As a library, NLM provides access to scientific literature.

Inclusion in an NLM
database does not imply endorsement of, or agreement with, the contents by NLM
or the National Institutes of Health.
Learn more: PMC Disclaimer | PMC Copyright Notice

Int J Environ Res Public Health. 2021 Jan; 18(2): 739. PMCID: PMC7830011
Published online 2021 Jan 16. doi: 10.3390/ijerph18020739 PMID: 33467118

The Tridirectional Relationship among Physical Activity, Stress, and Academic

Performance in University Students: A Systematic Review and Meta-Analysis
Kathrin Wunsch,*† Janis Fiedler,† Philip Bachert,† and Alexander Woll

Abstract

Higher education students often suffer from physiological and psychological health problems
caused by stress, which may negatively impact their academic performance (AP). Physical ac‐
tivity (PA) can be a promising strategy to buffer these stress-induced complaints. Therefore,
the aim of this investigation was to summarize evidence for the tridimensional construct of PA,
stress, and AP, as well as to quantify the relationships among these variables. Five databases
(PubMed, Scopus, SMEI, ERIC, and Web of Science) were systematically searched in No‐
vember 2019 for publications that examined PA, stress, and AP of university students, without
any restrictions regarding the publication period. The systematic review includes four original
research studies with a moderate-to-high risk of bias. Results of included studies were narra‐
tively summarized and quantified in a meta-analysis using random effect models. Whereas
study results point to a positive relation between PA and AP, relationships between PA and
stress seem to be negative, while the relation between stress and AP is undecided. The meta-
analysis found no significant associations and considerable heterogeneity of the results. Find‐

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 1 de 27
:
 ings indicate a research gap concerning the connection of PA, stress, and AP in university stu‐
dents. Future studies should use validated measuring tools and consider the timepoint of data
collection in order to extract truly stressful periods.

Keywords: academic stress, exams, exercise, student’s health, grade point average

1. Introduction

In recent years, a growing body of research has emerged, showing that a major concern of
higher education students is suffering from physiological and psychological health problems.
Stewart-Brown and colleagues showed that one-third of university students reported at least
one long-standing illness [1]. More recent investigations revealed a similar amount of students
suffering from mental issues, showing that student life can be a cause of distress, as students
report higher distress levels than their non-student peers [2], and high levels of stress impact
the quality of life [3]. An obvious causal factor being accountable for (periodic) high levels of
student stress is the examination period at the end of each semester, thus forming a real-life
stress situation. Particularly, this phase causes immediate negative effects on health-related
outcomes, such as poor sleep quality and well-being [4], which are positively related to cogni‐
tion and academic achievement or academic performance (AP) [5,6]. Hence, AP is commonly
affected in high-stress periods, where the highest cognitive functioning is required.

Physical activity (PA) and exercise are known to be stress-buffering behaviors, as engagement
in regular PA can buffer negative effects of stress on health, which is postulated by the stress-
buffering hypothesis [7,8]. In general, PA is known to have several positive effects on physio‐
logical and psychological stress-related parameters. There is early evidence to support the
stress-modulatory effect of PA. Brown and Siegel [9] revealed that sedentary participants with
high stress levels had an elevated disease incidence and that physically active participants with
high stress were protected against the stress-induced increases in disease incidence. Further‐
more, stress level, anxiety, and depression of university students increases as their sedentary
time increased [10]. Similar results have been drawn regarding psychological health [8].
Klaperski, Seelig and Fuchs showed that PA exhibits a health-protective effect, especially un‐
der chronic stress conditions [11]. Overall, Nguyen-Michel, Unger, Hamilton, and Spruijt-Metz
revealed a significant negative relationship between PA and stress in a student sample [12].
Especially in high-stress periods like examination phases, PA decreases and may therefore not
provide a suitable stress-buffer for students.

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 2 de 27
:
 Hence, it is especially the examination phase in which students could profit from good stress-
buffering abilities, as high amounts of perceived stress are known to diminish cognitive func‐
tioning in students [13], which in turn is highly correlated to AP [14]. Studies revealed signifi‐
cant negative correlations between perceived stress and AP in students, especially within ex‐
amination periods at the end of a semester [15,16,17].

Literature including child and adolescent populations suggests that PA positively influences
AP, as more active students show better AP [18,19], even if there is only limited evidence
[20,21]. Interestingly, this association is commonly examined in pupils (school children) and
needs to be further addressed in university student populations, particularly because the major‐
ity of university students do not meet the recommendations for PA [22,23,24].

Until today, there has been a lack of knowledge on the relationship between PA, stress, and AP
in university students. However, especially this tridirectional relationship is of interest, as
stress burden is exceptionally high in academic examination phases, where cognitive function
demands are concomitantly high to achieve best AP [13,14]. As the cross-stressor-adaptation
hypothesis [25] posits that regular PA (as a stressor itself) elicits unspecific adaptations en‐
abling humans to also show lower reactions to heterotypic stressors (i.e., psychosocial or cog‐
nitive stressors, like examinations periods; [26]), it is of high interest to also include AP as an
outcome variable into this consideration. Based on knowledge of the bidirectional relationships
of PA, stress and AP, it can be hypothesized that PA serves as a mediator or moderator in the
relationship between stress and AP. To gain insights into the possible stress-buffering and
cross-stressor-adaptation effects of PA and simultaneous benefits to AP in stressful periods in
university students, the current investigation aims to form a systematic review and meta-analy‐
sis to expand upon research on bidirectional relationships of PA and stress, stress and AP, as
well as PA and AP, while focusing only on studies assessing all three variables in order to gain
insights into the tridirectional relationship. This is especially important in terms of public
health, as policymakers and universities may profit from results in order to account for student-
specific, PA-based health interventions to increase AP in real-life stress situations.

2. Methods

This systematic review was performed and reported following the Preferred Reporting Items
for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [27].

2.1. Eligibility Criteria

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 3 de 27
:
 Primary source and peer-reviewed articles published in English were eligible for inclusion in
this systematic review and meta-analysis if data were presented for PA, stress, and AP simulta‐
neously. Specific eligibility criteria included the following: types of participants: university
students. Types of outcome measures: each dependent variable had to be measured and report‐
ed, i.e., PA (via self-report or accelerometry/pedometers), stress (via self-report or any physio‐
logical measure), and AP (via self-report or grades). Study design: no restrictions. Exclusion
criteria: articles were excluded if they did not meet inclusion criteria or did not include find‐
ings related to inclusion criteria (i.e., measured PA, but failed to compare with stress or AP).

2.2. Information Sources

Five different databases were used for literature search: PubMed, Scopus, SMEI, ERIC, and
Web of Science. Search terms were applied to meet the specific demands of each database.
Two authors performed the search independently. In case of divergence or ambiguity, results
were discussed until a consensus was reached.

