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STE Student Well-being & Performance

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STE Student Well-being & Performance

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haidiefigueroa9
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Link Between Student Well-being and Scholastic Proficiency: A

Predictive Study of STE Learners in Eastern Visayas


Girlie P. Camacho, Brian A. Donoga, and Rojen O. Martires
SSLG Leader-Researchers

Danhill C. Donoga, PhD


Adviser

Basilio B. Chan Memorial Agricultural and Industrial School, Lavezares, Northern Samar, 6404,
Philippines.

Authors’ contributions
This work was carried out in collaboration among all authors. All authors read and approved the
final manuscript.

ABSTRACT

This study explored the link between student well-being and scholastic proficiency among Science,
Technology, and Engineering (STE) students in Eastern Visayas for school year 2024-2025. The well-
being of students, particularly in high-pressure academic environments, plays a crucial role in their
academic success. Using standardized instruments such as the GAD-7 and PHQ-9, we assessed the
mental health of completely enumerated 123 STE students. Data on socioeconomic status, sleep
patterns, and lifestyle habits were collected and analyzed through descriptive statistics. Scholastic
proficiency was measured using 1st quarter grades in mathematics, science, and English. Using
predictive models such as Pearson correlation and regression analyses, the researchers determined
predictors of well-being and scholastic proficiency. The results showed that while lifestyle factors like
healthy eating and physical activity had significant correlations with well-being, socioeconomic status
and sleep patterns did not. Additionally, anxiety was identified as a significant predictor of English
proficiency. The findings suggest that responsive mental health and lifestyle interventions could
support both the well-being and academic performance of STE students. Based on these insights, a 3-
year student-led intervention program, Project CARES, was designed to cultivate academic resilience
and empower students to improve their mental health and academic outcomes.

Keywords: wellbeing, depression, anxiety, scholastic performance, predictive models, STE

for STE students, who are often under higher


1. INTRODUCTION academic pressure due to the rigorous demands of
The well-being of students, particularly those subjects such as mathematics, science, and
enrolled in Science, Technology, and Engineering English. Maintaining a healthy balance between
(STE) programs, is increasingly recognized as a mental well-being and academic expectations is
vital factor influencing their academic success and crucial, as research consistently shows that poor
personal development. Globally, about 10-20% of mental health can hinder academic performance in
adolescents experience mental health challenges, these critical subjects (Schwartz, 2021).
which significantly impact their academic The recent 2022 Programme for International
performance (World Health Organization [WHO], Student Assessment (PISA) results further
2021). This connection between well-being and highlight the struggles of Filipino students,
academic achievement is particularly important particularly in the areas of mathematics, science,
2024 Division Science. Mathematics and Technology Fair

and reading comprehension. The Philippines 3. Ascertain STE learners’ scholastic


continues to rank among the lowest globally, with proficiency.
only 24% of students reaching basic reading 4. Correlate between profile and well-being
proficiency and a mere 23% achieving basic of STE students.
proficiency in science (Organisation for Economic 5. Predict profile factors most significantly
Co-operation and Development [OECD], 2022). affect the wellbeing of STE students.
6. Correlate between wellbeing and
In mathematics, only 16% of Filipino students
scholastic proficiencies of STE students.
demonstrated the ability to solve basic
7. Predict wellbeing issues most
mathematical problems, such as comparing significantly affect the scholastic
distances or converting prices between currencies proficiency of STE students.
(Philippine Daily Inquirer, 2023). These results 8. Design intervention plan based on the
mirror the outcomes of the 2018 PISA, with study’s findings to support the well-being
Filipino students still performing five to six years and academic performance of STE
behind their peers in other countries (Philstar, learners in Eastern Visayas.
2023). The persistence of these low scores, despite
educational reforms, underscores the importance 2. METHODOLOGY
of exploring other factors, such as student well-
being, that could be affecting academic A quantitative approach was employed using
performance. standardized instruments such as the Generalized
Understanding the profiles of STE students, Anxiety Disorder-7 (GAD-7) and the Patient
including their socioeconomic backgrounds, Health Questionnaire-9 (PHQ-9). These tools,
personal habits, and well-being, is essential to validated for assessing mental health and overall
well-being, were adapted to capture the specific
addressing the challenges they face in subjects like
stressors and well-being indicators pertinent to
mathematics, science, and English. Research STE students, such as academic pressure, work-
shows that students from low-income households life balance, and physical health. A paper-and-
are more likely to suffer from poor mental health, pencil survey was administered to all STE students
which has a direct negative impact on their from selected schools in Eastern Visayas through
academic performance, particularly in STE complete enumeration. The profile and well-being
subjects (Schwartz, 2021). This study aims to data collected were anonymized to protect the
examine the correlation between STE students' privacy of the respondents. Profile data used
profiles and well-being, and their academic descriptive statistics while wellbeing responses
proficiencies in these subjects. Through predictive were then scored and analyzed to identify the
models, the study will identify the factors that general well-being trends among the students
most significantly affect their academic (Kroenke et al., 2001; Spitzer et al., 2006).
performance, providing insights for targeted
interventions. Such interventions will be crucial To ascertain STE learners’ proficiency in
mathematics, science, and English, the study
for improving both the well-being and academic
utilized students' 1st quarter grades in these
success of STE students, particularly in regions subjects, which were provided by the schools’
like Eastern Visayas, where educational resources records. These grades reflected the students'
are often limited. academic performance during the first quarter of
the school year and served as indicators of their
1.1 Objectives proficiency in each subject. Descriptive statistics
The study sought to: were calculated to summarize the performance of
students in mathematics, science, and English,
1. Determine the profile of STE Students. providing insight into the overall academic
2. Assess the wellbeing of STE students. proficiency of STE learners in the selected

