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Recent developments in stress and anxiety research

• Published: 01 September 2021
• Volume 128 , pages 1265–1267, ( 2021 )

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• Urs M. Nater 1 , 2  

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Stress and anxiety are virtually omnipresent in today´s society, pervading almost all aspects of our daily lives. While each and every one of us experiences “stress” and/or “anxiety” at least to some extent at times, the phenomena themselves are far from being completely understood. In stress research, scientists are particularly grappling with the conceptual issue of how to define stress, also with regard to delimiting stress from anxiety or negative affectivity in general. Interestingly, there is no unified theory of stress, despite many attempts at defining stress and its characteristics. Consequently, the available literature relies on a variety of different theoretical approaches, though the theories of Lazarus and Folkman ( 1984 ) or McEwen ( 1998 ) are relatively pervasive in the literature. One key issue in conceptualizing stress is that research has not always differentiated between the perception of a stimulus or a situation as a stressor and the subsequent biobehavioral response (often called the “stress response”). This is important, since, for example, psychological factors such as uncontrollability and social evaluation, i.e. factors that may influence how an individual perceives a potentially stressful stimulus or situation, have been identified as characteristics that elicit particularly powerful physiological stressful responses (Dickerson and Kemeny 2004 ). At the core of the physiological stress response is a complex physiological system, which is located in both the central nervous system (CNS) and the body´s periphery. The complexity of this system necessitates a multi-dimensional assessment approach involving variables that adequately reflect all relevant components. It is also important to consider that the experience of stress and its psychobiological correlates do not occur in a vacuum, but are being shaped by numerous contextual factors (e.g. societal and cultural context, work and leisure time, family and dyadic systems, environmental variables, physical fitness, nutritional status, etc.) and dispositional factors (e.g. genetics, personality, resilience, regulatory capacities, self-efficacy, etc.). Thus, a theoretical framework needs to incorporate these factors. In sum, as stress is considered a multi-faceted and inherently multi-dimensional construct, its conceptualization and operationalization needs to reflect this (Nater 2018 ).

The goal of the World Association for Stress Related and Anxiety Disorders (WASAD) is to promote and make available basic and clinical research on stress-related and anxiety disorders. Coinciding with WASAD’s 3rd International Congress held in September 2021 in Vienna, Austria, this journal publishes a Special Issue encompassing state-of-the art research in the field of stress and anxiety. This special issue collects answers to a number of important questions that need to be addressed in current and future research. Among the most relevant issues are (1) the multi-dimensional assessment that arises as a consequence of a multi-faceted consideration of stress and anxiety, with a particular focus on doing so under ecologically valid conditions. Skoluda et al. 2021 (in this issue) argue that hair as an important source of the stress hormone cortisol should not only be taken as a complementary stress biomarker by research staff, but that lay persons could be also trained to collect hair at the study participants’ homes, thus increasing the ecological validity of studies incorporating this important measure; (2) the incongruence between psychological and biological facets of stress and anxiety that has been observed both in laboratory and field research (Campbell and Ehlert 2012 ). Interestingly, there are behavioral constructs that do show relatively high congruence. As shown in the paper of Vatheuer et al. ( 2021 ), gaze behavior while exposed to an acute social stressor correlates with salivary cortisol, thus indicating common underlying mechanisms; (3) the complex dynamics of stress-related measures that may extend over shorter (seconds to minutes), medium (hours and diurnal/circadian fluctuations), and longer (months, seasonal) time periods. In particular, momentary assessment studies are highly qualified to examine short to medium term fluctuations and interactions. In their study employing such a design, Stoffel and colleagues (Stoffel et al. 2021 ) show ecologically valid evidence for direct attenuating effects of social interactions on psychobiological stress. Using an experimental approach, on the other hand, Denk et al. ( 2021 ) examined the phenomenon of physiological synchrony between study participants; they found both cortisol and alpha-amylase physiological synchrony in participants who were in the same group while being exposed to a stressor. Importantly, these processes also unfold over time in relation to other biological systems; al’Absi and colleagues showed in their study (al’Absi et al. 2021 ) the critical role of the endogenous opioid system and its relation to stress-related analgesia; (4) the influence of contextual and dispositional factors on the biological stress response in various target samples (e.g., humans, animals, minorities, children, employees, etc.) both under controlled laboratory conditions and in everyday life environments. In this issue, Sattler and colleagues show evidence that contextual information may only matter to a certain extent, as in their study (Sattler et al. 2021 ), the biological response to a gay-specific social stressor was equally pronounced as the one to a general social stressor in gay men. Genetic information is probably the most widely researched dispositional factor; Kuhn et al. show in their paper (Kuhn et al. 2021 ) that the low expression variant of the serotonin transporter gene serves as a risk factor for increased stress reactivity, thus clearly indicating the important role of dispositional factors in stress processing. An interesting factor combining both aspects of dispositional and contextual information is maternal care; Bentele et al. ( 2021 ) in their study are able to show that there was an effect of maternal care on the amylase stress response, while no such effect was observed for cortisol. In a similar vein, Keijser et al. ( 2021 ) showed in their gene-environment interaction study that the effects of FKBP5, a gene very closely related to HPA axis regulation, and early life stress on depressive symptoms among young adults was moderated by a positive parenting style; and (5) the role of stress and anxiety as transdiagnostic factors in mental disorders, be it as an etiological factor, a variable contributing to symptom maintenance, or as a consequence of the condition itself. Stress, e.g., as a common denominator for a broad variety of psychiatric diagnoses has been extensively discussed, and stress as an etiological factor holds specific significance in the context of transdiagnostic approaches to the conceptualization and treatment of mental disorders (Wilamowska et al. 2010 ). The HPA axis, specifically, is widely known to be dysregulated in various conditions. Fischer et al. ( 2021 ) discuss in their comprehensive review the role of this important stress system in the context of patients with post-traumatic disorder. Specifically focusing on the cortisol awakening response, Rausch and colleagues provide evidence for HPA axis dysregulation in patients diagnosed with borderline personality disorder (Rausch et al. 2021 ). As part of a longitudinal project on ADHD, Szep et al. ( 2021 ) investigated the possible impact of child and maternal ADHD symptoms on mothers’ perceived chronic stress and hair cortisol concentration; although there was no direct association, the findings underline the importance of taking stress-related assessments into consideration in ADHD studies. As the HPA axis is closely interacting with the immune system, Rhein et al. ( 2021 ) examined in their study the predicting role of the cytokine IL-6 on psychotherapy outcome in patients with PTSD, indicating that high reactivity of IL-6 to a stressor at the beginning of the therapy was associated with a negative therapy outcome. The review of Kyunghee Kim et al. ( 2021 ) also demonstrated the critical role of immune pathways in the molecular changes due to antidepressant treatment. As for the therapy, the important role of cognitive-behavioral therapy with its key elements to address both stress and anxiety reduction have been shown in two studies in this special issue, evidencing its successful application in obsessive–compulsive disorder (Ivarsson et al. 2021 ; Hollmann et al. 2021 ). Thus, both stress and anxiety are crucial transdiagnostic factors in various mental disorders, and future research needs elaborate further on their role in etiology, maintenance, and treatment.

In conclusion, a number of important questions are being asked in stress and anxiety research, as has become evident above. The Special Issue on “Recent developments in stress and anxiety research” attempts to answer at least some of the raised questions, and I want to invite you to inspect the individual papers briefly introduced above in more detail.

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Nater, U.M. Recent developments in stress and anxiety research. J Neural Transm 128 , 1265–1267 (2021). https://doi.org/10.1007/s00702-021-02410-3

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Accepted : 13 August 2021

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DOI : https://doi.org/10.1007/s00702-021-02410-3

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Stress research during the COVID-19 pandemic and beyond

Affiliations.

• 1 Cognitive Psychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany. Electronic address: [email protected].
• 2 Biopsychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany; General Psychology II and Biological Psychology, Institute of Psychology, School of Human Sciences, Osnabrück University, Osnabrück, Germany.
• 3 Biopsychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany.
• 4 Cognitive Psychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany.
• PMID: 34599918
• PMCID: PMC8480136
• DOI: 10.1016/j.neubiorev.2021.09.045

The COVID-19 pandemic confronts stress researchers in psychology and neuroscience with unique challenges. Widely used experimental paradigms such as the Trier Social Stress Test feature physical social encounters to induce stress by means of social-evaluative threat. As lockdowns and contact restrictions currently prevent in-person meetings, established stress induction paradigms are often difficult to use. Despite these challenges, stress research is of pivotal importance as the pandemic will likely increase the prevalence of stress-related mental disorders. Therefore, we review recent research trends like virtual reality, pre-recordings and online adaptations regarding their usefulness for established stress induction paradigms. Such approaches are not only crucial for stress research during COVID-19 but will likely stimulate the field far beyond the pandemic. They may facilitate research in new contexts and in homebound or movement-restricted participant groups. Moreover, they allow for new experimental variations that may advance procedures as well as the conceptualization of stress itself. While posing challenges for stress researchers undeniably, the COVID-19 pandemic may evolve into a driving force for progress eventually.

Keywords: COVID-19; Chronic stress; Corona virus; Ecological field research; Online studies; Social-evaluative threat; Stress research; Stress-related mental disorders; Trier social stress test (TSST); Virtual reality.

Copyright © 2021 Elsevier Ltd. All rights reserved.

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Review article, examining academics’ strategies for coping with stress and emotions: a review of research.

• Department of Educational and Counselling Psychology, McGill University, Montreal, QC, Canada

Existing research suggests that numerous aspects of the modern academic career are stressful and trigger emotional responses, with evidence further showing job-related stress and emotions to impact well-being and productivity of post-secondary faculty (i.e., university or college research and teaching staff). The current paper provides a comprehensive and descriptive review of the empirical research on coping and emotion regulation strategies among faculty members, identifies adaptive stress management and emotion regulation strategies for coping with emotional demands of the academic profession, synthesizes findings on the association between such strategies and faculty well-being, and provides directions for future research on this topic.

Introduction

Not unlike other professionals, post-secondary faculty (i.e., university or college research and teaching staff across ranks and tenure status) have consistently been found to report high levels of job-related stress ( Winefield et al., 2003 ). In the last few decades, higher education institutions worldwide have undergone fundamental changes. Major educational reforms, exponential expansion in student enrollment, escalating workloads, greater control by managers with respect to teaching quality and research productivity, and the movement towards commercialization have shifted the landscape of higher education into a competitive business ( Ogbonna and Harris, 2004 ; Biron et al., 2008 ; Rothmann and Barkhuizen, 2008 ; McAlpine and Akerlind, 2010 ). Subsequently, there is substantial pressure on academics to maintain high academic performance and productivity ( Catano et al., 2010 ; McAlpine and Akerlind, 2010 ).

Surveys carried out in the U.K. ( Tytherleigh et al., 2005 ; Kinman, 2014 ), Australia ( Winefield et al., 2003 ), and Canada ( Biron et al., 2008 ; Catano et al., 2010 ) suggest that these increased demands have contributed to high levels of job-related stress amongst academics. Most notably, a recent comparison of U.K. and Australian academics revealed that faculty suffered from higher levels of stress-related caseness (i.e., when some intervention is required) as compared with other university groups (e.g., post-secondary staff, support professonals; Kinman, 2014 ), with reported burnout by academics being comparable to that of school teachers and medical professionals for whom burnout levels are particularly high ( Watts and Robertson, 2012 ). Empirical evidence strongly supports the detrimental impact of stress on post-secondary faculty members’ physical (e.g., sleep problems, nausea, heart pounding) and psychological well-being (e.g., anxiety, depression, burnout, psychological distress)and professional competencies, as well as student attainment and institutional productivity ( Blix et al., 1994 ; Stevenson and Harper, 2006 ; Catano et al., 2010 ; Watts and Robertson, 2012 ; Barkhuizen et al., 2014 ; Kataoka et al., 2014 ; Shen et al., 2014 ; Salimzadeh et al., 2017 ).

A parallel line of research suggests that the academic profession elicits a wide variety of positive and negative emotions resulting from interactions with students, teaching and research-related activities, as well as organizational factors (e.g., Martin and Lueckenhausen, 2005 ; Postareff and Lindblom-Ylänne, 2011 ; Hagenauer and Volet, 2014a ). The emotion literature further underscores implications of emotions on our cognition, behavior, physical health, and psychological well-being (for meta-analytical summaries, see Houben et al., 2015 ; Lench et al., 2011 ). Importantly, these findings have been replicated in emergent research conducted with post-secondary faculty. For instance, a study of 175 Australian university teachers documented the impact of teaching-related emotions on instructional behavior: positive emotions concerning teaching was associated with student-focused teaching approaches and negative emotions instead linked to information transmission approaches ( Trigwell, 2012 ).

Similarly, a mixed-methods study of 18 U.S. faculty members showed that emotions predict faculty success in teaching and research as well as mediate the impact of perceived task value on teaching success and perceptions of academic control on research success ( Stupnisky et al., 2014 ). More precisely, faculty members who placed higher value on their teaching felt more enjoyment and pride in teaching and, in turn, experienced greater teaching success. As for research, the more faculty felt in control of their research, the more adaptive emotions they felt regarding research (e.g., enjoyment, pride) that, in turn, predicted greater research success. In the same vein, a study of 362 U.S. and Chinese college students found that students’ perceptions of university teachers’ positive emotions were significantly and positively correlated with students’ own positive emotions, behavioral and cognitive engagement, and critical thinking ( Zhang and Zhang, 2013 ).

As emotion and stress share overlapping dimensions, it is necessary to consider both their common and distinguishing features. Psychological stress is defined as “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” ( Lazarus and Folkman, 1984 , p. 19). While both stress and emotions are subject to appraisals of the personal significance of an emotional encounter, emotion is operationalized as a broader construct that encompasses negative experiences such as stress ( Lazarus, 1993 ). As such and as a subset of emotion, stress is more limited in scope and depth. While negative emotions are elicited when our goals are thwarted, perceived stress represents the belief that the challenges exceed one’s capabilities to cope with them ( Lazarus, 1993 ; Lazarus, 1998 ). In light of the above-mentioned common features, emotions and stress are reviewed together in the present paper.

Emotion regulation is defined as an everyday psychological process “by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions” ( Gross, 1998b , p. 275). In contrast, coping refers to individuals’ efforts to manage stronger and more persistent negative emotions (i.e., stress) that involve “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” ( Lazarus and Folkman, 1984 , p. 141). Emotional labor, on the other hand, involves the “process of regulating both the internal and expressive components of emotions according to an organization’s display rules” ( Grandey, 2000 , p. 97). As such, whereas emotion regulation involves managing both positive and negative emotions on a daily basis, and coping pertains to sustained efforts to combat strong negative emotions in response to significant stressors, emotional labor pertains specifically to the emotions one is expected to convey to others in occupational settings regardless of what one is internally experiencing.

Empirical evidence indicates that the ability to effectively manage stress and emotions has important consequences for health and adaptive functioning (e.g., Folkman and Moskowitz, 2004 ; Gross, 2002 ; Gross and Levenson, 1997 ; John and Gross, 2004 ; for meta-analytical summaries, Skinner et al., 2003 ; Aldao et al., 2010 ; Webb et al., 2012 ). However, although existing research highlights the relevance of coping and emotion regulation for functional and dysfunctional outcomes within work contexts in general (e.g., Murphy, 1996 ; Lawrence et al., 2011 ), the nature and significance of post-secondary academics’ coping and emotion regulation strategies is underexplored. Furthermore, the existing literature on coping and emotion regulation in post-secondary faculty is scattered with no reviews of empirical findings on the topic having been carried out to date. Given the stressful and emotion-laden nature of the academic profession as well as the increasingly problematic nature of stress and the impact of emotions in post-secondary faculty, a comprehensive review of empirical findings is required.

As such, the present review addresses this research gap by providing a comprehensive and descriptive review of quantitative and qualitative research findings on coping and emotion-regulation strategies as reported by post-secondary faculty. It is anticipated that findings from this review will generate insight into academics’ coping and emotion management strategies as well as the consequences of these strategies for well-being and productivity. Furthermore, the findings should shed light on the design and implementation of optimal faculty interventions for post-secondary institutions to equip their academic teaching and research staff with adaptive psychological strategies and maintain their well-being levels ( Implications of Faculty Emotion Regulation and Emotional Labor section for examples of potential interventions). Prior to presenting the method of the review and the main findings, a brief overview of relevant constructs and their corresponding theoretical frameworks are presented.

Constructs Under Review: Coping and Emotion Regulation

Coping strategies. A variety of conceptualizations have been utilized to describe the structure of individuals’ psychological strategies for coping with negative emotions, with models typically distinguishing between problem- and emotion-focused coping ( Folkman and Lazarus, 1980 , Folkman and Lazarus, 1985 ), engagement (active, approach) versus disengagement (avoidance, passive) coping ( Roth and Cohen, 1986 ; Tobin et al., 1989 ), and primary (assimilative) versus secondary (accomodative) control coping ( Weisz et al., 1994 ; Weisz et al., 1984 ; for detailed reviews, see; Skinner et al., 2003 ; Skinner and Zimmer-Gembeck, 2016 ). Problem-focused coping (e.g., strategizing for the purpose of goal attainment) consists of efforts to solve the problem through modifying or eliminating the source of stress whereas emotion-focused coping (e.g., wishful thinking) seeks to regulate distressing emotions in the face of adversity so as to manage the psychological impact of stress. Similarly, engagement coping (e.g., support-seeking) entails active attempts to directly deal with the stressful situation or related feelings whereas disengagement coping (e.g., social withdrawal) refers to efforts to physically and cognitively distance oneself from the stressor and associated emotions.

Whereas perceiving a situation as a challenge may induce positive emotions such as eagerness or excitement, interpreting it instead as personally threatening generates negative emotions such as anxiety or fear ( Folkman, 2008 ). This concept of cognitive appraisals is consistently highlighted in the coping literature due to one’s interpretations regarding the significance and meaning of a stressful encounter mediating the impact of such events on subsequent emotions ( Lazarus and Folkman, 1984 ; Lazarus, 2000 ; Folkman, 2008 ). Importantly, cognitive appraisals are also assumed to determine the types of coping strategies individuals adopt to manage their emotions in stressful situations. Specifically, appraisals of a stressful encounter being controllable tend to trigger problem-solving responses such as planning and strategizing, whereas perceiving the situation as uncontrollable provokes accomodating or emotion-focused strategis such as acceptance or positive thinking ( Aldwin, 2007 ; Skinner and Zimmer-Gembeck, 2016 ).

However, it is also important to note that the assumed emotional consequences of a coping strategy may not in fact be the same as the actual effects of that strategy in response to a specific stressor. As postulated by Lazarus and Folkman (1987) , although coping could be mainly classified as problem-focused or emotion-focused, “in reality any coping thought or act can serve both or many other functions” (p. 152). Coping strategies are thus not universally adaptive or maladaptive for emotional well-being and can be judged as such only after considering the context and the social and personal resources available to the individual, as well as how they influence one’s actions ( Aldwin, 2007 ; Skinner and Zimmer-Gembeck, 2016 ). Nonetheless, research attempting to identify adaptive and maladaptive strategies has found problem-focused coping, engagement coping, as well as primary and secondary control coping to be typically adaptive in that they are consistently found to be linked with better emotional well-being and functioning. In contrast, disengagement and emotion-focused coping are shown to be associated with more maladaptive emotions and behavioral outcomes ( Compas et al., 2001 ).

Given the overlap between coping and emotion regulation frameworks, it is necessary to consider both their convergences and differences. Compared with emotion regulation, coping is a broader construct. Although both coping and emotion regulation are regulatory processes that include controlled and purposeful (i.e., goal-directed) efforts to improve emotional well-being that change over time (i.e., are temporal processes), coping focuses on much larger periods of time (e.g., coping with bereavement over months). However, whereas coping includes only controlled processes, emotion regulation reflects a continuum of processes from conscious, effortful, and controlled regulation of emotions to automatic regulation that takes place without conscious awareness. Accordingly, coping is commonly understood as a form of emotion regulation in which one engages in response to prolonged stress. More precisely, whereas coping primarily focuses on decreasing negative emotions in stressful encounters, emotion regulation targets both expression and experience of positive and negative emotions in stressful situations as well as non-stressful situations. Finally, although coping is performed by the person encountering stress, emotion regulation could be either intrinsic (individuals regulate their own emotions) or extrinsic in nature (emotions are regulated by others; Compas et al., 2014 ; Gross, 1998b , Gross, 2013 ; Gross and Thompson, 2007 ; Koole, 2009 ; Skinner and Zimmer-Gembeck, 2007 ).

Emotion regulation and emotional labor. Regulation of emotions has been studied under two distinct, yet overlapping, research traditions: emotion regulation and emotional labor. The two constructs are comparable in that both focus on modifying feelings and expressions through the use of different strategies ( Gross, 2013 ; Grandey, 2015 ). As mentioned above, emotion regulation encompasses a heterogeneous set of processes whereby people seek to influence the types of emotions they experience, when these emotions are experienced, and how they are expressed ( Gross et al., 2006 ). Emotional labor, on the other hand, represents a subtype of emotion regulation that takes place within a given work context where “display rules” prescribe specific emotions that may or may not be publicly expressed ( Ashforth and Humphrey, 1993 ; Grandey, 2000 ; Gross, 2013 ; Grandey and Gabriel, 2015 ).

Regarding existing proposed frameworks concerning emotion regulation, Gross’ process model ( Gross, 1998a ; Gross, 1998b ) is the most commonly used (for a meta-analysis, Webb et al., 2012 ) and is used in the present review as the organizing structure to synthesize empirical evidence on faculty coping and emotion regulation. The model differentiates between two major forms of emotion regulation in terms of their timing during the unfolding of an emotion: antecedent-focused (i.e., preventative) and response-focused (i.e., responsive). The former strategies are activated before our appraisals initiate emotion response tendencies, and encompass four main strategy types. Situation selection (e.g., confrontation and avoidance) involves choosing or avoiding people, activities, or places that will lead to a situation that can generate the desired emotions. Situation modification pertains to efforts to alter the emotion-inducing situation in order to change its emotional impact, and includes strategies such as direct situation modification, help/support-seeking, and conflict resolution. Attentional deployment (e.g., distraction, rumination, mindfulness) entails managing emotions without modifying the situation by choosing which aspects of a situation to attend to. Cognitive change (e.g., self-efficacy appraisal, challenge and threat appraisals, and positive reappraisal) involves re-evaluating a situation and altering one’s appraisals of it ( Gross, 1998a ; Gross, 1998b ; Gross and Thompson, 2007 ; Peña-Sarrionandia et al., 2015 ). In contrast, response-focused strategies (e.g., emotion sharing, verbal/physical aggression, substance use, and expressive suppression) are activated after emotional responses have been developed and attempt to influence experiential, behavioral, and physiological emotional response tendencies ( Gross, 1998a ; Gross, 1998b ; Gross and Thompson, 2007 ; Peña-Sarrionandia et al., 2015 ).

Existing empirical evidence further indicates that different forms of emotion regulation are associated with notably different affective, cognitive, and social outcomes (for meta-analytical reviews, Aldao et al., 2010 ; Webb et al., 2012 ). For instance, expressive suppression has been shown to maintain or intensify the internal experience of the negative emotion, and also lead to lower positive emotions, higher physiological arousal, feelings of inauthenticity, depressive symptoms, pessimism, as well as decreased memory and negative social consequences. Suppression is additionally linked to job dissatisfaction and quitting intentions within occupational settings. In contrast, reappraisal has generally been found to lead to more positive and fewer negative emotional experiences and expressions, having few social costs and either no impact or positive effects on subsequent memory processes ( Gross and Levenson, 1997 ; Richards and Gross, 2000 ; Côté and Morgan, 2002 ; Gross, 2002 ; Gross, 2015 ; Gross and John, 2003 ; Sutton, 2004 ; Peña-Sarrionandia et al., 2015 ). Overall, emotion regulation processes that target early stages of emotion generation are more effective than the strategies that target emotional responses ( Sutton, 2007 ).

Concerning the construct of emotional labor, different conceptualizations have been proposed. Seminal work by Hochschild (1983) categorized emotional labor into two major forms: surface-acting and deep-acting. Surface-acting entails displaying emotions that one does not actually feel by revising one’s external expression of an emotion without modifying actual internal feelings. In contrast, deep-acting refers to consciously modifying feelings so as to express the desired emotions. Both types of emotional labor are aimed at displaying required emotions with different motives. Specifically, surface-acting involves modifying emotional expressions, whereas deep-acting entails internalizing the desired emotion to appear authentic. Building on Hochschild (1983) classification, subsequent research by Ashforth and Humphrey (1993) added a third form of emotional labor: genuine or natural emotional labor that involves the expression of naturally felt emotions such that the employees do not have to deliberately manage their emotions.

Based on the conceptualizations presented, emotion regulation can thus be understood as encompassing a broader and more pervasive set of behaviors as compared to emotional labor. Also, despite the similarities in the strategies proposed in the two conceptual frameworks, they can be differentiated in that emotion regulation addresses an individuals’ general dispositional approach to dealing with emotions and focuses on internal processes and individual differences, whereas emotional labor reflects a more specific examination of emotion regulatory processes in the context of displaying expected emotions in employment settings ( Wang et al., 2019 ). The two traditions could also be differentiated in their concentration on positive and negative emotions. Specifically, emotion regulation research has largely focused on response-focused processes (i.e., suppression) to inhibit the expression of undesired negative emotional responses. In contrast, emotional labor researchers have mainly concentrated on amplifying the expression of desired positive emotions (i.e., surface-acting; Taxer and Frenzel, 2015 ).

