By Cameron Boudreau, Michael Langlais 

Abstract

The goal of this study is to test if resonance frequency breathing exercises will minimize test anxiety. This study used an experimental within-person design where participants completed a resonance breathing exercise after completing the first exam in an undergraduate course of their choosing for seven consecutive days before the second exam in the same course. In total, 316 participants completed the pre-test and 279 completed the post-test. Test anxiety decreased and test performance improved as a result of the resonance breathing exercises, even when controlling for the delivery of the exam, the course, and the seating position used for the breathing exercises. Qualitative results revealed that 88.5% of participants reported utility in the resonance breathing activity, with many reporting themes associated with calmness and increased focus. Our results support the physiological benefits of resonance breathing in collegiate settings regarding test anxiety.

1. Introduction

Anxiety is characterized by the inability to control worry, often causing self-blame and self-doubt [1–3]. A common experience of anxiety is test anxiety, which has many sources including any assignment in the academic setting that requires evaluation, public presentation, and exam performance [4,5]. Since education systems place significant emphasis on passing tests, many students have been burdened with a greater pressure to perform, often promoting higher levels of anxiety in academic settings [6]. This anxiety, stemming from pressure to perform well academically, is labeled test anxiety, which is different from generalized anxiety disorder and anxiety in general [4,6].

Test anxiety is defined as phenomenological and behavioral responses associated with concerns about potential negative consequences before or during an evaluative situation [3,6]. Test anxiety is the situation-specific consequence of evaluation, seen though behavioral, cognitive, and/or physiological responses. The consequences of test anxiety include maladaptive thoughts, task-irrelevant behaviors, or ineffective test preparation strategies leading to declined performance [7]. This worsened performance often leads to decreased self-efficacy, resulting in a cycle of worry and avoidant behaviors, leaving individuals at a higher risk for other forms of anxiety and academic disengagement [7]. Although studies have tested and recommended approaches to help ease general anxiety [3], there are few studies that have examined approaches to temper test anxiety. The goal of this study is to test if resonance frequency breathing exercises will minimize test anxiety.

This study possesses several advantages. First, this study applies an experimental approach that encourages participants to utilize a breathing exercise that has shown positive effects for easing general anxiety. Second, participants completed a test without performing the breathing exercise, and then completed the breathing exercise prior to their next test, which offers the opportunity to test for differences within groups, rather than between groups, and provides empirical data for examining the effectiveness of an intervention [8]. This approach adds validity to the study, as participants engaged in resonance breathing for an actual real-life exam, rather than an exam in a controlled environment that may not have the same consequences as actual exams. Additionally, this study tests a resonance breathing technique to reduce test anxiety, as this slow breathing technique has shown benefits for general anxiety, stress, and depression [9,10]. This study also collected quantitative and qualitative data regarding the efficacy of the proposed breathing activity, which increases the credence of the study data. With these strengths, this study increases our understanding of test anxiety by testing a potential intervention that could alleviate symptoms of this phenomenon.

1.1. Test anxiety

Test anxiety is a situation-specific personality trait consisting of the psychological components of worry and emotional arousal [3,7,11]. Test anxiety is often caused by situations in academic settings where an individual is evaluated, and can occur prior to, during, or following evaluation [7]. The effects of test anxiety include emotional, physiological, and cognitive symptoms, ranging in severity depending on an individual’s predisposition. Symptoms include but are not limited to excessive sweating, racing heart, blushing, trembling, and avoidant behaviors [4–6]. Test anxiety differs from stress in that stress impacts an individual’s ability to interpret situations, whereas anxiety is the response to perceived danger or inability to handle a challenge [12,13].

Test anxiety causes individuals to see themselves as inadequate, only focusing on the possible undesirable consequences of their perceived inadequacy, leading to self-deprecating thoughts and task-irrelevant cognitive activity [14–16]. About 15–22% of elementary to university-aged students reported high levels of test anxiety [12,13], where age and test anxiety are positively correlated [17]. Other systemic examinations have suggested that 25–40% of the population suffers from varying levels of test anxiety, with women and racial minority groups being at higher risk [6,18]. The prevalence of test anxiety in college-aged students has been reported as high as 35%, leading to worsened academic performance [4]. As greater emphasis is placed on test performance in school systems, prevalence is expected to continue to increase [3,4,19].

Multiple models of test anxiety have been proposed in order to better understand this phenomenon. Older models include trait, state, and additive models, while newer models include cognitive interference, affective, and skill deficit models. Hembree [20] proposed trait test anxiety, which suggests that the probability of an individual experiencing test anxiety is based on the level of anxiety they experience in their daily lives. Test anxiety is context-dependent and is influenced by heightened evaluative situations [6]. The additive test anxiety model combines components of the trait and state model, suggesting that test anxiety levels are determined by an individual’s overall anxiety and the stressful context of evaluation [3]. Test anxiety has more recently been divided into components of worry, emotionality, and social factors [6]. The component of worry is seen as cognitive test anxiety, focusing on the cognitive processes causing the anxiety, leading to cognitive barriers that decrease performance. Emotionality is defined as affective test anxiety, focusing on the awareness of anxiousness caused by internal and external cues, leading to physiological reactions. More recent research has identified the effects of social components on test anxiety, yet its effects on anxiety levels are still unclear [3]. Although both cognitive and affective test anxiety are known to decrease academic performance, the worry caused by cognitive test anxiety is more detrimental as it prevents the individual from processing information at multiple phases in the learning cycle [3]. Test anxiety levels are determined by an individual’s traits and the context of evaluations, while anxious symptoms can be seen through cognitive barriers and physiological reactions.