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2024 Division Science. Mathematics and Technology Fair

schools. All grade data were treated confidentially no exercise 35 28.46


and coded for analysis (DepEd, 2020). no exercise and
42 34.15
healthy food
The correlations between profile and well- active in online
being and wellbeing and academic performance gaming, no
were analyzed using the Pearson correlation 36 29.27
exercise, no
coefficient to assess the strength and direction of healthy food
the relationship between well-being scores and the Total 123 100
students’ grades in mathematics, science, and
English. To predict which well-being factors most
significantly influenced academic performance, a The profile data of STE students in this
multiple regression analysis was conducted. The study reveals several key insights into their
statistical analyses were performed using Jamovi socioeconomic status, sleep patterns, and lifestyle
software, which enabled the application of choices. A substantial majority of the students,
correlation and regression models to the dataset. 50.41%, belong to families with a monthly income
Variables such as socio-economic status, sleep below PHP 5,000, while only 20% come from
patterns, lifestyle activity, and mental health households earning more than PHP 15,001 per
indicators were included in the regression model month. This indicates that most students come
to determine their predictive power. These from low-income families, which aligns with
findings provided the basis for designing research showing that socioeconomic status (SES)
interventions to support both the well-being and is a critical factor influencing academic
academic performance of STE learners in Eastern performance and well-being. Students from lower-
Visayas (Field, 2013). income households often face barriers such as
limited access to resources, higher stress levels,
and greater financial insecurity, which may
negatively affect their ability to focus on academic
3. RESULTS AND DISCUSSION success (Siraj, 2014; Murnane, 2015). This
financial hardship can also lead to higher dropout
3.1 Profile STE students rates and lower academic proficiency, especially
Profile Frequency Percentage in resource-intensive programs like STE.
Monthly Family Income
below 5,000 62 50.41 When it comes to sleep, the data show
5001-10, 000 40 181.82 that nearly 40% of students report getting less
10,001- 15, 000 15 68.18 than four hours of sleep per night, while only
15,001 above 6 20.00 17.89% sleep for the recommended eight
Total 123 100 hours or more. Sleep deprivation is a
Hours of Sleep significant concern, as multiple studies have
8 hours and demonstrated its negative impact on cognitive
22 17.89
above functioning, attention, and memory (Owens,
6-7 hours 22 17.89 2014). Adolescents, especially those in
4-5 hours 30 24.39 demanding academic tracks like STE, need
less than 4 hours 49 39.84 sufficient sleep to perform at their best.
Total 123 100 Chronic sleep deprivation can impair
Lifestyle students’ ability to retain information,
healthy food problem-solve, and concentrate, which are all
1 0.81
and exercise critical skills for excelling in mathematics,
exercise only 2 1.63 science, and English (Lo et al., 2016). The
healthy food high percentage of students sleeping less than
7 5.69
only the recommended amount suggests that many

