Occupational Balance and Meaning Mediate Higher Education Students’ Mental Health During War: A Structural Equation Modeling Analysis

Trauma is a global public health issue, with significant and often long-lasting effects on both the individual and the community (Magruder et al., 2017; Shalev et al., 2017). Exposure to trauma generates psychological distress and may affect the mental health status of individuals, contributing to various symptoms and syndromes, including anxiety, depression, and even posttraumatic stress disorder (Benjet et al., 2016; May & Wisco, 2016). Traumatic exposure is a general health issue that is associated with a wide range of chronic health conditions (Keyes et al., 2013; Scott et al., 2013), loss of productivity, and social contacts, resulting in substantial alterations in daily life routines and activities (Donahue et al., 2017; Jellestad et al., 2021). All these negative changes further exacerbate, in turn, the psychological distress and reduce one’s physical and mental health and well-being. Given the significant long-term burden of trauma on the individual and the community, it is critical to understand the factors contributing to one’s mental health during traumatic exposure (Magruder et al., 2017; Shalev et al., 2017).

Armed conflicts form a significant source of traumatic exposure, even for civilians (Carpiniello, 2023). The prevalence of mental health disturbances is two or three times higher among people exposed to armed conflict (Carpiniello, 2023). In Israel, which is involved in ongoing conflicts in the Middle East, 74.8% of the population reported exposure—either direct or indirect—to a traumatic event (Benjet et al., 2016). Previous studies with conflict-affected populations exposed to trauma have emphasized the critical importance of socioeconomic and demographic factors, loss of identity, and issues related to asylum and immigration policies in understanding the mental health costs of armed conflicts (Carpiniello, 2023; Garry & Checchi, 2020). Still, despite the consequences of traumatic events (Magruder et al., 2017), little research has investigated the inevitable changes in patterns of daily life occupations after the traumatic event that may have a serious impact on one’s mental health (Gallagher et al., 2015).

The Israeli population has been exposed to intense traumatic experiences caused by escalation in armed conflict since the October 7, 2023, terror attack (henceforth, “October 7 attack”), with significant loss of lives and tens of thousands evacuated from their homes (Office for the Coordination of Humanitarian Affairs, 2023). The ongoing warfare had—and still has—substantial effects on everyday life of Israel’s population across the country. Extended regions of Israel encountered prolonged lifestyle limitations stemming from months of bombardment, during which only essential services remained operational. During that time, the levels of depression and anxiety among the general population doubled, and probable posttraumatic stress disorder prevalence nearly doubled (Levi-Belz et al., 2024).

The higher education student population is of particular interest, given the generally high levels of psychological distress, altered resilience, and low satisfaction with life found among this population (Fradelos et al., 2019; Grøtan et al., 2019; Larcombe et al., 2016; Mellor et al., 2015). During armed conflicts, students—often young adults in their 20s and 30s—may experience additional and unique stressors because of their developmental stage. For example, young adults may be highly exposed to terrorist attacks and heavily involved in civil and security forces’ efforts to mitigate their impact. This was notably the case in Israel, where many students were drafted into active military service after the October 7 attack. In addition, educational and academic settings together with many other facilities shut down for extended periods, posing changes to everyday life routines and practices.

In this article, we examined the potential impact of the intense threat incurred by the escalation of armed conflict in Israel on higher education students’ mental health. Given the extent of impact of traumatic exposure on mental health and the high involvement of students in the escalating conflict, we aimed to characterize the students’ mental health status, resilience, executive functions (EFs), and occupational patterns and investigate the interplay between those factors and mental health status during these times. Building on results from previous related research, we made the following hypotheses:

• Hypothesis 1: Students will report reduced mental health status after being exposed to the traumatic threat, along with reduced resilience, satisfaction with life, and EFs.

• Hypothesis 2: Students will report significant interruption in their everyday occupations and participation in everyday activities.

