Japanese youth athletes’ mental health and psychological resilience during the COVID-19 pandemic
A cross-sectional study
Abstract
Abstract:Objectives: This study aimed to analyze Japanese youth athletes’ mental health and resilience during the COVID-19 pandemic, as well as the potential correlations between their demographic factors and mental health outcomes. Methods: Participants were recruited from a single high school with a student population encompassing national-level competitors (NCs), local-level competitors (LCs), and general students (i.e., others; OTs), aiming to reduce the impact of differences in environmental conditions affecting pandemic-related stress. In March 2021, the students completed an anonymous online survey comprising questions on demographics and COVID-19, as well as the following scales: Kessler 6 (K6), Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), and the Resilience Scale. Differences and correlations among these groups’ scores were analyzed while controlling for covariates. Results: Of 1,022 students (51.3% girls), 22.3% were NCs, 38.6% were LCs, and 39.0% were OTs. NCs reported significantly lower scores on the K6, PHQ-9, and GAD-7, as well as significantly higher resilience scores, compared with LCs and OTs. Resilience scores had a significantly negative correlation with the K6, PHQ-9, and GAD-7 scores. Female gender, participation in cultural clubs, and indoor sports were factors associated with scores above the cut-off on each scale. COVID-19 testing, history of illness, and family history were not associated with any of the psychological evaluation measures. Conclusion: Based on responses to the self-reported questionnaires, NCs appear to have better mental health than their peers, while resilience has a potential association with improved mental health during the COVID-19 pandemic.
Introduction
The COVID-19 pandemic has severely impacted the physical and mental well-being of people worldwide [1]. In Japan, following the confirmation of the initial COVID-19 case on January 15, 2020, the virus spread rapidly. This led to the closure of schools in March and a government-declared public health emergency in April, as well as the issuing of stay-at-home and social distancing orders. Such a public health response to the pandemic has disrupted individuals’ social lives worldwide, while physical isolation may result in elevated stress, depression, anxiety, and loneliness [2]. Adolescents, who are at a life stage of heightened sensitivity to social stimulation and need for peer interaction, may be particularly affected by the deprivation of social needs [3]. In fact, some studies have reported a worsening in mental health in this age group due to the COVID-19 pandemic [4, 5, 6].
Within this challenging context, young athletes experience unique hardships. Throughout 2020, in Japan, most premier sporting competitions involving young athletes underwent cancellations or significant reductions, thereby exacerbating the challenges faced by these athletes, compared with their non-athlete counterparts. Presently, young athletes confront multiple obstacles, including limitations in specialized training, concerns over physiological alterations resulting from modified workouts, risk of COVID-19 exposure, and uncertainties surrounding their athletic aspirations and careers [7, 8, 9, 10]. While athletes worldwide, including those in Japan, have generally reported deteriorating mental health during the pandemic [7, 11] – particularly female athletes and those at more competitive levels [7] – research on youth athletes remains limited, underscoring a need for further investigation [12, 13, 14, 15, 16].
In light of these multifaceted challenges, understanding factors such as psychological resilience – i.e., the ability to adapt to internal and external stressors, particularly through mental, emotional, and behavioral flexibility [17, 18] – is imperative [19]. Indeed, resilience plays a vital role in protecting individuals from psychological issues such as depression and anxiety during pandemics [20]. Notably, while previous studies have explored the relationship between athletes’ resilience and performance, its correlation with mental health remains mostly unexplored [21, 22, 23].
This study seeks to fill this research gap by investigating the complex relationship between Japanese youth athletes’ mental health and resilience during the COVID-19 pandemic. Based on the aforementioned observations, we formulated the following hypotheses:
Youth athletes’ mental health is worse than that of their non-athlete peers.
Resilience is potentially associated with better mental health outcomes.
COVID-19 testing history, illness, family history, and female gender are linked to worsened mental health.
