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Doctor of Nursing Practice (DNP) Translational and Clinical Research Projects School of Nursing

Spring 2021

Resilience 101: A Resilience Education Intervention for College Resilience 101: A Resilience Education Intervention for College

Freshmen Freshmen

Angie Childre [email protected]

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Recommended Citation Recommended Citation Childre, Angie, "Resilience 101: A Resilience Education Intervention for College Freshmen" (2021). Doctor of Nursing Practice (DNP) Translational and Clinical Research Projects. 50. https://kb.gcsu.edu/dnp/50

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Running head: RESILIENCY IN COLLEGE FRESHMEN 1

Resilience 101: A Resilience Education Intervention for College Freshmen

Angie Childre

GCSU

Jennifer Goldsberry, DNP, MSN, FNP-BC, APRN, CNE Committee Chair

Leslie Moore, PhD, RN, CNE, MBA, Committee Member

Catherine Fowler, DHSc, RN, CNE, Committee Member

Dixie Turner, PhD, Committee Member

RESILIENCY IN COLLEGE FRESHMEN 2

Table of Contents

Abstract 3

Chapter I: Introduction and Background 4

Problem Statement 5

Purpose 5

Specific Aim and Clinical Questions 6

Background and Significance 7

Theoretical Framework 11

Chapter II: Review of Literature 18

Synthesis of Evidence 29

Chapter III: Methodology and Design 34

Chapter IV: Results 44

Sample description 44

Instrument Characteristics 46

Clinical Questions 48

Miscellaneous Findings 52

Chapter V: Discussion 54

Strengths and Limitations 55

Future Research Implications 58

References 60

Appendices 70

RESILIENCY IN COLLEGE FRESHMEN 3

Abstract

This evidence-based project sought to evaluate resilience in freshmen college students enrolled

in a Bridge scholar program (BSP) in a liberal arts university in the southeastern United States.

The American College Health Association (ACHA) found that stress and anxiety were the top

two indicators for impacting academics in 2019 and had been at the top since 2009 at the

university of study (ACHA, 2019). The study used a pretest and posttest design method with the

implementation of a five-week resilience education intervention. There was no significant

difference found in students’ resilience, health promoting behaviors, anxiety or stress from

baseline to two months. However, there was a significant increase in students’ knowledge of

resilience, stress and anxiety demonstrated from baseline to 2 months supporting the hypothesis

(Z=2.787, p=.005). Results of the data may have been influenced by the current pandemic.

Limitations of the study included a small sample size and limited time for the intervention.

Future research should focus on a resilience education intervention for all college students,

beginning in their freshmen year and continuing throughout their college career in an effort to

prevent mental health problems and support student's future well-being.

Keywords: resilience, anxiety, stress, intervention, college students

RESILIENCY IN COLLEGE FRESHMEN 4

Resiliency in College Freshmen

Chapter 1: Introduction and Background

The rate of mental health issues in college students is increasing at an alarming rate

(Coiro, Bettis, & Compas, 2017; DeConinck, Matthijs, & Luyten, 2019; Dvorakova et al., 2017;

Herrero et al., 2019; Houston et al., 2017; Jafari, 2017; Lipson & Eisenberg, 2018). The

American College Health Association (2019) found that 87% of college students felt

“overwhelmed by all they had to do” in the past year and 54% of students reported anxiety that

had affected their academic performance (Coiro, Bettis, & Compas, 2017; Houston et al., 2017).

In a large survey of college students (N=25,475) seeking mental health, the Center for Collegiate

Mental Health (2015) found the most frequent reported concerns were anxiety (55%), depression

(45%) and stress (43%). Academic success is a fundamental goal of a college student, and the

inability to manage academic demands increases feelings of anxiety and depression which if not

addressed, can lead to suicidal ideation (Jafari, 2017; Lipson & Eisenberg, 2018). First year

college students can be vulnerable to stress and adversity due to an unfamiliar environment

(Dvorakova et al., 2017; Newcomb-Anjo, Barker, & Howard, 2017; Saleh et al., 2018; Turner,

Scott-Young, & Holdsworth, 2017). Academic engagement, mental health and well-being,

healthy lifestyle behaviors and academic achievement is connected to resilience which is the

approach to this project (Turner, Scott-Young, & Holdsworth, 2017).

Resilience has many definitions throughout the literature. Resilience is the ability to

positively adapt in the face of adversity, trauma or stress (Gras et al., 2019; Herrero et al., 2019;

Houston et al., 2017; Masten, 2001; Rathore, 2017). Resilience is the capacity of someone to

recover in the face of stressful situations (Leppin et al., 2014; Rahat & Ilhan, 2015). Resilience

requires an individual to first face a risk and then bounce back from the stressful circumstance

RESILIENCY IN COLLEGE FRESHMEN 5

(Masten, 2001; Rahat & Ilhan, 2015; Turner et al., 2017). When the definition of resilience is

applied to higher education, it is the student who achieves academic success when faced with

non-academic obstacles that could interfere with their ability to achieve and persevere towards

completing their degree (Debb, Colson, Hacker, & Park, 2018).

Problem Statement

College represents a change in the lives of adolescents. The transition into adulthood is

considered a stress that can lead to an increased risk of developing mental health issues and

unhealthy lifestyle behaviors (Dvorakova et al., 2017; Herrero et al., 2019; Saleh, Camart,

Sbeira, & Romo, 2018). Because of this, college entry is an important time to establish health

behavior practices that will be beneficial for the student, not only during transition into college

life, but also for their future (Dalton & Hammen, 2018). Universities face the challenge of

facilitating well-being among freshmen to prevent potential mental health problems that could

develop in the upcoming college years (Koydemir & Sun-Selisik, 2016). Therefore, a program

intended to increase students’ resilience as they transition from high school to college is needed

to help students establish these necessary healthy lifestyle behavior practices.

Purpose

The purpose of this study is to evaluate an on-line resilience training program

intervention, Resilience 101, to first semester freshmen enrolled in the university’s Bridge

Scholars Program (BSP). The goal of the intervention is to promote improved mental health and

healthy lifestyle behaviors through resilience as students transition into university life. A

resilience training program is a group of interventions that systematically attempt to enhance

resilience in individuals and prepare them for future adversity (Leppin et al., 2014; Enrique et al.,

2019). Resilience studies should be conducted when risk or adversity actually occurs, which

RESILIENCY IN COLLEGE FRESHMEN 6

supports the intervention at the beginning of the freshmen semester when change in the lives of

students is considered a stress (Dvorakova et al., 2017; Enrique et al., 2019; Herrero et al., 2019;

Jafari, 2017; Masten, 2001; Rahat & Ilhan, 2015; Saleh, Camart, Sbeira, & Romo, 2018).

Specific Aim and Clinical Questions

The specific aim of the study is to evaluate whether an on-line resilience program,

Resilience 101, is effective in preventing potential mental health problems and supporting

healthy lifestyle behaviors for incoming freshmen enrolled in Georgia College and State

Universities BSP. This will be accomplished through a three-step process: 1) identify the

population for the study and develop a resilience training program for the identified population;

2) measure the populations resilience level, perceived stress, general anxiety, health promoting

lifestyles and knowledge with instrumentation as a pre-test prior to implementing the five-week

resilience intervention program; and 3) determine the effectiveness of the resilience training

intervention with a post-test conducted eight weeks following the five-week resilience

intervention program. The clinical questions are as follows:

Following completion of the Resilience 101 education intervention:

1. What effect did the intervention have on BSP student's resilience? 2. What effect did the intervention have on BSP student's anxiety? 3. What effect did the intervention have on BSP student's perceived stress? 4. What effect did the intervention have on BSP student's health promoting

lifestyle behaviors? 5. What effect did the intervention have on BSP student's knowledge of resilience, anxiety,

stress and health promoting lifestyle behaviors?

RESILIENCY IN COLLEGE FRESHMEN 7

Background and Significance

The World Health Organization (1948) defined health as not only the absence of disease,

but the state of complete mental, physical and social well-being which showcases the

interconnection between mental health and physical health. Mental health focuses on emotions,

thoughts and feelings that help in the ability to solve problems and work through difficulties

(Centers for Disease Control [CDC], 2018). Physical health gives attention to the proper care of

one’s body and is affected by lifestyle behavior choices such as diet and physical activity. Poor

mental health can negatively impact physical health just as poor physical health can lead to an

increased risk of developing mental health problems (Mental Health Foundation, 2016). These

concepts solidify the significance behind the proposed DNP project to promote mental health and

healthy lifestyle behaviors through a resilience intervention program to college freshmen.

Stress is defined as a normal, non-specific physiological response to everyday pressures

and demands, but it can become unhealthy when it alters daily living (American Psychological

Association [APA], 2019). Stress is typically caused by an external trigger and can be short-

term, such as a school project deadline or relationship problems, or long-term, such as chronic

illness or discrimination (APA, 2019). Stress can be perceived as negative or positive. A

positive stress may motivate, excite, and improve focus, whereas stress that is high, chronic

and/or perceived as negative may have long-term effects on health (Rodriguez, Kozusznik, &

Peiro, 2013).

Anxiety, like stress, is an emotional response; however, anxiety brings about feelings of

tension, worried thoughts and physical change (APA, 2019). People with anxiety disorders such

as generalized anxiety, panic disorders, and phobias usually have repeated intrusive thoughts or

concerns and/or excessive worry that will not go away even without a stressor being present

RESILIENCY IN COLLEGE FRESHMEN 8

(APA, 2019). Both stress and anxiety can cause mental and physical symptoms such as

irritability, anger, fatigue, sleep difficulties, sweating, trembling, dizziness, and elevated heart

rate and blood pressure (APA, 2019).

Stress and anxiety are also associated with maladaptive health behavior practices related

to lifestyle choices (Dalton & Hammen, 2018). These can include unhealthy eating, sedentary

behavior, insufficient sleep, and substance use (Dalton & Hammen, 2018). Transition into

college alone can cause young adults to establish unhealthy lifestyle behaviors as well as develop

mental health problems due to the new demands they face. These lifestyle patterns adopted at

this stage in their life can continue into adulthood and possibly lead to an increased risk of

disease (Alzahrani, et al, 2019; Aminisani, et al., 2016).

According to the American College Counseling Association (ACCA) (2017), over the

last twenty years, there has been a growing trend of stress in university students. In 2000,

sixteen percent of college students sought help for mental health problems, as compared to 44%

in 2013 and 52 % in 2014 (Reetz, Krylowicz, & Mistler, 2014). According to Dr. Stephen

Wilson, Director of Counseling Services at GCSU, the demand of students seeking treatment at

GCSU Counseling Services has risen steadily over the past six years. The number of students

receiving treatment at GCSU has increased by 46.1% from 2011 to 2018 with a 51.5% increase

in student’s seeking treatment in August 2018 compared to August 2017 (Wilson, 2018).

The freshman year of college, as compared to the other years, supports higher levels of

ongoing and chronic stress which can lead to poor coping strategies, unhealthy relationships, and

a decrease in grades (Dvorakova et al., 2017). Lower academic performance is defined by the

American College Health Association National College Health Assessment II (ACHA-NCHA II)

as receiving a lower grade on an exam or an important project, receiving a lower grade in a

RESILIENCY IN COLLEGE FRESHMEN 9

course, receiving an incomplete or dropping a course, or experiencing a significant disruption in

thesis, dissertation, research or practicum work (ACHA, 2019). Lower academic performance

effects a student’s motivation and self-efficacy that can lead to anxiety and depression (Lipson &

Eisenberg, 2018). Further consequences of low academic performance are social disengagement,

homesickness, financial burdens, and an overall decrease in interest in long-term objectives such

as degree completion (Rahat & Ilhan, 2015).

Because stress is considered normal, the focus of health promotion efforts should not be

on the stress itself, but perhaps in how students individually respond to different levels of stress

(Rice, 2012). Coping is defined as cognitive and behavioral efforts to control, lessen or endure

internal and/or external strains related to stressful situations (Houston et al., 2017; Coiro, Bettis,

& Compas, 2017). Behaviors that help promote mental health and well-being and manage stress

are described as resilient (Koydemir & Sun-Selisik, 2016). Those who use resilient coping

strategies are able to manage stress in a healthy way and can lower unhealthy stress-related

symptoms and behaviors (Regehr et al., 2014). Awareness of one’s stress levels and recognizing

coping strategies are two important steps in promoting resiliency (Regehr et al., 2014).

