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Anxiety, Anxiety disorders, Stress, Students, University, Mental health.

Anxiety is a feeling of worry and concern, usually generalized rather than focused as an overreaction to a situation that is seen only subjectively as offensive. It is usually accompanied by muscle tension, discomfort, fatigue and problems with concentration. When anxiety is experienced regularly, the individual may be suffering from an anxiety disorder (Abdulghani HM, 2020). Experiencing anxiety from time to time is a normal part of life. However, people with anxiety disorders often have intense, excessive, and persistent worries and fears about everyday situations. Anxiety causes a hormonal surge that can make individuals feel tired and the feeling of exhaustion lingers. Difficulty concentrating is a common symptom of anxiety that can also be considered a side effect of restlessness or sleep problems. Anxiety can make people often feel irritable. When faced with a situation that incites anxiety and stress, a person may notice that his or her heart rate increases or begins to feel irregular. Anxiety sweating is the body’s way of responding to a rapid heart rate and an adrenaline rush caused by the hormonal system. Sweating, like tears, allows the body to discharge and return to normal by balancing heart rate and bad breathing. Stress related to anxiety can cause a person’s limbs to shake uncontrollably, especially the hands. Anxiety causes muscles to tense, which can lead to pain and stiffness in almost any area of the body, although the greatest concentration of pain occurs in the chest. The feeling that something bad is about to happen or is in the process of happening can sometimes appear out of nowhere (Aloufi MA,2021). Mental health researchers have found that childhood trauma can increase a person’s risk of developing anxiety disorders (Bandelow B,2002). These experiences can include physical and mental abuse, neglect, death of a loved one, abandonment, divorce and isolation. Clinicians use screening tools such as the GAD-7 and GAD-2 questionnaires to determine whether individuals may have GAD and warrant formal evaluation for the disorder. Additionally, screening tools can enable clinicians to assess the severity of GAD symptoms (Barrett PM, 2003) (Generalized Anxiety Disorder).

COGNITIVE BEHAVIORAL THERAPY: Cognitive Behavioral Therapy (CBT) focuses on helping children with SAD reduce feelings of anxiety through the practice of exposure to anxiety-provoking situations and active metacognition to reduce anxious thoughts. CBT has three phases: education, application, and relapse prevention. In the education phase, the individual is informed about the different effects that anxiety can have physically and most importantly mentally. Understanding and being able to recognize their reactions will help manage and ultimately reduce their overall response (Behrend D,2022).

According to Kendall and colleagues, there are four components that must be taught to a child undergoing CBT such as: Recognizing anxious feelings and behaviors, discussing situations that provoke anxious behavior, developing a coping plan with appropriate responses to situations, evaluation of the effectiveness of the coping plan (Brockelman KF, 2009).

STRESS: Stress, whether physiological, biological or psychological, is the response of an organism to a stress such as an environmental condition. Stress is the body’s way of reacting to a situation such as a physical and psychological threat, challenge or obstacle. There are two hormones that an individual produces during a stressful situation, these are known as adrenaline and cortisol. Stimuli that change an organism’s environment are responded to by multiple systems in the body. In humans and most mammals, the autonomic nervous system and the Hypothalamic-Pituitary- Adrenal (HPA) axis are the two main systems that respond to stress (Chu T, 2023).

Studies conducted in the military and combat fields show that some of the most powerful stressors can be due to personal organizational problems in the unit or on the home front. Stress due to poor organizational practices is often associated with “Toxic Leadership”, both in companies and in government organizations (Denovan A, 2017).

Chronic stress and the lack of coping resources available or used by an individual can often lead to the development of psychological issues such as depression and anxiety. Research suggests that chronic stress at a young age can have lifelong effects on biological, psychological, and behavioral responses to stress later in life (Ehrenreich JT, 2008).

Studies have shown that exercise reduces stress (Fares J, 2016). Exercise effectively reduces fatigue, improves sleep, improves general cognitive function such as alertness and concentration, lowers overall stress levels, and improves self-esteem. Cycling and walking activities have lower stress scores compared to other modes of transport or commuting (Fryers T, 2013).

ANXIETY AND STRESS AMONG STUDENTS: Selfesteem, confidence, personality types, and loneliness may be associated with SAD in college students. Students who have a lower level of self-esteem are more susceptible to anxiety and depression (Hoban Mary,2009). Also, students high in neuroticism and low in extraversion on the Five-Factor Personality Inventory are more likely to develop SAD during their college years (Ishii T, 2018). Other psychological factors, such as feelings of loneliness, play an important role in increasing the risk factors of SAD (Kawase E, 2008). Moving away from family and starting an independent life can pose challenges for fresher students, such as loneliness, until they adjust to university life and expand their social network. Indeed, Kawase et al. showed that students who live in cities other than their hometown for study purposes are more likely to develop anxiety, stress and depression. Various studies have shown that the level of anxiety, stress and depression in both international and domestic students can be related to the year of study with younger students entering university and students in their final year of studies (Ko Y, 2012).

