Report of Empirical Study

Health Psychology Open

July-December 2022: 1–13
The COVID-19 Student Stress © The Author(s) 2022
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Questionnaire: Validation in Spanish sagepub.com/journals-permissions
DOI: 10.1177/20551029221135293
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university students from health sciences

Federica Vallone1,2 , Maria Francesca Cattaneo Della Volta1,2, Luis Iván Mayor Silva3,
Alfonso Meneses Monroy3, Maura Galletta4, Felice Curcio5  and Maria Clelia Zurlo2 

Abstract
This study aimed to validate the Spanish version of the COVID-19 Student Stress Questionnaire (CSSQ), a 7-item tool
assessing COVID-19-related stressors among university students, namely, Relationships and Academic Life, Isolation, and
Fear of Contagion. Participants were 331 Spanish university students. Factor analyses sustained the three factor solution of
the original tool. Data also revealed satisfactory convergent and discriminant validity, suitable internal consistency, and
significant associations with psychological symptoms, as measured by the Symptom Checklist-90-Revised. The Spanish
version of the CSSQ represents a valid tool to be used in clinical settings to timely identify students at high psychological risk
and to develop evidence-based interventions during/after the pandemic.

Keywords
COVID-19, quantitative methods, risk factors, scale, Spanish version, stress, students

Introduction among university students as the pandemic was progressing

(Debowska et al., 2020; Volken et al., 2021; Zhang et al., 2020;
Over the 2 years of the Coronavirus Disease 2019 (COVID- Zurlo et al., 2022a). This has raised the necessity for timely
19) pandemic, research has increasingly highlighted re- assessment of students’ psychological health and its predictors
markable levels of stress and psychological disease among in order to develop tailored evidence-based interventions
the general population (Barrios et al., 2020; Bueno-Notivol preventing mental illness escalation (Wade et al., 2020).
et al., 2021; Lima et al., 2020; Liu et al., 2021; Martı́nez- I, research has developed several measurement tools to be
Lorca et al., 2020; Pietrabissa and Simpson, 2020; used for the assessment of specific COVID-19-related
Rajkumar, 2020; World Health Organization, 2020a).
However, a specific branch of research has focused on the
impact of the COVID-19 emergency on university students’ 1
Department of Humanities, University of Naples Federico II, Italy
wellbeing, since they were considered a vulnerable population 2
Dynamic Psychology Laboratory, Department of Political Sciences,
even before the pandemic (Auerbach et al., 2018; Ballester University of Naples Federico II, Italy
3
et al., 2020; Teixeira et al., 2021; Zivin et al., 2009). Spe- Departament of Nursing, Universidad Complutense de Madrid, Spain
4
Department of Medical Sciences and Public Health, University of Cagliari,
cifically, research conducted during the COVID-19 outbreak Monserrato, Italy
has underlined significant levels of anxiety and depression 5
Department of Medical, Surgical and Experimental Sciences, University of
reported by students worldwide (Aristovnik et al., 2020; Sassari, Italy
Browning et al., 2021; Cao et al., 2020; Charles et al., 2021;
Corresponding author:
Husky et al., 2020) as in Spain (Marques et al., 2021;
Federica Vallone, Department of Humanities, University of Naples
Odriozola-González et al., 2020). Moreover, research has also Federico II, Via Porta di Massa 1, Naples 80133, Italy.
demonstrated a significant increase in psychological suffering Email: [email protected]

