Article

Journal of Adult and Continuing

Education
Moderating effects of emotion 2022, Vol. 28(2) 397–413
© The Author(s) 2022
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sagepub.com/journals-permissions
DOI: 10.1177/14779714221099609
resilience on students’ mental journals.sagepub.com/home/adu

health and well-being during the

COVID-19 pandemic

Katrina A Rufino , Stephanie J Babb and Ruth M Johnson

The University of Houston-Downtown, Houston, TX, USA

Abstract
This study examined whether emotion regulation difficulties and resilience in college
students moderated changes in mental health over the course of the COVID-19 pan-
demic. Participants (N = 321) completed surveys assessing mental health, in addition to
levels of emotion dysregulation, and resilience during the pandemic, then utilized an
anchoring prompt to recall mental health experiences before the pandemic. Correlations
revealed participants with higher levels of emotion dysregulation also reported lower
levels of resilience. Analyses using the SPSS Macro MEMORE (Montoya, 2019) revealed
participants with higher levels of emotion regulation difficulties had greater increases in
depression and insomnia, and greater decreases in well-being over the course of the
COVID-19 pandemic, while participants with lower levels of resilience had greater in-
creases in depression, anxiety, and insomnia over the course of the pandemic. These
results highlight the importance of additional support services and mental health training
at universities to meet college students’ immediate and long-term emotional needs
stemming from the pandemic.

Keywords
Emotion dysregulation, resilience, mental health, well-being, COVID-19 pandemic

Corresponding author:
Katrina A Rufino, Department of Social Sciences, University of Houston-Downtown, 1 Main Street, Houston,
TX, 77002, USA.
Email: rufinok@uhd.edu
398 Journal of Adult and Continuing Education 28(2)

Before the onset of the COVID-19 pandemic, college students were already a population
vulnerable to various mental health issues (McFarland et al., 2019). Anxiety and de-
pression were common concerns that negatively affected students’ personal lives and
academic goals (Hart Abney et al., 2019). Sleep disturbances and insomnia were also
common in college students (Schlarb et al., 2017), and were associated with low GPA, a
low sense of well-being, and inadequate academic performance such as dropping a course
(Fischer et al., 2020; Hartmann & Prichard, 2018; Pagel & Kwiatkowski, 2010).
The stress and social isolation induced by the COVID-19 pandemic have led to an
increase in levels of sleep disturbances and insomnia (Babb et al., 2022; Lin et al., 2020),
as well as rising rates of depression, anxiety, and stress (Babb et al., 2022; Eysenbach
et al., 2020; Kibbey et al., 2021). Social distancing and online classes have resulted in less
social and emotional support for students from family, friends, classmates, and instructors
(Elmer et al., 2020). As the pandemic stretches indefinitely into the future, these effects
will continue to exacerbate mental health struggles, and will result in more students
seeking mental health services to cope with their new reality.
Students with good mental health typically exhibit a state of well-being, which in-
cludes the ability to recognize their own strengths and limitations, cope with normal life
stress, and maintain their social, academic, and personal roles and obligations. In order to
cope with the excessive negative experiences associated with the pandemic, students must
employ strategies to appropriately manage and respond to stress and negative emotions.
Emotion regulation refers to reducing emotional arousal and controlling the emotional
experience with the use of both conscious and unconscious strategies to handle stressful
situations and adapt to the demands of our environment (Gratz & Roemer, 2004). Some of
these strategies are healthy, such as engaging in exercise, talking with a friend, or paying
attention to negative thoughts and dealing with them accordingly. However, the inability
to use these types of healthy strategies can result in emotion dysregulation, whereby an
individual engages in unhealthy strategies, such as substance abuse, self-harm, with-
drawal from difficult situations, and aggression, to deal with overwhelming and intense
negative emotions (Duggan et al., 2015; Lafrance Robinson et al., 2013; Polk & Liss,
2009). Emotion dysregulation can lead to impulsivity, and prohibit goal-directed be-
havior, acceptance of emotions, emotional understanding, and effective emotion regu-
lation strategies (Gratz & Roemer, 2004).
The ability to appropriately regulate emotions is a very important characteristic for
college students, as emotion dysregulation is correlated with negative behaviors such as
internet addiction, binge drinking, substance use, social impairment, depression, eating
disorders, self-harm, test anxiety, and gambling (Bo et al., 2016; Davis et al., 2008;
Flannery et al., 2014; Gratz et al., 2002; Hormes et al., 2014; Kassel et al., 2000; Torrado
et al., 2020; Tsai et al., 2020). It is expected that, when facing a global pandemic, most
people will feel a lack of control over their own lives, and healthy coping strategies will be
essential. College students had to move out of campus housing, become online students,
and isolate themselves from peers, family, and friends, for an indefinite period. In many
instances, they had to take on new or more complicated roles in their families and jobs.
Previous findings tell us that, when faced with stressful events such as natural disasters
and outbreaks of infectious disease, lack of control leads to people experiencing feelings
Rufino et al. 399

