Artigo 1

CLINICAL STUDY PROTOCOL
published: 12 March 2019

doi: 10.3389/fpsyt.2019.00088
Short-Term Effects of a
Multidimensional Stress Prevention
Program on Quality of Life,
Well-Being and Psychological
Resources. A Randomized Controlled
Trial
Romina Evelyn Recabarren*, Claudie Gaillard, Matthias Guillod and Chantal Martin-Soelch
Division of Clinical and Health Psychology, IReach Lab, Department of Psychology, University of Fribourg, Fribourg,
Switzerland
It is well-documented that university students have an increased risk in developing

psychological problems because they face multiple stressors. Cognitive, behavioral,
and mindfulness-based stress prevention programs were shown to reduce symptoms
Edited by: of anxiety, depression, and perceived stress in university students. However, little is
Gianluca Serafini, known of their effect on resource activation. Additionally, most validated interventions are
Ospedale San Martino (IRCCS), Italy
unidimensional, i.e., including one stress-coping approach. In this study, we investigated
Reviewed by:
Piyanee Yobas,
the short-term effects of a multidimensional stress prevention program on students’
National University of Singapore, quality of life, psychological symptoms and resources, and resilience factors against
Singapore stress. Using an experimental design, 64 healthy undergraduate students (56 women),
Deborah Suchecki,
Federal University of São Paulo, Brazil between 18 and 34 years old (M = 21.34, SD = 2.53), from the University of Fribourg,
*Correspondence: Switzerland, were randomly allocated either to the intervention or the wait-list control
Romina Evelyn Recabarren group. The intervention group participated in a multidimensional stress prevention
[email protected]
program, integrating mindfulness-based activities, cognitive and behavioral strategies,
Specialty section:
social skills, and emotional regulation exercises. The program consisted of eight 2-h
This article was submitted to weekly sessions. Before and after the intervention, participants completed self-reported
Mood and Anxiety Disorders,
questionnaires evaluating quality of life; psychological symptoms such as depression,
a section of the journal
Frontiers in Psychiatry anxiety, social anxiety, and interpersonal problems; as well as psychological resources
Received: 15 July 2018 like self-efficacy, sense of coherence, self-compassion, and social support, presented
Accepted: 07 February 2019 online. A standardized clinical interview was performed at pre- and post-measurement
Published: 12 March 2019
times. To analyze the sort-term effects of the program, we used mixed, two-factorial
Citation:
Recabarren RE, Gaillard C, Guillod M
ANOVAs (per-protocol analyses). In accordance with our hypotheses, our results
and Martin-Soelch C (2019) showed significant reduction of psychological symptoms, including anxiety, interpersonal
Short-Term Effects of a
problems, and symptoms of pain; a significant increase in quality of life, sense of
Multidimensional Stress Prevention
Program on Quality of Life, Well-Being coherence, and self-compassion in students who participated in the intervention program
and Psychological Resources. A compared to the control group, (all p < 0.05). No significant results were found
Randomized Controlled Trial.
Front. Psychiatry 10:88.
for symptoms of depression, social anxiety, self-efficacy, and social support. These
doi: 10.3389/fpsyt.2019.00088 preliminary findings indicate specific short-term effects of our multidimensional stress
Frontiers in Psychiatry | www.frontiersin.org 1 March 2019 | Volume 10 | Article 88

Recabarren et al. Short-Term Effects of a Multidimensional Stress-Prevention Program
prevention program on psychological symptoms and on quality of life as well as promising

effects on psychological resources and factors associated with resilience against stress.
Future studies should investigate the long-term effects of the intervention as well as the
effects in clinical samples.
Keywords: stress, stress management, intervention program, psychological distress, anxiety, psychological
resources, quality of life, university students
INTRODUCTION physical inactivity) (43, 44), fewer leisure activities and less social
support, especially during the preparation and examination
University studies are a motivating step in life, yet at the same period (45) were described by university students. Students also
time students have to face new challenges and circumstances reported using more avoidance (46) and withdrawal coping
(1). The transition to university life requires them to adapt to strategies (2), and less adaptive coping strategies, like social
a new academic environment with unfamiliar assessment rules support (2, 47), cognitive reappraisal, and planning (48).
and a heavier workload (2, 3). Additionally some students have Personal and psychosocial resources were found to have a
jobs to make their financial needs meet or move away from protective role against stress in university students (3). High
friends and families in order to study in other cities (1, 2). levels of self-efficacy in university students were associated with
Students therefore have more freedom and autonomy, but also less burnout, emotional exhaustion (49), perceived stress (3),
other responsibilities and sometimes fewer resources (e.g., social and also with positive effects on grades (50), a more proactive
support) (1, 2). According to recent studies, university students attitude, and a better use of available support (49). In a study
reported increased psychological distress in different countries with French college students, self-efficacy was one of the most
worldwide. In particular, higher prevalence of psychological important predictors of stress (25).
distress was reported in medical students in Germany (3–5), the A strong sense of coherence is related to good stress
US (6), and Egypt (7). According to the results of a survey of the management and has an impact on the quality of life in
American College Association (8), around half of the Canadian different populations (51), including university students (52).
students reported depressive and anxiety symptoms during the A high sense of coherence was negatively associated with
last year. Studies in the UK, Spain, Jordan, and India indicated perceived stress (53, 54) and positively related with better social
that nurses and dental students showed high levels of distress (9– support and performance (53), and the use of active coping
12). Longitudinal studies in the US revealed that the first year (55) among university students. Self-compassion, being kind
of study is associated with particularly elevated psychological and understanding toward oneself in negative circumstances,
distress in college students (1, 13). Finally, university students predicted greater well-being (56) and correlated significantly with
were shown to experience higher psychological stress levels than positive mental health outcomes, such as less depression and
their peers in the general population. For instance, in Australia, anxiety and greater life satisfaction in undergraduate students
university students showed higher levels of distress than non- (57). Perceived social support has also been associated with fewer
students (14), and than the general population (15). The most stress symptoms, anxiety, and depression and with higher levels
frequent stress factors cited by university students are related to of resilience among university students from different countries
their studies and academic demands (e.g., exams, assessments, (Germany, Russia, and China) (21).
assignments, practicum) (2, 16), personal and social expectation Although university students report increased levels of
(17), living conditions, and financial situation (18, 19). psychological distress, only a minority of them seek help
Psychological distress in university students is associated (15, 58, 59). In the past few years however, diverse stress
with increased mental health disorders [31,4% of 12-month reduction interventions for university students have been
prevalence of any mental disorder in first year students from eight proposed. In a review and meta-analysis, Regehr et al. (60)
countries (20)], such as depression (21–25), and anxiety (22, 25). showed that cognitive, behavioral, and mindfulness-based
Burnout (26), suicidal ideation (22, 27), suicide attempts, and interventions aiming at reducing stress in university students
self-injurious behavior (28) were also reported in this population. were associated with decreased symptoms of anxiety, depression,
Somatic complaints (29, 30), and physical illnesses, such as and cortisol levels. Twenty-four randomized controlled
skin symptoms (31) and functional gastrointestinal disorders studies, including 1,431 students (24% male), were considered
(32) were also manifested by university students. Substance for the analysis. Taken together, the analyzed intervention
abuse, such as high consumption of alcohol (33, 34), tobacco had a significant impact in the reduction of symptoms of
(smoking), and cannabis (2) were also related with high levels anxiety in the experimental groups compared to the control
of distress. Higher levels of psychological distress are negatively groups. Furthermore, both cognitive-behavioral (CBT) and
correlated with student’s academic performance (35, 36), such mindfulness-based interventions showed an improvement in
as slipping grades. Poor quality of life (37) and well-being were anxiety levels.
also reported by university students (38). Sleep disturbances Mindfulness is characterized by paying attention in the
(30, 39–42), unhealthy lifestyle behaviors (e.g., poor nutrition, present moment, non- judgmentally, with self-awareness, and is

