Alleviating adolescent stress, anxiety, and fear through music and sports games during the COVID-19 pandemic: A randomized controlled trial

Summary

This study assessed the effects of combining music with sports games on stress and anxiety relief in adolescents during the COVID-19 pandemic. Methods: In an 8-week randomized trial, 200 participants were divided into four groups: music-only, sports-only, combined music and sports, and a control group (traditional exercise). Stress (SAVE-6), anxiety (FCV-19), SpO₂, and heart rate (HR) were measured before and after the intervention. (1) All groups reduced stress and anxiety (p < 0.05), with the combined group showing the greatest improvement (p < 0.05). (2) Sports and combined groups significantly reduced fear of COVID-19 (p < 0.05). (3) SpO₂ improved most in the combined group (p < 0.05). (4) HR decreased significantly in sports and combined groups (p < 0.05). Combining music and sports games effectively reduces stress and anxiety while improving physiological health in adolescents.

Graphical abstract

Highlights

• •Music-sports combo reduced stress/anxiety (p < 0.05)
• •Combo & sports alone eased COVID fear; music/control no change
• •Combo had higher SpO2, lower HR, better physiological regulation
• •Combo outperformed all groups in psycho/physiological metrics

Kinesiology; Psychology

Introduction

In the context of the ongoing COVID-19 pandemic, adolescents have been particularly vulnerable to elevated levels of stress, anxiety, and fear. The restrictions, social isolation, and uncertainty associated with the pandemic have disrupted their daily lives, educational routines, and social interactions. Existing literature has shown that such negative psychological states can have long-term impacts on adolescents’ mental and physical health, as well as their academic performance and social development. For example, persistent stress may lead to weakened immune systems, making adolescents more susceptible to illnesses, and anxiety can impede their ability to concentrate in school.¹ Despite the growing recognition of these issues, there is a lack of comprehensive research on effective, accessible, and non-invasive interventions that can be implemented in school settings to address these concerns. This study aims to fill this gap by investigating the potential of music and sports games as means to alleviate stress, anxiety, and fear among adolescents during the pandemic.

The enduring presence of COVID-19 has been recognized as a potential trigger for increased levels of stress, anxiety, and fear among adolescents, posing a significant risk to their mental and physical well-being.^2,3 Adolescence, being a crucial stage in psychological development, holds substantial influence over future mental health and social adaptability.^4,5,6 Given the heightened vulnerability of adolescents’ mental health during this period, the presence of elevated stress, anxiety, and fear becomes an even more pressing concern. Prolonged exposure to elevated levels of stress, anxiety, and fear can have detrimental effects on both the physical and mental health of adolescents.^7,8,9 Research indicates that persistent stress, anxiety, and fear may lead to various physical health issues, encompassing headaches, muscle tension, digestive problems, and a weakened immune system.^10,11,12,13 Moreover, subsequently, prolonged exposure to these negative states can contribute to mental health problems, such as depression, anxiety disorders, and post-traumatic stress disorder.^14,15 Consequently, adolescents may grapple with feelings of helplessness, despair, or hopelessness, potentially impacting academic performance through issues like lack of concentration, decreased memory, and reduced learning motivation.^16,17,18 In addition to its impact on individual well-being, long-term stress, anxiety, and fear can impede the development of social skills, making it challenging for adolescents to establish healthy relationships with peers.^19,20 This can lead to feelings of loneliness and social isolation, fostering the development of negative behaviors and lifestyle habits that may, in turn, affect their careers, family lives, and overall well-being.^21,22

Even with the current decline in COVID-19 incidence, the virus’s potential for generating new variants and subsequent infection waves²³ continues to pose a significant global threat. Thus, developing effective interventions to address the stress, anxiety, and fear it causes among adolescents’ remains a crucial research focus.