Test anxiety causes emotional, physiological, and cognitive reactions, and these reactions lead to worsened test performance and academic disengagement. An individual with test anxiety may experience symptoms prior to evaluation, during evaluation, or after the evaluation has occurred. Cognitive test anxiety is accompanied by cognitive reactions including maladaptive thoughts, distractions, self-doubt, inadequate perceptions, and self-blame prior to or during evaluation [6,20,21]. Physiological reactions accompany affective or test anxiety, such as tension, increased heart rate, dry mouth, involuntary trembling, dizziness, nausea, and increased experiences of panic [20]. All forms of test anxiety are caused by internal and external cues triggered by an individual feeling as if their self-esteem is being threatened [3,11]. DordiNejad and colleagues [17] evaluated the relationship between test anxiety and academic performance in Iranian students ranging from age 18 to 39. Using the Sarason [22] test anxiety questionnaire, they found that 44% of participants reported low test anxiety, 35.3% moderate test anxiety, and 20.7% high levels of test anxiety. They also found a significant negative correlation between test anxiety and academic performance, measured by GPA [17]. Chapell et al. [23] found that undergraduate and graduate students from New Jersey, Pennsylvania, and Illinois with low levels of test anxiety averaged a higher GPA than students with high test anxiety, with females reporting significantly higher levels of test anxiety and higher GPA than males. These contradictory findings may be explained by differences in test items, test frequencies, and differentiating academic disciplines between Iranian medical students and American undergraduate and graduate students. While researchers have recently increased their focus on the effects of test anxiety in academic settings, more research needs to be conducted to understand how test anxiety and academic performance are related.

1.2. Coping with test anxiety

Anxiety manifests in many forms–the most prevalent being generalized anxiety or excessive anxiety and worry about a number of events or activities [24]. Individuals with generalized anxiety cope using various approaches: prescriptions medications (SSRIs, SNRIs, and benzodiazepines); psychological therapies, such as acceptance and commitment; psychodynamic, emotion-focused, dialectical behavioral, and cognitive behavioral therapies; and mindfulness-based interventions [25]. More recent interventions for generalized anxiety disorder include magnetic stimulation and transcranial direct current stimulation [25]. Cognitive behavioral therapy and the use of pharmacological treatments, or a combination of the two, yield the best treatment outcomes for generalized anxiety disorder [26].

The use of prescription medication, brain simulation, and the use of psychological therapies have also been beneficial in treating test anxiety. A meta-analysis evaluated the use of test anxiety reduction techniques in group and individual settings, finding the most effective psychological interventions to be those that combined skill-focused approaches with behavioral or cognitive approaches in individual or individual and group settings, and when therapies were short in duration [19]. Zeidner [27] proposed a model that aimed to clarify the difference between cognition and emotion therapies for treating test anxiety. Emotion therapies include relaxation techniques, systematic desensitization, and anxiety management training, while cognition therapies include cognitive behavior modification, attentional training, and cognitive restructuring [27]. A meta-analysis by Neuderth et al. [28] summarized the effectiveness of emotions, cognitions, and skills training, finding systematic desensitization, cognitive restructuring, anxiety management training, flooding, and attentional training to produce significant declines in test anxiety across multiple studies. From these findings, the use of psychological therapies is an optimal form of treatment for test anxiety, but there are inconsistent findings regarding the different types of therapy.

An alternative approach could be mindfulness-based interventions or relaxation techniques, which are often represented by slow breathing techniques. The use of controlled breathing and yoga postures, for instance, has garnered clinical support [4,29,30]. Through randomized controlled trials, Cho et al. [29] found that mindfulness breathing and cognitive reappraisal significantly lowered test anxiety and that mindfulness breathing increased positive automatic thought compared to the control condition. Slow breathing has also been associated with physiological health benefits, such as lowered heart rate and stress levels, leading to a decreased in blood pressure and reduced risk for heart disease [10].

Studies have found that the neurophysiological processes engaged during slow breathing increase the functioning of cognitive and behavioral outcomes, which are found in alternative mindfulness exercises [9,31]. Slow breathing is a generalized term that includes many types of non-restricted breathing techniques with a rate of less than 10 breaths per minute [32]. Slow breathing techniques differ in inhale and exhale frequencies, body positions, and specifications of nostril or mouth breathing. Resonance breathing is a distinct class of slow breathing which has been found to reduce symptoms of anxiety and depression [10]. Resonance breathing is described as breaths that are the exact frequency of baroreflex-induced oscillations in heart rate and blood pressure, and the baroreflex effect is augmented by the effect of respiratory sinus arrhythmia [33]. This class of slow breathing is typically categorized by 4.5 to 7 breaths per minute [34]. Resonance breathing slows down an individual’s breathing by inhaling once one’s heart rate begins to ascend, changing the baroreflex to decrease blood pressure and heart rate [33].