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are at risk of underperforming due to poor 3.2 Wellbeing of STE Students


sleep habits. 3.2.1
Depression Mean
The lifestyle data provide further insight 1 Little interest or pleasure in
1.48
into potential barriers to well-being and doing things?
academic success. Only 0.81% of students 2 Feeling down, depressed, or
1.62
reported engaging in both healthy eating and hopeless?
exercise, and 34.15% indicated that they 3 Trouble falling or staying
neither exercised nor followed a healthy diet. 1.20
asleep, or sleeping too much?
Alarmingly, 29.27% of students were 4 Feeling tired or having little
categorized as active in online gaming but 1.78
energy?
lacking in both exercise and healthy food. 5 Poor appetite or overeating? 1.21
This sedentary lifestyle, compounded by poor 6 Feeling bad about yourself—
dietary habits, has been linked to several or that you are a failure or
adverse health outcomes, including obesity, 1.85
have let yourself or your
fatigue, and mental health issues (Nelson & family down?
Lytle, 2014). Research shows that adolescents 7 Trouble concentrating on
who do not engage in regular physical activity things, such as reading the
1.11
or maintain a healthy diet are more likely to newspaper or watching
experience stress, anxiety, and lower television?
academic performance (Biddle & Asare, 8 Moving or speaking so
2017). The high prevalence of inactive slowly that other people
students with poor dietary habits in this study could have noticed? Or the
is concerning and highlights the need for opposite—being so fidgety 1.07
targeted interventions to promote healthier or restless that you have been
lifestyles. moving around a lot more
than usual?
These findings underscore the 9 Thoughts that you would be
multifaceted challenges faced by STE better off dead, or of hurting
1.00
yourself in some way?
students, particularly those from low-income
families. The combination of financial Total 12.31
hardship, sleep deprivation, and unhealthy Interpretation Moderate
Legend:
lifestyle habits creates an environment where
Score Rage Severity
academic success becomes difficult to 0-4 Minimal or None
achieve. These issues are interconnected; 5-9 Mild
students from lower-income families often 10-14 Moderate
15-19 Moderate Severe
have less access to nutritious food and safe
20-27 Severe
spaces for physical activity, which in turn
affects their mental and physical health The well-being data of STE students reveals
(Murnane, 2015). a moderate level of depression based on a total
score of 12.31 on the depression scale, with
individual mean scores ranging from 1.00 to 1.85
across different indicators. The highest concerns
were feeling tired or having little energy (mean =
1.78) and feeling bad about oneself or
experiencing failure (mean = 1.85), which align

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with research suggesting that academic pressure in students feeling afraid as if something awful might
STEM fields can significantly contribute to happen, indicating that a significant number of
emotional exhaustion and self-doubt among students experience pervasive feelings of fear and
students (Sulkowski et al., 2016). Meanwhile, apprehension. This is consistent with literature
trouble sleeping (mean = 1.20) and poor appetite that shows academic stress, particularly in high-
or overeating (mean = 1.21) indicate that physical pressure environments like STE programs, can
health may also be compromised, potentially intensify feelings of anxiety and worry about
further aggravating students' mental health future outcomes (Sulkowski et al., 2016).
(Owens, 2014). Notably, the lowest score was for Additionally, worrying too much about different
thoughts of self-harm (mean = 1.00), indicating things (mean = 1.69) and not being able to control
fewer students experiencing severe mental worrying (mean = 1.49) further highlight the high
distress, but still highlighting the need for mental prevalence of anxiety, which is a common
health interventions given the moderate overall response to academic and social pressures (Beiter
depression level. The results imply that despite et al., 2015).
moderate severity, the cumulative strain from
emotional fatigue and academic stress could Moreover, trouble relaxing (mean = 1.20)
significantly impair students’ academic and restlessness (mean = 1.35) are indicators of
performance and well-being, reinforcing the need physical manifestations of anxiety, which can
for early interventions in STE education programs exacerbate cognitive overload and reduce
to mitigate depression risks (Biddle & Asare, students' capacity to focus and perform well
2017). academically (Biddle & Asare, 2017). These
findings suggest that many STE students are not
3.2.2 General Anxiety only struggling with cognitive anxiety but also
General Anxiety Mean experiencing physical symptoms such as
1 Not being able to stop or restlessness and irritability (mean = 1.55), which
1.49 can contribute to overall academic burnout and
control worrying?
reduced efficiency in learning (Owens, 2014).
2 Worrying too much about
1.69
different things?
3.3 Proficiency in Mathematics, Science and
3 Trouble relaxing? 1.20
English
4 Being so restless that it's
1.35 Learning 1st Quarter Interpretation
hard to sit still?
Areas Grade
5 Becoming easily annoyed or
1.55 Mathematics 86.56 Very
irritable?
Satisfactory
6 Feeling afraid as if
Science 87.91 Very
something awful might 1.79
happen? Satisfactory
Total 10.77 English 87.57 Very
Interpretation Moderate Satisfactory
Legend: Total 87.35 Very
Score Rage Severity Satisfactory
0-4 Minimal or None
5-9 Mild
10-14 Moderate
15-21 Severe The academic performance of STE students
in the three core subjects—mathematics, science,
The analysis of general anxiety levels among and English—was evaluated using their 1st
STE students shows a moderate level of anxiety, quarter grades, which show very satisfactory
with a total score of 10.77 on the anxiety scale. results across all areas. The average grade in
The highest mean score, 1.79, was related to mathematics was 86.56, in science it was 87.91,