related to the reduction of stress perception and stress-related end of the program (2 months later). We expected significant
symptoms (61). Mindfulness-based interventions were shown to decreases in psychological symptoms, including depression,
have an impact on stress during the examination period (62, 63), anxiety, pain, social phobia, and anxiety symptoms, a significant
as well as on perceived stress, mental distress, well-being and self- increase of quality of life and of psychological resources,
efficacy among medical students (64, 65), and self-compassion including self-efficacy, sense of coherence, self-compassion, and
in undergraduates students (66). In some studies, however, social support in the intervention group compared to the
mindfulness-based interventions had significant beneficial effects control group.
on psychological morbidity, but not on distress or coping (67).
Other studies indicated that there were no significant differences
between the effects of a mindfulness-based group compared MATERIALS AND METHODS
to a physical activity program in reducing anxiety, depression
and stress (68). With regard to the CBT interventions aiming Participants
at reducing stress, they are generally focused on awareness Participants were recruited at the University of Fribourg,
of automatic thoughts; on understanding of the relationship Switzerland. Data collection was carried out between March 2015
between thoughts and emotions, on cognitive restructuring, and May 2017. The recruitment was made by e-mail, which
on problem-solving, on self-instructions, and on relaxation were sent to all students of the university (N = 10,000), flyers,
techniques. For these interventions, a significant impact on presentation of the study in diverse classes, webpages of the
anxiety (69–72), on anger and neuroticism (69), on somatic student’s groups, and by word of mouth. The majority of students
symptoms and cortisol levels (70, 73), on hardiness, and interested in participating in this study contacted us by e-mail.
on general self-efficacy (71) was reported in undergraduates We answered all the questions and sent the students a document
students. A significant effect was found also on hope, but with all the detailed information about the study. Interested
not on the amount of self-reported positive or negative students were contacted by phone to explain the study in more
affect (72). Finally, a strength-based CBT intervention showed detail. A first interview was scheduled as soon as the students
significant improvements on distress, on protective factors, accepted to participate in the study, during which exclusion and
and on quality of life in first year psychology students inclusion criteria were tested.
(74). This specific intervention was focused on improving Initially, 201 students (around 2% of all university students)
resilience skills, by activating personal strengths and talents. contacted us to participate in the study; and, to be eligible
Other stress prevention programs included social cognitive to the study, participants had to be a university student and
methods, also including exercises on communication skills, and understand French. Criteria for exclusion included the presence
were shown to reduce psychological distress among university of an existing mental disorder or endocrinal disease, or brain
students (75). Relaxation-based interventions, focusing on injury or neurological disorder, and the use of psychotropic
autogenic training and progressive muscle relaxation, also drugs. Moreover, participants were excluded if they underwent
demonstrated significant effects on cognitive and emotional any type of therapy or coaching at the moment of the study (11
burnout stress, on trait anxiety, and on mental health in students). After the interview (14 students) withdrew from the
university students (76–78). Finally, an intervention focusing study due to lack of time. Figure 1 shows the participants flow
of resources, the Resilience and Coping Intervention, showed diagram of the study.
significant beneficial effects on optimism, hope, stress, and The final sample was composed of sixty-four university
on depression in undergraduate students (79). However, to students aged between 18 and 34 years (M = 21.34, SD = 2.53);
our knowledge, only one stress reduction program for college 87.5% were women and 68.8% were native French speakers
students integrated a multidimensional program including or spoke French fluently (see Table 1). The majority of the
psychoeducation, cognitive reconstructing, emotional control participants studied psychology (79.7%) and the other fields of
exercises, and communication skills (80). This intervention studies were pedagogy (4.7%), law, economy, history, social work,
showed a significant decrease in psychological distress, but Slavic studies, informatic, French, neurobiology, nursing care,
no effects on coping strategies or on cortisol levels. In and business communications. Only one person was married,
conclusion, to date, no stress prevention intervention for the majority single, 68% were alone and 25 % living with a
students integrates all dimensions of stress, i.e., behavioral, partner. The majority of participants (49%) were in a medium
cognitive, emotional, and social at the same time; focusing not socioeconomic position, according to the IPSE Index (81). Four
only on stress management mechanisms but also on improving cohorts of 16 participants were recruited in each semester.
stress protection resources. No significant differences were found in the sociodemographic
In this study, we aimed to evaluate the short-term effects variables between the participants of the wait-list control group
of a multidimensional stress prevention program integrating and of the intervention groups (all p >0.05) [age: t (62) = −0.393,
mindfulness-based activities, cognitive, and behavioral strategies, p = 0.696; sex: X 2 (1) = 0.571, p = 0.450; socioeconomic
social skills and assertiveness activities, and emotional regulation position: Cramer’s V = 0.135, p = 0.769; studies (psychology
exercises on indicators of quality of life, psychological symptoms, and other): X 2 (1) = 0.097, p = 0.756]. Eight students reported
well-being, and psychological resources in university students. past psychopathological problems. None of the participants was
We compared the outcome variables in an intervention group receiving a treatment (neither drug or psychological) at the time
and a wait-list control group before and shortly after the of the study.

