TYPE Original Research PUBLISHED 13 July 2023 DOI 10.3389/fpsyt.2023.1202625 A predictive model of perceived OPEN ACCESS stress during the first wave of the COVID-19 pandemic in university EDITED BY Michael Noll-Hussong, Saarland University, Germany REVIEWED BY Emanuele Maria Merlo, students Ecuadorians University of Messina, Italy Cesare Massimo Cavalera, Catholic University of the Sacred Heart, Italy Geovanny Genaro Reivan Ortiz 1*, Rafael Yanza 1, Ravi Philip Rajkumar, Ximena Campoverde 1, Johanna Paulina Estrada Cherres 1, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India Lourdes Priscila Reinoso García 2, José Diaz 2 and *CORRESPONDENCE Roser Granero Pérez 3 Geovanny Genaro Reivan Ortiz greivano@ucacue.edu.ec 1 Laboratory of Basic Psychology, Behavioral Analysis and Programmatic Development (PAD-LAB), Catholic University of Cuenca, Cuenca, Ecuador, 2 Catholic University of Cuenca, Cuenca, Azuay, RECEIVED 09 April 2023 Ecuador, 3 Autonomous University of Barcelona, Barcelona, Catalonia, Spain ACCEPTED 30 June 2023 PUBLISHED 13 July 2023 CITATION Reivan Ortiz GG, Yanza R, Campoverde X, Background and objectives: The situation caused by the confinement due to the Estrada Cherres JP, Reinoso García LP, Diaz J and Granero Pérez R (2023) A predictive COVID-19 pandemic and the mobility restriction implemented by governments model of perceived stress during the first wave worldwide had a significant impact on people’s routines. Stressors are known of the COVID-19 pandemic in university to increase emotional imbalance, uncertainty, and frustration in the general students Ecuadorians. Front. Psychiatry 14:1202625. population. This study explores the factors that predispose to the risk of perceived doi: 10.3389/fpsyt.2023.1202625 stress from COVID-19 and determines the underlying mediating mechanisms in COPYRIGHT the Ecuadorian population. © 2023 Reivan Ortiz, Yanza, Campoverde, Estrada Cherres, Reinoso García, Diaz and Method: The cross-sectional study an incidental non-probabilistic sample of Granero Pérez. This is an open-access article n=977 participating student volunteers from the four regions of the Republic of distributed under the terms of the Creative Ecuador (68.6% women and 31.4% men). Data on emotional regulation (ERQ), Commons Attribution License (CC BY). The use, distribution or reproduction in other perceived stress (PSS), active procrastination (APS), diagnosis and symptoms forums is permitted, provided the original related to COVID-19, social isolation, coexistence, and a sociodemographic author(s) and the copyright owner(s) are questionnaire (biological sex, marital status, and age) were recruited. Statistical credited and that the original publication in this journal is cited, in accordance with accepted analysis was based on a structural equation model. academic practice. No use, distribution or Results: The risk of suffering perceived stress in the COVID-19 pandemic was reproduction is permitted which does not comply with these terms. higher for single women who have lived longer in social isolation, have lived with more people, have poor emotional regulation and high rates of procrastination. This structural model is similar in all Ecuadorian regions χ2=21.54 (p=0.760), RMSEA=0.001 (95%CI, 0.00–0.02), CFI=0.998; TLI=0.999; SRMR=0.020. Discussion: Although our findings are consistent and revealing for the scientific community, the lack of discrimination of the data due to strict isolation measures, taken at different periods by the Ecuadorian government against positive cases of COVID-19, is discussed. The research was applied to the university population, it would be representative to extend the study to schools and colleges. Conclusion: We consider this work as a starting point for the creation of preventive models against perceived stress in the university environment in the event of health emergencies. KEYWORDS perceived stress, COVID-19, procrastination, emotional regulation, Ecuadorians Frontiers in Psychiatry 01 frontiersin.org Reivan Ortiz et al. 10.3389/fpsyt.2023.1202625 1. Introduction of stress is based on a bio-psycho-social model. A person perceives a situation as threatening and emits a global response that is excessive In December 2019, health authorities alerted a new variant of the and exceeds their capacity for resistance (20). In these situations, some coronavirus family, SARS-CoV-2, in Hubei Province, China (1, 2). subjects may use maladaptive coping strategies that lead to However, most cases affected by this virus present mild symptoms psychological distress (12, 21–26). similar to those of a common cold. Therefore, a fraction of those Several studies relate increased perceived stress levels to emotional infected present more severe symptoms that can lead to a severe acute dysregulation (27), understood as the lack of control over behavior, respiratory syndrome, pneumonia, renal failure, and even death (3). personal motivations, affect, and difficulty returning to a calm state. This new variant of the virus is transmitted from person to person by One of the dimensions most often related to stress states is expressive air through secretions or respiratory droplets expelled as aerosols suppression because it relates to emotional exhaustion (28). (contact with fomites), which facilitates its rapid spread (4). On Another stress-related maladaptive behavior observed is February 11, 2020, the World Health Organization (WHO) named procrastination (29–33). As is known, stress-induced discomfort this pathogenic virus COVID-19 and promoted several containment situations cause activities to be postponed or not completed. Precisely measures focused on personal hygiene habits, ventilation of private on this point, the confinement by COVID-19 has led the individuals and public areas, and social distancing (5). to postpone activities and avoid situations that were part of their daily Since its inception, COVID-19 has had a significant impact on life, such as work, social activities, and studies (34). As a result, many society, with substantial adverse effects on physical and mental health students and workers have been forced to be absent from school and (both of those directly infected and the rest of the general population) work (35, 36). (6–8). Government authorities worldwide have issued various Sociodemographic studies recorded during the confinement measures to encourage people to leave their homes as little as possible phase due to COVID-19 have identified variables with predictive and encourage teleworking (9). Consequently, the population has capacity for perceived stress, such as female sex (39.40), single marital been driven to adopt new lifestyles, which in some cases has involved status (37), isolation time (38), diagnosis of COVID-19, symptoms the use of negative coping strategies to mitigate the perceived stressful associated with COVID-19 (39) and population regions (15). situation, resulting in the emergence and aggravation of psychological Studies in Latin America (37–39) have reported high-stress cases problems (10–12). due to the COVID-19 pandemic. Precise Ecuador was one of the Currently, worldwide so far, in 2022, there are approximately 442 countries most affected by the pandemic (report of more than 65,000 million confirmed cases, 5 million deaths, and a total of 10 billion cases of people infected by COVID-19) (40) with deplorable financial doses of vaccines administered (13). In Ecuador, the approximate resources and incomplete health facilities. Ecuador has had severe calculation of these positive cases is 800,000, with 35,000 deaths and difficulties determining possible cases of infection, containing its 13 million doses of vaccines administered (78.08% of the population spread, and treating patients (41, 42). This critical situation, wrapped fully vaccinated) (14). Emergency preparedness and response at the in a context of significant vulnerability, has created a feeling of extreme onset of the COVID-19 pandemic have been insufficient. Neither helplessness among the population, affecting mental health (43), Ecuador nor any other country in the world was prepared for a especially generating perceived stress. pandemic of this type. The health crisis and the impacts on the In summary, the control measures promoted worldwide to control Ecuadorian population during 2020 and 2021 have severely affected the spread of the COVID-19 pandemic (characterized by the the national public health system and emergency response; still, they accentuation of social distance and home isolation) have substantially have also had socioeconomic, equity, and ethical dimensions in the impacted people’s lifestyles, increasing the risk of unhealthy behavioral country (9). Ecuador’s National Health System has been severely patterns (44). For example, disruption of the daily routine of work and overwhelmed by the COVID-19 pandemic despite the efforts of the studies, or being continuously exposed to news about the infection National Ministry of Public Health; this was primarily due to provided by the media, could have increased levels of uncertainty and inadequate emergency health planning responses. The provinces of frustration in the individuals, leading to increases in perceived stress Pichincha, Guayas, Manabí, Azuay, El Oro, and Tungurahua were the levels (7, 10, 37, 38). Therefore, identifying the underlying mechanisms most affected by the COVID-19 pandemic, with thousands of positive that mediate the level of perceived stress and knowing if these cases (15). mechanisms are different in the regions evaluated is necessary to One of the effects of COVID-19 has been to increase the perceived develop future actions in the face of new waves of the COVID-19 stress levels of the individuals, leading to a worsening of anxiety and pandemic or other situations potentially generating high pressure on depressive symptoms (16, 17). Perceived stress is defined as a process individuals. The objective of this study is to obtain mediation models of defensive response to a stimulus or pressure (which can be either that evaluate the direct and indirect effects (mediation relationships) positive or negative), and states of physical and emotional tension between the following variables: socio-demographic (ecuadorian characterize it. It involves activation of the hypothalamic–pituitary– region, marital status: single), contextual to COVID-19 confinement, adrenal axis with activation of corticosteroids and the autonomic procrastination, and emotional regulation on the levels of stress nervous system (18). Low levels of perceived stress are not harmful perceived by university students in Ecuador, during the time of since they are a consequence of the need for readjustment of the mandatory isolation (period March–September 2020), where there organism. Pathological stress produces an imbalance between the was no presence of vaccines against the virus. contextual demands and the response capacity of the subjects to face According to the available scientific evidence, a model has been them. The emitted response results from overexertion that leads to proposed, whose hypotheses represented in the direct associations are: situations of exhaustion, fatigue, psychosomatic states, and other The female sex acts as a direct predictor of symptoms of COVID-19 psychopathological alterations (19). The dominant explanatory theory (34). Greater symptoms related to COVID-19 increase procrastination Frontiers in Psychiatry 02 frontiersin.org Reivan Ortiz et al. 10.3389/fpsyt.2023.1202625 (35). Single marital status predicts: COVID-19 disease (34), 14 items with a 5-point Likert-type response scale (0 = never, procrastination (45), and emotional regulation dimensions (cognitive 1 = almost never, 2 = occasionally, 3 = often, 4 = very often). A higher reappraisal and expressive suppression) (46). Older years of age score indicates a higher level of perceived stress. The Spanish version increase cognitive reappraisal (47). Higher levels of procrastination of the instrument was used in the present study (49). Cronbach’s alpha (29–31, 33) and higher levels of the dimensions of emotional indices for our study sample are reported in the results (Table 1). regulation (cognitive reappraisal and expressive suppression) (27, 28) Active Procrastination Scale (APS) (51) is a 16-item scale based on increase perceived stress. Finally, the composition of these the underlying components of active procrastination. It is a 7-point relationships is different in the Ecuadorian regions evaluated (15). Likert-type scale with a response format ranging from 1 (not true at all) to 7 (absolutely true). A higher score indicates a higher level of procrastination. The Spanish version of the instrument was used in 2. Method the present study (49). Cronbach’s alpha indices for our study sample are reported in the results (Table 1). 2.1. Participants Sociodemographic questionnaire. It consists of a short, structured, closed-response survey containing sociodemographic questions The non-probabilistic sample consisted of n = 977 volunteer (biological gender, marital status, and age measured in years). university students from the four regions that are part of the Republic Pandemic questionnaire. Four exploration questions with two of Ecuador (68.6% women and 31.4% men): Insular n = 10 (1.01%), answer options (Yes/No) developed by principal investigators based Coast n = 291 (29.79%), Highlands n = 597 (61.11%) and West n = 79 on previous study (52). It consists of questions about the pandemic (8.09%). The students came from five representative universities in the context: symptoms related to COVID-19, diagnosis of COVID-19, country, relevant to the north (Central de Quito and Técnica de social isolation and coexistence (the questions were interpreted Ibarra) and the south (Técnica de Machala, Santiago de Guayaquil, dichotomously absence = 0 and presence = 1). and Católica de Cuenca), in areas related to health (medicine, dentistry, psychology, and nursing) and intermediate level of study (from fifth and sixth academic semester). Considering that many of 2.3. Process the students received their classes at their homes telematically, the territorial location where the data were collected depends on the Data were collected from March to September 2020 in the Republic geographic region where they would receive their computer classes of Ecuador. The participants were amid social isolation due to remotely. Therefore, making up the urban area where the universities COVID-19 and conducted their classes telematically by videoconference. are located and the rural area of their homes. Sampling was incidental The study was conducted under the guidelines of the latest due to accessibility. Inclusion criteria considered university students Declaration of Helsinki for research on human subjects (53) and was in the Ecuadorian regions who had signed the informed consent form approved by the Ethics Committee for Research on Human Subjects were between 18 and 25 years of age, were in home isolation, and had of the Universidad UTE (IRB-UTE /CEISH UTE) approval code: access to a computer or specialized service to answer the survey. None IMP-SIC-LLA CUIO 1408 20, and had the bioethics authorization of of the participants reported having any medical or organic condition the university academic council: Universidad Central de Quito, that prevented them from answering the tests, as well as having any Universidad Santiago de Guayaquil, Universidad Técnica de Ibarra, anxiety, depression or psychiatric comorbidity 6 months before the Universidad Técnica de Machal, a and Universidad Católica de Cuenca. evaluation. The distribution of participants according to their Approximately 25,000 students from the five universities received sociodemographic, clinical, and pandemic variants for each region is an email invitation to participate in the study voluntarily and free of reported in Table 1. charge, of which 977 students who agreed to participate gave informed consent and were sent an online survey conducted through the Google Forms™ program. 2.2. Instruments Emotional Regulation Questionnaire (ERQ) (48). Individual 3. Data analysis differences in emotional regulation processes: implications for affection, relationships, and well-being. The questionnaire is Statistical analysis was performed with Stata17 for Windows (54). composed of 10 items in which the individual must express their Comparisons between groups were based on the chi-square test (χ2) for degree of agreement about how they habitually regulate their categorical variables and analysis of variance (ANOVA) for quantitative emotions. The participant responds according to a seven-point Likert- measures. Path analyses implemented through structural equation type scale, ranging from 1 (strongly disagree) to 7 (strongly agree). modeling (SEM) assessed direct and indirect effects. That included The first factor collects the scores that assess cognitive reappraisal. The mediational links between sociodemographic variables (gender, marital second factor refers to emotional suppression. A higher score indicates status, and age), contextual and individual variables during COVID-19 a higher level of cognitive reappraisal and/or emotional suppression. confinement (social isolation, presence of psychological and/or The Spanish version of the instrument was used in the present study physical symptoms, and the use of treatment for mental or physical (49). Cronbach’s alpha indices for our study sample are reported in the illness). It also included measures of emotional regulation (ERQ results (Table 1). scores), procrastination, and perceived stress. Path analysis procedures Perceived Stress Scale (PSS) (50). A self-report instrument that are a direct extension of multiple regression models (55) and can assesses the level of stress perceived during the last month. It contains be used for both exploratory and confirmatory modeling (which allows Frontiers in Psychiatry 03 frontiersin.org Reivan Ortiz et al. 10.3389/fpsyt.2023.1202625 TABLE 1 Description of the sample. Range Total Insular Coast Mountain West (Min. – n=977 n=10 n=291 n=597 n=79 Max.) Sociodemographics n % n % n % n % n % χ2 df p Sex Women 670 68.6% 7 70.0% 220 75.6% 388 65.0% 55 69.6% 10.27 3 0.016* Men 307 31.4% 3 30.0% 71 24.4% 209 35.0% 24 30.4% Marital Single 869 88.9% 7 70.0% 266 91.4% 524 87.8% 72 91.1% 11.23 6 0.082 Married 88 9.0% 3 30.0% 23 7.9% 56 9.4% 6 7.6% Divorced 20 2.0% 0 0.0% 2 0.7% 17 2.8% 1 1.3% Mean SD Mean SD Mean SD Mean SD Mean SD F-stat df p Age (yrs-old) 12 (17– 20.13 2.62 20.40 4.58 20.09 2.58 20.14 2.60 20.20 2.69 3; 29) 0.08 973 0.971 Context during COVID-19 n % n % n % n % n % χ2 df p Symptoms No 479 49.0% 10 100.0% 103 35.4% 325 54.4% 41 51.9% 39.29 3 <0.001* Yes 498 51.0% 0 0.0% 188 64.6% 272 45.6% 38 48.1% Illness No 937 95.9% 10 100.0% 273 93.8% 577 96.6% 77 97.5% 5.00 3 0.164 Yes 40 4.1% 0 0.0% 18 6.2% 20 3.4% 2 2.5% Social isolation No 586 60.0% 5 50.0% 166 57.0% 363 60.8% 52 65.8% 2.75 3 0.431 Yes 391 40.0% 5 50.0% 125 43.0% 234 39.2% 27 34.2% Living with others No 26 2.7% 0 0.0% 6 2.1% 19 3.2% 1 1.3% 1.90 3 0.594 Yes 951 97.3% 10 100.0% 285 97.9% 578 96.8% 78 98.7% Questionnaires α Mean SD Mean SD Mean SD Mean SD Mean SD F-stat df p ERQ-cognitive 0.81 36 (6–42) 25.05 8.23 23.20 10.26 26.25 7.92 24.73 8.28 23.29 8.27 3.79 3; 0.010* reappraisal 973 ERQ-emotion 0.77 24 (4–28) 17.67 6.37 17.10 7.36 18.36 6.06 17.46 6.44 16.77 6.75 1.91 3; 0.126 suppression 973 Procrastination 0.88 105 (0– 52.35 18.67 51.20 25.51 53.79 18.25 51.64 18.64 52.56 19.58 0.88 3; 0.449 105) 973 Perceived stress 0.83 16 (4–20) 13.01 2.43 12.90 3.81 13.21 2.20 12.92 2.44 12.91 2.87 1.01 3; 0.386 973 df, degrees of freedom; SD, standard deviation; EQR, Emotional Regulation Questionnaire; α, Cronbach’s alpha. *Bold: significant comparisons. testing and development of theories) (56). This work used the stepwise procedure, which offers a more powerful capacity than the maximum likelihood estimation (MLE) parameter estimation method, classical Benforroni’s correction (58). and goodness-of-fit was evaluated. That is, using standard statistical measures: χ2 test, root mean square error of approximation (RMSEA), Bentler comparative fit index (CFI), Tucker-Lewis index (TLI), and 4. Results standardized root mean square residual (SRMR). The adequate model fit was considered non-significant in 2 tests and if the following criteria 4.1. Sample characteristics were met (57): RMSEA<0.08, TLI > 0.9, CFI > 0.9 and SRMR<0.1. In this study, we have used the Finner’s-method to control Type-I Table 1 shows the description of the participants in the study, and error due to multiple statistical analyses. This is a familywise error rate the psychological scales have good psychometric properties. The Frontiers in Psychiatry 04 frontiersin.org Reivan Ortiz et al. 10.3389/fpsyt.2023.1202625 majority of participants were female (n = 670, 68.6%) and single higher scores on the procrastination dimension directly predicted (n = 869, 88.9%). The mean age was 20.13 (SD = 2.62). Regarding higher stress levels, and more difficulties were found in emotional contextual variables during COVID-19 confinement, more regulation strategies (higher scores on the ERQ cognitive reappraisal participants reported the presence of physical or psychological and expressive suppression). It also observed different indirect symptoms (n = 498, 51.0%), lack of treatment for physical or mental (mediational) links explaining the measure of perceived stress. First, illness (n = 937, 95.9%), lack of social isolation (n = 586, 60.0%), and procrastination was a mediating variable in different ways: (a) Being cohabitation (n = 951, 97.3%). The comparison between geographic female increased the likelihood of symptoms during confinement, areas achieved statistical differences for the sex of the participants which increased procrastination and thus perceived stress levels. (b) (higher proportion of women among the Coast group), the presence Being single also directly increased procrastination and, therefore, stress of symptoms during the confinement (higher proportion among the score. (c) Singleness and older age were predictors of higher scores on Island group), and the ERQ cognitive reappraisal scale (higher mean the cognitive reappraisal dimension of the ERQ, which increased among the participants among the Coast group). procrastination and thus the likelihood of increased stress. 