2.3. Search

Search terms were defined through group discussion among the research team and were used
in each database without any restriction regarding the publication period to identify potential
articles with abstracts for review in November 2019. Using the PICO search tool [28], the fol‐
lowing key search-terms were identified: university students, PA, academic stress and AP. In
combination with synonyms of all components, combined searches were performed in the dif‐
ferent databases. The specific search terms for each database can be found in Supplementary
Table S1. Identified publications were then transferred to Citavi (version 6.5.0.0) for further
processing.

2.4. Study Selection

Title and abstracts of retrieved studies were independently assessed for eligibility for inclusion
in the review by two authors. Disagreements regarding eligibility for inclusion were resolved
via consensus among all authors. Full-text articles for eligible abstracts were retrieved and re‐
viewed by the same two authors prior to inclusion in the review. A Microsoft Excel spread‐
sheet was developed to track the eligibility status.

2.5. Data Collection Process and Data Items

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 4 de 27
:
 Extracted data were entered into an Excel spreadsheet. Relevant data were extracted from each
manuscript by one author and the coding was verified by a second author. Disagreements were
resolved by discussion among these authors. Data extracted from each article included general
information (authors, year, country), basic information on methods (aim, study design, sample
characteristics, sampling time, methods used regarding PA, stress and AP) as well as results
(direct association statistics, central results, and sub findings). If different measurement meth‐
ods (e.g., self-reported success vs. grade point average (GPA) or self-reported vs. device-mea‐
sured PA) were used in the studies, the ones which were most comparable between the studies
(i.e., self-reported PA and GPA) were included. For each relationship, relevant effect sizes
were retrieved.

2.6. Risk of Bias in Individual Studies and Risk of Bias across Studies

To assess the risk of bias across studies, funnel plots were compiled using R [29]. For the as‐
sessment of the risk of bias in individual studies, the Appraisal Tool for Cross-Sectional Stud‐
ies (AXIS) was used [30]. To quantify the risk of bias of individual studies, a scoring method
has been adapted [31]. Following this method, the studies were categorized as very low risk of
bias if they scored correctly on at least 19 out of 20 of the questions, low risk of bias if they
scored 17 or 18 out of 20; moderate risk of bias if they scored 15 or 16 out of 20 and high risk
of bias if the studies scored 14 or less.

2.7. Summary Measures

In order to perform the meta-analysis, all effect sizes were extracted from the original studies
and transformed into correlation coefficients. If betas or effect size estimates were reported in
the studies and the original correlation coefficients could not be obtained, the betas and effect
size estimates were treated as correlation coefficients [32]. F-values from ANOVAs were trans‐
formed to correlation coefficients using the online platform psychometrica [33]. X2 values
were transformed to Cramer’s V using the following formula:

−−−−−−−−−
√
X²
n (K − 1)

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 5 de 27
:
 Here, K is the number of rows or number of columns, whichever shows the smaller number
[34]. Cramer’s V was treated as a correlation coefficient subsequently [35].

2.8. Additional Analyses and Synthesis of Results

An original analysis of the tridirectional relationship was not possible due to missing informa‐
tion (see results of individual studies). Contacting the authors to provide the missing informa‐
tion was not successful. Therefore, articles were grouped by the respective dependent variable.
Hence, three datasets were derived, based on correlational findings on the relationships of: (1)
PA and AP, (2) PA and stress, and (3) AP and stress.

To gain a basis for meta-analytical interpretation, all effect sizes were transformed into correla‐
tion coefficients (see summary measures). These were Fishers-z-transformed to gain compara‐
ble results. A random-effects model was used for the three multilevel meta-analyses concern‐
ing the relationship of (1), (2), (3) (see above). The results were interpreted following [36].
Based on empirically derived effect size distribution, correlation coefficient values of 0.12,
0.24, and 0.41 should be interpreted as small, medium, and large effects for social psychology
studies.

The Q-test for heterogeneity [37] is reported to display the amount of heterogeneity among
with the I2 value [38], where values of 0% to 40% indicate no important, 30% to 60% moder‐
ate, 50% to 90% substantial, and 75% to 100% considerable heterogeneity [39]. The analysis
was carried out using R (version 3.6.1) [29] and the metafor package (version 2.1.0) [40].

3. Results

3.1. Study Selection

Out of the 2589 studies initially located and downloaded, 837 doublets were automatically re‐
moved in Citavi. Based on title and abstract screening, an additional 1710 studies were exclud‐
ed, which resulted in 42 studies for full-text screening. In this step, 38 studies were excluded
due to not meeting inclusion criteria. Thus, a total of four original research studies were in‐
cluded in this meta-analysis [41,42,43,44]. Please see Figure 1 for the full study selection
process and reasons for exclusion during screening.

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 6 de 27
:
 Figure 1

Flow chart of study selection process. Note: AP: academic performance; PA: physical activity.

3.2. Study Characteristics

Two out of the four studies were conducted in the USA, one in France, and one in China. The
studies included three cross-sectional and one cohort study and were published between 2011
and 2018. Participants were undergraduate students and sample sizes ranged from 203 [41] to
1071 [44], resulting in a total sample size of 1952 participants (nfemale = 1220, nmale = 732)
throughout included studies. Detailed study characteristics can be retrieved from Table 1.

Table 1

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 7 de 27
:
 Study characteristics of included studies.

Sample
Authors Study Sample Stress
Aim Size; PA Measure
(Year)/Country Design Characteristics/Population Measure
Age (SD)

Self-report
measure:
Freshmen
Stress Scale
(Boujut and
Bruchon-
Schweitzer,
2009); a
general score
of perceived
stress and four
specific scores:
(1) AS (e.g.,
"examination
revisions” or
Self-report “new working
To examine measure: single methods”, (2)
differences item regarding stress-related
between rare, 1071 frequency of to university
regular (weekly (690 sports practice disorganization
<8) h and female); in h/week (e.g.,
Décamps et al. cross First year students, type of
intensive (>8 h) 18.7 (categorization: “monotony of
Note. PA: Physical Activity. AP: Academic Performance. GS: General Stress. AS: Academic Stress. Vig:
vigorous. Mod: moderate. Obli: obligatory exercise. ICSRLE: Inventory of College Students’ Recent Life
Experiences. PSS: Perceived Stress Scale. ESE: Effect size estimate. GPA: Grade Point Average.

3.3. Risk of Bias within Studies

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 8 de 27
:
 While quantifying the risk of bias by the AXIS tool, one study was rated at moderate risk of
bias (15/20) [43] and three studies at high risk of bias (14/20) [41,42,44]. The main weakness‐
es were the lack of sample size justification, not addressing non-responders, not clarifying
funding sources or conflict of interest, and not describing the ethical approval or consent of
participants. For more information on risk of bias assessment see Table 2.

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 9 de 27
:
 Table 2

Risk of bias assessment using the Appraisal Tool for Cross-Sectional Studies (AXIS) tool for included stud‐
ies.