To test these hypotheses, we conducted a survey of Japanese high school students, including youth athletes, to assess their mental health status and resilience, and to understand their interrelationships during the pandemic.
Methods
Participants
The COVID-19 pandemic’s impact on mental health varies depending on environmental conditions, such as regional differences, infection control measures, and the phase of the epidemic [24, 25]. To minimize these conditional differences and study youth athletes’ mental health, we examined a single institution: High School A. Located in a metropolitan area, this average-sized public high school is known for its sports club activities and has an approximately even gender distribution. We engaged all students from High School A, encompassing 1,201 individuals aged 15–18 years, who ranged from elite youth athletes to general students, as participants for this study.
Background on the COVID-19 pandemic in Japan
Following Japan’s initial COVID-19 case on January 15, 2020, the virus spread rapidly nationwide, mirroring global trends, which led to school closures in March, as well as the declaration of a public health emergency and the implementation of numerous restrictions in April. The pandemic’s progression led to various activity limitations, and most major high school sporting events in 2020 were canceled or scaled back.
In March 2021, when this study was conducted, the incidence of new COVID-19 cases in Japan was 5.7 per 100,000 inhabitants, according to WHO data dated March 7 [26]. By this time, cumulative infections in Japan amounted to 437,717 cases – approximately 0.35% of the Japanese population [26, 27, 28]. Further, due to a cluster outbreak, High School A was briefly shut down in December 2020. However, by the time of the survey’s conduction in March 2021, both the school and its athletic teams had resumed their activities, albeit on a limited schedule.
Study design and data collection
This study employed an online cross-sectional design and was conducted anonymously between March 1 and 10, 2021. Integrating the survey completion into the homeroom schedule, specific dates varied per grade level, and students responded using their smartphones. To ensure uniform access, the response URL was disseminated via Microsoft Teams – the school’s primary communication platform. Although the URL was not individualized, we restricted access after the designated response time, minimizing the potential for duplicate entries. The survey took approximately 10 minutes.
Measures
Demographics and classification criteria
The survey collected participants’ demographic data, including gender, grade level, and club affiliations. Club affiliations were categorized into sports clubs, cultural clubs, and no affiliation. Cultural clubs are focused on arts, academics, and other non-sport activities, such as drama, music, science, and art. For students involved in sports clubs, we sought to assess their competitive level by asking about their past selection history and the level of tournaments in which they had participated (see Electronic Supplementary Material, ESM 1). Regarding past selection history, students chose from the following options, in descending order of achievement: Japan national team, Kanto selection, prefecture selection, regional selection, and no selection history. For past tournament participation, the options were, in descending level of competition: international championships, national championships, Kanto championships, prefectural championships, and regional championships. Both categories comprised ordinal scales. Based on their responses, students were assigned to one of three groups: national-level competitors (NCs), local competitors (LCs), and others (OTs). The criteria for each group were the following:
NCs comprised students who participated in international or national tournaments (indicated by their past tournament participation level) or those who indicated Japan national team, Kanto selection, or prefecture selection regarding their past selection history. To clarify, being selected as a prefecture representative indicates national-level competitiveness. Additionally, Kanto selection is a higher echelon in the prefectural system, indicating national-level competitiveness. Further, LCs comprised students who participated in local or school-level tournaments and those with a selection history below the prefecture level. Additionally, OTs comprised students not belonging to any sports club.
COVID-19-related questions
To evaluate the pandemic’s impact, participants were asked about PCR testing, COVID-19 history, and whether any of their family members living in the same household were infected (ESM 1).
Kessler-6 (K6)
The K6 [29] is a six-item scale designed to assess non-specific psychological distress – e.g., depression and anxiety – experienced over the past four weeks. Responses are recorded on a five-point scale, ranging from “none” (0) to “very much” (4). The total score ranges from 0 to 24. We utilized a cut-off score of 5 to pinpoint cases of psychological distress [29]. For this study, we employed the Japanese version of the K6, which has proven accurate and reliable [30]. Cronbach’s α coefficient was 0.87 in this study.
