Assessing the Relationship between Physical Health, Mental Health and Students’ Success among Universities in Lebanon: A Cross-Sectional Study

A cross-sectional study consisting of a random sampling procedure was conducted during the Fall semester of 2023 (October–December), involving students from three different universities across Lebanon. These universities included two renowned private institutions, the American University of Beirut (AUB) and the University of Balamand (UOB), as well as the Lebanese University, which is the sole public university with multiple branches and majors throughout the country. Based on a similar study conducted by Baert et al. [20], the required sample size was determined to be 220, with a 95% confidence interval and a precision level of 40%. To accommodate an additional 20% refusal rate, a total of 264 college students were included in this study. The sample size was stratified according to university size and gender, resulting in the need for a total of 137 women and 127 men for this study.

After obtaining approval from the Dean of the Student Affairs Office at the respective universities (to avoid any undue influence or coercion), the research team visited the universities included in the study. They randomly approached students and invited them to participate in a self-administered online questionnaire. Upon agreeing to take part in the study and reviewing the consent form (), participants proceeded to complete the survey (). The survey’s completion took approximately 10 min. Supplementary File S1 Supplementary File S2

Participation in the survey was entirely optional and anonymous. Additionally, participants were encouraged to ask questions related to the study or seek additional clarification before consenting to participate. Moreover, the study received approval from the Institutional Review Board (IRB) at AUB, and the research team was Collaborative Institutional Training Initiative (CITI)-certified.

The survey aimed to assess the mental and physical health of university students, along with factors associated with student success. According to the Cambridge University Reporter, examination performance is commonly used to assess academic performance [21]. In this study, academic achievement was measured by GPA, reflecting students’ performance in assignments, tests, and exams. A higher score indicates better academic performance [2]. The questionnaire was created based on similar studies in the literature [16,22] and comprised four sections. The first section consisted of questions about participants’ sociodemographic characteristics and university-related factors, including age, gender, area of residency, educational level, and major.

Section 2 included validated and reliable scales that are used to assess mental health on an ordinal scale: the Patient Health Questionnaire (PHQ-9) for depression, the General Anxiety Disorder (GAD-7) for anxiety, and Cohen’s Perceived Stress Scale (PSS) for stress. This section also encompassed some questions related to social support. The PHQ-9 comprises 9 statements on a 4-point Likert-type scale ranging from 0 (not at all) to 3 (nearly every day). For each respondent, the assigned values for PHQ-9 items were added to create a score ranging from 0 to 27. The resulting score was utilized to categorize individuals into different levels of depression: minimal (0–4), mild (5–9), moderate (10–14), moderately severe (15–19), and severe depression (20–27) [23]. The GAD-7 is a 7-item self-reported anxiety scale, where each item is graded on the Likert scale from 0 (not at all) to 3 (nearly every day). For each respondent, the assigned values for GAD-7 items were summed to create a score ranging from 0 to 21. This score was used to classify individuals into categories of minimal (0–4), mild (5–9), moderate (10–14), and severe anxiety (15–21), respectively [24]. The PSS consists of 10 items, with responses rated on the Likert scale from 0 (never) to 4 (very often). For questions 4, 5, 7, and 8, the assigned values were reversed (i.e., 0 = 4, 1 = 3, 2 = 2, 3 = 1, 4 = 0). For each respondent, the assigned values were then summed. The total scores of the PSS ranged from 0 to 40, with scores of 0-13 representing low stress, 14-26 indicating moderate stress, and 27–40 signifying high perceived stress [25].

The third section focused on the participants’ physical health (for instance, BMI) and lifestyle factors (for instance, physical activity, sleeping habits, and diet), whereas the last section included questions on students’ success. The questionnaire was pilot tested on 10 students to check for clarity. Data collected during the pilot testing phase were not incorporated into the present study.contains a copy of the questionnaire used for data collection. Supplementary File S2

Data were rigorously checked for completeness and were then entered into the Statis-tical Package for the Social Sciences (SPSS) version 29.0 (SPSS Inc., Chicago, IL, USA) for data analysis. Descriptive statistics were used, such as counts and percentages, for the categorical variables and means and standard deviations (SD) for the continuous ones. Chi-square (χ2) was used to calculate the association between two categorical variables. Note that GPA for UOB students was multiplied by 0.98, whereas for LU students, it was multiplied by 1.2 in accordance with AUB equivalence system. GPA was then dichotomized. The mean GPA score was considered the cut-point. Participants reporting a GPA below the mean score, i.e., between 0 and 79, were considered to have a low to moderate GPA, and those reporting a GPA above or equal to the mean score, i.e., 80 and above, were considered to have a high GPA.

