Scientists Build Expert-Validated Anxiety Literacy Programme for University Students

Anxiety has quietly become one of the defining health challenges of university life. Rising academic pressure, financial strain, social isolation and an uncertain job market have combined to make anxiety disorders among the most prevalent mental health problems reported by students in higher education. Yet despite how common these experiences are, many young people never seek help, often because they cannot recognise what is happening to them, fear being judged, or simply do not know where to turn. A new study published in BMC Nursing by researchers at the Nursing School of the University of Coimbra and the Nursing School of the University of Porto set out to close that gap by building and expert-testing a mental health literacy programme designed specifically around anxiety in the student population.

The research team, led by Andreia Sofia Cristina and including Inês Franco de Almeida, Carlos Alberto Cruz Sequeira and Amorim Gabriel Santos Rosa, framed their work around the concept of mental health literacy, often abbreviated as MHL. Mental health literacy encompasses the knowledge and beliefs about mental disorders that aid their recognition, management and prevention. In practical terms, it means being able to identify symptoms in oneself and others, understanding what treatments exist and how effective they are, knowing how to access professional help, and holding attitudes that reduce stigma rather than reinforce it. When literacy is low, symptoms are misread as personal weakness, help is delayed or never sought, and treatable conditions are allowed to harden into chronic problems that corrode academic performance and well-being.

While general mental health literacy programmes already exist, the authors identified a specific deficiency: very few interventions have targeted anxiety explicitly, and fewer still have been co-created with the students they are meant to serve and then subjected to rigorous expert content validation. Anxiety is a particularly demanding target because it sits on a continuum that runs from the normal, even useful nervousness before an examination to clinical states that can be disabling. Distinguishing adaptive stress from something requiring professional attention is precisely the kind of judgement that literacy education is designed to support, and it is a judgement students repeatedly report struggling with.

The study adopted an exploratory, qualitative design guided by the PRODUCES framework, a structured approach to developing complex health promotion interventions, and unfolded in two sequential phases. The first phase placed students at the centre of the design process. Nineteen higher education students took part in focus groups in which they discussed their experiences, needs and views concerning anxiety and mental health literacy. This participatory starting point matters technically because interventions imposed from above frequently fail on acceptability: if the language, examples and delivery format do not resonate with the intended audience, engagement collapses regardless of the underlying evidence base. By listening first, the researchers grounded the programme in the lived reality of student life.

From these focus groups, the team distilled six core domains that shaped the initial architecture of the programme. Although the published abstract does not enumerate every domain in detail, the resulting design was built to promote recognition of anxiety symptoms, develop self-regulation skills, reduce stigma and encourage help-seeking behaviours. These four objectives map directly onto the canonical components of mental health literacy, but they are here tailored to the specific phenomenology of anxiety, which includes physical manifestations such as palpitations, tension and sleep disturbance that students often misattribute to purely somatic causes.

The second phase subjected this draft to a modified electronic Delphi study, a well-established consensus methodology in health services research. The e-Delphi technique works by circulating structured questionnaires to a panel of experts over successive rounds, collecting quantitative ratings and qualitative feedback, then refining the material between rounds until either consensus is achieved or the panel agrees that further iteration is unproductive. In this study, 18 experts participated in each of two rounds, evaluating the programme’s structure, content and implementation strategies. The Delphi approach is particularly valuable for content validation because it separates panellists, preventing the dominance of any single vocal opinion and allowing anonymity to elicit honest judgements about weaknesses as well as strengths.

The results of the expert evaluation revealed a high level of agreement on most components of the programme, which is a strong signal of content validity. At the same time, the panel identified concrete areas for revision. Experts suggested changes to the duration of individual sessions, to the overall structure of the programme, to the delivery format, to the digital support components and to the practical activities embedded in the sessions. This pattern of granular, actionable critique illustrates why content validation is more than a rubber stamp: it converts a promising draft into an instrument that practitioners can realistically deliver. Digital support, for instance, has become a near-essential element for interventions aimed at young adults, whose expectations of on-demand access differ sharply from earlier generations, and expert feedback here pushed the programme toward greater technological relevance.

One item resisted resolution. Across the two Delphi rounds, no consensus was reached on the proposed programme duration of eight weeks. The researchers have deliberately left this question open, planning to evaluate it during pilot testing rather than forcing agreement at the design stage. This is a methodologically defensible choice. The optimal dose of a psychoeducational intervention depends on factors such as session length, participant engagement, competing academic demands and the depth of skills practice, and these are best observed empirically. A programme that is too short may fail to consolidate self-regulation skills, while one that is too long risks attrition in a population already juggling coursework, examinations and employment.

The final product is a structured yet adaptable programme of sessions aimed at prevention and early identification of anxiety among higher education students. Its adaptability is worth emphasising. In health promotion, a rigid protocol can be a liability in real-world settings where timetabling, group sizes and institutional cultures vary widely. A framework that specifies core content while allowing flexibility in format and pacing gives university counselling services, campus nurses and student support teams room to fit the intervention to their local context without diluting its validated components. Significantly, the programme is grounded in mental health nursing practice, positioning nurses, who are often embedded in university health services and skilled in both clinical assessment and health education, as central actors in campus mental health promotion rather than peripheral support staff.

With content validation complete, the programme now moves to the next stage of its evaluation pathway: pilot testing to assess feasibility, acceptability and preliminary effectiveness. Feasibility testing will determine whether the sessions can be delivered as designed within the constraints of academic calendars, whether students attend and complete the programme, and whether the unresolved question of total duration can be settled with empirical data. Acceptability testing will reveal whether the participatory foundation laid in the focus groups translates into genuine student engagement. Preliminary effectiveness measures will provide early signals of whether the programme actually improves symptom recognition, self-regulation capacity, stigma-related attitudes and help-seeking intentions. If those signals prove positive, the intervention could offer universities a practical, evidence-informed tool for addressing one of the most common and most under-treated mental health problems of student life, delivered by the professionals perhaps best placed to make a difference. For a field in which prevention has long been overshadowed by crisis response, a carefully co-created and expert-validated anxiety literacy programme represents a meaningful step forward.

Subject of Research: Development and content validation of an anxiety-specific mental health literacy programme for university students

Article Title: Development and content validation of an anxiety-specific mental health literacy promotion programme for higher education students

Article References: Cristina, A. S., de Almeida, I. F., Cruz Sequeira, C. A., & Santos Rosa, A. G. (2026). Development and content validation of an anxiety-specific mental health literacy promotion programme for higher education students. BMC Nursing, 25(1), Article 939. https://doi.org/10.1186/s12912-026-05395-0

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05395-0

Keywords: anxiety, mental health literacy, higher education students, e-Delphi, nursing, health promotion, programme development, stigma reduction, help-seeking, Portugal, participatory research, student mental health