Patient Health Questionnaire (PHQ-9)
The PHQ-9 [31] is a nine-item scale that assesses the severity of depressive symptoms experienced over two weeks on a four-point scale, ranging from “none” (0) to “almost every day” (3). The scores range from 0 to 27. A cut-off score of 10 was used to identify moderate to severe depressive symptoms [31]. For this study, we employed the Japanese version of the PHQ-9, which has proven accurate and reliable [32, 33]. Cronbach’s α coefficient was 0.85 in this study.
Generalized Anxiety Disorder-7 (GAD-7)
The GAD-7 [34] is a seven-item scale that assesses the severity of anxiety symptoms experienced over two weeks on a four-point scale, ranging from “none” (0) to “almost every day” (3). The scores range from 0 to 21. A cut-off score of 10 was used to identify cases of moderate-to-severe anxiety [34]. For this study, we employed the Japanese version of the GAD-7, which has proven accurate and reliable [35]. Cronbach’s α coefficient was 0.86 in this study.
Resilience Scale for Japanese High School Students (RS-JHS)
The RS-JHS ([36], ESM 1) is a 24-item scale that assesses resilience, comprising internal factors (personal strengths) and external factors (school, family, community, and friends), on a seven-point scale, ranging from “not at all applicable” (1) to “entirely applicable” (7). RS-JHS scores range from 24 to 168. Internal factors measure attributes such as problem-solving, self-efficacy, and self-awareness. Sample items include “When faced with difficulties, I can usually find a way out” and “My belief in myself gets me through tough times.” In contrast, external factors assess students’ perceptions of trust and their relationships with entities such as the school, community, family, and friends. Sample items include “There are teachers at school who always look out for me” and “Outside of school and home, there is an adult I can trust.” The RS-JHS Cronbach’s α coefficients in this study were: overall scale: 0.94; internal factors: 0.91; external factors: 0.91; school: 0.90; community: 0.92; family: 0.86; and friends: 0.89.
Statistical analysis
Group classification and descriptive statistics
Participants were classified into three groups: NCs, LCs, and OTs. Descriptive statistics including frequencies (n) and percentages (%) were used to characterize the sample.
Assessment of sociodemographic differences
Using the three groups (NCs, LCs, OTs) and sociodemographic items (grade, gender, PCR testing history, COVID-19 infection history, and family history), we generated cross-tabulation tables and conducted a chi-squared test for independence. The results revealed significant differences across gender, PCR testing history, COVID-19 infection history, and family history. Given these disparities, these variables were controlled as covariates in subsequent analyses to mitigate potential confounding.
Mental health and resiliency assessment
The K6, PHQ-9, GAD-7, and RS-JHS scores were calculated for each participant, and medians along with interquartile range (IQR) were determined for each group. The Shapiro-Wilk test indicated non-normal distribution for these scales, prompting the use of nonparametric analytical methods. The K6, PHQ-9, and GAD-7 scores were dichotomized based on established cut-off values, being classified as either below threshold (= 0) or above (= 1).
Logistic regression analysis
To test hypothesis (H1), we conducted binary logistic regression using dichotomized K6, PHQ-9, and GAD-7 scores as dependent variables, with the three groups (NCs, LCs, and OTs) as independent variables. The NC group served as the reference category, and differences in the LC and OT groups were examined relative to this reference. We adjusted for potential confounders, incorporating items that demonstrated biases across groups in prior analyses: gender, PCR testing history, COVID-19 infection history, and family history. For the RS-JHS, a continuous and non-normally distributed measure, we applied a generalized linear model. In this analysis, we included gender, PCR testing history, COVID-19 infection history, and family history as independent variables to control for potential confounders.
