Physical Activity and the Emotional State of Physiotherapy Students Who Finish Their Education

This study aimed to evaluate the emotional state and the level of the sense of coherence in the context of physical activity among physiotherapy students and investigate how the participating students’ emotional state changed after two years of studying and what factors were associated with the mood disorders. The study group consisted of 110 students—79 female and 31 male. The Back Depression Inventory (BDI), the Sense of Coherence Questionnaire (SOC-29) and the Perceived Stress Questionnaire (PSQ) were used. The results presented an increase in depressive symptoms during the studies of a group of physiotherapy students. Physical activity can play a protective role in the prevention and treatment of mood disorders. The students who regularly engaged in physical activity exhibited better mood, a lower perceived stress level and a higher level of the sense of coherence as compared to the physically inactive students.


Introduction
The existing research indicates that the incidence of depression among students rises as their studies progress [1,2]; in contrast, other publications demonstrate that the symptoms of depression are significantly more severe in first-year students [3]. Nonetheless, this phenomenon primarily affects the students of higher education institutions, majoring in medical fields, including physiotherapy, i.e., those preparing to enter the professions associated with helping other people [4][5][6].
Numerous stress factors, sleep deprivation, an unbalanced diet, the lack of regular physical activity, fatigue, high expectations, both their own and those of the society, an increased sense of responsibility while taking independent decisions and taking charge of their own lives, but primarily the contact with the suffering of other individuals and an insufficient support system increase the risk for the symptoms of depression developing [7,8].
The students majoring in those fields-despite the fact that they acquire the necessary knowledge on mental disorders during their studies-do not consider depression to be a condition that requires therapy [8]. Notably, the majority of those students do not seek help and they receive proper treatment less frequently than the members of the general population who suffer from depression [9]. Additionally, although they are aware of the protective function of physical activity in the prevention and treatment of multiple conditions, they engage in it less frequently [10][11][12][13]. These findings are very alarming due to the nature of the work that those students will perform in the future.
A protective role in the development of emotional disorders is also attributed to the sense of coherence [14]. In accordance with Antonovsky's salutogenic model, this is a key factor for being able to successfully cope with multiple stressors and maintain good health, which is influenced by the processes of growth and development throughout the individual's life based on the experiences they gain [15].
Therefore, it appears advisable (despite the existing, albeit not very extensive research) to regularly monitor the emotional state of the students majoring in medical fields, including physiotherapy, to identify the individuals who require help and determine the factors that accompany emotional disturbances. This is particularly important in the ever-changing world of needs, expectations, and demands that awaits young people who enter adulthood.
Therefore, the aim of the study was to evaluate the emotional state and the level of the sense of coherence in the context of physical activity among physiotherapy students and to investigate how the emotional state of the participating students changed after two years of studying and what factors were associated with the mood disorders in the group of students who were about to finish their education.

Participants and Procedure
The study was carried out between 2016 and 2019 at the Department of Physiotherapy of the University School of Physical Education in Wroclaw among the third-year bachelor's degree students majoring in physiotherapy (initial study-T1), who were subsequently re-evaluated two years later as second-year Master's degree students (final study-T2). The results of the initial study (N = 249) were presented in detail and discussed in an article published in WORK-A Journal of Prevention Assessment & Rehabilitation [13]. For this publication, only those participants who completed both the initial (T1) and the final (T2) questionnaire after two years of study were taken into account during the analysis. Ultimately, the study group consisted of 110 students-79 female and 31 male. All students consented to participate in the study and complete the questionnaires. The students were informed about the purpose of the study and the possibility to withdraw at any stage. The study was carried out in the form of a questionnaire, without any intervention or experiment structure, with the participants' consent and under the ethical and legal supervision of the Department of Physiotherapy of the University School of Physical Education in Wroclaw and the study was conducted in accordance with the Helsinki Declaration.
The characteristics of the study group are presented in Table 1.

