Adolescents’ perceived stress of COVID-19 and self-compassion in Saudi Arabia: A cross-sectional study

Sm S.Hmmd ,Mon D.Alzhrni ,Heh A.Almull

a College of Nursing,Imam Abdulrahman Bin Faisal University,Dammam,Saudi Arabia

b Nursing College,King Khalid University,Abha,Saudi Arabia

Keywords: Adolescent COVID-19 Pandemics Psychological stress Saudi Arabia Self-compassion

ABSTRACT Objectives: Worldwide,the COVID-19 pandemic has significantly impacted mental health challenges for adolescent populations.The current study aims to examine the levels of perceived stress of COVID-19 and self-compassion and their relationship among adolescents in Saudi Arabia.Methods:This study employed a cross-sectional online survey of adolescents from secondary schools in Asir,Saudi Arabia.Instruments that we distributed online included the modified Perceived Stress Scale(PSS-10) and the Self-Compassion Scale (SCS),in addition to demographic and health-related questions.A total of 500 adolescents completed the survey.Results:Adolescents in the study reported an average moderate perceived stress level of 18.6(SD=6.67)and an average moderate self-compassion level of 3.22(SD=0.53).A significant correlation is also found between the two variables(r=-0.460,P ＜0.001).This negative correlation indicates that lower levels of perceived stress are significantly correlated with higher levels of self-compassion.Conclusion:The study results show that the perceived stress of COVID-19 is inversely correlated with self-compassion in Saudi adolescents.Further research is needed to explore how to enhance adolescents’self-compassion.School nurses’ role should be given full play in this area.

What is known?

·Adolescents need unique support against the COVID-19 pandemic since they are at a critical stage of development.

·Adolescents from one culture to the other express perceived stress and self-compassion differently in levels and ways.

What is new?

·Perceived stress of COVID-19 among Saudi Arabian adolescents was inversely correlated with self-compassion in Saudi adolescents.

·Adolescents in Saudi Arab can express self-compassion in several cultural ways.

1.Introduction

The COVID-19 pandemic has led to drastic shifts in people’s lives.As a result,it has amplified mental health issues for different age groups.As half of all mental disorders develop before age 14[1,2],adolescents and children are more vulnerable to COVID-19[1,3].In addition,adolescents require unique support in coping with the effects of COVID-19 since they are at a critical stage of development [4].COVID-19,which spurred social distancing,has thus presented significant challenges to fostering experiences like social and learning activities,which bring adolescents together.Moreover,during the pandemic,adolescents have faced increased stress and anxiety,accompanied by fears of death,losing loved ones,and testing positive for the virus[4].Therefore,the pandemic has placed adolescents at risk for long-term mental health impacts and heightened stress levels [5].

Stress-related complaints are the reason for three-quarters of physician visits in mental health clinics[6],and adolescents feeling stressed in general is a primary health concern [7,8].During the pandemic,“COVID stress syndrome” was used repeatedly in the literature to denote the psychological distress that the pandemic caused various populations [9,10].Such stressful life experiences are critical environmental precursors to persistent and the later development of more severe mental and physical pathologies[8,11].Individuals perceive,evaluate,and respond to stress differently,especially during challenging situations [12].Furthermore,knowledge about stress levels helps people to better understand the relationship between stress and pathology [13].For example,studies have linked depression to past-focused ruminations and anxiety and stress to future concerns[14,15].Therefore,adolescents with high levels of perceived stress are more likely to develop a mental disorder[11].This burden,especially at a young age,poses public health challenges on different levels[16].Therefore,stressful life experiences are an important environmental factor to consider since they increase the risk of developing psychological issues among adolescents [11,17].

Past research defines self-compassion as how a person relates to themselves in moments of perceived failure,inadequacy,or personal suffering[18].Evidence supports self-compassion’s impact on moderating the relationship between psychological distress,stress,shame,stigma,and others [19].During heightened anxiety or tension,self-compassion has powerful physiological effects on decreasing this stress [20,21] through three main aspects: selfkindness,mindfulness practices,and the acknowledgment of common humanity in general experiencing stress,pain,and more[20].Cultural influences play a role in the way one perceives stress and self-compassion.For example,a multi-country study conducted during the pandemic found that self-compassion is a significant protective factor against mental health issues[19].