Simple and multiple logistic regression were applied to investigate which factors were associated with student success, using the GPA score as an dependent variable and the sociodemographic factors, such as mental and physical health and university, as independent variables. All variables that were found to be significant in the simple analysis were added simultaneously to the multiple regression models as independent variables. Results from the logistic regression analyses were expressed as odds ratios (ORs) with their respective 95% confidence intervals (CIs). A p-value below 0.05 was considered statistically significant in all analyses.

A total of 264 students completed the online survey, with 261 providing complete data and being included in the final analysis (resulting in a 99% completion rate). The sociodemographic characteristics of the study population, along with some information about their studies, are presented in Table 1. Based on the gender and university stratification plan, approximately 52% of the students were women, with 27.6% enrolled in AUB, 51.3% in LU, and 21.1% in UOB.

The average age of the college students was 20.29 years (SD = 2.025), ranging between 17 and 33 years old. The majority of students were from Beirut (40.2%) and Mount Lebanon (31%). A significant portion of the participants were Lebanese (92.3%), and many were enrolled in non-health-related majors (73.6%). About 64.4% of the participants lived with their families. Additionally, around 36% of the students reported a personal monthly income between USD 100 and 300. Nearly half of the participants’ parents held a university degree. Most students had working fathers (92.3%), while 56.7% had working mothers. Moreover, more than two-thirds of the participants had no employment (72.4%) and did not receive any financial aid or scholarship (67%). Approximately 32% reported studying more than 30 hours per week. Finally, 48.7% of college students had a low to moderate GPA, while 51.3% had a high GPA.

Among the study sample (Table 2), 73.5% of students exhibited mild to moderately severe symptoms of depression, and 80.5% displayed mild to severe symptoms of anxiety. Specifically, 44.1% showed mild symptoms of anxiety, while 10.7% exhibited severe symptoms. Approximately 75.1% presented with moderate symptoms of stress, and 13.4% of students exhibited high perceived stress. More than half of the participants (64.7%) believed that their mental health had a negative impact on their ability to learn, focus, and perform well in university.

As indicated in Table 2, significant differences were observed in the mental health status (depression, anxiety, and stress) of college students based on their GPA level. The rating of the negative impact of mental health was also significantly associated with GPA level.

As shown in Table 3, the majority of college students in the study sample did not report any physical disability (99.2%) or chronic disease (83.1%). Among those who reported chronic disease, asthma was the most prevalent (38.6%). About 52.1% of participants experienced frequent headaches, fatigue, or stomachaches. Only 36.4% considered themselves physically active, while 45.6% reported being moderately active, and 18% described themselves as sedentary. Moreover, 47.9% of students went to the gym, 38.3% were daily smokers, and 33.3% consumed alcohol, with 24.5% doing so less than two times per week. Approximately 14.2% of participants identified as underweight, while 11.5% considered themselves obese. More than half of the participants (59.4%) were satisfied with their weight, and 52.5% reported weight fluctuations during their university years. Additionally, 65.9% of students reported having regular sleeping habits, and 57.5% believed they followed healthy eating habits, with homemade food being the most preferred option (42.5%). Only 32.9% of participants believed that their physical health negatively impacted their ability to learn, focus, and perform well in university. Finally, GPA was significantly associated with physical activity, smoking habits, gym attendance, and weight satisfaction.

As shown in Table 4, a significant portion of the participants (79.3%) never thought of dropping out of university. More than half of them (59.4%) believed they would complete their studies on time. Approximately 40% engaged in internships or other opportunities to gain practical experience in their fields and actively participated in extracurricular activities (ECAs). Furthermore, 66.7% of students expressed satisfaction with the quality of education and the learning environment provided by their institution, while 54.8% were pleased with the quality of services offered by the student affairs office at their institution. Finally, the results revealed a significant association between GPA and the likelihood of finishing studies on time, as well as satisfaction with the quality of education provided by the institution.