The American College Health Association National College Health Assessment II

(ACHA-NCHA II) is a national survey that assists colleges and universities by collecting data on

their campus related to student habits, behaviors, and perceptions on prevalent health topics

(ACHA, 2019). According to the ACHA-NCHA II (2019), the top three impacts to academic

performance of students at GCSU within the last twelve months was stress (38.4%), anxiety

(32.9%) and sleep difficulties (26.8%). Further evaluation of past ACHA-NCHA II reports for

GCSU showed stress, anxiety, and sleep difficulties at the top of the list for impacting academics

RESILIENCY IN COLLEGE FRESHMEN 10

since 2009. Anxiety and sleep difficulties have doubled in ten years and stress has increased by

14%.

Colleges and universities throughout the United States have developed programs such as

a Bridge Scholar Program (BSP) to aid students in transitioning more successfully from high

school to college. Traditionally, a BSP targets minority, low-income, underprepared students by

providing them with foundational knowledge and skills required for transitional success (Bir &

Myrick, 2015; Grace-Odeleye & Santiago, 2019). According to Hali Sofala-Jones, director of

the BSP at GCSU, the BSP at GCSU looks quite different than other programs in that, like the

student body at GCSU, it is predominantly white with students coming from more economically

secure backgrounds. However, the students enrolled are the most academically vulnerable

students of the incoming freshmen (GCSU BSP, 2020). They typically fall into one of three

groups in order to get a nomination into the BSP: low standardized test scores but high GPA,

high standardized test scores but low GPA, or lower GPA/standardized test scores but impressive

experiences and recommendations (GCSU BSP, 2020).

Counseling services play an important role on college campuses by being available on-

campus and with the use of assertive outreach efforts to prevent mental health problems (Coiro,

Bettis, & Compas, 2017). Currently at GCSU, Counseling Services are available to all students

to assist with their mental health needs, particularly stress, anxiety and depression. GCSU’s

Counseling Services employs six full time and two part-time counselors. Counseling services

play an important role in supporting student retention and academic performance, and in

reducing risk to the university from issues such as student suicide. According to the Director of

Counseling Services, Dr. Stephen Wilson, resilience training is incorporated in daily counseling

of students; however, it is not offered as a stand-alone program. Although services are available

RESILIENCY IN COLLEGE FRESHMEN 11

to prevent mental health issues, university students need a wider variety of social support sources

to cope with stress they encounter in their first year (Coiro, Bettis, & Compas, 2017; Rahat &

Ilhan, 2015).

Stress reduction training includes resilience and coping strategies that can be taught and

reinforced beginning when students enter higher education and continuing through their college

career (Turner, Scott-Young, & Holdsworth, 2017). Stress reduction and resiliency and their

implications are important for college students, as this is a critical period in students’ lives where

either mental health issues can arise or health behavior practices are established, each

significantly influencing students later in life (Dalton & Hammen, 2018). Identifying the best

method to incorporate stress reduction, healthy lifestyle behaviors, and resiliency in the college

population needs consideration, and therefore is the focus of this project.

Theoretical Framework

The Transactional Model of Stress and Coping (TMSC) was used as a framework to

guide this DNP project towards a solution to the stated problem. Originally proposed by Lazarus

and Folkman in 1984, the TMSC is a theory rooted in psychology (Lazarus & Folkman, 1987).

The backbone of this model involves a relationship between a person and the environment

whereby stressors are identified, appraisals are made, and coping resources are applied in order

for adaptation to occur (Etchin, Fonda, McGlinchey, & Howard, 2019; Lazarus & Folkman,

1987). According to Lazarus (1987), personal resilience is valuable as an internal coping

resource for minimizing the negative effects of stress. This resilience can potentially lead to

maintenance of mental health during times of adversity (Lazarus & Folkman, 1987). The TMSC

will help universities such as GCSU to address the challenge of which difficulties facing college

RESILIENCY IN COLLEGE FRESHMEN 12

freshmen should be contended with, and how a students’ appraisal of their difficulties helps them

overcome their distress (Brooker, Brooker, & Lawrence, 2017).

Definitions

In order to better understand the concepts of Lazarus’ and Folkman’s theory, defining key

terms used within the context of the theory will be essential. The following definitions will be

used to guide this project:

Transactional- a relationship; the relationship or transaction in the TMSC is that of a

person and the environment joined together in a new state and losing their independent abilities

(Lazarus & Folkman, 1987).

Well-being- being happy and content; positive psychology that focuses on positive

concepts such as resilience and optimism instead of negative concepts (Ercan, 2017; Koydemir

& Sun-Selisik, 2016).

Stressor/stress- a stimulus; a response (Etchin, Fonda, McGlinchey, & Howard, 2019); in

the TMSC, it is seen as taxing or exceeding one’s resources that leads to decreased well-being

(Lohacheewa, Sitthimongkol, Sirapo-ngam, & Viwatwongkasem, 2016).

Appraisal- when people evaluate what is happening to them from the stand-point of its

significance towards their well-being (Lazarus & Folkman, 1987).

Cognitive appraisal- process of evaluating if an encounter with the environment is

relevant to well-being (Etchin, Fonda, McGlinchey, & Howard, 2019; Li & Yang, 2016)

Primary appraisal- first perception or awareness; a person’s decision about whether he or

she has any stakes in an encounter and if so, what kind (Lazarus & Folkman, 1987)

Secondary appraisal- also known as coping; a cognitive process where action is taken to

improve a stressor (Etchin, Fonda, McGlinchey, & Howard, 2019; Lazarus & Folkman, 1987).

RESILIENCY IN COLLEGE FRESHMEN 13

Coping- use of resources in an effort to control, lessen or endure internal and/or external

strains related to stressors (Coiro, Bettis, & Compas, 2017; Houston et al., 2017).

Adaptation- also known as resilience; a protective resistance against stressors; the

outcome of coping efforts (Etchin, Fonda, McGlinchey, & Howard, 2019).

Resilience- often an interaction between individuals and his/her environment (Ercan,

2017); the ability to adapt to life’s challenges and maintain a high quality of well-being (Herrero

et al., 2019; Leppin et al., 2014).

Identifying Stressors

In the TMSC, Lazarus and Folkman (1987) identify a stressor as a transaction between

the person and the environment. Different events in life can be stressors such as illness, loss,

trauma, a new school or job, or increase in demands (Leppin et al., 2014). People react

differently to stress based on their perception of the stress, the type or character of the stress, and

their ability to cope with stress (Etchin, Fonda, McGlinchey, & Howard, 2019). Stressors can

disrupt balance and affect a person’s well-being (Lazarus & Folkman, 1987). Understanding

how people react to stress is related to the timing and duration of the stressful event (Etchin,

Fonda, McGlinchey, & Howard, 2019).

Appraisals

There are two types of cognitive appraisals in the TMSC; primary and secondary. The

first involves a primary appraisal of stress where there are four different ways to evaluate or

appraise a situation (Brooker, Brooker, & Lawrence, 2017). The first type of primary appraisal

is considered harmful and occurs if a stress is currently causing a person damage or loss (Lazarus

& Folkman, 1987). The second type of primary appraisal is when the anticipation of harm in the

future would be considered a threatening situation, but harm has not yet been experienced

RESILIENCY IN COLLEGE FRESHMEN 14

(Brooker, Brooker, & Lawrence, 2017). A challenging appraisal, the third type of primary

appraisal, involves a person coping with obstacles and having a potential for a positive outcome

in the future (Lazarus & Folkman, 1987). Harmful, threatening and challenging appraisal

situations requires effort or causes discomfort (Brooker, Brooker, & Lawrence, 2017). In the

fourth type of primary appraisal, benefit appraisal, there is no difficulty, no effort required, and

no discomfort involved in the evaluation (Lazarus & Folkman, 1987).

After a primary appraisal is made in the TMSC, a secondary appraisal is conducted by the

individual. This appraisal requires action to be taken by use of coping resources to control the

stress (Etchin, Fonda, McGlinchey, & Howard, 2019). The person must decide if there are

actions to be taken to improve the stressful person-environmental relationship, and if so, which

coping mechanism may work (Lazarus & Folkman, 1987). Secondary appraisals are important

to the primary appraisal because it helps determine how a person can engage with the stressor

(Lazarus & Folkman, 1987). If a situation is harmful or threatening, the person may choose

avoidance or stagnation; if it is challenging, the person may choose to engage themselves in the

situation (Brooker, Brooker, & Lawrence, 2017).

When applying the transactional piece of the TMSC to appraisal, the person changes their

appraisal of the situation as their resources or skills change (Brooker, Brooker, & Lawrence,

2017). For example, in college students, their academic ability may seem like a threatening

situation, but when they receive feedback from their professor, they change their appraisal to

beneficial. Past experiences help to guide future appraisals and help build coping skills or

resilience for future encounters (Etchin et al., 2019).

RESILIENCY IN COLLEGE FRESHMEN 15

Coping and resources

People interpret and react differently to experiences and have varying individual coping

mechanisms. Lazarus and Folkman (1987) concluded in the TMSC that active coping strategies

require people to put forth efforts to identify the cause of stressors and discover helpful ways to

get rid of them. Coping further involves problem management and regulating emotions and

these coping efforts can change depending on the timing, context and character of the stressor

(Etchin et al., 2019). Ineffective coping of stress or not having adequate resources to cope can

lead to decreased mental and physical health (Leppin et al., 2014).

Cognitive appraisal is important to coping with stress because it influences what coping

resource a person will choose (Li & Yang, 2016). Resources for coping can be positive or

negative. Coping resources include problem-solving, social support, social skills, positive

beliefs and having the ability to find resources with material or financial resources (Etchin et al.,

2019). Other coping resources can be health related such as good sleep hygiene, regular

exercise, and a well-balanced diet which promote healthy life-style behaviors (Etchin et al.,

2019).

Adaptation and Resilience

The final phase of the TMSC involves adaptation and resilience to the stressor. The

outcome of coping efforts can be both positive and negative and short-term and long-term

depending on the context of the stressor and the environment (Etchin et al., 2019). Short-term

effects are immediate physiological changes such as emotional well-being and physical

functioning (Etchin et al., 2019; Lohacheewa, Sitthimongkol, Sirapo-ngam, & Viwatwongkasem,

2016). Long-term effects focus on somatic health and illness, morale and social functioning

(Etchin et al., 2019; Lohacheewa, et al., 2016).

RESILIENCY IN COLLEGE FRESHMEN 16

Relevance

Literature often uses resilience, adaptation and coping synonymously as an action and/or

outcome to challenging situations or stressors (Etchin et al., 2019). According to the TMSC,

resilience is a protective and adaptive resistance from any disruption in function that was caused

by the stress appraisals (Steinhardt & Dolbier, 2008). The TMSC by Lazarus and Folkman

(1987) is relevant to the DNP project due to the central point of the study being to evaluate if a

resilience intervention program would be beneficial to implement at GCSU to incoming

freshmen as a way to prevent potential mental health problems and promote healthy life-style

behaviors. The hope was to prove what Lazarus and Folkman ultimately determined in their

theory, that people who have a conscious awareness of their ability to face problems and tackle

them are less likely than others to appraise stressors as threatening, and more likely to experience

challenge that will lead to the use of successful coping (Lazarus & Folkman, 1987).

RESILIENCY IN COLLEGE FRESHMEN 17

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Chapter 2: Review of Literature

A review of existing literature was conducted to determine evidence related to stress,

anxiety and resilience in college freshmen students. The search was limited to the databases that

had the most representation of the key words chosen: CINAHL, Medline, and Psychology and

Behavioral Sciences Collection. The initial search strategy involved the key words:

resilience/y/t, college students, and anxiety/stress/coping and returned 5,456 articles. The search

was extended by combining and adding to the key words: Resilience AND College students OR

University students OR Undergraduate students AND stress OR anxiety OR coping. To narrow

the search, limitations were used. Databases were searched for journal articles that were peer

reviewed, written in English, used human subjects and published between 2014 to 2019 and had

the word resilience/y/t in the title. This reduced the number of articles to 537. These articles

were reviewed to include a population restricted to undergraduate college students and resiliency

with attention given to articles that mentioned stress, anxiety, coping, well-being and

interventions. Exclusion criteria included younger students and older graduate students,

rehabilitation, mental health issues other than anxiety and stress and other articles that did not

pertain to the topic. The screening process led to 38 articles that would be used for the review of

literature.