Measure Tools
The Beck Depression Inventory (BDI), the Sense of Coherence Questionnaire (SOC-29) and the Perceived Stress Questionnaire (PSQ) were used in the study. Additionally, the students answered other questions, e.g., about their physical activity; financial situation; place of residence; satisfaction with the chosen field of study; future plans after finishing education; friendships; and the need to consult a psychologist.
The BDI is a screening tool used for determining the presence of the symptoms of depression. It is a 21-item inventory consisting of two parts: emotional and somatic. The score of 0-11 points indicates no depression, 12-19-mild depression, 20-25-moderate depression and 26-63-severe depression. The BDI has very high internal consistency-Cronbach's alpha for the entire standardization sample is 0.93 and for patients suffering from depression-0.95 [16].
The SOC-29 comprises 29 questions and is used to evaluate the general level of the sense of coherence and its three aspects: comprehensibility, manageability and meaningfulness. The results are expressed as the sum of points calculated using the key. The score of <117 points indicates a low level, 117-156 points-a moderate level and >156 points-a high level of the sense of coherence. The reliability of the Polish version for the subscales ranges from 0.68 to 0.78 and amounts to 0.92 for the overall result [17].
The PSQ consists of 27 statements. Separate questionnaires for female and male respondents have been created and three dimensions have been specified, i.e., emotional strain, external stress, and internal stress. The total score indicates the general level of stress experienced by the respondent. The higher the score, the greater the sense of stress. The Cronbach's alpha, i.e., the internal consistency coefficient, for the three subscales ranges from 0.69 to 0.81 [18]. Raw results were used in the analysis.

Data Analysis
Descriptive statistics were used to compile the characteristics of the sample group. In the statistical analysis, the Shapiro-Wilk test was used to verify the normality of distribution. Due to the result obtained (normal distribution), the statistical analysis was carried out using parametric tests. The findings were compared between two groups of students using the independent sample t-tests and the analysis of variance (ANOVA) for three groups with at least five cases in a group. The results of the initial study and the final study were compared using the t-test for dependent groups. In the case of the t-test, the Bonferroni correction was applied. The relationship between two pairs of variables was calculated using Pearson's correlation. The statistical tests were verified at the significance level of p < 0.05 and p < 0.025 in the case of t-test results with Bonferroni correction. The calculations were performed using Stastistica 12 StatSoft Poland (StatSoft, Inc., Tulsa, OK, USA).

Results
The mean BDI score in the sample group in the initial study (T1) was 8.1 (±6.2) and in the final study (T2)-9.5 (±7.7). In the initial study, the symptoms of mood disorders were found in 28 (25.5%) participants; after two years (T2), the number of students exhibiting symptoms of depression increased to 34 (31%). The mean PSQ score in T1 was 52.0 (±15.5) and in T2-53.7 (±18.2). The mean SOC-29 score in T1 was 136.6 (±20.1). The majority of the students (73; 66%) demonstrated a moderate level of the sense of coherence; a high level of the sense of coherence was found only in 20 (18%) students. After two years of education, the mean SOC-29 score decreased slightly and amounted to 134.7 (±24.6). After this period, an increase in the number of students with low and high levels of the sense of coherence (31 (28%) and 28 (25.5%), respectively) and a decrease in the number of students with a moderate level of the sense of coherence (51; 46%) were recorded.
A statistically significant deterioration in the students' mood (the BDI scale) was observed in the final study, in particular in the emotional part. On the other hand, no statistically significant difference was recorded between the initial and final results in terms of the perceived stress level of the students (the PSQ scale) and their sense of coherence (SOC-29). These results were not significant after the Bonferroni correction (Table 2). In T1, no statistically significant difference in the mood between female and male participants was observed. In contrast, in T2, the female students were characterized as having worse moods as compared to the male students. Furthermore, significant mood deterioration after two years of education was found in the female group (p = 0.0246). InT1, the mean BDI scores were also statistically significantly higher in the students who declared the willingness to receive psychological help, the students who were not satisfied with the field of study they had chosen and the students who claimed that their studies did not prepare them for work as physiotherapists. After two years (T2), the aforementioned groups of students continued to show significantly worse moods; the statistically significant differences were not recorded only in terms of the preparation for professional work. With the application of Bonferroni correction, statistical significance was observed only in the students who declared the willingness to receive psychological help (in T1and T2) and the students who were not prepared for work as physiotherapists (Table 3). Table 3. Comparison of the initial and final BDI scores between the selected groups of students (Student t-test for independent groups or the ANOVA variance for three groups with at least five cases). In both T1and T2, the mean PSQ score of female participants was statistically significantly higher than that of male participants. On the other hand, no statistically significant changes in the perceived stress level in both groups were recorded after two years. InT1, the mean PSQ scores were also significantly higher in the students who declared the willingness to receive psychological help and the students who claimed that their studies did not prepare them for work as physiotherapists. Additionally, after two years (T2), the mean PSQ score was higher in the students who did not work while studying (Table 4). Male participants were characterized by a statistically significantly higher general sense of coherence as compared to the female participants in both T1and T2. This applies also to the Comprehensibility and Manageability subscales in T1 (p = 0.0337; p = 0.0008) and all three subscales in T2 (p = 0.0128; p = 0.0136; p = 0.0218). No statistically significant change in SOC-29 scores was recorded after two years. The other data is presented in Table 5. InT1, lower BDI scores were observed in the group of students who declared that they regularly engaged in physical activity. InT2, the same group continued to show statistically significantly lower BDI scores (in particular in somatic parts), significantly lower PSQ scores (in particular in terms of the emotional strain) and higher SOC-29 scores (in particular in the Meaningfulness subscale) ( Table 6). A statistically significant positive correlation was shown between BDI (in T2) and PSQ (in T2), PSQ (in T1) and BDI (in T2), while a statistically significant negative correlation was observed between BDI (in T2) and SOC-29 (in T2), PSQ (in T2) and SOC-29 (in T2), SOC-29 (in T1) and BDI (in T2).