Simple logistic regression analysis revealed that fifteen predictors were significantly associated with participants’ GPA level (Table 5). These predictors included the area of residency (OR = 0.396, p = 0.002), where participants from Mount Lebanon were less likely to have a better GPA than those residing in Beirut. Other significant predictors comprised the stage of study (OR = 2.718, p = 0.036), major (OR = 1.836, p = 0.035), mother’s employment status (OR = 3.904, p = 0.01), university enrollment (OR = 0.377, p = 0.009), PHQ9 (mild depression: OR = 0.448, p = 0.025; moderately severe depression: OR = 0.26, p = 0.002), GAD7 (OR = 0.338, p = 0.005), PSS (OR = 0.35, p = 0.045), negative impact of mental health (a great deal: OR = 2.271, p = 0.01; some: OR = 2.667, p = 0.004), physical activity (moderately active: OR = 0.501, p = 0.014; sedentary: OR = 0.396, p = 0.011), gym (OR = 0.479, p = 0.004), smoking (OR = 1.968, p = 0.009), weight satisfaction (OR = 0.584, p = 0.034), finishing study on time (OR = 0.47, p = 0.024), and satisfaction with the quality of education provided by the university (OR = 0.547, p = 0.023).

The results from the multiple logistic analysis revealed several significant associations with participants’ GPA levels. More specifically, participants with a health-related major were more likely to have a high GPA compared to those with a non-health major (OR = 3.874, p = 0.007). Students studying at UOB had lower odds of having a high GPA compared to those studying at AUB (OR = 0.222, p = 0.004). Additionally, participants who reported being moderately active were less likely to have a high GPA compared to those who reported being active (OR = 0.41, p = 0.045). Students who do not smoke daily were more likely to have a high GPA compared to those who smoke daily (OR = 2.948, p = 0.003). Further, participants who reported being unsatisfied with the quality of education and the learning environment provided by their institution were less likely to have a high GPA compared to those who reported being satisfied (OR = 0.439, p = 0.033). Also, students who have working mothers specifically self-employed were more likely to have a high GPA compared to those who have non-working mothers (OR = 3.971, p = 0.043). Finally, the results showed that the student’s area of residency, and whether they consider that mental health has a negative impact on their studies were all significantly associated with their GPA level (OR = 0.363, p = 0.011; OR = 3.019, p = 0.038, respectively).

The present study is among the few conducted in the MENA region, including Lebanon, that investigates the correlations between mental health, physical health, and academic achievement. To the best of our knowledge, this is the first study in Lebanon to employ GPA as a measure of students’ success, departing from more subjective methods such as the Subjective Academic Achievement Scale (SAAS) [19].

Our results revealed alarming rates of depression and anxiety, surpassing those documented in previous studies. Specifically, our findings indicated that nearly 76% of students exhibited mild to moderately severe symptoms of depression, and approximately 70% reported mild to moderate symptoms of anxiety. In contrast, studies conducted in 2018 showed that 56% of students were experiencing mild to moderate depression symptoms, with 36% and 34% presenting combined symptoms of depression and anxiety, respectively [26,27]. Despite using identical mental health indicators, these variations may be attributed to methodological differences, particularly the focus on single universities in the latter studies. The ongoing crisis in the country could be another influencing factor contributing to the increased prevalence of mental health issues among young adults, especially since the previous studies were conducted before the economic crisis and the onset of the COVID-19 pandemic. Furthermore, the levels of anxiety reported in our study were higher than those documented among college students in Lebanon in 2021 (50%) [16], the United States (15.9%) [26], and Canada (32.6%) [28]. Additionally, approximately 75% of our study sample exhibited moderate stress levels, a figure higher than the reported levels among pharmacy students in Lebanon (27.7%) [18].

The present study also revealed that a significant percentage of students reported a negative impact of their mental health on academic performance. This finding is consistent with a Student Voice survey on health and wellness conducted by Inside Higher Ed and College Pulse, where half of the students asserted that their well-being adversely affects their academic progress [29]. In a longitudinal study conducted in the United States, it was found that mental health problems predicted delayed academic success (GPA) [30]. It is worth noting that mental health issues and their relationship with students’ success have not received sufficient attention in the MENA region compared to other countries [31]. The present study’s findings highlight a significant association between mental health and student success. These findings highlight the urgent need for comprehensive mental health support services on university campuses to address the well-being of students and mitigate the adverse effects on their academic success.