Mental Health in College

Mental health disorders, such as stress, anxiety, and depression, decrease the quality of

life of people who suffer from them and increase their vulnerability for developing severe

disease (Banos et al., 2017; Herrero et al., 2019; Saleh et al., 2018). The onset of mental health

issues often begins in the college years with half of lifetime mental disorders appearing by mid-

adolescence and three quarters by the mid-twenties (Herrero et al., 2019; Lipson & Eisenberg,

RESILIENCY IN COLLEGE FRESHMEN 19

,2018). Stress, anxiety, and depression are frequent concerns of college students due to exposure

to new stressors, thereby increasing their risk for developing mental health problems (Herrero et

al., 2019; Saleh et al., 2018). Stress and depressive symptoms are associated with decreased

health behaviors such as unhealthy eating, sedentary behavior, insufficient sleep, and substance

abuse (Coiro, et al., 2017; Dalton & Hammer, 2018).

The high prevalence of mental health issues in the university population has shown to

impair academic performance and can lead to withdrawal (Coiro et al., 2017; Deconick, Matthijs,

& Luyten, 2019; Enrique et al., 2019; Lipson & Eisenberg, 2018). These problems can have

negative long-term effects on the student and society due to possible future functional

impairment (Enrique et al., 2019). Further research indicates that at-risk students such as

freshmen, those with low socioeconomic status and those with disabilities have higher stress and

anxiety levels than their peers (Rahat & Ilhan, 2016). The literature related to mental health and

college students supports the need for an intervention at this transitional time in their lives.

College Role in Mental Health

Entrance into university life is a substantial change in the lives of students and can be a

stressor that can heighten the risk of mental health problems (Dvorakova et al., 2017; Herrero et

al., 2019; Saleh et al., 2018). University life includes risk factors that is part of the development

of an individual’s resilient character which can play an important role in adjustment (Rahat &

Ilhan, 2016). These findings highlight the importance of having a strategy early in college to

enhance coping and resilience to mitigate stress during the freshmen year when risk or adversity

actually occurs (Enrique et al., 2019; Jafari, 2017; Rahat & Ilhan, 2016; Robbins, Kaye, &

Catling, 2018).

RESILIENCY IN COLLEGE FRESHMEN 20

Universities should consider what they can do to make students more resilient during

their time at school to foster the development of the whole person as well as academics (Debb et

al., 2018; Dvorakova et al., 2017). Resilience is being recognized as essential to helping

students manage academic demands to progress towards coping with the pressures of study,

work and life (Robbins, Kaye, & Catling, 2018). College is one of the last educational

opportunities to change a young adults life course and the educational community has accepted

resilience as an essential component for a student to thrive (Dvorakova et al., 2017; Newcomb-

Anjo, Barker, & Howard, 2017; Robbins, Kaye, & Catling, 2018). The ultimate goal of college

education is to build intelligence and prepare young people to be productive and successful

adults; however, students’ increased risk of mental health concerns and development of

unhealthy lifestyle behaviors can undermine the original purpose of college if not addressed

(Brooker, Brooker, & Lawrence, 2017; Dvorakova et al., 2017).

Freshmen Stressors

First year students experience more challenges than other university students due to the

difficulty associated with the transition from high school to higher education (Brooker, Brooker,

& Lawrence, 2017; Dvorakova et al., 2017; Koydemir & Sun-Selisik, 2016). Further studies

indicate that in comparison to other years, freshmen show higher levels of acute and chronic

stress resulting in social isolation, loneliness and depression which directly interfere with

academics (Dalton & Hammen, 2018; Dvorakova et al., 2017). Due to the first year of higher

education presenting challenges for students, the task for universities is to help students

overcome difficulties instead of avoiding them (Brooker, Brooker, & Lawrence, 2017).

One of the most common freshmen stressors is adjusting to a different environment or

unfamiliar setting than they experienced in high school (Newcomb-Anjo, Barker, & Howard,

RESILIENCY IN COLLEGE FRESHMEN 21

2017; Saleh et al., 2018; Turner, Scott-Young, & Holdsworth, 2017). Another challenge during

transition into higher education is being an autonomous adult requiring the student to take care of

basic needs such as washing clothes and cooking (Coiro et al., 2017; Dalton & Hammen, 2018;

DeConinck, Matthijs, & Luyten, 2019; Jafari, 2017). Other freshmen stressors include

modifying existing relationships and developing new relationships with roommates, romantic

partners, and higher academic standards that require new study patterns (Koydemir & Sun-

Selisik, 2015; Newcomb-Anjo, Barker, & Howard, 2017; Rahat & Ilhan, 2016). Financial

strains are often encountered due to improper management of money and the burden of student

loans (Brooker, Brooker, & Lawrence, 2017; Dalton & Hammen, 2018; DeConick, Matthijs, &

Luyten, 2019; Jafari, 2017).

Navigating unfamiliar university systems and adjusting to university culture can lead to

higher levels of chronic stress (Brooker, Brooker, & Lawrence, 2017; Dalton & Hammen, 2018;

Dvorakova et al., 2017). Research emphasizes that several undesired outcomes can occur from

transition into higher education (Brooker, Brooker, & Lawrence, 2017; Herrero et al., 2019;

Rahat & Ilhan, 2016). In an attempt to cope, young adults are more likely to smoke, eat

unhealth food, drink alcohol, and get insufficient sleep in response to stress (Dalton & Hammen,

2018; Herrero et al., 2019). A decrease in physical activity can affect the positive mental health

benefits gained from exercise (Jafari, 2017). Overall, freshman challenges can lead to having

lower academic achievement, poor coping strategies, and unhealthy relationships intensifying the

risk for anxiety, depression and dropping out of school (Dvorakova et al., 2017; Herrero et al.,

2019; Rahat & Ilhan, 2016).

RESILIENCY IN COLLEGE FRESHMEN 22

Health Promoting Behaviors

Health promoting behaviors are practices that people engage in to help maintain and

prevent diseases and is supported by the World Health Organization (WHO) as a key strategy in

maintaining quality of life (Bakouei et al., 2018; Roomaney et al., 2017). Research has found

the adolescent period is often a time when health-related behaviors are initiated and may

continue throughout adulthood (Alzahrani et al., 2019; Aminisani et al., 2016; Bakouei et al.,

2018). In university students, this is due to having greater independence, more responsibility for

their own health, and more choices over their lifestyle behaviors when they start this new phase

of their lives (Al-Qahtani, 2017; Alzahrani et al., 2019). Although they see themselves as

healthy and may not be interested in health promoting activities, promoting healthy lifestyle

behaviors at this age is important due to the challenge for adults to change unhealthy behaviors

later in life (Alzahrani et al, 2019; Aminisani et al., 2016).

Susan Walker, one of the authors of the Health-Promoting Lifestyle Profile, defines

health promoting lifestyle as six behavioral categories that encompass spiritual growth,

interpersonal relations, nutrition, physical activity, health responsibility, and stress management

(Walker et al., 1987). According to Walker (1987), spiritual growth is achieved through

transcending beyond ourselves, connecting with the universe, and developing a sense of purpose

while working towards goals in life. Interpersonal relations focus is on developing relationships

with others through verbal and nonverbal messages (Walker et al., 1987). Nutrition and physical

activity involve knowledge of a healthy daily diet and regular participation in moderate activity.

Health responsibility entails having an active sense of accountability for one’s own well-being,

and stress management includes identifying resources to reduce and manage stress (Walker et al.,

1987). These six categories of health promoting lifestyle serves to maximize personal fulfilment,

RESILIENCY IN COLLEGE FRESHMEN 23

maintain or boost well-being, and enhance self-actualization among individuals (Roomaney et

al., 2017; Walker et al., 1987).

Bridge Scholar Program

According to the United States Department of Education (2018), over the last fifty years,

nearly half of all students who enrolled in a two- or four-year university withdrew before earning

a degree. More universities are seeking to resolve this problem by offering a transitional support

program to incoming freshmen. College bridge scholar programs are designed to make the

transition into higher education easier by providing academic skills and social resources needed

to succeed (Bir & Myrick, 2015; Douglas & Attewell, 2014; Grace-Odeleye & Santiago, 2019).

Content among universities BSP vary, but they all have similar goals of helping students gain

understanding of the demands of college, increasing academic and social preparedness, and

promoting self-efficacy and persistence in an effort to increase the retention to graduate (Bir &

Myrick, 2015; Grace-Odeleye & Santiago, 2019).

Fostering engagement with the university experience can be challenging to a vulnerable

population of freshmen students. The key feature of a BSP is to create resilience through the

development of skills and support networks that academically and socially prepare students for

the rigors of college (Bir & Myrick, 2015; Cabrera, Miner, & Milem, 2013; Grace-Odeleye &

Santiago, 2019). These networks include orientation to college life with a focus on resources

available on campus, academic advising, formation of positive social and peer connections, and

faculty and mentor relationships (Bir & Myrick, 2015; Grace-Odeleye & Santiago, 2019).

Results for participants in the BSP may be the students increased motivation and belief in their

abilities to succeed and willingness to put forth the effort required for academics (Bir & Myrick,

RESILIENCY IN COLLEGE FRESHMEN 24

2015). The students in a BSP have a chance to show that they are prepared for college and

committed to their own success (Grace-Odeleye & Santiago, 2019).

Stress Reduction and Resilience Interventions

Pandemics, death, and illness are a few examples of challenges that we face in life. Some

people handle these stressors with ease whereas others struggle. One person may have the

strength to keep their hopes high in extremely difficult times where another may give up in a

lesser situation. These differences in character between people is called resilience and is often an

interaction between an individual and his/her environment (Ercan, 2017). This is supported by

Lazarus and Folkman (1987) in the Transactional Model of Stress and Coping.

According to Masten (2001), resilient people can reach physical, psychological and social

balance shortly after a stressful experience (Ercan, 2017). Resilient, stress-reducing behaviors

and perspectives influence the stress that individuals experience and can reduce feelings of

helplessness (Dalton & Hammen, 2018; Lipson & Eisenberg, 2018). Characteristics of resilient

individuals include having good communication, problem solving and organizational skills as

well as being optimistic, goal-oriented, and autonomous (Leppin et al., 2014; Li & Yang, 2014;

Masten, 2001). Resilient, stress-reducing behaviors contribute to overcoming adjustment issues

occurring during transition into university life (Li & Yang, 2014; Lazarus & Folkman, 1987;

Rahat & Ilhan, 2016). Resilience may be what separates the student who perseveres four years

to complete their degree from one who drops out when faced with adversity (Debb, et al., 2018).

Resilience Training/Interventions

Resilience training programs are a group of interventions that encourage resilient

behaviors to prepare individuals or groups for future difficulty (Enrique et al., 2019; Leppin et

al., 2014). Based on a systemic review and meta-analysis of randomized trials, resiliency

RESILIENCY IN COLLEGE FRESHMEN 25

training programs seem to have modest but consistent benefits in improving mental health and

well-being in diverse adult populations (Enrique et al., 2019; Leppin et al., 2014). However,

there was a lack of clarity in what defined the resilience programs and lack of a common

theoretical approach to the interventions in these studies (Enrique et al., 2019; Leppin et al.,

2014). Research further highlights the effectiveness of resilience intervention in college

students to significantly reduce anxiety and depression and improve well-being, self-esteem, and

hope (Dvorakova et al., 2017; Houston et al., 2017; Robbins, Kaye, & Catling, 2018). Life

satisfaction and resilience were also found to have a significant positive relationship in college

students (Lipson & Eisenburg, 2018; Rathore, 2017; Robbins, Kaye, & Catling, 2018).

Prevention of mental health problems through the promotion of resilience and well-being

is crucial due to the high prevalence of emotional problems in young adults (Enrique et al., 2019;

Herrero et al., 2019). This type of preventive strategy focuses on nurturing resilience instead of a

problem-focused approach which may be more attractive to the population of college students

(Enrique et al., 2019; Herrero et al., 2019). Beginning a preventive intervention during a high-

risk period, such as starting college, could reduce the risk of developing stress, anxiety, or other

mental disorders (Herrero et al., 2019). Providing resiliency training in college will increase the

likelihood of positive academic and employment outcomes in the future (Turner, Scott-Young, &

Holdsworth, 2017). Furthermore, intervention effects on depression, anxiety and life-satisfaction

play a foundational role in predicting student success and long-term adult outcomes (Enrique et

al., 2019).