Regular exercise provides numerous benefits to physical, mental, and social well-being. In the physical realm, numerous studies indicate that sustained sports participation enhances physical fitness across various domains. For skeletal and muscular functions, engaging in regular sports can improve muscle strength, endurance, and bone density, which is crucial for maintaining proper body posture and mobility.²⁴ In terms of cardiovascular and respiratory functions, regular exercise strengthens the heart, improves blood circulation, and enhances lung capacity, thereby reducing the risk of cardiovascular diseases and promoting better oxygen exchange in the body.^25,26 Regarding neurological functions, consistent physical activity has been shown to have positive impacts on brain health, including improved cognitive function and enhanced neural plasticity.²⁷ Moreover, appropriate sports have a preventive effect on many neurological disorders, including depression, anxiety, and stress.²⁸ Previous research has demonstrated that exercise plays a crucial role in maintaining mental well-being. Specifically, it has been shown to have a positive impact on alleviating common psychological burdens. For instance, regular exercise can help individuals manage feelings of fatigue, stress, anxiety, and depression. Additionally, exercise interventions not only aid in alleviating fatigue, stress, anxiety, and depression but also effectively enhance treatment outcomes, promote holistic recovery, and reduce mortality rates across various diseases.²⁹ Research indicates that long-term moderate-intensity aerobic exercise interventions, such as cycling, running, tai chi, and moderate-intensity resistance exercise, offer significant benefits and protective effects. These exercises can help regulate mood, reduce the risk of developing mental health issues like depression and anxiety, and enhance overall psychological resilience.³⁰

Sports games are a combination of sports and games, sports games have the dual characteristics of games and sports. The American educator John Dewey proposed, “Sports games differ from traditional sports. They are not specifically referring to athletic activities. The content of games is just one form of sports. What’s more important is to engage participants more actively in sports and allow them to enjoy themselves through games, experiencing the joy that sports bring.” Moreover, research indicates that when individuals face negative emotions or reactions due to certain difficulties in their growth process, sports games can provide them with the delight of success.³¹ In this study, sports games are activities that blend physical exercise with game-like structures. They are interactive, physical pursuits such as team sports like basketball, football, and volleyball, as well as individual sports games like badminton singles challenges or track and field relay games. These sports games are designed to engage participants in a physically active and enjoyable manner. Engaging in such sports games not only helps individuals regulate negative emotions but also enhances their confidence, making it a highly effective psychological intervention method.^32,33 Physically, these sports games contribute to improved cardiovascular function, increased muscle strength, and better motor coordination. Mentally, they offer a sense of accomplishment, reduce stress, and boost self-worth. However, potential negative impacts exist. For example, if the rules of the sports games are too complex or if the competition is overly fierce, it might cause frustration or a sense of inadequacy among participants, which could have a detrimental effect on their mental health. In this research, we will comprehensively examine both the beneficial and potentially harmful effects of sports games on the physical and mental well-being of adolescents, aiming to determine the optimal way to utilize sports games for promoting positive mental health outcomes.

On a different note, music therapy is an evolving field continually employed to alleviate illnesses, anxiety, and stress, reducing the dependence on medication among patients.³⁴ The positive effects of music on mental and physical health have been well-known for more than 30 years. Music, with its motivational elements, exerts a profound influence on participants at both psychological and physiological levels. Research by Gupta et al. (2011)³⁵ indicates that music can significantly impact aspects, such as emotional states and the alleviation of depression, affecting neurotransmitter release in the brain, which in turn influences mood regulation and psychological well-being. Research indicates that the application of music therapy can notably decrease depression levels in athletes.³⁶ Music, in various forms, has been explored for its potential benefits on psychological and physiological well-being. However, it is crucial to distinguish between music listening and music therapy. Music listening, as defined by Groarke & Hogan (2016),³⁷ refers to the passive or semi-active engagement with music for enjoyment, relaxation, or mood-enhancement purposes. In contrast, music therapy, as described in Jacobsen et al. (2019),³⁸ is a highly structured and goal-directed clinical intervention, typically provided by trained music therapists. It involves the use of music-based techniques to address specific psychological, emotional, cognitive, and physical needs of individuals. Gold et al. (2005)³⁹ suggest that when integrated into standard care, music therapy can improve the overall health of individuals with conditions like schizophrenia, potentially enhancing their mental well-being and functionality, especially with a sufficient number of music therapy sessions. In the context of sports, music is frequently utilized to manage specific mental states, such as pre-game anxiety.⁴⁰ Studies indicate that both soothing and more intense types of music can mitigate signs of competitive state anxiety, including physical and cognitive anxiety, subjective relaxation, and heart rate (HR).⁴¹ Additionally, several pre-game investigations on athletes propose that lively and loud music induces physiological changes, heightening athletes’ arousal levels.⁴² Hence, dynamic and high-volume music can enhance athletic performance with a focus on speed and power, elevating athletes’ mental energy, which refers to their level of motivation, concentration, and mental alertness. This increased mental energy allows athletes to maintain higher levels of focus during competition, react more quickly to changes in the game situation, and sustain their motivation to perform at their best, ultimately contributing to improved physical performance in terms of speed and power. As different types of music can have distinct effects on individuals, conversely, straightforward and slow-paced compositions, like classical music, folk, or ethnic songs, are often effective in reducing emotional and physiological arousal.⁴³

