The association between stressful life events and mental health among Cypriot university students: A cross-sectional descriptive correlational study

doi:10.21203/rs.3.rs-2321466/v1

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Research Article

The association between stressful life events and mental health among Cypriot university students: A cross-sectional descriptive correlational study

https://doi.org/10.21203/rs.3.rs-2321466/v1

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Background

Previous research indicates a causal link between stressful life experiences and mental health status. However, little is currently known about the impact of the frequency and seriousness of recent stressful life events on clinical mental discomfort among college students. The aim of this study was to explore the mental health status of undergraduate university students in Cyprus, particularly the association between the severity and number of stressful life events and their mental health status.

Methods

This cross-sectional descriptive correlational study was conducted to evaluate mental health among undergraduate students. The General Health Questionnaire-28 (GHQ-28) scale was applied to assess the psychological symptoms of the students and the Life Events Scale for Students (LESS) instrument stressful life events.

Results

After adjusting for socio-demographic characteristics with logistic regression analysis, it was confirmed that the variable that remained before and after the comparison of stressful life events is gender, with females being 1.6 times more likely to report clinical mental distress symptoms (95% confidence interval [CI]: 0.98–2.46). An association exists between clinical mental distress symptoms (GHQ-28 ≥ 24) and stressful life events, which are indicative of the severity of life stressors in a student’s life, and clinically significant mental distress symptoms (x² = 56.64, df = 1, p < .001), where an association was observed between high scores on the LESS. However, a statistically significant association was observed between gender and mental distress symptoms. Specifically, females had a higher level of mental distress than did males [n = 595 (56.6%) vs. n = 213 (47.4%), x² = 10.65, OR: 1.44, 95% CI: 1.15–1.80, p = .001].

Conclusion

Individual characteristics, stress, negative life events and psychological distress are all interconnected. University students are a population that is at risk of mental disorders owing to the exceptionally high frequency of mental health issues in this group. The findings emphasise the necessity of widespread early interventions to shield university students against the onset of severe mental illness.

GHQ-28 scale

Life Events Scale for Students (LESS)

stressful life events

mental health status

mental distress

university students

Globally, 35% of university students experience a mental disorder [1], and up to two-thirds of students can face challenges to optimal mental health, such as stress and anxiety [2, 3].

According to the Healthy Minds Study, which gathered information from 373 campuses nationally, more than 60% of college students during the 2020–2021 academic year satisfied the criteria for at least one mental health concern [4]. In terms of a student’s life, attending university could be a rewarding and pleasant experience. However, empirical data suggest that being a university student can sometimes be a stressful experience [5].

The pressure to perform academically, balancing priorities, fear of failure, critical incidents, economic and social problems, terrible relationships or post-graduation plans are the most common obstacles in a student’s life [6–9]. Studies have repeatedly shown that college students experience more mental anguish compared to the overall population [10].

While some undergraduate students may rely on formal services such as therapy to manage their mental health issues, many use informal help (e.g. friends or family), seek no support or employ potentially harmful methods to handle distress, such as heavy alcohol use [11].

These responses may lead to a further deterioration in mental health and intensify the challenges faced by academics and individuals [12].

Some authors claim that stress affects the academic success and well-being of students [13]. Accordingly, student stress affects students' performance, since pressure increases learning difficulties and should be a priority for researchers to analyse and explore this topic [14].

Several authors concluded that over the course of the curriculum, the causes of stress reduce and the remaining stressors are the same as those experienced by new practitioners [15]. The stress sources found in students are grouped into three categories: educational stress factors (related to testing and assessment, fear of failure and academic workload problems), stress factors (related to associated with training, fear of committing mistakes, and personal and social stress factors (linked to financial issues and life, research and family balance) [13, 14]. Nonetheless, these two studies did not agree on the factors that were most common among them or the most common among the students.

Various studies have also defined the effects of pressure faced by students, including anxiety, nervousness, depression, fear, disappointment, rage, sadness, isolation and feelings of inferiority or exhaustion [14]. All these factors could clearly affect the academic achievement and learning outcomes of students.

Research has shown the efficacy of techniques such as in-class relaxation training, mindfulness and carefulness exercises to strengthen the mental health of students, including stress reduction, anxiety and depression symptoms [16, 17].

A new systematic review revealed that teachers use a variety of approaches to alleviate the stress and anxiety of students, incorporating in the classroom a multitude of techniques such as art therapy, biofeedback calming, pet therapy, guided photography, co-meditation, aromatherapy, mindfulness, deep breathing and cognitive behavioural therapy [18].

Aim

The aim of the present study was to explore (a) the mental health status of undergraduate university students in Cyprus; (b) the association between mental health status and the severity and number of stressful life events; c) the differences in clinical mental distress by gender and the severity and number of stressful life events in LESS; and the associations between clinical mental distress and (i) socio-demographic characteristics and (ii) stressful life events.

Design and Study population

The present cross-sectional study was a convenience sample design. The study was carried out to evaluate mental health status among all undergraduate students of the Cyprus University of Technology. Following the design study population of our previous study [19]. All undergraduate students (1,783 at the time of the study) were eligible to participate, independent of age, gender, and nationality. Post graduate and doctoral students were excluded. In the final sample were included 1500 undergraduate students (response rate of 85%).