4.2. Mechanisms that explain the level of 5. Discussion perceived stress during confinement: trajectory analysis The objective of this study was to evaluate the relevance of a predictive model of perceived stress and to know its differences Table 2 shows the correlation matrix for the variables considered between the regions of the Republic of Ecuador in the period from in the study. As a result of the strong association between sample size March to September 2020 in university students. The results suggest and the results of the null hypothesis tests for the correlation model, that time spent in confinement, social isolation, living with more only coefficients within the ranges mild–moderate (|R|> > 0.24) to people in one environment, non-assertively regulated emotions large-high (|R|> > 0.37) were considered as relevant. Perceived stress (expressive suppression), procrastination, and being a woman increase levels positively correlated with higher scores on the ERQ (emotional the severity of perceived stress. The structure of these relationships is regulation questionnaire) and procrastination scales. The ERQ scales similar in all Ecuadorian regions (Insular, Coast, Mountain and West). also correlated very positively. Our results confirm the hypotheses studied in an integrated causal Figure 1 shows the path diagram with the standardized coefficients model. The data are consistent with reported studies on the influence (Table 3 contains the complete results of the model: direct, indirect, of confinement time on perceived stress (27, 47). Similarly, social and total effects). For the categorical variables, we have included into isolation is an aggravating factor in the course of stress in times of brackets the code used with the aim to allow the interpretation of the confinement by COVID-19 (27); with this, one can interpret that coefficients. This SEM selected in the study as the optimal model for withdrawing from the social context increases a set of long-term the data set retained only significant associations. An adequate fit was psychopathological states (59), including stress (16–18, 60). achieved: χ2 = 21.54 (p = 0.760), RMSEA = 0.001 (95% confidence Although the results are consistent with our hypotheses, several interval: 0.00–0.02), CFI = 0.998, TLI = 0.999 and SRMR = 0.020. studies mention that living with people in a family environment has According to the hypotheses raised, it is confirmed by a causal many positive effects on mental health (61–63). This is possibly due to model that: the female gender acts as a direct predictor of symptoms of the particular characteristics of the pandemic in Ecuador, such as the COVID-19; Similarly, single marital status influences the increase in strict social confinement in all regions of the country (64), presence symptoms associated with COVID-19. Years of age directly influence of overcrowding in homes (65), effects of gender violence (sexism) cognitive reappraisal; procrastination and emotional regulation (66), use of technologies for online learning (67), fear of getting dimensions act as direct predictors of perceived stress. In other words, infected (68), and economic problems derived from the health situation (69). Added to this, the characteristics of the social context in Ecuador are essential since most university students live with their TABLE 2 Correlation matrix. families, and it is also common to live in extended families. This 2 3 4 5 6 7 makes it possible that family problems have arisen during the pandemic and with the whole family staying at home. 1 Age (yrs-old) −0.031 0.006 0.070 0.037 0.027 0.010 On the other hand, our hypothesis that expressive suppression 2 COVID- – 0.031 0.015 0.015 0.026 0.003 becomes the non-assertive emotional component that acts directly and isolation mediates perceived stress is confirmed. This would indicate the clinical 3 COVID-living – −0.045 −0.017 −0.011 −0.049 and psychopathological relevance of emotional regulation, as occurs in with others many psychological disorders (23, 24) such as depression (70, 71), bipolar 4 ERQ-cognitive – 0.772 0.140 0.300 disorder (72), generalized anxiety disorder (73, 74), social anxiety (75, reappraisal 76), borderline personality disorder (77), eating disorders (78), and substance-related disorders (79). Therefore, the theoretical framework of 5 ERQ-emotion – 0.126 0.311 transdiagnosis would explain the high rates of comorbidity that occur suppression between different clinical disorders, emotional regulation being a key 6 Procrastination – 0.310 factor in their development and maintenance (80, 81). 7 Stress – These results indicate that emotion regulation has considerable Bold: statistically significant correlation. overlap with perceived stress management. The studies strengthen our Frontiers in Psychiatry 05 frontiersin.org Reivan Ortiz et al. 10.3389/fpsyt.2023.1202625 FIGURE 1 Diagram of the trajectory plot obtained in the SEM for stress: standardized coefficients. Only the significant coefficients remained in the final model. Sample size: n=977. analysis of the role of managed emotional reactions in perceived stress reappraisal of this region in a statistically significant way, as indicated by that involve emotional regulation, such as expressive suppression and our results, which would have