1_intro_aims 2_methods_study_design 3_ methods_sample_size

Décamps et
al. Yes Yes No
(2012)/France

See “Participants and See “Participants and

See “Introduction”
procedure” procedure”

Kayani et al.
Yes Yes No
(2018)/China

A sample of 358 students was

See “Theoretical background” See “Measures”
studied.

Rettinger
Yes Yes No
(2011)/USA

Three-hundred twenty
See “Introduction” Part 3 See “Methods”
students responded.

Ruthig et al.
Yes Yes No
(2011)/USA

See “Participants and Participants were 203

See “The current study”
Procedure“ undergraduate students

11_methods_description_overall 12_results_description 13_results_non_response_bias

Décamps et
al. Yes Yes No

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 10 de 27
:
 3.4. Risk of Bias across Studies

Publication bias across studies was assessed using funnel plots for the three bidirectional rela‐
tionships. Statistical tests of publication bias were not conducted due to the small number of
studies [28]. Visual inspection of funnel plots (Figure 2) indicated a small publication bias for
the relationship of PA and AP, but high publication bias for the relationships of PA and stress
as well as for stress and AP as of the visible asymmetry of effect sizes.

Figure 2

Funnel plots for publication bias between studies for the bidirectional relationships. (a) Physical activity and
academic performance; (b) physical activity and stress; (c) stress and academic performance.

3.5. Study Characteristics

Included studies used heterogeneous designs. Whereas Decamps and colleagues [44] and
Kayani and colleagues [43] used cross-sectional designs, Rettinger and colleagues [42] gained
longitudinal data, but performed their analyses from averaged data across measurement points
in a cross-sectional manner, therefore losing information from the repeated-measures design.
Ruthig and colleagues [41] were the only to use a longitudinal design and analyses and there‐
fore the only ones to account for time-based alterations.

Studies also differed in assessment methods, especially regarding PA measures. Whereas

Kayani and colleagues [43] and Rettinger and colleagues [42] used the short form of the In‐
ternational Physical Activity Questionnaire [45] consisting of seven items measuring PA, De‐
camps and colleagues [44] and Ruthig and colleagues [41] both used a single-item to assess
PA. However, they did not ask for PA in general, but for sports or exercise activity, therefore
excluding PA like active transport or gardening, which are not classified as sports or exercise
but also important in relation to PA. Analogous, measures for stress also differed between the

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 11 de 27
:
 studies. However, only validated and multi-item questionnaires were used by all studies
[46,47,48,49]. Regarding AP, Kayani and colleagues [43] and Rettinger and colleagues [42]
both used GPA measures in form of average course grades over the past semester, providing a
general view of AP. Decamps and colleagues [44] assessed AP with a dichotomous (only nom‐
inal scaled) variable (i.e., fail vs. success), and Ruthig and colleagues [41] used a single course
grade for operationalization, therefore not portraying the general AP of students.

While Decamps and colleagues [44], Kayani and colleagues [43] and Rettinger and colleagues
[42] aimed to recruit a representative student sample, Ruthig and colleagues [41] investigated
psychology students, resulting in a homogenous sample and limiting generalizability of results.

Furthermore, examining sample demographics it becomes apparent that PA of included partici‐

pants differs from what one could expect of a general student sample. The study conducted by
Decamps and colleagues [44] reveals a u-shaped distribution of activity levels: there are many
inactive students as well as many active students (>8 h of sports per week). Additionally,
Kayani and colleagues [43] report a mean of 3.1 metabolic equivalent (MET)-hours per week,
which would be far below average, therefore representing a very inactive student sample.

Regarding sampling time points, Kayani and colleagues [43] and Rettinger and colleagues [42]
reported examination of students to take place between October and December, which seems
to be at the beginning of the semester. Decamps and colleagues [44] did not report on sam‐
pling time. Only Ruthig and colleagues [41] chose to measure pre- and within-examination-
stress conditions. The stress level of the sample of Rettinger and colleagues does not differ sig‐
nificantly from a norm sample [43,44,45,46,47,48,49], whereas the samples of Ruthig et al.
[50] and Kayani et al. [49] tend to be more stressed, as there is no comparative data available,
no assumption can be drawn with regard to the stress level of the sample of Decamps and col‐
leagues.

3.6. Results of Individual Studies and Synthesis of Results

While all studies included all three dimensions (PA, AP, and stress), the only relationship re‐
ported in all studies was the relation between PA and AP. Three studies analyzed the relation‐
ship between stress and AP [41,42,43] and three studies provided results for the relation of PA
and stress [42,43,44]. Only one study [43] investigated the relationship of all three variables
within a mediation approach. Due to the fact that only one study examined this relationship
between all three variables, this relationship was not accounted for in the following meta-
analyses. Hence, bidirectional relationships were analyzed and the results merged in narrative
synthesis. As only one study used objective measures of PA, and subjective and objective mea‐

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 12 de 27
:
 sures are known to produce divergent results (e.g., [51]), only self-reported PA measures were
included in analyses. Moreover, self-reported stress as well as objectively documented AP (i.e.,
GPA) results were included to increase the comparability between the studies, since those were
reported in all studies.

Significant results for the relation between PA and AP were reported in one out of the four
studies [42] between walking and GPA and between total PA and GPA in a second study [43].

The examination of relationships between PA and stress showed significant results for oblig‐
atory exercise and the Inventory of College Students’ Recent Life Experiences (ICSRLE).
However, the other measurement tools for Stress (Perceived Stress Scale (PSS)) and PA (In‐
ternational Physical Activity Questionnaire (IPAQ)) did not indicate any statistical significant
relation [42]. Both academic and general stress measured by the Freshman-Stress Scale were
significantly associated with PA in one study (in the case of general stress, this significant rela‐
tionship was not present after the transformation to Fisher r-to-z transformed correlation coeffi‐
cients) [44] as well as general stress measured by the university-stress scale in another [43].

The relationship of AP and stress showed significant results between general stress measured
by the ICSRLE and GPA in one study [42] and between general stress measured by the univer‐
sity-stress scale and GPA by another [43]. The effect sizes and more detailed results of the four
included studies can be found in Table 1.

3.7. Overall Effect Sizes

A meta-analysis of effect sizes was conducted for the relationship between PA and AP, PA and
stress, and stress and AP.

The estimated average Fisher r-to-z transformed correlation coefficient based on the random-
effects model for the relationship between PA and AP, PA and stress, and stress and AP was
0.07 (95% confidence interval (CI): −0.06–0.20, Q5 = 14.31, p = 0.01; I2 = 75.8%), −0.05
(95% CI: −0.40–0.31, Q10 = 141.35, p < 0.01; I2 = 97.0%), and −0.18 (95% CI:−0.82–0.45,
Q2 = 30.13, p < 0.01; I2 = 94.4%), respectively. Therefore, none of the average outcomes of
these relationships differed significantly from zero and the I2 values indicate significant sub‐
stantial to considerable heterogeneity. The forest plots for these relationships are displayed in
Figure 3.