FIGURE 1 | Participant flow chart from recruitment until post-treatment measures.
TABLE 1 | Characteristics of participants (n = 64). stress intervention program with a wait-list control group.
The control group underwent the same measurements at
Intervention group Wait-list control group
the same measurement times as the intervention group but
n = 32 n = 32 did not follow the program, nor did they receive another
treatment. The outcome variables were assessed before (T1)
Age Mean (SD) 21.22 (2.27) 21.47 (2.8)
and after (T2) participation in the program in both groups.
Gender (Females) 29 (90.6 %) 27 (84.4%)
The study’s protocol was accepted by the Ethics Committee
Mother tongue (French) 21 (65.6%) 23 (71.9 %)
of the Cantons of Vaud and Fribourg (Protocol 261/14). All
Marital status (single) 25 (78.1%) 19 (59.4%)
participants received detailed information about the purpose
Single with partner 6 (18%) 10 (31%)
and the study’s process and signed a written informed consent.
Living with partner 1 (3.1%) 2 (6.3%)
Confidentiality was guaranteed and participants could withdraw
IPSE score [36–80] (middle 23 (76.67) 26 (81.25%)
class)
from the study at any time. This research followed the
Studies (Psychology) 26 (81.3 %) 25 (78.1 %)
ethical principles of the Declaration of Helsinki (82) and
Bachelor students (First year) 11 (34.4%) 13 (40.6%)
local regulatory law. For this protocol, we also followed
M.I.N.I. DIAGNOSTIC (LIFETIME)
the guidelines SPIRIT (83). This study was registered in
Past Depression 1 (3.1%) 4 (12%)
the research register of the University of Fribourg FUTURA
Panic Disorder 1 (3.1%) 1 (3.1%)
(Project number 6239; http://admin.unifr.ch/futura/content/
PTSD 1 (3.1%)
projects/6239) as well as in the Clinicaltrial Register (https://
clinicaltrials.gov. NCT03861013).
SD, Standard Deviation. Age in years. IPSE, Indice de position socioéconomique; BA, After having signed the written informed consent, students
Bachelor; M.I.N.I, Mini-International Neuropsychiatric Interview; PTSD, Post-traumatic
stress disorder.
participated in a structured interview, the Mini-International
Neuropsychiatric Interview [M.I.N.I., (84). French version, (85)],
conducted by a psychologist or by trained masters students in
psychology, which took between 30 and 60 min. When consent
Procedure was given, the interviews were filmed. The interviewers were
Using a randomized-controlled design, this study compared blinded to the group allocation. Following the interview, self-
an intervention group who participated in a multidimensional reported online questionnaires were sent and the participants

had to complete them in the following days. The participants TABLE 2 | Content of the program.
received a link to access to online questionnaires in an e-mail,
Session Content
and they received their participant’s code in a separate text
message. When completing the questionnaires using the survey 1 Organizational matters and program overview. Stress, triggers, and
program (LimeSurvey GmbH, Hamburg, Germany. http://www. coping strategies
limesurvey.org), the participants had to enter their codes. The 2 Cognitive and body techniques, mindfulness-based exercises
online questionnaires took the participants ∼1 h, with the 3 Cognitive and body techniques
possibility to take breaks whenever needed. Pre-measurements 4 Cognitive techniques
were completed at no more than 2 weeks before the beginning 5 Emotion and emotion regulation
of the study (T1). After that, participants were randomly 6 Emotion regulation
distributed in the intervention or the wait-list control group. The 7 Social skills and assertiveness
randomization was done using a free available software, i.e., www. 8 Social skills and assertiveness. Evaluation of the program and
randomization.com and was archived in an electronic document personal goals
saved separately. After randomization had been done and due to
the design of the study, investigators and participants were not
blinded about group allocation. The duration of the program was
2 months. Post-measures were taken after a maximum of 2 weeks theoretical information about the topic. Each session followed the
after the end of the intervention (T2) and included a structured same structure. From the second to the last, we always started
interview and the self-reported online questionnaires. In all with a brief breathing exercise. A summary of the former meeting
cohorts, T2 measurements were always performed at the end of and the objectives of the new session were presented. Afterwards,
the semester. For their participation, the students received money a review of the homework was done before starting with the new
(CHF 100) or experimental hour compensation (for psychology content. At the end of each session, homework was proposed
students). All the data collected were deidentified with a code and and participants answered questionnaires about group cohesion
confidentiality guaranteed. Participants did not have a dependent and the therapeutic alliance. Sessions 2 to 4 addresses behavioral
relationship with the research team, as the researchers were not and cognitive techniques (e.g., breathing exercises; planning and
involved in teaching of bachelor students. Once the study was cognitive restructuring) and also mindfulness-based exercises
completed, participants in the wait-list control group were given (e.g., awareness of breath meditation; exercises for living at
the possibility to participate in the program if they wished so, but the present moment). Sessions 5 and 6 addressed the topic of
finally none of them participated, because of lack of time. emotions and emotion regulation. Sessions 7 and 8 integrated
assertiveness training and social skills components (e.g.,
validating communication; interpersonal conflict resolution) (see
INTERVENTION Table 2 for a session overview).
The objective of this program is not only to experiment
A multidimensional stress prevention program integrating several techniques to prevent and to cope with stress, but
mindfulness-based activities, cognitive and behavioral strategies, also to increase resources of being more resilient against stress
social skills exercises, and emotional regulation was proposed that the participants could use as psychological tools in their
to the students. This intervention was composed of eight everyday life. The intervention was intended to be as experiential
modules and integrated validated techniques from different as possible. Participants sometimes worked alone, in pairs, in
approaches (Freiburger Training gegen Leistungsstress (86) subgroups or in plenum. They performed written exercises,
including cognitive behavioral techniques; RFSM-e-MOTION discussions, and role playing in personal or fictive situations.
(RFSM, Réseau Fribourgeois de Santé Mental, i.e., Fribourg Different types of material and triggers were also used, such as
Mental Health Network). The RFSM-e-MOTION intervention videos, audio, and visual supports. At the end of each exercise,
is a validated online program for relatives of individuals with a plenary discussion and a short theoretical link was made. The
mental disorders that focuses on the emotional aspects of program was manualized, and each session was protocoled by
the family members’ experiences and their relationship with a masters-level student to ensure compliance with the program.
the suffering person [(87)., see http://rfsm-e-motion.ch]. This Throughout the entire program, external psychotherapists were
program is based on Dialectical behavioral therapy (88). available for supervision when needed.
The intervention consisted of eight 2-h weekly group sessions.
The groups were composed of a maximum of eight students Measures
and were led by two trained clinical psychologists. Homework All students participated in a structure diagnostic interview the
between sessions was also proposed. Participants received the Mini-International Neuropsychiatric Interview [M.I.N.I., (84).
activities printed or on a CD. During the first session, participants French version, (85)] in order to exclude participants with
presented themselves, the rules of the group functioning psychopathological disorders. This short-structured interview
were discussed and a confidentiality document was signed. assesses DSM-IV (89) and ICD-10 (90) psychiatric disorders. At
Then, personal experience of stressful situations, triggered T1 we used the lifetime version, and at T2, the current one.
emotions, coping strategies, and their efficacy were discussed. Psychological symptoms and quality of life were measured
The participants’ experience with stress was the basis to introduce with the following self-reported instruments that were presented