Internet-based Intervention

The World Health Organization (WHO) found that only 6.7 – 23.1% of college students

surveyed received treatment for their mental health issues (Auerbach et al., 2016). These low

RESILIENCY IN COLLEGE FRESHMEN 26

treatment rates were due to students reporting their stress was normal for college, not serious

enough to be treated, or they did not have enough time to get treatment (Enrique et al., 2019).

This highlights the relevance of interventions that promote resilience for college students when

knowing the student’s help-seeking behaviors are low (Enrique et al., 2019).

Technology is important in young people’s lives; therefore, the information and

communication technologies are an excellent means to offer prevention and promotion of

positive mental health in college students (Banos et al., 2017; Herrero et al., 2019; Koydemir &

Sun-Selisik, 2016). Research found that adolescents use their technology devices for the same

amount of time an adult spends daily at work, seven days a week and often on more than one

device at the time (Banos et al., 2017). Using technology via the internet and mobile devices

could encourage the implementation of preventive resilience interventions by engaging this

population in the way they communicate best.

In the past ten years, internet-based interventions have been used to enhance the

accessibility and effectiveness of the traditional promotion of mental health (Herrero et al.,

2019). This method of intervention has substantial evidence supporting the efficacy for

prevention and treatment of mental health disorders such as stress, anxiety, and depression

(Banos et al., 2017; Enrique et al., 2019; Herrero et al., 2019). The goals of internet intervention

in mental health are similar to that of traditional face-to-face programs. These include reducing

the risk of targeted problems such as stress and anxiety, raising the students’ level of resilience

and well-being, boosting adaptation techniques, and increasing physical activity (Saleh et al.,

2018).

Advantages of internet-based interventions for resilience training are being more

recognized due to the high rate of accessibility to computers in college students (Banos et al.,

RESILIENCY IN COLLEGE FRESHMEN 27

2017; Herrero et al., 2019; Koydemir & Sun-Selisik, 2016). Among the advantages are reaching

a wide range of individuals at a low cost, ensuring anonymity, convenience with personalized

and interactive feedback, increased availability of services with less wait-time, and no

transportation needed (Banos et al., 2017; Enrique et al., 2019; Herrero et al., 2019; Koydemir &

Sun-Selisik, 2016; Saleh et al., 2018). Confidentiality is a major advantage to those who do not

seek treatment due to the stigma attached to mental health problems (Enrique et al., 2019; Saleh

et al., 2018). Undergraduates are immersed in a technical world where they prefer on-line

education for learning, relationships, activities, and tasks (Banos et al., 2017; Herrero et al.,

2019; Jafari 2017). Because of this, an on-line resilience education intervention may have an

advantage over a face-to-face intervention in this population.

Counseling/Community Intervention

On college campuses, counseling services as well as community intervention plays an

important role in supporting student’s mental health. Counseling services have trained and

prepared staff to meet a diverse population with a wide range of concerns that they encounter in

college (Coiro et al., 2017; Hartley, 2012; Houston et al. 2017). Both counseling services and

community services are a way to offer a supportive and accepting environment for all students.

These intervention methods help raise awareness of and support individualized coping

techniques as a way of managing stress (Coiro et al., 2017; Houston et al. 2017).

Studies have shown that coping styles, social support, and resilience are important

indicators of adjustment to university life (Coiro et al., 2017; Rahat & Ilhan, 2016). Coping

styles can be an advantage or disadvantage to the students’ ability to acclimate. These styles

range from planning, humor, religion, and venting to denial, disengagement, and substance abuse

(Coiro et al., 2017; Rahat & Ilhan, 2016). Sources of social support often come from family,

RESILIENCY IN COLLEGE FRESHMEN 28

friends and/or a significant other, but may reach further into the community to teachers,

neighbors, pastors, and mental health providers (Newcomb-Anjo, Barker, & Howard, 2017;

Rahat & Ilhan, 2016; Rathore 2017). University students who reported low social support,

compared to those who had an increased social support system, struggled more with transition

into college (Newcomb-Anjo, Barker, & Howard, 2017). Social support protects against

depression and anxiety in college students through their parental bonds as well as peer and

romantic relationships (Newcomb-Anjo, Barker, & Howard, 2017). The value of having

personal resilience as an internal resource is seen for decreasing the negative effects of stress and

maintaining mental health, especially in times of adversity (Leppin et al., 2014; Saleh et al.,

2018).

Policy and Health Intervention

Mental health concerns fall beyond college campus’ into state, national and world arenas

where initiatives strive to strengthen leadership for mental health and implement strategies to

promote and prevent mental health (WHO, 2019). The WHO comprehensive mental health

action plan 2013-2020 was adopted by the 66th World Health Assembly (WHO, 2019). The

action plan, grounded in human rights, encourages change in the attitudes that generate stigma

and discrimination in mental health, and it calls for expansion of services and resources

internationally (WHO, 2019).

In a detailed survey conducted by the WHO among college students with mental

disorders, it was evident that mental disorders are common around the world (Auerbach et al.,

2016). The World Mental Health survey also found that the majority of student’s onset of their

issue was before enrollment in college, showing an association with failure to enter college and

with attrition (Auerbach et al., 2016). According to the WHO, prevention of psychological

RESILIENCY IN COLLEGE FRESHMEN 29

problems should focus on the promotion and development of individual resilience and strength in

an effort to reduce the vulnerability of this population (Banos et al., 2017).

Synthesis of Evidence

The review of literature produced many ideas and thoughts surrounding the topic of

resilience, mental health issues in college students and effective interventions to address these

needs. Often by combining diverse concepts into a logical understanding, clarity can be gained

on future direction of measures that may benefit college students in gaining resilience as they

transition into higher education. Of the thirty-eight articles reviewed, thirty-two were studies

conducted on college students reflecting homogeneity, and six studies were specific to freshmen

students, which is the focus of the current project (Brooker, Brooker & Lawrence, 2017; Conley,

Travers & Bryant, 2013; DeConinck, Matthijs & Luyten, 2019; Dvorakova et al., 2017;

Koydemir & Sun-Selisik, 2015; Rahat & Ilhan, 2016). Two of the studies were systemic reviews

and meta-analysis of randomized trials indicating the highest level of evidence with the emphasis

being on interventions and the efficacy of resiliency training programs (Joyce et al., 2018;

Leppin et al., 2014). In addition to the meta-analysis’, seven other studies were randomized

controlled trials demonstrating further high quality of evidence (Conley, Travers, & Bryant,

2013; Enrique et al., 2019; Gras et al., 2019; Herrero et al; 2019; Houston et al., 2017; Rahat &

Ilhan, 2016; Saleh et al., 2018). It was noted that three of the studies conducted were on a

specific group of college students which in turn reduces the generalizability of the results (Debb

et al., 2018; Gras et al., 2019; Turner, Scott-Young, & Holdsworth, 2017).

The main differences noted in the synthesis of evidence was the type of intervention used

to promote resilience, the length of time of the intervention, and the sample size. Interventions

encompassed resilience through well-being, mindfulness, and positive psychology although the

RESILIENCY IN COLLEGE FRESHMEN 30

bulk of the studies were simply on resilience and coping. There were five studies that utilized

internet-based interventions as a way of being more accessible to reaching this population

(Banos et al., 2017; Enrique et al., 2019; Herrero et al., 2019; Koydemir & Sun -Selisik, 2015;

Saleh et al., 2018). The time frame for the interventions ranged from three weeks to eight

months with the majority being eight weeks in length (Dvorakova et al., 2017; Enrique et al.,

2019; Herrero et al., 2019; Koydemir & Sun -Selisik, 2015). Sample sizes ranged from thirty

students to 3,214.

Similarities and differences were observed in the type of tools used to measure the

variables in the studies and which variables were measured. The included studies consisted of

the following measures for resilience: Conner Davidson Resilience Scale 25-item and 10- item,

the Resilience Scale, the Dispositional Resilience Scale, the Response to Stressful Experiences

Scale and the Psychological Resilience Scale in Adults (Ercan, 2017; Joyce et al., 2018). Twelve

of the studies applied the Conner Davidson Resilience Scale, showing the most representation.

Other common variables measured included stress, anxiety, and depression. These variables

were mainly measured with the Perceived Stress Scale, the Generalized Anxiety Disorder

Questionnaire and the Patient Health Questionnaire. Less common measures observed were

lifestyle behavior, quality/satisfaction of life, self-efficacy, self-esteem, and personality. Fifteen

of the thirty-eight studies used three or more tools to access the variables related to resilience.

The Transactional Model of Stress and Coping (TMSC) was the theoretical basis for six

of the studies (Brooker, Brooker, & Lawrence, 2017; Li & Yang, 2015; Leppin et al., 2014;

Lochacheewa et al., 2016; Saleh et al., 2018; Steinhardt & Dolbier, 2008). Psychology

grounded, the TMSC places emphasis on the relationship between an individual and his or her

environment (Lazarus & Folkman, 1987). Two other frameworks were suggested through the

RESILIENCY IN COLLEGE FRESHMEN 31

literature. One was based on Ann Masten’s detailed work with resilience research and the other

was a combination of the TMSC with a nursing conceptual model, Neuman’s Systems Model to

create a new System Theory of Stress, Resilience, and Reintegration (Masten, 2001; Etchin et al.,

2019).

Analysis of the findings found that resilience training has a small to moderate effect on

improving resilience and other mental health outcomes and may be able to enhance resilient

behavior in college students (Leppin et al., 2014; Joyce et al., 2018). Resilience and resilient

characteristics were found to be linked to academic persistence, engagement and achievement as

well as predicting adjustment to university life (Lipson & Eisenburg, 2018; Rahat & Ilhan, 2016;

Turner, Scott-Young, & Holdsworth, 2017). College students showed significantly more hope

and less stress and depression after completion of a resilience intervention indicating evidence

that this type of intervention can be useful for college students (Coiro, Bettis, & Compas, 2017;

Dvorakova et al., 2017; Houston et al., 2017; Ng, Ang, & Ho, 2012). Relationships between

resilience and optimism, resilience and life satisfaction and resilience and self -esteem was

observed by the students in the intervention studies (Dvorakova et al., 2017; Jafari, 2017; Rahat

& Ilhan, 2016; Rathore, 2017, Kaye & Catling, 2018). Daily stress, such as college can bring,

and chronic stress were found to be associated with maladaptive lifestyle behaviors encouraging

the use of resilience programs as a stress prevention intervention for college students (Dalton,

2018; Saleh et al., 2018; Steinhardt & Dolbier Robbins, 2008). From the analysis of evidence,

there is sufficient high-quality evidence to support a resilience intervention program among

college students. Further evidence confirms a resilience intervention at the beginning of

student’s freshmen year when they are at high risk for adversity (Dvorakova et al., 2017; Enrique

et al., 2019; Herrero et al., 2019; Jafari, 2017; Masten, 2001; Rahat & Ilhan 2016; Saleh et al.,

RESILIENCY IN COLLEGE FRESHMEN 32

2018). Results of studies of the effects of participation in a BSP suggest a positive impact on

degree completion and retention (Bir & Myrick, 2015; Douglas & Attewell, 2014; Grace-

Odeleye & Santiago, 2019) with suggestions of a pre-test post-test design to determine the

effectiveness of a BSP (Grace-Odeleye & Santiago, 2019).

Evidence Strength

The strong attributes of the research are contributed to the two systematic reviews as well

as the number of randomized control trials that each produce a high level of evidence-based

knowledge. The studies used a variety of measures which helped to reach the diverse college

population. The current evidence supports promotion of resilience as an early intervention

strategy for those entering the college environment. Strength is seen in the consistency of a large

body of literature on a specific topic in a specific population.

Other positive qualities of the evidence include the practical implications for educators

and counselors who are invested in the success of college students. The knowledge gained

encourages colleges to create change through promotion of resilience interventions. This in turn

allows for improvement on past and current research for future benefits to the students and the

university. Though the literature varies in an exact protocol for the type of resilience

intervention and the length of the intervention, the evidence is in favor of addressing the

significant problem of mental health issues in college students through resilience education.

Evidence Limitations

The current studies evaluated have limitations that need to be considered when

interpreting the results. Self-reporting, generalization and sample size were three of the most

common components that created limits in the reviewed literature. Six of the studies had

significantly more females than males who participated. Attrition rates, timing of follow-up or

RESILIENCY IN COLLEGE FRESHMEN 33

no follow-up and convenience sampling reduced the strength of the results in various studies.