• Hypothesis 3: In accordance with the International Classification of Functioning, Disability, and Health model (McDougall et al., 2010; World Health Organization, 2001), the mental health status of the students facing a traumatic ongoing event will be accounted for by the magnitude of exposure to the traumatic events of the October 7 attack, as well as by their resilience, general satisfaction with life, and EFs, along with their current occupational patterns (see Figure 1).

The study was approved by the institutional review board of the Faculty of Medicine of the Hebrew University of Jerusalem (Approval No. 11112023). Data collection took place between November 12 and December 11, 2023, about a month after the October 7 attack and the start of the “Swords of Iron” war. We recruited participants via advertisements posted on social media platforms (e.g., Facebook) and on WhatsApp groups. Individuals ages 18 to 65 who spoke fluent Hebrew and who were students or were enrolled to begin their higher education studies in one of the academic institutions in Israel were eligible to participate. Data were collected remotely, using a 15-min online survey. All participants provided electronic informed consent before engaging in any study-related activities. The data were saved anonymously, without any identifying information, in electronic files secured with a password.

We used Hebrew versions of self-report validated questionnaires. Score range, normative data, and reliability of all scales are provided in Table A.1 in the Supplemental Material (available online with this article at https://research.aota.org/ajot).

We collected demographic information on age, gender, area of residence, stage at study curriculum, and level of exposure to the threatening events using a custom-made questionnaire. We assessed mental health status with the 21-item Depression, Anxiety, and Stress Scale (DASS–21; Henry & Crawford, 2005), a self-report measure designed to evaluate the severity of general psychological distress and symptoms related to depression (seven items), anxiety (seven items), and stress (seven items). Each item is scored on a 4-point scale (from 0 = never to 3 = almost always), with higher scores indicating higher levels of psychological distress.

Psychological factors include resilience and trait satisfaction with life. We assessed resilience using the 10-item self-report Connor–Davidson Resilience Scale (CD–RISC; Campbell‐Sills & Stein, 2007; Davidson, 2020). Each item is scored on 5-point Likert scale (from 0 = not true at all to 4 = true nearly all the time). The total score is the sum of all individual items, with higher scores indicating higher resilience. We assessed a person’s global satisfaction with life using the Satisfaction With Life Scale (SWLS; Diener et al., 1985). This brief instrument has five items rated on a 7-point Likert scale (from 1 = strongly disagree to 7 = strongly agree), with higher scores indicating higher satisfaction with life. Sense of belonging to the community was evaluated with a single item using a visual analog scale (from 0 = I don’t feel like I belong at all to 10 = I have strong feelings of belonging to my community).

We assessed personal factors using the Adult Executive Functioning Inventory (ADEXI; Holst & Thorell, 2018), a 14-item self-reported tool for measuring EF. Each item is rated on a 5-point Likert scale (from 1 = definitely not true to 5 = definitely true), with lower scores indicating better EF. In addition, participants were asked to report how their emotional and cognitive self-regulation changed after the war (one item for each construct) using a scale with three options: no change, decreased, or increased.

We measured occupational variables according to the constructs of the Occupational Therapy Practice Framework: Domain and Process (4th ed.; American Occupational Therapy Association, 2020). Occupational balance, meaning, and change in participation by areas of occupations (self-care, home management, care for others, learning, sports, entertainment, quiet leisure activities, spiritual activities, work, and volunteering) were rated using a visual analog scale, with scores ranging from 0 (no balance/not meaningful/noticeable reduce in participation) to 10 (exact balance/very meaningful/noticeable expansion in participation).

For analysis purposes, we transformed the scale of change in participation by areas from 0 to 10 to −5 to 5 (−5 = noticeable reduce in participation, 0 = no change in participation, 5 = noticeable expansion in participation), and we calculated the extent of change in participation in occupations as the mean of standard deviations for all areas. In addition, participants rated their perception of the environment as enabling everyday functioning versus restricting, using a visual analog scale, with scores ranging from 0 (my current environment is particularly restrictive for my occupations) to 10 (my environment enables all my occupations).