online using LimeSurvey R (LimeSurvey GmbH, Hamburg, In the present sample Cronbach’s alpha were between 0.77
Germany. URL http://www.limesurvey.org) and 0.95.
Sociodemographic information. At first, participants were Quality of life was measured using the World Health
asked to report age, sex, marital status, nationality, languages Organization Quality of Life [WHOQOL-BREF, (99)]. This
(mother tongue and the language used at home), studies, 26-item version, rated on a 5-point Likert-like scale, assesses
and grade level. They also answered the Indice de position quality of life. Global score and four domains: physical (PHYS),
socioéconomique (81) which provides an index on the socio- psychological (PSYCH), social (SOC), and environmental
economic position of the participant in relation to the (ENVIR) quality of life can be calculated. Higher score means
Swiss population. higher perception of quality of life. Cronbach’s alpha coefficients
A screening for mental health problems was done with the in this study were ranged from 0.66 to 0.80 for the subscales and
French version of the Symptom Checklist [SCL-27-plus, (91)]. 0.48 for the score global.
Composed of 27 items rated on a 5-point Likert-like scale, Psychological resources were measured using the following
this checklist evaluates five dimensions: depressive, vegetative, instruments presented online with LimeSurvey R .
agoraphobic, and social phobia and pain symptoms, and a global Participants evaluated their perceived self-efficacy with the
severity index. A lifetime assessment for depressive symptoms General Self-Efficacy Scale [GSES, (100). French translation and
and a screening question for suicidality are also included. Cut- validation by Dumont et al. (101)]. This 10-item scale assesses the
offs: social phobia = 1.86; vegetative = 1.54; pain = 1.77; general self-efficacy, optimistic self-beliefs to cope with a variety
agoraphobic = 0.93; actual depression = 1.28). Cronbach’s alpha of difficult demands in life. The items are rated on a 4-point-
coefficient in this study were from 0.52 to 0.86. Likert-like scale going from 1 “not at all true” to 4 “exactly true.”
Depression was measured with the Beck Depression Inventory A higher score indicates a better general self-efficacy. Cronbach’s
- II [BDI-II, (92)]. Composed of 21 items, this inventory assesses alpha in this sample was 0.94.
the intensity and severity of depressive symptoms over the past 2 Sense of coherence was assessed with the 13-item Sense of
weeks. Items are rated in majority on 4-point Likert-like scale, Coherence Scale [SOC-13, (102). French validation by Gana
from zero to three. Higher scores indicate severe depressive and Garnier (103)]. Items are rated on a 7-point Likert-like
symptoms. Score thresholds from 12 to 19: mild = depression, scale, ranging from 1 “Never have this feeling” to 7 “always
20 to 27 = moderate depression, and >27 = severe depression. have this feeling.” Three components can be distinguished:
In this study the Cronbach’s alpha coefficient was 0.84. comprehensibility, manageability and meaningfulness. A high
The State-Trait Anxiety Inventory [STAI, (93). French version score expresses a strong sense of coherence. Cronbach’s alpha in
translated by Schweitzer and Paulhan (94)] was used to assess this sample was 0.85.
the presence and severity of anxiety symptoms. The state anxiety Self-compassion was evaluating using the Self-compassion
subscale is composed of 20 items rated on a 4-point Likert-like scale Short Form [SCS-SF, (104). French translation and
scale from 1 “not at all” to 4 “very much so” and the trait- validation by Kotsou and Leys (105)]. Composed of 12 items,
anxiety, with also 20 items, from 1 “almost never” and 4 “almost rated on a 5-point Likert-like scale from 1 “almost never”
always.” Higher scores indicate severe anxiety. Cut-offs STAI- to 5 “almost always,” this scale measures through 6 subscales
S: mild between 36 and 45, median: 46–55, high: 56–65, very individual’s level of self-kindness, self-judgement, common
high: > 65. Cronbach’s alpha for both subscales were 0.91. humanity, isolation, mindfulness, and over-identification. A total
Social anxiety was assessed using the Liebowitz Social Anxiety score, can be also computed. A total score is calculated by taking
Scale self-reported version [LSAS-SR, (95)]. Validated in French the mean of the 12 items after reverse scoring negatively worded
by Yao et al. (96), this 24-item scale measures social phobia items. Higher scores suggesting higher level of self-compassion.
through two subscales: fear triggered and the avoidance of social Cronbach’s alpha in this study was 0.86.
situations considering the previous week. Items are rated on 4- The Multidimensional Scale of Perceived Social Support
point Likert-like scale. A total score can be also calculated by [MSPSS, (106)] was used to assess perceived social support. This
adding the score in each subscale. Higher scores indicated higher 12 items scale evaluated three dimensions: Family, Friends, and
levels of social anxiety. Scores: low social anxiety: 56–65, marked: Significant others. The items are rated on a 7-point Likert-like
65–80, severe: 80–95 and very high: > 95. Cronbach’s alpha scale from 1“very strongly disagree” to 7 “very strongly agree.” A
coefficients in this study was 0.88. total score can be calculated, the higher the score the higher the
The Outcome Questionnaire [OQ R -45.2, (97). French perceived social support. Cronbach’s alpha in this study was 0.93.
validation by Flynn et al. (98)] was used to evaluate the
progress of the course of therapy and the following termination. Statistical Analysis
Composed of 45 items rated on 5-point Likert-like scale, Determination of Adequate Sample Size
ranging from 0 “Never” to 4 “Almost always,” this questionnaire To determine the optimal sample size, we performed an a
contains three subscales: Symptom Distress (SD), evaluating priori power analysis using G∗ Power [Version 3.1.9.2, (107)]
depression and anxiety, Interpersonal Relationships (IR), and computed an expected medium effect size based on the
assessing loneliness, conflict with others and marriage and family meta-analysis of Regehr et al. (60) for an ANOVA with 2
difficulties, and Social Role (SR), evaluating the difficulties in the measurement points, 2 groups and between and within factors
workplace, at school or home duties. A total score can be also interaction. We obtained a sample size of N = 54. In addition, we
calculated. Higher scores suggesting higher functional problems. estimated a drop-out rate of 15% based on the results of similar