Overall, research findings suggest that emotional inauthenticity (i.e., faking or hiding emotions) and surface-acting are associated with adverse individual and organizational outcomes in the form of impaired well-being, job attitudes, and performance outcomes. However, deep-acting has been shown to be desirable in that it is positively associated with organizational attachment, emotional performance, and customer satisfaction (for meta-analytic findings, see Hülsheger and Schewe, 2011 ; Kammeyer-Mueller et al., 2013 ). Further, existing research has yielded mixed results regarding the impact of emotional labor on specific well-being indicators such as job satisfaction, with some studies reporting positive effects (e.g., Zapf, 2002 ) and others demonstrating negative relations (e.g., Kinman et al., 2011 ). Given the significance of coping and emotion regulatory processes for job performance and productivity, in general, and psychological well-being in particular, existing research on the ways in which post-secondary faculty cope with stress and emotions as well as the ways in which academics are affected by the strategies they adopt needs to be synthesized to shed light on how to promote their performance and protect psychological health.

Existing empirical research on the strategies used by post-secondary faculty to manage work-related stress and emotions were located through a comprehensive search of English language, peer-reviewed empirical investigations via four electronic databases (Educational Research Information Center (ERIC), Psychological Information (PsycINFO), Web of Science, and Scopus). The search terms used included: 1) population: “college” or “university” + “faculty” or “professors” or “academics” or “instructor” or “research staff” or “teaching staff” or “lecturer” or “educator”, 2) stress and emotion: “stress”+ “emotion” or “affect” or “mood”, 3) emotion regulation and coping: “coping” or “stress management” or “coping behavior” + “emotion regulation” or “emotion management” or “emotion control”, and 4) emotional labor: “emotion labor” or “emotional labor” or “emotional dissonance” or “emotional authenticity.” Since coping and emotion regulation among faculty are relatively under-researched and no review to date has examined these topics in post-secondary faculty, we did not limit the search to a specific time span. Further, the current review excluded studies of medical academics (e.g., physicians, nurses) as well as faculty who were also social workers due to the unique demands and pressures associated with their non-academic, service-oriented work conditions ( Le Blanc et al., 2001 ; Watts and Robertson, 2012 ). In addition to the database searches, snowball searches of references of the retrieved studies were conducted. As per the inclusion and exclusion criteria specific to the aim of the present review, 25 empirical publications were included, with six drawing on two datasets ( Amatea and Fong-Beyette, 1987 ; Amatea and Fong, 1991 ; Gates, 2000a ; Gates, 2000b ; Hagenauer and Volet, 2014a , Hagenauer and Volet, 2014b ), in which the stress management and emotion regulation strategies in post-secondary faculty were examined. All studies reviewed are included in Supplementary Appendix SA and identified with an asterisk in the reference list.

Prevalence and Outcomes of Coping and Emotion Regulation Strategies

The present section synthesizes and critically examines published empirical findings ( n = 22) concerning the coping and emotion regulation strategies (i.e., behaviors, cognitions, and perceptions) in which academics engage when facing stress and emotional encounters, as informed by the process model of emotion regulation proposed by Gross (1998a) . The studies examining academics’ coping with stress reviewed for this paper ( n = 13; Supplementary Table S1 ) can be categorized into three main groups according to their foci: 1) those primarily assessing the specific coping strategies faculty members employ to deal with stress ( n = 5; Abouserie, 1996 ; Brown and Speth, 1988 ; Devonport et al., 2008 ; Kataoka et al., 2014 ; Perlberg and Keinan, 1986 ), 2) those that report findings on coping styles among academics combined with general university staff and other occupational groups ( n = 3; Amatea and Fong-Beyette, 1987 ; Amatea and Fong, 1991 ; Gillespie et al., 2001 ; Narayanan et al., 1999 ), and finally, 3) those that explore the association between academics’ coping strategies and well-being outcomes ( n = 6; Dunn et al., 2006 ; Kataoka et al., 2014 ; Lease, 1999 ; Mark and Smith, 2012 ; Ramsey et al., 2011 ; Tümkaya, 2007 ). The review identified five empirical publications ( Gates, 2000a ; Gates, 2000b ; Hagenauer and Volet, 2014a , Hagenauer and Volet, 2014b ; Regan et al., 2012 ; Supplementary Table S2 ) that examined academics’ strategies in dealing with emotions, with four of the studies referencing two datasets ( Gates, 2000a ; Gates, 2000b ; Hagenauer and Volet, 2014a , Hagenauer and Volet, 2014b ). As for emotional labor and its consequences, six studies were identified ( Berry and Cassidy, 2013 ; Constanti and Gibbs, 2004 ; Mahoney et al., 2011 ; Ogbonna and Harris, 2004 ; Pugliesi, 1999 ; Zhang and Zhu, 2008 ; Supplementary Table S2 ).

As stress is a subset of emotion ( Lazarus, 1993 ), the research findings on both coping and emotion regulation strategies are synthesized using process model of emotion regulation ( Gross, 1998a ; Gross, 1998b ) as the guiding framework. Based on the evidence presented in the studies reviewed, faculty members apply a variety of coping and emotional management strategies, either before or after emotional events. The findings from the present review further align with the evidence from the broader emotion management research in showing different strategy types to yield significantly different outcomes for academics’ psychological adjustment ( Skinner et al., 2003 ; Folkman and Moskowitz, 2004 ; Compas et al., 2014 ). For instance, academics’ perceived ability to handle job stress, and appraisals of personal resources, were shown to significantly and negatively correlate with the level of stress and strain experienced ( Amatea and Fong, 1991 ; Blix et al., 1994 ). The strategies identified in the present review align directly with the afore-mentioned guiding framework, namely the process model of emotion regulation proposed by Gross (1998a) and can be categorized into antecedent- or response-focused according to Gross’s categorization. Although the primary objective of the current review is to synthesize the findings on the strategies academics use, the outcomes associated with those strategies are also considered to help put the proposed implications in context.

Antecedent-focused strategies. The antecedent-focused strategies academics use to regulate their emotions in order to minimize the aversive nature of potential stressors (as opposed to modulating behavioral or physiological responses to a given stressor) can be further categorized into situation selection, situation modification, attention deployment, and cognitive change.

Selecting the situation. The studies reviewed suggest that faculty choose or avoid some people, activities and places to generate desired emotional impact. For instance, focus group interviews from a sample of 178 faculty and general staff from 15 Australian universities identified situation selection by establishing tight role boundaries by avoiding non-essential student and staff contact or saying no to unnecessary demands to handle stressful experiences ( Gillespie et al., 2001 ). The review findings further suggest that some academic work experiences, such as interactions with students, provoke negative emotions of anger, irritation, and disappointment. Additionally, being anxious, apprehensive, helpless, inadequate, and overwhelmed were reported with respect to online teaching experiences ( Regan et al., 2012 ; Hagenauer and Volet, 2014a ). As such, university teachers reported adopting strategies to make it less likely that their negative emotions would be provoked. The six U.S. university teachers in Regan et al. (2012) focus group interviews reported a number of strategies to regulate the negative emotions of feeling stressed, restricted, and devalued while teaching online, including adequate technology training and support from the educational institution, synchronous office hours, and face-to-face or telephone interactions with students. Additionally, interview findings from the 15 Australian university teachers indicated that faculty reported making attempts not to get involved in the emotional issues of their students ( Hagenauer and Volet, 2014b ). Also, adopting student-centered teaching approaches to maintain productive and positive interactions with students, to create positive energy and to help circumvent the occurrence of negative emotions were reported. Furthermore, the 337 Japanese university teachers in ( Kataoka et al., 2014) survey study reported using behavioral disengaement as an effective stress mangemnet technique ( Kataoka et al., 2014 ).

As for the consequences associated with situation selection, regulating emotions through strategies such as behavioral disengagement was linked to lower psychological adjustment in the form of severe depression, anxiety, social dysfunction, somatic symptoms and insomnia ( Kataoka et al., 2014 ). Additionally, escape-avoidance (i.e., ignoring or avoiding problem) was found to be associated with higher levels of anxiety and depression and lower job satisfaction ( Mark and Smith, 2012 ), predict greater strain ( Lease, 1999 ), and partially mediate the association between maladaptive perfectionism and psychological distress ( Dunn et al., 2006 ). Moreover, proactive coping, defined as anticipating potential stressors as challenges and generating the psychololgical resources necessary to prepare for future stressors ( Scwarzer and Taubert, 2002 ), was found to be correlated with better physical and psychological health ( Amatea and Fong, 1991 ; Kataoka et al., 2014 ).

Modifying the situation. Examples of situation modification were reported by 135 female U.S. faculty, researchers, and university administrators in Amatea and Fong-Beyette (1987) study who opted to manage stress primarily by adopting strategies such as planning and strategizing across different types of work-life conflict situations. Similar findings were observed by the participants in Gillespie et al. (2001) study who identified planning and prioritizing as key stress management techniques. More recently, the sample of 10 U.K. faculty interviewed by Devenport et al. (2008) also unanimously reported strategies such as prioritizing, proactive planning, and time-management to avoid potentially stressful encounters to be invaluable in managing and controlling stress. Whereas proactive coping, such as planning, reduces the need for reactive coping, faculty reported that some circumstances of organizational constraints such as lack of control necessitate reactive coping ( Devonport et al., 2008 ; Kataoka et al., 2014 ). This finding supports the observation that coping is primarily determined by environmental factors ( Lazarus and Folkman, 1984 ).

A survey of 150 U.S. faculty members further identified strategies such as identifying the cause of the problem or finding more about the situation, as the most frequently used stress management responses ( Brown and Speth, 1988 ). This finding is consistent with a U.S. study that qualitatively compared coping strategies across three occupations (i.e., clerical workers, sales associates, and university professors; Narayanan et al., 1999 ). The study found that, compared to other professions, academics were more likely to engage in situation modification strategies such as taking direct action or discussing the problem with their chair or head of the department. Additionally, a qualitative field study of nine tenured U.S. university teachers (using observations, field notes and interview data) found that faculty reported using language and labels, such as telling students that it is OK to become confused while learning, and communicating their personal expectations to students about how the students should behave ( Gates, 2000b ). This was aimed at influencing students’ behavior and thereby reducing the possibility of triggering negative emotions in teachers. Strategies such as learning to recognize and understand stress were also identified to be effective in coping with stress ( Gillespie et al., 2001 ).

The findings from this review are consistent with the broader coping research (e.g., Lazarus, 1993 ; Aldwin, 2007 ; Skinner and Zimmer-Gembeck, 2016 ) in showing problem-focused coping to be an effective stress response among post-secondary faculty. For instance, the studies reviewed reported utilization of problem-focused coping to be linked to better psychological adjustment in the form of lower levels of stress, depression, and psychological distress as well as better job satisfaction ( Brown and Speth, 1988 ; Dunn et al., 2006 ; Mark and Smith, 2012 ). Similarly, active coping was negatively associated with social dysfunction and severe depression, whereas instrumental support was negatively associated with depression ( Kataoka et al., 2014 ).

Attention deployment. Faculty also reported selectively attending to the stimuli to cope with their emotional experiences. For instance, a quantitative study of 100 Israeli faculty memebrs ( Perlberg and Keinan, 1986 ) identified intellectual stimulation such as reading journals, magazines, and attending conferences as one of the most effective ways of coping with stress in that it helps faculty divert attention from daily stressors. Likewise, the university teachers in the Kataoka et al. (2014) study reported employing self-distraction to be effective in managing stress (e.g., engaging in other work or leisure activities in order to think about stressors less; Carver 1997 ). The findings from this review are consistent with the health impairment risks of self-distraction in linking the use of this strategy to severe depression, anxiety, social dysfunction, somatic symptoms and insomnia among academics ( Kataoka et al., 2014 ).

Cognitive change . Consistent with the empirical findings that advocate cognitive-restructuring (i.e., reappraisal) due to its commonly observed beneficial impact on negative emotional experiences ( Lazarus, 2000 ; Folkman and Moskowitz, 2004 ), academics reported applying reappraisal of specific situations to make it less likely for negative emotions to be triggered. For instance, the faculty members in Brown and Speth (1988) study reported reappraisal as a key coping strategy. It also appears that cognitive techniques that involve positive reappraisal of work situations may reduce faculty members’ stress and negative emotions. For instance, examples of cognitive change were reported by participants in ( Gates, 2000a ; Gates, 2000b ) studies who opted to positively reappraise stimuli, for instance by remembering positive interactions, to down-regulate negative emotions. A quotation from a university teacher, who helped a student adopt an effective learning strategy after failing on an exam, is illustrative: “He (the student) graduated with honors. When he walked away, for me that was a tremendous reward because, according to him, I had an impact. And that’s what I try to focus on” ( Gates, 2000b , p. 483). The participating university teachers further indicated that they try to redefine disruptive students as young and impressionable, or to think of a student who is doing poorly as developing, in order to manage feelings of anger, anxiety, frustration, and disappointment ( Gates, 2000a ; Gates, 2000b ).

Similarly, the faculty members in Regan et al. (2012) study reported changing their view of the instructor as transmitter of information to facilitator of knowledge to avoid the negative emotion of feeling devalued in online learning environments. Furthermore, faculty reported using cognitive strategies such as rationalization or acceptance by adapting their expectations. For instance, acceptance was the most commonly reported stress management strategy (58%) among the 414 academics, including faculty and research assistants, surveyed in Abouserie (1996) study. Faculty also used rational arguments in the form of self-talk to down-regulate negative emotions such as feeling annoyed: “They are still in that kind of school-girl, school-boy mode, which is pretty normal at this … this stage” ( Hagenauer and Volet, 2014b , p. 271). Also, acceptance of the specific situation by lowering their self-expectations and work standards helped teachers to reduce disappointment, frustration and stress ( Gillespie et al., 2001 ; Hagenauer and Volet, 2014b ). The participants in Abouserie (1996) study also reported lowering their expectations to decrease strain by trying to think that “I am only human being,” though it was not reported as a frequent way of coping. Similar findings were observed by the participants in Gillespie et al. (2001) study who identified practicing stress management techniques such as lowering their standards and self-expectations by withdrawing from voluntary service activities (e.g., leaving committees) as key stress management techniques. Furthermore, the teachers interviewed by Hagnauer and Volet (2014a) reported sharing humor and jokes to facilitate good rapport with students and thereby a relaxed classroom atmosphere.

Evidence from the studies reviewed suggests that cognitive change can yield significantly different outcomes for academics’ well-being depending on how adaptively this strategy is used. For instance, studies of 102 U.S. teaching faculty and 283 Turkish faculty members found utilization of humor to be significantly and negatively associated with burnout ( Tümkaya, 2007 ; Ramsey et al., 2011 ). In contrast, wishful thinking and denial were shown to be maladaptive in predicting lower psychological adjustment in the form of anxiety, depression, somatic symptoms and job dissatisfaction ( Mark and Smith, 2012 ; Kataoka et al., 2014 ). However, contrary to their expectations, they did not find positve reappraisal to be significantly linked to well-being among acadeimics. This finding seems to run counter to the existing empirical findings showing that coping via positive restructuring is related to better psychological health.

Response-focused strategies. According to ( Gross, 1998a ; Gross, 1998b ) model of emotion regulation, academics can also apply a variety of strategies intended not to change their exposure or perceptions of a given stressors (antecedent-focused strategies) but rather to alter the experiential, physiological, and behavioral reactions following from their emotional responses to a stressor (response-focused strategies).

Social support. One such strategy targeted at experiential facets is sharing emotions. For instance, the participants in Hagenauer and Volet (2014b) study indicated that, being aware of the effectiveness of emotion sharing, they expressed their positive and negative emotions with family members and departmental colleagues. However, they believed there were not many opportunities to share and discuss negative emotions and their triggers due to the lonely nature of university teaching profession. Abouserie (1996) also identified using emotion expression strategies such as trying to bring their feeling into the open to deal with stress (e.g., sharing their feelings with friends and others).

The current review also highlights support seeking as an effective stress management strategy among faculty. For instance, the faculty members in Perlberg and Keinan (1986) study reported seeking social support (i.e., talking with a friend or telling jokes) as one of the most effective ways of coping with stress. Similarly, the faculty in Devenport et al. (2008) study unanimously reported managing stress via emotional support as well as professional counseling or psychological services. Abouserie (1996) also identified support seeking through talking with colleagues, involving oneself with friends, and talking about the problem with colleagues as effective coping responses. Their findings support the assertion by Rimé (2007) who contends that emotion sharing is beneficial to psychological well-being due to the social bonds it fosters as well as transference of affection and warmth.

Additionally, the study by Gillespie et al. (2001) reported that the participants relied on social support from family or friends, as well as attending scholarly conferences, as a means of coping with stress. It appears that while preparing manuscripts and presenting in conferences can be stressful, it enabes faculty to discuss work-related problems with collaborators and others. Interestingly, the effectiveness of social support has also been found to be linked to the level of stress faculty experience. For instance, in a survey of 131 tenure-track U.S. faculty members, Lease (1999) found perceptions of social and environmental support from colleagues, administrators, and departmental support staff to be beneficial for psychological adjustment when work-role stressors (i.e., role ambiguity and role insufficiency) were perceived as low in magnitude.

In contrast, the beneficial effect of social support was not evident when faculty perceived high levels of stress resulting from the demands placed on them by their academic roles (e.g., role ambiguity, role conflict, role overload; see Rizzo et al., 1970). This finding thus indicates that social support may not be sufficient to address the psychological challenges posed by lack of clarity over academic roles and responsibilities. Perceived social support was also found to be correlated with better physical and psychological health ( Amatea and Fong, 1991 ; Kataoka et al., 2014 ) as well as negatively associated with maladaptive perfectionism and psychological distress ( Dunn et al., 2006 ).

Physiological strategies. Other emotion management strategies used to reduce stress included modifying one’s physiological state through practices such as deep breathing or expressive gestures aimed at dissipating (vs. internalizing) the emotional experience (e.g., glaring at disruptive students; Gates, 2000a ; Gates, 2000b ). Taking deep breaths allowed teachers to monitor their feelings and assess the consequences of their emotions ( Gates, 2000a ). Faculty also reported taking regular breaks from their work, regularly exercising, and seeking alternative therapies for stress relief (e.g., yoga, massage relaxing; Abouserie 1996 ; Gillespie et al., 2001 ). Such physiologically-oriented strategies are generally found to be beneficial for reducing stress, improving psychological well-being and sleep quality, as well as relieving physical symptoms in other populations (e.g., government employees, school teachers, general university staff; Hartfiel et al., 2012 , Klatt et al., 2009 ; Lin et al., 2015 ).

Other maladaptive strategies. The findings from this review further reveal that to handle stressful experiences some faculty resort to alcohol, substance use and self-blame (e.g., Gillespie et al., 2001 ; Kataoka et al., 2014 ). Consistent with the findings in the broader well-being literature ( Aldwin and Revenson, 1987 ; Single et al., 2000 ; Teesson et al., 2000 ; Skinner and Zimmer-Gembeck, 2016 ), use of these strategies by post-secondary faculty was linked to lower psychological adjustment in the form of severe depression, anxiety, social dysfunction, somatic symptoms and insomnia ( Kataoka et al., 2014 ). Additionally, 19.1% of the 414 academics in Abouserie (1996) study reported that they often retreated to their office, or opted not to go to work at all (10.7%); behaviors implying social withdrawal and stress-related job absenteeism, respectively.

Prevalence and Consequences of Emotional Labor Strategies

As mentioned above, Grandey (2000) likened Gross (2006) antecedent and response-focused types of emotion regulation to ( Hochschild, 1983) concepts of deep and surface-acting, respectively. However, Grandey did assert that emotion regulation processes cannot be directly equated with emotional labor strategies because surface-acting encompasses not only suppression but also amplification and faking of emotions. Furthermore, although deep-acting requires cognitive appraisal, the ultimate goal is not to improve personal well-being but to facilitate their efforts to better convey feelings that appear genuine to others. As such, the findings on faculty emotional labor are presented separately in the section below.

The studies reviewed suggest that academics view emotional labor as an intrinsic aspect of their work. Indeed, emotional labor is so inextricably linked to academics’ profession that for some, it equals professionalism—and to a greater degree than in many other professions ( Berry and Cassidy, 2013 ). Gates (2000a) asserted that faculty emotional management was essential for job satisfaction and effective teaching, and ultimately, student attainment. There are times when faculty express their genuinely felt emotions as well as times when they regulate (i.e., hide, fake, or minimize) their emotions to conform to contextually mandated display rules. As such, whether an emotion is appropriate for a given situation is determined by the tacit display rules of post-secondary institution. Research findings further indicate that academics’ engagement in emotional labor partly derives from the aforementioned changes in higher education organizations and the subsequent ever-intensifying expectations associated with those changes ( Gates, 2000a ; Ogbonna and Harris, 2004 ; Biron et al., 2008 ; McAlpine and Akerlind, 2010 ). Indeed, marketization of higher education has led some scholars to conceptualize students as customers ( Constanti and Gibbs, 2004 ), with academics being increasingly required to perform emotional labor to satisfy their job requirements and support student needs ( Ogbonna and Harris, 2004 ). For example, the following comment from one U.K. university teacher vividly describes the experience of conveying expected positive emotions to students despite internally feeling strong negative emotions: “Sometimes I feel like shouting at them (students) but I know what this will do to my teaching evaluations. I just stand there and pretend to be laughing even though I am fuming inside” ( Ogbonna and Harris, 2004 , p. 1197).

The studies reviewed further reveal that post-secondary faculty are particularly concerned with negative emotions and seek to down-regulate or suppress them (e.g., anger) to stay within the emotional boundaries of their profession. In contrast, faculty are more likely to openly express positive emotions such as enjoyment, humor, and happiness, as long as the display does not include intense emotional reactions ( Gates, 2000a ; Gates, 2000b ; Hagenauer and Volet, 2014b ). For instance, a national sample of 598 U.S. college and university faculty members ( Mahoney et al., 2011 ) consistently reported emotional suppression as a surface-acting emotional labor strategy. Similarly, a later mixed-methods study of 61 U.S. university teachers ( Berry and Cassidy, 2013 ) exploring use of emotional display, suppression, and faking strategies of emotional labor found that suppression was the most frequently used emotional labor strategy, followed by faking. Faculty also reported engaging in suppression of negative emotions, for example, masking or hiding negative emotions such as anger and disappointment during interactions with students, and instead expressing positive emotions (e.g., enthusiasm) or specific negative emotions (e.g., disappointment) that conveyed a belief in students’ potential ( Gates, 2000a ; Gates, 2000b ). Likewise, all participants in Hagenauer and Volet (2014b) study believed that negative emotions needed to be controlled in the classroom, either suppressed or expressed in a norm-accordant manner, in order to appear professional. They also reported suppressing negative emotions resulting from out of classroom issues such as high workload. These findings echo those of studies of school teachers ( Sutton, 2004 ; Aultman et al., 2009 ; Sutton et al., 2009 ).

Interestingly, although studies show academics to consistently report engaging in suppression of emotions, the reported reasons for this behavior vary considerably. While some academics do so for moral reasons, such as caring for their students ( Hagenauer and Volet, 2014b ) or fostering students’ social and emotional development ( Gates, 2000a ), for others emotion suppression is motivated by the belief that students are customers who need to be satisfied ( Constanti and Gibbs, 2004 ). In a qualitative study of 54 U.K. university lecturers, Ogbonna and Harris (2004) found that the participants performed surface-acting emotional labor more commonly than deep-acting, with interactions with students or one’s superiors being particularly likely to elicit surface-acting behavior. The authors further observed the most commonly reported form of deep-acting by faculty to involve the active and conscious attempt to arouse a given emotion. By contrast, Zhang and Zhu (2008) in a survey of 164 Chinese university lecturers found that, of the three dimensions of emotional labor, participants engaged the most in deep-acting and the least in surface-acting. The authors assert that this finding could be due to a prominent Chinese mentality of thinking through emotions and viewing teachers as parents who care for and nurture their students by trying to display appropriate emotions. The findings from the present review suggest that academics consistently engage in emotional labor aimed at 1) constructing an optimal learning environment, 2) nurturing positive student–teacher relationships, 3) serving as role models for their students, or 4) satisfying students and benefitting their post-secondary institutional expectations ( Gates, 2000a ; Gates, 2000b ; Constanti and Gibbs, 2004 ; Hagenauer and Volet, 2014b ).

Studies have further examined the empirical links between emotional labor and well-being as well as employment outcomes in academics ( Pugliesi, 1999 ; Ogbonna and Harris, 2004 ; Mahoney et al., 2011 ; Berry and Cassidy, 2013 ) including personal well-being outcomes such as work stress, psychological distress, and burnout as well as job-related outcomes such as job satisfaction, affective commitment, and career advancement. As for personal well-being consequences, research on post-secondary faculty has found faking of emotions to lead to greater job stress and psychological distress ( Ogbonna and Harris, 2004 ). Additionally, the requirement to suppress job-related stress and negative emotions has been linked to the experience of frustration ( Constanti and Gibbs, 2004 ). Similarly, a study of 2,069 U.S. academics (i.e., faculty and general university staff; Pugliesi, 1999 ) found self-focused emotional labor (e.g., deep-acting) to be less detrimental for job stress and psychological distress than other-focused forms of emotional labor (e.g., attempting to help coworkers feel better about themselves).