The Kingdom of Saudi Arabia (KSA) is situated in the Arabian Peninsula and has a population of about 35 million[22].The KSA is a country with a majority-younger population (under 40): people under and over age 40 number 23 million and 17 million,respectively.Moreover,children 19 and younger comprise 31% of the population-over a quarter [23].Thus,studying the younger population is crucial for the health and future of the KSA.Furthermore,given the KSA’s global economic,diplomatic,and geopolitical responsibilities,efforts have been aimed at mitigating the spread of the pandemic internationally rather than locally [24].However,to our knowledge,no studies in the literature examine the relationship between the perceived stress of COVID-19 and selfcompassion levels in Saudi adolescents.

Therefore,the current study examines Saudi adolescents’perceived stress and self-compassion levels and whether these variables correlate significantly.Findings from this study provide valuable information about adolescents’ perceived stress and selfcompassion levels during a pandemic,which can help decisionmakers to establish policies for schools and interventions for school nurses during times of crisis.Moreover,utilizing Healthy School program guidelines provides a roadmap for nurses and researchers to further test and enhance these programs in collaboration with relevant ministries.

2.Methods

2.1.Study design

A cross-sectional design was used to investigate COVID-19-related perceived stress and self-compassion levels among Saudi adolescents and to test whether these variables are significantly associated.Before conducting the study,we obtained institutional review board (IRB) approval from Imam Abdulrahman bin Faisal University (#PGS-2022-04-100).Finally,the study follows the Strengthening the Reporting Observational Studies in Epidemiology guidelines (STROBE).

2.2.Sampling and sample size

We recruited a convenience sample of adolescents from ten secondary schools in the KSA’s Asir region.Both female and male adolescents that attended governmental secondary schools in the 10th,11th,or 12th grades and could read and write in Arabic were eligible to participate.The sampling frame consisted of 2,800 Saudi adolescents who met the inclusion criteria and attended the selected secondary schools.The G*Power application determined the minimum required sample size for correlation analysis to be 84,calculated based on an α level of 0.05,a moderate effect size of (f)0.25,and a power of 0.8 [25].

2.3.Data collection procedure and ethical considerations

After receiving IRB approval,the education department’s general administration contacted secondary schools in the Asir region to assess their willingness to participate.Ten schools were interested in participating and were later assigned to the research team for recruitment.We arranged visits and meetings with the principal of each school to discuss the study’s purpose and the details of the data collection process.Data were collected from March 20 to April 20,2022.The survey was designed using QuestionPro software,which provides an anonymity feature to maintain participants’confidentiality.Next,the school counselor shared an invitation via WhatsApp,including the survey link,to the eligible adolescents’parents.Upon receiving consent from their children,parents then forwarded the survey link to their children for completion.

The participant information sheet(PIS)appeared on the study’s first page,describing its purpose,participation eligibility criteria,the risks and benefits of participation,and other related details.Following the PIS,we obtained implied consent by checking the agreement statements required to initiate the survey.Participants confirmed that they understood the PIS,their guardian was aware of their participation,they were participating voluntarily,and they knew of their identities' anonymity.

2.4.Measures

2.4.1.The Perceived Stress Scale (PSS-10)

The PSS-10 [26] is a 10-item scale that measures the extent to which an individual has,in the past month,perceived their life to be unpredictable,uncontrollable,and overwhelming;a 5-point Likert scale rated responses from 0(Never)to 4(Very often).In this study,to measure the adolescents’ perceived stress due to COVID-19,items were reviewed for their relevance in the context of the COVID-19 pandemic,we modified each item by replacing the statement,“In the last month,how often have you been upset because of something that happened unexpectedly?” with the following: “Due to the COVID-19 pandemic,how often have you been upset because of something that happened unexpectedly?”The total score was calculated by summing all scores after reversecoding the positively worded items (0-40).A higher total score indicated higher levels of perceived stress [13].The scale’s convergent validity and discriminant validity were also established,and it demonstrated an adequate Cronbach’s α coefficient of 0.82[27].The Arabic version of the scale used in the current study also revealed a good internal consistency reliability of 0.74 [28].