The majority of the studies took place at one university that may not represent an entire

university population. Interventions conducted on-line brought about ethical concerns and

considerations. Inconsistency was seen in the types and the length of interventions making it

difficult to have a set outline for how to conduct a resilience intervention in the future. Despite

the limitations, researchers agree of the importance in the role that resilience plays in promoting

health and well-being in the college population which ultimately can lead to academic success.

Conclusion

The current evidence and results have implications for health outcomes among college

students. The studies contribute to the better understanding and awareness of resilience as a

method to prevent and promote positive mental health and support healthy lifestyle behaviors.

Future research in the area of resilience training interventions for college students can seek to

overcome the limitations and strive to build upon the strengths identified in the current studies.

This in turn will create a clear and consistent strategy for creating gold standard resilience

intervention programs within universities.

RESILIENCY IN COLLEGE FRESHMEN 34

Chapter 3: Methodology

Project Design

The proposed research project used a pretest and posttest design method to determine the

effects of a five-week, on-line, synchronous educational intervention in college freshmen

enrolled in one universities’ Bridge Scholar Program. The educational intervention was a part of

an educational program, Resilience 101. During the initial session, the baseline (pretest)

assessment evaluated participant’s resilience, perceived stress, anxiety, health promoting

lifestyles, and knowledge prior to the intervention. The assessment was performed again eight

weeks after completion of the five-week resilience intervention program (posttest). Both the

pretest and posttest used four valid and reliable instruments. Resilience was measured with the

Conner-Davidson Resilience (CD-RISC) scale, stress was measured with the Perceived Stress

Scale (PSS), anxiety was measured with the Generalized Anxiety Disorder questionnaire (GAD-

7), and health promoting lifestyles was measured with the Health Promoting Lifestyle Profile II

(HPLP-II). A demographic and knowledge quiz developed by the investigator was used for

further descriptive statistics. The Transactional Model for Stress and Coping was the supporting

theoretical framework to guide the research project.

Setting

The project site for this study was a public, liberal arts university in the Southeastern

United States. The current enrollment for this university for the 2019-2020 academic year was

approximately 6,000 undergraduate students with 1,582 of those students being freshmen. The

participants in the study were incoming freshmen for the Fall semester of 2020 that have been

accepted into the universities’ Bridge Scholar Program.

RESILIENCY IN COLLEGE FRESHMEN 35

Protection of Human Subjects

Research studies involving human subjects must include a plan of protection for the

human subjects. Before the research began, the investigator completed an online training for

research ethics. The Institutional Review Board (IRB) at the University then reviewed the

proposed project to ensure the participants were protected. The IRB granted approval to proceed

with the proposed research project (see Appendix A). All records and data collected during the

research were kept confidential by the investigator.

All participants were given oral and written information about the study in-person by the

investigator during the introductory session. It was explained that the study involved research

and there are no anticipated risks involved in the study. This included no likely burden to the

participants while taking the pretest and posttest assessment or during the weekly, on-line

educational intervention. However, if the participants experience any undue stress or anxiety

from participation, they would be directed to the universities’ counseling services, a free, walk-in

services available to all university students.

Benefits of the study were to prevent potential mental health problems and promote

healthy lifestyle behavior during the transition into secondary education through the resilience

educational intervention entitled Resilience 101. The benefits could go beyond that of college

freshmen enrolled in a Bridge Scholar Program as disclosure of the study may lead to improved

resilience for all freshmen, other college students and other populations.

Participants had the opportunity to have any questions regarding the study answered

during the introductory session. The investigator had her name and contact information available

for future reference. Participants were instructed that the study was voluntary, and they could

RESILIENCY IN COLLEGE FRESHMEN 36

withdraw from the study at any time without penalty. It was explained the participants will invest

forty-five minutes per week for five weeks, and fifteen minutes to complete the questionnaires

each time. The total time burden was four hours and fifteen minutes for the participants.

The investigator obtained two signed copies of the informed consent as an agreement to

be in the proposed study (see Appendix B). Participants were given one copy of the consent for

their records and the investigator kept the other copy for her records. For all participants under

the age of 18, parental consent was obtained in addition to personal assent (see Appendix C).

Consents were obtained on-line by the investigator during the introductory session.

Each student participating was assigned a unique number code as an identifier that was

used for both pretesting and post testing. The investigator was the only one who had access to the

master list of assigned codes. To further protect the participants confidentiality, the investigator

kept the master list in a locked file cabinet that only the investigator has access to enter.

Data Security

Data security guaranteed further protection and confidentiality to the participants of the

study with proper utilization and storage of research data collected. All paper forms,

including the consent forms, were locked in a file cabinet when not in use and only handled by

the investigator when in active use for the study. Electronic data was protected by using

adequate firewalls, virus protection, and encryption on the investigator’s personal computer as a

means of preventing confidential data from being stolen. To further secure electronic data, the

investigator utilized a password to gain access to the computer and to data. This password was

difficult to determine and was not shared.

Destruction of the data after completion of the study was needed for security and IRB

purposes. Once the objectives of the project are met, data will be kept secure for three years

RESILIENCY IN COLLEGE FRESHMEN 37

according to the IRB guidelines. The investigator will then shred any paper documents, and any

electronic files will be permanently deleted.

Sampling Plan

The target sample was incoming freshman students at the public, liberal arts university in

the Southeast who were enrolled in the universities Bridge Scholars Program. Data collection

was held during the Fall semester of 2020. The sample size was determined by the number of

freshmen entering the universities’ Bridge Scholars Program (BSP). There were 130 enrolled for

the BSP for Fall 2020 and all 130 were recruited. Students were asked to participate by the

investigator on-line prior to the first week of the on-line intervention, Resilience 101. The

recruitment was taken place during the required BSP class, GCSU 1010: Student Success.

The inclusion criteria were incoming freshmen students participating in the BSP. The

BSP is for freshmen applicants who show potential for success in college, but who the

admissions office feel would benefit from a transitional support program in order to maximize

their achievements in college. The investigator chose the BSP population for the educational

intervention because both Resilience 101 and the BSP are similar programs supporting the

students’ transition into higher education. Further benefits for the BSP participants may be the

development of resilient behaviors and skills to help manage stress in a healthy way. This could

help support retention and be used throughout the participants college career and in the future.

Exclusion criteria were any other university students, such as other incoming freshmen

not participating in the BSP or any existing upper classmen. The exclusion was justified for the

purpose of having a specific, defined population and to minimize withdrawal from the study.

Participants were not compensated for participation in the study.

RESILIENCY IN COLLEGE FRESHMEN 38

Project Implementation

The on-line, resilience education intervention, Resilience 101, used sequential steps to

focus on and support incoming college freshmen’s resiliency by: 1) discussing stressors in a

college campus community; 2) raising awareness of current coping behavior and resilience; and

3) providing strategies for resilience that students may apply to future stressors. Intervention

components were delivered in forty-five-minute sessions on-line, once a week for five consecutive

weeks.

The topics for the five-week, on-line intervention was determined by the investigator and

Dr. Dixie Turner, psychologist at GCSU Counseling Services, and will be as follows:

Week 1 – Introduction to resilience

Week 2- Mindfulness

Week 3- Problem solving

Week 4- Using social support

Week 5- Exercise, diet, and sleep

Data Collection

Data type and source

Primary data was collected by the investigator in order to have specific information on

the research project. The investigator used Qualtrics survey tool and questionnaires taken from

the CD-RISC, PSS, GAD-7, and the HPLP-II instruments to collect primary data on-line. A

brief demographics and knowledge quiz created by the investigator was used. Primary data

assessed resilience, stress, anxiety, and health promoting lifestyles as well as knowledge in the

selected population of college freshmen. The questionnaires had close-ended questions making it

RESILIENCY IN COLLEGE FRESHMEN 39

quick to administer, flexible, and easy to analyze. Through the investigators research, the

combined use of the four self-administered questionnaires would fit the study design to measure

the participant’s overall state of resilience. For the research project, secondary data was not

utilized.

Data collection methods

Data was collected at two points during the project. The collection was conducted on-

line by the investigator. The first collection was during the introductory session as a pretest

assessment. This took place after consent had been received from the participants. Students

were given the Qualtrics survey tool questionnaire to complete at the session. The questionnaire

combined the four measurement tools to assess the participant’s current level of resilience, stress,

anxiety, and health promoting lifestyles. There were also demographic questions that was only

collected at the beginning of the study in addition to a 15-question knowledge quiz that was

collected pre- and post-intervention (see Appendix D & E).

The investigator then completed a second collection of data as a posttest assessment.

This took place eight weeks after completion of the five-week educational intervention,

Resilience 101. This was the same questionnaire that was utilized during week one, with the

exception of the demographic data. The second data collection was on-line and used Qualtrics

survey tool.

Measurement tools

Threats to internal validity are influences other than the independent variable that could

explain the results of the study (Terry, 2018). Bias, confounding and systematic error are a few

threats that the investigator considered with the design of the project to minimize these potential

effects. The project did risk sampling bias due to the participants being in a specific cohort

RESILIENCY IN COLLEGE FRESHMEN 40

(Bridge Scholars program) instead of a random sample of all incoming college freshmen.

However, the investigator felt this is an important population to consider for sustainability of the

project. Confounding variables are due to another exposure existing in the study population that

is associated with the independent variable. The investigator did not recognize any confounding

factors to internal validity. Systemic errors can influence a measurements accuracy and was

limited by the investigator by being familiar with the four measurement tools that was used in the

study.

Conner-Davidson Resilience Scale

The CD-RISC was used to measure the primary outcome of the study which was

resilience (see Appendix F). The CD-RISC is reliable through stability and internal consistency

with use of test-retest methods and assessed through Cronbach’s alpha coefficient ranging from

0.87 to 0.89 (Conner & Davidson, 2003; Debb et al., 2018; Houston et al., 2017; Rathore et al.,

2017; and Robbins & Catling,2018). In assessing the CD-RISC for validity, construct validity

was measured through factorial or structural validity (Conner & Davidson, 2003; Gras et al.,

2019). The CD-RISC is a 25-item questionnaire that assesses the participants ability to cope with

stress. The CD-RISC can be completed in 5 to 10 minutes by subjects. Each item is rated on a 5-

point Likert scale which is an interval/ratio level of measurement. The responses range from not

true at all (0), to true nearly all of the time (4), with total scores ranging from 0 to 100 (Gras et

al., 2019). Subjects were asked to answer the 25 items based on how they had felt over the last

month (Conner & Davidson, 2003). A higher score indicates a higher level of resilience (Gras et

al., 2019). The investigator was granted permission to use the CD-RISC by signing an

agreement and paying a one-time student fee to Jonathan Davidson, co-author of the CD-RISC

(see Appendix G).

RESILIENCY IN COLLEGE FRESHMEN 41

Perceived Stress Scale

The PSS was used to measure one of the secondary outcomes of the study, stress (see

Appendix H). The PSS is a 10-item questionnaire used to determine if recent life experiences are

thought of as stressful by the participant (Cohen et al., 1983). The questions are based on the

participant’s thoughts and feelings over the last month. The PSS is an interval/ratio level of

measurement. It is rated using a 5-point Likert scale ranging from 0 (never) to 4 (very often)

where a score between 27 and 40 is perceived as high stress (Cohen et al., 1983). The PSS has

been found to have internal consistency with the Cronbach’s alpha coefficient of .84 in a recent

study of university students (Saleh et al., 2018). The PSS was readily available for use and free

to the public.

Generalized Anxiety Disorder Questionnaire

The GAD-7 was used to measure one of the secondary outcomes of the study, anxiety

(see Appendix I). The GAD-7 is reliable as shown with internal consistency (alpha = .91) and

test-retest reliability as well as convergent, construct, procedural and factorial validity for the

assessment of generalized anxiety disorder (GAD) in college populations (Dvorakova, et al.,

2017; Herrero et al., 2019, Houston et al., 2017 and Spitzer et al., 2006). The self-administered

scale is a quick and efficient instrument for discovering the presence of anxiety and is not a

definitive scale for a diagnosis of GAD (Herrero et al., 2019). The GAD-7 is considered an

interval/ratio level of measurement. The responses range from not at all (0) to nearly every day

(3) with total scores ranging from 0 to 21. Subjects were asked to report how often they have

been bothered by each item over the last two weeks. A lower score indicates minimal (0 to 4) to

mild (5 to 9) anxiety, whereas a higher score indicates moderate (10 to 14) to serious (14 to 20)

anxiety. The GAD-7 was free to use and was readily available to the investigator.