We performed statistical analyses using IBM SPSS Statistics (Version 29.0) and IBM AMOS Graphics software (Version 29.0) and used descriptive statistics to examine demographic characteristics of the sample. Cronbach’s α was calculated for all tools to examine their internal reliability. Normality was not approved for all scales based on the Shapiro–Wilk test (p < .05); hence, nonparametric tests were applied. We conducted Mann–Whitney U test and Kruskal–Wallis tests to examine differences across the DASS–21 scores by groups of demographic variables, depending on the number of groups. We used Pearson correlation coefficients to examine correlations between the study variables and DASS–21 scores.

Independent variables for the model explaining the variance in mental health status (DASS–21 total score) were determined based on the between-group differences and correlation analysis. We conducted structural equation modeling (SEM) with maximum likelihood estimation to test the hypothesized model for the DASS–21 total score. Model fit was assessed using the following goodness-of-fit indices: χ², comparative fit index (CFI), Tucker–Lewis index (TLI), and root-mean-square error of approximation (RMSEA). A nonsignificant χ², CFI and TLI ≥ 0.95, and RMSEA ≤ 0.06 are indicative of an acceptable fit (Schermelleh-Engel et al., 2003). We assessed the standardized path coefficients to examine the statistical significance and directions of path estimates between the variables in the model. For all analyses, p < .05 was considered statistically significant.

The study was completed by 863 students ages 18 to 58 (Mdn = 25, IQR = 23–27); 699 (81%) of the students were women. Most participants were pursuing a bachelor’s degree (n = 659; 76.4%). A relatively small number of participants reported living in areas mostly affected by the war (n = 102; 11.8%), and only 22 (2.5%) were directly involved in the October 7 attack. Family members of 249 (28.8%) participants were directly involved in the October 7 attack, 65 (7.5%) participants were refugees after the events, 169 (19.6%) participants were drafted to active military service, and 430 (49.8%) participants had at least one family member who was drafted. Demographic characteristics of the study sample are given in Table A.2 in the Supplemental Material.

Fifty percent of participants reported having experienced at least moderate levels of depression (Mdn = 18, IQR = 10–28), anxiety (Mdn = 10, IQR = 4–20), and stress (Mdn = 24, IQR = 14–34), as measured by the DASS–21 scale. In addition, 25% of the sample experienced an extremely severe level of psychological distress (DASS–21 subscales) based on cutoff scores (Henry & Crawford, 2005; see Table A.1).

We next analyzed mental health status by demographic variables (see Table A.3). Better mental health status (DASS–21 scores for all subscale and total score) was found for male participants (42,275.5 > U > 4,920.5, p < .01), for those whose family members were not directly involved in the October 7 attack (59,436.5 < U < 65,315, p < .001), and for students in the fields of health, education, welfare, or nature and exact sciences (11.2 < H < 12, p < .05). Lower depression and stress and better general mental health (DASS–21 total score) was found for religious participants and for those who are currently drafted for military service (52,199 < U < 82,760, p < .05). In addition, reduced anxiety was found among Master of Arts and PhD students (H = 7.4, p < .05), among those whose family member(s) were not drafted, and for those who were not physically present in the October 7 attack (U = 59,436.5, p < .001).

For the psychological factors, 50% of participants reported having “slight satisfaction” with life or higher (SWLS total score; Mdn = 25, IQR = 19–28), whereas 25% reported “slight dissatisfaction” with life or lower (for cutoff scores, see Pavot & Diener, 2008), whereas their resilience (CD–RISC total score) fell within the known range for this population (Mdn = 25, IQR = 20–29; Campbell‐Sills & Stein, 2007). The self-reported EF (ADEXI total score: Mdn = 2.1, IQR = 1.7–2.7) also fell within the known range for students (Holst & Thorell, 2018). Finally, 66% of participants experienced at least an average sense of belonging to their community, 55.7% experienced reduction in their emotional self-regulative skills or emotional control, and 55.4% reported a decrease in their cognitive functioning (see Table A.1).

We next examined the changes in students’ occupations since the beginning of the war. Of the sample, 50% managed to keep their participation unchanged in only one to two areas of occupations (e.g., home management and spiritual activities, Mdn = 2, IQR = 1–3; Figure 2A), whereas 50% decreased their participation in at least four areas or increased their participation in three areas or more. The decrease was found more consistently in the fields of self-care, learning, entertainments, and sport activities (Mdn = 4, IQR = 2–6), whereas the increase was reported for activities involving care for others, quiet leisure, and volunteering activities (Mdn = 3, IQR = 2–5).

The extent of participation changes varied between fields of occupations, between individuals, and within the individual (variability, M = 2.5, SD = 0.8, Mdn = 2.5, IQR = 1.9–3.2; Figure 2A). More important, after these changes in occupational patterns, 85% of participants reported reduced occupational balance, and 70% experienced reduction in the significance of their occupations (Figure 2B). It is interesting to note that 72.5% of participants experienced that their environment, which included war-related restrictions and circumstance, enabled their occupations rather than limited them (Mdn = 8, IQR = 5–9). In addition, 50% of the participants reported on a higher-than-average sense of belonging (Mdn = 7, IQR = 5–8).

As a basis for the SEM analysis accounting for mental health (DASS–21 scale score), we first investigated correlations between mental health status and study variables (Tables A.4 and A.5). We found significant correlations between the DASS–21 subscales and all variables (–.387 < r < .526, p < .001), except for age. Interestingly, reduced mental health was associated with higher variability in occupational change.

The results of the SEM path analysis are presented in Figure 3. Nine observed variables were entered into the model based on their correlation with the outcome measure (DASS–21 total score): resilience, trait satisfaction with life, sense of belonging, EFs, variability in occupational change through different areas and occupational balance after the war outbreak, and demographic variables of gender, religious status, and current military service.

All fit indices indicated that the model had suitable fit to the data, χ²(15) = 15.969, p = .384, CFI = 0.999, NFI = 0.984, RMSEA = 0.009, and TLI = 0.996. Satisfaction with life, resilience, occupational balance, religious status, EFs, and variability in occupational change all had direct effect on mental health. The strongest effect was for EFs.

Reduced sense of belonging, being female, and current military service were correlated with reduced occupational balance, and all were associated indirectly with lower mental health. In addition, lower satisfaction with life, lower EFs, and being female were associated with higher variability in occupational change, which in turn related with lower mental health status.

This study set out to examine the mental health status of higher education students after ongoing exposure to intense traumatic threat as a result of the Swords of Iron war in Israel, as well as the factors associated with mental health during this time. As expected, the results indicated a significant reduction in self-reported mental health among at least 50% of the students, in addition to multiple changes in their participation in daily life occupations. However, in contrast to our hypotheses, the levels of resilience and EFs were comparable with normative data from students, and, interestingly, trait satisfaction with life was relatively high. Following our hypotheses, a path analysis accounted for the reductions in mental health status directly by lower resilience, EFs, trait satisfaction with life, being secular, and altered occupational patterns and occupational balance. Surprisingly, occupational indices mediated the correlation between mental health and additional factors, including gender, current military service, trait satisfaction with life, and EF.

The findings of this study are of relevance especially given recent geopolitical changes around the world, marked by growing traumatic events in general and armed conflicts in particular (e.g., in Syria, Ukraine, Israel). The results illustrate the effects of both direct and indirect exposure to intense traumatic threat on young adults, particularly students, who are more susceptible to distress and may be more directly involved. Their successful attainment of developmental goals, such as education, not only promises personal growth and prosperity but also benefits the community at large. Conversely, their failure to succeed could result in a significant burden to themselves and the entire community over the years (Fradelos et al., 2019; Grøtan et al., 2019; Larcombe et al., 2016; Mellor et al., 2015). In this respect, the study sheds light on the role of occupations, occupational balance, and EFs in sustaining mental health after trauma, expanding our understanding of possible mechanisms of distress and suggesting optional venues for alleviating the long-term impact of traumatic exposure.