Ethical considerations

Ethical approval for the study was granted by the Cyprus National Bioethics Committee [Ref. No 2010.01.38]. Potential participants were informed of the research’s objectives, hazards and advantages. They were also made aware that participation in the study was completely voluntary and that they could withdraw their participation at any time. The study was given the go-ahead by the Ethical Committee of the university before any data were collected. Each participant signed and provided a voluntary informed consent form. No financial incentive was given to the participants. Students who participated in the study had no instructional relationship with the researchers who administered the questionnaires.

Depending on their responses to the questionnaires, participants were told of the availability of a free psychological counselling service for university students at the end of the administration. This study was approved by the research ethics committee of Cyprus University of Technology in Limassol.

Procedures

The Life Events Scale for Students (LESS) and the General Health Questionnaire-28 (GHQ-28), as well as an informational page outlining the goals and methods of the study, were all included in the questionnaire pack. This pack was given out to the students during lecture periods in lecture halls or labs, and participation in the study required written consent. Participation was completely optional, anonymous and confidential. The students who did not want to participate had the option to not fill out the questionnaire after a brief introduction. In sealed envelopes, the completed questionnaire packs were placed in sealed envelopes and returned in a collection box. The research team made sure that the data-gathering process would not conflict with final exams, midterm exams or any other potential study-related stress scenarios, such clinical placements or internships.

Instruments

GHQ-28 scale

The GHQ-28 scale is used to evaluate 28 psychological symptoms that have previously been or are currently present. Garyfallos et al. [20] used a sample of clinic outpatients over the age of 15 years to translate the measure into Greek. For a clinical criterion of 4/5, the data showed extremely acceptable sensitivity (89%), specificity (81%), positive predictive value (80%), negative predictive value (90%) and overall misclassification rate (15%).

Additionally, Garyfallos et al. [20] observed strong internal consistency for the entire questionnaire (Cronbach’s alpha = .93) and a significant correlation with the Present State Examination (r = .77). Participants were asked to respond on a four-point Likert scale (0–3), where higher scores indicated worse psychological health. The questionnaire comprised two sections: 1) demographic information and (2) mental health tests. GHQ-28 is an independent tool that is considered suitable for research purposes [21]. The sum of the subscales shows overall poor psychological health, while the subscale scores for somatic complaints, anxiety/insomnia, social dysfunction and severe depression are calculated by summing the scores of the relevant items.

The GHQ-28 scale focuses on normal function breaks that lead to an inability to perform normal healthy activities. The questionnaire deals with occurrences of new phenomena of distressing nature within the last few weeks [21]. Guttman Split-Half Coefficient (GSHC) for reliability (Cronbach’s alpha of part 1 = 0.901 and for part 2 = 0.879, GSHC = 0.757) was employed for this study. The construct validity of GHQ-28 was evaluated using confirmatory factor analysis and varimax rotation. The Kaiser-Meyer-Olkin (KMO) index value for the relevance of factor analysis was sufficient (KMO = 0.936). The result of Bartlett’s test of sphericity was statistically significant (p-value < .001).

Life Events Scale for Students

We utilised a modified version of the LESS to quantify the experience of stressful life events [22], in which participants are questioned about whether they have ever gone through a series of potentially stressful experiences. Given their lack of relevance for this collegiate sample, a number of events from the original measure were eliminated (e.g. a vacation alone or with friends) and new events that were deemed relevant were included in their place (e.g. experiencing a natural disaster). There were 28 incidents in the modified version of the measure. Based on assessments provided by undergraduates who participated in earlier research, each item was given a weighted rating on a scale from 0 (not at all stressful) to 100 (very stressful) [23, 24].

This 36-item scale lists stressful events relevant to students. Each event listed is given a weighting based on how stressful it is perceived to be [22], and participants are required to mark whether they have experienced these events in the past 12 months. Scores are calculated by summing the total weightings of items checked. The test–retest reliability of individual items was .61 over six months [22].

There is some evidence to suggest that the life event weightings are cross-culturally generalisable [25, 26]. It is extremely likely that different events will be valued differently depending on the student’s cultural background. The initial study was completed 29 years ago in 1984). Therefore, it was determined that it would be more acceptable to collect culturally specific weights from a sample of Cypriot university students [19]. Prior to the main investigation, a pilot study was carried out for this aim. It was decided to enrol all active postgraduate diploma students because including undergraduate students in the pilot project would prevent their participation in the main investigation. For the sake of maintaining confidentiality, participation in the study was entirely voluntary. All postgraduate diploma students made up the final sample (N = 90, 90% response rate, mean = 24, minimum = 18, maximum = 36). A total 35% of the sample was male and 65% female, which is consistent with the gender split among college students. Participants in the pilot study were instructed to rate the stressfulness of each of the 36 items on the original checklist on a scale from 0 to 100 based on how much effort was necessary to adapt successfully to the specific life event described by the item. This rating was done in accordance with the original study. Death of a parent was the 100th-ranked item. The weights for each item were determined by averaging the participants’ replies. LESS scores of the participants in the main study were calculated using both the original weights and the culturally-specific weights derived in this pilot study (Table 1)