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2024 Division Science. Mathematics and Technology Fair

and in English it was 87.57, with a total average of The analysis of the relationship between STE
87.35. This strong performance is notable, as it students' profile variables and their well-being
reflects the students' capability to meet the reveals significant findings. Lifestyle (diet and
demanding expectations of the STE curriculum. exercise) showed a strong positive correlation with
According to Zimmerman (2014), academic well-being (Pearson’s r = 0.819, p = 0.004),
success in STE subjects is often linked to indicating that healthier habits are closely linked
cognitive engagement and the ability to apply to better mental health, consistent with studies that
critical thinking skills, both of which are reflected link physical activity and diet to improved
in these grades. emotional states (Biddle & Asare, 2017).
However, monthly family income (Pearson’s r =
Despite the moderate levels of anxiety and 0.343, p = 0.143) and sleep patterns (Pearson’s r =
depression reported earlier in the study, these 0.040, p = 0.620) did not show significant
students have maintained high academic relationships with well-being, suggesting that
performance, particularly in mathematics and
factors like lifestyle choices may play a more
science. Previous studies have found that high-
critical role in students' mental health than
achieving students may experience anxiety but
socioeconomic status or sleep alone (Murnane,
still perform well academically, often due to a
strong sense of resilience and support from school 2015; Owens, 2014).
systems (Beiter et al., 2015). The very satisfactory
performance in English also suggests a well- 3.5 Predictor of wellbeing of STE students
rounded skill set, as proficiency in language arts is
Profile Parameters Wellbeing Variables
critical for effective communication in STE fields Variables General
(Santos, 2016). These results indicate that, while Depression
Anxiety
students are achieving academically, their well- Family
being challenges should not be overlooked, as Income Pearson's r 0.145 0.094
prolonged stress and anxiety could eventually df 121 121
impair their ability to sustain high performance p-value 0.109 0.299
(Owens, 2014). Interpretation NS NS
sleep
pattern Pearson’s r 0.060 0.109

3.4 Relationship between profile df 121 121


and wellbeing of STE students p-value 0.510 0.232
Interpretation NS NS
Profile Parameters Pearson's r 0.089 0.030
Wellbeing Lifestyle
Variables
Profile df 121 121
Pearson's r 0.343 p-value 0.030* 0.042*
df 121 Interpretation Significant Significant
p-value 0.143 The analysis of well-being predictors among STE
Interpretation NS students reveals that lifestyle factors, specifically
sleep
Pearson’s r 0.040 diet and physical activity, significantly influence
pattern both depression and anxiety levels, as supported
df 121
by both local and international literature. For
p-value 0.620
example, Bernardo and Resurreccion (2018)
Interpretation NS
highlighted that Filipino high school students
Pearson's r 0.819 who engage in regular physical activity
Lifestyle
df 121 experience lower levels of depression and
p-value 0.004* anxiety, which aligns with findings from Biddle
Interpretation Significant and Asare (2017) that show consistent reductions
in mental health symptoms among adolescents