Research on the effects of slow breathing illustrates physical and psychological benefits, such as the reduction in anxiousness, and increases in academic performance. Tavoian and Craighead [10] found diaphragmatic breathing to have physiological and psychological benefits that carry over into the workplace, such as reduced costs related to sick time off, reduced workplace stress, and higher workplace morale. A known physiological benefit of slow breathing exercises is lowered blood pressure, which could reduce an individual’s risk of cardiovascular disease, stroke, and heart disease [10]. Researchers have also found that increased oxygen supply helps to distribute energy through the body and aids in waste disposal, allowing for optimal organ function [30,34,35]. Additional psychological benefits of slow breathing include reduced feelings of anxiety and depression, lowered stress levels, and a reduced risk of panic attacks [10,35,36]. The decline in blood pressure and heart rate linked to slow breathing increases oxygen flow to the brain while diminishing the energy needed for organ functioning. An increase in oxygen flow to the brain deactivates the sympathetic nervous system, reducing the levels of cortisol in the bloodstream and lowering blood pressure. Returning cortisol levels to homeostasis activates the parasympathetic nervous system and decreases stress. Zaccaro et al. [31] found that the deactivation of the stress response within the sympathetic nervous system stress and activation of the parasympathetic nervous system links slow breathing to decreased anxiety. Similarly, Won and Kim [37] found that lower stress levels increased sympathetic activity and reduced levels of depression caused by enzyme imbalance. Essentially, slow breathing exercises have been proven to reduce stress and anxiety.

There is some evidence that slow breathing can serve as a treatment for test anxiety. Heath and Cassady [3] examined the effectiveness of a brief digital mindfulness exercise on 138 undergraduate students. They randomly assigned participants to a relaxation group who watched a mindfulness video or a guided meditation group who watched a mindfulness video and received instructions. These researchers found that by viewing the mindfulness video, both groups experienced a decrease in state anxiety, and that there were no differences between groups [3]. Mindfulness techniques may be as beneficial when completed individually. Another study investigated the effects of device-guided breathing on reducing test anxiety in 21 college students [38]. In this study, students were randomized into control or breathing groups. Afterwards, the breathing group completed exercises for 15 min daily over three weeks with instruction from a RESPeRate device and the research team. As a result, Ovadiad-Blechman et al. [38] found a significant decrease in test anxiety in the breathing group.

Slow breathing can have a significant impact on decreasing test anxiety if administered over a long period of time. Rosenberg and Hamiel [39] ran a randomized controlled experiment on 34 students to examine the effect of biofeedback respiratory practice devices on test anxiety levels. They compared the biofeedback breathing device with self-directed breathing and psychoeducation groups. Participants in the biofeedback device group reported significantly reduced levels of test anxiety, as well as decreased levels of depression and anxiety [39]. Cho et al. [29] compared the effects of mindfulness breathing and cognitive reappraisal on test anxiety levels in highly anxious students. In this study, students were trained in mindfulness breathing or cognitive reappraisal, completing six additional days of training after the initial session. Findings showed that both cognitive reappraisal and mindfulness breathing techniques yielded significantly decreased levels of test anxiety, while the breathing group also reported an increase in positive automatic thoughts over time [29]. This study showed the efficacy of slow breathing in reducing test anxiety, while also showing its effects on increasing positive automatic thoughts.

The literature on test anxiety has focused on some similar themes. First, test anxiety is prevalent across multiple demographic variables. Second, slow breathing exercises have positive effects for decreasing general anxiety, with some initial evidence showing that slow breathing can also be beneficial for reducing test anxiety. The literature on slow breathing shows positive effects if it is in short duration, guided, and involves mindfulness. Given this information, the goal of this study is to examine the effects of resonance breathing exercises on reducing test anxiety symptoms. It is predicted that individuals who engage in these slow breathing exercises will experience a significant decrease in test anxiety. This study utilizes an experimental, within-person approach, where participants take an exam in a course and then engage in a slow breathing exercise for seven days prior to a second exam.