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 13 de 27
:
 Figure 3

Forest plots of bidirectional relationships. (a) Physical activity and academic performance; (b) physical ac‐
tivity and stress; (c) stress and academic performance. Abbreviations: vig: vigorous physical activity; mod:
moderate physical activity; as: academic stress; gs: general stress; obli: obligatory exercise; ICSRLE: Inven‐
tory of College Students’ Recent Life Experiences; PSS: perceived stress scale.

4. Discussion

This systematic review and meta-analysis provided an overview of studies that included PA,
stress, and AP in university students. Four studies with more than 1900 participants were iden‐
tified within this review. The aim was to examine the tridirectional relationship between PA,
stress, and AP and to expand upon knowledge on bidirectional relationships of PA and stress,
stress and AP, as well as PA and AP, while focusing only on studies assessingBackall three vari‐
to Top
ables. A mediating or moderating effect of PA on the relation between stress and AP was hy‐
pothesized based on theoretical assumptions [7,25]. Even though there were significant rela‐
tions between the three dimensions in the individual studies, the pooled bidirectional compar‐
isons showed no significant relationship between the dimensions. Only one of the included
studies investigated the relationship between all variables of interest: PA, AP, and stress [43].
The remaining three studies also assessed all three variables but only focused on bidirectional
relationships. Based on the meta-analytical analyses none of these relationships gained signifi‐
cance and ES indicate small effects for the relation of stress and AP (z’StressAP = −0.18, <30th
percentile), but no meaningful effects for the relations of PA and stress and PA and AP (z’PAS‐
tress = −0.05, z’PAAP= 0.07, both <15th percentile). Results will be shortly summarized below,
starting with the bidirectional relationships, leading to a summary on the tridirectional rela‐
tionship of PA, Stress and AP.

4.1. Bidirectional Relationship between Physical Activity and Academic Performance

Regarding the effects of PA on AP, current literature points to a positive influence of PA on AP

in students, as more active students show better AP. However, there is only limited evidence for
university student populations [20,52,53], while this association is commonly examined in
pupils [18,54,55]. The present review revealed one out of four studies to show a significant

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 14 de 27
:
 effect as well as a non-significant small pooled effect between these parameters in study re‐
sults. Visual inspection of the forest plots indicate that the results of Kayani and colleagues
[43] step out of the line by revealing a significant positive relationship. One reason for this
study being the only to reveal this positive relation might be that comprehensive measures for
both variables of interest were used, whereas other studies used singe-item measures. However,
the average PA was on a low level (3.1 MET-hours per week) in the study of Kayani and col‐
leagues. Therefore, it might be that only participants with low PA differ from those with a
higher amount concerning AP. Overall, the proposed positive relationship of PA and AP can‐
not be confirmed by present results. However, even if results showing the positive influence of
PA on AP could not have been replicated, this relation might not be denied as it might be me‐
diated by the positive effect of PA on cognitive performance, which has been repeatedly shown
for school children [56,57,58].

4.2. Bidirectional Relationship between Physical Activity and Stress

PA is also known to be a stress-buffering mechanism [7]. Inactive participants were formerly

shown to have higher stress-related disease incidences than their active counterparts [9], which
has also been reported for mental health factors [8]. Paralleling the results of Nguyen-Michel
and colleagues [10], the current review revealed a negative, however, non-significant and
meaningless relationship between PA and stress pooled over included studies in university stu‐
dents. Interestingly, two out of three studies found significant results, which however point to
opposite directions, therefore levelling out in the combined analysis. Whereas Kayani and col‐
leagues [43] found a negative relationship between PA and stress in participants with an overall
low PA, Decamps and colleagues [44] found a positive one, meaning that highly active stu‐
dents perceived more academic stress. This contradicts the stress-buffering hypothesis [7]. In
this case, however, being active might have been a stressor itself, as increasing time demands
for learning activities arose during the examination phase. In this sample, 46% of participants
reported a PA of more than 8 h a week making it more challenging to find time to exercise.
Based on 168 studies, a systematic review revealed that psychological stress generally predicts
less PA [59]. Especially in high-stress periods like examination phases, PA decreases and does
therefore not execute its potential as a suitable stress-buffer for students [4].

4.3. Bidirectional Relationship between Stress and Academic Performance

The pooled effect for stress and AP revealed a negative small, but non-significant relation,
meaning that participants with higher stress have a decreases AP in principle as shown by two
out of three studies, which is in line with former studies [15,17]. However, the study conducted

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 15 de 27
:
 by Ruthig and colleagues [41] is out of the line and found a positive relationship and therefore
higher stress to elicit better AP. Here, the absolute stress amount of the study population needs
to be considered. With a perceived stress scale ranging from 9 to 35, their sample scored
around 22 on average (SD = 5.72), showing a high stress amount as compared to the popula‐
tion mean [60,61]. One possible explanation for this result might be that participants who pre‐
pared more for the AP also perceived a higher amount of stress but at the same time showed
better performance due to their throughout preparation and probably their higher arousal as
stated, e.g., by the Individual Zones of Optimal Functioning (IZOF) Theory [62]. Therefore,
future studies should assess levels of arousal in students to examine student’s optimal stress
zone for optimal AP.

4.4. Tridirectional Relationship among Physical Activity, Stress, and Academic Performance

Kayani and colleagues [43] were the only to investigate the relationship of all three variables.
They used a parallel mediation model, however, measuring the influence of stress and self-es‐
teem as concurrent mediators of the relationship between PA and AP, with both were found to
be significant mediators. Hence, this study is, to the best of our knowledge, the only one to
show a mediating effect of stress on the relation of PA and AP, revealing that the higher the
amount of PA, the lower the stress level and the higher the stress level, the lower AP. However,
even though the mediating effect increases the direct effect of PA on PA, the stress-buffering
hypothesis postulates a moderating effect of PA on the relationship of stress and AP, which still
remains unclear.

Especially in the examination phase students should have good stress-buffering abilities by per‐
forming PA, as high amounts of perceived stress are known to diminish cognitive functioning
in students [13]. Moreover, cognitive functioning is highly correlated to AP [14]. The inclusion
of all three variables PA, stress, and AP in one statistical (moderation) model might be essen‐
tial in this context since this might reveal indirect effects not captured by bidirectional compar‐
isons. However, based on theoretical deliberations, it cannot be assured that a mediation ap‐
proach is the correct underlying mechanism. A moderation approach may also be expedient as
also suggested by a review on PA and stress reactivity [63], which has to be examined in future
studies by comparing model fits of different approaches.

4.5. Limitations

A couple of limitations have to be considered in regard to this review.