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2024 Division Science. Mathematics and Technology Fair

who maintain active lifestyles. Additionally, like STE programs, where students must manage
Puyat (2016) found that unhealthy dietary habits complex problem-solving tasks.
and lack of exercise were strong predictors of
mental health challenges among Filipino 3.7 Predictor of scholastic proficiency of STE
students. On an international scale, Garcia et al. students
(2019) further reinforced the importance of
Profile Parameters Scholastic Proficiency
lifestyle, noting that healthier eating and exercise Variables English
routines helped STEM students manage academic Math Science
stress more effectively. In contrast, sleep patterns Depression Pearson's
and family income did not emerge as significant 0.063 0.106 0.111
r
predictors, corroborating the findings of Owens df 121 121 121
(2014) that although sleep is crucial for cognitive p-value 0.489 0.245 0.221
function, other factors like lifestyle choices may Inter- NS
NS NS
play a more decisive role in mental health pretation
General Pearson’s
outcomes. These integrated findings suggest that Anxiety r
0.140 0.158 0.194
interventions aimed at improving lifestyle habits df 121 121 121
could significantly enhance the well-being of p-value 0.123 0.082 0.032*
STE students, reducing the prevalence of Interpreta Significa
tion NS NS nt
depression and anxiety.

3.6 Relationship between wellbeing and The analysis of predictors for scholastic
scholastic proficiency of STE students proficiency among STE students shows that
general anxiety is a significant predictor of
Profile Parameters Scholastic English proficiency, with a Pearson’s r = 0.194
Variables Proficiency and a p-value of 0.032, indicating that higher
levels of anxiety correlate with lower academic
Wellbeing performance in English. This is consistent with
Pearson's r 0.052 findings from Beiter et al. (2015), which indicate
df 121 that heightened anxiety can impair language-
p-value 0.023 based cognitive functions such as comprehension
Interpretation Significant and verbal reasoning. However, general anxiety
was not a significant predictor for mathematics
The analysis of the relationship between and science performance, as indicated by non-
well-being and scholastic proficiency among STE significant p-values. Similarly, depression was
students shows a significant correlation, with
not a significant predictor of academic
Pearson’s r = 0.052 and a p-value of 0.023. This performance in any subject, suggesting that while
indicates that students' well-being has a
anxiety impacts language-related tasks,
meaningful impact on their academic
performance. While the correlation is relatively depression may have a less direct effect on short-
small, it aligns with existing literature that term academic outcomes in STEM fields (Owens,
highlights the importance of mental health in 2014).
academic achievement. Beiter et al. (2015) found These results imply that interventions aimed
that students who experience lower levels of at reducing general anxiety may particularly
depression and anxiety tend to perform better benefit English proficiency in STE students, as
academically, as their cognitive functions, such anxiety can undermine confidence and
as attention and memory, are less impaired. communication skills critical to language
Similarly, Garcia et al. (2019) emphasized that acquisition (Garcia et al., 2019). However, the
mental well-being directly influences academic lack of significance for depression and its
success, particularly in high-stress environments
relationship with STEM subjects suggests that

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2024 Division Science. Mathematics and Technology Fair

more specific cognitive or motivational factors


might be at play in mathematics and science
performance.

5. CONCLUSIONS 6. RECOMMENDATIONS

Based on the findings of the study, the conclusions On the basis of the highlights of the study, the
below are drawn. hereunder recommendations are set forth.
1. The data revealed that most STE students face
significant socioeconomic and lifestyle 1. Provide targeted support programs like meal
challenges, such as low family income, sleep plans, fitness activities, and financial
deprivation, and unhealthy habits, which assistance. Aim to reduce socioeconomic
likely impede their academic performance and barriers and increase student participation in
well-being. support services by 15% within a year.
2. Both depression and anxiety were moderately 2. Implement mental health programs including
present among the students, with emotional counseling and stress management
fatigue and self-doubt being prominent issues. workshops. Target a 10% reduction in
This underscores the need for mental health reported depression and anxiety levels within
support to prevent further deterioration in the next academic year.
students' well-being and academic 3. Train 100% of teachers to recognize and
achievement. support mental health challenges by the next
3. Despite challenges in well-being, the students school year to sustain high academic
demonstrated high academic performance performance.
across subjects, indicating strong resilience. 4. Promote healthier lifestyles through
However, continued mental health concerns mandatory fitness and nutrition programs.
Aim for a 20% increase in participation within
may threaten sustained academic success.
six months.
4. While lifestyle factors like diet and exercise
5. Launch wellness campaigns focusing on diet
significantly influenced well-being, family
and exercise, with a goal of increasing healthy
income and sleep patterns showed no
habits among students by 15% in one year.
significant correlation, suggesting that 6. Ensure 100% of students flagged for academic
lifestyle interventions could effectively issues receive mental health support within
enhance student well-being. one week.
5. Lifestyle factors, particularly healthy eating 7. Address anxiety in English proficiency
and physical activity, were identified as key through workshops and tutoring, targeting a
predictors of better mental health, while 5% improvement in scores over the next
family income and sleep patterns were not academic year.
major contributors.
6. Well-being was significantly correlated with
scholastic proficiency, suggesting that mental
health positively influences academic
performance, particularly in demanding
programs like STE.
7. Anxiety was a significant predictor of English
proficiency, while no significant relationships
were found between well-being and
performance in mathematics and science,
suggesting the need for targeted mental health
interventions.