RESILIENCY IN COLLEGE FRESHMEN 42

Health Promoting Lifestyles Profile II

The HPLP-II was used to measure health promoting behaviors in the participants (see

Appendix J). The HPLP-II is a 52-item questionnaire that is divided into six subscale categories

including health responsibility, physical activity, nutrition, spiritual growth, interpersonal

relations, and stress management (Walker et al., 1987). Each behavior is measured with a

Likert-type scale ranging from never (1) to routinely (4) with a total score range of 52 to 208

(Alzahrani et al., 2019 and Bakouei et al., 2018). A higher score on the HPLP-II indicates more

frequent health promoting behaviors (Alzahrani et al., 2019 and Bakouei et al., 2018). The

HPLP-II has been validated with a wide variety of participants and in many countries

(Roomaney, EEden, & Kagee, 2017). Cronbach’s alpha for the total scale was found to be 0.94

and for the six subscales, it ranged from 0.79 to 0.87 (Alzahrani, et al., 2019, Bakouei, et al.,

2018, Roomaney et al., 2017, and Walker et al., 1987). Permission for use of the tool was given

by Susan Walker, developer of the HPLP-II.

Data Analysis Plan

The plan for data analysis was devised by the investigator by reviewing the project

design as well as identifying the clinical research questions that need to be answered. An a-

priori sample size calculator was utilized to determine how many participants were needed to

adequately power the study. Based on a medium effect size of 0.5, a desired statistical power

level of 0.8, and a probability level of 0.05, one hundred and twenty-eight participants were

needed to have sufficient statistical effect. The use of the Statistical Package for Social Sciences

(SPSS) version 25 computer program was utilized for data entry for each variable of the study

and descriptive statistics was used to analyze the demographic and knowledge characteristics of

the sample. Standard data cleaning and testing for normal distribution of the variables was

RESILIENCY IN COLLEGE FRESHMEN 43

included in the data analysis. For the data found to be normally distributed, a parametric test in

the form of a dependent samples paired T-test was used to determine differences between pretest

and posttest scores.

After completion of the Resiliency 101 education intervention program, the analysis of

the data answered the following clinical questions:

Clinical Question 1 What effect did the intervention have on BSP student's resilience? Clinical Question 2 What effect did the intervention have on BSP student's health promoting lifestyle behaviors? Clinical Question 3 What effect did the intervention have on BSP student's perceived stress? Clinical Question 4

What effect did the intervention have on BSP student's anxiety?

Clinical Question 5 What effect did the intervention have on BSP student's knowledge of resilience, anxiety, stress and health promoting lifestyle behaviors?

RESILIENCY IN COLLEGE FRESHMEN 44

Chapter 4: Results

Study results will be discussed in this chapter. Reported findings include participant

demographics and the effect of an educational intervention on their resilience, health promoting

lifestyles, perceived stress, anxiety, and knowledge. Data were entered into SPSS Version 25.

Data analysis began with evaluating for missing data and standard data cleaning. Six questions

had missing descriptive data that was resolved by mean substitution. Correlations were analyzed

for all study variables, and no multicollinearity was found. Distribution of data was assessed for

normality with the administration of the appropriate parametric and non-parametric testing.

Sample description

One hundred and thirty freshman students at a public liberal arts university in the

southeastern United States who were enrolled in a transitional support program were recruited to

participate in this translational research project. Eleven of the 130 students approached were not

able to participate due to the COVID-19 pandemic, leaving a starting sample size of 119

freshmen students. Six of the 119 freshmen students did not participate in the posttest due to

withdrawal because of illness or grades, leaving a final sample size of 113. Of the initial sample,

participants were primarily Caucasian (85.7%, n=102). There were slightly more female

participants (56.3%, n=67) than male participants (42.0%, n=50), and two participants (1.7%)

did not identify as male or female. Over half of the participants’ parents were married (68.1%,

n=81), and 40.3% (n=48) of participants’ mothers, and 44.5% (n=53) of participants’ fathers had

a bachelor’s degree. The number one source for financing college for participants was from

parents or other relatives (58.0%, n=69). The most popular degree sought by participants was

business (31.1%, n=37) (see Table 1).

RESILIENCY IN COLLEGE FRESHMEN 45

Table 1 Sample Characteristics (N=119) Variables N (%)

Age 17 18 19

2

96 21

(107)

(80.7) (17.6)

Gender

Female Male Other

50

67 2

(56.3)

(42.0) (1.7)

Race/ethnicity Caucasian African American Latino/Hispanic Asian/Pacific Two or more Other

102

4 6 3 3 1

(85.7)

(3.4) (5.0) (2.5) (2.5)

(.8)

Type degree seeking Public Health Psychology Business Computer Science Education Health-related field Music Liberal studies History Undecided Other

2

10 37 3

12 14 1 1 2

10 27

(1.7) (8.4)

(31.1) (2.5)

(10.1) (11.8)

(.8) (.8)

(1.7) (8.4)

(22.7)

Parental Marital Status Married Divorced Other

81

20 18

(68.1)

(16.8) (15.1)

Father’s Education Level Some high school High school Some college Associate degree

4

15 9 7

(3.4)

(12.6) (7.6) (5.9)

RESILIENCY IN COLLEGE FRESHMEN 46

Bachelor’s degree Master’s/higher Trade school Not sure

53 27 2 2

(44.5) (22.7) (1.7) (1.7)

Mother’s Education Level Some high school High school Some college Associate degree Bachelor’s degree Master’s/higher Not sure

1

12 14 11 48 31 2

(.8)

(10.1) (11.8) (9.2)

(40.3) (26.1) (1.7)

Sources for financing college Personal loan Scholarship Government/free Self-financing Parents/relative Other

21

14 6 4

69 5

(17.6)

(11.8) (5.0) (3.4)

(58.0) (4.2)

Instrument Characteristics

Total scores were computed for each instrument, and after reviewing all interval and ratio

level data for central tendencies, the Perceived Stress Scale (PSS), Generalized Anxiety Disorder

(GAD-7) scale, and Knowledge Quiz scores were not normally distributed for the pretest or

posttest. All remaining scores in the Conner-Davidson Resilience Scale (CD-RISC) and Health-

Promoting Lifestyle Profile (HPLP-II) for the pretest and posttest were normally distributed and

met the assumptions of all parametric statistical analyses used to answer the clinical research

questions. Cronbach’s alpha for the pretest and posttest CD-RISC sample was an acceptable

0.91 and 0.94 (Conner & Davidson, 2003). Cronbach’s alpha for the pretest and posttest HPLP-

II was an acceptable 0.94 and 0.95 (Alzahrani et al., 2019 and Bakouei et al., 2018). Cronbach’s

alpha for the pretest and posttest PSS was 0.48 and 0.59 indicating a less reliable scale.

RESILIENCY IN COLLEGE FRESHMEN 47

Cronbach’s alpha for the pretest and posttest GAD-7 was an acceptable 0.91 (Dvorakova, et al.,

2017). Cronbach’s alpha for the pretest and posttest Knowledge Quiz was 0.72 and 0.54,

indicating a less reliable scale.

The mean score for the CD-RISC was 72.4 pretest intervention and 72.9 posttest

intervention, indicating no change in participants’ resilience. The mean score for the HPLP-II

was 143.2 pretest intervention and 144.0 posttest intervention, indicating no significant change in

participants’ health promoting lifestyle behaviors. The mean score for the PSS was 22.2 pretest

intervention and 22.8 posttest intervention, indicating no significant change in participants’

perceived stress. The mean score for the GAD-7 was 6.8 pretest intervention and 6.4 posttest

intervention, indicating no significant change in participants’ anxiety. The mean score for the

KQ was 9.9 pretest intervention and 11.0 posttest intervention indicating a significant change in

the participants knowledge of resilience, health promoting behaviors lifestyle behaviors, stress,

and anxiety.

See Table 2 for pretest and posttest descriptive statistics, observed ranges and possible ranges,

and Cronbach’s alpha for each instrument.

Table 2 Descriptive Statistics and Cronbach’s Alpha for Variables at Pre-Test Intervention (T1) and Post-Test Intervention (T2)* Variable

M (SD) Observed Range

Possible Range

Cronbach’s Alpha

CD-RISC (T1) 72.36 (12.64) 41-100 0-100 .91 (T2)

72.89 (14.33) 35-100 0-100 .94

HPLP-II (T1) 143.24 (22.44) 92-207 52-208 .94 (T2)

143.97 (24.45) 92-208 52-208 .95

PSS (T1) 22.24 (3.96) 3-34 0-40 .48 (T2) 22.80 (4.26) 0-35 0-40 .59

RESILIENCY IN COLLEGE FRESHMEN 48

GAD-7 (T1) 6.84 (5.63) 0-21 0-21 .91 (T2) 6.41 (5.13) 0-21 0-21 .91 KQ (T1) 9.85 (3.01) 1-15 0-15 .72 (T2) 10.93 (2.08) 4-15 0-15 .54

*N for T1= 119. N for T2= 113.

Clinical Questions

Clinical Question 1: What effect did the Resilience 101 education intervention have on

freshmen student’s resilience?

A dependent samples t-test was used to test the hypothesis that freshmen students

receiving a five-week resilience education program would have increased resilience from

baseline to two months following the intervention. The research hypothesis was not supported.

There was no significant difference in resilience demonstrated from baseline (M 72.9, SD 14.3)

to two months (M 72.9, SD 12.5) t (112)=.000, p=1.000.

Clinical Question 2: What effect did the education intervention have freshmen student’s

health promoting lifestyle behaviors?

A dependent samples t-test was used to test the hypothesis that freshmen students

receiving a five-week resilience education program would have increased health promoting

lifestyle behaviors from baseline to two months following the intervention. The research

hypothesis was not supported. There was no significant difference in resilience demonstrated

from baseline (M 144.0, SD 24.5) to two months (M 143.6, SD 22.5) t (112)=.111, p=.912.

Clinical Question 3: What effect did the education intervention have on freshmen

student's perceived stress?

RESILIENCY IN COLLEGE FRESHMEN 49

In this analysis, the research hypothesis was tested that freshmen students receiving a five-

week resilience education program would have decreased stress from baseline to two months

following the intervention. The Perceived Stress Scale (PSS) Fisher’s exact score for skewness

was 3.05 and the kurtosis was 3.05 in the pretest. Further examination revealed one participant’s

score was more than three standard deviations below the mean. When the outlier was removed,

the data was normally distributed with a Fisher’s exact score of 1.31 for skewness and .79 for

kurtosis (Sylvia & Terhaar, 2018). However, in the posttest, the PSS Fisher’s exact score for

skewness was 5.18 and kurtosis was 3.91. and removing the four outliers that were more than three

standard deviations below the mean was not sufficient to create a normal distribution. Due to this,

a Wilcoxon Signed Ranks test was used to test the hypothesis. The research hypothesis was not

supported. There was no significant difference in stress reported from baseline (M 22.2, SD 4.0)

to two months (M 22.8, SD 4.3), (Z= -1.443, p= .149).

Clinical Question 4: What effect did the education intervention have on freshmen

students’ anxiety?

In this analysis, the research hypothesis was tested that freshmen students receiving a five-

week resilience education program would have decreased anxiety from baseline to two months

following the intervention. In the GAD-7 pretest, Fisher’s exact for skewness was 2.95 and

kurtosis was 1.05. Further examination found that nineteen participants ranked themselves as zero

on the scale, which is within the parameters of the instrument, not producing any outliers. The Q-

Q plot and box plot were normally distributed; therefore, this variable was treated as nearly

normally distributed even though the skewness was 2.95. However, in the GAD-7 posttest, Fisher’s

exact for skewness was 3.56 and kurtosis was .701. After removing three outliers from the posttest,

the data was still not normally distributed. Because the GAD-7 was not normally distributed, a

RESILIENCY IN COLLEGE FRESHMEN 50

Wilcoxon Signed Ranks test was used to test the hypothesis. The research hypothesis was not

supported. There was no significant difference in anxiety reported from baseline (M 6.8, SD 5.6)

to two months (M 6.4, SD 5.1), (Z=-.191, p=.848).

Clinical Question 5: What effect did the education intervention have on freshmen

students’ knowledge of resilience, anxiety, stress, and health promoting lifestyle behaviors?

