shelley & Oscar T Edginton

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Calderdale and Huddersfield NHS Foundation Trust, West Yorkshire, UK

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Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK

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Contributions

HMW conceptualised the study and collected the data. HMW, LF, RMD, BS and OTE conducted data analysis. HMW, LF, RMD and OTE wrote the manuscript. All authors reviewed the manuscript.

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Correspondence to Helen M West .

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Approval was granted by the University of Liverpool Institute of Population Health Research Ethics Committee (Reference: 8365). Students were fully informed about the study prior to the workshop and had an opportunity to ask questions. Participants provided informed consent, completing an electronic consent form before responding to prompts. The study was conducted in accordance with relevant guidelines and regulations, including the University of Liverpool Research Ethics and Research Data Management Policies, and the Declaration of Helsinki.

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West, H.M., Flain, L., Davies, R.M. et al. Medical student wellbeing during COVID-19: a qualitative study of challenges, coping strategies, and sources of support. BMC Psychol 12 , 179 (2024). https://doi.org/10.1186/s40359-024-01618-8

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Received : 12 December 2023

Accepted : 22 February 2024

Published : 28 March 2024

DOI : https://doi.org/10.1186/s40359-024-01618-8

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