Similarly, Mahoney et al. (2011) found genuine expression of negative emotions, faking positive emotions, and suppressing negative emotions to predict greater emotional exhaustion, whereas genuine expression of positive emotions, faking negative emotions, and suppressing positive emotions predicted lower emotional exhaustion. Likewise, Zhang and Zhu (2008) compared the effects of deep-acting and surface-acting strategies in a sample of 164 Chinese university teachers and found that deep-acting predicted lower burnout, whereas surface-acting predicted greater burnout. These findings are aligned with studies of school teachers showing comparable links between emotional labor and burnout (e.g., Näring et al., 2006 ; Lorente Prieto et al., 2008 ) and underscore the potential consequences of emotional labor for personal well-being in faculty.

Additionally, research indicates that emotional labor may correspond with job satisfaction in faculty members, with the relations varying depending on the context and type of labor involved. For instance, Berry and Cassidy (2013) found that although university lecturers reported high levels of emotional labor, they nevertheless felt satisfied with their jobs. A possible explanation for this contradictory finding is that the sample of university lecturers reported that they felt they had some job autonomy. As feelings of job autonomy and control tend to predict better job satisfaction (e.g., Thompson and Prottas, 2006 ), it is possible that this aspect of faculty members’ occupational environment may have mitigated the otherwise negative effects of high emotional labor levels. In contrast, Pugliesi (1999) found that performing self-focused and other-focused emotional labor negatively predicted job satisfaction. Similarly, Mahoney et al. (2011) found genuine expression of negative emotions to predict lower job satisfaction, with genuine expression of positive emotions instead contributing to greater job satisfaction and affective commitment. These authors also found that faking positive emotions and suppressing negative emotions were negatively linked to job satisfaction, whereas faking negative emotions was positively related to job satisfaction.

Additionally, greater emotional labor was reported to benefit faculty with respect to organizational rewards such as career progression ( Ogbonna and Harris, 2004 ). A quotation from a university teacher is illustrative: “It’s about image—creating a brand of “me.” In my place careers are built on teaching portfolios. If you can create an image of yourself as a brilliant teacher—you’ve got it made. I have no problem with faking concern about students if it gets me another increment (point)” ( Ogbonna and Harris, 2004 , p. 1197). Although career growth has generally been linked to higher levels of job satisfaction and commitment (e.g., Maia et al., 2016 ), the sample of U.K. lecturers assessed by Ogbonna and Harris (2004) found high levels of emotional labor due to occupational expectations to correspond with low levels of job satisfaction. Ogbonna and Harris (2004) further found academics to report engaging in emotional labor to contribute to feeling a lack of collegiality and teamwork due to diminished social interaction and a corresponding lack of emotional support from colleagues. These findings are, in general, consistent with studies of school teachers that link higher levels of emotional labor to greater burnout, job dissatisfaction, and health problems (e.g., Kinman et al., 2011 ; Wrobel, 2013 ).

Summary of Review Findings

Post-secondary academic employment poses various stressors for faculty members who are expected to ensure high quality teaching, research, and service in an evolving occupational context. However, despite the emotion laden nature of academic work, there is remarkably little research on the emotional experiences of post-secondary faculty with respect to coping, emotion regulation, and emotional labor processes. Given the significance of these topics for well-being and academic performance, efforts to improve workplace quality in post-secondary institutions should not only emphasize academics’ teaching, research, and service behaviors, but also how they deal with their emotions. As such, the topics of coping, emotion regulation, and emotional labor merit a more prominent niche in studies of academics. To address this research gap, the present paper reviewed the fragmented empirical literature pertaining to the strategies used by post-secondary faculty to cope with stress and regulate their emotions as organized according to the process model of emotion regulation ( Gross, 1998a ; Gross, 1998b ) and emotional labor theories ( Hochschild, 1983 ; Ashforth and Humphrey, 1993 ; Grandey, 2000 ).

There is growing evidence that the academic work has been intensified as a result of the substantial changes to the context of higher education (e.g., Biron et al., 2008 ; McAlpine and Akerlind, 2010 ). Consequently, in order to adequately meet the multiplicity of organizational and occupational demands, faculty are required to show or exaggerate some emotions as well as minimize or suppress the expression of other emotions ( Ogbonna and Harris, 2004 ). Findings from these few studies suggest that academics regularly attempt to not only control their emotions in stressful educational settings, but also to display appropriate emotional responses even if the response is inauthentic. In other words, although published research has consistently established the link between greater emotional inauthenticity (i.e., surface-acting) and lower employee well-being, post-secondary faculty nonetheless regularly perform this type of emotional labor as part of their emotion-related job expectations and their potential benefits for student development and learning.

The findings of the present review, albeit from a limited empirical basis, reveal that post-secondary faculty adopt a variety of coping and emotion regulation strategies. This scant evidence further indicates that the coping and regulatory strategies academics employ have implications for their well-being as well as performance. More specifically, cognitive reappraisal, problem-solving, and social support were found to be adaptive in helping academics reduce stress and maintain their well-being. Conversely, study findings revealed emotion suppression to be prevalent yet have mixed effects among post-secondary faculty, with suppression showing both benefits (e.g., achieving teaching and learning goals, fostering positive interactions with students; Constanti and Gibbs, 2004 ; Gates, 2000b ; Hagenauer and Volet, 2014b ) as well as negative effects for academics (e.g., maintaining and intensifying negative emotions; Hagenauer and Volet, 2014b ). As an illustration, the university teachers interviewed in Hagenauer and Volet (2014b) study indicated that they “boil underneath” if they tried to completely conceal their emotions. Similarly, maladaptive coping responses such as escape, social isolation, and submission were found to be detrimental for psychological and behavioral outcomes in post-secondary faculty ( Brown and Speth, 1988 ; Lease, 1999 ; Dunn et al., 2006 ; Mark and Smith, 2012 ; Kataoka et al., 2014 ).

Additionally, the evidence from limited studies shows emotional labor in post-secondary faculty to have potentially negative consequences for their psychological and occupational well-being. Specifically, when engaging in surface-acting emotional labor, the disparity between truly experienced emotions and external expressions corresponds with higher psychological strain. Further, faculty who reported performing more emotional labor experienced higher levels of job stress, were at a greater risk of developing burnout, and were less satisfied with their work ( Pugliesi, 1999 ; Constanti and Gibbs, 2004 ; Ogbonna and Harris, 2004 ; Mahoney et al., 2011 ). Nevertheless, post-secondary faculty do report viewing emotional labor as an intrinsic element of their academic work ( Berry and Cassidy, 2013 ), suggesting positive links between emotional labor and job satisfaction. Additionally, some evidence suggests that emotional labor may not be entirely detrimental for faculty as it can be perceived by students and others as conveying professionalism and objectivity in the classroom, potentially resulting in career benefits (e.g., better teaching evaluations; Ogbonna and Harris, 2004 ). Furthermore, evidence of job satisfaction despite high levels of emotional labor ( Berry and Cassidy, 2013 ) suggests that fulfilling the emotional demands of faculty position does not necessarily come at the expense of job satisfaction. In conclusion, given the pivotal role of academics in knowledge creation and instruction (e.g., Atkins et al., 2002 ), impaired well-being and performance among faculty has clear implications for quality of academic work, student development, and institutional efficacy ( Lease, 1999 ; Gillespie et al., 2001 ).

Implications of Faculty Emotion Regulation and Emotional Labor

In sum, the findings presented underscore the importance of continued research on the varied types of coping strategies, emotion regulation behaviors, and emotional labor approaches used by faculty in response to academic challenges given clear links to both personal well-being and employment outcomes. Moreover, these findings suggest that post-secondary administrators and support personnel (e.g., department heads, faculty workshop coordinators) are well-advised to raise faculty awareness of the implications of their emotion regulation strategies, and highlight the need for further investigation into avenues for enhancing faculty coping and regulatory skills. Indeed, promoting adaptive emotion regulation is necessary for successful job performance and can help academics deal more effectively with stress and emotions, and thus directly decrease the level of job stress and indirectly protect their well-being and productivity. By implication, stress reduction and health protection in post-secondary faculty could be achieved not only by decreasing work demands, but also by developing their personal resources such as coping and emotion regulation skills ( Gates, 2000b ; Zhang and Zhu, 2008 ; Regan et al., 2012 ; Kataoka et al., 2014 ). University administrators aiming to equip faculty with effective regulatory skills and promote well-being are encouraged to develop related orientation content for new faculty, developing counselling and mental health support for faculty in general, as well as improving training for administrators to better identify and respond to mental health concerns in faculty.

Additionally, university administrators, policy makers, and faculty development programs are ideally positioned to understand the emotional aspects of their primary institutional resources’ work ( Gmelch et al., 1984 ). These stakeholders are thus especially encouraged to take active steps in developing and implementing interventions to raise academics’ awareness regarding coping and emotion regulation strategies and their associated consequences, to promote coping and emotion regulation skills, and to foster academics’ use of effective strategies for improving faculty well-being and performance. Despite the lack of research on academics, research evidence from other occupational groups (e.g., teachers) raises the possibility that training post-secondary faculty to develop more adaptive coping and emotion management skills might result in favorable outcomes that will, by extension, benefit the academic institutions ( Kotsou et al., 2011 ). For example, empirical evidence across occupational settings consistently demonstrates the efficacy of cognitive reappraisal stress management interventions such as cognitive behavioral therapy (CBT; for meta-analytical summaries, see Kim, 2007 ; Richardson and Rothstein, 2008 ; Van der Klink et al., 2001 ). Additionally, mindfulness-based stress reduction (MBSR) programs show a range of cognitive (e.g., enhanced working memory and attention), psychological (i.e., improvements in emotion regulation skills and self-efficacy, decrease in stress, anxiety, emotional exhaustion, and depression as well as increase in positive emotions) and physiological benefits (i.e., improved immune function) among K-12 students and teachers (e.g., Napoli et al., 2005 ; Poulin et al., 2008 ; Roeser et al., 2012 ), university students ( Freeman et al., 2015 ; Ford et al., 2018 ), other occupational groups (e.g., Janssen et al., 2018 ), as well as general population (e.g., Davidson et al., 2003 ; Hölzel et al., 2011 ).

As such, post-secondary administrators are recommended to consider integrating CBT and MBSR interventions into faculty development programs to facilitate adaptive emotion regulation, well-being, and performance in faculty members. Increased health and well-being among post-secondary faculty should, in turn, lead to greater occupational engagement and satisfaction as well as lower levels of faculty burnout and attrition. Increased faculty well-being should also support the formation of positive relationships with students that, in turn, promote students’ sense of belonging, engagement, learning, and achievement. Nonetheless, given research findings showing mindfulness training to be inappropriate for chronically stressed individuals due to negative effects of chronic stress on sustained attention and complex thought processes (e.g., Sapolsky, 1994 ; Arnsten, 1998 ), it is possible that CBT or MBSR may be ineffective for the chronically stressed faculty they are intended to serve. Hence, it is incumbent on administrators to also focus on long-term improvements to academic work environments to make them less emotionally demanding by reducing workloads (e.g., excessive teaching responsibilities faced by non-tenure-track faculty; Baldwin and Wawrzynski, 2011 ), facilitating balance between academic responsibilities (e.g., teaching releases to offset research or administrative demands; Stupnisky et al., 2015 ), clarifying role expectations (e.g., tenure expectations), as well as providing effective physical and mental health resources (e.g., gym memberships, vacation time) and stress management workshops ( Gillespie et al., 2001 ).

With respect to the present findings concerning emotional labor strategies, this review further suggests that higher education institutions are well-advised to encourage deep-acting strategies and discourage surface-acting as part of existing professional development initiatives aimed at improving teaching effectiveness. Moreover, given that social support was consistently found to protect faculty against job stress, institutional efforts to promote faculty collegiality (e.g., regular social events, departmental lecture series) as well as develop collaborative work spaces, team teaching initiatives, and faculty mentorship programs should contribute to greater connectedness, enhanced well-being, and improved teaching and research productivity.

Empirical evidence demonstrates the beneficial effects of such initiatives. For instance, studies of faculty members have shown implementation of mentorship programs to result in favorable outcomes such as higher retention rates, improvement in self-perceived abilities, and higher academic success rates as measured by number of peer-reviewed publications, leadership and professional activities, honors, and awards ( Zeind et al., 2005 ; Ries et al., 2012 ; Jackevicius et al., 2014 ). Additionally, existing studies highlight the potential benefits of team teaching initiatives for faculty members, including deepened pedagogical knowledge, improvements in teaching skills and effectiveness, higher motivation to teach, overcoming feelings of isolation by creating a sense of community, and enhanced conflict management skills ( Robinson and Schaible, 1995 ; Cohen and DeLoise, 2002 ; Kluth and Straut, 2003 ; Lester and Evans, 2008 ). Furthermore, social activities have been shown to foster integration and social cohesion in faculty members ( Lindholm, 2003 ) and particularly among pre-tenure faculty ( Fleming et al., 2016 ).

Limitations and Future Directions

The methodologies of the studies reveiwed had multiple limitations, many of which were recognized by authors of the respective studies. Firstly, 12 of the 22 studies employed only quantitative analyses and thus failed to capture the full complexity of academics’ lived experiences concerning their challenges and emotion regulation otherwise afforded by qualitative protocols ( Creswell and Creswell, 2017 ). Second, the few studies that investigated emotion regulation among faculty focused largely on negative emotions such as anger, burnout, and stress, thus neglecting the potential benefits of upregulation of positive emotions on well-being and performance ( Fredrickson, 2000 ; Fredrickson, 2001 ; Folkman, 2008 ; Fredrickson, 2013 ; Quoidbach et al., 2015 ). Third, the majority of the studies focused on how academics regulate their teaching-related emotions, thereby neglecting various other domains of academic work such as research, service, or administration. Considering recent empirical evidence regarding the domain specificity of emotional experiences in post-secondary faculty (e.g., teaching vs. research; Stupnisky et al., 2014 ), future studies are encouraged to explore the strategies academics employ to regulate their emotions in domains other than teaching.

Fourth, a majority of the studies reviewed drew on populations from single organizations thus raising concerns of generalizability to academics at large. Hence, future studies are encouraged to draw on larger numbers of academics from varied institution types (e.g., colleges, trade schools, universities; teaching vs. research intensive schools) to better ascertain the external validity of the study findings. Relatedly, although the studies reviewed were conducted across several countries (e.g., U.K., U.S., Canada, Australia, Japan), there are to date insufficient studies conducted within a given cultural context or geographical setting to allow for generalizations as to how cultural or geographic differences may moderate the prevalence and effects of emotion regulation and coping in faculty. Fifth, all but two studies ( Constanti and Gibbs, 2004 ; Gates, 2000a ; Gates, 2000b ) employed exclusively self-report measures that are susceptible to response biases warranting that future research also investigate academics’ coping and emotion regulation strategies using more objective assessments such as observations, experience sampling, and physiological markers ( Spector, 2006 ; Paulhus and Vazire, 2007 ; Pekrun and Bühner, 2014 ).

Finally, given that multiple studies reported data from aggregate samples that included both faculty and non-faculty participants (e.g., researchers, administrators, see Amatea and Fong-Beyette, 1987 ; Gillespie et al., 2001 ), it was not possible in these studies to more closely examine factors that pertain specifically to post-secondary faculty (e.g., thesis supervision, tenure pressures). Accordingly, further research on stress management and emotion regulation in post-secondary faculty specifically, as well as further differentiation between disparate types of faculty employment (e.g., non-tenure-track vs. tenure-track employment; Hall, 2019 ), are needed to better examine the role of coping, emotion regulation, and emotional labor among faculty in the context of modern academic employment.

Author Contributions

Conceptualization, RS; methodology, RS; writing—original draft preparation, RS; writing—review and editing, NCH, RS, and AS; supervision, AS; funding acquisition. RS.

This research was funded by Fonds de Recherche duQuébec-Sociétéet Culture (fund number: 192306).

Conflict of Interest

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

Publisher’s Note

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

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/feduc.2021.660676/full#supplementary-material

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Keywords: post-secondary faculty, stress, coping, emotions, emotion regulation

Citation: Salimzadeh R, Hall NC and Saroyan A (2021) Examining Academics’ Strategies for Coping With Stress and Emotions: A Review of Research. Front. Educ. 6:660676. doi: 10.3389/feduc.2021.660676

Received: 29 January 2021; Accepted: 23 August 2021; Published: 20 September 2021.

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*Correspondence: Raheleh Salimzadeh, [email protected]

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Article contents

Work, stress, coping, and stress management.

• Sharon Glazer Sharon Glazer University of Baltimore
•  and  Cong Liu Cong Liu Hofstra University
• https://doi.org/10.1093/acrefore/9780190236557.013.30
• Published online: 26 April 2017

Work stress refers to the process of job stressors, or stimuli in the workplace, leading to strains, or negative responses or reactions. Organizational development refers to a process in which problems or opportunities in the work environment are identified, plans are made to remediate or capitalize on the stimuli, action is taken, and subsequently the results of the plans and actions are evaluated. When organizational development strategies are used to assess work stress in the workplace, the actions employed are various stress management interventions. Two key factors tying work stress and organizational development are the role of the person and the role of the environment. In order to cope with work-related stressors and manage strains, organizations must be able to identify and differentiate between factors in the environment that are potential sources of stressors and how individuals perceive those factors. Primary stress management interventions focus on preventing stressors from even presenting, such as by clearly articulating workers’ roles and providing necessary resources for employees to perform their job. Secondary stress management interventions focus on a person’s appraisal of job stressors as a threat or challenge, and the person’s ability to cope with the stressors (presuming sufficient internal resources, such as a sense of meaningfulness in life, or external resources, such as social support from a supervisor). When coping is not successful, strains may develop. Tertiary stress management interventions attempt to remediate strains, by addressing the consequence itself (e.g., diabetes management) and/or the source of the strain (e.g., reducing workload). The person and/or the organization may be the targets of the intervention. The ultimate goal of stress management interventions is to minimize problems in the work environment, intensify aspects of the work environment that create a sense of a quality work context, enable people to cope with stressors that might arise, and provide tools for employees and organizations to manage strains that might develop despite all best efforts to create a healthy workplace.

• stress management
• organization development
• organizational interventions
• stress theories and frameworks

Introduction

Work stress is a generic term that refers to work-related stimuli (aka job stressors) that may lead to physical, behavioral, or psychological consequences (i.e., strains) that affect both the health and well-being of the employee and the organization. Not all stressors lead to strains, but all strains are a result of stressors, actual or perceived. Common terms often used interchangeably with work stress are occupational stress, job stress, and work-related stress. Terms used interchangeably with job stressors include work stressors, and as the specificity of the type of stressor might include psychosocial stressor (referring to the psychological experience of work demands that have a social component, e.g., conflict between two people; Hauke, Flintrop, Brun, & Rugulies, 2011 ), hindrance stressor (i.e., a stressor that prevents goal attainment; Cavanaugh, Boswell, Roehling, & Boudreau, 2000 ), and challenge stressor (i.e., a stressor that is difficult, but attainable and possibly rewarding to attain; Cavanaugh et al., 2000 ).

Stress in the workplace continues to be a highly pervasive problem, having both direct negative effects on individuals experiencing it and companies paying for it, and indirect costs vis à vis lost productivity (Dopkeen & DuBois, 2014 ). For example, U.K. public civil servants’ work-related stress rose from 10.8% in 2006 to 22.4% in 2013 and about one-third of the workforce has taken more than 20 days of leave due to stress-related ill-health, while well over 50% are present at work when ill (French, 2015 ). These findings are consistent with a report by the International Labor Organization (ILO, 2012 ), whereby 50% to 60% of all workdays are lost due to absence attributed to factors associated with work stress.

The prevalence of work-related stress is not diminishing despite improvements in technology and employment rates. The sources of stress, such as workload, seem to exacerbate with improvements in technology (Coovert & Thompson, 2003 ). Moreover, accessibility through mobile technology and virtual computer terminals is linking people to their work more than ever before (ILO, 2012 ; Tarafdar, Tu, Ragu-Nathan, & Ragu-Nathan, 2007 ). Evidence of this kind of mobility and flexibility is further reinforced in a June 2007 survey of 4,025 email users (over 13 years of age); AOL reported that four in ten survey respondents reported planning their vacations around email accessibility and 83% checked their emails at least once a day while away (McMahon, 2007 ). Ironically, despite these mounting work-related stressors and clear financial and performance outcomes, some individuals are reporting they are less “stressed,” but only because “stress has become the new normal” (Jayson, 2012 , para. 4).

This new normal is likely the source of psychological and physiological illness. Siegrist ( 2010 ) contends that conditions in the workplace, particularly psychosocial stressors that are perceived as unfavorable relationships with others and self, and an increasingly sedentary lifestyle (reinforced with desk jobs) are increasingly contributing to cardiovascular disease. These factors together justify a need to continue on the path of helping individuals recognize and cope with deleterious stressors in the work environment and, equally important, to find ways to help organizations prevent harmful stressors over which they have control, as well as implement policies or mechanisms to help employees deal with these stressors and subsequent strains. Along with a greater focus on mitigating environmental constraints are interventions that can be used to prevent anxiety, poor attitudes toward the workplace conditions and arrangements, and subsequent cardiovascular illness, absenteeism, and poor job performance (Siegrist, 2010 ).

Even the ILO has presented guidance on how the workplace can help prevent harmful job stressors (aka hindrance stressors) or at least help workers cope with them. Consistent with the view that well-being is not the absence of stressors or strains and with the view that positive psychology offers a lens for proactively preventing stressors, the ILO promotes increasing preventative risk assessments, interventions to prevent and control stressors, transparent organizational communication, worker involvement in decision-making, networks and mechanisms for workplace social support, awareness of how working and living conditions interact, safety, health, and well-being in the organization (ILO, n.d. ). The field of industrial and organizational (IO) psychology supports the ILO’s recommendations.

IO psychology views work stress as the process of a person’s interaction with multiple aspects of the work environment, job design, and work conditions in the organization. Interventions to manage work stress, therefore, focus on the psychosocial factors of the person and his or her relationships with others and the socio-technical factors related to the work environment and work processes. Viewing work stress from the lens of the person and the environment stems from Kurt Lewin’s ( 1936 ) work that stipulates a person’s state of mental health and behaviors are a function of the person within a specific environment or situation. Aspects of the work environment that affect individuals’ mental states and behaviors include organizational hierarchy, organizational climate (including processes, policies, practices, and reward structures), resources to support a person’s ability to fulfill job duties, and management structure (including leadership). Job design refers to each contributor’s tasks and responsibilities for fulfilling goals associated with the work role. Finally, working conditions refers not only to the physical environment, but also the interpersonal relationships with other contributors.

Each of the conditions that are identified in the work environment may be perceived as potentially harmful or a threat to the person or as an opportunity. When a stressor is perceived as a threat to attaining desired goals or outcomes, the stressor may be labeled as a hindrance stressor (e.g., LePine, Podsakoff, & Lepine, 2005 ). When the stressor is perceived as an opportunity to attain a desired goal or end state, it may be labeled as a challenge stressor. According to LePine and colleagues’ ( 2005 ), both challenge (e.g., time urgency, workload) and hindrance (e.g., hassles, role ambiguity, role conflict) stressors could lead to strains (as measured by “anxiety, depersonalization, depression, emotional exhaustion, frustration, health complaints, hostility, illness, physical symptoms, and tension” [p. 767]). However, challenge stressors positively relate with motivation and performance, whereas hindrance stressors negatively relate with motivation and performance. Moreover, motivation and strains partially mediate the relationship between hindrance and challenge stressors with performance.

Figure 1. Organizational development frameworks to guide identification of work stress and interventions.

In order to (1) minimize any potential negative effects from stressors, (2) increase coping skills to deal with stressors, or (3) manage strains, organizational practitioners or consultants will devise organizational interventions geared toward prevention, coping, and/or stress management. Ultimately, toxic factors in the work environment can have deleterious effects on a person’s physical and psychological well-being, as well as on an organization’s total health. It behooves management to take stock of the organization’s health, which includes the health and well-being of its employees, if the organization wishes to thrive and be profitable. According to Page and Vella-Brodrick’s ( 2009 ) model of employee well-being, employee well-being results from subjective well-being (i.e., life satisfaction and general positive or negative affect), workplace well-being (composed of job satisfaction and work-specific positive or negative affect), and psychological well-being (e.g., self-acceptance, positive social relations, mastery, purpose in life). Job stressors that become unbearable are likely to negatively affect workplace well-being and thus overall employee well-being. Because work stress is a major organizational pain point and organizations often employ organizational consultants to help identify and remediate pain points, the focus here is on organizational development (OD) frameworks; several work stress frameworks are presented that together signal areas where organizations might focus efforts for change in employee behaviors, attitudes, and performance, as well as the organization’s performance and climate. Work stress, interventions, and several OD and stress frameworks are depicted in Figure 1 .

The goals are: (1) to conceptually define and clarify terms associated with stress and stress management, particularly focusing on organizational factors that contribute to stress and stress management, and (2) to present research that informs current knowledge and practices on workplace stress management strategies. Stressors and strains will be defined, leading OD and work stress frameworks that are used to organize and help organizations make sense of the work environment and the organization’s responsibility in stress management will be explored, and stress management will be explained as an overarching thematic label; an area of study and practice that focuses on prevention (primary) interventions, coping (secondary) interventions, and managing strains (tertiary) interventions; as well as the label typically used to denote tertiary interventions. Suggestions for future research and implications toward becoming a healthy organization are presented.