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2 Health Psychology Open

stressors (e.g., the COVID-19 Stressor Scale, CSS; Tambling In this direction, the main purpose of the present study is to
et al., 2021; the Pandemic Stressor Scale, PaSS; Lotzin et al., translate and validate the Spanish version of the CSSQ. This is
2021a, 2021b), and psychological health outcomes (e.g., the also considering that the Spanish language, spoken by 543
COVID-19 Peritraumatic Distress Index, CPDI; Qiu et al., million people worldwide, represents one of the most
2020; the Coronavirus Anxiety Scale, CAS; Lee, 2020; the widespread languages globally (Szmigiera, 2021). To test the
Fear of COVID-19 Scale, FCV-19S; Ahorsu et al., 2020). psychometric proprieties of the Spanish version of the
Nonetheless, despite their proven validity, all these COVID-19 Student Stress Questionnaire (CSSQ), namely the
measures target the general population. However, the COVID-19 Student Stress Questionnaire-Español (CSSQ-es),
COVID-19-related experiences may significantly vary ac- the following research objectives (RO) are defined:
cording to different population groups (i.e., university
students), thus requiring the adoption of specific tools ad- RO1. Testing whether the factor structure of the CSSQ-
dressing the specificities of each target population. es confirms those of the original CSSQ (Structural
Accordingly, in response to the abovementioned need, Validity).
research has provided a tailored tool, namely the COVID-19 RO2. Testing whether the CSSQ-es has a satisfactory
Student Stress Questionnaire (CSSQ; Zurlo et al., 2020). Convergent Validity.
The CSSQ represents a brief (7-item) and psychometrically RO3. Testing whether the CSSQ-es has satisfactory
robust instrument, tapping specific sources of stress po- Discriminant Validity.
tentially experienced by students due to the COVID-19 RO4. Testing whether the CSSQ-es has satisfactory
outbreak: (1) Relationships and Academic Life (i.e., assessing Internal Consistency.
perceived stress related to changes in relationships with rel-
atives, university colleagues, professors, and in academic life);
(2) Isolation (i.e., assessing perceived stress related to the Method
condition of social isolation and changes in couple’s
relationship/intimacy/sexual life); and (3) Fear of Contagion
Study design and participants
(i.e., assessing perceived stress related to the fear about the An online cross-sectional survey form (hosted by Microsoft
contagion risk). The scale also provides the Global Stress score Teams) was developed for this study. A convenience sample
(i.e., a composite measure including the three abovementioned was used, and data were collected from 12 to 29 April 2021
subscales), which can be useful to evaluate the overall per- with students from four Spanish Universities (Universidad
ceived levels of stress related to the COVID-19 pandemic and Complutense de Madrid, Universidad Francisco de Vitoria,
containment measures among university students. Escuela Cruz Roja, Universidad de Córdoba). The survey
The CSSQ is currently available in Italian, English link was sent via academic mailing lists and social media
(Zurlo et al., 2020), and Turkish versions (Gundogan, groups. The research project and its objectives were also
2022), and it is increasingly addressed by researchers ex- widely diffused by the authors during their class. Students
ploring the impact of the COVID-19 pandemic among enrolled in Faculties of Health Sciences were asked to
university students worldwide (e.g., Co et al., 2021; participate on a voluntary basis and did not receive rewards
Bhargav and Swords, 2022; Barad et al., 2022; Bobade and for completing the survey. At the beginning of the survey
Naik, 2021; Eloff, 2021; Hoferichter and Steinberg, 2022; link, there was an information sheet explaining the research
Lardone et al., 2021; Mahadi et al., 2022; Maryin and aims and students’ rights. Specifically, information on their
Nikiforova, 2021; Momo, 2021; Okun et al., 2022; rights to not participate in the study (refusal to take part in
Procentese et al., 2021; Rogowska et al., 2021; Rusch et al., the study won’t impact their course of study), as well as to
2021; Somma et al., 2021; Sommantico et al., 2022). withdraw at any time, without giving any reason and
Specifically, recent studies have provided evidence sup- without suffering consequences of any kind, were fully
porting CSSQ-subscales as significant predictors of psy- given. Furthermore, students were informed about the
chological disease among university students (e.g., Bhargav privacy policy (i.e., data collected can be used for future
and Swords, 2022; Gundogan, 2022; Mahadi et al., 2022; research; data will be analyzed for research objectives only;
Zurlo et al., 2022a; Zurlo et al., 2022b), so indicating the statistical data obtained can be presented at scientific
key role of CSSQ as a mental health screener. conferences and publications; their personal information
Therefore, the current study aims at responding to the will remain fully anonymous and confidential; only re-
need to foster timely psychological assessment of spe- searchers will have access to the data that will be processed
cific stressors influencing mental illness escalation in accordance with the current regulations). The research
among students in the current pandemic period and, project - targeting Spanish students enrolled in Faculties of
accordingly, to develop tailored interventions promoting Health Sciences - was approved by the Ethical Committee
psychological health among Spanish-speaking univer- of Universidad Complutense de Madrid (22/03/2021) and
sity students. was implemented in accordance with the 1964 Helsinki
Vallone et al. 3