2. Materials and methods

2.1. Procedures and participants

The data for this study are derived from undergraduate students taking Human Development and Family Science courses at a large university in the southeastern United States. Participants were recruited using announcements on Canvas in volunteering classes. Before the study began, all participants provided consent electronically, which was on the first page of the online survey representing the pre-test. For the pre-test, participants answered questions about their current level of test anxiety and then provided dates of when they had exams in a selected course that semester (participants could choose the course that they were enrolled in, but more than 80% of participants chose a different course) and the score on the first exam. Participants were instructed to choose a course in which they had already had at least one exam and would have at least one more exam before the end of the semester (22 participants were excluded from the study because they did not provide a score for their first exam, or the course they selected did not have any exams or only had one exam that semester). All exams were required to be on the same scale (0 to 100, with higher scores meaning higher grades). A week before the date of their second exam, participants were sent instructions for how to complete the resonance breathing activity. This approach was selected because previous studies used written instructions to engage in mindfulness or slow breathing techniques [28]; the written instructions were reviewed by two experts in the field to ensure that they were clear and adequately described how to conduct the exercise. These instructions illustrated that participants should sit comfortably in a quiet, dark room, turn off anything that could be a distraction (such as a TV or mobile phone), choose one of four breathing positions, and follow the instructions of a Slow Breathing YouTube video, adopting a rate of 6 breaths per minute (BPM), where participants inhaled for 5 s and exhaled for 5 s. Within 24 h of participants completing their second exam, they were emailed an online post-test. Participants were told to complete this survey within 24 h; on the post-test, participants reported their scores on the second exam, their test anxiety, and the format of the second exam. All aspects of this study were approved by the Florida State University Institutional Review Board (STUDY 00003555).

Demographic information regarding the percentage of participants who completed the post-test is presented in Table 1. Of those that completed the post-test, the majority identified as female (89.6%) and 10.4% identified as male (no participants selected “other” or abstained from the question). Most participants identified as white (65.5%), followed by Hispanic (21.1%), Black (13.3%), other (3.2%), and Asian (2.9%). Most participants were second-year students (46.2%), followed by third-year students (21.1%), first-year students (16.5%), and fourth-year students (15.8%; one participant selected “other”). The average age of participants was 20.04 years (SD = 2.97). The average GPA of participants was 3.70 out of 4.00 (SD = 2.04) and the average number of credit hours that participants were enrolled in during the study was 14.62 (SD = 10.23).

Categorial data are presented as counts with column percentages in parentheses. Quantitative data are presented as means with standard deviations in parentheses. For ethnicity, participants could select multiple options; thus, the percentages exceed 100%.

2.2. Measures

Test anxiety was measured using two different scales. The first scale was the Test Anxiety Questionnaire (TAQ) [40], which has been recommended by other researchers to reduce participant fatigue [7]. This scale comprises four items on a 7-point Likert scale, ranging from 1 (none) to 7 (a lot). Scores were summed and therefore range from 4 to 28. A low score (4–7) indicates no or extremely low test anxiety. Scores ranging from (8–15) indicate some characteristics of test anxiety, but the level of stress and tension is not unhealthy. Scores over 16 indicate unhealthy levels of test anxiety [40]. This scale displayed acceptable internal reliability (Cronbach’s alpha = 0.89). The second scale is Sarason’s [22] test anxiety scale. This scale has 36 true/false items. True items were scored as one and false items were scored as zero. Scores over 20 indicate high test anxiety [22]. This scale displayed acceptable internal reliability (Cronbach’s alpha = 0.83).

Resonance breathing was measured by having participants watch a 10 min YouTube video [41] prior to an exam. This video was selected based on recommendations from three professional clinicians who used it with their clients. The video provided instructions about when to inhale and exhale and is similar to those applied in other studies that use slow breathing techniques [19,30]. Additionally, participants were asked to assume one of four positions, all sitting, in order to increase the amount of oxygen delivered to the brain [19,30]. Information about the four breathing positions and the instructions given to participants regarding the resonance breathing are presented in Supplementary materials.

Exam performance was measured by first, asking participants to provide their percent grade (out of 100%) for an exam prior to performing the resonance breathing exercise again after they took a second exam. Second, participants were asked to identify the format of their tests and whether the format of the test changed over the course of the study. It is important to note that test format did not change for any participant during the study. The options for the format of test included in-person, online, open-note, closed-note, HonorLock (HonorLock is a software that monitors students while they take an exam remotely and tracks whether the student may cheat, by accessing different web browsers or looking away from a computer monitor), and other. Participants could select multiple options for the format of their exams for that semester.

2.3. Data analysis

First, data were analyzed using paired-samples t-tests to examine differences between test anxiety before the slow breathing started (pre-test) and within 24 h of taking an academic exam (post-test). Participants completed the breathing exercise before the second or subsequent exam in the selected course, so that scores between the initial exam and the subsequent exam could be compared. Second, regressions were used to determine whether the type of test or the breathing position that participants used during the study significantly predicted test anxiety. Third, participants’ open-ended responses were coded using Braun and Clarke’s [42] thematic coding structure, which involves six steps: (1) become familiar with the data by reviewing participants’ responses over and over; (2) identify emerging themes and patterns to put into codes; (3) re-organize data by theme and manually code into smaller themes, when necessary; (4) review themes for continuity; (5) organize data into a code book to generate a report; and (6) produce a report based on the themes and the other elements of the study (literature review and methodology). Themes were reviewed by an individual who was blind to the study hypothesis to ensure consistency with participant responses [43].