led its inhabitants to adopt an emotional cognitive reappraisal (24, 82). This could be because when people face regulation strategy that implies resignifying an event to change their events, emotion regulation allows them to assess the emotional impact perception. Emotional effect, this ability would have allowed them to of the condition and helps determine what types of emotional reduce negative emotional experiences, denoting it as a protection factor reactions are appropriate, as well as when and how they express against the health situation of COVID-19. emotions, as might have occurred in the pandemic by COVID-19 (83). Empirical evidence has shown that procrastination is one of the most frequent stressors presented by confinement, revealing that 5.1. Strengths procrastination is associated with poorer psychological health (84–86). The results of the study corroborate our hypothesis, indicating that a The present study has three strengths: the study sample, the greater tendency to procrastinate is related to the presence of greater composition of the data collected in the natural course of the pandemic, stress. Despite the fact that studies have reported the association of and the statistical analysis. According to the first strength, the population anxiety and depression associated with procrastination (83, 87–89), in our was marked by the geographic regions of Ecuador, giving a sociocultural study these variables were not considered because our model was to know representation of the country made up of university students of middle the direct prediction of perceived stress, integrating emotional regulation, cycles of academic careers related to the area of health who have access procrastination and contextual variables related to COVID-19. to the Internet through the modality online survey, allowing for specific A recent study revealed that female college students, compared to external validity in the selected study population. The second strength males, have higher levels of perceived stress due to the COVID-19 included acquiring information on variables inherent to the measures lockdown (71, 90–93). Our hypothesis corroborates these results. Possibly, established by the leaders of each country, representative of and in these findings were due to the fact that the composition of the sample was keeping with the natural context of health. Thirdly, path analysis involves made up of young university students. In the same way, we believe that the study of all the variables in the same model, allowing us to determine these results may be influenced by a greater proportion of women in our the direct and indirect effects of the study. study sample, statistically differentiated in each Ecuadorian region, so we believe that the results should be interpreted with caution. Finally, despite the fact that our hypothesis was to find a different 5.2. Limitations relationship model between regions (15), our results indicate the opposite. Possibly this is due to the fact that the composition of the Although our findings are consistent and revealing for the sample is homogeneous among its characteristics (university profile). scientific community, however, there were limitations in conducting Regarding the presence of symptoms related to COVID-19, the results the study. One of them was the use of digital platforms to receive indicated a statistically significant difference indicating high values in the information, which probably hindered the natural response of the Coast region. We believe that this result is due to the fact that most of the participant, as it could have been completed without supervision. presence of deaths due to COVID-19 have been presented by the Coast One possibility to cover this bias was using self-applied paper region of Ecuador, as mentioned by several studies (9, 14, 15). Possibly this instruments; however, this was not feasible given the current situation situation has influenced the presence of high values in the cognitive due to the pandemic. On the other hand, another fact that can Frontiers in Psychiatry 06 frontiersin.org TABLE 3 Results obtained in the path analysis. Frontiers in Psychiatry Reivan Ortiz et al. Direct effects Indirect effects Total effects Coeff. SE z-stat p- 95%CI (coeff) Coeff. SE z-stat p- 95%CI (coeff) Coeff. SE z-stat p- 95%CI (coeff) value value value Sex (1 = male vs. −8.636 5.587 −1.55 0.122 −19.587 2.315 0.000 No. −8.636 5.587 −1.55 0.122 −19.587 2.315 COVID-isolation 0 = female) path COVID- Sex (1 = male vs. −0.133 0.034 −3.89 0.000 −0.199 −0.066 0.000 No. −0.133 0.034 −3.89 0.000 −0.199 −0.066 symptoms 0 = female) path 