declaration and its later amendments or comparable ethical Depression (13 items, Cronbach’s α = 0.91), Anxiety (10
standards, as well as with the Law 3/2018 (December 5) on items, Cronbach’s α = 0.89), Hostility (6 items, Cronbach’s
the Protection of Personal Data and guarantee digital rights α = 0.81), Phobic Anxiety (7 items, Cronbach’s α = 0.80),
and Regulation 2016/679 of the European Parliament of 27 Paranoid Ideation (6 items, Cronbach’s α = 0.78), and
April 2016 on the Protection of Natural Persons in Data Psychoticism (10 items, Cronbach’s α = 0.83). The SCL-90-
Processing. R also provides the Global Severity Index (GSI; Cronbach’s
After reading the information sheet, students were asked α = 0.97)—calculated by summing all the responses divided
to complete the informed consent form, in which they by 90—which addressed the number as well as the intensity
declare their consensus to participate in the study and the of the symptoms.
consequent processing of their sensitive personal data. To be
eligible, participants must be university students (post-
Procedure
secondary; including undergraduate students and post-
graduate students—masters or equivalent) with age ≥18 In order to obtain the Spanish version of the CSSQ, a
years. Exclusion criteria were the absence of consensus and back-translation process, in line with Brislin’s classic
not being a post-secondary student or being a doctoral level back-translation model (Brislin, 1970), and following
students (PhD student or equivalent). For evaluating the the international guidelines (Muñiz and Bartram,
sample size required, we considered the rules of thumb on 2007; World Health Organization, 2020b), was car-
the adequacy of sample size for factor analysis, which ried out.
suggested a ratio of 5–10 participants per item for N = 300 In particular, a process of repeated independent trans-
(for N > 300 this ratio can become progressively lower) and lation and back-translation by a team of translators was
which defined a factor analysis sample of 50 as very poor, conducted. A bilingual translator blindly translated the
100 as poor, 200 as fair, and 300 as good (Comrey and Lee, CSSQ from the original language to the Spanish language; a
1992; Costello and Osborne, 2005; DeVellis, 2017). second bilingual translator independently back-translated
Overall, 331 university students participated in the study on the tool from the target language to the original language.
a voluntary basis and provided written informed consent. Furthermore, the two versions of the CSSQ (original lan-
There were no missing data. Therefore, in the present study, guage and back-translated version) were compared for
the sample of N = 331 was evaluated as adequate to test the concept equivalence. According to Brislin’s classic back-
factor structure of the 7-item CSSQ-es. translation model (Brislin, 1970), minor changes should be
made when an error was found in the back-translated version,
and another translator should retranslate the items. In our
Measures
process, no significant discrepancies were found between the
First, background information was collected by using two versions. Afterwards, five bilingual experts, including
single-item questions on Age, Gender, University Name, the authors of the original version of the CSSQ, evaluated the
Degree-Program, and Year of Study. translations. They made minor changes and then agreed that
Second, the proposed Spanish version of the COVID-19 the final version of the tool has no errors in meaning. The
Student Stress Questionnaire (CSSQ) was administered. final Spanish version of CSSQ was, therefore, administered
The CSSQ was created by Zurlo et al. (2020) and measures (see Appendix 1).
COVID-19-related sources of stress among university In order to test the psychometric proprieties of the
students. It comprises 7 items (on a 5-point Likert scale Spanish version of the CSSQ, the European Federation of
ranging from 0 = Not at all stressful to 4 = Extremely Psychologists’ Association’ standards and guidelines (Evers
stressful) divided into three subscales: Relationships and et al., 2013) and the COnsensus-based Standards for the
Academic Life (4 items), Isolation (2 items), and Fear of selection of health status Measurement INstruments
Contagion (1 item). The range of the Global Stress score is (COSMIN) Checklist (Mokkink et al., 2012) were followed
0–28. The CSSQ revealed a suitable internal consistency as frameworks to guide our choices of measurement
(McDonald’s ω = 0.71; Cronbach’s α = 0.71). properties and parameters. Therefore, validity evidence was
Finally, the questionnaire included the Symptom examined in relation to Structural Validity, hypotheses
Checklist-90-Revised (SCL-90-R; Casullo and Pérez, 2004; testing for Convergent Validity and Discriminant Validity,
Derogatis, 1994), assessing the presence of symptoms of and Internal Consistency. Interpretability was also
psychological suffering over the past week. The SCL-90-R described.
consists of 90 items (on a 5-point Likert scale ranging from
zero = Not at all to four = Extremely) divided into 9 sub-
Data analysis
scales: Somatization (12 items, Cronbach’s α = 0.90),
Obsessive-Compulsive (10 items, Cronbach’s α = 0.88), The statistical analyses were carried out by using SPSS
Interpersonal Sensitivity (9 items, Cronbach’s α = 0.84), version 21 and AMOS tool version 26. Descriptive statistics
4 Health Psychology Open