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 16 de 27
:
 First, a meta-analytic analysis of only four (quite heterogenic) studies was performed, whose
results has to be viewed with caution. However, the Cochrane Consumers and Communication
Review Group [64] stated that as few as two studies are sufficient to conduct a meta-analysis.
To account for the small sample, results drawn are less generalizable than results drawn from
bigger samples.

From a methodological perspective, the sample size was quite divergent across included stud‐
ies, ranging from 203 [41] to 1071 [44] and added up to a total of 1952 participants (nfemale =
1220, nmale = 732) throughout all studies. Individual sample sizes do not appear to be extreme‐
ly small. However, most studies did not provide any justification for sample size estimation,
leaving the question of appropriate sample size and power.

Besides restricted sample sizes, the risk-of-bias assessment revealed three out of the four stud‐
ies to suffer from a high risk of bias [41,42,44] within studies. Closer inspection revealed that
this high risk is commonly caused by not reporting on non-responders. Therefore, more infor‐
mation is needed about non-responders and dropouts in future investigations to be able to bet‐
ter evaluate study quality and weighting results. A similar picture emerged when evaluating
risk of bias between studies. Here, a small bias can only be assumed for the relation between
PA and AP, whereas the other two suffer from high publication bias. However, this finding was
accounted for by using random-effect models for meta-analyses as suggested by the Cochrane
Consumers and Communication Group [65]. Nevertheless, findings have to be interpreted with
caution, as sources of heterogeneity are unclear. Notably, the studies included different designs
and various additional outcomes that were not included in the meta-analysis to achieve a better
comparison.

Several other methodological differences between studies made results difficult to compare.
Included studies used either cross-sectional [43,44] or longitudinal designs [41] or analyzed
longitudinal data cross-sectionally [42]. Moreover, studies differed regarding assessment meth‐
ods in all three variables of interest: PA is not thoroughly assessed in any of the studies. As
two studies used a 7-item short form of the IPAQ [45] measuring PA in different facets [42,43],
the two remaining studies only used single-item measures to quantify PA. Here, the next
methodological concern arises, as these two studies stated to measure PA, though they explicit‐
ly asked for sport and exercise activities, excluding PA like active transportation or gardening,
for example. Hence, results regarding PA are difficult to compare between studies. Another
concern about terminology arose in the study of Kayani and colleagues [43], who stated to
measure depression, but used the University Stress Scale [49] and therefore measured stress to
operationalize depression. Moreover, all studies used different, however validated measures for
stress. Regarding AP, two studies used GPA as course grade average [42,43], whereas one

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 17 de 27
:
 study used a dichotomous outcome [44] and one used only a specific course grade of a single
course [41]. As all studies were interested in influences of or on academic stress, sampling
points at the start of a semester, i.e., in a period with only low stress demands, is questionable.
If stress is a variable of interest, it should be measured towards the end of a semester (i.e., just
before the examination period), where stress demands are known to increase as examinations
approach. These differences make results difficult to compare and may have influenced results
on relationships of variables of interest.

Last, but not least, a major limitation of the current investigation is that we were not successful
in identifying and examining more studies elaborating the tridimensional relationship of PA,
stress, and AP, even though we explicitly included only studies with all three variables. Unfor‐
tunately, only one of them examined the relation of interest. All other studies focused on bidi‐
rectional relationships; thus, not enabling us to draw clear conclusions.

5. Conclusions and Future Directions

The current investigation did not evoke any significant relationships between the three vari‐
ables of interest. Moreover, heterogeneity, the small amount of included studies and above-
mentioned limitations prohibited to state clear evidence at this point. Therefore, more studies
are needed, expanding upon the investigation of bidirectional relationships and build up upon
the study of Kayani and colleagues [43], investigating the tridirectional relationship between
PA, stress, and AP. Hence, to encounter the above discussed limitations of the current investi‐
gation as well as of existing and included examinations, directions for future research will be
systematically compiled below.

(1) Adequate and validated measurement tools should be used. Regarding PA measurement,
objective measurement should be the means of choice [66] to conduct a comprehensive
quantification of PA. If for feasibility reasons or large sample size requirements PA has to
be measured by self-report, validated tools like the IPAQ [45] should be used instead of
single items to increase study quality. Regarding stress measurement, a more
comprehensive assessment method should be used which also includes objective measures
like cortisol to determine real stress exposure as compared to perceived stress because this
of the higher relevance from a physiological perspective on stress and health (e.g., [67,68]).
Regarding AP measurement, future studies should either use objective measures which can
display the overall AP or should collect to the AP data which is directly associated to the
measured stress period.

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 18 de 27
:
 (2) All variables should not only be assessed, but their relations should be analyzed in terms of
bi- and tridirectional relationships. Possibly, a theoretical foundation should be used to
investigate moderating or mediating effects of one or more variables. To enable secondary
data analyses, data should be provided by authors upon request, or should be uploaded for
common use in agreement with open science practices.
(3) Future studies should at least control for stressful and non-stressful times during the
semester and therefore control for real-life-stress situations or rather experimentally
manipulate the perceived amount of stress using randomized controlled designs.
(4) In addition, consistent use of terminology should be strived for to encounter
misinterpretation of findings regarding PA, sports and exercise influences.
(5) Encouraging students to be more physically active could be achieved by awareness raising
campaigns through lecturers and tutors as well as investments in the sports association and
sports facilities at the campus. Following the Okanagan Charter for Health Promoting
Universities and Colleges [69], this approach can strengthen student health by forming long
term health habits [70]. There are plenty of opportunities to implement PA habits in
university students for example by offering sports courses during the examination period or
by providing mobile health interventions, which are promising new tools in the area of
primary prevention [71].

Taken together, there is currently not enough research available to make reliable statements
about the interaction of the three constructs regarding university students. Therefore, it is rec‐
ommended to conduct further research in this area in order to raise the potential of PA as a pre‐
dictor for AP under consideration of real life stressors.

Acknowledgments

We acknowledge support by the KIT-Publication Fund of the Karlsruhe Institute of Technolo‐

gy.

Supplementary Materials

The following are available online at https://www.mdpi.com/1660-4601/18/2/739/s1, Table S1:

Individual search terms for databases.

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 19 de 27
:
 Click here for additional data file.(105K, pdf)

Author Contributions

K.W., J.F. and P.B. designed the study, undertook the study selection process, data extraction,
risk of bias assessment, as well as statistical analyses. All authors contributed equally and
wrote the first draft of the manuscript. A.W. critically revised the manuscript and gave useful
comments to further improve study quality. All authors have read and agreed to the published
version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author,
upon reasonable request.

Conflicts of Interest

The authors declare no conflict of interest.

Footnotes

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 20 de 27
:
 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institu‐
tional affiliations.

