Exploring the influence of COVID-19 stress on mental health among international undergraduate and graduate students: A mixed-methods approach.

COVID-19 stress was significantly associated with anxiety among international undergraduate and graduate students.

• Cross-sectional online survey completed by 219 international undergraduate and graduate students in the US
• Path analysis was used to assess the relationships between COVID-19 stress and anxiety
• Validated psychometric scales included the Depression, Anxiety, and Stress Scale (DASS-21), COVID-19 Stress Scale (CSS), and Perceived Stress Scale 4 (PSS-4)
• The association between COVID-19 stress and anxiety was statistically significant

COVID-19 stress was significantly associated with depression among international undergraduate and graduate students.

• Path analysis was used to assess the relationship between COVID-19 stress and depression
• The association between COVID-19 stress and depression was statistically significant
• Depression was measured using the DASS-21 validated psychometric scale
• Both undergraduate and graduate students showed this association

Education level moderated the relationship between COVID-19 stress and anxiety, but not the relationship between COVID-19 stress and depression.

• Path analysis was used to assess whether education level (undergraduate vs. graduate) moderated relationships between COVID-19 stress and mental health outcomes
• Moderation by education level was significant for the COVID-19 stress–anxiety pathway
• Moderation by education level was not significant for the COVID-19 stress–depression pathway
• Graduates and undergraduates experienced stress differently, particularly related to anxiety

Applied thematic analysis identified five major themes of COVID-19-related stressors affecting international students' mental health.

• Open-ended survey questions were analyzed using applied thematic analysis
• The five major themes identified were: academic performance, financial difficulties, travel constraints, social isolation, and grief
• These themes were derived from qualitative responses within the same cross-sectional survey of 219 international students
• Pandemic-related stressors were described as 'multifaceted in nature'

International college students in the United States are at increased risk of developing mental health disorders and are less likely to seek mental health services.

• This characterization is noted as background context motivating the study
• Little was known about the differential effects of COVID-19 pandemic stress on international undergraduate versus graduate students studying in the US prior to this study
• A mixed-methods approach (quantitative psychometric scales plus qualitative open-ended questions) was used to address this gap

Adequate mental health interventions and support tailored separately for graduate and undergraduate international students are needed to address students affected during global crises.

• Findings highlighted that graduates and undergraduates experienced pandemic stress differently, particularly related to anxiety
• The study used a cross-sectional design with 219 international students completing an online survey
• The authors recommend interventions be tailored to education level given the moderation finding for anxiety