0.132 0.063 2.08 0.038 0.008 0.256 0.000 No. 0.132 0.063 2.08 0.038 0.008 0.256 ERQ-reappraiss Age (yrs-old) path 2.943 0.832 3.54 0.000 1.312 4.574 0.000 No. 2.943 0.832 3.54 0.000 1.312 4.574 Single path COVID- 4.950 1.161 4.26 0.000 2.675 7.225 0.000 No. 4.950 1.161 4.26 0.000 2.675 7.225 Procrastination symptoms path 0.276 0.071 3.89 0.000 0.137 0.415 0.000 No. 0.276 0.071 3.89 0.000 0.137 0.415 ERQ-reappraiss path Sex (1 = male vs. 0.000 No. −0.656 0.228 −2.88 0.004 −1.104 −0.209 −0.656 0.228 −2.88 0.004 −1.104 −0.209 0 = female) path 0.000 No. 0.036 0.020 1.83 0.067 −0.003 0.075 0.036 0.020 1.83 0.067 −0.003 0.075 07 Age (yrs-old) path Marital (1 = single 8.481 1.862 4.55 0.000 4.831 12.130 0.812 0.310 2.62 0.009 0.203 1.420 9.293 1.865 4.98 0.000 5.638 12.947 vs. 0 = other) COVID- 0.000 No. 0.174 0.045 3.87 0.000 0.086 0.262 0.174 0.045 3.87 0.000 0.086 0.262 Stress symptoms path ERQ-reappraiss 0.036 0.014 2.63 0.009 0.009 0.062 0.010 0.003 3.58 0.000 0.004 0.015 0.045 0.014 3.30 0.001 0.018 0.072 0.035 0.004 9.20 0.000 0.028 0.043 0.000 No. 0.035 0.004 9.20 0.000 0.028 0.043 Procrastination path ERQ-suppression 0.070 0.017 4.03 0.000 0.036 0.104 0.000 No. 0.070 0.017 4.03 0.000 0.036 0.104 path Sex (1 = male vs. 0.000 No. −0.023 0.008 −2.74 0.006 −0.039 −0.007 −0.023 0.008 −2.74 0.006 −0.039 −0.007 0 = female) path Age (yrs-old) 0.000 No. 0.006 0.003 1.76 0.079 −0.001 0.013 0.006 0.003 1.76 0.079 −0.001 0.013 10.3389/fpsyt.2023.1202625 path Marital (1 = single 0.000 No. 0.538 0.110 4.91 0.000 0.323 0.753 0.538 0.110 4.91 0.000 0.323 0.753 vs. 0 = other) path frontiersin.org ERQ-suppression Marital (1 = single 1.529 0.648 2.36 0.018 0.259 2.799 0.000 No. 1.529 0.648 2.36 0.018 0.259 2.799 vs. 0 = other) path COVID-illness Marital (1 = single −0.038 0.020 −1.87 0.061 −0.077 0.002 0.000 No. −0.038 0.020 −1.87 0.061 −0.077 0.002 vs. 0 = other) path Coeff., non-standardized coefficient; SE, standard error; 95%CI, 95% confidence interval. Reivan Ortiz et al. 10.3389/fpsyt.2023.1202625 be considered a limitation was the lack of discrimination of data Committee Catholic University of Cuenca. The patients/participants taken in different periods since in Ecuador, there were times when provided their written informed consent to participate in this study. there were high numbers of cases with a proven diagnosis, which forced the Emergency Operations Committee (COE by its Spanish acronym) of Ecuador to take strict isolation measures on several Author contributions occasions. Finally, since this study is applied to the university population, schools and colleges would be left aside. Following GR conducted the introduction and discussion of the study. RG studies along these lines may involve the different educational cycles developed the method and the results. RY, XC, JE, LR and JD recruited to have a complete distribution of the results in the country. These the data, reviewed and proofread the entire manuscript. All authors deficiencies can be counterbalanced in future studies to provide novel contributed to the article and approved the submitted version. reports to the scientific community. However, we consider this work a starting point for creating preventive models against perceived stress in the university setting in the face of health emergencies. Funding RG was supported by the ICREA-Academy-2021 award. 6. Conclusion We concluded that being a woman, the time spent in confinement, Acknowledgments social isolation, living with more people in one environment, not assertively regulating emotions (expressive repression), and A special thanks from RG for having obtained the ICREA- procrastinating activities increased the risk of suffering perceived Academy-2021 award. stress during the COVID-19 pandemic. The underlying model of relationships between the study variables to predict the severity of perceived stress is the same in the Ecuadorian regions evaluated. Conflict of interest The authors declare that the research was conducted in the Data availability statement absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author. Publisher’s note All claims expressed in this article are solely those of the authors Ethics statement and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product The studies involving human participants were reviewed and that may be evaluated in this article, or claim that may be made by its approved by CEISH-UCACUE is the Human Beings Research Ethics manufacturer, is not guaranteed or endorsed by the publisher. References 1. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological 7. 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