of the study sample’ background information were pre- among factors (Fornell and Larcker, 1981), and the cor-
liminary carried out. Firstly, in order to assess the Structural relations between each CSSQ-es subscale and the Global
Validity of the CSSQ-es (RO1), Exploratory Factor Analysis Stress scores are significant and higher in size than the
(EFA) was preliminary performed to explore the structure of the correlations among factors.
CSSQ-es. Principal Components Analysis (PCA) with oblique For testing the Internal Consistency of the CSSQ-es
promax rotation was used. The factorability of the correlation (RO4), McDonald’s Omega (ω; McDonald, 1999) and
matrix of the scale was evaluated by Kaiser–Meyer–Olkin Composite Reliability (CR; Fornell and Larcker, 1981) were
(KMO) measure and Barlett test, of sphericity. Communality calculated, considering ω ≥ 0.7 and CR ≥ 0.7 as indicators of
>0.30 for each item, Cattell’s scree test, and inspection of scree adequate internal consistency.
plot were used to verify the factor structure of the CSSQ-es In addition, considering the Interpretability of the CSSQ-
(Costello and Osborne, 2005). Afterwards, Confirmatory es, item means, standard deviations, and ranges of the
Factor Analysis (CFA) was performed by using the maximum CSSQ-es scales were calculated. Skewness and Kurtosis
likelihood (ML) as estimation method (Kline, 2016; Pritikin were used to judge the normality of data. A Z-score was
et al., 2018). Standard indices were used to evaluate the calculated by dividing the skew values or excess kurtosis by
goodness-of-fit, namely χ2 non-significant (p > 0.05), Stan- their standard errors. The distribution is considered to be
dardized Root Mean Square Residual (SRMR < 0.08), Root approximately normal when Z-scores fall between 2 to +2
Mean Square Error of Approximation (RMSEA < 0.08), (George and Mallery, 2012).
Comparative Fit Index (CFI > 0.95), and Tucker-Lewis Index
(TLI > 0.95) (Hu and Bentler, 1998). Results
Secondly, Convergent Validity was evaluated (RO2).
Specifically, Convergent Validity was tested by exploring Participants
standardized factor loadings and AVE of factors as well as
The sample comprised 51 men and 280 women (age mean =
by analyzing correlational analyses between the scales
21.29 years; SD = 4.64). The sample was composed of all
scores of the CSSQ-es and the scales scores of the SCL-90-
students enrolled in Faculties of Health Sciences, specifi-
R. A questionnaire is considered as possessing adequate
cally in Nursing (n = 207, 62.6%), Pharmacy (n = 65, 19.6%),
convergent validity whether the standardized factor loadings
Physiotherapy (n = 32, 9.7%), Podiatry (n = 18, 5.4%), and
are all equal to or above 0.5 and statistically significant, and
Other Healthcare Science (n = 9, 2.7%) degree programs.
when AVE of each factor is equal or above 0.5 (Fornell and
More than one half of them were enrolled at the Universidad
Larcker, 1981; Hair et al., 2010). Considering the correlation
Complutense de Madrid (n = 236, 71.3%), while the remaining
analyses, we hypothesized that the scales scores of the CSSQ-
were studying at the Universidad Francisco de Vitoria (n = 41,
es and the scales scores of the SCL-90-R should be signif-
12.4%), the Universidad de Córdoba (n = 28, 8.5%), and the
icantly and positively related (i.e., the higher the perceived
Escuela Cruz Roja (n = 26, 7.9%). Furthermore, the majority
levels of COVID-19-related stressors, the higher would be
of them were first and third year students (first year n = 104,
the perceived levels of psychological disease). For correla-
31.4%; second year n = 62, 18.7%; third year n = 103, 31.2%;
tions, Cohen’s thresholds (Cohen, 1988) were used to in-
terpret the effects size, considering that r < 0.30 denotes a
small/weak correlation; 0.30 < r < 0.50 denotes a medium/ Table 1. Characteristics of study participants (N = 331).
moderate correlation; r > 0.50 denotes a large/strong cor-
Characteristics Value Range
relation. Disattenuated correlations of the CSSQ-es subscales
scores with all the SCL-90-R subscales scores were also Gender [n (%)]
calculated, and a second-order factor analysis was performed Male 51 (15.4)
to test the correlation between the Global Stress Score of the Female 280 (84.6)
CSSQ-es and the Global Severity Index of the SCL-90-R. Age [Mean (SD)] 21.29 (4.64) [18–59]
Finally, Means and Standard Deviations scores of the Global Degree program [n (%)]
Severity Index (GSI) from the SCL-90-R were also calcu- Podiatry 18 (5.4)
lated for women and men. Physiotherapy 32 (9.7)
Thirdly, Discriminant Validity (RO3) was tested. Spe- Pharmacy 65 (19.6)
cifically, Discriminant Validity was examined by carrying Nursing 207 (62.6)
out a comparison between the square root of the AVE values Other 9 (2.7)
Year of study [n (%)]
(SQRT AVE) and the correlations between the CSSQ-es
1st year 104 (31.4)
subscales, as well as by exploring the correlations between
2nd year 62 (18.7)
the CSSQ-es subscales and the Global Stress scores. A
3rd year 103 (31.2)
questionnaire is considered as having suitable discriminant
Last year (4rd -5th year) 62 (18.7)
validity if the SQRT AVE values are above the correlations
Vallone et al. 5

fourth -fifth year n = 62, 18.7%). Characteristics of study SRMR = 0.04; RMSEA = 0.05; CFI = 0.97; TLI = 0.95).
participants are summarized in Table 1. Specifically, as for the original version of the CSSQ, the
factor Relationship and Academic Life comprises 4 items
assessing perceived stress related to relationships with
RO1. Structural Validity: Exploratory Factor Analysis relatives, relationships with university colleagues and with
and Confirmatory Factor Analysis professors, and academic studying; the factor Isolation
comprises 2 items assessing perceived stress related to
Data indicated that the factor structure of the CSSQ-es isolation and changes in couples’ relationship/intimacy/
confirms that of the original CSSQ. In particular, findings sexual life due to the social isolation; and the factor Fear
from the Exploratory Factor Analysis (Principal Com- of Contagion consists of a single item assessing perceived
ponents Analysis; Oblique promax rotation) showed that stress related to the infection risk (Figure 1).
the Kaiser–Meyer–Olkin measure was 0.74 and Bartlett’s
test of sphericity was significant (χ 2 = 354.537, df = 21,
p < .001), confirming that the data were adequate for the RO2. Hypothesis Testing: Convergent Validity
factor analysis. All the items have communalities >0.4, Data indicated that the CSSQ-es has strong convergent
supporting the inclusion of all the 7 items comprised validity. In particular, the standardized factor loadings of
within the CSSQ-es. The examination of the scree plot and each of the 7 items were well-above 0.5 and statistically
the scree test showed that the departure from linearity significant (p < .001) (Figure 1), and the values of AVE of
corresponded to a three-component solution, revealing the three factors were all above 0.5 (i.e., AVE values:
that our data should be analyzed for three components. Relationships and Academic Life = 0.577; Isolation =
These findings were, therefore, in line with the original 0.637; Fear of Contagion = 0.557).
version of the CSSQ (Zurlo et al., 2020). The three-factor Furthermore, the CSSQ-es scales and Global Stress
solution explained a variance of 63.46% from a total of 7 scores showed significant positive correlations with the
items. SCL-90-R scales scores (Table 2). Considering psycho-
Therefore, Confirmatory Factors Analysis demonstrated logical health conditions reported by students, GSI Mean
that the three-factors model, including all the 7 items, re- Scores were, respectively, 1.45 (SD = 0.73) for Women and
vealed good fit for all the indices (χ2 = 10.31, p = .89; 1.36 (SD = 0.81) for Men.