Our findings indicate that only 11.5% of students perceive themselves as overweight or obese, a considerably lower proportion compared to other studies. For example, a cross-sectional study encompassing university students from 22 low-, middle-income, and emerging economy countries reported that 22% of participants were overweight or obese [32]. Similarly, a study conducted in Egypt found that approximately one quarter of males and one third of females fell into the overweight/obese category [31]. A potential explanation for our results may be attributed to self-reported bias, as students were required to assess their weight based on BMI. Additionally, the mean BMI of college students in our study sample was 22.41 ± 3.37, aligning with acceptable ranges observed in previous studies conducted in Lebanon, Morocco, and Saudi Arabia [19,33,34,35]. Although our study did not identify any association between BMI and GPA, it is noteworthy that several studies have indicated a negative relationship between BMI and academic achievement [36,37]. Future studies should examine the complex relationship between academic achievement and weight status, accounting for variables like health behaviors and body image perception.

Our results indicated an association between GPA and the area of residency, contrary to findings in other studies. For instance, Alfifi et al. discovered that the residential area has no significant influence on academic achievement [38,39,40]. In contrast, their research found that women outperformed male students, while our findings revealed no gender-based differences in GPA among college students in the study sample. Additionally, in line with previous studies, our results demonstrated that students pursuing health-related majors were more likely to achieve higher GPAs compared to non-health majors [39,40]. This differs from a study conducted in Lebanon, where better academic achievement was observed among students with non-scientific majors, potentially influenced by the subjective method used to measure academic achievement in that region [19]. It follows from previous research that parents’ socio-economic status, including academic and professional qualifications and income, can be associated with student success [22]. However, in the present study, only the mother’s employment status was found to be significantly associated with GPA. The university in which students were enrolled was also identified as a factor affecting GPA, possibly attributed to varying resources and facilities offered by each institution. This finding aligns with the significant association observed between students’ satisfaction with the quality of education provided by their institution and GPA. Regarding physical and lifestyle factors, a significant association was revealed between smoking and GPA, consistent with lower GPAs among students who smoke, as reported in previous studies [19,41]. Physical activity also showed an association with GPA, with sedentary students being less likely to achieve high GPAs compared to their active counterparts. This association was previously highlighted in a study among medical students in Saudi Arabia [42].

Sleep deprivation is common among university students and has been linked to poor academic performance [43]. While a study in Belgium found a positive relationship between sleep quality and academic achievement [20], no association was found between sleeping habits or hours and GPA in our study.

The results of our study have consequences not just for Lebanon but also for other nearby countries in the MENA region, where problems with university students’ mental, physical, and academic well-being may be common. The MENA region shares certain issues including economic instability, political turmoil, and the effects of global health crises [44]. Thus, the knowledge gathered from our research could guide the development of interventions and policies meant to promote the academic achievement and general well-being of university students in surrounding countries.

Moreover, our research highlights the necessity of paying more attention to mental health concerns among college students worldwide. The concerning rates of stress, anxiety, and depression that our research revealed are likely not specific to Lebanon; rather, they could be a reflection of larger patterns that influence young adults across a range of cultural contexts [45]. Because of this, international efforts to address mental health on college campuses should be prioritized, with an emphasis on developing supportive learning environments, facilitating access to mental health services.

The findings of the current study should be interpreted considering the study’s limitations. First, our study was cross-sectional; causal relationships cannot be drawn. For instance, students from low-income families may face unique challenges such as limited access to opportunities for physical activities, which could affect their academic performance. Moreover, time constraints may be associated with students’ ability to dedicate sufficient time to learning. Therefore, future studies using longitudinal designs could be developed to better understand causal relationships. Second, the data collection process utilized self-reported responses to assess the relationship between both physical and mental health factors and the academic success of university students. However, it is important to acknowledge the potential for inaccuracies stemming from memory recall or social desirability bias within these responses. Third, this study primarily employed quantitative methods for assessment. Future research endeavors may benefit from incorporating qualitative approaches to further explore the relationship between physical health, mental health, and university students’ success, thereby offering a more comprehensive understanding of the subject matter.