intervention program (80), leading to an adequate sample size of The ANOVA analyses for the SCL-27-plus showed a
64 participants. significant interaction effect (time x intervention) for the pain
dimension [F (1,58) = 4.80, p = 0.033, η2 = 0.08] evaluated by post-
Analyses of Intervention Effects hoc independent t-tests indicated that the mean score on the pain
The statistical analyses were computed with IBM R SPSS R perception in the intervention group was significantly lower at T2
Statistics 25 (IBM Corp. Released 2017). Two-way mixed in comparison to the wait-list control group (p = 0.008; d = 0.73).
ANOVAs were computed. The within and between Furthermore, paired post-hoc t-test, revealed that the students
independent variables were, respectively, time (pre/T1 who participated in the intervention revealed significantly less
vs. post/T2), and group (intervention vs. control), both pain symptoms at T2 than at T1 (p < 0.001; d = −0.85),
with two levels. The dependent variables are the different but also the wait-list control (p = 0.002; d = −0.40). For the
outcome scores of psychological symptoms, quality of life and other dimensions, significant effects of time were found for
psychological resources. the agoraphobic [F (1,58) = 4.27, p = 0.043, η2 = 0.69], and
We analyzed our data using the per-protocol (PP) approach vegetative symptoms [F (1,57) = 16.33, p < 0.001, η2 = 0.22].
(108). In that respect, we calculated the ANOVA analyses but These results indicated that the agoraphobic and the vegetative
only with data from participants who participated in at least symptoms scores were significantly lower in both groups at T2
five of the eight intervention sessions and who answered the that at T1. Larger significant time main effect was found for
post-treatment measures. Considering the completion of post- the dimension of social phobia [F (1,57) = 17.33, p < 0.001,
treatment measures and according to the dependent variable η2 = 0.23], and moderate for group main effect [F (1,57) = 5.56,
considered, the sample of post-treatment participants for the p =0.022, η2 = 0.09], indicating that the scores at T2 were
PP-analyses varies from 56 to 60. Post-hoc t-tests were used to significantly lower that at T1, and that the intervention group
analyze the significant effects related to the a priori hypotheses. had significantly lower scores than the wait-list control group in
Effect sizes (Cohen’s d) were also calculated, using https://www. this dimension.
psychometrica.de/effektstaerke.html. The ANOVA analyses of the outcome questionnaire (OQ-
To increase the confidence of our results, we performed 45.2) showed a significant interaction effect between time and
the same analyses considering an intention-to-treat approach intervention for the IR sub-scores [F (1,55) = 4.71, p = 0.034,
(ITT). In the ITT analyses, all randomized participants who η2 = 0.08]. Post-hoc paired t-tests revealed that participants
completed the pre-treatment assessment (T1) were taken into of the intervention group report significant lower difficulties in
account, including non-completing participants and those with interpersonal social relationships at T2 than at T1 (p = 0.021;
missing outcomes. Missing data at post-treatment assessment d = −0.39). A significant main effect of time was found for the
(T2) were dealt by using the last observation carried forward sub-score of SD [F (1,55) = 13.05, p = 0.001, η2 = 0.19] and for
method (LOCF), which in this case correspond to the pre- the total score [F (1,55) = 8.17, p = 0.006, η2 = 0.13]. No other
treatment measure (T1) (108). A total of 64 participants were significant effects were found.
taken account for these analyses. The differences between the With regard to the quality of life (WHOQOL-BREF), the
two analyses are reported in the results’ section related to the results of the ANOVA’s indicated a significant interaction effect
concerned outcomes. between time and intervention for the dimensions psychological
[F (1,55) = 4.65, p = 0.035, η2 = 0.08] and social of the quality of
RESULTS life [F (1,55) = 4.81, p = 0.033, η2 = 0.08]. Post-hoc independent t-
tests revealed that the mean score in the dimension psychological
Participants present in the sessions varies from 5 (1 person) to quality of life was significantly higher in the intervention group
all session (11 students), a majority of students (70%) attended 7 at T2, compared to the wait-list control group (p = 0.045;
or 8 sessions, 25% of students were present at 6 and all of them d = −0.56), and paired t-test showed also that the intervention
finished the treatment. group revealed significantly higher scores at T2 compared with
Means and standard deviation (SD) of total scores and sub- T1 (p = 0.032; d = 0.42). No simple effects were found for
scores are presented in Table 3 for the outcomes variables social health quality (p >0.05). A significant moderate main effect
evaluating the psychological symptoms, quality of life and was found for time in the physical dimension [F (1,55) = 5.55,
psychological resources for the PP- sample. p = 0.022, η2 = 0.09], the scores in this dimension were
significant higher at T2 in comparison with the score at T1
Pre-post Treatment Analyses for both groups. No other significant effects were found in the
Psychological Symptoms and Quality of Life analysis of the other dimensions (physical and environment) and
Results of the mixed ANOVA’s for the psychological symptoms in the global score of quality of life (all p > 0.05).
and the quality of life (Figure 2), showed a significant interaction The ANOVA analyses for the BDI-II and the LSAS-SR showed
effect between time and intervention in the trait anxiety levels no significant interaction effects between time and intervention
measured with the STAI [F (1,56) = 4.87, p = 0.031, η2 = 0.08]. for the scores of depression [F (1,57) = 1.91, p = 0.173] or
Post-hoc paired t-test revealed that students who participated in social anxiety. A significant main effect was found for time
the intervention group reported significantly less anxiety traits [F (1,56) = 6.74, p = 0.012, η2 = 0.10], but not for group
at T2 in comparison to T1(p < 0.001; d = −0.68). No other [F (1,56) = 1.02, p = 0.317] for social anxiety. No other significant
significant effects were found (all p > 0.05). results were found.