Defining Stressors and Strains

Work-related stressors or job stressors can lead to different kinds of strains individuals and organizations might experience. Various types of stress management interventions, guided by OD and work stress frameworks, may be employed to prevent or cope with job stressors and manage strains that develop(ed).

A job stressor is a stimulus external to an employee and a result of an employee’s work conditions. Example job stressors include organizational constraints, workplace mistreatments (such as abusive supervision, workplace ostracism, incivility, bullying), role stressors, workload, work-family conflicts, errors or mistakes, examinations and evaluations, and lack of structure (Jex & Beehr, 1991 ; Liu, Spector, & Shi, 2007 ; Narayanan, Menon, & Spector, 1999 ). Although stressors may be categorized as hindrances and challenges, there is not yet sufficient information to be able to propose which stress management interventions would better serve to reduce those hindrance stressors or to reduce strain-producing challenge stressors while reinforcing engagement-producing challenge stressors.

Organizational Constraints

Organizational constraints may be hindrance stressors as they prevent employees from translating their motivation and ability into high-level job performance (Peters & O’Connor, 1980 ). Peters and O’Connor ( 1988 ) defined 11 categories of organizational constraints: (1) job-related information, (2) budgetary support, (3) required support, (4) materials and supplies, (5) required services and help from others, (6) task preparation, (7) time availability, (8) the work environment, (9) scheduling of activities, (10) transportation, and (11) job-relevant authority. The inhibiting effect of organizational constraints may be due to the lack of, inadequacy of, or poor quality of these categories.

Workplace Mistreatment

Workplace mistreatment presents a cluster of interpersonal variables, such as interpersonal conflict, bullying, incivility, and workplace ostracism (Hershcovis, 2011 ; Tepper & Henle, 2011 ). Typical workplace mistreatment behaviors include gossiping, rude comments, showing favoritism, yelling, lying, and ignoring other people at work (Tepper & Henle, 2011 ). These variables relate to employees’ psychological well-being, physical well-being, work attitudes (e.g., job satisfaction and organizational commitment), and turnover intention (e.g., Hershcovis, 2011 ; Spector & Jex, 1998 ). Some researchers differentiated the source of mistreatment, such as mistreatment from one’s supervisor versus mistreatment from one’s coworker (e.g., Bruk-Lee & Spector, 2006 ; Frone, 2000 ; Liu, Liu, Spector, & Shi, 2011 ).

Role Stressors

Role stressors are demands, constraints, or opportunities a person perceives to be associated, and thus expected, with his or her work role(s) across various situations. Three commonly studied role stressors are role ambiguity, role conflict, and role overload (Glazer & Beehr, 2005 ; Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1964 ). Role ambiguity in the workplace occurs when an employee lacks clarity regarding what performance-related behaviors are expected of him or her. Role conflict refers to situations wherein an employee receives incompatible role requests from the same or different supervisors or the employee is asked to engage in work that impedes his or her performance in other work or nonwork roles or clashes with his or her values. Role overload refers to excessive demands and insufficient time (quantitative) or knowledge (qualitative) to complete the work. The construct is often used interchangeably with workload, though role overload focuses more on perceived expectations from others about one’s workload. These role stressors significantly relate to low job satisfaction, low organizational commitment, low job performance, high tension or anxiety, and high turnover intention (Abramis, 1994 ; Glazer & Beehr, 2005 ; Jackson & Schuler, 1985 ).

Excessive workload is one of the most salient stressors at work (e.g., Liu et al., 2007 ). There are two types of workload: quantitative and qualitative workload (LaRocco, Tetrick, & Meder, 1989 ; Parasuraman & Purohit, 2000 ). Quantitative workload refers to the excessive amount of work one has. In a summary of a Chartered Institute of Personnel & Development Report from 2006 , Dewe and Kompier ( 2008 ) noted that quantitative workload was one of the top three stressors workers experienced at work. Qualitative workload refers to the difficulty of work. Workload also differs by the type of the load. There are mental workload and physical workload (Dwyer & Ganster, 1991 ). Excessive physical workload may result in physical discomfort or illness. Excessive mental workload will cause psychological distress such as anxiety or frustration (Bowling & Kirkendall, 2012 ). Another factor affecting quantitative workload is interruptions (during the workday). Lin, Kain, and Fritz ( 2013 ) found that interruptions delay completion of job tasks, thus adding to the perception of workload.

Work-Family Conflict

Work-family conflict is a form of inter-role conflict in which demands from one’s work domain and one’s family domain are incompatible to some extent (Greenhaus & Beutell, 1985 ). Work can interfere with family (WIF) and/or family can interfere with work (FIW) due to time-related commitments to participating in one domain or another, incompatible behavioral expectations, or when strains in one domain carry over to the other (Greenhaus & Beutell, 1985 ). Work-family conflict significantly relates to work-related outcomes (e.g., job satisfaction, organizational commitment, turnover intention, burnout, absenteeism, job performance, job strains, career satisfaction, and organizational citizenship behaviors), family-related outcomes (e.g., marital satisfaction, family satisfaction, family-related performance, family-related strains), and domain-unspecific outcomes (e.g., life satisfaction, psychological strain, somatic or physical symptoms, depression, substance use or abuse, and anxiety; Amstad, Meier, Fasel, Elfering, & Semmer, 2011 ).

Individuals and organizations can experience work-related strains. Sometimes organizations will experience strains through the employee’s negative attitudes or strains, such as that a worker’s absence might yield lower production rates, which would roll up into an organizational metric of organizational performance. In the industrial and organizational (IO) psychology literature, organizational strains are mostly observed as macro-level indicators, such as health insurance costs, accident-free days, and pervasive problems with company morale. In contrast, individual strains, usually referred to as job strains, are internal to an employee. They are responses to work conditions and relate to health and well-being of employees. In other words, “job strains are adverse reactions employees have to job stressors” (Spector, Chen, & O’Connell, 2000 , p. 211). Job strains tend to fall into three categories: behavioral, physical, and psychological (Jex & Beehr, 1991 ).

Behavioral strains consist of actions that employees take in response to job stressors. Examples of behavioral strains include employees drinking alcohol in the workplace or intentionally calling in sick when they are not ill (Spector et al., 2000 ). Physical strains consist of health symptoms that are physiological in nature that employees contract in response to job stressors. Headaches and ulcers are examples of physical strains. Lastly, psychological strains are emotional reactions and attitudes that employees have in response to job stressors. Examples of psychological strains are job dissatisfaction, anxiety, and frustration (Spector et al., 2000 ). Interestingly, research studies that utilize self-report measures find that most job strains experienced by employees tend to be psychological strains (Spector et al., 2000 ).

Leading Frameworks

Organizations that are keen on identifying organizational pain points and remedying them through organizational campaigns or initiatives often discover the pain points are rooted in work-related stressors and strains and the initiatives have to focus on reducing workers’ stress and increasing a company’s profitability. Through organizational climate surveys, for example, companies discover that aspects of the organization’s environment, including its policies, practices, reward structures, procedures, and processes, as well as employees at all levels of the company, are contributing to the individual and organizational stress. Recent studies have even begun to examine team climates for eustress and distress assessed in terms of team members’ homogenous psychological experience of vigor, efficacy, dedication, and cynicism (e.g., Kożusznik, Rodriguez, & Peiro, 2015 ).

Each of the frameworks presented advances different aspects that need to be identified in order to understand the source and potential remedy for stressors and strains. In some models, the focus is on resources, in others on the interaction of the person and environment, and in still others on the role of the person in the workplace. Few frameworks directly examine the role of the organization, but the organization could use these frameworks to plan interventions that would minimize stressors, cope with existing stressors, and prevent and/or manage strains. One of the leading frameworks in work stress research that is used to guide organizational interventions is the person and environment (P-E) fit (French & Caplan, 1972 ). Its precursor is the University of Michigan Institute for Social Research’s (ISR) role stress model (Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1964 ) and Lewin’s Field Theory. Several other theories have since evolved from the P-E fit framework, including Karasek and Theorell’s ( 1990 ), Karasek ( 1979 ) Job Demands-Control Model (JD-C), the transactional framework (Lazarus & Folkman, 1984 ), Conservation of Resources (COR) theory (Hobfoll, 1989 ), and Siegrist’s ( 1996 ) Effort-Reward Imbalance (ERI) Model.

Field Theory

The premise of Kahn et al.’s ( 1964 ) role stress theory is Lewin’s ( 1997 ) Field Theory. Lewin purported that behavior and mental events are a dynamic function of the whole person, including a person’s beliefs, values, abilities, needs, thoughts, and feelings, within a given situation (field or environment), as well as the way a person represents his or her understanding of the field and behaves in that space. Lewin explains that work-related strains are a result of individuals’ subjective perceptions of objective factors, such as work roles, relationships with others in the workplace, as well as personality indicators, and can be used to predict people’s reactions, including illness. Thus, to make changes to an organizational system, it is necessary to understand a field and try to move that field from the current state to the desired state. Making this move necessitates identifying mechanisms influencing individuals.

Role Stress Theory

Role stress theory mostly isolates the perspective a person has about his or her work-related responsibilities and expectations to determine how those perceptions relate with a person’s work-related strains. However, those relationships have been met with somewhat varied results, which Glazer and Beehr ( 2005 ) concluded might be a function of differences in culture, an environmental factor often neglected in research. Kahn et al.’s ( 1964 ) role stress theory, coupled with Lewin’s ( 1936 ) Field Theory, serves as the foundation for the P-E fit theory. Lewin ( 1936 ) wrote, “Every psychological event depends upon the state of the person and at the same time on the environment” (p. 12). Researchers of IO psychology have narrowed the environment to the organization or work team. This narrowed view of the organizational environment is evident in French and Caplan’s ( 1972 ) P-E fit framework.

Person-Environment Fit Theory

The P-E fit framework focuses on the extent to which there is congruence between the person and a given environment, such as the organization (Caplan, 1987 ; Edwards, 2008 ). For example, does the person have the necessary skills and abilities to fulfill an organization’s demands, or does the environment support a person’s desire for autonomy (i.e., do the values align?) or fulfill a person’s needs (i.e., a person’s needs are rewarded). Theoretically and empirically, the greater the person-organization fit, the greater a person’s job satisfaction and organizational commitment, the less a person’s turnover intention and work-related stress (see meta-analyses by Assouline & Meir, 1987 ; Kristof-Brown, Zimmerman, & Johnson, 2005 ; Verquer, Beehr, & Wagner, 2003 ).

Job Demands-Control/Support (JD-C/S) and Job Demands-Resources (JD-R) Model

Focusing more closely on concrete aspects of work demands and the extent to which a person perceives he or she has control or decision latitude over those demands, Karasek ( 1979 ) developed the JD-C model. Karasek and Theorell ( 1990 ) posited that high job demands under conditions of little decision latitude or control yield high strains, which have varied implications on the health of an organization (e.g., in terms of high turnover, employee ill-health, poor organizational performance). This theory was modified slightly to address not only control, but also other resources that could protect a person from unruly job demands, including support (aka JD-C/S, Johnson & Hall, 1988 ; and JD-R, Bakker, van Veldhoven, & Xanthopoulou, 2010 ). Whether focusing on control or resources, both they and job demands are said to reflect workplace characteristics, while control and resources also represent coping strategies or tools (Siegrist, 2010 ).

Despite the glut of research testing the JD-C and JD-R, results are somewhat mixed. Testing the interaction between job demands and control, Beehr, Glaser, Canali, and Wallwey ( 2001 ) did not find empirical support for the JD-C theory. However, Dawson, O’Brien, and Beehr ( 2016 ) found that high control and high support buffered against the independent deleterious effects of interpersonal conflict, role conflict, and organizational politics (demands that were categorized as hindrance stressors) on anxiety, as well as the effects of interpersonal conflict and organizational politics on physiological symptoms, but control and support did not moderate the effects between challenge stressors and strains. Coupled with Bakker, Demerouti, and Sanz-Vergel’s ( 2014 ) note that excessive job demands are a source of strain, but increased job resources are a source of engagement, Dawson et al.’s results suggest that when an organization identifies that demands are hindrances, it can create strategies for primary (preventative) stress management interventions and attempt to remove or reduce such work demands. If the demands are challenging, though manageable, but latitude to control the challenging stressors and support are insufficient, the organization could modify practices and train employees on adopting better strategies for meeting or coping (secondary stress management intervention) with the demands. Finally, if the organization can neither afford to modify the demands or the level of control and support, it will be necessary for the organization to develop stress management (tertiary) interventions to deal with the inevitable strains.

Conservation of Resources Theory

The idea that job resources reinforce engagement in work has been propagated in Hobfoll’s ( 1989 ) Conservation of Resources (COR) theory. COR theory also draws on the foundational premise that people’s mental health is a function of the person and the environment, forwarding that how people interpret their environment (including the societal context) affects their stress levels. Hobfoll focuses on resources such as objects, personal characteristics, conditions, or energies as particularly instrumental to minimizing strains. He asserts that people do whatever they can to protect their valued resources. Thus, strains develop when resources are threatened to be taken away, actually taken away, or when additional resources are not attainable after investing in the possibility of gaining more resources (Hobfoll, 2001 ). By extension, organizations can invest in activities that would minimize resource loss and create opportunities for resource gains and thus have direct implications for devising primary and secondary stress management interventions.

Transactional Framework

Lazarus and Folkman ( 1984 ) developed the widely studied transactional framework of stress. This framework holds as a key component the cognitive appraisal process. When individuals perceive factors in the work environment as a threat (i.e., primary appraisal), they will scan the available resources (external or internal to himself or herself) to cope with the stressors (i.e., secondary appraisal). If the coping resources provide minimal relief, strains develop. Until recently, little attention has been given to the cognitive appraisal associated with different work stressors (Dewe & Kompier, 2008 ; Liu & Li, 2017 ). In a study of Polish and Spanish social care service providers, stressors appraised as a threat related positively to burnout and less engagement, but stressors perceived as challenges yielded greater engagement and less burnout (Kożusznik, Rodriguez, & Peiro, 2012 ). Similarly, Dawson et al. ( 2016 ) found that even with support and control resources, hindrance demands were more strain-producing than challenge demands, suggesting that appraisal of the stressor is important. In fact, “many people respond well to challenging work” (Beehr et al., 2001 , p. 126). Kożusznik et al. ( 2012 ) recommend training employees to change the way they view work demands in order to increase engagement, considering that part of the problem may be about how the person appraises his or her environment and, thus, copes with the stressors.

Effort-Reward Imbalance

Siegrist’s ( 1996 ) Model of Effort-Reward Imbalance (ERI) focuses on the notion of social reciprocity, such that a person fulfills required work tasks in exchange for desired rewards (Siegrist, 2010 ). ERI sheds light on how an imbalance in a person’s expectations of an organization’s rewards (e.g., pay, bonus, sense of advancement and development, job security) in exchange for a person’s efforts, that is a break in one’s work contract, leads to negative responses, including long-term ill-health (Siegrist, 2010 ; Siegrist et al., 2014 ). In fact, prolonged perception of a work contract imbalance leads to adverse health, including immunological problems and inflammation, which contribute to cardiovascular disease (Siegrist, 2010 ). The model resembles the relational and interactional psychological contract theory in that it describes an employee’s perception of the terms of the relationship between the person and the workplace, including expectations of performance, job security, training and development opportunities, career progression, salary, and bonuses (Thomas, Au, & Ravlin, 2003 ). The psychological contract, like the ERI model, focuses on social exchange. Furthermore, the psychological contract, like stress theories, are influenced by cultural factors that shape how people interpret their environments (Glazer, 2008 ; Thomas et al., 2003 ). Violations of the psychological contract will negatively affect a person’s attitudes toward the workplace and subsequent health and well-being (Siegrist, 2010 ). To remediate strain, Siegrist ( 2010 ) focuses on both the person and the environment, recognizing that the organization is particularly responsible for changing unfavorable work conditions and the person is responsible for modifying his or her reactions to such conditions.

Stress Management Interventions: Primary, Secondary, and Tertiary

Remediation of work stress and organizational development interventions are about realigning the employee’s experiences in the workplace with factors in the environment, as well as closing the gap between the current environment and the desired environment. Work stress develops when an employee perceives the work demands to exceed the person’s resources to cope and thus threatens employee well-being (Dewe & Kompier, 2008 ). Likewise, an organization’s need to change arises when forces in the environment are creating a need to change in order to survive (see Figure 1 ). Lewin’s ( 1951 ) Force Field Analysis, the foundations of which are in Field Theory, is one of the first organizational development intervention tools presented in the social science literature. The concept behind Force Field Analysis is that in order to survive, organizations must adapt to environmental forces driving a need for organizational change and remove restraining forces that create obstacles to organizational change. In order to do this, management needs to delineate the current field in which the organization is functioning, understand the driving forces for change, identify and dampen or eliminate the restraining forces against change. Several models for analyses may be applied, but most approaches are variations of organizational climate surveys.

Through organizational surveys, workers provide management with a snapshot view of how they perceive aspects of their work environment. Thus, the view of the health of an organization is a function of several factors, chief among them employees’ views (i.e., the climate) about the workplace (Lewin, 1951 ). Indeed, French and Kahn ( 1962 ) posited that well-being depends on the extent to which properties of the person and properties of the environment align in terms of what a person requires and the resources available in a given environment. Therefore, only when properties of the person and properties of the environment are sufficiently understood can plans for change be developed and implemented targeting the environment (e.g., change reporting structures to relieve, and thus prevent future, communication stressors) and/or the person (e.g., providing more autonomy, vacation days, training on new technology). In short, climate survey findings can guide consultants about the emphasis for organizational interventions: before a problem arises aka stress prevention, e.g., carefully crafting job roles), when a problem is present, but steps are taken to mitigate their consequences (aka coping, e.g., providing social support groups), and/or once strains develop (aka. stress management, e.g., healthcare management policies).

For each of the primary (prevention), secondary (coping), and tertiary (stress management) techniques the target for intervention can be the entire workforce, a subset of the workforce, or a specific person. Interventions that target the entire workforce may be considered organizational interventions, as they have direct implications on the health of all individuals and consequently the health of the organization. Several interventions categorized as primary and secondary interventions may also be implemented after strains have developed and after it has been discerned that a person or the organization did not do enough to mitigate stressors or strains (see Figure 1 ). The designation of many of the interventions as belonging to one category or another may be viewed as merely a suggestion.

Primary Interventions (Preventative Stress Management)

Before individuals begin to perceive work-related stressors, organizations engage in stress prevention strategies, such as providing people with resources (e.g., computers, printers, desk space, information about the job role, organizational reporting structures) to do their jobs. However, sometimes the institutional structures and resources are insufficient or ambiguous. Scholars and practitioners have identified several preventative stress management strategies that may be implemented.

Planning and Time Management

When employees feel quantitatively overloaded, sometimes the remedy is improving the employees’ abilities to plan and manage their time (Quick, Quick, Nelson, & Hurrell, 2003 ). Planning is a future-oriented activity that focuses on conceptual and comprehensive work goals. Time management is a behavior that focuses on organizing, prioritizing, and scheduling work activities to achieve short-term goals. Given the purpose of time management, it is considered a primary intervention, as engaging in time management helps to prevent work tasks from mounting and becoming unmanageable, which would subsequently lead to adverse outcomes. Time management comprises three fundamental components: (1) establishing goals, (2) identifying and prioritizing tasks to fulfill the goals, and (3) scheduling and monitoring progress toward goal achievement (Peeters & Rutte, 2005 ). Workers who employ time management have less role ambiguity (Macan, Shahani, Dipboye, & Philips, 1990 ), psychological stress or strain (Adams & Jex, 1999 ; Jex & Elaqua, 1999 ; Macan et al., 1990 ), and greater job satisfaction (Macan, 1994 ). However, Macan ( 1994 ) did not find a relationship between time management and performance. Still, Claessens, van Eerde, Rutte, and Roe ( 2004 ) found that perceived control of time partially mediated the relationships between planning behavior (an indicator of time management), job autonomy, and workload on one hand, and job strains, job satisfaction, and job performance on the other hand. Moreover, Peeters and Rutte ( 2005 ) observed that teachers with high work demands and low autonomy experienced more burnout when they had poor time management skills.

Person-Organization Fit

Just as it is important for organizations to find the right person for the job and organization, so is it the responsibility of a person to choose to work at the right organization—an organization that fulfills the person’s needs and upholds the values important to the individual, as much as the person fulfills the organization’s needs and adapts to its values. When people fit their employing organizations they are setting themselves up for experiencing less strain-producing stressors (Kristof-Brown et al., 2005 ). In a meta-analysis of 62 person-job fit studies and 110 person-organization fit studies, Kristof-Brown et al. ( 2005 ) found that person-job fit had a negative correlation with indicators of job strain. In fact, a primary intervention of career counseling can help to reduce stress levels (Firth-Cozens, 2003 ).

Job Redesign

The Job Demands-Control/Support (JD-C/S), Job Demands-Resources (JD-R), and transactional models all suggest that factors in the work context require modifications in order to reduce potential ill-health and poor organizational performance. Drawing on Hackman and Oldham’s ( 1980 ) Job Characteristics Model, it is possible to assess with the Job Diagnostics Survey (JDS) the current state of work characteristics related to skill variety, task identity, task significance, autonomy, and feedback. Modifying those aspects would help create a sense of meaningfulness, sense of responsibility, and feeling of knowing how one is performing, which subsequently affects a person’s well-being as identified in assessments of motivation, satisfaction, improved performance, and reduced withdrawal intentions and behaviors. Extending this argument to the stress models, it can be deduced that reducing uncertainty or perceived unfairness that may be associated with a person’s perception of these work characteristics, as well as making changes to physical characteristics of the environment (e.g., lighting, seating, desk, air quality), nature of work (e.g., job responsibilities, roles, decision-making latitude), and organizational arrangements (e.g., reporting structure and feedback mechanisms), can help mitigate against numerous ill-health consequences and reduced organizational performance. In fact, Fried et al. ( 2013 ) showed that healthy patients of a medical clinic whose jobs were excessively low (i.e., monotonous) or excessively high (i.e., overstimulating) on job enrichment (as measured by the JDS) had greater abdominal obesity than those whose jobs were optimally enriched. By taking stock of employees’ perceptions of the current work situation, managers might think about ways to enhance employees’ coping toolkit, such as training on how to deal with difficult clients or creating stimulating opportunities when jobs have low levels of enrichment.

Participatory Action Research Interventions

Participatory action research (PAR) is an intervention wherein, through group discussions, employees help to identify and define problems in organizational structure, processes, policies, practices, and reward structures, as well as help to design, implement, and evaluate success of solutions. PAR is in itself an intervention, but its goal is to design interventions to eliminate or reduce work-related factors that are impeding performance and causing people to be unwell. An example of a successful primary intervention, utilizing principles of PAR and driven by the JD-C and JD-C/S stress frameworks is Health Circles (HCs; Aust & Ducki, 2004 ).

HCs, developed in Germany in the 1980s, were popular practices in industries, such as metal, steel, and chemical, and service. Similar to other problem-solving practices, such as quality circles, HCs were based on the assumptions that employees are the experts of their jobs. For this reason, to promote employee well-being, management and administrators solicited suggestions and ideas from the employees to improve occupational health, thereby increasing employees’ job control. HCs also promoted communication between managers and employees, which had a potential to increase social support. With more control and support, employees would experience less strains and better occupational well-being.

Employing the three-steps of (1) problem analysis (i.e., diagnosis or discovery through data generated from organizational records of absenteeism length, frequency, rate, and reason and employee survey), (2) HC meetings (6 to 10 meetings held over several months to brainstorm ideas to improve occupational safety and health concerns identified in the discovery phase), and (3) HC evaluation (to determine if desired changes were accomplished and if employees’ reports of stressors and strains changed after the course of 15 months), improvements were to be expected (Aust & Ducki, 2004 ). Aust and Ducki ( 2004 ) reviewed 11 studies presenting 81 health circles in 30 different organizations. Overall study participants had high satisfaction with the HCs practices. Most companies acted upon employees’ suggestions (e.g., improving driver’s seat and cab, reducing ticket sale during drive, team restructuring and job rotation to facilitate communication, hiring more employees during summer time, and supervisor training program to improve leadership and communication skills) to improve work conditions. Thus, HCs represent a successful theory-grounded intervention to routinely improve employees’ occupational health.

Physical Setting

The physical environment or physical workspace has an enormous impact on individuals’ well-being, attitudes, and interactions with others, as well as on the implications on innovation and well-being (Oksanen & Ståhle, 2013 ; Vischer, 2007 ). In a study of 74 new product development teams (total of 437 study respondents) in Western Europe, Chong, van Eerde, Rutte, and Chai ( 2012 ) found that when teams were faced with challenge time pressures, meaning the teams had a strong interest and desire in tackling complex, but engaging tasks, when they were working proximally close with one another, team communication improved. Chong et al. assert that their finding aligns with prior studies that have shown that physical proximity promotes increased awareness of other team members, greater tendency to initiate conversations, and greater team identification. However, they also found that when faced with hindrance time pressures, physical proximity related to low levels of team communication, but when hindrance time pressure was low, team proximity had an increasingly greater positive relationship with team communication.