Discussion
The preliminary findings published in WORK-A Journal of Prevention Assessment & Rehabilitation (2020) encouraged the authors to continue their research and monitor the emotional state of the students who continued their education during the Master's degree programme in physiotherapy. The analysis of the results revealed an alarming upward trend in the incidence of mood disorders in this group of students. Despite the fact that the mean BDI scores were not indicative of any symptoms of depression, the percentage of individuals who required psychological/ psychiatric support increased from 25% to 31%. An increase in the number of symptoms of depression can be observed in the studies carried out on physiotherapy students in 2008 and 2014 [5,19,20].
On the other hand, a continuing trend was observed, i.e., despite significant mood deterioration in the evaluated participants, their perceived stress level was low and their level of the sense of coherence was moderate. This may result from effective stress-coping strategies, which have not been studied and should perhaps be included in future research.
After two years of education, female physiotherapy students continued to exhibit significantly worse mood, a higher perceived stress level and a lower level of the sense of coherence as compared to the male students. These findings are not surprising for the authors and are consistent with the results obtained by other authors [21][22][23]. It should also be noted that regular physical activity was reported by 65% of female students and 74% of male students at that time point. It demonstrates that in the sample group, male students engaged in physical activity more often. Some numerous factors and theories confirm the differences in the incidence of emotional disorders between genders, from biological factors (e.g., hormonal imbalance), through psychological and social factors, to stress-coping strategies.
However, it is concerning that these results clearly indicate that the mood in this group of female students deteriorates during subsequent years of education.
Taking into consideration other factors covered by the study, it can be concluded that upon finishing their education, the participants who declared the willingness to receive psychological help and expressed dissatisfaction with the field of study they had chosen, the participants who did not work, as well as the participants who claimed that their studies did not prepare them for work as physiotherapists were characterized by worse mood, a higher perceived stress level and a lower level of the sense of coherence. These factors were also mentioned in the initial study carried out on a larger group of students (N = 249), which identified the stress level, the emotional state, and the sense of coherence [13], as well as in the research conducted by other authors [5,22,24].
Declaring the willingness to get psychological help is not equivalent to actually seeking and receiving it. We do not know how many students actually received such help over two years. However, we can presume that as they continued their education at the Department of Physiotherapy, the students' knowledge of stress and stress-coping strategies increased, which may explain the lower results in this group inT2. Unfortunately, the results also indicate that the level of stress increased in the group of students who did not declare the willingness to receive psychological help, which confirms the trend described in the literature and observed among the students majoring in medical fields, i.e., that seeking help would suggest that their own coping abilities are inadequate [8].
Notably, a multidirectional relationship was revealed, confirmed by the analysis of the correlation between mood disorders, stress, and the sense of coherence. In both the initial study and the final study, carried out after two years of studying, mood disorders were accompanied by a higher perceived stress level and a lower level of the sense of coherence. It was also recorded that a higher perceived stress level and a low level of the sense of coherence during the third year of higher education is correlated with the deterioration of mood after further two years of studying. The relationship between these three parameters has been thoroughly studied [13,25,26]; it is crucial from the perspective of the students themselves and of the preventive measures that should be implemented among the individuals who are at the highest risk of mood deterioration and who decide to continue their education to become physiotherapists.