Also, students studying in a non-native language report the highest level of anxiety and depression during their first years, and their stress levels decrease during the subsequent years of study (McCrae RR, 1992). A negative and abusive relationship with teachers and mentors may be another factor causing SAD in university students (Miller G, 2009).

A link between gender and depressive, anxiety and stress disorders has been observed in several studies. Female students had a higher prevalence of SAD compared to male students (Otto MW, 2011). Experiencing poverty during childhood can have long-term negative consequences in adulthood, leading to the development of SAD during college life (Ratanasiripong P, 2018).

PURPOSE: To evaluate the factors that influence the development of anxiety and stress disorders among the students of Ismail Qemali Vlore University in order to design new policies for 2023.

TIME PERIOD OF THE STUDY: January-July 2023. The preparatory phase of the study began in the time period January 2023 with the selection of structured questionnaires, with self-reporting, anonymous and fully maintaining confidentiality. The student survey process was done in April-May 2023. Characteristics of the sample included in the study. Our study was conducted in the four faculties of the Ismail Qemali University of Vlore, from which the students of the first, second, third year of the master’s degree were selected.

TYPE OF STUDY: This study is a cross-sectional epidemiologic study.

HYPOTHESIS: The academic period affects students in increasing the risk of developing anxiety and stress disorders. The study was carried out with the approval obtained from the Ismail Qemali Vlore University, rectory and from the Deanships of the Relevant Faculties. The students selected to participate in the study gave their consent after being informed about the purpose of the study.

INCLUSION CRITERIA:

• All students of all three years and master regardless of chronological age.

• All students of all three years regardless of gender and civil status.

• All the above students, regardless of whether or not they are users of any substance (coffee, alcohol, drugs, drugs).

EXCLUSION CRITERIA:

• Students who refused to participate in the study.

SAMPLE SELECTION:

• The size of the sample according to the faculty results:

• Faculty of Health N= 200 students.

• Faculty of Technical and Natural Sciences N= 135 students.

• Faculty of Humanities and Law N= 34 students.

• Faculty of Economics N= 143 students.

INSTRUMENT USED FOR DATA COLLECTION: Assessment of anxiety level was performed using the Beck Anxiety Inventory (BAI) self-report questionnaire. The Beck Anxiety Inventory (BAI), created by Aron T. Beck, is a 21-question, multiple-choice, self-report instrument that measures anxiety levels in adolescents and adults.

• DISTRIBUTION OF CASES BY FACULTY: It turns out that the highest percentage of students included in the study belongs to the Faculty of Health with 39.1%, followed by the Faculty of Economics with 27.9%, the Faculty of Technical and Natural Sciences 26.4% and the Faculty of Humanities and Law 6.6%. (Table 1).

Table 1. Distribution of students by faculty

• DISTRIBUTION OF CASES ACCORDING TO PLACE OF RESIDENCE: The distribution of cases by place of residence indicates that the majority of students included in the study live in the city, namely 70.1% (n=359), and the remaining 29.9% (n=153) live in the countryside (Table 2).

Table 2. Distribution of students by place of residence

• DISTRIBUTION OF CASES BY ACADEMIC YEAR: It turns out that the highest percentage of students involved in the study is represented by students of the first bachelor’s year 55.5% (n=284) and second bachelor’s year 20.1% (n=103). Master’s students were in a lower % than other years with 10.4% (n=53) (Table 3).

Table 3. Distribution of students by academic year

According to our study, it was found that according to gender, the highest level of stress was found in women with a percentage of 72.7% compared to men 27.3%, it was also studied that the significance of the relationship between gender and the appearance of stress resulted in a relationship with high statistical significance p= 0.000 (Saboo AV, 2019).

A link between gender and depressive, anxiety and stress disorders has been observed in several studies. Based on the results of a study carried out in Ireland,23 and Saudi Arabia,21 the prevalence of academic stress was higher in females than in males and data analysis revealed significant relationships between the prevalence and level of academic stress and gender with values P; 0.013 and 0.042, respectively (Schalet BD, 2014).

Referring to the factor “I feel stressed when I think about where I will work after I finish my studies” in our study it was found that 37.7% of female students fully agreed with the impact of this factor in the development of stress and anxiety disorders. In a study conducted in the United States, 24% of students are stressed about their future and finding a job after graduation (Scholz M, 2016).

From our study on the “Recent stress level” 34.2% of the students expressed “Light stress” and only 8.4% of the students showed no stress, while moderate stress appeared in 34.2% of the students and “A lot of stress” 23.2%. Compared to a study conducted where 45% of American college students claimed to be under “more than average stress”, while 33% of students reported “moderate stress” and 12.7% said it was “extreme stress”. Students who reported “no stress” or “less than average stress” combined for 9% of the total (Schweizer S, 2018).

In our study, it was found that economic factors and employment during the time of studies influenced the students, mainly the factor “Having a job to cover school expenses, makes me not regularly attend lectures and seminars” where out of 512 students, 398 students were exposed to this factor where 43% stated that this factor had no influence, followed by 21.6% who referred to Completely agree. In a study conducted in the United States, in order to afford tuition, 43% of students worked full-time and 81% of American students worked part-time during their hours outside of study (Shri R, 2010).