In addition to considering the type of work demand teams must address, other physical workspace considerations include whether people need to work collaboratively and synchronously or independently and remotely (or a combination thereof). Consideration needs to be given to how company contributors would satisfy client needs through various modes of communication, such as email vs. telephone, and whether individuals who work by a window might need shading to block bright sunlight from glaring on their computer screens. Finally, people who have to use the telephone for extensive periods of time would benefit from earphones to prevent neck strains. Most physical stressors are rather simple to rectify. However, companies are often not aware of a problem until after a problem arises, such as when a person’s back is strained from trying to move heavy equipment. Companies then implement strategies to remediate the environmental stressor. With the help of human factors, and organizational and office design consultants, many of the physical barriers to optimal performance can be prevented (Rousseau & Aubé, 2010 ). In a study of 215 French-speaking Canadian healthcare employees, Rousseau and Aubé ( 2010 ) found that although supervisor instrumental support positively related with affective commitment to the organization, the relationship was even stronger for those who reported satisfaction with the ambient environment (i.e., temperature, lighting, sound, ventilation, and cleanliness).

Secondary Interventions (Coping)

Secondary interventions, also referred to as coping, focus on resources people can use to mitigate the risk of work-related illness or workplace injury. Resources may include properties related to social resources, behaviors, and cognitive structures. Each of these resource domains may be employed to cope with stressors. Monat and Lazarus ( 1991 ) summarize the definition of coping as “an individual’s efforts to master demands (or conditions of harm, threat, or challenge) that are appraised (or perceived) as exceeding or taxing his or her resources” (p. 5). To master demands requires use of the aforementioned resources. Secondary interventions help employees become aware of the psychological, physical, and behavioral responses that may occur from the stressors presented in their working environment. Secondary interventions help a person detect and attend to stressors and identify resources for and ways of mitigating job strains. Often, coping strategies are learned skills that have a cognitive foundation and serve important functions in improving people’s management of stressors (Lazarus & Folkman, 1991 ). Coping is effortful, but with practice it becomes easier to employ. This idea is the foundation for understanding the role of resilience in coping with stressors. However, “not all adaptive processes are coping. Coping is a subset of adaptational activities that involves effort and does not include everything that we do in relating to the environment” (Lazarus & Folkman, 1991 , p. 198). Furthermore, sometimes to cope with a stressor, a person may call upon social support sources to help with tangible materials or emotional comfort. People call upon support resources because they help to restructure how a person approaches or thinks about the stressor.

Most secondary interventions are aimed at helping the individual, though companies, as a policy, might require all employees to partake in training aimed at increasing employees’ awareness of and skills aimed at handling difficult situations vis à vis company channels (e.g., reporting on sexual harassment or discrimination). Furthermore, organizations might institute mentoring programs or work groups to address various work-related matters. These programs employ awareness-raising activities, stress-education, or skills training (cf., Bhagat, Segovis, & Nelson, 2012 ), which include development of skills in problem-solving, understanding emotion-focused coping, identifying and using social support, and enhancing capacity for resilience. The aim of these programs, therefore, is to help employees proactively review their perceptions of psychological, physical, and behavioral job-related strains, thereby extending their resilience, enabling them to form a personal plan to control stressors and practice coping skills (Cooper, Dewe, & O’Driscoll, 2011 ).

Often these stress management programs are instituted after an organization has observed excessive absenteeism and work-related performance problems and, therefore, are sometimes categorized as a tertiary stress management intervention or even a primary (prevention) intervention. However, the skills developed for coping with stressors also place the programs in secondary stress management interventions. Example programs that are categorized as tertiary or primary stress management interventions may also be secondary stress management interventions (see Figure 1 ), and these include lifestyle advice and planning, stress inoculation training, simple relaxation techniques, meditation, basic trainings in time management, anger management, problem-solving skills, and cognitive-behavioral therapy. Corporate wellness programs also fall under this category. In other words, some programs could be categorized as primary, secondary, or tertiary interventions depending upon when the employee (or organization) identifies the need to implement the program. For example, time management practices could be implemented as a means of preventing some stressors, as a way to cope with mounting stressors, or as a strategy to mitigate symptoms of excessive of stressors. Furthermore, these programs can be administered at the individual level or group level. As related to secondary interventions, these programs provide participants with opportunities to develop and practice skills to cognitively reappraise the stressor(s); to modify their perspectives about stressors; to take time out to breathe, stretch, meditate, relax, and/or exercise in an attempt to support better decision-making; to articulate concerns and call upon support resources; and to know how to say “no” to onslaughts of requests to complete tasks. Participants also learn how to proactively identify coping resources and solve problems.

According to Cooper, Dewe, and O’Driscoll ( 2001 ), secondary interventions are successful in helping employees modify or strengthen their ability to cope with the experience of stressors with the goal of mitigating the potential harm the job stressors may create. Secondary interventions focus on individuals’ transactions with the work environment and emphasize the fit between a person and his or her environment. However, researchers have pointed out that the underlying assumption of secondary interventions is that the responsibility for coping with the stressors of the environment lies within individuals (Quillian-Wolever & Wolever, 2003 ). If companies cannot prevent the stressors in the first place, then they are, in part, responsible for helping individuals develop coping strategies and informing employees about programs that would help them better cope with job stressors so that they are able to fulfill work assignments.

Stress management interventions that help people learn to cope with stressors focus mainly on the goals of enabling problem-resolution or expressing one’s emotions in a healthy manner. These goals are referred to as problem-focused coping and emotion-focused coping (Folkman & Lazarus, 1980 ; Pearlin & Schooler, 1978 ), and the person experiencing the stressors as potential threat is the agent for change and the recipient of the benefits of successful coping (Hobfoll, 1998 ). In addition to problem-focused and emotion-focused coping approaches, social support and resilience may be coping resources. There are many other sources for coping than there is room to present here (see e.g., Cartwright & Cooper, 2005 ); however, the current literature has primarily focused on these resources.

Problem-Focused Coping

Problem-focused or direct coping helps employees remove or reduce stressors in order to reduce their strain experiences (Bhagat et al., 2012 ). In problem-focused coping employees are responsible for working out a strategic plan in order to remove job stressors, such as setting up a set of goals and engaging in behaviors to meet these goals. Problem-focused coping is viewed as an adaptive response, though it can also be maladaptive if it creates more problems down the road, such as procrastinating getting work done or feigning illness to take time off from work. Adaptive problem-focused coping negatively relates to long-term job strains (Higgins & Endler, 1995 ). Discussion on problem-solving coping is framed from an adaptive perspective.

Problem-focused coping is featured as an extension of control, because engaging in problem-focused coping strategies requires a series of acts to keep job stressors under control (Bhagat et al., 2012 ). In the stress literature, there are generally two ways to categorize control: internal versus external locus of control, and primary versus secondary control. Locus of control refers to the extent to which people believe they have control over their own life (Rotter, 1966 ). People high in internal locus of control believe that they can control their own fate whereas people high in external locus of control believe that outside factors determine their life experience (Rotter, 1966 ). Generally, those with an external locus of control are less inclined to engage in problem-focused coping (Strentz & Auerbach, 1988 ). Primary control is the belief that people can directly influence their environment (Alloy & Abramson, 1979 ), and thus they are more likely to engage in problem-focused coping. However, when it is not feasible to exercise primary control, people search for secondary control, with which people try to adapt themselves into the objective environment (Rothbaum, Weisz, & Snyder, 1982 ).

Emotion-Focused Coping

Emotion-focused coping, sometimes referred to as palliative coping, helps employees reduce strains without the removal of job stressors. It involves cognitive or emotional efforts, such as talking about the stressor or distracting oneself from the stressor, in order to lessen emotional distress resulting from job stressors (Bhagat et al., 2012 ). Emotion-focused coping aims to reappraise and modify the perceptions of a situation or seek emotional support from friends or family. These methods do not include efforts to change the work situation or to remove the job stressors (Lazarus & Folkman, 1991 ). People tend to adopt emotion-focused coping strategies when they believe that little or nothing can be done to remove the threatening, harmful, and challenging stressors (Bhagat et al., 2012 ), such as when they are the only individuals to have the skills to get a project done or they are given increased responsibilities because of the unexpected departure of a colleague. Emotion-focused coping strategies include (1) reappraisal of the stressful situation, (2) talking to friends and receiving reassurance from them, (3) focusing on one’s strength rather than weakness, (4) optimistic comparison—comparing one’s situation to others’ or one’s past situation, (5) selective ignoring—paying less attention to the unpleasant aspects of one’s job and being more focused on the positive aspects of the job, (6) restrictive expectations—restricting one’s expectations on job satisfaction but paying more attention to monetary rewards, (7) avoidance coping—not thinking about the problem, leaving the situation, distracting oneself, or using alcohol or drugs (e.g., Billings & Moos, 1981 ).

Some emotion-focused coping strategies are maladaptive. For example, avoidance coping may lead to increased level of job strains in the long run (e.g., Parasuraman & Cleek, 1984 ). Furthermore, a person’s ability to cope with the imbalance of performing work to meet organizational expectations can take a toll on the person’s health, leading to physiological consequences such as cardiovascular disease, sleep disorders, gastrointestinal disorders, and diabetes (Fried et al., 2013 ; Siegrist, 2010 ; Toker, Shirom, Melamed, & Armon, 2012 ; Willert, Thulstrup, Hertz, & Bonde, 2010 ).

Comparing Coping Strategies across Cultures

Most coping research is conducted in individualistic, Western cultures wherein emotional control is emphasized and both problem-solving focused coping and primary control are preferred (Bhagat et al., 2010 ). However, in collectivistic cultures, emotion-focused coping and use of secondary control may be preferred and may not necessarily carry a negative evaluation (Bhagat et al., 2010 ). For example, African Americans are more likely to use emotion-focused coping than non–African Americans (Knight, Silverstein, McCallum, & Fox, 2000 ), and among women who experienced sexual harassment, Anglo American women were less likely to employ emotion focused coping (i.e., avoidance coping) than Turkish women and Hispanic American women, while Hispanic women used more denial than the other two groups (Wasti & Cortina, 2002 ).

Thus, whereas problem-focused coping is venerated in Western societies, emotion-focused coping may be more effective in reducing strains in collectivistic cultures, such as China, Japan, and India (Bhagat et al., 2010 ; Narayanan, Menon, & Spector, 1999 ; Selmer, 2002 ). Indeed, Swedish participants reported more problem-focused coping than did Chinese participants (Xiao, Ottosson, & Carlsson, 2013 ), American college students engaged in more problem-focused coping behaviors than did their Japanese counterparts (Ogawa, 2009 ), and Indian (vs. Canadian) students reported more emotion-focused coping, such as seeking social support and positive reappraisal (Sinha, Willson, & Watson, 2000 ). Moreover, Glazer, Stetz, and Izso ( 2004 ) found that internal locus of control was more predominant in individualistic cultures (United Kingdom and United States), whereas external locus of control was more predominant in communal cultures (Italy and Hungary). Also, internal locus of control was associated with less job stress, but more so for nurses in the United Kingdom and United States than Italy and Hungary. Taken together, adoption of coping strategies and their effectiveness differ significantly across cultures. The extent to which a coping strategy is perceived favorably and thus selected or not selected is not only a function of culture, but also a person’s sociocultural beliefs toward the coping strategy (Morimoto, Shimada, & Ozaki, 2013 ).

Social Support

Social support refers to the aid an entity gives to a person. The source of the support can be a single person, such as a supervisor, coworker, subordinate, family member, friend, or stranger, or an organization as represented by upper-level management representing organizational practices. The type of support can be instrumental or emotional. Instrumental support, including informational support, refers to that which is tangible, such as data to help someone make a decision or colleagues’ sick days so one does not lose vital pay while recovering from illness. Emotional support, including esteem support, refers to the psychological boost given to a person who needs to express emotions and feel empathy from others or to have his or her perspective validated. Beehr and Glazer ( 2001 ) present an overview of the role of social support on the stressor-strain relationship and arguments regarding the role of culture in shaping the utility of different sources and types of support.

Meaningfulness and Resilience

Meaningfulness reflects the extent to which people believe their lives are significant, purposeful, goal-directed, and fulfilling (Glazer, Kożusznik, Meyers, & Ganai, 2014 ). When faced with stressors, people who have a strong sense of meaning in life will also try to make sense of the stressors. Maintaining a positive outlook on life stressors helps to manage emotions, which is helpful in reducing strains, particularly when some stressors cannot be problem-solved (Lazarus & Folkman, 1991 ). Lazarus and Folkman ( 1991 ) emphasize that being able to reframe threatening situations can be just as important in an adaptation as efforts to control the stressors. Having a sense of meaningfulness motivates people to behave in ways that help them overcome stressors. Thus, meaningfulness is often used in the same breath as resilience, because people who are resilient are often protecting that which is meaningful.

Resilience is a personality state that can be fortified and enhanced through varied experiences. People who perceive their lives are meaningful are more likely to find ways to face adversity and are therefore more prone to intensifying their resiliency. When people demonstrate resilience to cope with noxious stressors, their ability to be resilient against other stressors strengthens because through the experience, they develop more competencies (Glazer et al., 2014 ). Thus, fitting with Hobfoll’s ( 1989 , 2001 ) COR theory, meaningfulness and resilience are psychological resources people attempt to conserve and protect, and employ when necessary for making sense of or coping with stressors.

Tertiary Interventions (Stress Management)

Stress management refers to interventions employed to treat and repair harmful repercussions of stressors that were not coped with sufficiently. As Lazarus and Folkman ( 1991 ) noted, not all stressors “are amenable to mastery” (p. 205). Stressors that are unmanageable and lead to strains require interventions to reverse or slow down those effects. Workplace interventions might focus on the person, the organization, or both. Unfortunately, instead of looking at the whole system to include the person and the workplace, most companies focus on the person. Such a focus should not be a surprise given the results of van der Klink, Blonk, Schene, and van Dijk’s ( 2001 ) meta-analysis of 48 experimental studies conducted between 1977 and 1996 . They found that of four types of tertiary interventions, the effect size for cognitive-behavioral interventions and multimodal programs (e.g., the combination of assertive training and time management) was moderate and the effect size for relaxation techniques was small in reducing psychological complaints, but not turnover intention related to work stress. However, the effects of (the five studies that used) organization-focused interventions were not significant. Similarly, Richardson and Rothstein’s ( 2008 ) meta-analytic study, including 36 experimental studies with 55 interventions, showed a larger effect size for cognitive-behavioral interventions than relaxation, organizational, multimodal, or alternative. However, like with van der Klink et al. ( 2001 ), Richardson and Rothstein ( 2008 ) cautioned that there were few organizational intervention studies included and the impact of interventions were determined on the basis of psychological outcomes and not physiological or organizational outcomes. Van der Klink et al. ( 2001 ) further expressed concern that organizational interventions target the workplace and that changes in the individual may take longer to observe than individual interventions aimed directly at the individual.

The long-term benefits of individual focused interventions are not yet clear either. Per Giga, Cooper, and Faragher ( 2003 ), the benefits of person-directed stress management programs will be short-lived if organizational factors to reduce stressors are not addressed too. Indeed, LaMontagne, Keegel, Louie, Ostry, and Landsbergis ( 2007 ), in their meta-analysis of 90 studies on stress management interventions published between 1990 and 2005 , revealed that in relation to interventions targeting organizations only, and interventions targeting individuals only, interventions targeting both organizations and individuals (i.e. the systems approach) had the most favorable positive effects on both the organizations and the individuals. Furthermore, the organization-level interventions were effective at both the individual and organization levels, but the individual-level interventions were effective only at the individual level.

Individual-Focused Stress Management

Individual-focused interventions concentrate on improving conditions for the individual, though counseling programs emphasize that the worker is in charge of reducing “stress,” whereas role-focused interventions emphasize activities that organizations can guide to actually reduce unnecessary noxious environmental factors.

Individual-Focused Stress Management: Employee Assistance Programs

When stress become sufficiently problematic (which is individually gauged or attended to by supportive others) in a worker’s life, employees may utilize the short-term counseling services or referral services Employee Assistance Programs (EAPs) provide. People who utilize the counseling services may engage in cognitive behavioral therapy aimed at changing the way people think about the stressors (e.g., as challenge opportunity over threat) and manage strains. Example topics that may be covered in these therapy sessions include time management and goal setting (prioritization), career planning and development, cognitive restructuring and mindfulness, relaxation, and anger management. In a study of healthcare workers and teachers who participated in a 2-day to 2.5-day comprehensive stress management training program (including 26 topics on identifying, coping with, and managing stressors and strains), Siu, Cooper, and Phillips ( 2013 ) found psychological and physical improvements were self-reported among the healthcare workers (for which there was no control group). However, comparing an intervention group of teachers to a control group of teachers, the extent of change was not as visible, though teachers in the intervention group engaged in more mastery recovery experiences (i.e., they purposefully chose to engage in challenging activities after work).

Individual-Focused Stress Management: Mindfulness

A popular therapy today is to train people to be more mindful, which involves helping people live in the present, reduce negative judgement of current and past experiences, and practicing patience (Birnie, Speca, & Carlson, 2010 ). Mindfulness programs usually include training on relaxation exercises, gentle yoga, and awareness of the body’s senses. In one study offered through the continuing education program at a Canadian university, 104 study participants took part in an 8-week, 90 minute per group (15–20 participants per) session mindfulness program (Birnie et al., 2010 ). In addition to body scanning, they also listened to lectures on incorporating mindfulness into one’s daily life and received a take-home booklet and compact discs that guided participants through the exercises studied in person. Two weeks after completing the program, participants’ mindfulness attendance and general positive moods increased, while physical, psychological, and behavioral strains decreased. In another study on a sample of U.K. government employees, study participants receiving three sessions of 2.5 to 3 hours each training on mindfulness, with the first two sessions occurring in consecutive weeks and the third occurring about three months later, Flaxman and Bond ( 2010 ) found that compared to the control group, the intervention group showed a decrease in distress levels from Time 1 (baseline) to Time 2 (three months after first two training sessions) and Time 1 to Time 3 (after final training session). Moreover, of the mindfulness intervention study participants who were clinically distressed, 69% experienced clinical improvement in their psychological health.

Individual-Focused Stress Management: Biofeedback/Imagery/Meditation/Deep Breathing

Biofeedback uses electronic equipment to inform users about how their body is responding to tension. With guidance from a therapist, individuals then learn to change their physiological responses so that their pulse normalizes and muscles relax (Norris, Fahrion, & Oikawa, 2007 ). The therapist’s guidance might include reminders for imagery, meditation, body scan relaxation, and deep breathing. Saunders, Driskell, Johnston, and Salas’s ( 1996 ) meta-analysis of 37 studies found that imagery helped reduce state and performance anxiety. Once people have been trained to relax, reminder triggers may be sent through smartphone push notifications (Villani et al., 2013 ).

Smartphone technology can also be used to support weight loss programs, smoking cessation programs, and medication or disease (e.g., diabetes) management compliance (Heron & Smyth, 2010 ; Kannampallil, Waicekauskas, Morrow, Kopren, & Fu, 2013 ). For example, smartphones could remind a person to take medications or test blood sugar levels or send messages about healthy behaviors and positive affirmations.

Individual-Focused Stress Management: Sleep/Rest/Respite

Workers today sleep less per night than adults did nearly 30 years ago (Luckhaupt, Tak, & Calvert, 2010 ; National Sleep Foundation, 2005 , 2013 ). In order to combat problems, such as increased anxiety and cardiovascular artery disease, associated with sleep deprivation and insufficient rest, it is imperative that people disconnect from their work at least one day per week or preferably for several weeks so that they are able to restore psychological health (Etzion, Eden, & Lapidot, 1998 ; Ragsdale, Beehr, Grebner, & Han, 2011 ). When college students engaged in relaxation-type activities, such as reading or watching television, over the weekend, they experienced less emotional exhaustion and greater general well-being than students who engaged in resources-consuming activities, such as house cleaning (Ragsdale et al., 2011 ). Additional research and future directions for research are reviewed and identified in the work of Sonnentag ( 2012 ). For example, she asks whether lack of ability to detach from work is problematic for people who find their work meaningful. In other words, are negative health consequences only among those who do not take pleasure in their work? Sonnetag also asks how teleworkers detach from their work when engaging in work from the home. Ironically, one of the ways that companies are trying to help with the challenges of high workload or increased need to be available to colleagues, clients, or vendors around the globe is by offering flexible work arrangements, whereby employees who can work from home are given the opportunity to do so. Companies that require global interactions 24-hours per day often employ this strategy, but is the solution also a source of strain (Glazer, Kożusznik, & Shargo, 2012 )?

Individual-Focused Stress Management: Role Analysis

Role analysis or role clarification aims to redefine, expressly identify, and align employees’ roles and responsibilities with their work goals. Through role negotiation, involved parties begin to develop a new formal or informal contract about expectations and define resources needed to fulfill those expectations. Glazer has used this approach in organizational consulting and, with one memorable client engagement, found that not only were the individuals whose roles required deeper re-evaluation happier at work (six months later), but so were their subordinates. Subordinates who once characterized the two partners as hostile and akin to a couple going through a bad divorce, later referred to them as a blissful pair. Schaubroeck, Ganster, Sime, and Ditman ( 1993 ) also found in a three-wave study over a two-year period that university employees’ reports of role clarity and greater satisfaction with their supervisor increased after a role clarification exercise of top managers’ roles and subordinates’ roles. However, the intervention did not have any impact on reported physical symptoms, absenteeism, or psychological well-being. Role analysis is categorized under individual-focused stress management intervention because it is usually implemented after individuals or teams begin to demonstrate poor performance and because the intervention typically focuses on a few individuals rather than an entire organization or group. In other words, the intervention treats the person’s symptoms by redefining the role so as to eliminate the stimulant causing the problem.

Organization-Focused Stress Management

At the organizational level, companies that face major declines in productivity and profitability or increased costs related to healthcare and disability might be motivated to reassess organizational factors that might be impinging on employees’ health and well-being. After all, without healthy workers, it is not possible to have a healthy organization. Companies may choose to implement practices and policies that are expected to help not only the employees, but also the organization with reduced costs associated with employee ill-health, such as medical insurance, disability payments, and unused office space. Example practices and policies that may be implemented include flexible work arrangements to ensure that employees are not on the streets in the middle of the night for work that can be done from anywhere (such as the home), diversity programs to reduce stress-induced animosity and prejudice toward others, providing only healthy food choices in cafeterias, mandating that all employees have physicals in order to receive reduced prices for insurance, company-wide closures or mandatory paid time off, and changes in organizational visioning.

Organization-Focused Stress Management: Organizational-Level Occupational Health Interventions

As with job design interventions that are implemented to remediate work characteristics that were a source of unnecessary or excessive stressors, so are organizational-level occupational health (OLOH) interventions. As with many of the interventions, its placement as a primary or tertiary stress management intervention may seem arbitrary, but when considering the goal and target of change, it is clear that the intervention is implemented in response to some ailing organizational issues that need to be reversed or stopped, and because it brings in the entire organization’s workforce to address the problems, it has been placed in this category. There are several more case studies than empirical studies on the topic of whole system organizational change efforts (see example case studies presented by the United Kingdom’s Health and Safety Executive). It is possible that lack of published empirical work is not so much due to lack of attempting to gather and evaluate the data for publication, but rather because the OLOH interventions themselves never made it to the intervention stage, the interventions failed (Biron, Gatrell, & Cooper, 2010 ), or the level of evaluation was not rigorous enough to get into empirical peer-review journals. Fortunately, case studies provide some indication of the opportunities and problems associated with OLOH interventions.

One case study regarding Cardiff and Value University Health Board revealed that through focus group meetings with members of a steering group (including high-level managers and supported by top management) and facilitated by a neutral, non-judgemental organizational health consultant, ideas for change were posted on newsprint, discussed, and areas in the organization needing change were identified. The intervention for giving voice to people who initially had little already had a positive effect on the organization, as absence decreased by 2.09% and 6.9% merely 12 and 18 months, respectively, after the intervention. Translated in financial terms, the 6.9% change was equivalent to a quarterly savings of £80,000 (Health & Safety Executive, n.d. ). Thus, focusing on the context of change and how people will be involved in the change process probably helped the organization realize improvements (Biron et al., 2010 ). In a recent and rare empirical study, employing both qualitative and quantitative data collection methods, Sørensen and Holman ( 2014 ) utilized PAR in order to plan and implement an OLOH intervention over the course of 14 months. Their study aimed to examine the effectiveness of the PAR process in reducing workers’ work-related and social or interpersonal-related stressors that derive from the workplace and improving psychological, behavioral, and physiological well-being across six Danish organizations. Based on group dialogue, 30 proposals for change were proposed, all of which could be categorized as either interventions to focus on relational factors (e.g., management feedback improvement, engagement) or work processes (e.g., reduced interruptions, workload, reinforcing creativity). Of the interventions that were implemented, results showed improvements on manager relationship quality and reduced burnout, but no changes with respect to work processes (i.e., workload and work pace) perhaps because the employees already had sufficient task control and variety. These findings support Dewe and Kompier’s ( 2008 ) position that occupational health can be reinforced through organizational policies that reinforce quality jobs and work experiences.

Organization-Focused Stress Management: Flexible Work Arrangements

Dewe and Kompier ( 2008 ), citing the work of Isles ( 2005 ), noted that concern over losing one’s job is a reason for why 40% of survey respondents indicated they work more hours than formally required. In an attempt to create balance and perceived fairness in one’s compensation for putting in extra work hours, employees will sometimes be legitimately or illegitimately absent. As companies become increasingly global, many people with desk jobs are finding themselves communicating with colleagues who are halfway around the globe and at all hours of the day or night (Glazer et al., 2012 ). To help minimize the strains associated with these stressors, companies might devise flexible work arrangements (FWA), though the type of FWA needs to be tailored to the cultural environment (Masuda et al., 2012 ). FWAs give employees some leverage to decide what would be the optimal work arrangement for them (e.g., part-time, flexible work hours, compressed work week, telecommuting). In other words, FWA provides employees with the choice of when to work, where to work (on-site or off-site), and how many hours to work in a day, week, or pay period (Kossek, Thompson, & Lautsch, 2015 ). However, not all employees of an organization have equal access to or equitable use of FWAs; workers in low-wage, hourly jobs are often beholden to being physically present during specific hours (Swanberg McKechnie, Ojha, & James, 2011 ). In a study of over 1,300 full-time hourly retail employees in the United States, Swanberg et al. ( 2011 ) showed that employees who have control over their work schedules and over their work hours were satisfied with their work schedules, perceived support from the supervisor, and work engagement.

Unfortunately, not all FWAs yield successful results for the individual or the organization. Being able to work from home or part-time can have problems too, as a person finds himself or herself working more hours from home than required. Sometimes telecommuting creates work-family conflict too as a person struggles to balance work and family obligations while working from home. Other drawbacks include reduced face-to-face contact between work colleagues and stakeholders, challenges shaping one’s career growth due to limited contact, perceived inequity if some have more flexibility than others, and ambiguity about work role processes for interacting with employees utilizing the FWA (Kossek et al., 2015 ). Organizations that institute FWAs must carefully weigh the benefits and drawbacks the flexibility may have on the employees using it or the employees affected by others using it, as well as the implications on the organization, including the vendors who are serving and clients served by the organization.

Organization-Focused Stress Management: Diversity Programs

Employees in the workplace might experience strain due to feelings of discrimination or prejudice. Organizational climates that do not promote diversity (in terms of age, religion, physical abilities, ethnicity, nationality, sex, and other characteristics) are breeding grounds for undesirable attitudes toward the workplace, lower performance, and greater turnover intention (Bergman, Palmieri, Drasgow, & Ormerod, 2012 ; Velez, Moradi, & Brewster, 2013 ). Management is thus advised to implement programs that reinforce the value and importance of diversity, as well as manage diversity to reduce conflict and feelings of prejudice. In fact, managers who attended a leadership training program reported higher multicultural competence in dealing with stressful situations (Chrobot-Mason & Leslie, 2012 ), and managers who persevered through challenges were more dedicated to coping with difficult diversity issues (Cilliers, 2011 ). Thus, diversity programs can help to reduce strains by directly reducing stressors associated with conflict linked to diversity in the workplace and by building managers’ resilience.

Organization-Focused Stress Management: Healthcare Management Policies

Over the past few years, organizations have adopted insurance plans that implement wellness programs for the sake of managing the increasing cost of healthcare that is believed to be a result of individuals’ not managing their own health, with regular check-ups and treatment. The wellness programs require all insured employees to visit a primary care provider, complete a health risk assessment, and engage in disease management activities as specified by a physician (e.g., see frequently asked questions regarding the State of Maryland’s Wellness Program). Companies believe that requiring compliance will reduce health problems, although there is no proof that such programs save money or that people would comply. One study that does, however, boast success, was a 12-week workplace health promotion program aimed at reducing Houston airport workers’ weight (Ebunlomo, Hare-Everline, Weber, & Rich, 2015 ). The program, which included 235 volunteer participants, was deemed a success, as there was a total weight loss of 345 pounds (or 1.5 lbs per person). Given such results in Houston, it is clear why some people are also skeptical over the likely success of wellness programs, particularly as there is no clear method for evaluating their efficacy (Sinnott & Vatz, 2015 ).

Moreover, for some, such a program is too paternalistic and intrusive, as well as punishes anyone who chooses not to actively participate in disease management programs (Sinnott & Vatz, 2015 ). The programs put the onus of change on the person, though it is a response to the high costs of ill-health. The programs neglect to consider the role of the organization in reducing the barriers to healthy lifestyle, such as cloaking exempt employment as simply needing to get the work done, when it usually means working significantly more hours than a standard workweek. In fact, workplace health promotion programs did not reduce presenteeism (i.e., people going to work while unwell thereby reducing their job performance) among those who suffered from physical pain (Cancelliere, Cassidy, Ammendolia, & Côte, 2011 ). However, supervisor education, worksite exercise, lifestyle intervention through email, midday respite from repetitive work, a global stress management program, changes in lighting, and telephone interventions helped to reduce presenteeism. Thus, emphasis needs to be placed on psychosocial aspects of the organization’s structure, including managers and overall organizational climate for on-site presence, that reinforces such behavior (Cancelliere et al., 2011 ). Moreover, wellness programs are only as good as the interventions to reduce work-related stressors and improve organizational resources to enable workers to improve their overall psychological and physical health.

Concluding Remarks

Future research.

One of the areas requiring more theoretical and practical attention is that of the utility of stress frameworks to guide organizational development change interventions. Although it has been proposed that the foundation for work stress management interventions is in organizational development, and even though scholars and practitioners of organization development were also founders of research programs that focused on employee health and well-being or work stress, there are few studies or other theoretical works that link the two bodies of literature.

A second area that requires additional attention is the efficacy of stress management interventions across cultures. In examining secondary stress management interventions (i.e., coping), some cross-cultural differences in findings were described; however, there is still a dearth of literature from different countries on the utility of different prevention, coping, and stress management strategies.

A third area that has been blossoming since the start of the 21st century is the topic of hindrance and challenge stressors and the implications of both on workers’ well-being and performance. More research is needed on this topic in several areas. First, there is little consistency by which researchers label a stressor as a hindrance or a challenge. Researchers sometimes take liberties with labels, but it is not the researchers who should label a stressor but the study participants themselves who should indicate if a stressor is a source of strain. Rodríguez, Kozusznik, and Peiró ( 2013 ) developed a measure in which respondents indicate whether a stressor is a challenge or a hindrance. Just as some people may perceive demands to be challenges that they savor and that result in a psychological state of eustress (Nelson & Simmons, 2003 ), others find them to be constraints that impede goal fulfillment and thus might experience distress. Likewise, some people might perceive ambiguity as a challenge that can be overcome and others as a constraint over which he or she has little control and few or no resources with which to cope. More research on validating the measurement of challenge vs. hindrance stressors, as well as eustress vs. distress, and savoring vs. coping, is warranted. Second, at what point are challenge stressors harmful? Just because people experiencing challenge stressors continue to perform well, it does not necessarily mean that they are healthy people. A great deal of stressors are intellectually stimulating, but excessive stimulation can also take a toll on one’s physiological well-being, as evident by the droves of professionals experiencing different kinds of diseases not experienced as much a few decades ago, such as obesity (Fried et al., 2013 ). Third, which stress management interventions would better serve to reduce hindrance stressors or to reduce strain that may result from challenge stressors while reinforcing engagement-producing challenge stressors?

A fourth area that requires additional attention is that of the flexible work arrangements (FWAs). One of the reasons companies have been willing to permit employees to work from home is not so much out of concern for the employee, but out of the company’s need for the focal person to be able to communicate with a colleague working from a geographic region when it is night or early morning for the focal person. Glazer, Kożusznik, and Shargo ( 2012 ) presented several areas for future research on this topic, noting that by participating on global virtual teams, workers face additional stressors, even while given flexibility of workplace and work time. As noted earlier, more research needs to be done on the extent to which people who take advantage of FWAs are advantaged in terms of detachment from work. Can people working from home detach? Are those who find their work invigorating also likely to experience ill-health by not detaching from work?

A fifth area worthy of further research attention is workplace wellness programing. According to Page and Vella-Brodrick ( 2009 ), “subjective and psychological well-being [are] key criteria for employee mental health” (p. 442), whereby mental health focuses on wellness, rather than the absence of illness. They assert that by fostering employee mental health, organizations are supporting performance and retention. Employee well-being can be supported by ensuring that jobs are interesting and meaningful, goals are achievable, employees have control over their work, and skills are used to support organizational and individual goals (Dewe & Kompier, 2008 ). However, just as mental health is not the absence of illness, work stress is not indicative of an absence of psychological well-being. Given the perspective that employee well-being is a state of mind (Page & Vella-Brodrick, 2009 ), we suggest that employee well-being can be negatively affected by noxious job stressors that cannot be remediated, but when job stressors are preventable, employee well-being can serve to protect an employee who faces job stressors. Thus, wellness programs ought to focus on providing positive experiences by enhancing and promoting health, as well as building individual resources. These programs are termed “green cape” interventions (Pawelski, 2016 ). For example, with the growing interests in positive psychology, researchers and practitioners have suggested employing several positive psychology interventions, such as expressing gratitude, savoring experiences, and identifying one’s strengths (Tetrick & Winslow, 2015 ). Another stream of positive psychology is psychological capital, which includes four malleable functions of self-efficacy, optimism, hope, and resilience (Luthans, Youssef, & Avolio, 2007 ). Workplace interventions should include both “red cape” interventions (i.e., interventions to reduce negative experiences) and “green cape” interventions (i.e., workplace wellness programs; Polly, 2014 ).

A Healthy Organization’s Pledge

A healthy workplace requires healthy workers. Period. Among all organizations’ missions should be the focus on a healthy workforce. To maintain a healthy workforce, the company must routinely examine its own contributions in terms of how it structures itself; reinforces communications among employees, vendors, and clients; how it rewards and cares for its people (e.g., ensuring they get sufficient rest and can detach from work); and the extent to which people at the upper levels are truly connected with the people at the lower levels. As a matter of practice, management must recognize when employees are overworked, unwell, and poorly engaged. Management must also take stock of when it is doing well and right by its contributors’ and maintain and reinforce the good practices, norms, and procedures. People in the workplace make the rules; people in the workplace can change the rules. How management sees its employees and values their contribution will have a huge role in how a company takes stock of its own pain points. Providing employees with tools to manage their own reactions to work-related stressors and consequent strains is fine, but wouldn’t it be grand if organizations took better notice about what they could do to mitigate the strain-producing stressors in the first place and take ownership over how employees are treated?

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Practice of stress management behaviors and associated factors among undergraduate students of Mekelle University, Ethiopia: a cross-sectional study

• Gebrezabher Niguse Hailu 1  

BMC Psychiatry volume  20 , Article number:  162 ( 2020 ) Cite this article

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Stress is one of the top five threats to academic performance among college students globally. Consequently, students decrease in academic performance, learning ability and retention. However, no study has assessed the practice of stress management behaviors and associated factors among college students in Ethiopia. So the purpose of this study was to assess the practice of stress management behaviors and associated factors among undergraduate university students at Mekelle University, Tigray, Ethiopia, 2019.

A cross-sectional study was conducted on 633 study participants at Mekelle University from November 2018 to July 2019. Bivariate analysis was used to determine the association between the independent variable and the outcome variable at p  < 0.25 significance level. Significant variables were selected for multivariate analysis.

The study found that the practice of stress management behaviors among undergraduate Mekelle university students was found as 367(58%) poor and 266(42%) good. The study also indicated that sex, year of education, monthly income, self-efficacy status, and social support status were significant predictors of stress management behaviors of college students.

This study found that the majority of the students had poor practice of stress management behaviors.

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Stress is the physical and emotional adaptive response to an external situation that results in physical, psychological and behavioral deviations [ 1 ]. Stress can be roughly subdivided into the effects and mechanisms of chronic and acute stress [ 2 ]. Chronic psychological stress in early life and adulthood has been demonstrated to result in maladaptive changes in both the HPA-axis and the sympathetic nervous system. Acute and time-limited stressors seem to result in adaptive redistribution of all major leukocyte subpopulations [ 2 ].

Stress management behaviors are defined as behaviors people often use in the face of stress /or trauma to help manage painful or difficult emotions [ 3 ]. Stress management behaviors include sleeping 6–8 h each night, Make an effort to monitor emotional changes, Use adequate responses to unreasonable issues, Make schedules and set priorities, Make an effort to determine the source of each stress that occurs, Make an effort to spend time daily for muscle relaxation, Concentrate on pleasant thoughts at bedtime, Feel content and peace with yourself [ 4 ]. Practicing those behaviors are very important in helping people adjust to stressful events while helping them maintain their emotional wellbeing [ 3 ].

University students are a special group of people that are enduring a critical transitory period in which they are going from adolescence to adulthood and can be one of the most stressful times in a person’s life [ 5 ]. According to the American College Health Association’s National College Health Assessment, stress is one of the top five threats to academic performance among college students [ 6 ]. For instance, stress is a serious problem in college student populations across the United States [ 7 ].

I have searched literatures regarding stress among college students worldwide. For instance, among Malaysian university students, stress was observed among 36% of the respondents [ 8 ]. Another study reported that 43% of Hong Kong students were suffered from academic stress [ 9 ]. In western countries and other Middle Eastern countries, including 70% in Jordan [ 10 ], 83.9% in Australia [ 11 ]. Furthermore, based on a large nationally representative study the prevalence of stress among college students in Ethiopia was 40.9% [ 12 ].

Several studies have shown that socio-demographic characteristics and psychosocial factors like social support, health value and perceived self-efficacy were known to predict stress management behaviors [ 13 , 14 , 15 , 16 , 17 ].

Although the prevalence of stress among college students is studied in many countries including Ethiopia, the practice of stress management behaviors which is very important in promoting the health of college students is not studied in Ethiopia. Therefore this study aimed to assess the practice of stress management behaviors and associated factors among undergraduate students at Mekelle University.

The study was conducted at Mekelle university colleges from November 2018 to July 2019 in Mekelle city, Tigray, Ethiopia. Mekelle University is a higher education and training public institution located in Mekelle city, Tigray at a distance of 783 Kilometers from the Ethiopian capital ( http://www.mu.edu.et/ ).

A cross-sectional study was conducted on 633 study participants. Students who were ill (unable to attend class due to illness), infield work and withdrawal were not included in the study.

The actual sample size (n) was computed by single population proportion formula [n = [(Za/2)2*P (1 − P)]/d2] by assuming 95% confidence level of Za/2 = 1.96, margin of error 5%, proportion (p) of 50% and the final sample size was estimated to be 633. A 1.5 design effect was used by considering the multistage sampling technique and assuming that there was no as such big variations among the students included in the study.

Multi-stage random sampling was used. Three colleges (College of health science, college of business and Economics and College of Natural and Computational Science) were selected from a total of the seven Colleges from Mekelle University using a simple random sampling technique in which proportional sample allocation was considered from each college.

Data were collected using a self-administered questionnaire by trained research assistants at the classes.

The questionnaire has three sections. The first section contained questions on demographic characteristics of the study participants. The second section contained questions to assess the practice of stress management of the students. The tool to assess the practice of stress management behaviors for college students was developed by Walker, Sechrist, and Pender [ 4 ]. The third section consisted of questions for factors associated with stress management of the students divided into four sub-domains, including health value used to assess the value participants place on their health [ 18 ]. The second subdomain is self-efficacy designed to assess optimistic self-beliefs to cope with a variety of difficult demands in life [ 19 ] and was adapted by Yesilay et al. [ 20 ]. The third subdomain is perceived social support measures three sources of support: family, friends, and significant others [ 21 ] and was adapted by Eker et al. [ 22 ]. The fourth subscale is perceived stress measures respondents’ evaluation of the stressfulness of situations in the past month of their lives [ 23 ] and was adapted by Örücü and Demir [ 24 ].

The entered data were edited, checked visually for its completeness and the response was coded and entered by Epi-data manager version 4.2 for windows and exported to SPSS version 21.0 for statistical analysis.

Bivariate analysis was used to determine the association between the independent variable and the outcome variable. Variables that were significant at p  < 0.25 with the outcome variable were selected for multivariable analysis. And odds ratio with 95% confidence level was computed and p -value <= 0.05 was described as a significant association.

Operational definition

Good stress management behavior:.

Students score above or equal to the mean score.

Poor stress management behavior:

Students score below the mean score [ 4 ].

Seciodemographic characteristics

Among the total 633 study participants, 389(61.5%) were males, of those 204(32.2%) had poor stress management behavior. The Median age of the respondents was 20.00 (IQR = ±3). More ever, this result showed that 320(50.6%) of the students came from rural areas, 215(34%) of them had poor stress management behavior.

The result revealed that 363(57.35%) of the study participants were 2nd and 3rd year students, of them 195 (30.8%) had poor stress management.

This result indicated that 502 (79.3%) of the participants were in the monthly support category of > = 300 ETB with a median income of 300.00 ETB (IQR = ±500), from those, 273(43.1%) students had poor stress management behavior (Table  1 ).

Status of practice of stress management behaviors of under graduate students at Mekelle University, Ethiopia

Psychosocial factors

This result indicated that 352 (55.6%) of the students had a high health value status of them 215 (34%) had good stress management behavior. It also showed that 162 (25.6%) of the students had poor perceived self-efficacy, from those 31(4.9%) had a good practice of stress management behavior. Moreover, the result showed that 432(68.2%) of the study participants had poor social support status of them 116(18.3%) had a good practice of stress management behavior (Table  1 ).

Practice of stress management behaviors

The result showed that the majority (49.8%) of the students were sometimes made an effort to spend time daily for muscle relaxation. Whereas only 28(4.4%) students were routinely concentrated on pleasant thoughts at bedtime.

According to this result, only 169(26.7%) of the students were often made an effort to determine the source of stress that occurs. It also revealed that the majority (40.1%) of the students were never made an effort to monitor their emotional changes. Similarly, the result indicated that the majority (42.5%) of the students were never made schedules and set priorities.

The result revealed that only 68(10.7%) of the students routinely slept 6–8 h each night. More ever, the result showed that the majority (34.4%) of the students were sometimes used adequate responses to unreasonable issues (Table  2 ).

Status of the practice of stress management behaviors

The result revealed that the practice of stress management behaviors among regular undergraduate Mekelle university students was found as 367(58%) poor and 266(42%) good. (Fig  1 )

Factors associated with stress management behaviors

In the bivariate analysis sex, college, year of education, student’s monthly income’, perceived-self efficacy, perceived social support and perceived stress were significantly associated with stress management behavior at p < =0.25. Whereas in the multivariate analysis sex, year of education, student’s monthly income’, perceived-self efficacy and perceived social support were significantly associated with stress management behavior at p < =0.05.

Male students were 3.244 times more likely to have good practice stress management behaviors than female students (AOR: 3.244, CI: [1.934–5.439]). Students who were in the age category of less than 20 years were 70% less to have a good practice of stress management behaviors than students with the age of greater or equal to 20 year (AOR: 0.300, CI:[0.146–0.618]).

Students who had monthly income less than300 ETB were 64.4% less to have a good practice of stress management behaviors than students with monthly income greater or equal to 300 ETB (AOR: 0.356, CI:[0.187–0.678]).

Students who had poor self- efficacy status were 70.3% less to have a good practice of stress management behaviors than students with good self-efficacy status (AOR: 0.297, CI:[0.159–0.554]). Students who had poor social support were 70.5% less to have a good practice of stress management behaviors than students with good social support status (AOR: 0.295[0.155–0.560]) (Table  3 ).

The present study showed that the practice of stress management behaviors among regular undergraduate students was 367(58%) poor and 266(42%) good. The study indicated that sex, year of education, student’s monthly income, social support status, and perceived-self efficacy status were significant predictors of stress management behaviors of students.

The current study revealed that male students were more likely to have good practice of stress management behaviors than female students. This finding is contradictory with previous studies conducted in the USA [ 13 , 25 ], where female students were showed better practice of stress management behaviors than male students. This difference might be due to socioeconomic and measurement tool differences.

The current study indicated that students with monthly income less than 300 ETB were less likely to have good practice of stress management behaviors than students with monthly income greater than or equal to 300 ETB. This is congruent with the recently published book which argues a better understanding of our relationship with money (income). The book said “the people with more money are, on average, happier than the people with less money. They have less to worry about because they are not worried about where they are going to get food or money for their accommodation or whatever the following week, and this has a positive effect on their health” [ 26 ].

The present study found that first-year students were less likely to have good practice of stress management behaviors than senior students. This finding is similar to previous findings from Japan [ 27 ], China [ 28 ] and Ghana [ 29 ]. This might be because freshman students may encounter a multitude of stressors, some of which they may have dealt with in high school and others that may be a new experience for them. With so many new experiences, responsibilities, social settings, and demands on their time. As a first-time, incoming college freshman, experiencing life as an adult and acclimating to the numerous and varied types of demands placed on them can be a truly overwhelming experience. It can also lead to unhealthy amounts of stress. A report by the Anxiety and Depression Association of America found that 80% of freshman students frequently or sometimes experience daily stress [ 30 ].

The current study showed that students with poor self-efficacy status were less likely to have good practice of stress management behaviors. This is congruent with the previous study that has demonstrated quite convincingly that possessing high levels of self-efficacy acts to decrease people’s potential for experiencing negative stress feelings by increasing their sense of being in control of the situations they encounter [ 14 ]. More ever this study found that students with poor social support were less likely to have a good practice of stress management behaviors. This finding is similar to previous studies that found good social support, whether from a trusted group or valued individual, has shown to reduce the psychological and physiological consequences of stress, and may enhance immune function [ 15 , 16 , 17 ].

Ethics approval and consent to participate

Ethical clearance and approval obtained from the institutional review board of Mekelle University. Moreover, before conducting the study, the purpose and objective of the study were described to the study participants and written informed consent was obtained. The study participants were informed as they have full right to discontinue during the interview. Subject confidentiality and any special data security requirements were maintained and assured by not exposing the patient’s name and information.

Limitation of the study

There is limited literature regarding stress management behaviors and associated factors. There is no similar study done in Ethiopia previously. More ever, using a self-administered questionnaire, the respondents might not pay full attention to it/read it properly.

This study found that the majority of the students had poor practice of stress management behaviors. The study also found that sex, year of education, student’s monthly income, social support status, and perceived-self efficacy status were significant predictors of stress management behaviors of the students.

Availability of data and materials

The datasets used during the current study is available from the corresponding author on reasonable request.

Abbreviations

Adjusted Odd Ratio

College of Business& Economics

College of health sciences

Confidence interval

College of natural and computational sciences

Crud odds ratio

Ethiopian birr

Master of Sciences

United States of America

United kingdom

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Hailu, G.N. Practice of stress management behaviors and associated factors among undergraduate students of Mekelle University, Ethiopia: a cross-sectional study. BMC Psychiatry 20 , 162 (2020). https://doi.org/10.1186/s12888-020-02574-4

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Transforming stress through awareness, education and collaboration.

Stress Research

“The difficulty in science is often not so much how to make the discovery but rather to know that one has made it.” – J.D. Bernal

2024 Stress Statistics

The 2024 results of the American Psychiatric Association’s annual mental health poll show that U.S. adults are feeling increasingly anxious. In 2024, 43% of adults say they feel more anxious than they did the previous year, up from 37% in 2023 and 32% in 2022. Adults are particularly anxious about current events (70%) — especially the economy (77%), the 2024 U.S. election (73%), and gun violence (69%).

When asked about a list of lifestyle factors potentially impacting mental health, adults most commonly say stress (53%) and sleep (40%) have the biggest impact on their mental health. Younger adults (18-34 years old) are more likely than older adults (50+) to say social connection has the biggest impact on their mental health. Despite the increasing anxiety, most adults have not sought professional mental health support. In 2024, just one in four (24%) adults say they talked with a mental health care professional in the past year. Notably, younger adults (18-34) are more than twice as likely as older adults (50+) to have done so.

“Living in a world of constant news of global and local turmoil, some anxiety is natural and expected,” said APA President Petros Levounis, M.D., M.A. “But what stands out here is that Americans are reporting more anxious feelings than in past years. This increase may be due to the unprecedented exposure that we have to everything that happens in the world around us, or to an increased awareness and reporting of anxiety. Either way, if people have these feelings, they are not alone, and they can seek help from us.”

Among adults who have used mental health care this year, more than half prefer to meet with a mental health professional in person (55%) rather than via telehealth; 30% prefer telehealth; and 15% have no preference. Also among adults who have used mental healthcare this year, more than half (59%) are worried about losing access to mental healthcare, and 39% of insured adults are worried about losing their health insurance, as a result of the election this year.

Americans perceive broad impacts of untreated mental illness: 83% of adults say it negatively impacts families and 65% say it negatively impacts the U.S. economy. Also, 71% of adults feel that children and teens have more mental health problems than they did 10 years ago. That said, more than half of adults (55%) think there is less mental health stigma than 10 years ago.

“Over the past ten years, we’ve grown more comfortable talking about mental health, and that’s absolutely key to helping us through the current crisis,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “The continued work of APA is to ensure that people can access care when they need it, especially in areas that need it badly, like child and adolescent psychiatry.”

Other issues people said they were anxious about include:

• Keeping themselves or their families safe, 68%.
• Keeping their identity safe, 63%.
• Their health, 63%.
• Paying bills or expenses, 63%.
• The opioid epidemic, 50%.
• The impact of emerging technology on day-to-day life, 46%.

In addition, 57% of adults are concerned about climate change.

This annual poll was conducted April 9 to 11, 2024, among a sample of more than 2,200 adults. This annual survey is complemented by APA’s Healthy Minds Monthly series, conducted by Morning Consult on behalf of APA. See  past Healthy Minds Monthly polls . For a copy of the results, contact us at  [email protected] .

American Psychiatric Association

The American Psychiatric Association, founded in 1844, is the oldest medical association in the country. The APA is also the largest psychiatric association in the world with more than 38,900 physician members specializing in the diagnosis, treatment, prevention, and research of mental illnesses. APA’s vision is to ensure access to quality psychiatric diagnosis and treatment.

Causes and Sources of Stress

Living conditions, the political climate, financial insecurity, and work issues are some stressors US adults cite as the cause of their stress. Ineffective communications increase work stress to the point of frustration that workers want to quit.  These stressors, unfortunately, are not something people can just ignore. Quitting a job would result in debt and financial instability which, in turn, would be added stressors.

• 35% of workers say their boss is a cause of their workplace stress.
• 80% of US workers experience work stress because of ineffective company communications.
• 39% of North American employees report their workload the main source of the work stress.
• 49% of 18 – 24 year olds who report high levels of stress felt comparing themselves to others is a stressor.
• 71% of US adults with private health insurance say the cost of healthcare causes them stress while 53% with public insurance say the same.
• 54% of Americans want to stay informed about the news but following the news causes them stress.
• 42% of US adults cite personal debt as a source of significant stress.
• 1 in 4 American adults say discrimination is a significant source of stress.
• Mass shootings are a significant source of stress across all races; 84% of Hispanic report this, the highest among the races.

Stress and Relationships

People under stress admit to taking out their frustration on other people. Targets for venting out include strangers and those they have personal relationships with. Men and women report different levels of how work stress affects their relationships with their spouses.

• 76% of US workers say their workplace stress has had a negative impact on their personal relationships.
• Seven in 10 adults report work stress affects their personal relationships.
• 79% of men report work stress affects their personal relationship with their spouse compared to 61% for women.
• 36% of adults reported experiencing stress caused by a friend or loved one’s long-term health condition.

Stress Management Statistics

A look at the stress management techniques employed by US adults to deal with their stress, an overwhelming majority are self-care practices. Though very helpful, it does not address the stressor at the root of the problem. Stress management programs would be beneficial not only for employees but for the company in the long run.

• 30% of Us adults eat comfort food “more than the usual” when faced with a challenging or stressful event.
• 51% of US adults engage in prayer—a routine activity—when faced with a challenge or stressful situation.
• Coping mechanisms of Gen Z and Millenials experiencing stress in the US 44% of Gen Z and 40% of Millenials sleep in while exercising counts for 14% and 20% respectively.
• 49% of US adults report enduring stressful situations as a coping behavior to handle stress.
• Less than 25% of those with depression worldwide have access to mental health treatments.

CompareCamp

American Psychological Association

Cardiac Coherence and Post-traumatic Stress Disorder in Combat Veterans

Jay P. Ginsberg, Ph.D.; Melanie E. Berry, M.S.; Donald A Powell, Ph.D.

Alternative Therapies in Health and Medicine, A Peer-Reviewed Journal, 2010;16 (4):52-60. PDF version of the complete paper: Cardiac Coherence and PTSD in Combat Veterans

Abstract-PTSD

Background: The need for treatment of posttraumatic stress disorder (PTSD) among combat veterans returning from Afghanistan and Iraq is a growing concern. PTSD has been associated with reduced cardiac coherence (an indicator of heart rate variability [HRV]) and deficits in early-stage information processing (attention and immediate memory) in different studies. However, the co-occurrence of reduced coherence and cognition in combat veterans with PTSD has not been studied before.

Primary Study Objective: A pilot study was undertaken to assess the covariance of coherence and information processing in combat veterans. An additional study goal was an assessment of the effects of HRV biofeedback (HRVB) on coherence and information processing in these veterans.

Methods/Design: A two-group (combat veterans with and without PTSD), a pre-post study of coherence and information processing was employed with baseline psychometric covariates.

Setting: The study was conducted at a VA Medical Center outpatient mental health clinic.

Participants: Five combat veterans from Iraq or Afghanistan with PTSD and five active-duty soldiers with comparable combat exposure who were without PTSD.

Intervention: Participants met with an HRVB professional once weekly for 4 weeks and received visual feedback in HRV patterns while receiving training in resonance frequency breathing and positive emotion induction.

Primary Outcome Measures: Cardiac coherence, word list learning, commissions (false alarms) in go—no go reaction time, digits backward.

Results: Cardiac coherence was achieved in all participants, and the increase in coherence ratio was significant post-HRVB training. Significant improvements in the information processing indicators were achieved. Degree of increase in coherence was the likely mediator of cognitive improvement.

Conclusion: Cardiac coherence is an index of the strength of control of parasympathetic cardiac deceleration in an individual that has cardinal importance for the individual’s attention and affect regulation.

The Effect of a Biofeedback-based Stress Management Tool on Physician Stress: A Randomized Controlled Clinical Trial

Jane B. Lemaire, Jean E. Wallace, Adriane M. Lewin, Jill de Grood, Jeffrey P. Schaefer

Open Medicine 2011; 5(4)E154. PDF version of the complete paper: physician-stress-randomized-controlled-clinical-trial

Abstract- Biofeedback-based Stress Management

Background: Physicians often experience work-related stress that may lead to personal harm and impaired professional performance. Biofeedback has been used to manage stress in various populations.

Objective: To determine whether a biofeedback-based stress management tool, consisting of rhythmic breathing, actively self-generated positive emotions and a portable biofeedback device, reduces physician stress.

Design: Randomized controlled trial measuring the efficacy of a stress-reduction intervention over 28 days, with a 28-day open-label trial extension to assess effectiveness.

Setting: Urban tertiary care hospital.

Participants: Forty staff physicians (23 men and 17 women) from various medical practices (1 from primary care, 30 from a medical specialty and 9 from a surgical specialty) were recruited by means of electronic mail, regular mail and posters placed in the physicians’ lounge and throughout the hospital.

Intervention: Physicians in the intervention group were instructed to use a biofeedback-based stress management tool three times daily. Participants in both the control and intervention groups received twice-weekly support visits from the research team over 28 days, with the intervention group also receiving re-inforcement in the use of the stress management tool during these support visits. During the 28-day extension period, both the control and the intervention groups received the intervention, but without intensive support from the research team.

Main outcome measure: Stress was measured with a scale developed to capture short-term changes in global perceptions of stress for physicians (maximum score 200).

Results: During the randomized controlled trial (days 0 to 28), the mean stress score declined significantly for the intervention group (change -14.7, standard deviation [SD] 23.8; p = 0.013) but not for the control group (change -2.2, SD 8.4; p = 0.30). The difference in mean score change between the groups was 12.5 (p = 0.048). The lower mean stress scores in the intervention group were maintained during the trial extension to day 56. The mean stress score for the control group changed significantly during the 28-day extension period (change -8.5, SD 7.6; p < 0.001).

Conclusion: A biofeedback-based stress management tool may be a simple and effective stress-reduction strategy for physicians.

Coherence Training In Children With Attention-Deficit Hyperactivity Disorder: Cognitive Functions and Behavioral Changes

Anthony Lloyd, Ph.D.; Davide Brett, B.Sc.; Ketith Wesnes, Ph.D.

Alternative Therapies in Health and Medicine, A Peer-Reviewed Journal, 2010; 16 (4):34-42

PDF version of the complete paper: coherence-training-in-children-with-adhd

Abstract-ADHD

Attention-deficit hyperactivity disorder (ADHD) is the most prevalent behavioral diagnosis in children, with an estimated 500 000 children affected in the United Kingdom alone. The need for an appropriate and effective intervention for children with ADHD is a growing concern for educators and childcare agencies. This randomized controlled clinical trial evaluated the impact of the HeartMath self-regulation skills and coherence training program (Institute of HeartMath, Boulder Creek, California) on a population of 38 children with ADHD in academic year groups 6, 7, and 8. Learning of the skills was supported with heart rhythm coherence monitoring and feedback technology designed to facilitate self-induced shifts in cardiac coherence. The cognitive drug research system was used to assess cognitive functioning as the primary outcome measure. Secondary outcome measures assessed teacher and student reposted changes in behavior. Participants demonstrated significant improvements in various aspects of cognitive functioning such as delayed word recall, immediate word recall, word recognition, and episodic secondary memory. Significant improvements in behavior were also found. The results suggest that the intervention offers a physiologically based program to improve cognitive functioning in children with ADHD and improve behaviors that is appropriate to implement in a school environment.

Coherence and Health Care Cost – RCA Actuarial Study: A Cost-Effectiveness Cohort Study

Woody Bedell; Mariette Kaszkin-Bettag, Ph.D.

Alternative Therapies in Health and Medicine, A Peer-Reviewed Journal, 2010;16 (4):26-31. PDF version of the complete paper: rca-actuarial-study-coherence-and-health-care

Abstract-Health and Medicine

Chronic stress is among the most costly health problems in terms of direct health costs, absenteeism, disability, and performance standards. The Reformed Church in America (RCA) identified stress among its clergy as a major cause of higher-than-average health claims and implemented HeartMath (HM) to help its participants manage stress and increase physiological resilience. The 6-week HM program Revitalize You! was selected for the intervention including the emWave Personal Stress Reliever technology.

From 2006 to 2007, completion of a health risk assessment (HRA) provided eligible clergy with the opportunity to participate in the HM program or a lifestyle management program (LSM). Outcomes for that year were assessed with the Stress and Well-being Survey. Of 313 participants who completed the survey, 149 completed the Revitalize You! The program and 164 completed the LSM. Well-being, stress management, resilience, and emotional vitality were significantly improved in the HM group as compared to the LSM group.

In an analysis of the claims costs data for 2007 and 2008, 144 pastors who had participated in the HM program were compared to 343 non-participants (control group). Adjusted medical costs were reduced by 3.8% for HM participants in comparison with an increase of 9.0% for the control group. For the adjusted pharmacy costs, an increase of 7.9% was found compared with an increase of 13.3% for the control group. Total 2008 savings as a result of the HM program are estimated at $585 per participant, yielding a return on investment of 1.95:1. These findings show that HM stress-reduction and coherence-building techniques can reduce health care costs.

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Can scientists ‘solve’ stress? They’re trying.

From cardiovascular disease and obesity to a weakened immune system, the side effects of stress can be life-altering. But there may be a way to prevent those outcomes.

As modern-day stress ratchets up to what feels like unbearable levels, researchers are striving to learn more about the precise mechanisms through which it affects our body and mind. The hope is that by unlocking more about how stress works physiologically, we can find ways to prevent it from permanently harming people.

Over the last five decades, scientists have established beyond doubt that persistent stress really can poison our overall health. In addition to increasing the risk of cardiovascular disease , stress plays a role in obesity and diabetes and can weaken the immune system , leaving us more vulnerable to infectious diseases. You can recover swiftly from an episode of acute stress—for example, the alarm one might feel when caught unprepared for a presentation. Chronic stress, on the other hand, is more toxic as it is an unrelenting circumstance that offers little chance for a return to normalcy. Financial strain, having a bully for a boss, and social isolation are all examples.

Today chronic stress seems to be increasing worldwide, as people grapple with rapid socioeconomic and environmental change.   A 2023 national survey by the American Psychological Association found that stress has taken a serious toll since the start of the pandemic , with the incidence of chronic illnesses and mental health problems going up significantly, especially among those ages 35 to 44.

( Do you have chronic stress? Look for these signs. )

So far, one of the major realizations among scientists is that stress harms all of us in different and powerful ways. But is there any way to avoid it—or at least recover more quickly? Some promising avenues of research offer hope for the future.

Preventing chronic stress from harming you in the first place

Groundbreaking studies in orphans showed how stress in early life can leave an indelible mark on the brain.

For Hungry Minds

“Chronic stress in early life has more serious and lasting effects, because that’s when a lot of connections are being laid down in the brain,” says Aniko Korosi, a researcher at the University of Amsterdam who has been conducting experiments on mice to elucidate that link between early-life stress and brain development.

Korosi may have found a surprising link between stress and the resulting nutrient composition in the brain . She and her colleagues noticed that mouse pups that had been exposed to stress in the first week of their lives—having been moved from their mother’s care to a cage—had lower levels of certain fatty acids and amino acids in their brains compared with pups being raised in a stress-free environment.

She wondered if it was possible to normalize a stressed pup’s development by feeding it a diet rich in the specific nutrients its brain would be lacking. To find out, the researchers first fed a supplemented diet to the mothers so it would pass through their milk, then continued to provide it in the pups’ feed for two weeks after they were weaned. A few months later, the researchers tested the now adult mice in learning and memory. Unlike stressed mice that had never received an enriched diet, these mice did not display cognitive impairments.

( How wild animals cope with stress—from overeating to sleepless nights. )

“I was surprised that changing the nutrition could have such a powerful effect, because it’s such an easy intervention,” Korosi says.

If further studies provide more evidence of the nutritional pathway, she says, there would be a strong basis for supplementing the diets of infants born to mothers living in stressful conditions.

Developing an early warning system for stress

Katie McLaughlin, a psychologist at the University of Oregon, is investigating how mental health problems arise in adolescents as they’re going through a particularly vulnerable time in their lives, transitioning to adulthood.

She and her colleagues are still collecting data , but a smaller, precursor study tracking 30 teenagers offers clues about what the researchers might learn—and how it might help them identify stress before it goes too far.  

In that study, McLaughlin found that the extent of stress experienced by a subject in the month before their lab visit changed how their brain responded to emotionally impactful information such as when they were shown a picture of a threatening face. The brain’s prefrontal cortex, which helps regulate emotions, showed less activation when the subject had experienced higher levels of stress.

McLaughlin is optimistic that data from the ongoing study will help pinpoint changes in behavior as well as brain activity that predict the emergence of mental health problems like anxiety and depression. This could enable the development of targeted interventions delivered to teenagers at just the right time, she says. If the identified marker of stress were a sudden decrease in sleep duration or a sharp decline in social interactions, for example, it would be possible to push the intervention out to the individual on their smartphone.

“Like, here’s a reminder about good sleep hygiene, or this might be a good time to check in with your counselor at school about what’s been going on in your life,” McLaughlin explains.

( ‘Hysterical strength’? Fight or flight? This is how your body reacts to extreme stress. )

Learn more about stress and how to manage it

Preventing inflammation caused by chronic stress.

Gaining a deeper understanding of how stress affects the immune system may also help find a way to reverse those effects.

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In the 1980s, psychologist Janice Kiecolt-Glaser and her virologist husband, Ronald Glaser, began exploring the physiological impact of stress on two notably stressed segments of society: medical students and older caregivers. The researchers found the students’ immune systems were less robust when they were taking exams than during non-exam times—and that stress altered the body’s response to vaccines.

Researchers then administered the flu and pneumonia vaccines to individuals responsible for a spouse with dementia. Unlike medical students taking exams, who were likely stressed only in the short term, these people were experiencing unrelenting stress. When tested at set periods after inoculation, they had fewer antibodies compared with a control group —they couldn’t maintain their protective response. “That gave us good evidence that the changes brought on by stress were biologically meaningful,” says Kiecolt-Glaser, now an emeritus professor at the Ohio State University.

Around the same time, researchers led by Sheldon Cohen, now emeritus professor of psychology at Carnegie Mellon University, delivered cold-causing viruses into the nostrils of about 400 adult volunteers in the U.K. “The more stress they reported prior to our exposing them to a virus, the higher the risk was for them to develop a cold,” says Cohen. The duration and type of stress mattered: Chronic economic or interpersonal stress were what really put people at high risk—and the longer it went on, the greater the susceptibility to falling sick.

Cohen and his colleagues also learned that when exposed to viruses, chronically stressed people tended to produce an excess of cytokines—proteins that serve as messengers of the immune system, traveling to sites of infection and injury and activating inflammation and other cellular processes to protect the body. Too many cytokines cause an excess of inflammation.

Researchers still don’t know enough about how stress alters the immune system’s ability to regulate cytokines to devise an intervention to reduce the inflammation, but in one way, these findings signal some hope: There are clear targets for more work to be done.  

Understanding stress on a cellular level

The future of understanding and combating stress may lie in our DNA.

In 2023, Ursula Beattie, then a doctoral student at Tufts University, and her colleagues found possible evidence that stress can overwhelm DNA’s repair mechanisms . In their study, researchers repeatedly tapped on sparrow cages with pens, played the radio loudly, and other actions designed to cause distress but no physical harm. Blood and tissue samples from the sparrows after three weeks of this unpleasant treatment revealed damage to the DNA. “It’s like if you had two pieces of string coiled up, just like DNA, and you took a pair of scissors and cut them,” Beattie says.

While these kinds of double-strand breaks in DNA occur all the time in sparrows and other species, including humans, the damage is typically reversed through self-repair mechanisms. In a chronic-stress setting, “those repair mechanisms get overwhelmed, which is how we see a buildup of DNA damage,” Beattie explains. The damage in the birds appears to be the most severe in cells of the liver, she adds, suggesting that for humans, too, the extent and type of damage inflicted by stress might be different for different tissues of the body.

Separately, Kiecolt-Glaser and psychologist Lisa Christian at OSU are conducting a longitudinal study to determine whether chronic stress ages you more quickly. If results support a smaller, earlier study, it appears that chronically stressed caregivers not only are more likely to get sick and heal more slowly but they also show signs of accelerated aging.

We’re still learning how deep stress goes into our bodies. But these exploratory findings mean we’re getting closer to solving the puzzle that is stress, which promises a future where we can better meet the ongoing demand for change.

( 20 stress-relief gifts for the frazzled friend in your life. )

Related Topics

• MENTAL HEALTH
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‘Hysterical strength’? Fight or flight? This is how your body reacts to extreme stress

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Do you really need 10,000 steps a day? Here’s what the science says.

Many people wean off antidepressants too quickly. That can be dangerous.

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Risk factors associated with stress, anxiety, and depression among university undergraduate students

Mohammad mofatteh.

1 Lincoln College, University of Oxford, Turl Street, Oxford OX1 3DR, United Kingdom

2 Merton College, University of Oxford, Merton Street, Oxford OX1 4DJ, United Kingdom

3 Sir William Dunn School of Pathology, University of Oxford, South Parks Road, Oxford OX1 3RE, United Kingdom

It is well-known that prevalence of stress, anxiety, and depression is high among university undergraduate students in developed and developing countries. Students entering university are from different socioeconomic background, which can bring a variety of mental health risk factors. The aim of this review was to investigate present literatures to identify risk factors associated with stress, anxiety, and depression among university undergraduate students in developed and developing countries. I identified and critically evaluated forty-one articles about risk factors associated with mental health of undergraduate university students in developed and developing countries from 2000 to 2020 according to the inclusion criteria. Selected papers were analyzed for risk factor themes. Six different themes of risk factors were identified: psychological, academic, biological, lifestyle, social and financial. Different risk factor groups can have different degree of impact on students' stress, anxiety, and depression. Each theme of risk factor was further divided into multiple subthemes. Risk factors associated with stress, depression and anxiety among university students should be identified early in university to provide them with additional mental health support and prevent exacerbation of risk factors.

1. Introduction

Mental health is one of the most significant determinants of life quality and satisfaction. Poor mental health is a complex and common psychological problem among university undergraduate students in developed and developing countries [1] . Different psychological and psychiatric studies conducted in multiple developed and developing countries across the past decades have shown that prevalence of stress, anxiety, and depression (SAD) is higher among university students compared with the general population [2] – [4] . It is well established that as a multi-factorial problem, SAD cause personal, health, societal, and occupational issues [5] which can directly influence and be influenced by the quality of life. The level of stress cited in self-reported examinations and surveys is inversely correlated with life quality and well-being [6] .

Untreated poor mental health can cause distress among students and, hence, negatively influence their quality of lives and academic performance, including, but not limited to, lower academic integrity, alcohol and substance abuse as well as a reduced empathetic behaviour, relationship instability, lack of self-confidence, and suicidal thoughts [7] – [9] .

A 21-item self-evaluating questionnaire, Beck Depression Inventory (BDI), is the most common tool used for diagnoses of depression [10] . A BDI-based survey in five developed countries in Europe (European Outcome of Depression International Network-ODIN in the United Kingdom, Netherlands, Greece, Norway, and Spain) concluded that overall 8.6% (95% CI, 7.95–10.37) of the resident population are dealing with depression [11] . Similar studies confirmed that about 8% of the population in developed and developing countries suffer from depression [12] . Data from systematic review studies revealed that this depression rate is much higher among university students and around one third of all students in the majority of the developed countries have some degree of SAD disorders; and depression prevalence has been increasing in academic environments over the past few decades [3] .

Despite all the efforts to increase awareness and tackle mental health problems among university students, there is still an increasing number of depression and suicide among students [13] , indicating a lack of effectiveness of the measures adopted. In addition to an increase in the prevalence of mental health issues, comparing students and non-college-attending peers demonstrated that the severity of psychological disorders that students receive treatment for has also increased [14] . For example, the rate of suicide among adolescents has increased significantly over the past few decades [15] . In fact, suicide as a result of untreated mental health is the second cause of death among American college students [16] , emphasizing the importance of identifying and treating risk factors associated with SAD.

SAD can be manifested in different forms; however, some common overt symptoms include loss of appetite, sleep disturbance, lack of concentration, apathy (lack of enthusiasm and concern), and poor hygiene. Studying SAD is particularly important among university students who are future representatives and leaders of a country. Furthermore, most undergraduate students enter university at an early age; and dealing with SAD early in life can have long-term negative consequences on the mental and social life of students [3] . For example, a longitudinal study in New Zealand over 25 years demonstrated that depression among people aged 16–21 could increase their unemployment and welfare-dependence in long-term [17] .

A better understanding of SAD among students in developed and developing countries not only helps governments, universities, families, and healthcare agencies to identify risk factors associated with mental health problems in order to minimise such risk factors, but also provides them with an opportunity to study how these factors have been changing in the academia.

This review aims to provide an updated understanding of risk factors associated with SAD among post-secondary undergraduate and college students in developed and developing countries by using existing literature resources available to answer the following question:

“Aetiology of depression and anxiety: What are risk factors associated with stress, anxiety and depression among university and college undergraduate students studying in developed and developing countries?”

It is worth mentioning that this review focuses on SAD risk factors of university students in developed and developed countries, and does not cover underdeveloped countries which can have their own niche problems (such as poverty). However, this review takes into account international students who migrate from underdeveloped countries to developed and developing countries to pursue their education.

2.1. Aims and objectives

The aims of this review were to identifying principal themes associated with depression and anxiety risk factors among university undergraduate students. The objectives of this review are to design a rigorous searching methodology approach by using appropriate inclusion and exclusion criteria, to conduct literature searches of publicly available databases using the designed methodology approach, to investigated collected literature resources to identify risk factors associated with the depression and anxiety which have not changed, and to identify principal themes associated with SAD risk factors among university undergraduate students.

2.2. Designed approach for literature review

A narrative review based on a comprehensive and replicable search strategy is used in this review. This approach is justified and preferred, over other approaches such as primary data gathering, because of the timescale of the research (2000 to 2020-temporal reasons), and extent of the research (developed and developing countries-spatial reasons).

2.3. Criteria for inclusion and exclusion of articles

Inclusion and exclusion criteria for articles and academic writings used in this review are as follows:

2.3.1. Date

2000 to 2020 are included Academic writings which are published between in this review. Initially, during a pilot search, search strategies covered 1990 to 2020. However, the majority of the search results (more than 80% of the search results and more than 88% of applicable search results) were from 2000 to 2020, which indicates the importance of mental health issue and increased awareness over the past two decades. Therefore, for the final search, papers from 2000 to 2020 were included.

2.3.2. Study design

Literatures included in this narrative review were primary research articles, review articles, systematic reviews, mini-reviews, opinion pieces, correspondence, clinical trials, and cases reports published in peer reviewed journals.

2.3.3. Country

The narrative review was limited to developed and developing countries definition by the United Nations Department of Economic and Social Affairs [18] . Abstract and method sections of search results were screened to check the country of research.

2.3.4. Language

Peer-reviewed articles published in English were only included in this narrative review.

2.3.5. The explanation for papers exclusion

The main reason for papers excluded from consideration after search results was that they focused on intervention and therapies associated with SAD. Other reasons for exclusion was that studies were conducted on a mixture of undergraduate and graduate students or focused solely only graduate students. Studies which focused on other types of mental disorders such as eating disorders but did not focus on SAD were excluded too. The conducted search did not exclude any gender or specific age category.

2.4. Strategies used for search and limitations

In this review, a robust and replicable search strategy was designed to identify appropriate articles by searching PubMed, MEDLINE via Ovid, and JSTOR electronic databases. These databases were selected because they encompass biopsychosocial papers published on SAD. The date chosen for this search was for articles published between 2000 to 2020 which covers the past two decades. Once key articles were identified, a search for citation of those papers was conducted, and the bibliography of those papers were further screened to identify potential articles which can be relevant.

2.5. Search terminologies used

To conduct searches in databases mentioned above, the following search terms were used: students stress, anxiety, depression risk factors, university stress, anxiety, depression risk factors, student mental health developed and developing countries, students stress, anxiety and depression developed and developing countries. The operation AND was used to connect stress, anxiety, depression, mental health, developed, developing, countries, students. The search for each term was conducted in all fields (title, abstract, full text, etc.).

2.6. Screening, selecting search results, and data extraction

The search results were exported into separate Excel and EndNote X8 files. Titles and abstracts from all articles were screened to determine their relevance to the topic of this review. Potentially relevant articles were fully read to establish their relevance. Each paper which was included according to the inclusion criteria described above was read fully. A word file was created to identify themes associated with SAD risk factors which is included in the Results. An initial search resulted in 1305 articles. The title and abstract of individual papers were read for relevance, resulting in 60 papers which were relevant for the research question asked in this review. All 60 papers were read completely, and from those, 19 were excluded based on the criteria mentioned before. Therefore, the total number of papers for consideration was 41. A flowchart explaining the procedure for identification, screening, eligibility, and inclusion of papers is shown in Figure 1 .