Table 1

Frequency and ranking of LCU reported stressful life events on the LESS scale in Cypriot post-graduate university students
Less scale for university students	Rank of the severity+
1. Death of parent	100
2. Death of your best friend or very close friend	91
3. Major car accident (car wrecked, people injured)	83
4. Major personal injury or illness	82
5. Getting kicked out of college	76
6. Major and/or chronic financial problems	76
7. Break-up of parent’s marriage/divorce	72
8. Seriously thinking about dropping college problems	72
9. Failing in one course	71
10. Losing a part-time job	69
11. Parent losing his/her job	68
12. Pregnancy (either yourself or being the father)	64
13.Failing in a number of course	64
14. Sex difficulties with boy/girlfriend	64
15.Jail term (self)	62
16. Breaking up/ loosing contact/with a close friend	62
17.Breaking up with boy/girlfriend	62
18.Major argument with boy/girlfriend	60
19.Major change of health status in a close family member	57
20.Minor financial probleml	57
21. Getting an unjustified low mark in a test	54
22. Major argument with parents	53
23. Moving away from home	52
24. Moving out of town with parents	51
25. Change of job	50
26. Seeking psychological or psychiatric consultation	49
27. Switch in a program within the same college or university	47
28. Establishing a new steady relationship with a partner	39
29. Minor car accident	38
30. Getting your own car	33
31. Finding a part-time job	33
32. Beginning an undergraduate program in the university	31
33. Minor violation of the law (e.g. speeding ticket)	27
34. Family getting together	22
35.Vacation with parents	15
36.Vacation alone/with friends	14
+ Severity ranking given in a previous study by university students in Cyprus

Data analysis

The Statistical Package for Social Sciences Software (version 20) was used to analyse the data. Descriptive statistics for all socio-demographic characteristics, mental distress symptoms and life events of the participants were calculated and expressed in frequencies, mean values and standard deviation. One-way ANOVA and independent sample t-test were conducted to compare the GHQ-28 subscales with groups of number of events and total score in LESS. The GHQ-28 item scores were summed up to provide an overall score, theoretically ranging from 0 to 84. In terms of LESS, chi square test was conducted on both the number and severity groups to compare the proportion of students with total GHQ score (above the cut-off point) with the LESS scale. Related to the aim of this study, we aimed to investigate the degree of mental distress symptoms with values greater than 24 in the scale. For the cut-off points for LESS scale scores, we formed categories approximately based on the quartiles of the distribution of scores. For instance, the last category of LESS scores (i.e. 351–1110) comprises the quartile of participants with the highest scores. Likewise, for the number of stressful events, categorisation was done in accordance with the quartile of participants with the greatest number (i.e. 12–14). The scale has been dichotomised as well. In particular, based on the number in LESS, the first category included participants who declared 0–7 events and the second category included those who declared 8 and above. The same pattern applied for total score in LESS, with participants separated below 350 and above 351 in total score. Odds ratio and 95% confidence intervals (CI) of clinical mental distress symptoms (GHQ-28 ≥ 24) by the demographic and other variables were estimated in logistic regression before and after controlling for potential confounders. All statistical analyses were performed at a significance level of 0.05.

The Socio-demographic and academic characteristics of sample

Socio-demographic and academic characteristics of the final sample (N = 1500, response rate 85%) are pressed in Table 2. The vast majority of the participants were female (n = 29.9, 70.1%), while males were almost one- third of the sample (n = 448, 29.9%). Τhe students' ages ranged from 18–40 years old and the mean age was 20.3 (SD ± 2.1). Most of the students were living in urban (n = 850, 58%) and rural areas (n = 452, 27.6%) and only 198 (14.4%) were living in suburban areas. In terms of family status, the majority of participants were single (n = 1402, 93.5%) and 6.2% (n = 92) were living with a partner or were married. Concerning academic characteristics of the students, most of participants were from the first (n = 443, 29.5%) and second (n = 426, 28.4%) year of study.

Table 2

Socio-demographic and academic characteristics of sample (N = 1500)
	Frequency (N)	Percentage (%)
Age
18–20	933	62.2
21–24	502	33.5
25–40	65	4.3
Gender
Male	448	29.9
female	1052	70.1
Place of residence
Urban area	850	58
Rural areas	452	27.6
Sub-urban area	198	14.4
Family status
Single	1402	93.5
Divorce	6	0.4
Married /living with partner/parents	92	6.2
Employment
Yes	437	29
No	1063	71
Academic year of study
First	443	29.5
Second	426	28.4
Third	377	25.1
Fourth	254	16.9

Mean total score of GHQ-28 by socio-demographics, individual and academic characteristics and self-reported health

In terms of total score of GHQ-28 and socio-demographic characteristics, the females reported a higher mean score than did the males [27.71(13.32) vs. 25.22(14.20), p = 0.002]. In addition, the students with an annual family income above 36,301 euros had noted a higher mean value [28.34(± 13.10), p < .05] than did the other categories of annual family income; for instance, the category with incomes between 28,001 and 36,300 euros noted the lower mean value of total score in the GHQ-28 scale [24.84(± 11.99)].

Moreover, participants who self-assessed their mental health [27.75(± 14.19), p < .05] as poor or very poor during the last month reported a higher mean score of GHQ-28 in relation to other students who characterised their mental health as excellent/very good or good [25.52(± 13.79) and 25.82(± 12.89), respectively].