In this analysis, the research hypothesis was tested that freshmen students would have

increased knowledge of resilience, anxiety, stress, and health promoting lifestyle behaviors from

baseline to two months following the intervention. In the Knowledge Quiz pretest, Fisher’s

exact for skewness was 3.94 and kurtosis was .739. In the posttest, Fisher’s exact for skewness

was 3.10 and kurtosis was 1.17. Numerous outliers were identified with attempts to remove

those less than 4 and then those less than 3, however, too many participants were lost; therefore,

no outliers were removed. An attempt was then made to transform using inverse natural

logarithm, but this only improved the skewness moderately; therefore, the variable was treated as

non-normally distributed. Because the Knowledge Quiz was not normally distributed, a

Wilcoxon Signed Ranks test was used to test the hypothesis. The research hypothesis was

supported. An examination of changes in score rankings indicated participants reported

significantly greater knowledge of resilience, anxiety, stress and health promoting lifestyle

behaviors. There was significant improvement in knowledge from baseline (M 9.9, SD 2.1) to

two months (M 10.9, SD 2.1), (Z=2.787, p=.005).

When comparing individual items pretest and posttest for the Knowledge Quiz, the

percentage of participants who answered each item correctly increased with all but three of the

items (see Table 3). The percentage decrease among those items (items 1, 6 & 14) indicates the

participants did not understand the material presented in regard to these particular items.

RESILIENCY IN COLLEGE FRESHMEN 51

Table 3 KQ Items and Percentage of Participants Answering Each Item Correctly at Pretest and Posttest

Item Pretest Posttest % n % n

1.What is resilience? 81.5 97 77.9 88

2.Which of the following can help someone become more resilient?

64.7 77 75.2 85

3.Which action would a resilient person take if they made a mistake?

81.5 97 91.2 103

4.All of the following are an example of dealing with conflict and compromise, EXCEPT:

63.0 75 69.9 79

5.Midfulness teaches you to be aware of your feeling and _______.

73.9 88 88.8 95

6.Mindfulness helps with stress by _________. 56.3 67 43.4 49

7.Which of these is an example of social support? 80.7 96 93.8 106

8.While at college, where would you NOT go for social support?

70.6 84 77.9 88

9.An example of good _____ health is getting 8 hours of sleep.

40.3 48 54.9 62

10.Opening your mind to new ways of doing things can improve your _______.

59.7 71 74.3 84

11.The life skill that helps you deal with problems and emotions in an effective way is _________.

52.1 62 58.0 65

12.Which of these is cardiovascular exercise? 67.2 80 82.3 93

13.What is the most important meal of the day? 83.2 99 98.2 111

14.Which of the following can result from NOT getting enough sleep?

21.0 25 8.0 9

15.Which of the following is a benefit to physical activity?

89.1 106 98.2 111

RESILIENCY IN COLLEGE FRESHMEN 52

Miscellaneous Findings

A few significant findings were discovered from data analysis that were not specifically

addressed by the clinical research questions. For example, a Pearson’s analysis revealed a

significant positive relationship between days of week participants get outside to exercise and

pretest resilience, r (119) = .27, p = .003, and a small to medium positive correlation between days

of week participants get outside to exercise and pretest health promoting lifestyle behaviors, r(119)

= .43, p = .000. Participants who report higher numbers for exercise are significantly more likely

to report significantly higher levels of resilience and higher levels of health promoting lifestyle

behaviors (see Table 4).

Pearson’s analysis revealed significant but small positive relationships between days of

week participants get seven hours of sleep or more and pretest resilience, r(119) = .21, p = .020,

and pretest health promoting lifestyle behaviors, r(119) = .19, p = .043. Participants who report

higher numbers for sleep per week were significantly more likely to report higher levels of

resilience and higher levels of health promoting behaviors. There was no significant relationship

between pretest and posttest resilience and health promoting behaviors and the number of days

participants ate fast food.

Spearman’s rho indicated a significant negative relationship between days of week

participants get seven hours of sleep or more and pretest anxiety, rs (119) = -.23, p = .012.

Participants who report more hours of sleep per week were significantly more likely to report lower

levels of anxiety. There was no significance between pretest and posttest perceived stress or

knowledge and the number of days of week for outside exercise or days of week eating fast food.

Table 4 Pearson’s Analysis

Variable Pretest Posttest Pretest Posttest

RESILIENCY IN COLLEGE FRESHMEN 53

CD-RISC CD-RISC HPLP-II HPLP-II

Days of week

for

outside exercise

.003* .371 .000** .275

Days of week of

getting 7 hours

of sleep or more

Days of week

eating fast food

.020*

.726

.079

.657

.043*

.173

.209

.357

*p= <.05, **p=<.001

Conclusion

The educational intervention, Resilience 101, had no effect on resilience, healthy lifestyle

behaviors, stress, or anxiety from baseline to two months. However, there was a significant

improvement in participants’ knowledge of resilience, healthy lifestyle behaviors, stress, and

anxiety from baseline to two months. Additionally, participants’ exercise and sleep habits were

noted to have positive, significant correlations with their resilience. There was also a negative

significant correlation between amount of sleep and participant’s anxiety level.

RESILIENCY IN COLLEGE FRESHMEN 54

Chapter 5: Discussion

A discussion of findings from this study will be examined in this chapter. The effect of

an on-line resilience program, Resilience 101, on prevention of potential mental health problems

and supporting healthy lifestyle behaviors for incoming freshmen enrolled in GCSU’s BSP is

presented. A review of students’ demographic characteristics is included. Study strengths and

limitations are also discussed as are the implications to future research.

This project demonstrated the implementation of a resiliency program designed to

promote resilience while providing additional data to existing literature related to the topic. In an

effort to show the potential of such an intervention, the identified populations resilience, health

promoting lifestyle behaviors, perceived stress, general anxiety, and knowledge levels were

measured with a pre-test. The effectiveness of the intervention was determined with a post-test

conducted eight weeks following the five-week resilience program.

According to the research, resilience training programs seem to have modest but

consistent benefits in improving mental health and well-being (Enrique et al., 2019) which were

similar to the results found in this study. The current findings of this study suggest there were no

significant improvements in the participants resilience, health-promoting lifestyle behaviors,

perceived stress or anxiety; however, there was a significant improvement in the participants

knowledge of the topics.

Participant demographics in this study were mostly Caucasian (n=113, 85.1%). These

demographics were similar to those reported by the ACHA conducted at the university in 2019

(Caucasian: 87%). All participant demographics were freshmen with an average age of eighteen

years. Fifty-five percent of participants identified as female and 42 percent identified as male.

RESILIENCY IN COLLEGE FRESHMEN 55

The gender of the demographics of this study was evenly distributed due to the selection into the

universities BSP. The current gender demographics at the university is 77.9% female and 19.8%

male. It was noted that 18.3% of participants got two days of outdoor exercise per week, 33.3%

of participants ate fast food three days per week, and 24.2% of participants got five to seven hour

of sleep per week. The results gave the researcher an indication of the participants healthy

lifestyle behaviors.

Strengths and Limitations

The major strength of this study was the use of an on-line intervention program.

Research found that among the population of study, internet-based intervention promotes the

accessibility and enhances the effectiveness of mental health interventions (Enrique et al., 2019;

Saleh et al., 2018). An on-line intervention allows for an increase in types of services offered

with decreased wait times as well as reduced stigma attached to receiving mental health help in

the college population (Enrique et al., 2019; Saleh et al., 2018). In the current study, the on-line

resilience education intervention was advantageous due to the inability to conduct face-to-face

intervention. Another strength of this study was the use of a preventive strategy of intervention

that focused on nurturing resilience instead of a problem-focused approach which may be more

attractive to the population of college students (Enrique et al., 2019; Herrero et al., 2019). A

further strength of the study was the resilience education intervention being incorporated within

a required course offering which increased the likelihood of attendance.

A final strength was the use of the Transactional Model of Stress and Coping (TMSC) as

a theoretical framework to guide the study. The foundation of the theory created by Lazarus and

Folkman (1987) is based on people identifying stressors and learning to cope through resilience

and adaptation. The strategy of the TMSC can lead to decreasing the negative effects of stress

RESILIENCY IN COLLEGE FRESHMEN 56

such as the mental health challenges that face college students (Etchin et al., 2019). The

education intervention utilized in this study followed the guidelines of the theory by helping the

students identify their stressors, evaluate, or appraise their situation, and provide resource

options to help them cope with their stressors. These interventions included mindfulness,

problem-solving, use of social support, and education on the benefits of exercise, diet, and sleep

to support resilience.

Limitations of the study that may have an impact on the significance of the data were

numerous. The world-wide Covid-19 pandemic may have had a direct impact on the research

project as a whole. The first impact was felt when implementation of the research intervention

and data collection was postponed for a semester due to shifting of college courses on-line

during quarantine. The investigator then had to create an on-line version for consents, survey

collection, and the educational intervention due to the BSP not being offered face-to-face.

The second impact of the pandemic was the uncertainty of whether the BSP was going to

be offered due to the pandemic. The Bridge Scholar program (BSP) is typically held during the

Summer semester for five weeks which was not possible due to the pandemic. After much

thought and deliberation on if, and when the BSP would be offered, the university made the

decision to conduct the BSP program in the Fall. This required the curriculum for the BSP as

well as the educational intervention for the project to be completely remodeled due to having a

15-week semester for both interventional programs.

Although the intervention of resilience was chosen before the pandemic, the third impact

was the effect the pandemic may have had on the college students’ resilience, mental health, and

health promoting lifestyle behaviors. Without a pandemic, freshmen are already considered a

vulnerable population with the normal stressors of entering college. The incoming freshmen had

RESILIENCY IN COLLEGE FRESHMEN 57

already shown exceptional resilience on making it to college during a pandemic. Due to Covid-

19 restrictions, they had endured finishing high school with less than normal events such as

proms, sports, and graduation, and perhaps had seen family members suffer or die from the virus.

These negative effects of the Covid-19 outbreak continued to impact their journey towards

higher education. Stressors identified among the students included fear and worry of their health

and their families’ health, difficulty concentrating, disruption of sleep, decreased social

interaction due to physical distancing, and increased concerns of academic performance, all of

which increased their stress and anxiety (Son et al, 2020).

The impact of the pandemic did not go unnoticed on the mental health status of many

college students. Six months after the pandemic began in the United States, $11.5 million was

made available through the Governors Emergency Education Relief (GEER) to address mental

health concerns across the University System of Georgia (USG). Understanding the preliminary

recommendations from the USG Mental Health Task Force concerning counseling centers

waiting list and the need for establishing long-term strategic planning for mental health, the

University System Office (USO) entered partnerships with Christie Campus Health and the JED

Foundation. An immediate need for clinical support began in January of 2021 that was provided

by Christie Campus Health through their Connect@College program. This outreach offers

telephonic psychiatric care, increased clinical support capacity for the university counseling

center, a well-being support program, and a 24/7 hotline for mental health concerns and issues.

The JED Foundation’s role in the partnership is to provide short- and long-term strategies to

support mental health and well-being needs unique to the university campus of study. This

emergency education relief to aid in mental health expresses the direct impact the pandemic had

on the mental health status of college students in Georgia including those in the study.

RESILIENCY IN COLLEGE FRESHMEN 58

Other limitations of the study included a small sample size (n=113) which reduced the

power and generalizability in the study. The small convenience sample was recruited from one

liberal arts university in the south eastern United States, and it is not clear if these results would

generalize to other types of colleges. The study was further restricted using only freshmen

students enrolled in the universities’ BSP. Duration of the intervention was limited to five weeks

in order to have a posttest follow-up before the end of the semester. Finally, survey exhaustion

was noted in posttest surveys as evident by the participants completing the survey in less than

half of the expected time of the pretest surveys. This could be avoided by not conducting the

posttest during the final week of the semester and having fewer than five surveys to complete.

Future Research Implications

This study has added to the on-going research into supporting college students with a

resilience education intervention at a time in their lives when it could be most impactful.

Incorporation of a resilience education intervention in each phase of a students’ college career

could provide lasting effects and improved results in building resilience and health promoting

lifestyle behaviors while reducing stress and anxiety. This more long-term, structured

environment could be accomplished by recruiting various departments of the university to

support the efforts of resilience training, particularly in areas such as counseling services, student

health, and the wellness division. Future research in resilience education interventions would

benefit from a long-term follow-up to determine the retention of the intervention on mental

health and well-being throughout the entire freshmen year and possible throughout the students

four years in college. The development of resilience is enhanced by practice and experiences

over time (Robbins & Catling, 2018). In this study, it is possible that additional time following

interventions may result in significant improvement in students' lifestyle and behaviors. Perhaps,

RESILIENCY IN COLLEGE FRESHMEN 59

if these same students were given the posttest at the end of their college career, the results would

have been more significant.