Existing research, such as studies by Chethik (2000)³² and Liu et al. (2021)³³ on sports games, and research by Gupta et al. (2011)³⁵ and Standley (1995)³⁴ on music therapy, has separately identified sports games and music therapy as effective interventions for alleviating anxiety and stress. In terms of the mutual enhancement relationship between music and sports games, music can enhance the motivation and enjoyment of participants during sports games. For example, energetic music can increase the arousal level of athletes, making them more engaged and perform better in sports games. Conversely, sports games provide a context for music to be integrated, and the physical activity involved can enhance the emotional resonance of the music. When individuals are actively participating in sports games accompanied by music, they may experience a more immersive and positive emotional state, which further alleviates anxiety and stress. However, despite the established effectiveness of sports games and music therapy in alleviating anxiety and stress separately, there is a lack of research that combines these two intervention methods. Given the significant impact of stress and anxiety on adolescents, especially during the COVID-19 pandemic, developing more comprehensive and effective intervention strategies is crucial. Combining music and sports games may offer a synergistic effect, potentially enhancing the benefits of each individual intervention. For instance, music can modulate the mood during sports games, creating a more engaging and motivating environment, which in turn could lead to greater psychological improvements. Such a combined approach might be particularly appealing and accessible in school settings, where both music and physical activities are integral parts of the curriculum. By filling this research gap, we can provide educators, parents, and mental health professionals with a novel and potentially more effective tool to support the mental well-being of adolescents, thus justifying the need for a study like this. Moreover, the relative effectiveness of each method in addressing these issues remains unclear. Therefore, given the profound impact of the COVID-19 pandemic on adolescents’ mental health, characterized by elevated stress, anxiety, and fear levels due to restrictions, social isolation, and uncertainty, it is necessary to conduct randomized controlled experiments on the three intervention methods (solely music listening intervention, solely sports games intervention, combined music, and sports games intervention). By comparing these interventions, we can determine the most effective approach specifically tailored to address the mental health challenges faced by adolescents during the pandemic. This research will provide valuable insights into how best to support this vulnerable population in the context of the ongoing COVID-19 situation, enabling the development of targeted and practical strategies for mental health promotion.

Hypotheses

Main hypothesis

We hypothesize that all three intervention methods (solely music listening intervention, solely sports games intervention, and combined music and sports games intervention) will be more effective than the control group in alleviating stress, anxiety, and fear among adolescents during the COVID-19 pandemic.

Comparative hypotheses

Specifically, the combined music and sports games intervention will be more effective than either the sole music listening intervention or the sole sports games intervention in reducing stress, anxiety, and fear levels.

We also expect that the sports games intervention will be more effective than the music listening intervention in improving physiological parameters such as oxygen saturation (SpO2) and reducing HR, given the direct physical activity involved in sports games. However, the music listening intervention may have a more significant impact on psychological parameters related to mood and relaxation in the short-term, while the combined intervention will show the most balanced improvement in both psychological and physiological aspects.

Results

Demographic characteristics of the participants

Table 1 displays the demographic characteristics of the 200 participants in the study’s second phase. The participants consisted of Chinese middle school students, with 140 boys (70.0%) and 60 girls (30%). The average age of the participants was 15.5 years.

Table 1.