3. Results

3.1. Quantitative results

Of the 316 participants who completed the pre-test, 279 completed the post-test (88.3%). The hypothesis of this study stated that resonance breathing exercises would significantly reduce test anxiety. To first test this hypothesis, paired-samples t-tests were conducted. The results of these analyses are presented in Table 2. The hypothesis was supported, as participants reported significant declines in test anxiety across both measures. Additionally, participants reported significantly improved test scores as a result of the resonance breathing exercises. Next, the type of test was used a predictor variable to understand if the test method impacted test anxiety after the breathing exercises. In other words, did the type of exam matter regarding reductions in test anxiety? The results are presented in Table 3 and show no significant effects for type of test. This analysis initially support the effectiveness of the resonance breathing exercise, regardless of the type of test that the participants took. Next, a linear regression analysis sought to predict whether the breathing position that participants adopted impacted participants’ test anxiety scores after the resonance breathing exercise. The results of this analysis are presented in Table 4. None of the positions that participants used for resonance breathing predicted differences in testing anxiety. It is important to note that gender and ethnicity (both dichotomized) were added as control variables; however, they were not significant, and therefore are not presented for parsimony.

Data are presented as means with standard deviation in parentheses. Exam 1 vs. Exam 2 refers to the grade for Exam 1, which was captured in the pre-test, and the grade for Exam 2, which was captured in the post-test. Note that all exams were on grading scales of 0 to 100, with higher scores indicating better grades. Test anxiety 1 refers to data using the Test Anxiety Questionnaire (TAQ) [40], and test anxiety 2 refers to data using Sarason’s [22] test anxiety scale.

Data are presented as standardized beta coefficients with standard error in parentheses. Test anxiety 1 refers to data using the Test Anxiety Questionnaire (TAQ) [40], and test anxiety 2 refers to data using Sarason’s [22] test anxiety scale. In-person and online refer to the format of the exam; open- and closed-note refer to whether or not notes were allowed (open) or not (closed) for the exam. HonorLock refers to whether or not this software was used to prevent students from accessing other webpages or browsers while taking the exam. Other refers to any other specific parameter that was established for the exam, such as using a specific tool to complete the exam. *** p < 0.001.

Data are presented as standardized beta coefficients with standard error in parentheses. Test anxiety 1 refers to data using the Test Anxiety Questionnaire (TAQ) [40] and test anxiety 2 refers to data using Sarason’s [22] test anxiety scale. The breathing positions refer to each of the five different positions that participants could use when completing the breathing technique. *** p < 0.001.

3.2. Qualitative results

Participants were asked the following question, “After completing this study would you continue to implement slow breathing into your everyday life or before a stressful exam? If so, please explain why.” Of the 289 participants who completed the post-test, 116 participants reported “yes” they would continue to implement breathing exercises, 7 participants reported “maybe”, 8 participants reported “no”, and 157 left this question blank. Additionally, three themes were derived from participants’ explanations of why they would or would not continue to implement the resonance breathing exercise: calm (64.9%), stay focused (15.3%), and too much time (5.3%). First, participants reported that breathing exercises helped them stay calm and stay focused. Participants reported that the breathing exercises helped them stay calm before and during their exams. One participant stated, “the breathing exercise helped me fall asleep easier”, while other participants reported “it helped ground myself”, “it helps me calm down before a big exam”, and “it really helped calm my nerves and help me relax”. Participants reported that the breathing exercises helped them stay focused during their exams, as one reported, “they helped prevent my mind from wandering”. Other participants stated, “it kept me calm and focused”, “it helped me focus more and overall do better than I did before”, and “it allowed me to clear my head and I felt more relaxed”. However, not all themes were positive. Participants that reported “no” stated the breathing exercise took up too much time. One participant stated, “took up time I could have been using to study”. Others wrote, “I got distracted sitting for that long” and “I was getting stressed out having to breath for 10 min”. Most participants (88.5% of those who answered) found the breathing exercises to be beneficial and would continue implementing them after completing this study. Those that reported “no” found the exercise to be too long and became distracted or overwhelmed.

4. Discussion

Test anxiety is a common experience in academic contexts. Given that mindfulness and slow breathing exercises have been helpful in reducing general anxiety [3,19,30,39], the goal of this study was to experimentally test if a resonance breathing exercise would reduce test anxiety. Quantitative and qualitative results suggest that this approach did effectively reduce test anxiety for the majority of participants. The exercise also led to higher grades in second or subsequent exams compared to previous exams within the same course. These effects remained significant even when controlling for different testing conditions and breathing positions. This study adds to the literature about the benefits of slow breathing for anxiety by specifically honing in on test anxiety.

First, it is important to identify the strengths of the resonance breathing exercise and why it was helpful for many participants. Previous studies have illustrated the physiological benefits of resonance breathing, which aids in supplying the body with oxygen and releasing carbon dioxide as well as other toxins [34]. The increased oxygen intake helps stimulate endocrine glands; provide energy for the brain, nerves, heart, and other vital organ functions; and distribute energy throughout the body [30]. Reduced oxygen intake caused by errors in breathing causes incorrect waste disposal from the body, slowing organ functions [30]. Thus, by increasing oxygen intake, individuals had more time to focus and relax when preparing for the exam, which likely helped reduce test anxiety. This explanation is consistent with other studies that showed the benefits of other types of mindfulness breathing for decreasing test anxiety while increasing test performance [3,19,30]. However, this study highlights the benefits of expanding the method for completing breathing exercises, such as completing the exercises individually and when convenient for the participant.