of sadness, fear, anxiety, and anger, which can affect their long-term well-being, or current
state of being healthy, happy, and comfortable (Bai et al., 2004; Bults et al., 2011; Lau
et al., 2008; Restubog et al., 2020; Thompson et al., 2017). Studies have already indicated
increased levels of stress, anxiety, depression, and insomnia, and lowered well-being and
sleep quality in college students due to the current pandemic (Babb et al., 2022); therefore,
it is expected that an increased proportion of students will display emotion dysregulation
behaviors due to the overwhelming effects of COVID-19.
Emotional resilience refers to an individual’s capacity to cope with stressful situations
and maintain constancy in their lives, or the ability to “bounce back” (Martin et al., 2015;
Mestre et al., 2017; Waugh et al., 2008). Therefore, emotion regulation is the core of
emotional resilience; adults with higher levels of emotion dysregulation typically have
lower levels of resilience. Because resilience helps college students cope with everyday
academic and personal life stresses in a healthy way, students who lack resilience are more
likely to develop depression, anxiety, or other mood disorders (Rogers, 2013).
High levels of resilience are also positively correlated with high levels of cognitive
flexibility and emotion regulation; positive emotions can help individuals more effec-
tively deal with stress and adversity (Arici-Ozan et al., 2019; Gloria et al., 2013; Ong
et al., 2006). Previous studies have defined emotional intelligence as the ability to problem
solve with and about emotions, by perceiving emotions, using emotions to facilitate
thought, understanding emotions, and regulating own and other’s emotions (Mayer &
Salovey, 1997; Mayer et al., 2016). Artuch-Garde et al. (2017) found that the ability to
self-regulate behavior is correlated with high levels of resilience in adolescents. Resil-
ience is also positively correlated with problem-focused coping strategies in college
students (de la Fuente et al., 2017; Mestre et al., 2017), as well as with emotion-focused
coping strategies (Lee et al., 2017).
Resilience can also be an adaptive, dynamic process, by which an individual develops
strategies to deal with ongoing challenges and stress (Mestre et al., 2017). Learning
healthy emotion regulation strategies can increase resilience in the face of adversity
(Artuch-Garde et al., 2017; Tugade & Fredrickson, 2004; Ong et al., 2006), and increased
resilience can lead to better problem-focused coping strategies (Lee et al., 2017).
Resilience will be an important predictor of how well college students mentally cope
with the effects of the pandemic (Caston & Mauss, 2011). Individuals with emotion
dysregulation are less likely to display resilience, and therefore more likely to exhibit poor
mental coping strategies. Previous studies have found that resilience is negatively cor-
related with anxiety and depression in college students, and positively correlated with
well-being (Hartley, 2011; 2012; Wu et al., 2020). Resilience is also negatively correlated
with insomnia, wherein individuals with lower levels of resilience experience higher
levels of sleep disturbances and insomnia (Cheng et al., 2020; Palagini et al., 2018).
During the COVID-19 pandemic, when faced with the threat of the virus and the un-
certainty regarding a vaccine or cure, increased levels of resilience correlate with lower
levels of anxiety (Kimhi et al., 2020). Resilience, as well as adaptive coping strategies and
social support, can also moderate acute stress disorder when faced with increased life
stressors associated with the pandemic (Ye et al., 2020). In addition, Barzilay et al. (2020)
found that adults with higher resilience scores had fewer worries about COVID-19 and
400 Journal of Adult and Continuing Education 28(2)