2.4.2.The Self-Compassion Scale (SCS)

The SCS [20] is a 26-item scale that measures individuals’ actions toward themselves in difficult times.The SCS includes six subscales: self-kindness,self-judgment,mindfulness,common humanity,isolation,and over-identification.Responses are rated on a 5-point Likert scale ranging from 1 (Almost never) to 5 (Almost always).A sample item is“I’m disapproving and judgmental about my own flaws and inadequacies.”After reverse-coding the negative subscale,the total score was calculated by computing the average mean score of all six subscales.Notably,higher average mean scores indicated higher levels of self-compassion.The scale was also shown to be valid and had an excellent internal consistency reliability of 0.92 [20].The Arabic version of the scale also had a good internal consistency reliability of 0.86 [29].

In addition to the above two scales,demographic items were added to the survey,including age,gender,high school year,and parent education levels.Yes or no questions asking the adolescents whether they have a chronic physical illness,such as diabetes,or a common mental disorder,such as anxiety,were also included.

2.5.Statistical data analysis

Data were analyzed using the SPSS version 28.There were no missing data in the completed surveys since QuestionPro includes a feature requiring the participant to complete all missing fields before continuing to the next page of the survey.Additionally,frequencies and proportions were computed to summarize the categorical data;means and standard deviations were calculated to summarize the continuous variables and describe the studied variables (i.e.,perceived stress and self-compassion).Finally,the Pearson correlation coefficient (r) was selected to test the association between the perceived stress of COVID-19 and selfcompassion after attaining the four tested assumptions of the parametric test(Pearson correlation):normality,homoscedasticity,and linearity.Both variables were continuous (See Supplementary Figs.S1 and S2) [30].

3.Results

From the sampling frame of 2,800 adolescents eligible to participate in the study,we sampled 500 adolescents for the online survey,all of whom completed it.Notably,the collected sample size(n=500) exceeded the calculated minimum sample size for correlational analysis based on Cronbach’s α of 0.05,a moderate effect size of (f) 0.25,and a power of 0.8 [25].About half of the participants were between 17 and 18(50.6%),and two-thirds were female (62.4%) (see Table 1).

The perceived stress and the self-compassion scales demonstrated adequate internal consistency reliability and cohere with the previously measured validity reported in the literature[28,29].Cronbach’s α coefficients were 0.74 and 0.78 for the PSS and the SCS,respectively.Additionally,adolescents in the study sample reported an average moderate perceived stress level(Mean=18.6,SD=6.67,range 0-36) and a moderate self-compassion level(Mean=3.22,SD=0.53,range 1.28-4.87).

Pearson’s correlation revealed a significant linear association between the perceived stress and self-compassion mean scores(r=-0.46,P＜0.001),indicating that lower levels of perceived stress are significantly correlated with higher levels of self-compassion.

Table 2 presents a cross-tabulation between perceived stress and self-compassion levels.Notably,70.6%(228/323)of adolescents who reported a moderate perceived stress level also had an intermediate self-compassion level.Interestingly,among adolescents with lower stress levels,49.6% (57/115) reported moderate selfcompassion,and 47.0% (54/115) reported high self-compassion.Therefore,evidence supports a relationship between perceived stress and self-compassion levels in Saudi adolescents (χ2=84.1,df=4,P＜0.001).

Table 1 Descriptive sample characteristics (n=500).

Table 2 The cross-tabulation and chi-square test of perceived stress and self-compassion levels.

4.Discussion

Several studies have examined the association between adolescents’perceived stress and self-compassion across cultures[18].However,this is the first to our knowledge conducted in Saudi Arabia that examines Saudi adolescents’perceived stress of COVID-19 and self-compassion levels and whether these variables are significantly correlated.Our results showed that most of the sample had moderate perceived stress and self-compassion levels.The results also illustrated that lower levels of perceived stress were significantly correlated with higher levels of self-compassion.This section,to explain this relationship,provides specific cultural components of adolescents in Saudi Arabia that may explain how self-compassion is expressed in the culture and applied in daily life.

Moderate levels of perceived stress were found in similar age populations in various countries globally,including the UK,Europe,the Netherlands,and others [15,31,32].For example,researchers conducting a study on a Jordanian sample found that many adolescents lacked knowledge about COVID-19;therefore,efforts are needed to increase knowledge levels,beliefs,attitudes,and practices among this population [33].Our study’s results align with others in the literature,indicating that when stressful life events occur in an adolescent’s environment,practicing self-compassion,self-awareness,and forgiveness can decrease their perceived stress[34,35].