There were also logistical reasons why the resonance breathing exercises were helpful. First, participants could complete the breathing exercise in a location that they felt most comfortable and in a preferred seating position. This positioning is important because sitting aids with oxygen being delivered to the brain. Participants were not restricted on the time of day that breathing exercises must be completed, and therefore they were able to complete the breathing exercises when most convenient for them. Since participants had the choice about where and when they could participate in the breathing exercises, they may have been less likely to be stressed when completing the activity, which was advocated by consulted physicians, the associated institutional review board for this study, and similar to previous studies [19].

Furthermore, resonance breathing may have had positive impacts on participants because it can reduce stress, which is comorbid with test anxiety [10,30,44]. The reduction in stress may have helped participants score higher on their second exam after completing the resonance breathing exercises. Increased test performance may have been caused by the increased oxygen intake or the increased positive automatic thoughts caused by resonance breathing, which occurs when stress declines [19]. In addition, some participants reported that they would continue to implement resonance breathing into their daily lives after completing this study, a common theme that was found with participants’ open-ended responses.

4.1 Limitations

Although this study advances the literature on text anxiety, it is not without limitations. First, the sample for this study was relatively homogeneous and only included participants from a single university, limiting its generalizability. Additionally, there are other factors that could have impacted the results of this study that were not controlled for by the research team. For example, the longer a student is on a course, the more likely they are to become familiar with a course and its evaluation materials, meaning that participants may have become less anxious simply due to already taking a test in the class and/or becoming more familiar with course materials. Students have shown developmental improvement in college courses as a result of time spent on the course (i.e., [45]). This study also did not measure or control for study habits, which have also been linked to improved academic outcomes [46,47]. Other potential confounding variables include the number of difficult classes participants are taking, the total number of hours they are enrolled for, or whether or not this is the first time they are taking this class (or if they are re-taking this class). Future studies are encouraged to control for each of these confounding variables to determine if study findings are replicable.

Additionally, the implementation of the resonance breathing technique could have been improved. Rather than providing instructions to participants via a handout, the research team could have worked individually with participants to teach them how to engage in the resonance breathing techniques. Additionally, another video demonstrating resonance breathing could have been selected for the activity. The video selected for this study met the criteria of being accessible to all participants, being clear in its instructions, and following a 6 BPM pattern, which is known to reduce stress [34,35]. Although the current video was similar to those used in other studies and supported by consulted clinicians, it could have provided a more calming background and more peaceful tone.

Additionally, the research team did not monitor participants to ensure that the participants engaged in the resonance breathing activity; thus, we cannot guarantee that all the participants completed the resonance breathing activity for each of the seven days leading up to their next exam. Although this reduces faith in the findings, this decision was made after consulting clinicians about watching participants perform the resonance breathing activity and consulting the institutional review board. First, given the small number of people on the research team, it would have been difficult to schedule individual meetings with participants to teach them how to do resonance breathing, and even harder to individually monitor participants while they carried out the activity. These feasibility and confidentiality issues limited the ability of the research team to meet individually with participants and monitor their resonance breathing. We believe that by providing participants the opportunities to perform the resonance breathing activity on their own in a location and position they selected, participants would be less anxious about the activity and could fully focus on the breathing exercise. We also captured qualitative information to better understand participants’ experiences with the intervention to ensure the validity of the proposed intervention.

5. Conclusions

Given these limitations, we propose some specific ideas for future studies. First, we recommend selecting different resonance breathing videos to determine if there are differences based on multimedia delivery. Second, we recommend that researchers meet with participants to model and practice resonance breathing activities to ensure that participants understand how to conduct the exercise. Third, future studies could monitor participants to ensure that they perform the activity, but this should be carried out in such a way that participants are not anxious about being monitored. The approach analyzed in this study incorporated a cost- and time-effective breathing technique that would be feasible for participants to complete.

Although this study has some limitations, it contributed to the literature in a number of ways. First, it directly addressed a call to examine ways to minimize test anxiety [7]. Second, it advanced the literature on resonance breathing techniques by exploring the effectiveness of slow breathing in the context of test anxiety. Third, this study used a within- and between-participant approach to test if the approach was effective in reducing test anxiety. Results of the current study reflect many benefits of resonance breathing in reducing test anxiety in a college sample. Future studies are encouraged to examine test anxiety with other academic contexts to confirm the findings of the current study. Generally, this study provides the foundation for future studies seeking to explore the efficacy of resonance breathing for reducing test anxiety and improving academic performance.