Demographic characteristics of participants based on group

Characteristics	Intervention				Control
	Frequencies	Percentage	Median (IQR)	Mean (SD)	Frequencies	Percentage	Median (IQR)	Mean (SD)
Gender
Male	112	74.7%			28	56.0%
Female	38	25.3%			22	44.0%
Age			15.0	15.5			15.0	15.4
Total	150	100%			50	100%

The results of mixed factorial ANOVA of variance for the intervention effect

The scores of SAVE-6, FCV-19, SpO₂, and HR for all participants were subjected to normality analysis before and after intervention. The results indicated that the data at both time points followed a normal distribution, meeting the normality assumption required for conducting mixed factorial ANOVA. The results of the mixed factorial ANOVA evaluated the effectiveness of three intervention measures in reducing stress, anxiety, fear, and HR while simultaneously increasing SpO₂, as shown in Table 2.

Table 2.

Descriptive statistics and effects of intervention in control and experimental groups over time

Variables	Groups	Pre-intervention	Post-intervention	Between group difference (group effect)			Within group difference (time effect)			Within-between groups
		M (SD)	M (SD)	F (df)	p value	Partial η2	F (df)	p value	Partial η2	F (df)	p value	Partial η2
SAVE-6	MG	18.96 (7.44)	15.20 (5.84)	1.15 (3)	0.328	0.017	129.93(1, 196)	<0.001	0.399	14.07 (1, 196)	<0.001	0.177
	SG	19.24 (6.83)	15.46 (5.50)
	MCSG	19.08 (7.32)	11.98 (5.88)
	CG	18.00 (6.98)	17.14 (6.21)
FCV-19	MG	23.66 (7.06)	22.68 (7.32)	6.15 (3)	0.001	0.086	118.42 (1, 196)	<0.001	0.377	22.34 (1, 196)	<0.001	0.255
	SG	23.20 (6.90)	17.00 (5.43)
	MCSG	22.54 (6.99)	14.48 (4.86)
	CG	23.02 (7.10)	21.82 (7.19)
SpO2	MG	92.50 (5.144)	93.66 (5.053)	4.17 (3)	0.007	0.06	39.78 (1, 196)	<0.001	0.169	8.77 (1, 196)	<0.001	0.118
	SG	92.08 (4.54)	96.10 (4.50)
	MCSG	91.84 (4.98)	98.86 (4.95)
	CG	93.04 (5.45)	93.56 (5.56)
HR	MG	81.76 (12.39)	81.08 (12.65)	1.82 (3)	0.146	0.027	24.11 (1, 196)	<0.001	0.11	8.56 (1, 196)	<0.001	0.116
	SG	85.60 (12.85)	77.58 (12.86)
	MCSG	87.12 (12.80)	71.14 (12.81)
	CG	83.70 (14.16)	83.48 (14.28)

MG = music group (n = 50), SG = sport games group (n = 50), MCSG = music combined with sports games group (n = 50), CG = control group (n = 50), η2 = effect size; F = F statistic; mixed factorial ANOVA was used.

The analysis indicates that significant differences exist within groups for all variables over time. This suggests a significant time effect for the variables under consideration (p < 0.001) (Table 2). In terms of between-group differences (group effect), the analysis revealed significant differences among groups for FCV-19 and SpO₂ data, as indicated by the between-subjects effects test (p < 0.001). However, for SAVE-6 and HR data, the between-subjects effects test showed no significant differences among groups (Table 2). In terms of within-between groups (time∗group effect), the analysis revealed significant differences within and between groups for the intervention data of participants’ SAVE-6, FCV-19, SpO₂, and HR before and after the intervention (p < 0.001) (Table 2).

The results of paired t tests of variance for the intervention effect

The use of paired t tests was conducted for further analysis to assess the changes before and after intervention in each group. Figure 1 depicts the changes in SAVE-6 data before and after intervention. As shown in Figure 1, significant reductions in stress and anxiety were observed in all intervention groups. However, no significant changes in stress and anxiety levels were observed in the control group. Additionally, when comparing post-intervention data, the “music combined with sports games” group exhibited significantly lower levels of stress and anxiety compared to the control group (p < 0.001) and the other two intervention groups (p = 0.040, 0.020).

Figure 1.

Main effect results between simple effect groups for SAVE-6

Note. ∗ = The difference in average scores within the groups before and after the intervention is significant at the 0.05 level.