The analysis of the findings regarding the students' physical activity once again demonstrates its protective role [10,27]. The mechanism of the effect of exercise on the mood is particularly important; it is based on two types of theories: psychological ("faith in oneself" and the concept of distractors) and biological (e.g., the beta-endorphin theory and the thermogenic theory) [28][29][30]. The students who regularly engaged in recreational physical activity showed considerably better mood and fewer symptoms of depression, as well as a lower perceived stress level (in particular in terms of the emotional strain). They also achieved higher scores on the sense of coherence scale (in particular in the Meaningfulness subscale). It should be noted that these findings pertained to the students both at the first measuring point (during their third year) and after further two years of education. Similar results were obtained by other authors [5,22,31]. Therefore, it is worthwhile to promote regular physical activity among the students of all years, particularly since-as reported by researchers-on average, the first symptoms of depression appear between the ages of 20 and 30 [13]. It is a unique time in a young person's life-they have to choose their path, often both personal and professional, and confront both themselves and the burdens they notice in the outside, social world.
It is particularly crucial in physiotherapy students because they are expected to serve as models for their patients in the future. The more benefits they derive from regularly engaging in physical activity themselves and the more they are aware of the role it plays in the preservation of good mental health, the more credible they will appear to their patients and the more able they will be to convince the patients that this is a key factor in their recovery.
The sense of coherence is one of the crucial elements that make up the humans' ability to cope with day-to-day life, also in the areas related to professional activity. This is also confirmed by the findings of the questionnaires completed by the students. The students who had a job were characterized by the highest level of the sense of coherence compared to the unemployed students or the students who worked from time to time. These differences are particularly visible in Table 2, i.e., among the students who were about to finish their education. A high level of the sense of coherence may influence not only the engagement in health-oriented activities, but also the effectiveness on the labour market and it may ultimately translate into professional success, i.e., finding employment [32].
As the findings discussed above clearly show, it is necessary to monitor the emotional state of the students at each stage of their education and to develop or modify the measures undertaken by higher education institutions in order to provide the students with more effective support, perhaps off-campus to avoid stigmatization [8].

Limitations
The study presented in this article has several limitations. First and foremost, the studies were based on screening tests and did not involve reaching a medical diagnosis. The sample group consisted of the students of one faculty; therefore, it cannot be regarded as representative. On the other hand, the findings are sufficiently interesting to justify the continuation of the studies with the participation of students of all years. In future research, incorporating the measurement of stress biomarkers and the analysis of the stress-coping strategies adopted by the students should be considered.

Conclusions
The results presented in this article indicate increase of depressive symptoms during the studies in the group of physiotherapy students.
The factors associated with worse mood, a higher perceived stress level and a lower level of the sense of coherence in the study group after two years of studying included: the female gender, the need to receive psychological support, dissatisfaction with the chosen field of study, unemployment, and the sense of not being prepared for work as physiotherapists.
Physical activity can play a protective role in the prevention and treatment of mood disorders. The students who regularly engaged in physical activity exhibited better mood, a lower perceived stress level, and a higher level of coherence than the physically inactive students.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Conflicts of Interest:
The authors declare no conflict of interest.