References

1. Stewart-Brown S., Evans J., Patterson J., Petersen S., Doll H., Balding J., Regis D. The health of students in
institutes of higher education: An important and neglected public health problem? J. Public Health Med.
2000;22:492–499. doi: 10.1093/pubmed/22.4.492. [PubMed] [CrossRef] [Google Scholar]

2. Pereira S., Reay K., Bottell J., Walker L., Dzikiti C. University Student Mental Health Survey 2018: A Large Scale
Study into the Prevalence of Student Mental Illness within UK Universities. [(accessed on 24 March 2020)]; Available
online: https://uploads-
ssl.webflow.com/561110743bc7e45e78292140/5c7d4b5d314d163fecdc3706_Mental%20Health%20Report%202018.p
df

3. Ribeiro Í.J., Pereira R., Freire I.V., de Oliveira B.G., Casotti C.A., Boery E.N. Stress and Quality of Life Among
University Students: A Systematic Literature Review. Health Prof. Educ. 2018;4:70–77.
doi: 10.1016/j.hpe.2017.03.002. [CrossRef] [Google Scholar]

4. Wunsch K., Kasten N., Fuchs R. The effect of physical activity on sleep quality, well-being, and affect in academic
stress periods. Nat. Sci. Sleep. 2017;9:117–126. doi: 10.2147/NSS.S132078. [PMC free article] [PubMed] [CrossRef]
[Google Scholar]

5. Ahrberg K., Dresler M., Niedermaier S., Steiger A., Genzel L. The interaction between sleep quality and academic
performance. J. Psychiatr. Res. 2012;46:1618–1622. doi: 10.1016/j.jpsychires.2012.09.008. [PubMed] [CrossRef]
[Google Scholar]

6. Topham P., Moller N. New students’ psychological well-being and its relation to first year academic performance in
a UK university. Couns. Psychother. Res. 2011;11:196–203. doi: 10.1080/14733145.2010.519043. [CrossRef]
[Google Scholar]

7. Cohen S., Wills T.A. Stress, social support, and the buffering hypothesis. Psychol. Bull. 1985;98:310–357.
doi: 10.1037/0033-2909.98.2.310. [PubMed] [CrossRef] [Google Scholar]

8. Gerber M., Pühse U. Review article: Do exercise and fitness protect against stress-induced health complaints? A
review of the literature. Scand. J. Public Health. 2009;37:801–819. doi: 10.1177/1403494809350522. [PubMed]
[CrossRef] [Google Scholar]

9. Brown J.D., Siegel J.M. Exercise as a buffer of life stress: A prospective study of adolescent health. Health Psychol.
1988;7:341–353. doi: 10.1037/0278-6133.7.4.341. [PubMed] [CrossRef] [Google Scholar]

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 21 de 27
:
 10. Lee E., Kim Y. Effect of university students’ sedentary behavior on stress, anxiety, and depression. Perspect.
Psychiatr. Care. 2019;55:164–169. doi: 10.1111/ppc.12296. [PMC free article] [PubMed] [CrossRef] [Google
Scholar]

11. Klaperski S., Seelig H., Fuchs R. Sportaktivität als Stresspuffer. Z. Sportpsychol. 2012;19:80–90.
doi: 10.1026/1612-5010/a000061. [CrossRef] [Google Scholar]

12. Nguyen-Michel S.T., Unger J.B., Hamilton J., Spruijt-Metz D. Associations between physical activity and
perceived stress/hassles in college students. Stress Health. 2006;22:179–188. doi: 10.1002/smi.1094. [CrossRef]
[Google Scholar]

13. Pradhan G., Mendinca N.L., Kar M. Evaluation of Examination Stress and Its Effect on Cognitive Function among
First Year Medical Students. J. Clin. Diagn. Res. 2014;8:BC05-7. doi: 10.7860/JCDR/2014/9014.4680. [PMC free
article] [PubMed] [CrossRef] [Google Scholar]

14. Cadoret G., Bigras N., Duval S., Lemay L., Tremblay T., Lemire J. The mediating role of cognitive ability on the
relationship between motor proficiency and early academic achievement in children. Hum. Mov. Sci. 2018;57:149–
157. doi: 10.1016/j.humov.2017.12.002. [PubMed] [CrossRef] [Google Scholar]

15. Vaez M., Laflamme L. Experienced stress, psychological symptoms, self-rated health and academic achievement:
A longitudinal study of swedish university students. Soc. Behav. Personal. 2008;36:183–196.
doi: 10.2224/sbp.2008.36.2.183. [CrossRef] [Google Scholar]

16. Talib N., Zia-ur-Rehman M. Academic performance and perceived stress among university students. ERR.
2012;7:127–132. doi: 10.5897/ERR10.192. [CrossRef] [Google Scholar]

17. Rafidah K., Azizah A., Norzaidi M.D., Chong S.C., Salwani M.I., Noraini I. Stress and academic performnce:
Empirical evidence from university students. Acad. Educ. Leadersh. J. 2009;13:37–51. [Google Scholar]

18. Castelli D.M., Hillman C.H., Buck S.M., Erwin H.E. Physical fitness and academic achievement in third- and fifth-
grade students. J. Sport Exerc. Psychol. 2007;29:239–252. doi: 10.1123/jsep.29.2.239. [PubMed] [CrossRef] [Google
Scholar]

19. Howie E.K., Pate R.R. Physical activity and academic achievement in children: A historical perspective. J. Sport
Health Sci. 2012;1:160–169. doi: 10.1016/j.jshs.2012.09.003. [CrossRef] [Google Scholar]

20. Taras H. Physical Activity and Student Performance at School. J. Sch. Health. 2005;75:214–218.
doi: 10.1111/j.1746-1561.2005.00026.x. [PubMed] [CrossRef] [Google Scholar]

21. Donnelly J.E., Hillman C.H., Castelli D., Etnier J.L., Lee S., Tomporowski P., Lambourne K., Szabo-Reed A.N.
Physical Activity, Fitness, Cognitive Function, and Academic Achievement in Children: A Systematic Review. Med.
Sci. Sports Exerc. 2016;48:1197–1222. doi: 10.1249/MSS.0000000000000901. [PMC free article] [PubMed]
[CrossRef] [Google Scholar]

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 22 de 27
:
 22. Irwin J.D. Prevalence of university students’ sufficient physical activity: A systematic review. Percept. Mot. Skills.
2004;98:927–943. doi: 10.2466/pms.98.3.927-943. [PubMed] [CrossRef] [Google Scholar]

23. Rouse P.C., Biddle S.J.H. An ecological momentary assessment of the physical activity and sedentary behaviour
patterns of university students. Health Educ. J. 2010;69:116–125. doi: 10.1177/0017896910363145. [CrossRef]
[Google Scholar]

24. Clemente F.M., Nikolaidis P.T., Martins F.M.L., Mendes R.S. Physical Activity Patterns in University Students:
Do They Follow the Public Health Guidelines? PLoS ONE. 2016;11:e0152516. doi: 10.1371/journal.pone.0152516.
[PMC free article] [PubMed] [CrossRef] [Google Scholar]