A statistically significant difference was likewise observed in participants who were not satisfied with their relationship with their parents (no/low level of satisfaction); they reported a higher mean score [27.81(± 14.07), p < .05] compared with those who stated they were satisfied (High/Very high level of satisfaction) with their relationship with their parents [25.82(± 13.54)]. In addition, students who spend little or no time with their friends noted a higher mean score on the GHQ-28 scale [27.81(± 13.31), p < .005] than did the other students who spend more time with their friends [25.63(± 14.07)] (Table 3).

Table 3

The mean total score of GHQ-28 based on Sociodemographic characteristics
Total score in GHQ-28	n	Mean	SD	F	P
	1500	26.95	13.63
Gender
Male	449	25.22	14.02	0.342	0.002
Female	1051	27.71	13.32
Age
17–20	933	27.20	13.40	0.706	0.494
21–25	520	26.72	14.20
26–40	47	25.00	11.60
Parental status
Married	1290	27.20	13.73	2.267	0.104
divorce	140	24.63	12.51
Widower/widow	70	27.20	13.80
Family status
Single	1402	26.98	13.64	0.516	0.597
Married/Living with a partner	92	27.10	13.72
Separated/divorced	6	21.33	11.84
Annual family income
0-19500	710	26.66	13.74	2.444	0.045
19501–28000	442	27.52	14.20
28001–36300	201	24.84	11.99
> 36301	147	28.34	13.10
Learning difficulties
No	1181	25.85	12.93	1.023	0.087
Yes	319	27.27	13.80
Chronic physical disorder or disability
No	1371	25.63	12.81	0.445	0.220
Yes	129	27.09	13.71
*Academic year of study
First	443	27.40	13.21	1.914	0.125
Second	426	25.71	13.38
Third	377	26.95	14.22
Fourth	254	26.95	13.81
Level of satisfaction with program/course of study
No/ Low	312	27.07	13.42	2.216	0.581
Hight/ Very high	1188	26.57	14.45
Satisfaction with relationship with friends
No/ Low	177	27.06	13.77	3.654	0.376
Hight/ Very high	1323	26.10	12.52
Satisfaction with relationship with parents
No/ Low	470	27.46	13.54	0.494	0.031
Hight/ Very high	1030	25.82	13.65
Frequency of spending time with my friends
No/Low	542	27.81	13.31	0.379	0.004
Hight/Very high	958	25.63	14.07
Mental health self-assessment during last month
Excellent/very good	917	25.52	13.79	3.941	0.020
Good	405	25.82	12.89
Poor/very poor	178	27.75	14.19
Physical health self-assessment during last month
Excellent/very good	424	25.62	12.99	2.836	0.059
Good	999	27.48	13.63
Poor/very poor	77	27.73	16.08

Differences in GHQ-28 total score / subscale scores by gender

As presented in Table 4, the females had a higher mean value in total score of GHQ-28 than the males [27.71(13.32) vs. 25.22(14.20), MD: -2.49, 95% CI: -4.0–0.95, p = .002]. The same statistically significant difference was observed in the subscales [somatic symptoms: 8.22(4.19) vs. 6.99(4.28), MD: -1.3, 95% CI: -1.77–0.83, p < .001, anxiety/insomnia symptoms: 8.46(5.0) vs. 7.22(4.75), MD: -1.23, 95% CI: -177–0.68, p < .001]. There was no statistically significant difference between male and female and social dysfunction/severe depression. Overall, the mean total score of the GHQ-28 was 26.95 (SD = 13.33) (min = 0, max = 84).

Table 4

The mean total score/ subscales of GHQ-28 scores and differences by gender
	GENDER					TOTAL
	Male	Female	MD	95%CI	P
	M (SD)	M (SD)				M (SD)
Somatic Symptoms	6.99(4.28)	8.22(4.19)	-1.30	-1.77-0.83	< 0.001	7.83(4.26)
Anxiety/Insomnia	7.22(4.75)	8.46(5.0)	-1.23	-1.77- 0.68	< 0.001	8.10(4.95)
Social dysfunction	7.57(3.16)	6.68(3.2)	-0.18	-0.47- 0.26	0.567	7.64(3.33)
Severe depression	3.50(4.72)	3.35(4.0)	0.15	-0.32-0.62	0.530	3.40(4.24)
Total score of GHQ-28	25.22(14.20)	27.71(13.32)	-2.49	-4.0—0.95	0.002	26.96(13.63)

Differences in GHQ-28 total score / subscale scores by number of events and total score in LESS scale

Most of the students 754(50.3%) reported four to seven stressful life events while 35 (2.3%) students did not report any stressful event in the last 12 months. In terms of the relationship between GHQ-28 and LESS, the total score of the GHQ-28 scale and all subscales (except the subscale of social dysfunction) had statistically significant differences in mean values. Specifically, in terms of the total score of GHQ-28, the highest mean value was noted by participants who reported 12–21 stressful life events [n = 84, [M(± SD) 34.30(± 14.9), p < .001]. Statistically significant differences were likewise observed between the same group of stressful life events and subscales [somatic symptoms: 9.93(± 4.6), p < 0.001, anxiety/insomnia: 11.04(± 5.5), p < .001 and severe depression: 5.11(± 4.8), p < 0.001]. There was a clear stepwise increase in the mean value of the GHQ-28 scale among students who reported more events. The differences between GHQ-28 total score / subscale scores and the number of events in LESS are presented in Table 5.

Table 5

The mean scores of subscales (GHQ-28) based on numbers of stressful life event groups
	Number of events in LESS	n	Mean	SD	F	P
Somatic Symptoms	1	35	6.51	4.4	12.50	< 0.001
	2	339	6.92	4.1
	3	754	7.77	4.0
	4	288	8.59	4.4
	5	84	9.93	4.6
	Total	1500	7.83	4.26
Anxiety/Insomnia	1	35	5.83	4.9	18.69	< 0.001
	2	339	6.86	4.8
	3	754	8.02	4.7
	4	288	9.16	4.9
	5	84	11.04	5.5
	Total	1500	8.10	4.95
Social dysfunction	1	35	6.89	3.0	1.99	0.094
	2	339	7.46	3.2
	3	754	7.58	3.3
	4	288	7.94	3.5
	5	84	8.23	3.7
	Total	1500	7.64	3.3
Severe depression	1	35	2.40	4.0	12.03	< 0.001
	2	339	2.57	3.5
	3	754	3.23	4.10
	4	288	4.44	4.86
	5	84	5.11	4.8
	Total	1500	3.40	4.29
Total score of GHQ-28	0	35	21.63	14.7	16.62	< 0.001
	1–3	339	23.81	12.7
	4–7	754	26.60	13.0
	8–11	288	30.13	14.2
	12–21	84	34.30	14.9
	Total	1500	26.96	13.63
Groups of number of stressful life events: 1: the participants who reported 0 Events, 2: the participants who reported 1–3 Events, 3: the participants who reported 4–7 Events, 4: the participants who reported 8–11 Events, 5 the participants who reported 12–21 Events.

A similar pattern was observed in terms of total score in LESS and GHQ-28 scale. Statistically significant differences were detected between the participants who noted the highest total scores in the LESS scale as well as GHQ-28 and all its subscales. In particular, for somatic symptoms the mean value was 9.93(± 4.6) (p < .001), for anxiety/insomnia symptoms it was 11.04(± 5.5) (p < 0.001) and for severe depression it was 5.11(± 4.8), (p < .001). Meanwhile, with regard to the total score in the LESS scale, the group that scored between 351–1100 also scored the highest mean on the scale [32.31(14.6), p < .001] (Table 6).

Table 6

The mean scores of subscales (GHQ-28) based on total score of stressful life event groups
	Total Score in LESS	n	Mean	SD	F	P
Somatic Symptoms	1	110	6.04	4.0	21.7	< 0.01
	2	341	6.72	3.8
	3	331	7.55	4.1
	4	326	8.39	4.1
	5	392	9.06	4.4
	Total	1500	7.83	4.2
Anxiety/Insomnia	1	110	6.05	5.0	28.5	< 0.01
	2	341	6.54	4.4
	3	331	7.69	4.6
	4	326	8.77	4.7
	5	392	9.80	5.1
	Total	1500	8.10	4.9
Social dysfunction	1	110	6.89	2.8	9.3	< 0.01
	2	341	7.13	2.9
	3	331	7.33	2.8
	4	326	7.90	3.5
	5	392	8.36	3.7
	Total	1500	7.64	3.3
Severe depression	1	110	1.82	2.8	31.1	< 0.01
	2	341	2.04	3.0
	3	331	3.06	3.6
	4	326	3.65	4.4
	5	392	5.09	5.0
	Total	1500	3.40	4.2
Total score of GHQ-28	0–49	110	20.80	12.7	35.1	< 0.01
	50–149	341	22.43	11.3
	150–241	331	25.63	12.3
	242–350	326	28.71	13.6
	351–1100	392	32.31	14.6
	Total	1500	26.96	13.6
*Groups of total score in LESS 1: the participants who scored 0–49 on the LESS scale, 2: the participants who scored 50–149 on the LESS scale, 3: the participants who scored 150–241 on the LESS scale, 4: the participants who scored 242–350 on the LESS scale, 5: the participants who scored 351–1100 on the LESS scale.

Prevalence of clinical mental distress symptoms and associations between degree of clinical mental distress symptoms and stressful life events

Concerning the association between clinical mental distress symptoms (GHQ-28 ≥ 24) and stressful life events, a positive statistically significant association was observed between high scores on the LESS scale, indicative of the severity of life stressors in a student’s life, and clinically significant mental distress symptoms (x² = 56.64, df = 1, p < .001). Similarly, there was an association between the number of stressful life events and clinically significant mental distress (x² = 26.12, df = 1, p < .001). In terms of the students who had reported the greatest number of stressful life events (≥ 8), they were 1.8 times more likely to report mental clinical distress symptoms (95% CI: 1.47–2.39). Equally, the students who had noted the highest score in LESS appeared 2.8 times more likely to report mental clinical distress symptoms (95% CI: 1.98–3.24) (Table 6).

Α statistically significant association was observed between gender and mental distress symptoms. Specifically, females had a higher level of mental distress than did males [n = 595 (56.6%) vs. n = 213 (47.4%), x² = 10.65, OR: 1.44, 95% CI: 1.15–1.80, p = .001]. The female students who reported the greatest number of stressful life events (≥ 8) also appeared 1.93 times (95% CI: 1.43–2.59) more likely to report mental clinical distress symptoms compared with males who reported more than 8 events (OR: 1.77, 95% CI: 1.14–2.74, p < .001). Contrariwise, with regard to the total score in LESS, males with the highest score (≥ 351) were 2.8 times more likely to report mental clinical distress symptoms compared with females (95% CI: 1.79–4.36, p < .001) (Table 7). By contrast, a slight difference that was not statistically significant [n = 110 (24.5%) vs. n = 262(24.9%), p = .860] was observed between male and female in the number of stressful life events and total score in LESS [n = 115 (25.6%) vs. n = 277(26.4%), p = .764] before comparison with clinical mental distress.

Table 7

Prevalence of clinically mental distress symptoms (CES-D ≥ 24) by classification of participants in terms of the number of stressful life events and total score on the LESS scale and by gender
		Male						Female
Life Events Scale for Students (LESS) (N = 1500)														X²	OR (95% CI)	DF	P
		GHQ-28				Total		GHQ-28				Total
		0–23		≥ 24				0–23		≥ 24
		n	%	n	%	n	%	n		%		n	%
Number of events in LESS	0–7	190	80.5	149	70	236	52.6	373	81.8	416	69.9	789	75.1	26.12	1.8(1.47–2.39)	1	< 0.001
	≥ 8	46	19.5	64	30	213	47.4	83	18.2	179	30.1	262	24.9
Total Score in LESS	0-350	197	83.5	137	64.3	334	74.4	378	82.9	396	66.6	774	73.6	56.64	2.53(1.98–3.24)	1	< 0.001
	≥ 351	39	16.5	76	35.7	115	25.6	78	17.1	199	33.4	277	26.4
Total		236	52.6	213	47.4	449	100	456	43.4	595	56.6	1051	100
*Relative risk: Male odds ratio for total score in LESS 0-350/≥551: 2.8 with 95% CI: 1.79–4.36, Female odds ratio for total score in LESS 0-350/≥551: 2.43 with 95% CI: 1.80–3.27 Male odds ratio for number of events 0–7/≥ 8: 1.77 with 95% CI: 1.14–2.74, Female odds ratio for number of events in LESS 0–7/≥ 8: 1.93 with 95% CI: 1.43–2.59

Associations between clinical mental health distress (GHQ-28 ≥ 24) by socio-demographic characteristics and self-assessment of participants’ health

We performed multivariable logistic regression to investigate the effect of socio-demographic characteristics on the occurrence of clinical mental distress symptoms (GHQ-28 ≥ 24). First, a logistic regression was performed adjusted with the main socio-demographic characteristics and self-assessment of participants’ health. Next, the analysis was repeated to include those who scored ≥ 8 number of events and ≥ 351 of total score in LESS (n = 460, 30.6%). Τhe variable that remained before and after the comparison of stressful life events was gender, with females being 1.6 times more likely to report clinical mental distress symptoms (95% CI: 0.98–2.46). Regarding academic characteristics, the second year of the study appeared to be 0.74 times more likely to have mental clinical distress symptoms compared to the first year (95% CI: 0.55–0.99, p < .005), and third-year students who had scored the greatest number of stressful life events and the highest total score in LESS appeared 1.79 times more likely to report clinically significant mental distress compared with first-year students. However, this difference was not statistically significant (95% CI: 0.96–3.34, p = .066).

In terms of the self-assessment of participants’ health, a statistically significant difference was observed in students who evaluated their mental health as good; they are 1.5 times more likely to report clinically significant mental distress compared with those who rated their mental health as very good or excellent (95% CI: 1.07–2.21, p = .019).

Overall, in most of the evaluated parameters, the people who noted the greatest number of stressful life events and the highest total score in LESS are more likely to have clinically significant mental distress (Table 8).

Table 8

Odds ratios (and 95% CI) of clinically mental distress symptoms (GHQ ≥ 24) by the number of stressful life events (≥ 8) and total score in LESS scale (≥ 351) after adjusting for all sociodemographic factors as estimated in multivariable logistic regression models
LESS	Adjusted (n = 1500)		┼Adjusted (n = 460)
	OR (95%CI)	P value	OR (95%CI)	P value
Gender
Male	1	---------	1	----------
female	1.57(1.23-2.00)	0.000	1.6(0.98–2.46)	0.044
Age
18–20	1	---------	1	----------
21–25	0.89(0.66–1.21)	0.478	0.88(0.51–1.30)	0.327
26–40	0.94(0.46–1.90)	0.870	1.79(0.43–7.36)	0.420
Family status
Single	1	---------	1	----------
Married /living with partner	4.13(0.45–38.05)	0.210	4.0(0.27–61.21)	0.308
separated/divorced	4.31(0.45–41.30)	0.205	2.6(0.16–43.83)	0.492
Parental status
Married	1	---------	1	----------
divorce	1.16(0.68–1.97)	0.569	2.0(0.80–5.43)	0.132
widow	0.82(0.44–1.53)	0.541	0.91(0.28–2.9)	0.884
Annual family income
0-19500	1	---------	1	----------
19501–28000	1.09(0.84–1.41)	0.504	0.79(0.47–1.35)	0.400
28001–36300	0.77(0.55–1.07)	0.123	0.66(0.34–1.27)	0.202
> 36301	1.32(0.90–1.92)	0.149	1.22(0.56–2.62)	0.600
Learning difficulties
No	1	---------	1	----------
Yes	0.89(0.66–1.18)	0.440	0.67(0.41–1.10)	0.118
Chronic physical disorder or disability
No	1	---------	1	----------
Yes	1.01(0.68–1.50)	0.943	0.81(0.37–1.80)	0.621
Academic year of study
First	1	---------	1	----------
Second	0.74(0.55–0.99)	0.048	1.16(0.64–2.13)	0.614
Third	1.03(0.76–1.39)	0.845	1.79(0.96–3.34)	0.066
Fourth	0.96(0.68–1.34)	0.818	1.58(0.69–3.61)	0.270
Level of satisfaction with program/course of study
No/ Low	1	---------	1	----------
Hight/ Very high	1.14(0.86–1.52)	0.339	1.22(0.71-2.0)	0.453
Satisfaction with relationship with friends
No/ Low	1	---------	1	----------
Hight/ Very high	1.05(0.74–1.49)	0.761	0.84(0.43–1.65)	0.624
Table 8: Odds ratios (and 95% CI) of clinically mental distress symptoms (GHQ ≥ 24) by the number of stressful life events (≥ 8) and total score in LESS scale (≥ 351) after adjusting for all sociodemographic factors as estimated in multivariable logistic regression models
LESS	*Adjusted (n = 1500)		┼Adjusted (n = 460)
	OR (95%CI)	P value	OR (95%CI)	P value
Satisfaction with relationship with parents
No/ Low	1	---------	1	----------
Hight/ Very high	0.81(0.55–1.14)	0.218	1.0(0.49–213)	0.934
Frequency of spending time with my friends
No/Low	1	---------	1	----------
Hight/Very high	1.09(0.85–1.40)	0.488	1.18(0.72–1.93_	0.508
Mental health self-assessment during last month
Excellent/very good	1	---------	1	----------
Good	1.54(1.07–2.21)	0.019	1.72(0.85–3.4)	0.131
Poor/very poor	1.23(0.83–1.83)	0.290	1.16(0.55–2.4)	0.682
Physical health self-assessment during last month
Excellent/very good	1	---------	1	----------
Good	1.0(0.58–1.70)	0.996	2.15(0.75–6.12)	0.151
Poor/very poor	0.99(0.75–1.31)	0.978	0.94(0.57–1.55)	0.825
┼ estimated in multivariable logistic regression with students who reported ≥ 8 numbers of Events and noted ≥ 351 total score in LESS

From the above results, it can be summarised that a high prevalence of stressful events exists among Cypriot university students. Academic stress among college and university students has been well documented [27]. Studies conducted at universities in Thailand, Malaysia, the United Kingdom and India found that students around the world perceive academics as a stressor [28–34]. According to scientific research, stress is fairly common in Saudi academia, especially among female students pursuing health-related courses [35, 36].

In the present study, the majority of the participants were females and all were single. All participants in the current study belonged to the student stressor, which was a sizable prevalence of stress with a mean of 8.46 (5.0) for females. The primary conclusions demonstrated that the female gender might be regarded as a risk factor linked to a higher likelihood of somatic complaints and anxiety in university students. It is well known that women are more likely than men to experience mental illnesses and report having those illnesses [37]. This can be explained by the fact that men have a lower threshold for sensing mental impairment [38]. Additionally, since the causes of mental issues are more common in females, they are more prone than males to develop risk factors for mental disorders as early as adolescence [39–42].

According to studies, students believe that failing exams will result in humiliation and social issues, which will in turn cause them to feel anxious and depressed, adopt bad habits and experience worsening of physical and mental health changes since they began their university studies [43–45].

Our results show that clinical mental distress was at its highest at the second academic year, which contradicts the results of other studies [46] stating the opposite. Data on changes in stress levels during school, however, are contradictory; some authors [47] found that stress levels remained constant throughout university, others [48] revealed that stress levels declined during education, while others reported that stress levels peaked at the start of the third year [49, 50]. To comprehend the clinical mental distress symptoms during certain years, more research is required. Nevertheless, it is crucial to note that research has indicated the prevalence of psychological distress may change depending on the academic year [51].

In terms of gender differences, compared to men, female students experience more stress [52]. According to this study’s findings, considerably more female students than male students reported experiencing stress, which is in line with findings from studies of university students from Hong Kong [53], Turkey [54] and Australia [55]. Acharya [56] indicated that the decreased stress experienced by male students has been linked to their propensity to downplay and conceal their unpleasant emotions, because showing them is a sign of weakness.

The study found that students had the highest rates of appearance in the subscale (GHQ-28) in the variable for anxiety/insomnia. Similarly, poor sleeping habits were found in 51–59%, especially of medical students in other studies conducted worldwide [57–60]. Increased study time and a heavy workload in the pursuit of academic excellence have a significant impact on sleeping patterns. Cognitive abilities, physical and mental health, academic achievement and psychiatric illnesses are all significantly influenced by sleep [57, 61–65]. Scant research has been done linking academic stress and sleep. Nevertheless, several studies have linked stress with issues like insomnia, depression, anxiety and restlessness [66, 67]. Our study’s findings are in line with the studies mentioned above, which indicate that a variety of sleep disorders and self-reported mental health issues (e.g. anxiety, phobias, sadness and restlessness) have a strong positive correlation with overall academic stress. On the basis of these findings, the current study provides evidence of how academic stress affects both mental and physical health of university students.