To test hypotheses (H2) and (H3), we employed binary logistic regression, adopting a stepwise method with the dichotomized K6, PHQ-9, and GAD-7 scores as dependent variables. All analyses were conducted using IBM SPSS software, ver. 29. All tests were two-tailed, and the statistical significance level was set at p < 0.05.
Results
Demographic data
Of the 1,201 students surveyed, 1,133 completed the survey. From this group, 111 students were excluded due to non-response or invalid responses, leaving a complete sample of 1,022 students (90.2% valid response rate). Detailed demographics are reported in Table 1. We categorized 228 students (22.3%) as NCs, 395 (38.6%) as LCs, and 399 (39.0%) as OTs. There were demographic imbalances among the three groups.
Scores of psychological status and resilience scale
The detailed distribution of each scale score by median, IQR, and cut-off values is reported in Table 2.
For the K6: The overall median score was 2, with an IQR of 0–6. The percentage above the cut-off (≥5), suggesting distress, was 21.5% (n = 49) for NCs, which was significantly lower than 39.8% (n = 159) for OTs (p < 0.001, OR = 2.2, 95% CI 1.4–3.4).
For the PHQ-9: The overall median score was 2, with an IQR of 0–5. The percentage above the cut-off (≥10), suggesting depression, was 3.9% (n = 9) for NCs, which was significantly lower than 9.0% (n = 36) for OTs (p < 0.001, OR = 2.8, 95% CI 1.3–6.3).
For the GAD-7: The overall median score was 1 with an IQR of 0–3. The percentage above the cut-off (≥10), suggesting anxiety, was 2.2% (n = 5) for NCs, which was significantly lower than 6.8% (n = 27) for OTs (p = 0.02, OR = 3.7, 95% CI 1.2–3.5).
For the RS-JHS: NCs had significantly higher median scores than LCs and OTs (p < 0.001). In the subscale analysis, NCs scored significantly higher than LCs and OTs for both internal and external factors (all p’s < 0.001).
Risk factors of mental health problems
The relationship between demographic data and the percentages meeting the K6, PHQ-9, and GAD-7 cut-offs is detailed in Table 3. Girls reported a higher percentage of K6 and PHQ-9 cut-off or higher values, compared with boys. Similarly, students in cultural clubs reported higher percentages meeting the K6 and GAD-7 cut-off values, compared with those in athletic clubs. Regarding activity location, students participating in indoor sports reported higher percentage meeting the PHQ-9 cut-offs, compared with those participating in outdoor sports. Additionally, higher RS-JHS scores were negatively associated with K6, PHQ-9, and GAD-7 scores (all p’s < 0.001). For COVID-19-related factors, no association was found with each rating scale with a history of PCR testing, infection, or the presence of infected family members.
Discussion
In this study, we aimed to uncover the relationship between Japanese youth athletes’ mental health and resilience during the COVID-19 pandemic. To control for external factors that might affect pandemic-related stress, we included a single school in the sample. Our main findings were: (i) NCs reported significantly lower scores on the K6, PHQ-9, and GAD-7, compared with OTs; (ii) NCs reported significantly higher resilience scores in both internal and external factors, compared with LCs and OTs; (iii) resilience scores had a significantly negative correlation with K6, PHQ-9, and GAD-7 scores; (iv) Female gender, participation in cultural clubs, and indoor activities were associated with scores above the cut-off on the K6, PHQ-9, and GAD-7; and (v) COVID-19 testing, history of illness, and family history were not associated with the psychological evaluation measures.
In this study, NCs reported significantly lower levels of distress, depression, and anxiety, compared with other adolescents, suggesting that NCs have better mental health. Thus, youth athletes at higher levels of competition may be better able to manage the stress of the pandemic. This result did not support hypothesis (H1). However, referring to the results of the 2019 Japan Comprehensive Survey of Living Conditions (i.e., during the pre-pandemic period), 19.4% of adolescents experienced distress, as determined by the K6 (≥5) in Japan [37]. In this study, 31.1% of participants were identified as distressed, with OTs exhibiting the highest percentage (39.8%), followed by LCs (27.8%) and NCs (21.5%); this pattern was also observed for depression and anxiety. This suggests that Japanese adolescents’ (including youth athletes) mental health deteriorated due to the pandemic.