Students in our sample experienced at least moderate depression, anxiety, and stress in response to the potential or actual exposure to the traumatic threat caused by the October 7 attack in Israel and the warfare that followed. The level of psychological distress in this study was almost double that generally reported for student populations (Fradelos et al., 2019; Grøtan et al., 2019; Larcombe et al., 2016; Mellor et al., 2015) and higher than those previously reported for Israeli medical students, who experience particularly stressful studies (Kaides & Ben-Shlomo, 2021). However, the psychological distress of the students in our study is comparable with that found for the general population in Israel at these times (Levi-Belz et al., 2024).

It is surprising that the level of anxiety was the only measure of distress that differed according to circles of exposure, being significantly higher among students who were personally affected by the October 7 attack. In addition, the levels of psychological distress were similar across geographic locations, which had different levels of proximity to the attack. These findings contradict other findings on the impact of level of exposure. The results can be accounted for by the relatively low number of participants who were personally involved in the events. Alternatively, our findings are comparable with those found in relation to previous incidents of mass terror attacks on the general population, such as the September 11th attack in the United States. Specifically, these studies have demonstrated that mass attacks may lead to large-scale distress, even among general populations that were not physically present but were exposed to them through the media (Ben-Zur et al., 2012; Matt & Vázquez, 2008; May & Wisco, 2016). These findings further emphasize that the mental health needs of the general population should be addressed at times of threat in armed conflicts and wars using public health strategies to alleviate the burden of trauma.

Coping with escalation in armed conflicts not only pertains to the security forces but also substantially affects everyday life of the civil population, who still need to attain a range of daily life tasks (Carsone & Pitts, 2018). Previous literature, mostly related to refugee populations, had indicated that such situations lead to major changes to everyday life activities, affecting employment, education, health management, social participation, and home management (Bendavid et al., 2021; Carpiniello, 2023; Schlechter et al., 2021). Similarly, after the October 7 attack and the war in Israel, everyday life of the general population was substantially interrupted by practical aspects of security regulation, among others. Accordingly, we found multiple changes in daily life participation patterns of higher education students, which in the long term can reduce their chances of successful engagement in learning and education. Aside from the expected reduction in entertainment activities, we found high-scale reduction in self-care activities and sport activities and considerable growth in volunteering and quiet leisure activities, as well as in caring for others.

Based on the literature on meaning of caregiving and belonging in war times (Carsone & Pitts, 2018; McCarthy, 2020), we suggest that the occupational alterations seen in this study reflect changes in personal occupational priorities after emergency and traumatic exposure, rather than technical environmental restrictions (Center for Substance Abuse Treatment [CSAT], 2014; Muldoon et al., 2019). The impact of the situation on the valence of occupational experience may be further supported by the findings on reduction in both the meaningfulness of the occupations and the experience of occupational balance. The findings on reduced occupational balance and meaning are in line with those reported by individuals who faced war in Syria and became refugees (Darawsheh, 2019). Still, it is important to remember that the displacement itself may have extensive effect on occupations, in addition to the trauma (Huot, Kelly, & Park, 2016). It is interesting that some areas of participation—including home management, spirituality, and employment—were relatively resistant to the impact of the traumatic exposure, suggesting possible pathways for building stability after such exposure. These may stem from the nature of these occupations, being inherently more structured (i.e., instrumental activities of daily living and employment; Brown, 2019), or alternatively, from their meaning (e.g., supporting daily life and spirituality). However, given the cross-sectional nature of this study, we cannot rule out that it is important to maintain certain areas of occupation, such as self-care and sports, to enhance quality of life after traumatic exposure.