Figure 1. Confirmatory factor analysis of the COVID-19 Student Stress Questionnaire-Español (CCSQ-es) (three-factor model).
6 Health Psychology Open

Disattenuated correlations of the CSSQ-es subscales between CSSQ-es subscales and the Global Stress scores
scores with all the SCL-90-R subscales scores were also were higher in size and significant (Table 3), demon-
calculated; they ranged from 0.18 to 0.52 and were all strating that the questionnaire measured different but
significant (p < .01) (Appendix 2). The correlations were connected dimensions.
greater between the Relationship and Academic Life sub-
scale and, respectively, the Depression (0.52) and
Obsessive-Compulsive subscales (0.53). Moreover, the RO4. Internal Consistency
correlation between the second-order factor of the Global
Data revealed that McDonald’s omega coefficient was 0.71
Stress Score of the CSSQ-es and the Global Severity Index
and the Composite Reliability value was 0.90, so indicating
(GSI) of the SCL-90-R showed an overall correlation of
a suitable internal consistency.
0.67 (p < .01). Accordingly, data endorsed that the CSSQ-es
Finally, with respect to CSSQ-es Interpretability, Table 4
has strong convergent validity.
illustrates items, mean values, standard deviations, and
ranges of the CSSQ-es scales and the Global Stress score in
RO3. Hypothesis Testing: Discriminant Validity Spanish university students.
Data indicated that the CSSQ-es has strong discriminant Mean scores ranged from 1.49 (Item 7. How do you
validity. In particular, the square root of AVE values (i.e., perceive the changes in your sexual life due to the social
SQRT AVE: Relationships and Academic Life = 0.759; isolation during this period of COVID-19 pandemic?) to
Isolation = 0.798; Fear of Contagion = 0.746) were well- 3.00 (Item 6. How do you perceive your academic studying
above the correlations among factors (i.e., correlation experience during this period of COVID-19 pandemic?),
coefficient between Relationships and Academic Life and while standard deviations ranged from 0.88 (Item 1. How do
Fear of Contagion, r = 0.597; correlation coefficient be- you perceive the risk of contagion during this period of
tween Isolation and Fear of Contagion, r = 0.615; corre- COVID-19 pandemic?) to 1.32 (Item 7. How do you per-
lation coefficient between Relationships and Academic ceive the changes in your sexual life due to the social
Life and Isolation, r = 0.634). Moreover, it emerged that isolation during this period of COVID-19 pandemic?).
intercorrelations among the CSSQ-es subscales revealed Skewness and kurtosis values for all the variables fall within
medium levels of correlation, whereas correlations the range of 2 to +2 (i.e., Skewness values from 1.28 to

Table 2. Correlations of the COVID-19 Student Stress Questionnaire-Español (CCSQ-es) scales with SCL-90-R scales.

COVID-19 Student Stress Questionnaire-Español

SCL-90-R scales Relationships and Academic Life Isolation Fear of Contagion Global Stress

Anxiety 0.359** 0.288** 0.280** 0.413**

Depression 0.498** 0.297** 0.250** 0.509**
Somatization 0.385** 0.223** 0.176** 0.387**
Obsessive-Compulsive 0.490** 0.347** 0.216** 0.516**
Interpersonal Sensitivity 0.382** 0.317** 0.298** 0.444**
Hostility 0.373** 0.290** 0.185** 0.406**
Phobic Anxiety 0.404** 0.231** 0.377** 0.442**
Paranoid Ideation 0.308** 0.208** 0.151** 0.323**
Psychoticism 0.308** 0.208** 0.151** 0.323**
Global Severity Index (GSI) 0.469** 0.327** 0.280** 0.506**

*p < .01, *p < .05.

Table 3. Intercorrelations between the COVID-19 Student Stress Questionnaire-Español (CCSQ-es) scales.

CCSQ-es scales Relationships and Academic Life Isolation Fear of Contagion Global Stress

Relationships and Academic Life 1

Isolation 0.415** 1
Fear of Contagion 0.270** 0.255** 1
Global Stress 0.910** 0.719** 0.471** 1

*p < 0.05; **p < 0.01.

Vallone et al. 7

Table 4. Items, mean, SD, and range scores of the COVID-19 and academic life (Conceição et al., 2021; Dotson et al.,
Student Stress Questionnaire-Español (CCSQ-es). 2022), isolation (Chen et al., 2020; Leal Filho et al., 2021),
CSSQ-es scales Items Mean ± SD. Range
and fear of contagion (Rodrı́ guez-Hidalgo et al., 2020), we
can emphasize the great potential of adopting a valid and
Relationships and Academic Life 3, 4, 5, 6 8.45 ± 3.35 0–16 brief (7-item) tool able to comprehensively capture the main
Isolation 2, 7 4.06 ± 1.81 0–8 challenges university students dealt with and are still facing
Fear of Contagion 1 2.32 ± 0.88 0–4 during the current period of the pandemic.
Global Stress All items 14.84 ± 4.77 2–28 From this perspective, significant associations between
the CSSQ-es scales scores and psychological disease, as
measured by means of the SCL-90-R subscales, were also
1.70; Kurtosis values from 1.28 to 0.52), indicating that found. This provided further support for the potential of the
the data were approximately normally distributed. CSSQ-es as a useful mental health screener (Gundogan,
High perceived levels of stress related to the COVID-19 2022; Zurlo et al., 2022a, 2022b). Indeed, these findings
pandemic and containment measures are represented by suggested the meaningfulness to adopt the CSSQ-es to
scores that are one standard deviation above the mean value identify those students in need of psychological support, as
(e.g., 84th percentile), whereas low perceived levels of stress well as to recognize specific risk factors requiring careful
are represented by scores that are one standard deviation consideration, exploration, and re-definition within
below the mean value (e.g., 16th percentile) of the distri- evidence-based interventions (Zurlo et al., 2020). This is
bution of the CSSQ-es scores among Spanish university particularly relevant considering that students participating
students. Accordingly, scores equal to 20 or above indicate in the present study showed remarkable levels of psycho-
high perceived levels of COVID-19-related Global Stress; logical suffering compared to the general population. In-
scores equal to 10 or below indicate low perceived levels of deed, in the present study, the SCL-90-R Global Severity
COVID-19-related Global Stress; scores between 11 and 19 Index (GSI) Scores were for Women M = 1.45 (SD = 0.73)
indicate average perceived levels of COVID-19-related and for Men M = 1.36 (SD = 0.81), while, in the Spanish
Global Stress among Spanish university students. validation study of SCL-90-R (Casullo and Pérez, 2004),
the GSI Scores were for Women M = 0.16 (SD = 0.09) and
for Men M = 0.13 (SD = 0.07).
Discussion
In line with these findings, research conducted during the
This study aimed to translate and validate the Spanish COVID-19 emergency (e.g., Aristovnik et al., 2020; Browning
version of the 7-item COVID-19 Student Stress Ques- et al., 2021; Marques et al., 2021; Odriozola-González et al.,
tionnaire, namely the COVID-19 Student Stress Ques- 2020) and, specifically, those studies adopting the SCL-90-R
tionnaire-Español (CSSQ-es). Indeed, given the remarkable to detect psychological suffering in the university student
rates of severe psychological suffering reported by uni- population revealed severe psychopathological portraits re-
versity students before the pandemic (Auerbach et al., 2018; lated to the pandemic. For example, a study conducted by
Ballester et al., 2020; Teixeira et al., 2021; Zivin et al., Jiang (2020) showed that, during the pandemic, students re-
2009), and also considering the increasing rates of mental ported higher than normative values in anxiety and phobic
health disorders reported by students during the pandemic anxiety, somatization, obsessive-compulsive, interpersonal-
(Marques et al., 2021; Odriozola-González et al., 2020), a sensitivity, and paranoid ideation scores.
wider application of a brief, tailored, and valid tool as- In the same direction, a study conducted by Vallone et al.
sessing specific COVID-19-related sources of stress could (2021) revealed that 31.9% of male students and 27.4% of
promote a timely identification of those university students female students reported clinical levels of anxiety, while
at high psychological risk in the current pandemic time. 28.3% of male students and 32.9% of female students re-
Overall, our findings indicated that the CSSQ-es is a ported clinical levels of depression due to the substantial
multidimensional tool, which revealed satisfactory con- changes in daily routines and to the perceived “sense of
vergent and discriminant validity, and acceptable internal losses” experienced at the relational level. In addition, this
consistency. Specifically, the CSSQ-es covers three study also underlined remarkable clinical levels of paranoid
meaningful factors (i.e., Relationships and Academic Life, ideation and psychoticism reported by students during the
Isolation, and Fear of Contagion) and provides a Global COVID-19 emergency (i.e., 35.5% of male students and
stress score, as for the original version (Zurlo et al., 2020), 14.0% of female students reported clinical levels of para-
measuring the overall stress related to COVID-19 and noid ideation; 33.8% of male students and 23.2% of female
containment measures among university students. students reported clinical levels of psychoticism). These
Considering the existing research exploring the impact of latter findings highlighted the significant presence of ex-
the COVID-19 pandemic on university students’ life, in periences of alienation related to this unprecedented global
terms of perceived stress related to changes in relationships crisis.
8 Health Psychology Open

