Implementation and Evaluation of an Internet-Based Stress Management Program for Health Students in the Sfax Region

This randomized controlled trial aims to assess the effectiveness of an internet-based stress management program tailored for healthcare students in Sfax, Tunisia. The intervention is an adaptation of the validated French program "Je gère mon stress," redesigned to fit the local sociocultural context.

The study targets healthcare students aged 18 and above, from various disciplines (nursing, physiotherapy, midwifery, anesthesia, etc.), regardless of their baseline perceived stress levels.

Participants in the intervention group will receive access to an 8-week structured online program composed of:

Weekly psychoeducational video capsules (covering stress mechanisms, coping strategies, relaxation techniques, etc.), Guided breathing and relaxation exercises, Simple cognitive-behavioral tools, Time management and lifestyle advice.

All participants will be assessed at baseline (pre-intervention) and post-intervention using three validated instruments:

PSS-10 (Perceived Stress Scale) to evaluate perceived stress, HADS (Hospital Anxiety and Depression Scale) to assess symptoms of anxiety and depression, PSQI (Pittsburgh Sleep Quality Index) to measure sleep quality. A control group will not receive any intervention during the 8-week period but will be offered the program after the study ends (waiting list design). This design allows a fair comparison between groups and ensures ethical access to the intervention.

The program is fully accessible online via a secure platform and requires no in-person attendance. Participants will receive weekly reminders to complete the sessions and questionnaires.

The main outcome is the change in perceived stress levels. Secondary outcomes include changes in anxiety, depression, and sleep quality.

This study contributes to addressing the high psychological burden observed in healthcare students in Tunisia and promotes the use of digital tools for mental health support in academic settings.

• Online Stress Management Program (Behavioral): This is an online pilot stress management program tailored for health students, combining cognitive-behavioral therapy and guided mindfulness meditation. Over eight sessions, participants engage with interactive psychoeducation modules, videos, and practical exercises to understand stress and develop coping strategies. The sessions cover stress awareness, mindfulness meditation (basic and advanced), breathing techniques, time management using the Eisenhower matrix, and cognitive-behavioral methods to foster positive thinking and problem-solving. The final session helps participants create a personalized action plan to integrate learned skills into daily life. Throughout the program, a support group encourages interaction and provides ongoing guidance to enhance well-being and stress management.

Primary outcomes

• Perceived Stress Level in Health Students [At baseline (week 0), at the end of the program (week 8), one month post-intervention (week 12), and six months post-intervention (approximately week 34)]: This measure assesses participants' perceived stress intensity before and after the intervention using a validated tool such as the Perceived Stress Scale (PSS). It quantifies changes in stress management and evaluates the program's impact on students' psychological well-being. Follow-up assessments were conducted one month and six months after the program ends to evaluate the durability of treatment effects.

Secondary outcomes

• Anxiety and Depression Levels (HADS) and Sleep Quality (Pittsburgh Sleep Quality Index) [At baseline (week 0), at the end of the program (week 8), one month post-intervention (week 12), and six months post-intervention (approximately week 34)]: This measure assesses anxiety and depression symptoms using the Hospital Anxiety and Depression Scale (HADS) and evaluates sleep quality through the Pittsburgh Sleep Quality Index (PSQI). These validated tools will track changes in participants' anxiety, depression, and sleep disturbances before and after the intervention. A long-term follow-up assessment was added six months post-intervention to evaluate the durability of these effects.

Sex: All, ages: 18 Years to any, accepts healthy volunteers

Inclusion Criteria:

* The target population includes all students enrolled in the third year at the Higher Institute of Nursing Sciences (ISSIS) and the Higher School of Health Sciences and Techniques (ESSTSS) for the 2025-2026 academic year.
* Own a smartphone, tablet, or computer.
* Have internet access.
* Have an email address.
* Be willing to be randomized.
* Have given informed consent to participate in the study.
* Be available and committed to completing the entire online intervention program and participating in all evaluations.

Exclusion Criteria:

* Current enrollment in another stress management program;
* History of chronic psychiatric illness;
* Current use of anxiolytic or psychotropic medication.

• Study Protocol (PDF, 2026-06-24)

• Rim Masmoudi, Professor in Medicine, Study director, University of Sfax
• Jihen Jdidi, Professor in Medicine, Study director, University of Sfax