In line with previous studies (May & Wisco, 2016; Schlechter et al., 2021; Shalev et al., 2017; Vieselmeyer et al., 2017), we found that most of the investigated factors, including resilience, trait satisfaction with life, EF, and sense of belonging, were associated with participants’ mental health status. Our results showed that mental health after trauma exposure was accounted for by occupational balance and the extent of change in patterns of daily life occupations; this further suggests that the scope of changes in everyday life as a result of the traumatic event is of importance for coping with trauma (Magruder et al., 2017; May & Wisco, 2016). The pattern of maintaining certain occupations without change while significantly reducing or enhancing others can have particularly detrimental effects on one’s mental health. Our results are in line with previous studies demonstrating that subjective experience within occupations, such as occupational balance, contributes to one’s mental health (Eklund et al., 2017; Gallagher et al., 2015; Hammell, 2014) and is of particular importance for coping with trauma (CSAT, 2014; Muldoon et al., 2019). Thus, addressing patterns of participation, rather than targeting a specific activity, with a focus on experience of balance and change in these patterns after the traumatic exposure, may be a valuable practice to mitigate the impact of the trauma.

Finally, we found that EF was directly associated with participants’ mental health status, confirming theories of cognitive underpinnings of trauma (Shalev et al., 2017). Importantly, we found that EF was associated with mental health indirectly, through the enhancement of occupational adaptation, as was previously demonstrated (Baum et al., 2009). The findings show that occupational balance and consistency of change in daily life occupations mediate the link between mental health and other factors during stressful times, supporting previous theories on the interplay between the factors for participation and health (Eklund et al., 2017; Hammell, 2014; McDougall et al., 2010) and suggesting pathways that may be effective for mitigating multifaceted impacts of trauma. For example, the model revealed that women experienced lower occupational balance, with lower consistency within the occupational change, and had poorer mental health. In addition, participants who were deployed to military service experienced lower occupational balance but still reported having better mental health, possibly because of the higher consistency of changes in occupations. Finally, participants who experienced a higher sense of belonging also had higher occupational balance, followed by better mental health, suggesting the contribution of increased bonding with family and community for coping with trauma (CSAT, 2014; Muldoon et al., 2019).

Our study had several limitations. First, although the sample size was quite large, it may have been less representative given the online data collection procedures. The fact that only a relatively small number of participants were directly involved in the October 7 attack limits our understanding of the potential effect such direct involvement may have. Although we used well-established validated instruments, some of the items were tailored to the purpose of this study, which may have affected the strength of the results. In addition, the use of a cross-sectional design, while still informative, limits our ability to draw causal inferences and may be biased (Savitz & Wellenius, 2023). Future studies should address these limitations.

The field of occupational therapy possesses extensive expertise with regard to occupations, participation, occupational balance, and factors enabling participation. Occupational therapists are uniquely positioned to enhance health-promoting participation and facilitate adaptation amid challenging circumstances, including residing in conflict zones and being exposed to trauma.

This study has the following implications for occupational therapy practice:

• Exposure to traumatic threat can significantly affect participation in various areas of life and occupational balance, debilitating one’s mental health.

• In the context of traumatic threat, it is important to recognize the role of remaining active, keeping balance, and having a sense of belonging in a flexible and adaptive manner, as well as considering the dynamics of individuals’ reality, the environment, and personal values and needs.

• Occupational therapy should be among the core professions that operate at a population level in areas of conflict and exposure to trauma, supporting mental health of young adults during times of crisis.

Given the significant long-term burden of trauma on the individual and the community in general, understanding the factors relating to mental health is of critical importance and may contribute to the prevention of psychological distress and the design of effective evaluations and interventions (Magruder et al., 2017; Shalev et al., 2017). The modifiable factors associated with mental health status found in this study, including occupational change and balance and sense of belonging, may serve as goals for occupation-based intervention approaches and may contribute to better coping mechanisms during traumatic events.