lower anxiety. College students with a high level of resilience should better understand
and attend to their negative emotions regarding COVID-19, and employ healthy strategies
for dealing with those emotions.
The purpose of the present study was to determine if difficulties with emotion reg-
ulation and resilience moderate the change in anxiety, depression, well-being, and in-
somnia in college students over the course of the COVID-19 pandemic. It is hypothesized
that (1) college students who report higher levels of emotion dysregulation will also report
lower levels of resilience, (2) emotion regulation difficulties will exacerbate the change in
key study variables, and (3) resilience will mitigate the change in mental health over the
course of the pandemic. More specifically, students reporting higher levels of emotion
dysregulation will also experience greater increases in levels of depression, anxiety,
insomnia, and greater decreases in well-being after the onset of the pandemic. Conversely,
participants with higher levels of resilience will experience smaller increases in levels of
depression, anxiety, insomnia, and less of a decrease in their well-being after the onset of
the pandemic.

Method
Participants
Participants (N = 321) in the present study were recruited from undergraduate psychology
classes at a large, urban, non-residential university in the southern United States. The
participants ranged in age from 18 to 62 (M = 25.88, SD = 8.29) and were predominantly
female (77.7%; n = 249) with 22.4% male (n = 72) and a majority identified as Latinx
(53.0%, n = 170), followed by Black/African-American (23.1%, n = 74), and White
(13.1%, n = 42). A large majority of participants identified as single (80.1%, n = 257),
followed by married (14.6%, n = 47), and divorced (4.4%, n = 14). Participants were split
by academic level with the most participants reporting their academic level as senior
standing (37.4%, n = 120), followed by junior (29.0%, n = 93), sophomore (16.8%, n =
54), freshman (15.6%, n = 50), and finally graduate students (1.2%, n = 4).

Measures
Depression. The Patient Health Questionnaire (PHQ-9; Spitzer et al., 1999) is a 9-item
self-report measure assessing the presence of depressive symptoms in the prior 2 weeks,
via four Likert-type answer choices ranging from “not at all” to “nearly every day.” The
PHQ-9 includes items that assess sleep, appetite, anhedonia, and self-harm and is
considered a reliable and valid measure of depressive symptoms (Löwe et al., 2004).
Cronbach’s alpha for the present sample was .91.

Anxiety. The General Anxiety Disorder Scale (GAD-7; Spitzer et al., 2006) is a 7-item
self-report measure evaluating anxiety symptoms and severity over the last 2 weeks. Items
on the GAD-7 include “Not being able to stop or control worrying,” “Trouble relaxing,”
and “Feeling afraid as if something awful might happen.” Participants rated these items on
Rufino et al. 401

a Likert-type scale ranging from “Not at all” to “Nearly every day.” Research has shown
the GAD-7 as a measure of anxiety is both valid and reliable (Kroenke et al., 2010; Löwe
et al., 2008). Cronbach’s alpha for the present sample was .93.

Insomnia. The Insomnia Severity Index (ISI; Bastien et al., 2001) is a 7-item self-report
measure that assesses insomnia symptoms over the last 2 weeks. The first three items rate
difficulty falling asleep, staying asleep, and waking up too early on a four-point scale.
Each subsequent item is scored on a 0–4 scale, with total scores ranging from 0–25. A
sample item is “To what extent do you consider your sleep problem to INTERFERE with
your daily functioning?” with options ranging from 0 for “Not at all Interfering” to 4 for
“Very much Interfering.” The ISI has been shown to have adequate test-retest reliability
over 3 months and concurrent validity with sleep diaries and polysomnography (Bastien
et al., 2001; Savard et al., 2005). Cronbach’s alpha in the present sample was .89.

Well-being. The WHO-5 Well-Being Index (WHO-5; Topp et al., 2015) is a five item self-
report instrument assessing positive quality of life, in a deliberate attempt to avoid
symptom-related terminology. Sample items include “I have felt cheerful and in good
spirits” and “My daily life has been filled with things that interest me.” Item statements are
rated on a 6-point Likert-type scale with answer choices ranging from “At no time” to “All
of the time.” Greater scores indicate greater well-being. Prior research has found support
for the psychometric properties of the WHO-5 (Bech et al., 2003). Cronbach’s alpha in the
present sample was .93.