4.1.Compassion and culture

Compassion for oneself,others,and the surrounding environment are influenced partly by the sociocultural aspects of one’s life[29].Additionally,self-compassion can be divided into three main domains:self-kindness(i.e.,positive self-reflection),recognition of our common humanity (i.e.,stress is a shared experience),and mindfulness (i.e.,meditative practices,deep breathing,etc.)[18,36,37].In studies conducted on self-compassion,the levels of self-compassion of young adults from several countries have varied due to differences in cultural and religious beliefs [37-39].

Islam is a way of life in Saudi Arabia,and the concepts of both religiosity and spirituality are intertwined within one’s life.In Saudi Arabian culture,religiosity is a component of human life demonstrated through one’s values,belief systems,attitudes,and behaviors [40,41].Therefore,Islamic values are among the core influencers of Saudi culture[40].Activities that may be considered self-compassionate include moments of silence during prayers,fasting,supplication,mindfulness,patience,and a positive outlook toward life and situations that occur and are beyond one’s control.One of the core beliefs described in the Quran exemplifies more specific sociocultural applications of self-compassion among Saudi adolescents.Translated,it means that “one must not induce harm or destruction to themselves”[42]:in other words,one ought to be kind to themselves.Moreover,the month of Ramadan illustrates actions related to recognizing our common humanity;in this holy month,Muslims worldwide fast while trying to acquire many good deeds.Finally,mindfulness can be practiced through the five daily prayers and reciting self-centering affirmations,such as theAthkarsupplications.

The cultural structures of society also shape our worldviews.For example,similar to our study,moderate levels of self-compassion were found in another Saudi sample of younger adults,explained as deriving from Saudi cultural changes [38].Likewise,a Turkish study found younger adults’scores to be at moderate levels for selfcompassion,reasoning that it was due to societal structures moving from highly collectivistic to a combination of individualistic and collectivistic[39].The results from our study coincide with those of studies,emphasizing that self-compassion in adolescents is an adaptive or protective factor against COVID-19 and can decrease levels of perceived stress,symptoms of depression,symptoms of anxiety,and feelings of hopelessness in their lives [43,44].

4.2.Stress and coping mechanisms

Earlier studies have also found higher levels of perceived stress and lower levels of resilience in students during the peak of the pandemic[45,46].For instance,in a longitudinal survey,perceived stress explained the pathway between perfectionist traits and psychological distress in adolescents before and during the pandemic [47].Although the authors did not examine selfcompassion directly,the links between perfectionistic traits and self-compassion were inversely correlated[18,20,21].

Moreover,culture influences stress and coping techniques,causing various responses to stress and approaches to dealing with it [48].Here,a systematic review of the impact of COVID-19 on adolescents’ mental health found that lockdown causes stress and psychological distress,and vulnerable groups with past mental health issues were most at risk[49].Notably,another Saudi study of adolescents showed moderate use of coping strategies,identifying four ways to reduce stress related to COVID-19,including seeking social support,accepting the situation,disengaging mentally,and practicing humanitarianism[50].Other ways to reduce adolescents’perceived stress that can have cultural implications include setting routines,communicating with family members,seeking social support,and allotting appropriate time to play and leisure[49].One way to prevent the risk of further psychological distress through the integration of the techniques mentioned above is through the accessibility of school or community nurses.

4.3.Nurses’ roles

Nurses play important roles in school settings and the broader community regarding adolescents’ mental and physical health needs.School and community health nurses are not limited to providing health check-ups but may bring awareness to stress management and self-compassion practices.Studies have also outlined nurses’ roles in medical treatment,urgent care,and first aid from parents’ and teachers’ perspectives [51,52].One study found that some teachers were unaware of the exact role that nurses play in schools [51].Therefore,in the current research,student advisers were the point of contact during data collection due to the urgent need for hospital nurses during the pandemic.Nevertheless,studies have highlighted school nurses’ importance and influence as crucial members fighting against the COVID-19 pandemic and other crises [33].