TABLE 3 | Descriptive statistics for outcome variables evaluating psychological symptoms, quality of life, and psychological resources.
Variable T1 T2 Statistics
Intervention group Wait-list control group Intervention group Wait-list control group
Mean SD Mean SD Mean SD Mean SD t p
PSYCHOLOGICAL SYMPTOMS AND QUALITY OF LIFE

BDI-II 5.96 4.19 6.22 5.50 4.63 4.37 6.69 5.49 ns
STAI-S 31.19 7.42 32.06 9.12 30.33 10.04 34.00 12.35 ns
STAI-T 38.85 7.56 38.97 10.87 33.85 7.24 37.47 9.63 t(25)= 4.11b <0.001
LSAS-SR - Total 38.27 19.72 41.44 25.15 31.12 22.05 39.91 24.97 ns
SCL-27-PLUS
Social phobia 1.30 0.75 1.68 0.93 0.90 0.74 1.48 0.86 ns
Vegetative 1.07 0.55 1.23 0.56 0.76 0.55 1.04 0.50 ns
Pain 1.43 0.71 1.61 0.66 0.88 0.57 1.34 0.69 t(58)= −2.77a 0.008
Agoraphobic 0.45 0.53 0.61 0.51 0.39 0.52 0.48 0.50 ns
Current 0.52 0.47 0.62 0.61 0.50 0.75 0.71 0.61 ns
depression
OQ45.2 - Total 41.08 20.60 45.35 23.82 32.65 15.40 42.39 23.71 ns
SD 21.96 11.27 25.55 13.63 16.27 8.19 22.97 14.08 ns
IR 10.00 6.70 9.61 6.80 7.61 5.49 9.97 6.14 t(25)= 2.47b 0.021
SR 8.50 4.00 9.30 5.11 8.19 4.27 8.52 4.87 ns
WHOQOL-Bref - 17.15 1.97 17.19 2.59 17.62 2.40 17.25 2.68 ns
Global
PHYS 16.56 1.89 16.09 2.52 17.12 1.97 16.54 2.50 ns
PSYCH 14.62 2.24 14.48 2.42 15.46 1.77 14.31 2.32 t(55)= 2.05a 0.045
SOCIAL 15.36 2.83 16.17 2.93 16.33 2.73 15.74 3.41 ns
ENVIR 16.83 2.03 16.34 2.32 17.37 1.20 16.74 2.29 ns
PSYCHOLOGICAL RESOURCES
SOC - Total 65.89 9.95 66.28 12.44 71.04 8.04 67.09 11.70 t(25)= −0.48b 0.002
SCS-SF - Total 3.09 0.51 3.09 0.85 3.49 0.59 3.16 0.98 t(24)= −0.61b 0.001
GSES 31.40 6.05 31.78 7.35 34.72 3.37 33.25 5.05 ns
MSPSS 6.05 0.83 6.04 0.94 6.21 0.68 5.82 1.31 ns
Mean (SD) value at pre- (T1) and post-treatment (T2) by treatment condition (intervention group vs. wait-list control group) in the PP-sample (n = between 56 and 60)
SD, Standard Deviation; BDI-II, Beck Depression Inventory-II; STAI-S and STAI-T, Spielberger State-Trait Anxiety Inventory; LSAS-SR, Liebowitz Social Anxiety Scale; SCL-27-plus,
Symptom Checklist; OQ45.2, The Outcome Questionnaire 45.2; SD, Symptom Distress; IR, Interpersonal Relationships; SR, Social Role; WHOQOL-Bref, World Health Organization
Quality of Life-Bref; PHYS, Physical; PSYCH, Psychological; SOC, Social; ENVIR, Environmental; SOC, Sense of Coherence Scale; SCS-SF, Self-compassion Scale Short Form; GSES,
General Self-Efficacy Scale; MSPSS, Muldimensional Scale of Perceived Social Support.
a Post-hoc independent t-test
b Post-hoc paired t-test
* p <0.05.
Results analyses of the psychological symptoms and quality of Psychological Resources