Emotion dysregulation. The Difficulties in Emotion Regulation Scale (DERS; Gratz &
Roemer, 2004) is a self-report measure assessing emotion regulation difficulties. It
contains 36 items, and the individual rates how often each statement applies to them on a
5-point Likert-type scale ranging from “Almost never” to “Almost always.” Each item
loads onto one of six factors: Nonacceptance of Emotional Responses, Difficulties in
Engaging in Goal-Directed Behavior, Impulse Control, Lack of Emotional, Limited
Access to Emotion Regulation Strategies, and Lack of Emotional Clarity (Gratz &
Roemer, 2004). The instrument developers report high internal consistency and strong
predictive validity (Gratz & Roemer, 2004). Cronbach’s alpha for the present sample was
.95.

Resilience. The Multidimensional Individual and Interpersonal Resilience Measure

(MIIRM; Martin et al., 2015) is a 22-item self-report measure designed to assess eight
factors (Self Efficacy, Access to Support Network, Optimism, Perceived Economic and
Social Resources, Spirituality and Religiosity, Relational Accord, Emotional Expression
and Communication, Emotional Regulation) in adults. A sample item includes, “I tend to
bounce back after illness or hardship,” with options ranging from 0 for Not True At All to 4
for True Nearly All the Time with greater scores indicative of great resilience. Evidence is
strong for validity and reliability in the MIIRM. Cronbach’s alpha for the present sample
was .77.
402 Journal of Adult and Continuing Education 28(2)

Procedure
Students were recruited for participation in their undergraduate psychology courses using
the Sona Systems online experiment management system. After reviewing the details of
the study, participants were directed to a Qualtrics link to complete the consent form and
the questionnaires. This study was approved by the University’s Institutional Review
Board. Participation in this study was voluntary, and students were offered compensation
of extra credit or completion credit of a research requirement in a psychology course.
After providing consent, participants completed a series of demographic questions,
followed by questionnaires pertaining to their current state (summer or fall 2020). Next,
following an anchoring prompt, which included major events that took place in the fall of
2019, participants were then asked to complete the same measures again pertaining to
their recalled experiences in the fall of 2019. At the completion of the study, students were
provided with contact information for support services that included both local and
national hotlines, as well as information for free counseling services available on campus.

Data analysis
All analyses were calculated with SPSS Version 26 and the SPSS Macro MEMORE
(Montoya, 2019). MEMORE allows for moderation analysis with the use of two-instance
repeated measures. As such, in the present study, analyses were used to determine if
difficulties in emotion regulation moderate participant scores on key study variables over
the course of the COVID-19 pandemic. Similar analyses were conducted to determine if
resilience moderates participant scores on key study variables over the course of the
COVID-19 pandemic. This allowed us to examine the interaction between emotion
regulation and resilience, respectively, at low, mean, and high levels across time. Ad-
ditionally, Pearson correlations were conducted between all study variables.

Results
Examining the first hypothesis, results revealed a significant negative correlation between
emotion dysregulation and resilience (r = .57, p < .001), suggesting participants high in
resilience were low in emotion regulation difficulties (see Table 1 for the remainder of the
correlations). Results examining hypothesis two, using emotion regulation difficulties as a
moderator of the change in depression scores over the course of the COVID-19 pandemic,
revealed that emotion regulation difficulties (b = .06, p < .001) were significantly related
to change in depression scores (R2 = .06, F(1,318) = 21.82, p < .001). The interaction
between emotion regulation difficulties and change in depression scores was significant at
low (b = 2.38, p < .001), mean (b = 3.96, p < .001), and high (b = 5.54, p < .001) levels of
emotion regulation difficulties such that participants with higher levels of difficulties with
emotion regulation had greater increases in depression over the course of the COVID-19
pandemic (see Figure 1).
A similar analysis examining emotion regulation difficulties as a moderator of the
change in well-being scores over the course of the pandemic revealed that emotion
Rufino et al. 403

Table 1. Pearson correlations of key study variables from before the onset of the COVID-19
pandemic.

1 2 3 4 5 6

1. Resilience —
2. Emotion dysregulation .57* —
3. Depression .36* .46* —
4. Anxiety .31* .43* .79* —
5. Well-Being .39* .34* .52* .47*
6. Insomnia .20* .25* .62* .58* .48* —

Note. * = p < .001. Resilience = MIIRM, Emotion Dysregulation = DERS, Depression = PHQ-9, Anxiety = GAD-7,
Well-Being = WHO-5, and Insomnia = ISI.