25. Sothmann M.S., Buckworth J., Claytor R.P., Cox R.H., White-Welkley J.E., Dishman R.K. Exercise training and
the cross-stressor adaptation hypothesis. Exerc. Sport Sci. Rev. 1996;24:267–288. doi: 10.1249/00003677-199600240-
00011. [PubMed] [CrossRef] [Google Scholar]

26. Wunsch K., Wurst R., von Dawans B., Strahler J., Kasten N., Fuchs R. Habitual and acute exercise effects on
salivary biomarkers in response to psychosocial stress. Psychoneuroendocrinology. 2019:216–225.
doi: 10.1016/j.psyneuen.2019.03.015. [PubMed] [CrossRef] [Google Scholar]

27. Moher D., Liberati A., Tetzlaff J., Altman D.G. Preferred reporting items for systematic reviews and meta-
analyses: The PRISMA statement. BMJ. 2009;339:b2535. doi: 10.1136/bmj.b2535. [PMC free article] [PubMed]
[CrossRef] [Google Scholar]

28. Higgins J.P.T., Green S. Cochrane Handbook for Systematic Reviews of Interventions. Wiley-Blackwell;
Chichester, UK: Hoboken NJ, USA: 2008. [Google Scholar]

29. R Core Team . R. R Foundation for Statistical Computing; Vienna, Austria: 2014. [Google Scholar]

30. Downes M.J., Brennan M.L., Williams H.C., Dean R.S. Development of a critical appraisal tool to assess the
quality of cross-sectional studies (AXIS) BMJ Open. 2016;6:e011458. doi: 10.1136/bmjopen-2016-011458. [PMC
free article] [PubMed] [CrossRef] [Google Scholar]

31. Taylor M., Masood M., Mnatzaganian G. Longevity of complete dentures: A systematic review and meta-analysis.
J. Prosthet. Dent. 2020:1–9. doi: 10.1016/j.prosdent.2020.02.019. [PubMed] [CrossRef] [Google Scholar]

32. Peterson R.A., Brown S.P. On the use of beta coefficients in meta-analysis. J. Appl. Psychol. 2005;90:175–181.
doi: 10.1037/0021-9010.90.1.175. [PubMed] [CrossRef] [Google Scholar]

33. Lenhard W., Lenhard A. Computation of Effect Sizes. [(accessed on 15 January 2021)]; Available online:
https://www.psychometrica.de/effect_size.html

34. McHugh M.L. The chi-square test of independence. Biochem. Med. (Zagreb) 2013;23:143–149.
doi: 10.11613/BM.2013.018. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 23 de 27
:
 35. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Elsevier Science; Burlington, NJ, USA: 2013.
[Google Scholar]

36. Lovakov A., Agadullina E. Empirically Derived Guidelines for Interpreting Effect Size in Social Psychology.
[(accessed on 15 January 2021)]; Available online: https://psyarxiv.com/2epc4/

37. Cochran W.G. The Combination of Estimates from Different Experiments. Biometrics. 1954;10:101–129.
doi: 10.2307/3001666. [CrossRef] [Google Scholar]

38. Higgins J.P.T., Thompson S.G. Quantifying heterogeneity in a meta-analysis. Stat. Med. 2002;21:1539–1558.
doi: 10.1002/sim.1186. [PubMed] [CrossRef] [Google Scholar]

39. Deeks J.J., Higgins J.P.T., Altman D.G., Cochrane Statistical Methods Group . Chapter 10: Analysing Data and
Undertaking Meta-Analyses. In: Higgins J.P.T., Thomas J., Chandler J., Cumpston M., Li T., Page M.J., Welch V.A.,
editors. Cochrane Handbook for Systematic Reviews of Interventions. Cochrane; London, UK: 2019. [(accessed on 23
April 2020)]. Version 6.0 (Updated July 2019) Available online:
https://training.cochrane.org/handbook/current/chapter-10 [Google Scholar]

40. Viechtbauer W. Conducting Meta-Analyses in R with the metafor Package. J. Stat. Softw. 2010;36:1–48.
doi: 10.18637/jss.v036.i03. [CrossRef] [Google Scholar]

41. Ruthig J.C., Marrone S., Hladkyj S., Robinson-Epp N. Changes in College Student Health: Implications for
Academic Performance. J. Coll. Stud. Dev. 2011;52:307–320. doi: 10.1353/csd.2011.0038. [CrossRef] [Google
Scholar]

42. Rettinger V.W. Ph.D. Thesis. Volume 72. University of South Carolina; Columbia, SC, USA: 2011. The
Relationship between Physical Activity, Stress, and Academic Performance; p. 2011. [Google Scholar]

43. Kayani S., Kiyani T., Wang J., Sanchez M.L.Z., Kayani S., Qurban H. Physical Activity and Academic
Performance: The Mediating Effect of Self-Esteem and Depression. Sustainability. 2018;10:3633.
doi: 10.3390/su10103633. [CrossRef] [Google Scholar]

44. Decamps G., Boujut E., Brisset C. French college students’ sports practice and its relations with stress, coping
strategies and academic success. Front. Psychol. 2012;3:104. doi: 10.3389/fpsyg.2012.00104. [PMC free article]
[PubMed] [CrossRef] [Google Scholar]

45. Craig C.L., Marshall A.L., Sjöström M., Bauman A.E., Booth M.L., Ainsworth B.E., Pratt M., Ekelund U., Yngve
A., Sallis J.F., et al. International physical activity questionnaire: 12-country reliability and validity. Med. Sci. Sports
Exerc. 2003;35:1381–1395. doi: 10.1249/01.MSS.0000078924.61453.FB. [PubMed] [CrossRef] [Google Scholar]

46. Cohen S., Kamarck T., Mermelstein R. A Global Measure of Perceived Stress. J. Health Soc. Behav. 1983;24:385.
doi: 10.2307/2136404. [PubMed] [CrossRef] [Google Scholar]

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 24 de 27
:
 47. Boujut E., Bruchon-Schweitzer M. A construction and validation of a freshman stress questionnaire: An
exploratory study. Psychol. Rep. 2009;104:680–692. doi: 10.2466/pr0.104.2.680-692. [PubMed] [CrossRef] [Google
Scholar]

48. Kohn P.M., Lafreniere K., Gurevich M. The Inventory of College Students’ Recent Life Experiences: A
decontaminated hassles scale for a special population. J. Behav. Med. 1990;13:619–630. doi: 10.1007/BF00844738.
[PubMed] [CrossRef] [Google Scholar]

49. Stallman H.M., Hurst C.P. The University Stress Scale: Measuring Domains and Extent of Stress in University
Students. Aust. Psychol. 2016;51:128–134. doi: 10.1111/ap.12127. [CrossRef] [Google Scholar]