life outcome variables using the ITT-sample were similar as the The ANOVA analyses of the SOC-13 and SCS-SF, yielded a
findings in the PP-sample only for the interaction effects between significant interaction effect between time and intervention for
time and intervention for the Interpersonal relationship (IR) sub- sense of coherence [F (1,56) = 5.50, p = 0.023, η2 = 0.09] and self-
score of the outcome questionnaire (OQ-45.2) [F (1,62) = 4.08, compassion [F (1,54) = 4.64, p = 0.036, η2 = 0.08]. Post-hoc paired
p = 0.048, η2 = 0.06], and for the dimensions psychological t-tests indicating that the participants of the intervention group
[F (1,60) = 4.08, p = 0.048, η2 = 0.06] and social [F (1,60) = 4.48, showed significant higher levels of sense of coherence and of self-
p = 0.038, η2 = 0.07] quality of life (WHOQOL-BREF). Similar compassion at T2 than at T1 (p =0.002; d = 0.57; p = 0.001;
to the analyses in the PP-sample no significant effects were found d = 0.72, respectively) (Figure 3).
in the ANOVA analyses of the BDI-II, and the LSAS-SR in the With regard to self-efficacy, the ANOVA analyses of the
ITT-sample. However, contrary to the analyses in the PP-sample, GSES revealed no significant interaction effect between time
the analyses of the ITT-sample for the trait anxiety (STAI) and and intervention [F (1,55) = 1.35, p = 0.251] but a large
for the pain dimension of the SCL-27-plus, showed no significant significant main effect for time [F (1,55) = 9.01, p = 0.004,
interaction effects between time and intervention (for details see η2 = 0.14] but no for group. The score of self-efficacy
Supplementary Material). was significant higher after the treatment for both groups,

FIGURE 2 | Results of the interaction effects (time x intervention) in psychological symptoms and quality of life: (A) Anxiety trait: the intervention group reported
significantly less anxiety trait at T2 compared with T1. (B) Pain symptoms: the intervention group reported significantly lower pain symptoms at T2 in comparison to
the wait-list control group; both groups showed also significantly less pain symptoms at T2 than at T1. (C) Interpersonal relationships: the intervention group reported
significantly lower interpersonal difficulties at T2 than at T1. (D) Psychological quality of life: the intervention group reported significantly higher scores in the
psychological quality of life perceived at T2, compared to the wait-list control group. The intervention group showed also significantly higher scores at T2 than at T1.
Errors bars represent standard errors. P < 0.05.
FIGURE 3 | Results of the interaction effects (time × intervention) in psychological resources: (A) Sense of coherence: the intervention group reported significantly
higher levels of sense of coherence at T2 than at T1. (B) Self-compassion: the intervention group revealed significantly higher scores in self-compassion at T2
compared with T1. Errors bars represent standard errors. P < 0.05.
in comparisons with the scores at T1. ANOVA analyses of DISCUSSION

the MSPSS showed no significant interaction effects or main
effects for time and group for the perceived social support This study aimed at evaluating the short-term effects of a
(all p > 0.05). multidimensional stress prevention program on psychological
Considering the ANOVA analysis of the psychological symptoms, well-being, and psychological resources in university
resources taken into account in the ITT-sample, the results students. The most remarkable results are the improvement in
are similar to the PP-sample results (for details see the quality of life, and psychological resources, including sense of
Supplementary Material). coherence and self-compassion, as well as the decrease of specific

psychological symptoms, such as anxiety, pain, and interpersonal with research indicating the link between stress and quality of
problems, in the intervention group compared with the wait-list life in university students, and the importance to reinforce the
control group. mediators between them, such as personal and psychological
With regard to the psychological symptoms, we found, resources (54). Furthermore, in recent studies, the use of
as expected, significant decrease in anxiety scores in the individual strength in university students showed benefits in
intervention group as compared to the wait-list control group. mental health among students (121) and was positive related with
These findings are consistent with previous research analyzing positive affect, self-esteem, and vitality, and negatively with stress
stress prevention programs among university students (60, and negative affect (122).
109, 110). A meta-analysis about the evaluation of stress Very interestingly, the short-term effects of our intervention
reduction interventions among medical university students, indicate significant increases in specific psychological resources,
indicated that mindfulness-based stress reduction, meditation including higher levels of sense of coherence and self-compassion
techniques and self-hypnosis are effective in reducing anxiety after the intervention in the intervention group than the wait-list
(111). Many studies have reflected the improvement of control group. These results are consistent with other findings
anxiety (60). Surprisingly, our findings reflected a reduction suggesting that sense of coherence is an indicator of resilience
in trait-anxiety but not in state-anxiety. This could be and can be regarded as an attitude or predisposition promoting
explained by the composition of our sample, we included health and resilience by using different personal resources (123,
only participants without psychopathological complains, which 124). Higher sense of coherence was found to be associated with
could have affected their level of state anxiety. Furthermore, less stress and better quality of life in students (52, 54, 123, 125).
the post-intervention measurements were always at the end of In addition, improvement in the sense of coherence is interesting
the semester, during the review period, and they were closed because this concept is comprised as an attitude or predisposition
to the exams. This could also have an effect on the levels of (126). In this sense, it is important because it will allow the
anxiety because it is known as an anxious and stressful period participants to change their attitude toward future stressful
for students. events and other situations (124). Previous research indicates
The significant reduction in pain symptoms in the the relationship between self-compassion and psychological well-
intervention group is in line with our hypothesis of a being in university students (127, 128). In view of previous
diminution of psychopathological symptoms. This is particularly research that showed the importance of personal resources (54),
important as university students were shown to report increased like optimism (129), self-efficacy, and resilient coping (3) related
psychosomatic symptoms (30). This is also interesting as other with decreased perceived stress, these results are important for an
validated intervention programs in students did not find any intervention aiming at reducing stress and increasing resources
effect on somatic and/or psychosomatic symptoms. We should in a students’ population. Nevertheless, further long-term studies
also note that the control group reported a reduction in the pain have to be done to investigate the potential protective effect of
score, but to a lesser extent. The lack of significant results for the these increased personal resources against stress.
other dimensions of the SCL-27-plus could be explained again Contrary to our expectations and previous studies, social
by the fact that we included only asymptomatic participants, support and self-efficacy are not improved after the participation
i.e., without clinically significant psychopathological symptoms. in the program (130, 131). Self-efficacy is one the most important
Therefore, it is not surprising that we did not find any significant predictors of distress (25), but also an important personal
changes on measures of psychopathological symptoms. This resource to reduce the effects of stress in well-being (132), like
could also explain the lack of differences observed for the social support (133, 134).
depression scores. Taken together these results indicated promising short-
The intervention improves, as expected, the functional level term effects of our program. Specifically, because it increases
of the participants, but only in the domain concerning the some important resources against stress but also because the
interpersonal problems in the intervention group, compared to participation in the program have effects in psychological
the wait-list control group. These results are very relevant as symptoms in an asymptomatic sample. The results are consistent
recent researches indicated that psychosocial factors, such as with the objective of this multidimensional intervention,
perceived social support, and resilience, are protective factors of which is not only to focus on stress reduction, but also
mental health in university students (21). Stress levels are related to improve some personal skills and psychological resources
also with social isolation [e.g., among law students (112, 113)], to prevent future stressful situations. The replication of the
and also with not having a satisfying relationship with the family results across different samples, per-protocol and intention-
and friends in university students (114). Interpersonal stress to-treat, suggest that our program have an important short-
was also associated with depression, anxiety and somatization effect on psychological symptoms and quality of life, particularly
(115), and suicide risk (116, 117) in university students. To interpersonal relationship difficulties, psychological, and social
better adjust at the university context campus connectedness quality of life, but also in personal resources (sense of coherence
(118), family and peer support, and satisfying relationships are and self-compassion). Unfortunately, we cannot specify exactly
important (38, 119) for university students. These psychosocial which dimension of our program has a particular effect on
factors are a mediator between stress and health consequences which variable, but our results show that the entire program
(120). Therefore, as predicted, we found an improvement in the has an effect on psychological symptoms, well-being and psycho-
quality of psychological health. These findings are consistent social resources.