Specifically,Saudi Arabian nurses can help via the national Healthy Schools program,a collaborative effort between the Ministries of Health and Education to promote children’s and adolescents’ health in schools [53].As stated in the program guidelines,nurses from several domains can take action via numerous methods.These include generally supporting adolescents’ wellbeing,teaching people to deal with infectious diseases,instructing people to deal with emergency or infectious cases,helping people to prevent and detect mental issues in students and staff early,and instructing people how to address mental health issues[53].Moreover,the participating schools in this program are expected to open school spaces for community service,as outlined in their guidelines.Therefore,nurses and researchers can utilize school spaces after hours to hold health lectures or workshops for students and families for self-compassion and stress management training.Another way is implementing global health days,such as for mental wellness,recommended in their evaluation forms [54].These days of awareness can prompt collaboration between school staff,nurses,and researchers to ensure that schools are health conscious.

4.4.Limitations

This study had several limitations:First,a cross-sectional design is limited to correlation relationships between the perceived stress of COVID-19 and self-compassion,and thus,care must be taken when interpreting the results.Second,most schools in Saudi Arabia are not gender-mixed;therefore,the research team needs female and male researchers for easy accessibility and data collection.Third,although online surveys offer many advantages over traditional surveys,participants’ opinions are subject to self-selection bias.However,the schools were receptive to scientific research based on the ease with which we collected our data.

Moreover,despite this study being descriptive,supportive evidence for self-compassion interventions for reducing adolescent stress during the COVID-19 pandemic is extensive.Nevertheless,mobile applications tailored to improving mental well-being during the COVID-19 pandemic showed mixed results.One pilot study found a significant reduction in perceived stress but no change in self-compassion [55].Another study explored a more specific intervention using seven modules and a larger sample,finding significant results for perceived stress and self-compassion [56].Other studies were conducted on interventions ranging from mobile applications to supportive interventions tailored to adolescents during COVID-19,and these found mainly positive results [56-58].Within the Arab world,however,these types of interventions are still in their early stages of implementation,but evidence supports that positive psychology interventions effectively improve well-being[57].Research on self-compassion has additionally shown that it positively influences mental states[18].Forexample,results from periods as short as 4 to 10 weeks for studies examining self-compassion focusing on mindfulness,self-kindness,and common humanity all found significant differences between the experimental and control groups[57].

4.5.Implications

Future studies will benefit from examining different regions using longitudinal designs,interventions,and community-based participatory research.These approaches can clarify the differences between regions to promote the creation of school policies tailored to the Saudi culture and applicable across the developmental stages of childhood and adolescence.Tailored policies are essential for disaster preparedness in any crisis or pandemic.Moreover,techniques aimed at teaching self-compassion ought to be tested and implemented within schools and homes to test their efficacy.Furthermore,intervention research on adolescents in various settings during a pandemic or crisis can also be conducted in the school or home setting to examine compassionate mind training and,second,in hospitals or mental health clinics to study compassion-focused therapy [19,59,60].

5.Conclusion

Adolescents comprise a large proportion of the Saudi Arabian population,and during the COVID-19 pandemic,there has been much uncertainty globally.Perceived stress and self-compassion are two concepts that have been interconnected within the context of Saudi culture during the pandemic.By studying these two concepts and their relationship in Saudi adolescents,we found that the perceived stress of COVID-19 is inversely correlated with self-compassion in Saudi adolescents.This study also explored several cultural ways to express self-compassion in Saudi culture and among adolescents.With the return to pre-pandemic patterns of living,more research should closely examine the areas related to school health during a pandemic.Finally,school and community nurses occupy an influential position within the school environment to promote the well-being and safety of adolescents and their families through designing and implementing culturally tailored policies and interventions.

Funding

Nothing to declare.

CRediT authorship contribution statement

Sama S.Hammad:Conceptualization,Methodology,Validation,Investigation,Data curation,Writing-original draft,Writing-review&editing,Supervision,Project administration.Mona D.Alzahrani:Conceptualization,Methodology,Validation,Software,Investigation,Writing-review &editing,Data collection,Project administration.Hebah A.Almulla:Conceptualization,Methodology,Questionnaire design,Validation,Investigation,Formal analysis,Writing-review &editing,Supervision,Project administration.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declaration of competing interest

The authors have declared no conflict of interest.

Acknowledgments

We would like to express our gratitude to the participants of our study and for the school systems in Saudi Arabia for allowing us to collect data during the COVID-19 pandemic.

Appendices.Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2023.03.008.