50. Cohen S., Janicki-Deverts D. Who’s Stressed? Distributions of Psychological Stress in the United States in
Probability Samples from 1983, 2006, and 2009. J. Appl. Soc. Psychol. 2012;42:1320–1334. doi: 10.1111/j.1559-
1816.2012.00900.x. [CrossRef] [Google Scholar]

51. Hagstromer M., Ainsworth B.E., Oja P., Sjostrom M. Comparison of a subjective and an objective measure of
physical activity in a population sample. J. Phys. Act. Health. 2010;7:541–550. doi: 10.1123/jpah.7.4.541. [PubMed]
[CrossRef] [Google Scholar]

52. Liposek S., Planinsec J., Leskosek B., Pajtler A. Phyical activity of university students and its relation to physical
fitness and academic success. Ann. Kinesiol. 2018;9:89–104. doi: 10.35469/ak.2018.171. [CrossRef] [Google Scholar]

53. El Ansari W., Stock C. Relationship between attainment of recommended physical activity guidelines and
academic achievement: Undergraduate students in Egypt. Glob. J. Health Sci. 2014;6:274–283.
doi: 10.5539/gjhs.v6n5p274. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

54. Shephard R.J. Habitual physical activity and academic performance. Nutr. Rev. 1996;54:S32–S36.
doi: 10.1111/j.1753-4887.1996.tb03896.x. [PubMed] [CrossRef] [Google Scholar]

55. Lindner K.J. The Physical Activity Participation–Academic Performance Relationship Revisited: Perceived and
Actual Performance and the Effect of Banding (Academic Tracking) Pediatric Exerc. Sci. 2002;14:155–169.
doi: 10.1123/pes.14.2.155. [CrossRef] [Google Scholar]

56. Donnelly J.E., Lambourne K. Classroom-based physical activity, cognition, and academic achievement. Prev. Med.
2011;52(Suppl. 1):S36–S42. doi: 10.1016/j.ypmed.2011.01.021. [PubMed] [CrossRef] [Google Scholar]

57. Takehara K., Ganchimeg T., Kikuchi A., Gundegmaa L., Altantsetseg L., Aoki A., Fukuie T., Suwabe K., Bat-
Erdene S., Mikami M., et al. The effectiveness of exercise intervention for academic achievement, cognitive function,
and physical health among children in Mongolia: A cluster RCT study protocol. BMC Public Health. 2019;19:697.
doi: 10.1186/s12889-019-6986-8. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 25 de 27
:
 58. Wunsch K., Meier M., Ueberholz L., Strahler J., Kasten N. Acute psychosocial stress and working memory
performance: The potential of physical activity to modulate cognitive functions in children. BMC Pediatr.
2019;19:271. doi: 10.1186/s12887-019-1637-x. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

59. Stults-Kolehmainen M.A., Sinha R. The effects of stress on physical activity and exercise. Sports Med.
2014;44:81–121. doi: 10.1007/s40279-013-0090-5. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

60. Roberti J.W., Harringtion L.N., Storch E.A. Further Psychometric Support for the 10-Item Version of the Perceived
Stress Scale. J. Coll. Couns. 2006;9:135–147. doi: 10.1002/j.2161-1882.2006.tb00100.x. [CrossRef] [Google Scholar]

61. Klein E.M., Brähler E., Dreier M., Reinecke L., Müller K.W., Schmutzer G., Wölfling K., Beutel M.E. The
German version of the Perceived Stress Scale—Psychometric characteristics in a representative German community
sample. BMC Psychiatry. 2016;16:159. doi: 10.1186/s12888-016-0875-9. [PMC free article] [PubMed] [CrossRef]
[Google Scholar]

62. Hanin Y.L. Emotions in Sport. Individual Zones of Optimal Functioning (IZOF) Model. Human Kinetics;
Champaign, IL, USA: 1999. [Google Scholar]

63. Gerber M., Pühse U. Sportliche aktivität und stressreaktivität: Ein review. Dtsch. Z. Sportmed. 2008;59:4–10.
[Google Scholar]

64. Ryan R., Cochrane Consumers and Communication Review Group Cochrane Consumers and Communication
Group: Meta-analysis. [(accessed on 28 August 2020)]; Available online:
http://cccrg.cochrane.org/sites/cccrg.cochrane.org/files/public/uploads/meta-
analysis_revised_december_1st_1_2016.pdf

65. Ryan R., Hill S., Cochrane Consumers and Communication Group Heterogeneity and Subgroup Analyses:
Cochrane Consumers and Communication Group Reviews: Planning the Analysis at Protocol Stage. [(accessed on 28
August 2020)]; Available online: https://figshare.com/articles/Heterogeneity_and_subgroup_analysis/6818882

66. Burchartz A., Anedda B., Auerswald T., Giurgiu M., Hill H., Ketelhut S., Kolb S., Mall C., Manz K., Nigg C.R., et
al. Assessing physical behavior through accelerometry—State of the science, best practices and future directions.
Psychol. Sport Exerc. 2020;49:101703. doi: 10.1016/j.psychsport.2020.101703. [PMC free article] [PubMed]
[CrossRef] [Google Scholar]

67. Singh R., Goyal M., Tiwari S., Archana G., Shankar M.N., Das S. Effect of examination stress on mood,
performance and cortisol levels in medical students. Indian J. Physiol. Pharmacol. 2021;56:48–55. [PubMed]
[Google Scholar]

68. Takatsuji K., Sugimoto Y., Ishiazaki S., Ozaki Y., Matsuyama E., Yamaguchi Y. The effects of examination stress
on salviary cortisol, immunoglobulin A, and chromogranin A in nursing students. Biomed. Res. 2008;29:221–224.
doi: 10.2220/biomedres.29.221. [PubMed] [CrossRef] [Google Scholar]

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 26 de 27
:
 69. International Conference on Health Promoting Universities & Colleges Okanagan Charter: An International
Charter for Health Promoting Universities & Colleges. [(accessed on 15 January 2021)]; Available online:
http://hdl.handle.net/2429/54938

70. Kwan M.Y., Cairney J., Faulkner G.E., Pullenayegum E.E. Physical activity and other health-risk behaviors during
the transition into early adulthood: A longitudinal cohort study. Am. J. Prev. Med. 2012;42:14–20.
doi: 10.1016/j.amepre.2011.08.026. [PubMed] [CrossRef] [Google Scholar]

71. Fiedler J., Eckert T., Wunsch K., Woll A. Key facets to build up eHealth and mHealth interventions to enhance
physical activity, sedentary behavior and nutrition in healthy subjects—An umbrella review. BMC Public Health.
2020;20:1605. doi: 10.1186/s12889-020-09700-7. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

https://www-ncbi-nlm-nih-gov.proxy.unisanitas.edu.co/pmc/articles/PMC7830011/ 28/05/24, 10 03 a. m.
Página 27 de 27
: