Stress is intricately intertwined with both physical and psychological dimensions of health and overall well-being, underscoring its significance as a vital subject of examination in the field of psychiatry [1]. Perceived stress is defined as ‘the feelings or thoughts of an individual about how much they are under stress at a given point in time” [2]. The stress phenomenon encompasses a combination of physiological [3, 4], psychological [5], and social [6] reactions occurring when unpredictable environmental changes disrupt an individual's equilibrium or homeostasis, subsequently eliciting a stress response [7]. Thus, the progression of stress responses is influenced by factors such as environmental predictability and physiological limits [8].
Strong evidence suggests that the cumulative effects of stress have been linked to various mental health issues, including depression [10–12], anxiety and suicidal ideation [13], poor sleep quality [14], challenging living conditions, health problems [15], and difficulties in interpersonal relationships [16]. Additionally, stress was found to be linked to socio-demographic and psychosocial factors in both males and females, including lower household income, lower educational attainment, and living alone [19]. Hence, evaluating stress holds great significance for both research and clinical objectives.
Measures of stress
While concise instruments like the Subjective Units of Distress Scale [20] have been employed to gauge momentary emotions and internal states (including anxiety, anger, agitation, stress, or other distressing feelings), there hasn't been a scale specifically designed for measuring momentary stress. Littman, White, Satia, Bowen, and Kristal [21] highlight that stress assessment has predominantly concentrated on quantifying stressors or investigating psychological reactions to stressors.
Subjective stress scales validated for use with pediatric populations include the Children’s Hassles Scale (comprising 43 questions) [22], the Perceived Stress Scale (with 14 questions; a shorter version has 10 questions) [6], and the Children’s Hassles and Uplifts Scale (consisting of 25 questions) [23]. While these tools are valuable, their completion can be time-consuming, ranging from 10 to 43 questions [24]. With the exception of The Children’s Hassles Scale, most of these scales primarily assess past stress levels to estimate current stress. As an example, the Perceived Stress Scale (PSS), validated in different languages [25–28] including Arabic [29–32], assesses an individual's overall life stressors over the preceding month. The respondent's evaluation of the frequency with which they have experienced nervousness and stress in the past month may be susceptible to retrospective bias, influenced by their recall of past events and their current emotional state.
Overall, the currently employed subjective stress scales have drawbacks, such as their length, mode of administration, potential retrospective bias [33, 34], and the challenge of evaluating past stress to estimate present stress [35]. Therefore, creating a concise and easily administered tool for assessing current stress response levels, adaptable to various modes of administration, and incorporating a brief screening approach, would be valuable for both clinical and research purposes. In pursuit of this objective, the Stress Numerical Rating Scale-11 (SNRS-11) has been developed [24].
The Stress Numerical Rating Scale-11 (SNRS-11)
The Stress Numerical Rating Scale (SNRS-11) captures both momentary (state) and day-to-day stress, as indicated by Karvounides et al. (2016) [24]. Modeled closely after the pain Numerical Rating Scale (NRS) by Von Baeyer [36], the SNRS-11 is a single-item scale with a range of 0 to 10 and similar endpoint anchors: 0 = "No stress" and 10 = "Highest stress possible." For momentary stress, respondents provide their level of stress factually in the moment, while for day-to-day stress, they rate stress experienced over the past week. Emphasizing stress intensity as one dimension of the multidimensional stress construct, the SNRS-11 mirrors the NRS-11's focus on assessing and measuring pain intensity as one dimension of pain.
The Stress Numerical Rating Scale-11 (SNRS-11) is a straightforward, one-item stress scale with demonstrated preliminary validation in samples of adolescents and emerging adults [24]. Additionally, the 0 to 10 scale is readily comprehensible and accomplished by children, as indicated by Crandall et al. [37]. In particular, the Numerical Rating Scale (NRS) is validated for use in children as young as 8 years old, and potentially even as young as 6 years, depending on the context [38]. Moreover, employing a numerical scale with straightforward anchors helps prevent misunderstandings and reduces the likelihood of a broad range of interpretations [37].
The present study
Stress is a universal aspect of everyday life, but its manifestations vary significantly across cultures [39] due to differences in physical, climatic, ecological, social, and political factors. Thereby, Western cultures differ from Eastern cultures in terms of the four theoretical dimensions [40]: individualism vs. collectivism, cognitivism vs. emotionalism, free will vs. determinism, and materialism vs. spiritualism. Research by Hashimoto et al. (2012) has shown that collectivist societies often report higher levels of perceived stress, particularly related to interpersonal relationships [41]. This heightened sensitivity in interdependently oriented cultures, where social harmony is highly valued, can lead to greater perceived stress. Moreover, individualistic societies tend to prioritize acknowledging and expressing their psychological states and emotions [42]. In contrast, collectivist individuals often believe that psychological states and bodily sensations are intertwined and place a higher value on emotional reserve for the sake of social harmony [42].
In the past decade, numerous Arab nations have experienced wars, conflicts, and significant social and geopolitical transformations, all of which have had detrimental effects on the mental well-being of their populations [43, 44]. A recent study involving secondary school students in Saudi Arabia indicated a prevalence of anxiety at 35.2%, followed by depression at 30.8%, and stress at 14.7% [45]. This underscores the significance of addressing social stressors like bullying and physical assault and advocating for a secure and supportive school environment to prevent mental health disorders in this population. Another study conducted among adolescents in the United Arab Emirates [46], utilizing the PSS-14, found that the overall perceived stress level was high in 20% of respondents and moderate in 76%. This emphasizes the importance of early identification of adolescents experiencing severe academic stress. Data collected from Lebanon underscores the high levels of stress experienced by the population, all within a country grappling with limited resources [47].
In order to facilitate and encourage research both within and across Arab nations on the stress topic, we embarked on an investigation into the psychometric properties of an Arabic translation of the SNRS-11, denoted as Arabic SNRS-11. This investigation encompassed an exploration of its factor structure, reliability, and construct validity. Furthermore, we analyzed the connections between Arabic SNRS-11 scores and indicators such as psychological distress, and perceived stress. The aim of introducing this straightforward and cost-effective tool for assessing stress to the Arabic-speaking community, which largely resides in low- and middle-income countries, where research endeavors can be particularly challenging, holds substantial value. Hence, having a straightforward, rapid, and precise assessment method could offer numerous advantages, such as streamlining the creation of tailored interventions. [37].