Moreover, a repeated-cross sectional study conducted by individual and relational disease is significantly increasing
Zurlo et al. (2022b) in the Italian university context at three according to the progression of the COVID-19 emergency
stages during the pandemic (Stage 1, April 2020; Stage 2, (Debowska et al., 2020; Volken et al., 2021; Zhang et al.,
November 2020; Stage 3, April 2021) revealed that stu- 2020; Zurlo et al., 2022a, 2022b), we hypothesize these
dents’ perceived levels of COVID-19-related stress (mea- higher levels of COVID-19-related stress could be ex-
sured by the CSSQ) and psychological symptoms plained in light of the protracted global crisis and its related
(measured by the SCL-90-R) significantly increased as the containment measures. Further applications of the CSSQ,
pandemic was progressing. and specifically of the CSSQ-es, are therefore needed to
All these studies sustained the meaningfulness of assess perceived levels of COVID-19-related stressors in
adopting specific tools, such as the CSSQ, so effectively the current pandemic time.
responding to the global necessity for researchers and ı̀ despite the proven validity of the CSSQ-es, some
practitioners to undertake significant efforts to prevent limitations need to be addressed. Firstly, the sample was a
mental disease escalation and promote students’ psycho- convenience homogeneous sample of Spanish students
logical adjustment during this critical stage of transition. enrolled in degree courses from Faculties of Health Sciences
However, interestingly, although the three-factor struc- with a majority being women (84.6% are females).
ture of the original CSSQ was confirmed, the means scores Therefore, further studies on larger and more representative
(standard deviations) of the CSSQ-es scales reported in the samples of the student population from Spain are needed to
current study were greater than those reported in the original allow the generalizability of these results (e.g., a nationally
validation study conducted with a sample of students from representative sample, more men). In particular, students
Italy (Relationships and Academic Life M = 4.95, SD = 2.74; from different fields (e.g., Humanities, Engineering, Busi-
Isolation M = 3.51, SD = 2.05; Fear of Contagion M = 1.61, ness) and diverse academic and social backgrounds are
SD = 1.12; Global Stress M =10.07, SD = 4.52). This seems needed to confirm the results reported in the current study.
to suggest that sampled students in Italy reported lower Another limitation refers to the physical health of students.
perceived stress related to COVID-19 and containment Indeed, there are no questions assessing whether or not the
measures than Spanish students sampled in the present study. participants were infected with the COVID-19 virus.
Nonetheless, these findings can be also interpreted in Therefore, considering that being personally infected by the
light of the differences in the two study samples; that is, the virus may impact differently on individuals’ mental health
CSSQ was validated with a sample of students from Hu- (Rahman et al., 2021), future research could also include
manities degree courses, while, in the present study, stu- this information in order to address its potential impact on
dents were all from Health Sciences degree courses. students’ perceived levels of COVID-19-related stressors
Although both samples consisted of university students and on their psychological health. Also, the sample was not
(not personally involved—like healthcare professionals—in necessarily representative of the students from other
providing care services during the COVID-19 pandemic), countries with Spanish-speaking population, and further
we can hypothesize that the greater participation of their applications of the CSSQ-es are needed to evaluate its
educational environment in facing the pandemic may have generalizability in those countries.
resulted in higher levels of COVID-19-related stress. This Moreover, despite its merits (i.e., low research costs,
hypothesis could be sustained by considering the large body convenience for researchers and participants, ease of data
of studies conducted during the pandemic which have entry and analysis, reaching target populations during the
targeted university students from the healthcare fields ; that COVID-19 pandemic), the use of online surveys may entail
is, Aslan and Pekince, 2021; Safa et al., 2021), highlighting the risk of fraudulent activity (Lawlor et al., 2021). Nev-
remarkable levels of perceived stress and psychological ertheless, considering the lack of rewards and the absence of
suffering. In particular, students from health sciences may suspicious responses in our dataset, we considered the
have experienced higher levels of perceived stress related to chance of multiple and/or inconsistent responses to be
changes in relational and academic life (e.g., faculty relatively low. Furthermore, given that the CSSQ-es is a
members/supervisors were frontline in facing the pandemic) self-report measure and is based on positive self-reporting
and to the fear of the virus (e.g., increased scientific items (no retroverted items or distracting items are in-
knowledge of the effects of the virus). cluded), we should also mention the risk of social desir-
However, these data may also be interpreted considering ability bias. Finally, although findings showed that the
the timing of questionnaire administration. Specifically, CSSQ-es has robust psychometric properties, this study
whereas the CSSQ validation study was conducted in the is based on a single measurement wave, and no extended
early stages of the pandemic (2020), the data from the test of psychometric properties could be performed, such as
present study were collected after 1 year from the beginning test—retest reliability.
of the pandemic (2021). Accordingly, in line with studies Nevertheless, despite these limitations, this study sup-
providing evidence supporting that university students’ ports the appropriateness of the Spanish version of the
Vallone et al. 9

