Stress Among Graduate

Students
In Relation to Health
Variables
Carroll University Exercise Physiology
Kelly Van Berkel
2015

INTRODUCTION
As graduate students we experience some level of stress almost all the time and are called
upon to finish final reports, deliver great presentations, and thrive in our practicum settings all
while trying to maintain relationships with our family and friends. While one cannot remove the
stressful events from their life, they can adjust the way they react to these events (Woodberry,
2010). Being able to perform at a more productive level and feel better about ones self, if those
high levels of stress can be brought to a more manageable level. By understanding potential
sources of stress, perceived severity of stress, and stress responses, stress reduction
interventions can be developed. In addition, modifiable factors such as regular exercise and
other health behaviors should be considered in the development of strategies to improve
graduate students coping skills (Ogunsanya, 2015).
LITERATURE REVIEW
What is Stress?
Stress is a medical term for a wide range of strong external stimuli, both physiological and
psychological, which can cause a physiological response called the fight or flight response,
first described in 1936 by Hans Selye in the journal Nature. These stressors can be either
positive (eustress) or negative (distress), which can then be broken down into chronic or life
event forms of stressors (Oswalt & Riddock, 2007). That being said there is no doubt that
graduate students can experience both eustress and distress in the chronic or life event forms.
Stress and physical activity
Physical Activity and exercise off the potential to reduce the risk of stress-induced mental and
physical diseases (Warburton, Katzmarzyk, Rhodes & Shephard, 2007). Until now, the existing
link between the health enhancing effects of physical exercise and the phenomenon of stress
has been mostly explained by the stress-buffer hypothesis (Gerber & Puhse, 2009;
Hamer, 2012; Sothmann, 2006; Tsatoulis & Fountoulakis, 2006), which is based on the
assumption that the positive health effects of physical activity and fitness serve as a moderation

in the relationship between stress and health (B. von Haaren et al., 2015). In the study, Vigorous
Physical Activity, Mental Health, Perceived Stress, and Socializing Among College Students,
researchers looked to determine the association between vigorous physical activity, mental
health, perceived stress, and socializing among 4-year college students. This study included
14,804 bachelor students at ninety-four different four-year colleges in the United States.
Participants in this study self-reported vigorous physical activity using questions from Youth Risk
Behavior Survey. A shortened four-item version of the Cohen Perceived Stress Scale was used
to assess perceived stress. The five-item SF-36 health scale was used to measure mental
health. Self-report was used to assess socializing and required participants to count the number
of friends and hours spent socializing in a given time frame.
Results from this study indicated that students who met vigorous physical activity
recommendations in college were less likely to report poor mental health and perceived stress
than students who did not meet recommendations. It was also determined that part of the
positive benefits of vigorous physical activity on mental health and perceived stress occur
through a socializing pathway.
A significant limitation of this study was the use of an online self-report survey. Not only was the
entire study self-report, but there were also limitations with survey response rate. With those
that did respond there was a significant association between response rate and level of physical
activity. In addition, the scales used to assess mental health and perceived stress were
shortened versions of a full, more in-depth scale in order to maintain a more reasonable survey
length in the particular survey for socializing the indicators for socialization involved measures of
the number of friends and the amount of time spent socializing, which has not been directly
validated as a good measure of socialization.
Additional research using longitudinal data is needed to more accurately assess the influence of
physical activity on mental health and perceived stress from transitioning periods.

Nguyen-Michael et al. looked at the associations between physical activity and perceived stress
in college students. This study included 716 students from three southern California colleges.
Participants in this study self-reported physical activity and perceived stress level and hassles.
Physical activity was assessed by a total weekly leisure activity score. This assessment score
was developed and validated by Godin and Shephard (1985). The score was comprised of three
items that asked the number of times mild, moderate, strenuous activity was performed in a
given week. The number of times the activity was performed per week was multiplied by three,
five, or nine metabolic equivalents. The sum was computed as the total activity score. Perceived
stress was assessed using a subscale of the Graduate Stress Inventory (Rocha-Singh, 1994).
This modified scale consisted of eight items that required subjects to report how much they
have worried about particular college related issues over the past year. Hassles were measured
using the Brief College Student Hassle Scale and included 26 items about hassles experienced
in the last month. This scale has been shown to be both valid and reliable (Blankstein, Flett, &
Koledin, 1991).
Results from this study showed a modest association between physical activity and hassles,
and no significant association with perceived stress. A significant relationship was found but
based on the beta estimates, physical activity may not produce a very large change in stress.
The findings form this study may be attributed to number of different factors. As with the
previous study, the biggest limitation was the use of self-report. As discussed in the study, the
variation in data collection methods and resulting differential response rates affects the
generalizability of the results. The results of the study are generalizable to those college
students who were willing and motivated to complete surveys on colleges health and variables
including stress, hassles, and physical activity. In addition, a clear distinction between hassles
and perceived stress was not made. Therefore, making the statement that there was a modest
association between physical activity and hassles, but not with perceived stress could be
misleading.

Additional research is needed to determine if the results found on this study are generalizable to
the entire college population. In addition, further research needs to be conducted to determine
the exact relationship and potential benefits of physical activity as a way to reduce distress in
college students,
The relationship between physical activity and stress was further examined in the study,
Reduced Emotional Stress Reactivity to a Real-Life Academic Examination Stressor in Students
Participating in a 20-Week Aerobic Exercise Training: A Randomized Controlled Trial Using
Ambulatory Assessment. In this study, 61 moderately active male electrical engineering
students were randomly assigned to a control and an aerobic exercise-training group.
Assessments were taken at the beginning of the semester and at the end of the semester.,
specifically during exam time. The study was conducted using Ambulatory Assessment, which is
the method used for repeated sampling of subjective psychological variables in real time and in
the natural environment (Trull & Ebner-Priemer, 2013). All psychological variables were
assessed via electronic diaries, using the software MyExperience, mood and stress scales were
installed on the diaries, and time stamps and intervals between diary prompts were
programmed. Subjects in the experimental group attached a 20-week aerobic running training
course. Heart rate zones were calculated for each participant. Participants completed two
training sessions every week. Initially running sessions lasted 30 minutes and included a
walking phase of two minutes, Intensity was progressively increased by adding intervals of three
and four minutes in heart rate zone two after week four. Emotional stress was assessed pre and
post intervention for two days each. The study used a wait list control group; thus, participants
who were randomized to the control group received aerobic exercise training at the end of the
study.
Results from this study showed that a preventative 20-week aerobic exercise intervention can
lower emotional stress reactivity to real-life stress. In addition, the aerobic capacity of previously
inactive students improved following the 20 weeks of an aerobic exercise intervention.

Although the results from this study concluded that aerobic training exercise significantly
reduced emotional stress compared to a control group, it is difficult to generalize theses findings
to all college students. Participants in this study were young, healthy, and physically active
individuals. Additionally, timing of the participants rating their perceived stress might have
influenced the results. Participants were asked to rate perceived stress repeatedly throughout
the day; therefore moments of increased stress may have been missed based on the time of
day
Future studies should investigate in further detail how individuals at different fitness level react
in situations of difficult stress severity and contexts and how the impacts of acute and regular
exercise interact regarding emotional reactivity to stress in real life (B. von Haaren et al.,2015).
Stress and Sleep
Although there is substantial evidence that physical activity is related to stress, there is also
supporting evidence that sleep and stress are related as well. Past studies have demonstrated
that accumulation of emotional and academic stress may lead to sleep disturbances and
inadequate amounts of sleep (Buboltz et al., 2001; Buboltz et al., 2002; Lund et al., 2010). In
addition, it was found that sleeping less at night was correlated with higher levels of anxiety,
depression, and fatigue during the following day ( Fuligni and Hardway, 2006). In one particular
study, Sadeh at al. assessed the role of the individuals coping style in moderating the link
between stress and sleep. Unlike other studies, this study used objective measures to assess
sleep.
Thirty-six psychology students participated in this study. Each participant completed a COPE
inventory (Carver, Scheier, & Weintraub, 1989) during the low-stress week. This questionnaire
included 52 items that described different behaviors and mental activities associated with coping
with stress. Sleep was assessed using an actigraph (AMA-32, Ambulatory Monitoring Inc.) over
a five consecutive night period during both high and low stress weeks. These steep wake
measures have been validated against polysomnography with agreement rates for sleep-wake

identification higher than 90% (Sadehet al., 1994). The actigraphic sleep measures included:
sleep onset time, sleep period, true sleep time (sleep time excluding all periods wakefulness),
sleep percentage, night wakings (number of wakings that lasted five minutes of longer), and
morning rise time. Subjects also completed daily logs to measure perception of sleep quality
and self-reported stress level. These daily logs assessed morning and evening stress level
using a nine-point scale (one being not at all stressed and nine being very stressed) as well as a
three-point scale assessing perceived sleep quality (one being very poor sleep and three being
very good sleep). Stress scores were calculated for each participant for both the low and high
stress periods. The average and maximum values were assessed; sleep data was translated
using the Actigraph Scoring Analysis program for an IBM-compatable PC (Sadeh, Sharkey, &
Carskadon, 1994).
Results from this study show a significant correlation between the change in perceived sleep
quality (from the low-stress to high stress period) and the change in level of stress between the
periods (Sadeh et al., 2004). In particular, increased stress level was associated with significant
deceases in perceived sleep quality.
The major strength of this study was the use of an actigraph to objectively measure sleep. This
allowed for reliable and consistent results within subjects. One of the limitations of this study
was the timing of the measuring of stress and sleep. Measurements were taking during one lowstress period (regular school week) and one high stress period (screening week) but some order
effects could not be ruled out (Sadeh et al., 2004).
Further research needs to be conducted using these objective measures to assess the
correlation between stress and sleep and how various coping methods play a role.
Another study explored the possible patterns of sleep, affective states, and sense of stress
across college students in Israel. In this study, two hundred and eighty-six college students
enrolled in four universities in the center of Israel participated.

Subjects were set up with a personal code for a website where they logged information for
seven days. On this website subjects kept a daily log of their activities per hour. This included
hours of day spent at school, studying, sleeping, watching TV, participating in sports, etc. The
second part of the daily log required subjects to rate their negative affect, perceived stress, and
how well they felt they coped with the stressor of that particular day. The daily log included
questions form the following surveys: the Profile of Mood States Questionnaire, the Stressful
Demands Questionnaire, the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale and the
Brief Symptom Inventory for psychological symptoms. Assessments were conducted at two
different time-points: during the middle of the first semester and then again during the middle of
the second semester.
Results from this study showed that college students underwent significant changes during the
course of the school year. Students in this study reported a slightly higher level if daily stress
and negative affect during the second assessment (after six months in school) In contrast, daily
reports of about 40% of the sample depicted students who reported less hours of sleep and
lower sleep quality. In addition, subjects reported higher levels of negative affect and stress as
well as lower capability of dealing with the experienced stressors (Ari & Shulman, 2012).
There were a few limitations in this study. The most important to note was that this study was
conducted using Israeli Students, many of which had experience in the military. The factor alone
could have caused changes in the perceived stress assessment part of the data. Additionally, it
is difficult to generalize the finding of this study to other college students, especially those in the
United States.
However, the overall design of the study was interesting as it allowed the data to be compared
at different times. Future students should look at these variables not only during the first year,
but over the entire college time span.
Lund et al. examined sleep patterns and predictors of disturbed sleep in a large population of
college students. 1,125 students form a Midwestern University participated in this study.

Subjects completed an online survey that included five different scales related to sleep, mood,
and stress. The scales included: the Pittsburgh sleep quality index, the Epworth Sleepiness
Scale, the Home Ostberg Morningness Eveningness Scale, the Profile of Mood States, and the
Subjective Units of Distress Scale.
Results from this study indicated that subjects were limited on quantity of sleep. The average
total amount of time actually spent sleeping was 7.2 hours. 25% of subjects reported getting
less than 6.5 hours and only 29.4% reported getting 8 or more hours per night (Lund et al.,
2010). In addition, poor sleep quality was associated with significantly higher self-reported
negative moods. Poor-quality sleeps also reported higher levels of stress during the week and
weekends compared to optimal-quality sleepers. There was also clear evidence that pointed to
stress as being a major contributor to poor sleep quality in college students. Lastly, it was
concluded that perceived stress (rather than sleep schedule, regularity, alcohol or drug use,
exercise frequency, or electronic usage) provided the most explanatory power for poor sleep in
this population (Lund et al., 2010).
Despite the clear results presented in this study, there were few limitation. The first limitation
was specific sample chosen to participate. Subjects were all from the Midwest, were generally
healthy, and were well educated. This, the findings form this study are not necessarily
generalizable to other college students in the United States, Another limitation was the use of a
one time online survey. Not only was the study all self-report, but it was only conducted once,
making it difficult to justify the results over a period of time.
Stress continues to be one of the biggest mental health issues that graduate students face, and
although attempts have been made to soften the problem, the issue of stress is largely dusted
under the rug, quieted by the unrelenting pressure to publish. As the previous research
indicated, there is a correlation between stress in students and various health variables.
However, few of these studies have been able to assess these variables in an objective manner.

Therefore, in our research we utilized current technology to more accurately assess these
health variables as well as stress to compare to the perceived stress of the students.
METHODS
Purpose
The purpose of this study was to determine the relationships among calculated and selfreported stress levels and health variables in graduate students enrolled in a health related
graduate program.
Participants
Fifty-eight apparently healthy, graduate students were recruited from various health related
graduate programs, including occupational therapist, physical therapist, physicians assistants,
and exercise physiologists. Participants were recruited through word of mouth during class
announcements during the fall semester 2015 at a small private university in the Midwest.
Inclusion criteria include 1) being 18 years and older, 2) no known cardiorespiratory and/or
musculoskeletal limitations that would limit physical activity, and 3) no known nickel, latex or
adhesive allergies. In addition, participants needed to own an Android or Apple smartphone to
utilize the software application.
Measures
Metria IH-1 Patch
The Metria IH1 was the primary assessment tool utilized during this study. The Metra IH1 patch
is a disposable lifestyle assessment tool that collects over 5,000 data points per minute and
reports multiple parameters for health, fitness, and wellness purposes (Vancive Medical
Technologies). The Metria IH1 is a capable of logging activity level, step count, calories burned,
sleep quality and duration. The different sensors include three axis accelerometers (range
4G), skin temperature (accuracy 0.8C), near body temperature (accuracy 0.8C), and
galvanic skin response. The accuracy (per day, for adults) for: total calories/METs for free living
activities: mean error <10%, total minutes of ambulatory physical activity: <5%, and total step

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count: mean error <9% (Vancive Medical Technologies). Specific variables assessed from the
patch included: total minutes of moderate and vigorous activity, number of steps, sleep quantity
and quality.
Calculated Stress
Symptoms of stress were monitored daily using the Stress Check App by Azumio. Stress Check
is the most innovative smartphone app that turns your mobile device into an easy-to-use, highly
accurate tool for measuring and tracking the physiological signs of stress. This was done by
measuring ones heart rate through the camera and light features on a smartphone; Stress
Check could estimate the level of stress in real time. Subjects were asked to obtain at least one
Stress check measurement each day. During days of elevated stress subjects were asked to
take additional measurements.
Perceived Stress
Participants perceived stress was assessed via an online survey that was administered upon
the completion of the study. This online survey was a modified version based off of the Graduate
Stress Inventory, consisting of a total of 18 questions. It required participants to rank their
perceived stress on a scale of 0-5. 0 being not at all stress full and 5 being extremely stressful
(See Appendix #).
Methods
Initial Assessment
Participants were instructed to wear clothing that allows for easy access of the upper arm.
Investigators initially confirmed that each participant met the inclusion criteria. Next, the
participants affiliated program (PT, MEXP, OT, PA), gender, height, weight, body mass index,
waist circumference, and blood pressure were recorded. Following the measurement of
common health vital signs, a three-inch by three-inch area on the participant's upper left arm
was cleansed with an alcohol wipe and dried for two minutes, per the manufacturer's
instructions. The patch was then activated and placed on the medial, left triceps. The Metria

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patch was held in place for three seconds to ensure adhesion. Participants were asked to carry
out normal daily activities once the assessment patch had been placed.
Procedures
The Metria patch was worn for a total of six days (as long as the battery allows), collecting
health information on sleep quality, physical activity classification and duration, total energy
expenditure, activity energy expenditure, metabolic equivalent (MET) levels, numbers of steps,
distance, lying down time, and sedentary time. On the sixth day, participants returned to the lab
for removal of the Metria patch, retrieval of the Stress Check app log, and completion of a brief
survey of perceived stress. Data was extracted from the patch, extrapolated, and analyzed.
Data Analysis
In addition, scores from the Stress Check app and stress survey were analyzed and correlated
with the data extracted from the patch utilizing multi-linear regression analysis in StatPlus.
RESULTS
See Future Published Work
DISCUSSION
See Future Published Work
CONCLUSIONS and FUTURE PERSPECTIVES
See Future Published Work

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