References

1

Crocq M-A. The history of generalized anxiety disorder as a diagnostic category. Dialogues Clin Neurosci. 2017;19(2):107–16. doi: 10.31887/dcns.2017.19.2/macrocq

2

DeMartini J, Patel G, Fancher TL. Generalized anxiety disorder. Ann Intern Med. 2019;170(7):ITC49–64. doi: 10.7326/aitc201904020

3

Heath JA, Cassady JC. The efficacy of brief digital mindfulness interventions on student anxiety [Ph.D thesis]. Muncie: Ball State University; 2021 [cited 2023 Jun 17]. Available from: https://www.proquest.com/openview/71933221fd726e79a3452f20c291b18e/1?pq-origsite=gscholar&cbl=18750&diss=y

4

Hjeltnes A, Binder PE, Moltu C, Dundas I. Facing the fear of failure: An explorative qualitative study of client experiences in a mindfulness-based stress reduction program for university students with academic evaluation anxiety. Int J Qual Stud Health Well-being. 2015;10(1):27990. doi: 10.3402/qhw.v10.27990

5

Leitenberg H. Handbook of social and evaluation anxiety. Berlin/Heidelberg: Springer; 1990.

6

Bradley RT, McCraty R, Atkinson M, Arguelles L, Rees RA, Tomasino D. Reducing test anxiety and improving test performance in America’s schools: Results from the TESTEDGE national demonstration study. PsycEXTRA Dataset. 2007. doi: 10.1037/e503102012-001

7

von der Embse N, Jester D, Roy D, Post J. Test anxiety effects, predictors, and correlates: A 30-year meta-analytic review. J Affect Disord. 2018;227:483–93. doi: 10.1016/j.jad.2017.11.048

8

Singer JD, Willett JB. Applied longitudinal data analysis: Modeling change and event occurrence. Oxford: Oxford University Press; 2003.

9

Noble DJ, Hochman S. Hypothesis: Pulmonary afferent activity patterns during slow, deep breathing contribute to the neural induction of physiological relaxation. Front Physiol. 2019;10:1179. doi: 10.3389/fphys.2019.01179

10

Tavoian D, Craighead DH. Deep breathing exercise at work: Potential applications and impact. Front Physiol. 2023;14:1040091. doi: 10.3389/fphys.2023.1040091

11

Cassady JC. Anxiety in the schools: Causes, consequences, and solutions for academic anxieties. In: Handbook of Stress and Academic Anxiety. Berlin/Heidelberg: Springer; 2022. p. 13–30. doi: 10.1007/978-3-031-12737-3_2

12

Putwain D, Daly AL. Test anxiety prevalence and gender differences in a sample of English secondary school students. Educ Stud. 2014;40(5):554–70. doi: 10.1080/03055698.2014.953914

13

Thomas CL, Cassady JC, Finch WH. Identifying severity standards on the Cognitive Test Anxiety Scale: Cut score determination using latent class and cluster analysis. J Psychoeduc Assess. 2017;36(5):492–508. doi: 10.1177/0734282916686004

14

Bedell JR, Marlowe HA. An evaluation of test anxiety scales: Convergent, divergent, and predictive validity. In: Spielberger CD, Vagg PR, editors. Test anxiety: Theory, assessment, and treatment. Abingdon: Taylor & Francis; 1995. p. 35–45.

15

Putwain DW, von der Embse NP, Rainbird EC, West G. The development and validation of a new Multidimensional Test Anxiety Scale (MTAS). Eur J Psychol Assess. 2021;37(3):236–46. doi: 10.1027/1015-5759/a000604

16

Sommer M, Arendasy ME. Comparing different explanations of the effect of test anxiety on respondents’ test scores. Intelligence. 2014;42:115–27. doi: 10.1016/j.intell.2013.11.003

17

DordiNejad FG, Hakimi H, Ashouri M, Dehghani M, Zeinali Z, Daghighi MS, et al. On the relationship between test anxiety and academic performance. Procedia Soc Behav Sci. 2011;15:3774–78. doi: 10.1016/j.sbspro.2011.04.372

18

Cartwright-Hatton S, McNicol K, Doubleday E. Anxiety in a neglected population: Prevalence of anxiety disorders in pre-adolescent children. Clin Psychol Rev. 2006;26(7):817–33. doi: 10.1016/j.cpr.2005.12.002

19

Ergene T. Effective interventions on test anxiety reduction. Sch Psychol Int. 2003;24(3):313–28. doi: 10.1177/01430343030243004

20

Hembree R. Correlates, causes, effects, and treatment of test anxiety. Rev Educ Res. 1988;58(1):47–77. doi: 10.3102/00346543058001047

21

Segool NK, von der Embse NP, Mata AD, Gallant J. Cognitive behavioral model of test anxiety in a high-stakes context: An exploratory study. Sch Ment Health. 2013;6(1):50–61. doi: 10.1007/s12310-013-9111-7

22

Sarason IG. Test anxiety: theory, research, and applications. Ann Arbor: L. Erlbaum Associates; 1980.

23

Chapell MS, Blanding ZB, Silverstein ME, Takahashi M, Newman B, Gubi A, et al. Test anxiety and academic performance in undergraduate and graduate students. J Educ Psychol. 2005;97(2):268–74. doi: 10.1037/0022-0663.97.2.268

24

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington (DC): American Psychiatric Association, 2013. doi: 10.1176/appi.books.9780890425596

25

Lee HJ, Stein MB. Update on treatments for anxiety-related disorders. Curr Opin Psychiatry. 2022;36(2):140–45. doi: 10.1097/yco.0000000000000841

26

Antony MM. Recent advances in the treatment of anxiety disorders. Can Psychol/Psychol Can. 2011;52(1):1–9. doi: 10.1037/a0022237

27

Zeidner M. Test anxiety: The state of the art. New York (NY): Plenum Press; 1998.