RS-JHS scores showed a significantly negative correlation with distressed, depressive, and anxiety statuses in this study. This suggests that resilience is potentially associated with better adolescents’ mental health outcomes, confirming hypothesis (H2). Additionally, NCs’ significantly greater resilience, both in terms of internal and external factors, suggests that higher levels of sports competition correlate with enhanced resilience. Specifically, regarding the internal factors, individual’s personal qualities and psychological skills (developed through competitive sports) could be a useful tool to confront pandemic-induced challenges. Concurrently, our study found that external factors also exhibited a marked increase among NCs. As Fletcher pointed out, in any moment of time, personal qualities are consistently influenced by both stressors and the support derived from social and environmental resources [18]. Furthermore, research has indicated that athletic coaches might act as an important source of social support [18, 38]. Since most Japanese high school athletic teams receive coaching from schoolteachers, belonging to an athletic team may be an easy way to receive support from the school. Further, High School A’s athletic teams have performed excellently over a prolonged period, eliciting widespread recognition and support from the community. Our findings suggest that resilience-enhancing support is needed for young people in situations with negative mental health consequences, such as the COVID-19 pandemic.
Our investigation revealed that female gender, cultural clubs, and indoor sports participation were related to cut-off or higher values on psychological evaluation measures (K6, PHQ-9, GAD-7), suggesting that these are risk factors for mental health problems. The higher tendency for girls to be depressed is consistent with previous studies on adolescents during the pandemic [39], lends partial support to hypothesis (H3). The difference in mental health status between athletic and cultural groups suggested that physical activity acts as a buffer for mental health. Wolf et al. found that, amidst the pandemic, those reporting higher total time spent in moderate-to-vigorous physical activity had 12–32% and 15–34% lower chances of presenting depressive and anxiety symptoms, respectively [40]. Students involved in indoor sports had higher depressive status scores than those in outdoor activities. This may partly be because of concerns regarding the risk of infection in enclosed spaces, especially against the background of a documented COVID-19 outbreak in an indoor sports club at the same high school.
In this study, we found no link between COVID-19 history and mental health. This result did not support hypothesis (H3). One reason could be the limited number of individuals infected in our sample. Lima et al. [7] reported that mental health symptoms in athletes were associated with a history of COVID-19 infection, with 29% of participants being infected; however, in our study, only 8.9% of participants were infected. Therefore, further research is needed on the association between youth athletes’ COVID-19 history and mental health.
Limitations
This study had several limitations. First, it was an online, self-administered survey; therefore, mental health results may not reflect actual clinical diagnoses. Second, its cross-sectional design limits our understanding of the pandemic’s evolving impact on participants’ mental health and prevents establishing a direct causal relationship between resilience and mental health. As resilience is a multifaceted, dynamic process, our study design might not have adequately captured it in full, thus highlighting the need for more in-depth research. Third, this study did not specify students’ training duration and frequency. This lack of information could potentially influence our interpretations of the impact of activity levels on mental health, especially considering the adjustments many sports clubs made due to the COVID-19 pandemic. Lastly, we did not assess participants’ socio-economic background, which could profoundly influence mental health outcomes.
Conclusion
In conclusion, based on the responses to the self-reported questionnaires, Japanese youth athletes competing at the national level appear to have better mental health than their peers and that resilience is observed to have a potential association with improved mental health during the COVID-19 pandemic. Further research is needed to understand how the pandemic has impacted their mental health and resilience in the long term.
Electronic Supplementary Materials
The following electronic supplementary material is available with this article at https://doi.org/10.1024/2674-0052/a000063
The authors would like to acknowledge the students and teachers from High School A who cooperated in the survey.
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