Conclusion

In conclusion, the first year of college is a transitional time for young adults and an

opportunity for universities to not only make an educational impact, but an impact on the

students mental and physical well-being. The current study found that a five-week resilience

educational intervention can make an impression on the freshmen students’ knowledge of

resilience, health promoting lifestyle behaviors, perceived stress, and anxiety. This project is a

building block that may be viewed as a strategy for universities to promote resilience as a way of

decreasing the burden of mental health issues in college students and preparing them for future

adversities in life.

RESILIENCY IN COLLEGE FRESHMEN 60

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Appendix A

Institutional Review Board Approval

Institutional Review Board Office of Academic Affairs [email protected] http://www.gcsu.edu/irb

DATE: 2020-05-13

TO: Mary Childre

FROM: Sallie Coke, Ph.D., APRN, BC - Chair of Georgia College Institutional Review Board

RE: Your IRB protocol 14092 is Approved for 2020-05-13 - 2021-05-13

Dear Mary Childre,

The proposal you submitted, “Resilience101,” has been granted approval by the Georgia College Institutional Review Board. You may proceed but are responsible for complying with all stipulations described under the Code of Federal Relationship 45 CFR 46 (Protection of Human Subjects). This document can be obtained from the following address:

http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html

The approval period is for one year, starting from the date of approval. After that time, an extension may be requested. It is your responsibility to notify this committee of any changes to the study or any problems that occur. You are to provide the committee with a summary statement. Please use the IRB Portal (https://irb-portal.gcsu.edu/) to request an extension, report changes, or report the completion of your study.

RESILIENCY IN COLLEGE FRESHMEN 71

Finally, on behalf of IRB, we wish you the best of luck with your study. Please contact GC IRB at any time for assistance.

Sincerely,

Sallie Coke, Ph.D., APRN, BC

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Appendix B

Informed Consent I, _________________________________________________, agree to participate in the research project entitled Resilience 101, which is being conducted by Mary Angela Childre, who can be reached at [email protected] or 478-454-8255. I understand that my participation is voluntary; I can withdraw my consent at any time. If I withdraw my consent, my data will not be used as part of the study and will be destroyed. The following points have been explained to me: 1. The purpose of this study is to evaluate a 5-week resilience education intervention

program. 2. The procedures are as follows: you will be asked to complete a pre evaluation survey

before the 5-week Resilience 101 class. Following completion of the course, you will repeat the survey.

3. Your name will not be connected to your data. Therefore, the information gathered will be confidential.

4. You will be asked to sign two identical consent forms. You must return one form to the investigator before the study begins, and you may keep the other consent form for your records.

5. You may find that some questions are invasive or personal. If you become uncomfortable answering any questions, you may cease participation at that time.

6. This research project is being conducted because of its potential benefits, either to individuals or to humans in general. The expected benefits of this study include promoting resilience to improve mental health and a healthy transition into university life.

7. You are not likely to experience physical, psychological, social, or legal risks beyond those ordinarily encountered in daily life or during the performance of routine examinations or tests by participating in this study.

8. Your individual responses will be confidential and will not be released in any individually identifiable form without your prior consent unless required by law.

9. The investigator will answer any further questions about the research should you have them now or in the future (see above contact information).

10. In addition to the above, further information, including a full explanation of the purpose of this research, will be provided at the completion of the research project on request.

11. By signing and returning this form, you are acknowledging that you are 18 years of age or older.

Signature of Investigator Date Signature of Participant Date

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Research at Georgia College involving human participants is carried out under the oversight of the Institutional Review Board. Address questions or problems regarding these activities to the GC IRB Chair, email: [email protected].

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Appendix C

Minor Written Assent

Project Title: Resilience 101 Investigator and contact information: Mary Angie Childre [email protected] 478-454-8255 1. What is this study about? What will I do in this study? We are doing a research study about being resilient. A research study is a way to learn more about people. If you decide that you want to be part of this study, you will be asked to complete a pre and post survey and a 5-week resilience intervention program that will be once a week. 2. Could anything bad happen to me? The are no foreseen risks in the study. However, should any of the questions cause any undue stress or anxiety, the researcher will be available, either in person or by her personal contact information to resolve any issues or answer any questions. Counseling services will be available for further evaluation if you feel you need further guidance beyond what the investigator can provide. This study is on a voluntary basis, so you can also stop any part of the study after we start. 3. Can anything good happen to me? We think this study has some benefits. A benefit means that something good happens to you. We think these benefits might be to prevent potential mental health problems and support well-being as you transition into college. 4. Will anyone know I am in the study? No; this study is completely confidential or kept in secret. You will be assigned a coded number at the beginning of the study that will be a way for the researcher to identify you. No one else will have access to this number. 5. What if I don’t want to be in the study? You do not have to be in this study if you do not want to be. If you decide to stop after we begin, that’s okay too. Your parents know about the study too and will also be signing a consent.

RESILIENCY IN COLLEGE FRESHMEN 75

If you decide you DO want to be in this study, please write and sign your name in the blank below. I, _________________________________, want to be in this research study. (Write your name here) ___________________________________ ______ (Sign your name here) (Date) Research at Georgia College involving human participants is carried out under the oversight of the Institutional Review Board. Address questions or problems regarding these activities to the GC IRB Chair, email: [email protected].

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Appendix D

Demographics

Please circle or fill in the answer to the following questions: 1. Age ____________________

2. What gender to you identify as?

Male Female Transgender Other___________________

3. Please specific your racial or ethnic identification. African American Caucasian Latino or Hispanic Asian/Pacific Islander Two or more Other/unknown___________________

4. What type of degree are you seeking? Public Health Psychology Business Economics Computer Science Education Health-related field Music Foreign language Liberal studies History Mathematics Undecided Other________________________________________

5. What is your father’s education level? Some high school High school Some college Associate degree Bachelor’s degree Master’s degree or higher Trade school Not sure

RESILIENCY IN COLLEGE FRESHMEN 77

N/A

6. What is your mother’s education level? Some high school High school Some college Associate degree Bachelor’s degree Master’s degree or higher Trade school Not sure N/A

7. What is your parental marital status? Married Divorced N/A

8. What are your sources for financing college? Personal loan Scholarship Government grant/free tuition Self-financing Parents/relative Other

9. Including yourself, how many members are in your core family? _____________________

10. How many days per week do you get outside to exercise? ______________

11. How many days per week do you eat at a fast food restaurant? ______________

12. How many days per week do you get 7 hours of sleep or more per night? ______________

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Appendix E

Knowledge Quiz

1. What is resilience?

A. Bouncing back from an adverse event B. A negative approach to tough situations C. Depression that occurs after a challenging situation D. Approaching problems in a positive manner

2. Which of the following can help someone become more resilient?

A. Avoiding tasks that are challenging or time-consuming B. Thinking that a tough situation is impossible C. Planning ahead to solve problems D. Relying only on yourself to get through a tough situation

3. Which of the following actions would a resilient person take if they made a mistake?

A. Forget about the mistake and move on B. Not waste time trying to figure out what went wrong C. Give up on the task D. Figure out why the mistake happened and how to learn from it

4. All of the following are examples of strategies for dealing with conflict and compromise,

EXCEPT: A. Telling someone they are right, at the cost of your perspective B. Not being afraid of conflict, and facing a hard situation with courage C. Speaking up for yourself, even if you know someone will disagree with you D. Listening to others with genuine concern and understanding

5. Mindfulness teaches you to be aware of your feelings and

A. Then move on B. Accept them C. Change them D. None of the above

6. Mindfulness helps with stress by

A. Making your body resistant to stress hormones B. Changing how you react to stress C. Distracting you until the stress passes D. All of the above

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7. Which of these is an example of social support? A. Jenny turns to her friends to help her through a break-up B. Jeff goes running when he is stressed out C. Jill eats ice cream after she loses her job D. John uses medication to help him through depression caused by social stressors

8. While at college, where would you NOT go for social support?

A. Friends and family B. Your dormitory C. Clubs and student organizations D. Social media

9. An example of good ___________ health is getting 8 hours of sleep each night.

A. Physical B. Lifestyle C. Emotional D. Mental

10. Opening your mind to new ways of doing things can improve your

A. Physical health B. Social Health C. Emotional Health D. Mental Health

11. The life skill that helps you deal with problems and emotions in an effective way is

A. Communicating effectively B. Setting goals C. Coping/Resilience D. Assessing your health

12. Which of these is cardiovascular exercise?

A. Heavy weight-lifting B. Brisk walking C. Full-body stretching D. Sit-ups/crunches

13. What is the most important meal of the day?

A. Breakfast B. Lunch C. Dinner D. Midnight snack

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14. Which of the following can result from NOT getting enough sleep?

A. Diarrhea B. Low-grade fever C. Blurred vision D. All of the above

15. Which of the following is a benefit to physical activity?

A. Reducing stress B. Improving sleep C. Sharpening your focus D. All of the above

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Appendix F

Conner-Davidson Resilience Scale 25 (CD-RISC-25)

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Appendix G

Permission of use of CD-RISC

Dear Mary: Thank you for your interest in the Connor-Davidson Resilience Scale (CD-RISC). We are pleased to grant permission for use of the CD-RISC in the project you have described under the following terms of agreement:

1. You agree (i) not to use the CD-RISC for any commercial purpose unless permission has been granted, or (ii) in research or other work performed for a third party, or (iii) provide the scale to a third party without permission. If other colleagues or off-site collaborators are involved with your project, their use of the scale is restricted to the project described, and the signatory of this agreement is responsible for ensuring that all other parties adhere to the terms of this agreement.

2. You may use the CD-RISC in written form, by telephone, or in secure electronic format whereby the scale is

protected from unauthorized distribution or the possibility of modification. In all presentations of the CD- RISC, including electronic versions, the full copyright and terms of use statement must appear with the scale. The scale should not appear in any form where it is accessible to the public and should be removed from electronic and other sites once the project has been completed.

3. Further information on the CD-RISC can be found at the www.cd-risc.com website. The scale’s content may not be

modified, although in some circumstances the formatting may be adapted with permission of either Dr. Connor or Dr. Davidson. If you wish to create a non-English language translation or culturally modified version of the CD-RISC, please let us know and we will provide details of the standard procedures.

4. Three forms of the scale exist: the original 25 item version and two shorter versions of 10 and 2 items

respectively. When using the CD-RISC 25, CD-RISC 10 or CD-RISC 2, whether in English or other language, please include the full copyright statement and use restrictions as it appears on the scale.

5. A student-rate fee of $ 30 US is payable to Jonathan Davidson at 2434 Racquet Club Drive, Seabrook Island,

SC 29455, USA either by PayPal (www.paypal.com, account [email protected]), cheque, bank wire transfer (in US $$) or international money order.

6. Complete and return this form via email to [email protected].

7. In any publication or report resulting from use of the CD-RISC, you do not publish or partially reproduce items

from the CD-RISC without first securing permission from the authors. If you agree to the terms of this agreement, please email a signed copy to the above email address. Upon receipt of the signed agreement and of payment, we will email a copy of the scale. For questions regarding use of the CD-RISC, please contact Jonathan Davidson at [email protected]. We wish you well in pursuing your goals. Sincerely yours, Jonathan R. T. Davidson, M.D.

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Appendix H

Perceived Stress Scale

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Appendix I

Generalized Anxiety Disorder 7-item (GAD-7) scale

Over the last 2 weeks, how often have you been bothered by the following problems?

Not at all sure Several days Over half the days Nearly every day

1.Feeling nervous, anxious, or on edge

0 1 2 3

2.Not being able to stop or control worrying

0 1 2 3

3.Worrying too much about different things

0 1 2 3

4.Trouble relaxing 0 1 2 3

5.Being so restless that it’s hard to sit still

0 1 2 3

6.Becoming easily annoyed or irritable

0 1 2 3

7.Feeling afraid as if something awful might happen

0 1 2 3

Add the score for each column

Total Score (add your column scores) =

If you checked off any problems, how difficult have these made it for you to do your work, take care of

things at home, or get along with other people?

Not difficult at all __________

Somewhat difficult _________

Very difficult _____________

Extremely difficult _________

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Appendix J

Health Promoting Lifestyle Profile II (HPLP-II)

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