COVID-19 Students Stress Questionnaire, a 7-item scale accordance with the 1964 Helsinki declaration and its later
with robust psychometric properties, to be used for the amendments or comparable ethical standards.
assessment of COVID-19 sources of stress among Spanish
university students and for the development of tailored ORCID iDs
interventions aiming to promote their psychological well- Federica Vallone  https://orcid.org/0000-0001-9461-3446
being during and after this unique global emergency. Felice Curcio  https://orcid.org/0000-0001-5759-1065
In particular, specific recommendations for actions to be Maria Clelia Zurlo  https://orcid.org/0000-0003-0045-2800
implemented at the individual, community, and policy levels
should be highlighted. At the individual level, we considered
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The author(s) declared no potential conflicts of interest with re-
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spect to the research, authorship, and/or publication of this article.
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2021 DOI: 10.24052/IJHEM/V08N01/ART-3
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Brislin RW (1970) Back-translation for cross-cultural research.
The author(s) disclosed receipt of the following financial support Journal of Cross-Cultural Psychology 1: 185–216. DOI: 10.
for the research, authorship, and/or publication of this article: 1177/135910457000100301
STUDENT-WELL (Erasmus+ Project). This publication reflects Browning MH, Larson LR, Sharaievska I, et al. (2021) Psycho-
the views only of the authors, and the Commission cannot be held logical impacts from COVID-19 among university students:
responsible for any use which may be made of the information Risk factors across seven states in the United States. Plos One
contained therein (2020-1-UK01-KA226-HE-094622). 16(1): e0245327.
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Appendix 1

The COVID-19 Student Stress Questionnaire-Español.

Nada Algo Moderadamente Muy Estremamente

estresante estresante estresante estresante estresante

(Not at all (Somewhat (Moderately (Very (Extremely

stressful) stressful) stressful) stressful) stressful)

1. ¿Cómo valoras el riesgo de contagio durante 0 1 2 3 4

este perı́odo de pandemia COVID-19? (How
do you perceive the risk of contagion during
this period of COVID-19 pandemic?)
2. ¿Cómo valoras la condición de aislamiento 0 1 2 3 4
social impuesta durante este perı́odo de
pandemia COVID-19? (How do you perceive
the condition of social isolation imposed
during this period of COVID-19 pandemic?)
3. ¿Cómo valoras las relaciones con tus familiares 0 1 2 3 4
durante este perı́odo de pandemia COVID-19?
(How do you perceive the relationships with
your relatives during this period of COVID-19
pandemic?)
4. ¿Cómo valoras las relaciones con tus 0 1 2 3 4
compañeros universitarios durante este
perı́odo de pandemia COVID-19? (How do
you perceive the relationships with your
university colleagues during this period of
COVID-19 pandemic?)
5. ¿Cómo valoras las relaciones con tus 0 1 2 3 4
profesores universitarios durante este perı́odo
de pandemia COVID-19? (How do you
perceive the relationships with your university
professors during this period of COVID-19
pandemic?)

(continued)
Vallone et al. 13

(continued)

Nada Algo Moderadamente Muy Estremamente

estresante estresante estresante estresante estresante

(Not at all (Somewhat (Moderately (Very (Extremely

stressful) stressful) stressful) stressful) stressful)

6. ¿Cómo valoras tu experiencia académica de 0 1 2 3 4

estudio durante este perı́odo de pandemia
COVID-19? (How do you perceive your
academic studying experience during this
period of COVID-19 pandemic?)
7. ¿Cómo valoras los cambios en tu vida sexual 0 1 2 3 4
debido al aislamiento social durante este
perı́odo de pandemia COVID-19? (How do
you perceive the changes in your sexual life
due to the social isolation during this period of
COVID-19 pandemic?)
_____ + _____ + _____ + _____ + _____ +
Global score _______

The English version is provided in brackets.

Appendix 2

Disattenuated correlations of the Student Stress Questionnaire-Español (CSSQ-es) scales

with the Symptom-Checklist-90-Revised (SCL-90-R) scales.

SCL-90-R scales Relationships and Academic Life Isolation Fear of Contagion

Anxiety 0.377* 0.308* 0.299*

Depression 0.523* 0.334* 0.283*
Somatization 0.408* 0.246* 0.198*
Obsessive-Compulsive 0.532* 0.390* 0.237*
Interpersonal Sensitivity 0.436* 0.352* 0.324*
Hostility 0.401* 0.331* 0.225*
Phobic Anxiety 0.422* 0.255* 0.393*
Paranoid Ideation 0.330* 0.222* 0.182*
Psychoticism 0.362* 0.238* 0.188*
*p < 0.05; **p < 0.01.