Objective:
to determine the prevalence of anxiety and depression symptoms, as well as their association with screen time, diet and physical activity, in a cohort comprised by nursing students.
Method:
a descriptive and cross-sectional study conducted with a sample of 648 Nursing students. The instruments used were the Hospital Anxiety and Depression Scale, the short version of the International Physical Activity Questionnaire and the Spanish Healthy Eating Index (Índice de Alimentación Saludable Español, IASE). Different multiple linear regression models were performed to analyze the association between anxiety/depression symptoms and screen time, diet and physical activity.
Results:
the prevalence values for anxiety and depression symptoms were 24.1% and 3.7%, respectively. Prolonged screen times (>6 hours a day), low levels of physical activity and inadequate diet were independently and significantly associated with deeper psychological symptoms.
Conclusion:
Nursing students’ mental health might benefit from the implementation of initiatives promoting healthy lifestyles.
Descriptors:
Nursing Students; Anxiety; Depression; Motor Activity; Diet; Cross-Sectional Studies
Objetivo:
determinar la prevalencia de síntomas de ansiedad y depresión, al igual que su asociación con el tiempo de pantalla, la dieta y la actividad física, en una cohorte de estudiantes de enfermería.
Método:
estudio descriptivo y transversal sobre una muestra de 648 estudiantes de enfermería. Se utilizaron la Hospital Anxiety and Depression Scale, la versión corta del International Physical Activity Questionnaire y el Índice de Alimentación Saludable español. Se llevaron a cabo diferentes modelos de regresión lineal múltiple para analizar la asociación entre los síntomas de ansiedad y depresión, y el tiempo de pantalla, la dieta y la actividad física.
Resultados:
la prevalencia de síntomas de ansiedad y depresión fue de 24,1% y 3,7%, respectivamente. El tiempo de pantalla prolongado (>6 horas por día), baja actividad física y dieta inadecuada se asociaron de manera independiente y significativa con una mayor sintomatología psicológica.
Conclusión:
la salud mental de los estudiantes de enfermería podría beneficiarse de implementarse iniciativas que promuevan estilos de vida saludables.
Descriptores:
Estudiantes de Enfermería; Ansiedad; Depresión; Actividad Motora; Dieta; Estudios Transversales
Objetivo:
determinar a prevalência de sintomas de ansiedade e depressão e sua associação com tempo de tela, dieta e atividade física em uma coorte de estudantes de enfermagem.
Método:
estudo descritivo transversal com amostra de 648 estudantes de enfermagem. Utilizou-se a Hospital Anxiety and Depression Scale, a versão curta do International Physical Activity Questionnaire e o Índice Espanhol de Alimentação Saudável. Foram realizados diferentes modelos de regressão linear múltipla para analisar a associação entre sintomas de ansiedade e depressão e tempo de tela, dieta e atividade física.
Resultados:
a prevalência de sintomas de ansiedade e depressão foi de 24,1% e 3,7%, respectivamente. O tempo prolongado de tela (>6 horas por dia), a baixa atividade física e a dieta inadequada foram associados de forma independente e significativa ao aumento da sintomatologia psicológica.
Conclusão:
a saúde mental dos estudantes de enfermagem pode ser beneficiada com a implementação de iniciativas que promovam estilos de vida saudáveis.
Descritores:
Estudantes de Enfermagem; Ansiedade; Depressão; Atividade Motora; Dieta; Estudos Transversais
Highlights:
(1) Anxiety and depression signs are usual in nursing students.
(2) Deficient diet, sedentary lifestyle and low levels of physical activity are prevalent behaviors.
(3) Diet, screen time and physical activity are related to psychological distress.
(4) It is necessary to monitor and promote future nurses’ mental health.
Introduction
Mental health problems are one of the leading causes of disability and an increasing public health issue at the global level due to disease progressions, their increased prevalence and the difficulties associated with their therapeutic management(11. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020; 396(10258):1204-22. https://doi.org/10.1016/S0140-6736(20)30925-9
https://doi.org/10.1016/S0140-6736(20)30...
). On many occasions, mental health problems appear in early adulthood and, in this life phase, they are associated with higher incidence of medium- and long-term physical and emotional problems(22. McGrath JJ, Lim CCW, Plana-Ripoll O, Holtz Y, Agerbo E, Momen NC, et al. Comorbidity within mental disorders: a comprehensive analysis based on 145 990 survey respondents from 27 countries. Epidemiol Psychiatr Sci. 2020;29:e153. https://doi.org/10.1017/S2045796020000633
https://doi.org/10.1017/S204579602000063...
), with difficulties entering the labor market(33. Pérez-Vigil A, Mittendorfer-Rutz E, Helgesson M, Fernández de la Cruz L, Mataix-Cols D. Labour market marginalisation in obsessive-compulsive disorder: a nationwide register-based sibling control study. Psychol Med. 2019;49(6):1015-24. https://doi.org/10.1017/S0033291718001691
https://doi.org/10.1017/S003329171800169...