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2024 Division Science. Mathematics and Technology Fair

OUTPUT
- Monitor
improvem
- "Study Power Hours":
Project CARES Weekly study groups where
1. 20% ents in
participation English
(Cultivating Academic Resilience, SSLG members act as
facilitators, offering
in tutoring scores
Academic and study (target:
Empowerment, and Support) Support & tutoring for subjects like
groups. 5%
Year Math, Science, and English.
Anxiety 2. Improve increase).
2 - Exam Stress Busters:
Managemen English - Survey
Breakdown of Project CARES: t📚
Organize fun, pre-exam
proficiency students
workshops on time
and reduce for stress
management and relaxation
anxiety levels
• Cultivating: Promoting healthier lifestyles and techniques like guided
levels. before and
meditation.
mental well-being through fun activities like after exam
periods.
Wellness Wednesdays and Chill Sports Days.
• Academic Support: Providing targeted academic
assistance through Study Power Hours and peer- - Track
to-peer tutoring to help students excel. - "Foodie Fridays": SSLG
participati
• Resilience: Building resilience by teaching organizes healthy eating 1. 20% more
on in
challenges
students stress management, relaxation challenges and cooking students
(Foodie
demos where students share adopting
techniques, and time management strategies affordable, nutritious healthier
Fridays,
Sleep
through workshops. Healthy meals. eating and
Challenge
• Empowerment: Empowering students with the Year
3
Lifestyle &
Holistic
- Sleep Challenge: Run a
month-long challenge
fitness
habits.
).
knowledge and skills to take control of their well- - Use
Living 🥦 encouraging 8 hours of 2. Improve
surveys
being through interactive challenges and sleep, complete with a overall
and fitness
reward system. mental and
community involvement. - Fitness Fun Runs: Host physical
logs to
• Support: Offering constant emotional and student-led fun runs or well-being.
monitor
health
fitness marathons.
academic support through initiatives like the Chat improvem
Buddy system and regular student feedback ents

mechanisms.

Project CARES will transform the


school community by making mental health CONSENT
and academic success a shared goal, with fun
As per international research standard,
and meaningful activities led by SSLG.
Participants’ written consent has been collected
and preserved by the author(s).
Outcome
Interventio Goals/
Year SSLG-Led Activities Measure
n Focus Targets
ment
ETHICAL APPROVAL

As per international standard or DepEd standard


- "Wellness Wednesdays":
Weekly talks on stress - written
Track ethical approval has been collected and
1. Increase
management, mental health
mental preserved by the author(s).
student
first aid, and mindfulness. attendance
health
- Peer-to-Peer Support: in
awareness
SSLG officers organize a wellness
COMPETING INTERESTS
across all
Mental "Chat Buddy" system, events.
Year year levels.
Health & where upperclassmen are - Use
1 2. 15% more
Well-being trained to help peers student
struggling with stress or
students Authors
surveys to have declared that no competing interests
actively
anxiety.
participating exist.
gauge the
- Chill Sports Days: effectiven
in wellness
Organize light sports like ess of the
events.
volleyball or badminton to programs.
promote physical activity.

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2024 Division Science. Mathematics and Technology Fair

Nelson, M. C., & Lytle, L. A. (2014). The


relationship between diet and physical
activity patterns of adolescents.
American Journal of Health
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