Figure 2 provides a quantitative summary of the papers included in this narrative review. In terms of the distribution of the countries where the research was conducted, included papers were mainly articles which carried out studies in the USA (n = 17), followed by China and Canada (each n = 5), UK (n = 4), Japan (n = 3), Germany and Australia (each n = 2), South Korea, Hungary, Switzerland (each n =1) ( Figure 2A ). As for article types included in this review, original research articles, including quantitative and qualitative studies, which relied on obtaining data including cross-sectional studies, interviews, case-control studies, surveys, and questionnaire, were the highest (n = 37) followed by meta-analysis, literature and systematic reviews ( Figure 2B ). Another interesting observation was that although the search was carried out from 2000–2020, most papers were concentrated in the period from 2016 to 2020 ( Figure 2C ). This can be due to the reason that mental health is becoming more important over the past few years. Alternatively, a higher number of papers included from 2016 onward can be due to unintended selection bias. The smallest study covered in this narrative review was conducted on 19 students and the largest one on 153,635 students, adding up to 236,104 students, who were included in articles covered in this narrative review in total. Most studies on mental health, anxiety, and depression use standardised approaches such as patient-filled general health questionnaires, Pearling coping questionnaire, internally regulated surveys, BDI, DSM-IV symptomology, and general anxiety and burnout scales such as Maslach Burnout Inventory.

3.1. Literature search results

Following the search protocol shown in Figure 3 , a list of included papers identified which can be found in the Table 1 .

3.2. Prevalence of mental health disorders in students

Literature showed that mental health problems are common phenomenon among students with a higher prevalence compared to the general public. For example, surveying more than 2800 students in five American large public universities demonstrated that more than half of them experienced anxiety and depression in their last year of studies [19] . Similarly, a survey of Coventry University undergraduate students in the UK showed that more than one-third of them had experienced mental health issues such as anxiety and depression over the past one year since they were surveyed [20] . In agreements with these results, Maser et al. [21] found that prevalence of mental health disorders including anxiety and depression was higher among medical students compared to the general non-student population of the same age. These studies demonstrated that the prevalence of SAD among students has remained higher than the average population over the past two decades.

SAD are not only prevalent among students, but also persistent. By conducting a follow-up survey study of students over two years, Zivin et al. [19] demonstrated that more than half of students retain their higher levels of anxiety and depression over time. This can be due to a lack of SAD treatment or persistence of existing risk factors over time.

3.3. Risk factors associated with stress, anxiety, and depression

SAD are multifactorial, complex psychological issues which can have underlying biopsychosocial reasons. Multiple risk factors which affect the formation of SAD among undergraduate university students in developed and developing countries were identified in this review. These factors can be categorized into multiple themes including psychological, academic, biological, lifestyle, social and financial. A summary of risk factors and their associated publications are shown in Table 2 .

3.3.1. Psychological factors

Self-esteem, self-confidence, personality types, and loneliness can be associated with SAD among university students. Students who have a lower level of self-esteem are more susceptible to develop anxiety and depression [22] . Also, students with high neuroticism and low extraversion in five-factor personality inventory [23] are more likely to develop SAD during university years [24] . Other psychological factors such as feeling of loneliness plays important roles in increasing SAD risk factors [24] . Moving away from family and beginning 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. [24] showed that students who live in other cities than their hometown for studying purposes are more likely to develop anxiety and depression.

Some students enter the university with underlying mental conditions, which can become exacerbated as they transition into the independent life at university. While depression is higher among university and college students compared to the general public, students with a history of mental health problems, such as post-traumatic stress disorder (PTSD), are more prone to development of anxiety and depression during their university lives compared to students who did not have such experience before starting their degrees [25] . Furthermore, exposure to violence in childhood either at the household or the community correlates with SAD formation later in life and at University [26] . Therefore, low self-esteem and self-confidence, having an underlying mental health condition before beginning the university, personality type (high neuroticism and low extravasation), and loneliness can increase the probability of SAD formation in students.

3.3.2. Academic factors

Multiple university-related academic stressors can lead to SAD among students. One of these factors which was strongly present in many studies evaluated in this review was the subject of the degree. Medical, nursing, and health-related students have a higher prevalence of depression and anxiety compared to their non-medical peers [24] , [27] – [28] . Medical and nursing students who have both theoretical duties and patient-related work usually have the highest level of workload among university students, consequently deal more with anxiety and depression [27] , [29] . In addition, students who major in psychology and philosophy, similar to nursing and medical students, are more likely to develop depression during their studies compared to others [24] . These studies did not identify whether students who have underlying mental health conditions are more likely to choose certain subjects such as philosophy, psychology, or subjects which lead to caring roles such as nursing and medicine. Because of the nature of their work, medical and nursing students who deal with people's health can experience depression and anxiety as a result of fears of making mistakes which can result in harming patients [27] . Students with practical components in their degree are required to travel to unfamiliar places for fieldwork and work experience which can add to their stress and anxiety [27] .

Also, some prospective students, especially those who study nursing and medicine, usually do not have a clear understanding of the curriculum and workload associated with the subject before entering the university, therefore, they can face a state of disillusionment once they begin their studies at university [27] – [29] . It is worth mentioning that not all studies found a significant correlation between the subject of study and SAD development [30] . This can be explained by differences in sample type and size which results in variations existing in the amount of workload and curriculum in similar subjects taught in various universities in different countries.

Studying a higher degree can be a challenging task which requires mental effort. Mastery of the subject can negatively correlate with self-esteem, anxiety, and depression among university students with students who have a mastery of subject demonstrating a lower level of stress and anxiety [31] . Also, students who study in a non-native language report the highest level of anxiety and depression during their freshman years, and their stress levels decrease during the subsequent study years [32] . This can be explained by the fact that students who are studying in a foreign language usually are those who have migrated abroad, therefore, require some time to adjust to their new lives. Different studies showed that the level of anxiety and depression among both international and home students could correlate with the year of study with fresher students who enter the university and students at the final year of their studies experience the greatest amount of anxiety and depression with different risk factors [22] , [32] . While fresher students experience SAD because of challenges in adjustments to university life, past negative family experience, social isolation and not having many friends, final year students report uncertainty about their future, prospective employment, university debt repayment and adjusting to the life after university as major risk factors for their SAD [22] , [32] . Therefore, a shift in SAD risk factors themes are observed as students make a progress in their degrees.

Students spend a significant portion of their time at university being engaged with their academic activities, and unpleasant academic outcomes can influence their mental health. Receiving lower grades during the time of studies can negatively influence students' mental health, causing them to develop SAD [33] , [34] . Academic performance during undergraduate studies can determine the degree classification, which can, subsequently, influence students' opportunities such as employment success rate or access to postgraduate courses [27] . Conversely, both the number of students with mental health problem symptoms and the severity of students' SAD increase during exam time [35] , reflecting a direct relationship between academic pressure and students' mental health states. However, the causal relationship is not well-established; it is possible that depression and associated problems such as temporary memory loss and lack of concentration [36] are reasons for poor academic grades or inversely, students feel stressed leading to depression because of their poor performance in their exams. A mutual relationship can exist between grades and mental health, as having a poor mental health can reciprocally cause students to get lower grades [34] , leading to a vicious cycle of mental health and academic performance. Interestingly, students' sense of social belonging and coherence to the university community was reduced during exam periods [35] . This can be explained by the reduced participation rate of students in university social activities and clubs as well as an increased sense of competition with their peers. Furthermore, students interact directly and indirectly with teachers, lecturers, tutors, and other staff; therefore, the relationship between students and academic staff can influence students' mental health. A negative and abusive relationship with teachers and mentors can be another factor causing SAD among undergraduate students [27] .

On the other hand, being a part-time student is a protective factor for anxiety and depression, and part-time students have better mental health compared to students with full-time status [34] . This can be explained by financial securities which have a source of income can bring or because part-time students are usually older than full-time students [34] , and therefore, more emotionally stable. In conclusion, risk factors increasing SAD among university students include high workload pressure, fear of poor performance in exams and assessments, wrong expectations from the course and university, insufficient mastery in the subject, year of study, and a negative relationship with academic staff.

3.3.3. Biological factors

Mental health can be influenced by ones' physical health. Presence of an underlying health condition or a chronic disease before entering the university can be a predictor of having SAD during university years [31] , [33] . Students with physical and mental disabilities can be in a more disadvantaged position and do not fully participate in university life leading to SAD formation [33] .

An association between gender and depressive disorders have been observed in several studies [21] , [27] , [34] , [37] . Female students had a higher prevalence of SAD compared to male students. Interestingly, while female students demonstrated a higher level of SAD, the dropout rate of female students with a mental health problem from university was lower compared to their male counterparts [33] . On the other hand, while females are at a higher risk of developing depressive disorders, males with depressive disorders are less willing to seek professional help and ask for support due to the stigma attached to mental health [38] , causing exacerbation of their problem over time [20] .

Age can be another factor related to SAD. Younger students report a higher level of SAD compared to older students [34] , [37] . However, other meta-analysis studies did not find a significant correlation between students' age and their mental health which can be due to sampling differences [39] . Some studies showed that while older undergraduate students have a higher determination to do well in the university [40] , those who have family commitments are more prone to develop SAD during their degrees [27] . These discrepancies in findings can be explained by different sample sizes and types of studies which can be influenced by various confounding factors such as nationality, country of study, degree of studies, gender, and socioeconomic status. Similarly, a lack of correlation between depression prevalence and year of study is observed as some studies have reported a higher prevalence among earlier years of studies, while others have shown a higher prevalence among students as they move closer to the end of their studies [41] . These differences can be explained by different causes of depression in a different age; for example, while depression in younger adults can be due to changes in their environment and difficulties in adapting to a new life, older adults can have depression symptoms because of a lack of certainty for their future and employment. Nevertheless, differences exist between SAD risk factors associated with young and older students. Overall, biological risk factors affecting SAD include age of students, gender, and underlying physical conditions before entering the university.

3.3.4. Lifestyle factors

Moving away from families and beginning a new life requires flexibility and adaptation to adjust to a new lifestyle. As most undergraduate students leave their family environment and enter a new life with their peers, friends, and classmates, their behaviour and lifestyle change too. Multiple lifestyle factors such as alcohol consumption, tobacco smoking, dietary habits, exercise, and drug abuse can affect SAD. Alcohol consumption is high among students with SAD [28] ; a causal relationship was not been established in this study though.

Tobacco smoking is another risk factor associated with SAD which is common among students, especially students who study in Eastern developed and developing countries such as China, Japan and South Korea [24] , [42] . Most students, especially male students, smoke because of social bonding and the rate of social smoking is directly correlated with SAD [24] , [42] . Social smokers are less willing to quit smoking, and more likely to persist in their habit, resulting in long term negative physical and psychological health consequences [42] . Illegal substance abuse can be another factor important in SAD among young people [43] . Academic-related stress and social environment in university dormitories and student accommodations can encourage students to use illegal drugs, smoke tobacco and consume alcohol excessively as a coping mechanism, resulting in SAD [44] . Interestingly, students who perceived they had support from the university were feeling less stressed and were less at the risk of substance abuse [45] , indicating the important role of social support in preventing and alleviating depression symptoms. This is of particular importance as a new social habit and behaviour adapted early during life can last for a long time. Furthermore, students who do not have a healthy lifestyle can feel guilt, which can worsen their SAD condition [46] . Interestingly, Rosenthal et al. [47] showed that negative behaviours resulting from alcohol consumption such as missing the next day class, careless behaviour and self-harm, verbal argument or physical fight, being involved in unwanted sexual behaviour, and personal regret and shame could be the main reasons for depression associated with drinking alcohol, rather than the amount of alcohol consumed.

In contrast, a moderate to vigorous level of physical activity can be a protective factor against developing SAD during university life [37] , [48] . Students who have a perception of having inadequate time during their studies do not spend enough time for exercise and can develop SAD symptoms [27] .

Another lifestyle-related risk fact associated with SAD is sleep. Many young people do not receive sufficient sleep, and sleep deprivation is a serious risk factor for low mood and depression [28] , [47] . Self-reported high level of stress and sleep deprivation is common among American students [31] , [49] . Insufficient sleep can act as a vicious cycle- academic stress can cause sleep deprivation, and insufficient sleep can cause stress due to poor academic performance since both sleep quality and quantity is associated with academic performance [28] . Overall, poor sleeping habit is associated with a decreased learning ability, increase in anxiety and stress, leading to depression.

Different negative lifestyle behaviours such as tobacco smoking, excessive alcohol consumption, unhealthy diet, lack of adequate physical activity, and insufficient sleep can increase the risk of SAD formation among university students.

3.3.5. Social factors

Having a supportive social network can influence students' social and emotional wellbeing, and subsequently lower their probability of having anxiety and depression in university [27] , [37] , [50] . The quality of relationship with family and friends is important in developing SAD. Having a well-established and supportive relationship with family members can be a protective factor against SAD development, which, in turn, can affect the sense of students' fulfilment from their university life [27] . The frequency of family visits during university years negatively correlates with SAD development [33] . Family visits can be more challenging for international students who live far away from their families, therefore adding to existing problems of international students who live and study abroad.

In contrast, having a negative relationship with family members, especially parents, can cause SAD formation among students in university [51] . Similarly, having a strict family who posed restrictions on behaviours and activities during childhood can be a predictor of developing SAD during university years [51] .

Also, it is shown that being in a committed relationship has a beneficial protective factor against developing depressive symptoms in female, but not male, students [52] . Interestingly, both male and female students who were in committed relationships reported a lower alcohol consumption compared to their peers who were not in committed relationships [52] .

Involvement in social events such as participating in sporting events and engaging in club activities can be a protective factor for mental health [32] , [37] . Assessing preclinical medical students' social, mental, and psychological wellbeing showed that while first year students demonstrate a decrease in their mental wellbeing during the academic year, they have an increase in their social wellbeing and social integration [53] . This can be explained by the time period required for fresher students who enter the university to adjust to the social environment, make new friends, and integrate into the social life of the university.

Access to social support from university is another factor which is negatively correlated with developing anxiety and depression [31] . It is worth mentioning that different universities provide different degrees of social support for students which can reflect on different anxiety and depression observed among students of different universities.

Importantly, sexual victimization during university life can be a predictor of depression. By surveying female Canadian undergraduate students, McDougall et al. [54] found that students who were sexually victimized and had non-consensual sex were at a higher chance of developing depression following their experience, emphasizing the importance of safeguarding mechanism for students at university campuses.

While the internet and social media can be great tools for maintaining a social relationship with classmates, pre-university friends and family members, it can have negative mental health effects. Excessive usage of social media and the internet during freshman year can be a predictor of developing SAD during the following years [55] . Students who have a higher dependence on the social media report a higher feeling of loneliness, which can result in SAD [56] . Students with internet addiction and excessive usage of social media are usually in first year of their degrees [55] , [56] which can reflect a lack of adjustment to university life and forming a social network. Also, students who use social media more often have a lower level of self-esteem and prefer to recreate their sense of self [56] , indicating an intertwined relationship between biopsychosocial factors in developing SAD among students.

Demographic status, ethnic and sexual minority groups including international Asian students, black and bisexual students were at an elevated risk of depression and suicidal behaviour [16] , [50] . The frequency of mental health is usually more common among ethnic minorities. For example, Turner et al. [20] showed that ethnic minority students report a higher level of anxiety and depression compared to their white peers; however, they do not ask for help as much. Other studies supported these findings by showing that students from ethnic and religious minorities, regardless of their country of origin and country in which they study, have a higher prevalence of anxiety and depression compared to their peers [50] . Also, students' expectations from university can be different among ethnic minorities students, and most of them do not have a sufficient understanding of the services that university can provide for them [40] .

Therefore, lack of support from family and university, adverse relationships with family, lack of engagement in social activities, sexual victimization, excessive social media usage, belonging to ethnic and religious minority groups, and stigma associated with the mental health are among risk factors for SAD in university students.

3.3.6. Economic factors

Students' family economic status can influence their mental health. A low family income and experiencing poverty can be predictors of SAD development during university years [22] , [50] , [57] , [58] . A higher family income can even ameliorate negative psychological experiences during childhood, which can have long-term negative consequences on the mental health of students once they enter university [57] . Also, experiencing poverty during childhood can have negative long-term consequences on adults, leading to SAD development during university life [58] .

Some students take up part-time job to partially fund their studies. Vaughn et al. [59] showed that relationship of employed students with their colleagues in the workplace could affect students' mental health; and those students who had a poor relationship with their colleagues had worse mental health. However, it is worth mentioning that a causal relationship was not established. It can be possible that students who have poor mental health cannot get along with their co-workers, resulting in an adverse working relationship.

Because of paying higher tuition fees and less access to scholarships and bursaries available, international students can have more financial problems, causing a higher degree of anxiety and depression compared to home students [60] .

Lack of adequate financial support, low family income and poverty during childhood are risk factors of SAD in students of undergraduate courses in developed and developing countries.

3.4. Stigma associated with mental health

While efforts have been put to reduce the stigma associated with receiving help for mental health problems, this still remains a challenge. For example, more than half of students who had SAD did not receive any help or treatment for their condition because of the stigma associated with mental health [19] , [61] . This is not related to the awareness of the availability of mental health resources which was ruled out by authors, as most of the students who did not receive any help for their mental health problem were aware of available help and support to them [19] .

Furthermore, the social stigma associated with receiving help for mental health problems was significantly associated with suicidal behaviour, acting as a preventive barrier to seek help (planning and attempt) [16] . Among students, those with a history of mental health problem such as veterans with PTSD are less likely to seek for help compared to non-veteran students [25] , making them more susceptible to struggling with untreated mental health.

4. Discussion

This review tried to identify and summarise risk factors associated with SAD in undergraduate students studying in developed and developing countries. The prevalence of SAD is high among undergraduate university students who study in developed and developing countries. Untreated SAD can lead to eating disorders, self-harm, suicide, social problems [28] . Similar to a complex society, differences exist among students leading to complicated risk factors causing SAD. Because different themes influencing SAD has been investigated as a distinct body of research by different literature, a concept map is created to demonstrate the relationship between various risk factors contributing to the development of SAD in undergraduate students in developed and developing countries. Figure 3 bridges risk factors concepts between different literature. For most students, entering university is a new step in their lives which is associated with certain challenges such as moving into independent accommodation, social identity, financial management, making decisions, and forming a social network. Different students have different needs depending on the stage of their degree, which needs to be fulfilled. For example, coping with a new university life style can be a challenging task for students who enter the university. This becomes more significant for students moving abroad for their studying who need to adapt to a new lifestyle, speak in a different language, and live away from their families. In agreement with this, different levels of anxiety and depression with different risk factors are observed among students as they progress in their degrees. On the other hand, students who are finishing their degrees can have SAD because of uncertainties about their future.

Students learn different modules in different degrees and have different abilities. Mastery of the subject can be a factor affecting students' sense of self-esteem, influencing their anxiety level and developing depressive symptoms. This partially can explain changes in risk factors observed as students' progress in their degrees. Final year students who adjust to the university environment and develop mastery in their subject can deal with academic pressure better compared to freshers who transform from secondary school life to university lifestyle.

Students can come with a varied and challenging background such as those who experienced household and domestic violence, sexual abuse, and child poverty which can make them susceptible to developing anxiety and depression once academic pressure is mounted. As universities are diverse environment which enrol students from different socioeconomic background and different cultures, universities need to identify risk factors for different students and have robust plans to tackle them to provide a fostering environment for future leaders of the society. Therefore, early mental health screening can help to identify those students who are at risk to provide them with special and additional mental health support. Students not only should be screened for their mental health state as they enter university, but also regular follow up check-ups should be conducted to monitor their conditions as they progress in their degrees to detect early signs of SAD.

University and academic staff can play a significant role in either exaggerating or ameliorating risk factors associated with anxiety and depression. While teachers and mentors can support students to cope with SAD, they can be a source of problem too by discriminating, bullying, and hampering students' progress.

Managing finance and expenses can be a challenging task for students who are stepping into an independent lifestyle and need to pay for their tuitions in addition to their maintenance fees. While some students have access to private funding, bursaries, and scholarships, other students receive loans which they need to pay back or have part-time jobs to meet their expenses. Students who work need to have a work-life balance and the time spent in their jobs can affect the quality of their education.

Fresher students try to establish their social network and might feel isolated, which can push them to excessive usage of social media to fill their social gap. While internet addiction and excessive usage of social media can have a negative impact on students' mental health, technology, such as mobile phone applications can be used in universities campuses to promote a healthier lifestyle and reducing risk factors among students. For example, many students refuse to receive face-to-face mental health counselling support during their anxiety and depression due to stigma associated with disclosure of mental health issues. Providing students with anonymized counselling services through mobile phone applications can be one way of delivering help to students at universities.

With the advent of social media platforms such as Facebook, Twitter, Instagram, TikTok, etc., more and more students rely on such networks for socialisation. While the internet and online platforms can have beneficial consequences for students, such as rapid access to a variety of online learning resources and keeping in contact with friends and families, excessive usage of social media and internet can have negative consequences on students' academic performance. A poor mental health state at the beginning of university life is a predictor of internet addiction later during the degree. Heavy reliance on the internet can be a coping mechanism for students with anxiety and depression to overcome their mental health problems.

As governments and educational bodies in developed and developing countries are emphasising recruitment of ethnic minority students to university to increase the range of equality and diversity among students, it is important to consider the mental health of those students in the university as well. Students in minority groups such as black, international Chinese and bisexual student report a higher level of anxiety and depression compared to other non-minority group students. This can be due to either pre-existing conditions which student experience before entering the university, and can be exacerbated during the university, or can be because of problems which can develop during university life.

Also, more mental health support is available in universities as the number of university students is increasing, and there is a better understanding of the importance of mental health in academia; however, the stigma associated with mental health has not changed proportionately.

While research and understanding of mental health have changed significantly over the past two decades and many more articles are present, risk factors associated with SAD remain unchanged.

One caveat with studies of mental health among student is that most studies have been conducted among medical and nursing students and neglected non-medical students. One potential explanation for the tendency to conduct depression surveys among medical students is the higher response rate as medical students are more willing to fill out the questionnaires and surveys. It is understandable that students studying medical subjects, who directly interact with the public and treating them once they enter the healthcare profession should have a reasonably sound mental health to be able to conduct their duties, but it does not justify neglecting the mental health of other students. Therefore, more research on mental health and risk factors associated with SAD of non-medical students is required in the future.

Another caveat with most mental health studies is that they are based on self-reports and surveys. Different people can have different perception and understanding of mental health and anxiety, and many confounding factors can influence the response of participants in the time of participation. Furthermore, students with severe mental health conditions are less likely to participate in any activity including surveys and questionnaires, leading to a non-response bias.

Another area which requires improvement in future studies of mental health is the categorisation of different types of depression and their severity. Depression and anxiety are a spectrum which can comprise of minor and major symptoms; however, most studies did not specify the scale of depression in their findings. Furthermore, while various risk factors were identified, a causal relationship between mental health and behaviours were not established.

While counselling services provided by universities in Western countries such as the UK and USA have increased over the past few years [62] , it is still not clear how effective such services are; therefore, more research is required to assess the effectiveness of counselling services at universities.

Therefore, a better understanding of the aetiology, associated factors is required for an effective intervention to reduce the disease incidence and prevalence among students in the population and providing them with a fostering environment to achieve their potential.

University undergraduate students are at a higher risk of developing SAD in developed and developing countries. Promoting the mental health of students is an important issue which should be addressed in the education and healthcare systems of developed and developing countries. Since students entering university are from different socioeconomic background, screening should be carried out early as students.

A personalized approach is required to assess mental health of different students. In addition, a majority of mental health risk factors can be related to the academic environment. A personalised, student-centred approach to include needs and requirements of different students from different background can help students to foster their talent to reach their full potential. Furthermore, more training should be provided for teaching and university staff to help students identify risk factors, and provide appropriate treatment.

5. Conclusion

Despite all the efforts over the past two decades to destigmatise mental health, the stigma associated with mental health is still a significant barrier for students, especially male students and students from ethnic and religious minorities to seek help for SAD treatment. Universities need to continue to destigmatise mental health in university campuses to enable students to receive more in campus support by providing designated time for positive metal health activities such as group exercise, physical activities, and counselling services. There is no shortage of athletic and group activities in form of clubs and social classes in most universities in developed and developing countries; however, more incentives such as athletic bursaries and prizes should be provided to students to encourage their participation in such activities which can act as protective factors against SAD development. Therefore, universities need to allocate more resources for sporting and social activities which can impact the mental health of students. Furthermore, an increase in mental health problems in universities has created a huge burden on university counselling services to meet the demands of students. More novel approaches, such as online counselling services can help universities to meet those increased demands.

Students in different years of studies deal with different risk factors from the time that they enter the university until they graduate, therefore, different coping strategies are required for students at different levels. Universities should be aware of these risk factors and implement measures to minimise those factors while providing mental health treatments to students.

Future studies are required to investigate long-term effects of experiencing SAD on students. A longitudinal study with a large randomly recruited sample size (different age, sex, degree of study, – socioeconomic status, etc.) is required to address how students' mental health change from entering the university until they graduate. Also, more extended follow up studies can be included to address the effect of depression and poor mental health on people's lives after they graduate from the university.

Abbreviations

Conflict of interest: All authors declare no conflicts of interest in this paper.