Some limitations deserve to be taken into consideration. have to analyze the medium and long-term effects of our
First, the sample was composed by a majority of students of program in a larger healthy sample, but also, evaluate the effects
the University of Fribourg, females and studying psychology, in clinical samples. Furthermore, it could be interesting to
which limits the generalization of our results. The gender evaluate the effects of this program using biomarkers or daily
disparity does not allow to compare the differences in the life assessments.
short-term effects of our program between men and females. In conclusion, our findings provide very promising
Bachelor students in psychology had an additional motivation preliminary evidence of the efficacy of our multidimensional
factor for their participation, they could receive experimental stress prevention program, not only in the reduction of
points instead of financial reimbursement in order to meet psychological symptoms, but also in the improvement of well-
the requirements of the bachelor studies. A second limitation being and some important psychological resources increasing the
is the control group chosen, the wait-control list. A better resilience to stress. In that way, we can also define our program
control group would be an active one, in this sense it could be as a resource-activating intervention.
interesting to evaluate the effects of our program with an already
well-validated stress intervention (i.e., cognitive, behavioral, or AUTHOR CONTRIBUTIONS
mindfulness-based), in order to distinguish more in detail, the
effect of the multidimensionality. Third, the use of self-report RR, CG, MG, and CM-S contributed to the conception and
instruments can lead to memory bias and greater subjectivity in design of the study and were involved in the interpretation
the responses, specially the length of our online questionnaires of the data. RR, CG, and MG contributed to the conception
(∼1 h) may have led to less accurate answers due to fatigue, of the measurements and collection of data. RR performed
even if participants could take breaks. Fourth, the relatively the statistical analyses. RR and CM-S wrote sections of the
small sample size can be also a factor to take into account manuscript. All authors contributed to manuscript revision, read,
in the limitations. Fifth, we did not control for past finished and approved the submitted version.
psychological or drug treatments. However, we controlled that
none of the participants was receiving a treatment (neither drug FUNDING
or psychological) at the time of the study. A last limitation
is that we cannot completely rule out that a person external This study was supported by the research pool of the University
to the study has filled the online questionnaires using the of Fribourg (grant number 578).
personal codes.
However, our study also has some specific strengths, including ACKNOWLEDGMENTS
for instance the use of a randomized controlled design. There
is also very little drop-out related to the intervention. It seems Our acknowledgments go to the participants on this study, the
that the participants who engaged in the program also stayed Bachelor and Master students that collaborate with the study,
until the end since all participants have completed the program; and the University of Fribourg. We thank Andrew Niemann for
and 70% of them participated to all sessions. Future studies correcting the English version of this article.
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competency, self-efficacy and self-esteem experienced by nursing Conflict of Interest Statement: The authors declare that the research was
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00492 be construed as a potential conflict of interest.
132. He FX, Turnbull B, Kirshbaum MN, Phillips B, Klainin-Yobas P.
Assessing stress, protective factors and psychological well-being among Copyright © 2019 Recabarren, Gaillard, Guillod and Martin-Soelch. This is an open-
undergraduate nursing students. Nurse Edu Today. (2018) 68:4–12. access article distributed under the terms of the Creative Commons Attribution
doi: 10.1016/j.nedt.2018.05.013 License (CC BY). The use, distribution or reproduction in other forums is permitted,
133. Bore M, Kelly B, Nair B. Potential predictors of psychological provided the original author(s) and the copyright owner(s) are credited and that the
distress and well-being in medical students: a cross-sectional pilot original publication in this journal is cited, in accordance with accepted academic
study. Adv Med Educ Pract. (2016) 7:125–35. doi: 10.2147/AMEP. practice. No use, distribution or reproduction is permitted which does not comply
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CLINICAL STUDY PROTOCOL

published: 12 March 2019

It is well-documented that university students have an increased risk in developing

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prevention program on psychological symptoms and on quality of life as well as promising

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FIGURE 1 | Participant flow chart from recruitment until post-treatment measures.

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Mean SD Mean SD Mean SD Mean SD t p

PSYCHOLOGICAL SYMPTOMS AND QUALITY OF LIFE

Results analyses of the psychological symptoms and quality of Psychological Resources

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in comparisons with the scores at T1. ANOVA analyses of DISCUSSION

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Frontiers in Psychiatry | www.frontiersin.org 10 March 2019 | Volume 10 | Article 88

REFERENCES 8. American College Health. American College Health Association-National

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Frontiers in Psychiatry | www.frontiersin.org 12 March 2019 | Volume 10 | Article 88

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