28

Neuderth S, Jabs B, Schmidtke A. Strategies for reducing test anxiety and optimizing exam preparation in German university students: A prevention-oriented pilot project of the University of Würzburg. J Neural Transm. 2008;116(6):785–90. doi: 10.1007/s00702-008-0123-7

29

Cho H, Ryu S, Noh J, Lee J. The effectiveness of daily mindful breathing practices on test anxiety of students. PLoS ONE. 2016;11(10):e0164822. doi: 10.1371/journal.pone.0164822

30

Nemati A. The effect of pranayama on test anxiety and test performance. Int J Yoga. 2013;6(1):55. doi: 10.4103/0973-6131.105947

31

Zaccaro A, Piarulli A, Laurino M, Garbella E, Menicucci D, Neri B, et al. How breath-control can change your life: A systematic review on psycho-physiological correlates of slow breathing. Front Hum Neurosci. 2018;12:353. doi: 10.3389/fnhum.2018.00353

32

Birdee G, Nelson K, Wallston K, Nian H, Diedrich A, Paranjape S, et al. Slow breathing for reducing stress: The effect of extending exhale. Complement Ther Med. 2023;73:102937. doi: 10.1016/j.ctim.2023.102937

33

Lehrer PM, Vaschillo EG, Vidali V. Heart rate and breathing are not always in phase during resonance frequency breathing. Appl Psychophysiol Biofeedback. 2020;45(3):145–52. doi: 10.1007/s10484-020-09459-y

34

Chaitanya S, Datta A, Bhandari B, Sharma VK. Effect of resonance breathing on heart rate variability and cognitive functions in young adults: A randomised controlled study. Cureus. 2022;14(2):e22187. doi: 10.7759/cureus.22187

35

Russo MA, Santarelli DM, O’Rourke D. The physiological effects of slow breathing in the healthy human. Breathe (Sheff). 2017;13(4):298–309. doi: 10.1183/20734735.009817

36

Steffen PR, Austin T, DeBarros A, Brown T. The impact of resonance frequency breathing on measures of heart rate variability, blood pressure, and mood. Front Public Health. 2017;5:222. doi: 10.3389/fpubh.2017.00222

37

Won E, Kim YK. Stress, the autonomic nervous system, and the immune-kynurenine pathway in the etiology of depression. Curr Neuropharmacol. 2016;14(7):665–73. doi: 10.2174/1570159×14666151208113006

38

Ovadia-Blechman Z, Tarrasch R, Velicki M, Chalutz Ben-Gal H. Reducing test anxiety by device-guided breathing: a pilot study. Front Psychol. 2022;13:678098. doi: 10.3389/fpsyg.2022.678098

39

Rosenberg A, Hamiel D. Reducing test anxiety and related symptoms using a biofeedback respiratory practice device: A randomized control trial. Appl Psychophysiol Biofeedback. 2021;46(1):69–82. doi: 10.1007/s10484-020-09494-9

40

Nist P, Diehl M. Test anxiety questionnaire. 1990. [cited 2024 Aug 16]. Available from: https://nursing.lsuhsc.edu/apps/AcademicSuccessProgram/AnxietyQuestionnaire/

41

Resonance. HRV breathing exercise (6 BPM)—5 seconds in, 5 seconds out (resonance frequency breathing) [internet]. YouTube. 2019 [cited 2023 Jun 17]. Available from: https://www.youtube.com/watch?v=eRWtytSjKZs

42

Braun V, Clarke V. Conceptual and design thinking for thematic analysis. Qual Psychol. 2022;9(1):3–26. doi: 10.1037/qup0000196

43

Braun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol. 2021;18(3):328–52. doi: 10.1080/14780887.2020.1769238

44

Sundram BM, Dahlui M, Chinna K. Taking my breath away by keeping stress at bay: An employee assistance program in the automotive assembly plant. Iran J Public Health. 2014;43(3):263–72.

45

Naujoks N, Harder B, Händel M. Testing pays off twice: Potentials of practice tests and feedback regarding exam performance and judgment accuracy. Metacogn Learn. 2022;17(2):479–98. doi: 10.1007/s11409-022-09295-x

46

Kasyoka A. Self-esteem, study habits and academic performance among university students. Afr J Educ Pract. 2023;9(2):43–53. doi: 10.47604/ajep.1995

47

Rabia M, Mubarak N, Tallat H, Nasir W. A study on study habits and academic performance of students. Int J Asian Soc Sci. 2017;7(10):891–97. doi: 10.18488/journal.1.2017.710.891.897

Published in Academia Mental Health and Well-Being

Volume 1; Issue 3 doi.org/10.20935/MHealthWellB7461

Keywords; breathing, anxiety, mental health