), with worse sleep quality(44. Farhadian N, Moradi A, Nami M, Kazemi K, Ghadami MR, Ahmadi A, et al. The nexus between sleep disturbances and mental health outcomes in military staff: a systematic review. Sleep Sci. 2022;15(3):356-62. https://doi.org/10.5935/1984-0063.20220063
https://doi.org/10.5935/1984-0063.202200...
) or with dysfunctional social relationships(55. Oliveros B, Agulló-Tomás E, Márquez-Álvarez LJ. Risk and Protective Factors of Mental Health Conditions: Impact of Employment, Deprivation and Social Relationships. Int J Environ Res Public Health. 2022;19(11):6781. https://doi.org/10.3390/ijerph19116781
https://doi.org/10.3390/ijerph19116781...
), among others.
University students are faced with important challenges, risks and transitions inherent to social development that increase the risk of suffering mental health problems(66. Lei X, Liu C, Jiang H. Mental health of college students and associated factors in Hubei of China. PLoS One. 2021;16(7):e0254183. https://doi.org/10.1371/journal.pone.0254183
https://doi.org/10.1371/journal.pone.025...
). In addition, the stressors can be even greater in the case of future nurses. Clinical practices imply close human contact based on deep emotional commitment, and may include dealing with severe diseases and deaths(77. Demir S, Ercan F. The first clinical practice experiences of psychiatric nursing students: A phenomenological study. Nurse Educ Today. 2018;61: 146-52. https://doi.org/10.1016/j.nedt.2017.11.019
https://doi.org/10.1016/j.nedt.2017.11.0...
).
Previous studies have characterized psychological distress by assessing depression and anxiety in nursing students at the global level, reporting high results, although significantly dissimilar(88. Zeng Y, Wang G, Xie C, Hu X, Reinhardt JD. Prevalence and correlates of depression, anxiety and symptoms of stress in vocational college nursing students from Sichuan, China: a cross-sectional study. Psychol Health Med. 2019;24(7):798-811. https://doi.org/10.1080/13548506.2019.1574358
https://doi.org/10.1080/13548506.2019.15...
9. Gao J, Wang F, Guo S, Hu F. Mental Health of Nursing Students amid Coronavirus Disease 2019 Pandemic. Front Psychol. 2021;12:699558. https://doi.org/10.3389/fpsyg.2021.699558
https://doi.org/10.3389/fpsyg.2021.69955...
-1010. Milić J, Škrlec I, Milić Vranješ I, Podgornjak M, Heffer M. High levels of depression and anxiety among Croatian medical and nursing students and the correlation between subjective happiness and personality traits. Int Rev Psychiatry. 2019;31(7-8):653-60. https://doi.org/10.1080/09540261.2019.1594647
https://doi.org/10.1080/09540261.2019.15...
). From this perspective, it is of special importance to monitor and early detect psychological distress in nursing students, as well as its associated factors. In this sense, both in the clinical population and among adolescents and young individuals, several research studies have observed certain associations between specific behaviors and anxiety/stress. Among them, inadequate diet(1111. Saul A, Taylor BV, Blizzard L, Simpson-Yap S, Oddy WH, Probst YC, et al. Associations between diet quality and depression, anxiety, and fatigue in multiple sclerosis. Mult Scler Relat Disord. 2022;63:103910. https://doi.org/10.1016/j.msard.2022.103910
https://doi.org/10.1016/j.msard.2022.103...
-1212. Daneshzad E, Keshavarz SA, Qorbani M, Larijani B, Azadbakht L. Association between a low-carbohydrate diet and sleep status, depression, anxiety, and stress score. J Sci Food Agric. 2020;100(7):2946-52. https://doi.org/10.1002/jsfa.10322
https://doi.org/10.1002/jsfa.10322...
) and sedentary lifestyle with considerable time devoted to using devices with a screen(1313. Khouja JN, Munafò MR, Tilling K, Wiles NJ, Joinson C, Etchells PJ, et al. Is screen time associated with anxiety or depression in young people? Results from a UK birth cohort. BMC Public Health. 2019;19(1):82. https://doi.org/10.1186/s12889-018-6321-9
https://doi.org/10.1186/s12889-018-6321-...
-1414. Nakshine VS, Thute P, Khatib MN, Sarkar B. Increased Screen Time as a Cause of Declining Physical, Psychological Health, and Sleep Patterns: A Literary Review. Cureus. 2022 Oct;14(10):e30051. https://doi.org/10.7759/cureus.30051
https://doi.org/10.7759/cureus.30051...
) seem to be associated with greater psychological distress. On the other hand, physical activity seems to exert a protective mechanism against anxiety and depression. However, these relationships are yet to be confirmed in specific populations such as university students and, more in particular, nursing students.
Based on these deficits, the objective of this study was to characterize psychological distress in local nursing students, based on determining the prevalence of anxiety and depression symptoms, as well as their association with screen time, physical activity and quality of the diet.
Method
Study design and locus
A descriptive and cross-sectional study was conducted with a sample comprised by nursing students enrolled in any of the two institutions that offer this degree in the Aragon Region (Spain), namely: Universidad de Zaragoza and Universidad San Jorge.
Population
Calculation of the minimum sample size required to meet our main objective of determining the prevalence of anxiety and depression was based on results recently obtained through the Hospital Anxiety and Depression Scale (HADS) in a sample of Nursing students from the Principality of Asturias (Northern Spain)(1515. Mendez-Pinto I, Antuña-Casal M, Mosteiro-Diaz MP. Psychological disorders among Spanish Nursing students three months after COVID-19 lockdown: A cross-sectional study. Int J Ment Health Nurs. 2023;32(2):479-89. https://doi.org/10.1111/inm.13086
https://doi.org/10.1111/inm.13086...
). Consequently, for a 95% confidence level and 2% absolute precision, a required minimum of 610 participants was estimated for our study.
Recruitment of the participants and data collection were conducted in the classrooms from September to November 2022. Thus, the students were informed about the study nature and objectives, the voluntary character of their participation and about how the data obtained would be managed based on the anonymity criterion. From an eligible enrolled population of 1,182 students, 682 consented to take part in this study and answered the required questionnaires (response rate: 57.6%). Of all 682 questionnaires received, 34 were considered as not valid (generalized absence of data or overtly unreal data) and were consequently excluded from the analysis (rejection rate: 5.0%).
Variables and instruments used for data collection
The data collection questionnaire had three sections: 1. Sociodemographic and academic data; 2. Lifestyles and 3. Psychological symptomatology (anxiety and depression). In the first section, which was prepared ad hoc, the participants reported information about their age, gender, housing arrangement (living alone, living with roommates/partner, living with parents/family members), work situation (unemployed, part-time job, full-time job), perceived economic level (low/very low, average, high/very high), academic year, and mean grade throughout the course.
Screen time, quality of the diet and physical activity were assessed in the second section. Screen time was evaluated using the following question: “On a normal day, how much time do you devote to using devices with a screen (smartphone, tablet, computer, television, etc.?”. Based on the answers to this question, the participants were categorized into 3 groups by use time (<3 hours/day, 3-6 hours/day, >6 hours/day).
Physical activity was evaluated by means of the International Physical Activity Questionnaire-Short Form (IPAQ-SF). IPAQ-SF provides information about the intensity, frequency and duration of the physical activity performed in the last 7 days. This questionnaire offers both quantitative and qualitative information about the physical activity performed. In the quantitative analysis, the unit of measure was Metabolic Equivalent of Task (MET) per week, where 1 MET is the energy expenditure derived from the at-rest metabolic level. In the qualitative study, the official interpretation protocol of the tool(1616. IPAQ scoring protocol - International Physical Activity Questionnaire [Internet]. s.d. [cited 2023 Jan 21]. Available from: https://sites.google.com/site/theipaq/scoring-protocol
https://sites.google.com/site/theipaq/sc...
) allows classifying the population into 3 activity levels (low, moderate, high). IPAQ-SF has been validated for the Spanish university population, showing a satisfactory correlation (0.69) with the accelerometer(1717. Rodríguez-Muñoz S, Corella C, Abarca-Sos A, Zaragoza J. Validation of three short physical activity questionnaires with accelerometers among university students in Spain. J Sports Med Phys Fitness. 2017 Dec;57(12):1660-8. https://doi.org/10.23736/S0022-4707.17.06665-8
https://doi.org/10.23736/S0022-4707.17.0...
).
The participants’ eating habits were assessed with the Spanish Healthy Eating Index (Índice de Alimentación Saludable Español, IASE)(1818. Norte Navarro AI, Ortiz Moncada R. Spanish diet quality according to the healthy eating index. Nutr Hosp. 2011;26(2):330-6. https://doi.org/10.1590/S0212-16112011000200014
https://doi.org/10.1590/S0212-1611201100...
). This tool is an adaptation of the Healthy Eating Index(1919. Kennedy ET, Ohls J, Carlson S, Fleming K. The Healthy Eating Index: design and applications. J Am Diet Assoc. 1995;95(10):1103-8. https://doi.org/10.1016/S0002-8223(95)00300-2
https://doi.org/10.1016/S0002-8223(95)00...
) to the Spanish context according to the recommendations proposed by the Spanish Society of Community Nutrition. The index has 10 items (scoring range: 0-10) for a final score varying from 0 to 100 points. Based on the score obtained, the participants are categorized as follows: scores >80 points (healthy diet), between 50 and 80 (diet requiring changes), and scores <50 (inadequate diet). This questionnaire is repeatedly used in Spanish university populations(2020. Ramón-Arbués E, Martínez Abadía B, Granada López JM, Echániz Serrano E, Pellicer García B, Juárez Vela R, et al. Eating behavior and relationships with stress, anxiety, depression and insomnia in university students. Nutr Hosp. 2019;36(6):1339-45. https://doi.org/10.20960/nh.02641
https://doi.org/10.20960/nh.02641...
-2121. Ramón-Arbués E, Granada-López JM, Martínez-Abadía B, Echániz-Serrano E, Antón-Solanas I, Jerue BA. Factors Related to Diet Quality: A Cross-Sectional Study of 1055 University Students. Nutrients. 2021;13(10):3512. https://doi.org/10.3390/nu13103512
https://doi.org/10.3390/nu13103512...
). Although it has not yet been validated for the Spanish university population, the original Healthy Eating Index questionnaire has indeed been validated through plasma biomarkers, showing satisfactory correlation levels ranging from a minimum of r=0.23 (for cereals) to a maximum of r=0.71 for food variety(2222. Hann CS, Rock CL, King I, Drewnowski A. Validation of the Healthy Eating Index with use of plasma biomarkers in a clinical sample of women. Am J Clin Nutr. 2001;74(4):479-86. https://doi.org/10.1093/ajcn/74.4.479
https://doi.org/10.1093/ajcn/74.4.479...
).
Finally, the anxiety and depression symptoms were assessed with the HADS scale(2323. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361-70. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x
https://doi.org/10.1111/j.1600-0447.1983...
), a tool originally conceived for the clinical population, although it is currently widely employed and has proved to be useful in the community scope. HADS consists of two 6-item subscales: HADS-Depression and HADS-Anxiety. Each item is classified following a 4-point Likert (from 0 = Never to 3 = Almost all the time), for a global score in each subscale ranging from 0 to 21. Based on this result, possible depression and possible anxiety were considered for the participants with scores ≥8, whereas probable depression and probable anxiety for those with values ≥11 in the respective subscales(2424. Martínez-Gestoso S, García-Sanz MT, Carreira JM, Salgado FJ, Calvo-Álvarez U, Doval-Oubiña L, et al. Impact of anxiety and depression on the prognosis of copd exacerbations. BMC Pulm Med. 2022;22(1):169. https://doi.org/10.1186/s12890-022-01934-y
https://doi.org/10.1186/s12890-022-01934...
). In its validation study on the Spanish population, this questionnaire has shown optimum properties for anxiety and depression screening(2525. Herrero MJ, Blanch J, Peri JM, De Pablo J, Pintor L, Bulbena A. A validation study of the hospital anxiety and depression scale (HADS) in a Spanish population. Gen Hosp Psychiatry. 2003;25(4):277-83. https://doi.org/10.1016/s0163-8343(03)00043-4
https://doi.org/10.1016/s0163-8343(03)00...
-2626. Quintana JM, Padierna A, Esteban C, Arostegui I, Bilbao A, Ruiz I. Evaluation of the psychometric characteristics of the Spanish version of the Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 2003;107(3):216-21. https://doi.org/10.1034/j.1600-0447.2003.00062.x
https://doi.org/10.1034/j.1600-0447.2003...
).
Data analysis
The descriptive analysis corresponding to the characteristics of the sample (sociodemographic, academic, lifestyle-related, and psychological symptomatology) is presented through mean values and standard deviations for the quantitative variables, and with numbers and percentages for the categorical ones. The bivariate comparison of those characteristics based on gender was performed through the Student’s t test for the quantitative variables using the χ2 test (or Fisher’s Exact test when applicable) for the categorical ones.
In addition, several multiple linear regression models were performed with the objective of determining the association degree between screen time, physical activity, diet and anxiety/depression symptoms, both for the total population and by sex. The models performed on the total sample were adjusted by age, sex, economic situation, mean grade, academic year, housing arrangement and work situation, as well as by screen time and diet (for physical activity) or by physical activity and diet (for screen time) or by physical activity and screen time (for diet). The models disaggregated by sex were adjusted by age, economic situation, mean grade, academic year, housing arrangement and work situation, as well as by screen time and diet (for physical activity) or by physical activity and diet (for screen time) or by physical activity and screen time (for diet). All calculations were made in the Statistical Package for the Social Sciences (SPSS), Version 23.0, accepting p-values<0.05 as statistically significant.
Ethical considerations
Prior to initiating the study, due authorization was obtained from the Aragon Clinical Research Ethics Committee. Initially, the participants were informed about the objectives, methodology and potential risks arising from their participation in the study and about the possibility of withdrawing from the research at any moment. Subsequently, and prior to data collection, all the participants signed the informed consent form.
Results
Characteristics of the sample
A total of 648 nursing students comprised the final study sample. The participants’ mean age was 21.7 years old and the female gender prevailed (84.2%). Most of the participants were enrolled in 2nd or 3rd year of the course (50.3%), lived with their parents/family members (60.2%), perceived their economic level as average (85,2%) and had no paid jobs (76.9%). By sex, no statistically significant differences were observed in relation to age, academic year and grade or work situation. However, men were more prone to living alone than women (p<0.05) (Table 1).
Physical activity, screen time and diet
Assessed by means of IASE, the quality of the participants’ diet turned out to be deficient. Up to 93.5% reported inadequate diet or requiring changes. The time spent in front of screens was high (5.8 hours a day on average), with a vast majority of the participants (72.2%) indicating daily times of more than 3 hours. 51.9% of the participants reported low physical activity, whereas only 23.1% reported high levels. By sex, the men presented not-so-negative diets, with higher IASE scores and more chances of following a healthy diet. They also showed lower use of devices with a screen and greater willingness for physical activity, as evidenced by their higher weekly metabolic expenditure and by the higher proportion of men with moderate and high levels of physical activity (p<0.05) (Table 2).
Physical activity, screen time and diet among the participants (n=648). Zaragoza, AR, Spain, 2022
Anxiety and depressive symptoms
The mean scores obtained in the HADS-A and HADS-D scales were 8.34±3.30 and 4.12±2.82, respectively. Only 47.2% of the participants did not present any type of symptoms compatible with anxiety, with confirmation of the anxious symptomatology in up to 24.1% of the participants. Referring to depression, 88% of the participants did not show depressive symptoms, and only 3.7% had clinical signs compatible with depression (Table 3). By sex, the scores obtained in HADS indicated greater anxiety and depression traits in women and men, respectively (p<0.05), although the probability of finding severe clinical signs of depression was slightly higher in the women’s group.
Association between physical activity, screen time, diet and psychological symptoms
All three multivariate analysis models (for the total and by gender) performed to evaluate the association between physical activity, screen time, diet and the anxiety symptoms showed that low levels of physical activity, prolonged screen times (>6 hours) and unhealthy diets (diet requiring changes and inadequate diet) are statistically and significantly associated with higher scores in the HADS-A anxiety scale. These behaviors are maintained both for the general sample and in the analysis disaggregated by gender. The predictive capacity of these three models ranged between 19.5% and 67.4% (Table 4).
Multiple linear regression of factors associated with the scores obtained in the HADS-A* scale (n=648). Zaragoza, AR, Spain, 2022
Referring to the association between physical activity, screen time, diet and depressive symptoms, the different multiple linear regression models developed evidenced that longer screen times (>6 hours) and diets not following the recommendations (diet requiring changes and inadequate diet) are statistically and significantly associated with higher scores in the HADS-D scale. The behavior of these associations was similar in men and in women. However, an inverse association between physical activity and depression was only observed in the men’s group. Thus, the higher the physical activity level, the fewer the depressive symptoms (lower HADS-D scores) in men. The predictive capacity of these models ranged between 20% and 78% (Table 5).
Multiple linear regression of factors associated with the scores obtained in the HADS-D* scale (n=648). Zaragoza, AR, Spain, 2022
Discussion
The objective of this research was to examine the prevalence of anxiety and depression in a sample comprised by Spanish nursing students, as well as their association with screen time, physical activity and quality of the diet. We were able to detect high prevalence of risk behaviors for health, such as low levels of physical activity (51.9%), deficient diet (40.7%) and prolonged screen times (13.9%) among local future nurses. These values are similar to those already obtained in samples comprised by Spanish university students(2727. Carballo-Fazanes A, Rico-Díaz J, Barcala-Furelos R, Rey E, Rodríguez-Fernández JE, Varela-Casal C, et al. Physical Activity Habits and Determinants, Sedentary Behaviour and Lifestyle in University Students. Int J Environ Res Public Health. 2020;17(9):E3272. https://doi.org/10.3390/ijerph17093272
https://doi.org/10.3390/ijerph17093272...
-2828. Ramón-Arbués E, Granada-López JM, Martínez-Abadía B, Echániz-Serrano E, Antón-Solanas I, Nash M. Prevalence and Factors Associated with Problematic Internet Use in a Population of Spanish University Students. Int J Environ Res Public Health. 2021;18(14):7620. https://doi.org/10.3390/ijerph18147620
https://doi.org/10.3390/ijerph18147620...
). They are high prevalence values for unhealthy lifestyles, which deserves double consideration in the case of nursing students. On the one hand, unhealthy habits predict medium- and long-term health problems for these young people. On the other hand, the nursing staff is a reference in relation to health education and the promotion of healthy lifestyles. In this sense, the already published literature suggests that the health professionals’ behaviors exert an influence on their health promotion practices(2929. Lobelo F, Duperly J, Frank E. Physical activity habits of doctors and medical students influence their counselling practices. Br J Sports Med. 2009;43(2):89-92. https://doi.org/10.1136/bjsm.2008.055426
https://doi.org/10.1136/bjsm.2008.055426...
). It is worth noting that these behaviors were associated with psychological distress. Thus, high levels of physical activity were inversely associated with presence of anxiety and depression symptoms. This relationship has already been reported in various populations(3030. Sampasa-Kanyinga H, Colman I, Goldfield GS, Janssen I, Wang J, Podinic I, et al. Combinations of physical activity, sedentary time, and sleep duration and their associations with depressive symptoms and other mental health problems in children and adolescents: a systematic review. Int J Behav Nutr Phys Act. 2020;17(1):72. https://doi.org/10.1186/s12966-020-00976-x
https://doi.org/10.1186/s12966-020-00976...
) and may be sustained from a neurobiological point of view due to the activating effect of physical activity on the endocannabinoid system and the brain-derived neurotrophic factor(3131. Heyman E, Gamelin FX, Goekint M, Piscitelli F, Roelands B, Leclair E, et al. Intense exercise increases circulating endocannabinoid and BDNF levels in humans-possible implications for reward and depression. Psychoneuroendocrinology. 2012 Jun;37(6):844-51. https://doi.org/10.1016/j.psyneuen.2011.09.017
https://doi.org/10.1016/j.psyneuen.2011....
).
Previous research studies have evidenced significant associations between healthy eating habits (moderate calorie intake, having breakfast or not eating snacks, among others) or intake of certain food products and nutrients (vegetables and fruit, polyunsaturated fatty acids, certain minerals or vitamins, among others) and good psychological health(3232. Guzek D, Gła Bska D, Groele B, Gutkowska K. Fruit and Vegetable Dietary Patterns and Mental Health in Women: A Systematic Review. Nutr Rev. 2022;80(6): 1357-70. https://doi.org/10.1093/nutrit/nuab007
https://doi.org/10.1093/nutrit/nuab007...
-3333. Dharmayani PNA, Juergens M, Allman-Farinelli M, Mihrshahi S. Association between Fruit and Vegetable Consumption and Depression Symptoms in Young People and Adults Aged 15-45: A Systematic Review of Cohort Studies. Int J Environ Res Public Health. 2021;18(2):780. https://doi.org/10.3390/ijerph18020780
https://doi.org/10.3390/ijerph18020780...
). In this same line, the quality of our participants’ diet was inversely and strongly associated with presence of anxiety and depression.
Finally, prolonged screen times (>6 hours a day) were associated with worse mental health results in our sample. Screen time is a variable of interest nowadays, as it contributes two types of information. On the one hand, data related to use/abuse of new technologies and, on the other hand, an indirect measure of the presence of a sedentary life pattern. In this sense, excessive use of new screen-based technologies (social networks, smartphones, etc.) and their associated sedentary lifestyle have already been related to psychological distress, especially in the young population(3434. Hoare E, Milton K, Foster C, Allender S. The associations between sedentary behaviour and mental health among adolescents: a systematic review. Int J Behav Nutr Phys Act. 2016;13(1):108. https://doi.org/10.1186/s12966-016-0432-4
https://doi.org/10.1186/s12966-016-0432-...
-3535. Hrafnkelsdottir SM, Brychta RJ, Rognvaldsdottir V, Gestsdottir S, Chen KY, Johannsson E, et al. Less screen time and more frequent vigorous physical activity is associated with lower risk of reporting negative mental health symptoms among Icelandic adolescents. PLoS One. 2018;13(4):e0196286. https://doi.org/10.1371/journal.pone.0196286
https://doi.org/10.1371/journal.pone.019...
).
A recent meta-analysis published in 2022 and conducted with an aggregated sample of more than 100,000 subjects determined 33.6% and 39.0% prevalence of depression and anxiety symptoms in university students, respectively(3636. Li W, Zhao Z, Chen D, Peng Y, Lu Z. Prevalence and associated factors of depression and anxiety symptoms among college students: a systematic review and meta-analysis. J Child Psychol Psychiatry. 2022;63(11):1222-30. https://doi.org/10.1111/jcpp.13606
https://doi.org/10.1111/jcpp.13606...
). Comparing these values with those obtained in cross-sectional studies, such as in this case, is a difficult task given the heterogeneity of socioeconomic contexts and the variety of diagnostic instruments used. In any case, they are higher numbers than those observed in our sample of nursing students, where approximately one-fourth of the participants presented some type of psychological distress, with higher prevalence of anxiety (24.1%) than of depression (3.7%) symptoms. These results seem to be contrary to the theory which asserts that students from the health area present higher psychological distress levels than others for being subjected to more stressors, including contact with diseases and deaths(3737. Bartlett ML, Taylor H, Nelson JD. Comparison of Mental Health Characteristics and Stress Between Baccalaureate Nursing Students and Non-Nursing Students. J Nurs Educ. 2016;55(2):87-90. https://doi.org/10.3928/01484834-20160114-05
https://doi.org/10.3928/01484834-2016011...
).
Several studies have already analyzed the prevalence of psychological distress in nursing students, with very heterogeneous results according to the participants’ countries of origin. For example, in Canada, depression and anxiety symptoms have been observed in 32% and 39% of the students, respectively(3838. Chernomas WM, Shapiro C. Stress, depression, and anxiety among undergraduate nursing students. Int J Nurs Educ Scholarsh. 2013. https://doi.org/10.1515/ijnes-2012-0032
https://doi.org/10.1515/ijnes-2012-0032...
). These values differ from those obtained in Turkey (depression symptoms in 55.5% and anxiety symptoms in 50.9%)(3939. Kalkan Uğurlu Y, Mataracı Değirmenci D, Durgun H, Gök Uğur H. The examination of the relationship between nursing students’ depression, anxiety and stress levels and restrictive, emotional, and external eating behaviors in COVID-19 social isolation process. Perspect Psychiatr Care. 2021;57(2):507-16. https://doi.org/10.1111/ppc.12703
https://doi.org/10.1111/ppc.12703...
), Brazil (depression symptoms in 54.2% and anxiety symptoms in 40.1%)(4040. Coelho LS, Tony ACC, Laguardia GCA, Santos KBD, Friedrich DBC, Cavalcante RB, et al. Are symptoms of depression and anxiety in nursing students associated with their sociodemographic characteristics? Rev Bras Enferm. 2021;74(suppl 3):e20200503. https://doi.org/10.1590/0034-7167-2020-0503
https://doi.org/10.1590/0034-7167-2020-0...
), Japan (depression symptoms in 18.3% and anxiety symptoms in 34.6%)(4141. Sakai M, Nakanishi M, Yu Z, Takagi G, Toshi K, Wakashima K, et al. Depression and anxiety among nursing students during the COVID-19 pandemic in Tohoku region, Japan: A cross-sectional survey. Jpn J Nurs Sci. 2022;19(3):e12483. https://doi.org/10.1111/jjns.12483
https://doi.org/10.1111/jjns.12483...
) or Saudi Arabia (depression symptoms in 43.3% and anxiety symptoms in 37.2%)(4242. Alsolais A, Alquwez N, Alotaibi KA, Alqarni AS, Almalki M, Alsolami F, et al. Risk perceptions, fear, depression, anxiety, stress and coping among Saudi nursing students during the COVID-19 pandemic. J Ment Health. 2021;30(2):194-201. https://doi.org/10.1080/09638237.2021.1922636
https://doi.org/10.1080/09638237.2021.19...
), among others. In general terms, they are higher numbers than those obtained in this study. A possible explanation for the lower prevalence of psychological distress in our sample can be the time when the data were collected. Whereas the bulk of the recent bibliography on psychological distress in nursing students is circumscribed to the confinement period and to the effects of the COVID-19 pandemic, this study determines the psychological symptoms at a post-pandemic euphoric moment after the removal of all restrictions in Spain.
This research study has some limitations that are worth noting. In the first place, the sample was fully extracted from a single locus, the Aragon Region, which can raise doubts when extrapolating the results to the global population of Spanish nursing students. However, the participants’ gender and age profiles in this study coincide with those existing in the bulk of the Spanish nursing training programs. Secondly, our cross-sectional design only allows establishing associations, precluding causality relationships. Future research studies with longitudinal designs might provide better grounds to understand the associations observed in this survey, especially regarding how the health-related behaviors of nursing students can affect their psychological health, and vice versa. Despite these limitations, several factors lead us to believe that our results may be useful and serve as the starting point for future initiatives that promote mental health in the university context. The use of standardized data collection procedures and of validated questionnaires both to assess the psychological symptoms and to determine health-related behaviors, as well as the plausibility of the associations established, support this assumption.
To the best of our knowledge, this is the first study that analyzes depression and anxiety symptoms, as well as their association with various health-related behaviors, in a broad sample of Spanish nursing students. The results obtained in this study report considerable prevalence values for psychological distress and unhealthy behaviors among these students, which demand attention both from those responsible for formulating health policies and from the university authorities. From this perspective, it is imperative to implement new mental health monitoring and promotion activities and healthy behaviors in the university setting. Currently, students can usually access certain support services, such as tutoring or counseling. However, they are not specific to any given academic discipline or based on scientific evidence. In this sense, some authors suggest certain strategies capable of minimizing psychological distress, such as behavioral interventions(4343. Demir S, Ercan F. The effectiveness of cognitive behavioral therapy-based group counseling on depressive symptomatology, anxiety levels, automatic thoughts, and coping ways Turkish nursing students: A randomized controlled trial. Perspect Psychiatr Care. 2022;58(4): 2394-406. https://doi.org/10.1111/ppc.13073
https://doi.org/10.1111/ppc.13073...
), mindfulness(4444. Chen X, Zhang B, Jin SX, Quan YX, Zhang XW, Cui XS. The effects of mindfulness-based interventions on nursing students: A meta-analysis. Nurse Educ Today. 2021;98: 104718. https://doi.org/10.1016/j.nedt.2020.104718
https://doi.org/10.1016/j.nedt.2020.1047...
) or mentoring programs(4545. Fard ZR, Azadi A, Khorshidi A, Mozafari M, O’Connor T, Budri AMV, et al. A comparison of faculty led, mentorship program and peer mentoring on nursing students wound dressing clinical skills. Nurse Educ Today. 2020;89:104378. https://doi.org/10.1016/j.nedt.2020.104378
https://doi.org/10.1016/j.nedt.2020.1043...
). In addition, nursing students subjected to stressful situations in their care practice internships might be benefited if simulation scenarios were incorporated into the curriculum. These spaces may help nursing students to gain confidence, anticipate situations and develop effective coping strategies for their future performance in emotionally complex situations(4646. Labrague LJ, McEnroe-Petitte DM, Bowling AM, Nwafor CE, Tsaras K. High-fidelity simulation and nursing students’ anxiety and self-confidence: A systematic review. Nurs Forum. 2019;54(3):358-68. https://doi.org/10.1111/nuf.12337
https://doi.org/10.1111/nuf.12337...
).
Conclusion
The results of this study show considerable prevalence of depression and anxiety symptoms in Spanish nursing students. In addition, these symptoms are associated with low levels of physical activity, prolonged screen times and unhealthy diets. These data suggest two important problems towards the future. The first one refers to the future nurses’ medium- and long-term health. The second one concerns their future performance as nursing professionals, which can be impaired by lower promotion of their patients’ health (a person cannot so vehemently promote something they do not comply with) and by greater exposure to the burnout phenomenon, which is more incident in professionals with a less favorable baseline psychological status. These predictions denote the importance of implementing strategies that promote general and mental health in the university setting.
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» https://doi.org/10.1111/jcpp.13606 -
37.Bartlett ML, Taylor H, Nelson JD. Comparison of Mental Health Characteristics and Stress Between Baccalaureate Nursing Students and Non-Nursing Students. J Nurs Educ. 2016;55(2):87-90. https://doi.org/10.3928/01484834-20160114-05
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» https://doi.org/10.1515/ijnes-2012-0032 -
39.Kalkan Uğurlu Y, Mataracı Değirmenci D, Durgun H, Gök Uğur H. The examination of the relationship between nursing students’ depression, anxiety and stress levels and restrictive, emotional, and external eating behaviors in COVID-19 social isolation process. Perspect Psychiatr Care. 2021;57(2):507-16. https://doi.org/10.1111/ppc.12703
» https://doi.org/10.1111/ppc.12703 -
40.Coelho LS, Tony ACC, Laguardia GCA, Santos KBD, Friedrich DBC, Cavalcante RB, et al. Are symptoms of depression and anxiety in nursing students associated with their sociodemographic characteristics? Rev Bras Enferm. 2021;74(suppl 3):e20200503. https://doi.org/10.1590/0034-7167-2020-0503
» https://doi.org/10.1590/0034-7167-2020-0503 -
41.Sakai M, Nakanishi M, Yu Z, Takagi G, Toshi K, Wakashima K, et al. Depression and anxiety among nursing students during the COVID-19 pandemic in Tohoku region, Japan: A cross-sectional survey. Jpn J Nurs Sci. 2022;19(3):e12483. https://doi.org/10.1111/jjns.12483
» https://doi.org/10.1111/jjns.12483 -
42.Alsolais A, Alquwez N, Alotaibi KA, Alqarni AS, Almalki M, Alsolami F, et al. Risk perceptions, fear, depression, anxiety, stress and coping among Saudi nursing students during the COVID-19 pandemic. J Ment Health. 2021;30(2):194-201. https://doi.org/10.1080/09638237.2021.1922636
» https://doi.org/10.1080/09638237.2021.1922636 -
43.Demir S, Ercan F. The effectiveness of cognitive behavioral therapy-based group counseling on depressive symptomatology, anxiety levels, automatic thoughts, and coping ways Turkish nursing students: A randomized controlled trial. Perspect Psychiatr Care. 2022;58(4): 2394-406. https://doi.org/10.1111/ppc.13073
» https://doi.org/10.1111/ppc.13073 -
44.Chen X, Zhang B, Jin SX, Quan YX, Zhang XW, Cui XS. The effects of mindfulness-based interventions on nursing students: A meta-analysis. Nurse Educ Today. 2021;98: 104718. https://doi.org/10.1016/j.nedt.2020.104718
» https://doi.org/10.1016/j.nedt.2020.104718 -
45.Fard ZR, Azadi A, Khorshidi A, Mozafari M, O’Connor T, Budri AMV, et al. A comparison of faculty led, mentorship program and peer mentoring on nursing students wound dressing clinical skills. Nurse Educ Today. 2020;89:104378. https://doi.org/10.1016/j.nedt.2020.104378
» https://doi.org/10.1016/j.nedt.2020.104378 -
46.Labrague LJ, McEnroe-Petitte DM, Bowling AM, Nwafor CE, Tsaras K. High-fidelity simulation and nursing students’ anxiety and self-confidence: A systematic review. Nurs Forum. 2019;54(3):358-68. https://doi.org/10.1111/nuf.12337
» https://doi.org/10.1111/nuf.12337
-
How to cite this article
Ramón-Arbués E, Granada-López JM, Satústegui-Dordá PJ, Echániz-Serrano E, Sagarra-Romero L, Antón-Solanas I. Psychological distress in nursing students: relationship with screen time, diet and physical activity. Rev. Latino-Am. Enfermagem. 2023;31:e3960 [cited year mon day]. Available from: URL . https://doi.org/10.1590/1518-8345.6746.3960 -
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Publication Dates
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Publication in this collection
21 July 2023 -
Date of issue
2023
History
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Received
01 Mar 2023 -
Accepted
08 May 2023