Our study referred that the factor “I am concerned about the increase in academic obligations for each school year” only in 16.2% of female students resulted in “Completely agree”. While from a study conducted in the USA, 33% of college students think of leaving college due to financial problems and the inability to meet academic obligations (Stallman HM, 2010).

In our study, it was found that the factor “Excessive load of exams within one season stresses me out” in 35.5% of students resulted in complete agreement compared to a study conducted in the U.S. where 11. 31% of students say that the tests they give every semester are the most important sources of stress (Sznitman SR, 2011).

Our study referred to the distribution of the symptom “Difficulty concentrating” in 71% of students, of which 22.3% state that this symptom appears “Very often”. In another study conducted at the University of Botswana, the occurrence of this symptom resulted in a percentage of 88%, which indicated that 88% of students had difficulty concentrating when they had to do something.

From the study of the factor “Parents cause me stress with their demands for my academic achievements” 63% were “Not at all agree” and only 7% were Totally agree. This study point contradicts a study conducted at the University of Botswana in which 47% of students referred to high expectations from their parents and 24% did not agree with this factor, which means that in this study the exposure of students to the pressure of family expectations for their academic achievements, it turned out that the impact was high.

Our study also made an assessment of the recent academic achievements of the students, where the students expressed themselves against the factor “I am dissatisfied with the recent results, they are lower in relation to my expectations” that only 27.5% did not agree at all and 73 % agreed with the impact of this factor, of which 16.4% “Completely agree”. This can also be a result of the high impact of stress and anxiety experienced recently which has affected the academic performance of these students, as it can also be considered a factor for increasing anxiety and stress among students. Even in a study carried out at the University of Botswana, there was a similar result, where the academic performance of students recently appeared to be low in 66% of students.

In our study, the influence of the residence factor on the prevalence of stress was also studied, where it was reported that the highest prevalence of stress appeared in the City P=16.80% while in the Village P=6.45%. The significance of this relationship was also evaluated, which resulted in p=0.03 and stated that there is a statistically significant relationship, but not a very strong relationship.

In other studies, it was found that the demographic status influenced the appearance of anxiety and stress disorders, where a higher % of SAD was reported in students who did not live in their hometown, this was influenced by the lack of support from the family, financial problems (Wanda MC, 2013).

Our study showed that the prevalence of stress among students based on the faculty was “A lot of stress “Faculty of Health” Prev.=10.94% Faculty of Humanities and Law Prev.=2.34%, “Faculty of Economics” Prev.=5.5 % and the Faculty of technical and natural sciences Prev=4.49%, p=0.000 which means a strong connection between the impact that the Faculty has on the development of stress. From this result we can prove that the prevalence of stress was higher in the Faculty of Health compared to other faculties.

The same conclusion appears in another study according to which medical, nursing and health students have a higher prevalence of depression and anxiety compared to their nonmedical peers (Whicker ML, 1996). Medical and nursing students who have both theoretical assignments and patientrelated work usually have the highest level of workload among university students, thus dealing more with anxiety, stress and depression

According to our study, it was found that the students refer to the factor “I feel stress and anxiety before the start of the exams because I want to do well” 90% of the students reported agreement, of which 47% completely agreed.

The same results have been evidenced in other studies, which showed that both the number of students with symptoms of mental health problems and the severity of DUD of students increase during the exam reflecting a direct relationship between the pressure academic and mental health status of students . However, the causal relationship is not well established; it is possible that depression and related problems such as temporary memory loss and lack of concentration are reasons for poor academic grades or conversely, students feel stressed leading to depression due to their poor performance in exams theirs. A reciprocal relationship may exist between grades and mental health, as having poor mental health can cause students to receive lower grades, leading to a vicious cycle of mental health and academic performance (Yang, X, 2021).

This study showed that most of the students involved in the study showed the body of anxiety and stress thus affecting their academic behavior but in other aspects, therefore it is also important the essence of the intervention as for the evidence of people who are other people.

Some aspects where attention should be focused based on the results of our study are:

➢ Instructing students through promotional activities for self-care such as: physical exercises, sufficient sleep, involvement in social activities.

➢ The addition of promotional activities by mental health specialists with the aim of instructing students in learning the mechanisms for adapting “Healthy academic learning” such as: searching for information to solve a problem.

➢ Drafting of economic policies in order to financially support low-income students, groups of students who study far from their family and hometown.

➢ Creating stress-reducing environments on university premises in order for students to spend more productive time when they have free time.

➢ Promotion of social and emotional support of students from family, friends and teaching staff, since in our study, support from family and social integration have an impact on the mental health of students.

➢ Universities should pay attention to active social promotion, such as the creation of “academic communities with students” that promote the formation of social groups and activate and unite students.

It is important to emphasize that there is the fact that our study shows limits in time and cost, therefore we recommend that a series of other studies should be carried out, with a higher population number in order to increase the accuracy and reduce the margin of error and the emergence of more connections that result in the emergence of anxiety and stress disorders.

This whole study is funded by the authors themselves.

The authors declare no conflicts of interest.

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