Undergraduate students are one group that might benefit most from measures that reduce stress. Most undergraduates endure significant amounts of stress, and those who do tend to have worsening physical and mental health [5, 68, 69]. However, stress is a significant if not essential component of the university experience. University is full of difficult intellectual and social experiences, including disappointments, and dealing with these trying times can eventually help students learn about themselves and grow [70]. Therefore, emphasising the reduction of stress in students’ life may be both unfeasible and detrimental to the objectives of higher education. Instead of concentrating on stress reduction, a more effective approach could be to optimise stress. Reappraising the stress response is one type of stress optimisation that has been shown to be beneficial for enhancing the academic performance of undergraduate students. Recall that reappraisal interventions focus on assessments of a specific stress reaction rather than more general ideas about the nature of stress. This is how they vary from stress mindset interventions. Test performance on a first university midterm has been demonstrated to improve with reappraisal therapies targeting test anxiety [71].

By encouraging students to consider the benefits of stress and what they may do to experience these benefits, a recent imagery-based intervention attempted to change students’ perceptions of stress to ‘stress-can-be-enhancing’ [72]. Students with high baseline levels of perceived distress benefited most from the intervention; at a two-week follow-up, the students showed improvements in coping, affect and academic performance in addition to decreases in their reported distress. These results imply that it may be advantageous to influence university students’ perceptions of stress, but there are still many unanswered problems. The objectives of the current investigation are specified by these queries.

Note that the participants in this study were university students recruited through convenience sampling. Previous research has indicated that recruiting participants in this manner can lead to biased results, as university students often have less crystallised attitudes than do individuals in later adulthood [73]. To predict how personality attributes affect psychological distress, a longitudinal study should be conducted by examining participants and their coping, depression and somatic symptoms over time. Moreover, as few males participated in this study, the results cannot be generalised. There may even be some biased answers provided for self-reported measures. In the future, an equal number of male and female participants will be considered for research. It is important to acknowledge some of the study’s limitations. Initially, our sample was not representative because it came from more than one university of all students in Cyprus. Additionally, the cross-sectional design of this study did not provide any inference about the direction of the relationship between mental health symptoms and the frequency and severity of stressful life events. For instance, failing a course could both cause and result from mental health issues. Similar to this, cross-national comparisons are challenging since multi-centred international research is required to investigate the incidence of mental health issues in student populations as well as in various contexts and cultures using the same instruments and technique.

The prevalence of stressful events among Cypriot university students is frightening. The results of this study have significant ramifications for identifying the most vulnerable children who require psychological empowerment. Most importantly, there is a greater need to teach this population how to deal with stress symptoms in light of the relatively high prevalence of mental health symptoms among Cypriot university students. This will not only enable them to achieve a better quality of life but also an elevated performance at the individual and institutional level. Additionally, reducing stress among students in Cyprus may help lower the frequency of clinical distress. Interventions that help students acclimatise to their university experience, such as improving their social networks, spirituality and effective coping strategies, may have a favourable impact on their personal and academic lives. School counselling programmes and educational initiatives promoting healthy lifestyles may also be efficient approaches to lessen and even prevent significant mental health issues (e.g. education workshops or symposia or even individual consultations). These programmes may help students avoid using passive coping mechanisms and give them the social networks they need to pursue more active ones.

Ethics approval and consent to participate

Our study was approved by the National Bioethics Committee [Ref. No 2010.01.38] Additionally, the study was approved by universities research committees. All methods were carried out in accordance with the relevant guidelines and regulations of the aforementioned committees. The participants were informed about the purpose of the study and the data collection procedures prior to providing their consent. All participants agreed to participate and informed consent was obtained from all subjects and/or their legal guardians. Participation in the study was voluntary and anonymous in order to guarantee confidentiality. Questionnaires and consent forms were distributed to the students at the beginning of the conference. Then, after a short briefing on the study aim and procedures, students who wished to participate could place their filled-in questionnaires in sealed envelopes in a collection box located outside of the conference room.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and/or analyzed during the present study are not publicly available because the authors are currently working on them in order to prepare the final version of this manuscript. However, they are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The present study was partially funded by the Cyprus University of Technology (internal funding code=319).

Authors’ contributions

The present study was jointly designed by all of the authors. Each author made substantial contributions to the conception, design, analysis, and interpretation of the data; was involved in drafting and/or critically revising the manuscript for important intellectual content; and gave final approval for the version to be published.

Acknowledgements

We would like to thank all of the healthcare students who participated in this study. We would also like to acknowledge the fieldworkers who contributed to the collection of the data.

Research involving human embryos, gametes, and stem cells

Not applicable. (The present study involved data collection but did not involve experiments that used human embryos or gametes, human

Embryonic stem cells or related materials, or clinical applications of stem cells.

The present study strictly followed the rules and guidelines of the aforementioned committees).

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No competing interests reported.

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The association between stressful life events and mental health among Cypriot university students: A cross-sectional descriptive correlational study

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Abstract

Background

Methods

Results

Conclusion

Background

Aim

Methods

Design and Study population

Ethical considerations

Procedures

Instruments

GHQ-28 scale

Life Events Scale for Students

Data analysis

Results

The Socio-demographic and academic characteristics of sample

Mean total score of GHQ-28 by socio-demographics, individual and academic characteristics and self-reported health

Differences in GHQ-28 total score / subscale scores by gender

Discussion

Limitation

Conclusion

Declarations

References

Additional Declarations

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