Figure 1. Change in depression moderated by emotion dysregulation.

regulation difficulties (b = .04, p = .009) were significantly related to change in well-

being scores (R2 = .02, F(1,315) = 7.00, p = .009). The interaction between emotion
regulation difficulties and change in well-being scores was significant at low (b = 3.65, p
< .001), mean (b = 4.71, p < .001), and high (b = 5.77, p < .001) levels of emotion
regulation difficulties such that participants with higher levels of emotion dysregulation
had greater decreases in well-being over the course of the pandemic (see Figure 2).
The same analysis was also conducted utilizing emotion regulation difficulties as a
moderator of the change in insomnia over the course of the pandemic which revealed
that emotion regulation difficulties (b = .06, p < .001) were significantly related to
change in insomnia scores (R2 = .05, F(1,315) = 15.99, p < .001). The interaction
between emotion regulation difficulties and change in insomnia scores was significant at
404 Journal of Adult and Continuing Education 28(2)

Figure 2. Change in well-being moderated by emotion dysregulation.

low (b = 2.00, p < .001), mean (b = 3.49, p < .001), and high (b = 4.97, p < .001) levels of
emotion regulation difficulties such that participants with greater difficulties with
emotion regulation had greater increases in insomnia scores from before to after the
onset of the pandemic (see Figure 3). Finally, the analysis was calculated utilizing
emotion regulation difficulties as a moderator of change in anxiety scores; however, the
relationship was not significant (R2 = .01, F(1,319) = 3.72, p = .055).
To examine hypothesis three, the same analyses were conducted using resilience as a
moderator. Examining change in depression scores over the course of the pandemic
revealed that resilience (b = .13, p < .001) was significantly related to change in
depression scores (R2 = .05, F(1,318) = 18.26, p < .001). The interaction between re-
silience and change in depression scores was significant at low (b = 5.41, p < .001), mean
(b = 3.96, p < .001), and high (b = 2.51, p < .001) levels of resilience such that participants
with lower levels of resilience had greater increases in depression scores over the course
of the pandemic (see Figure 4). When examining change in anxiety scores over the course
of the pandemic, results revealed that resilience (b = .07, p = .040) was significantly
related to change in anxiety scores (R2 = .01, F(1,319) = 4.28, p = .040). The interaction
between resilience and change in anxiety scores was significant at low (b = 4.47, p < .001),
mean (b = 3.75, p < .001), and high (b = 3.04, p < .001) levels of resilience such that
participants with lower levels of resilience had greater increases in anxiety scores over the
course of the pandemic (see Figure 5).
The same analysis was also conducted utilizing resilience as a moderator of the change
in insomnia over the course of the pandemic which revealed that resilience (b = .13, p <
.001) was significantly related to change in insomnia scores (R2 = .05, F(1,315) = 15.18, p
< .001). The interaction between resilience and change in insomnia scores was significant
at low (b = 4.93, p < .001), mean (b = 3.49, p < .001), and high (b = 2.04, p < .001) levels
Rufino et al. 405

Figure 3. Change in insomnia moderated by emotion dysregulation.

Figure 4. Change in depression moderated by resilience.

of resilience such that participants with lower resilience had greater increases in insomnia
scores over the course of the pandemic (see Figure 6). Finally, the analysis was calculated
utilizing resilience as a moderator of change in well-being scores; however, the rela-
tionship was not significant (R2 = .01, F(1,315) = 3.80, p = .052).
406 Journal of Adult and Continuing Education 28(2)

Figure 5. Change in anxiety moderated by resilience.

Figure 6. Change in insomnia moderated by resilience.

Discussion
Results of the present study revealed that students reported both depression and insomnia
increased, and well-being decreased, after the onset of the pandemic, particularly in
students with high levels of emotion dysregulation, in support of hypothesis two. There
was no correlation between emotion regulation and anxiety. However, as expected from
Rufino et al. 407

previous findings, the results showed a negative correlation between resilience and
emotion dysregulation in college students, in that students who reported a lower level of
resilience were more likely to exhibit emotion dysregulation in support of hypothesis one
(Arici-Ozan et al., 2019; Gloria et al., 2013; Ong et al., 2006; Tugade & Fredrickson,
2004). Furthermore, in support of hypothesis three, resilience moderated increases in
depression (Hartley, 2011, 2012; Nrugham et al., 2010; Wu et al., 2020), anxiety (Barzilay
et al., 2020; Kimhi et al., 2020) and insomnia (Cheng et al., 2020; Palagini et al., 2018)
associated with the COVID-19 pandemic. This study found no relationship between
resilience and well-being.
These findings are significant, in that they point to an increasing need to offer ad-
ditional mental health services to meet students’ rising levels of depression, anxiety, and
insomnia resulting from the COVID-19 pandemic. Before the pandemic, anxiety and
depression were common causes for concern in college students (McFarland et al., 2019),
with students reporting that their personal and academic lives were affected by mental
health struggles (Hart Abney et al., 2019). Studies have demonstrated that students are
reporting increased levels of anxiety, depression, and sleep disturbances due to worries
regarding the pandemic (Eysenbach et al., 2020). Because the results of the study found
that students with more emotion regulation difficulties reported more mental health
problems over the course of the pandemic, it is important that universities ensure their
support services for students teach emotion regulation strategies in order to cope with
long-term emotional effects from the pandemic. This can include mindfulness, distress
tolerance, and even relaxation. Past research has found correlations between outbreaks of
disease and elevated levels of depression (Bai et al., 2004) and anxiety (Thompson et al.,
2017), and lower levels of well-being (Lau et al., 2008). It will be imperative for uni-
versities to meet the mental health needs of students both during and after the pandemic, in
order to help students maintain their GPA and enrollment hours, juggle personal, work,
and academic demands, and prepare for their future careers. There is a concern that
students with low resilience and high emotion dysregulation may cope using unhealthy
behaviors such as disordered eating, self-harm, and substance abuse (Gratz et al., 2002;
Kassel et al., 2000). One strategy may be to first identify these students, and subsequently
increase their resilience through teaching them to regulate their negative emotions and
practice mindfulness in order to be successful in this current environment (Finkelstein-
Fox et al., 2018; MacDonald & Baxter, 2017). Additionally, university counseling
services should focus on teaching emotion regulation strategies and coping skills to
ensure students have the effective tools necessary to be academically successful while
simultaneously dealing with the mental health effects of the COVID-19 pandemic.
One limitation of this study is that the data was collected at an urban, commuter
campus in the southern United States; therefore, although this data provides a good look at
how students are affected by the ongoing pandemic, and how resilience can help moderate
these effects, the findings may not be generalizable to students enrolled in traditional, non-
commuter campuses, or students in other countries. Additionally, students in the present
study were often non-traditional, such that they were older, and typically had family and
work responsibilities outside of school which could influence the impact of the pandemic
on their mental health. Future studies should examine emotion regulation, mental health,
408 Journal of Adult and Continuing Education 28(2)

and resilience in students at traditional, residential campuses, as well as at universities

outside the United States to examine the more global impact of the pandemic on mental
health.
In addition, students were asked on the survey to retroactively analyze their pre-
COVID/Fall 2019 rates of anxiety, depression, well-being, and insomnia. Due to the
sudden onset of the pandemic, there was no baseline rate of these issues, so the
methodology was not ideal, but necessary. This study also would have benefited from
surveys regarding pre-COVID and post-onset stress levels. In the future, the authors plan
to investigate further short-term effects of the pandemic, as well as long-term effects such
as how students’ grades, retention, attrition, graduation, and career goals were affected by
their increased levels of depression, anxiety, and insomnia, and decreased levels of well-
being. Future research should also determine how to best increase resilience in students,
and what other services students need from their university. It is also possible that there
were positive consequences from the pandemic, such as the ability to spend more time
with family, that were not highlighted in this study, and therefore their correlation with
mental health and well-being could not be examined.
In conclusion, this study allowed for a substantial examination of the effects of
COVID-19 on college students. It is not surprising that anxiety, depression, and insomnia
have increased due to the COVID-19 pandemic, and that feelings of well-being decreased.
These results are consistent with previous studies that show students with better emotion
regulation will experience fewer mental health issues, and that resilience is positively
correlated with emotion regulation, and can help moderate mental health problems. These
findings suggest that, despite facing an unprecedented world event with long-reaching
health, social, educational, and financial consequences, college students should be able to
cope with stressful life events if they have the proper tools. Institutions of higher ed-
ucation should be prepared to increase availability to support services for students, in
particular mental health counseling, and focus on utilizing programs designed to increase
resilience and coping skills in adults.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/
or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this
article.

ORCID iD
Katrina A Rufino  https://orcid.org/0000-0002-8268-7285
Rufino et al. 409

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