Figure 2 illustrates the changes in FCV-19 data for each group before and after intervention. Figure 2 shows that both the sports game and music combined with sports game groups significantly reduced fear of COVID-19. However, no significant changes in fear of COVID-19 were observed in the music group and the control group. Furthermore, when comparing post-intervention data, the music combined with sports game group exhibited significantly lower levels of fear of COVID-19 compared to the control group (p < 0.001) and the music group (p < 0.001). Similarly, the sports game group significantly reduced fear of COVID-19 compared to the control group (p = 0.001) and the music group (p < 0.001).

Figure 2.

Main effect results between simple effect groups for FCV-19

Note. ∗ = The difference in average scores within the groups before and after the intervention is significant at the 0.05 level.

Figure 3 displays the changes in SpO₂ data for each group before and after intervention. Figure 3 shows that both the sports game and music combined with sports game groups had significantly enhanced SpO₂. Conversely, no significant changes in SpO₂ were observed in the control group and the music group. Additionally, the post-intervention data comparison showed that the SpO₂ levels of the music combined with sports game group were significantly higher than those of the control group and the music group (p < 0.001), as well as the sports game group (p = 0.040).

Figure 3.

Main effect results of simple effects with respect to SpO₂

Note. ∗ = The difference in average scores within the groups before and after the intervention is significant at the 0.05 level.

Figure 4 exhibits the changes in HR data for each group before and after intervention. Figure 4 shows that both the sports game and music combined with sports game groups experienced significant reductions in HR from pre-test to post-test. However, no significant changes in HR were observed in the music group and the control group. Furthermore, by comparing post-intervention data, the HR levels of the music combined with sports game group were significantly lower than those of the control group (p < 0.001) and the music group (p = 0.001).

Figure 5.

Flow chart of intervention

Figure 4.

The main effect of the simple effect group for the heart rate

Note. ∗ = The difference in average scores within the groups before and after the intervention is significant at the 0.05 level.

Discussion

This paper holds significant importance in the field of mental health research, particularly in the context of addressing the psychological impacts of the COVID-19 pandemic on adolescents. Our study is one of the first to comprehensively explore the combined effects of music and sports games as interventions for alleviating stress, anxiety, and fear among this vulnerable population. The main findings clearly demonstrate that all three intervention methods—solely music listening, solely sports games, and combined music and sports games—are effective in reducing stress and anxiety levels. However, the combined music and sports games intervention stands out as the most effective approach across all measures, including subjective assessments like SAVE-6 and FCV-19 scores, as well as objective physiological indicators such as SpO2 and HR. These results not only contribute to our understanding of how different interventions can impact mental health but also provide practical implications for schools and mental health professionals. By highlighting the superiority of the combined intervention, we offer a novel and accessible strategy to promote the mental well-being of adolescents during challenging times, potentially leading to broader implementation in educational and community settings.

SAVE-6

Our findings regarding the SAVE-6 scores offer valuable insights into the effectiveness of different intervention methods. The significant within-group time effects indicate that, overall, all intervention approaches were successful in reducing stress and anxiety levels among participants. This could be attributed to the nature of both physical activity and music, which have independently been shown to modulate the body’s stress response systems. Physical activity stimulates the release of endorphins, often referred to as “feel-good” hormones, which can alleviate stress and improve mood.⁴⁴ Music, on the other hand, has been found to influence the limbic system, the part of the brain associated with emotions, leading to relaxation and reduced anxiety.

The lack of significant between-group differences in SAVE-6 scores before the intervention validates the randomization process of our study, ensuring that the groups were initially comparable. Post-intervention, the marked reduction in scores for the music combined with sports games group can be explained by a potential synergistic effect. When music is integrated with physical activity, it may enhance the motivation and enjoyment of the participants, leading to a more immersive and engaging experience. This, in turn, could result in a more substantial reduction in stress and anxiety levels.

In practical terms, schools and community centers could implement combined music and sports activities as part of their mental health support programs for adolescents. For example, organizing music-accompanied sports clubs or exercise classes could be an effective way to target stress and anxiety. Additionally, future research could focus on optimizing the types of music and sports activities used in these combined interventions. Different genres of music may have varying effects on different individuals, and exploring these nuances could lead to more personalized and effective interventions. Long-term follow-up studies could also be beneficial to determine the sustainability of the observed effects. This would help in developing more comprehensive and lasting strategies for promoting mental well-being in adolescents.

FCV-19

The significant within-group time effects in FCV-19 scores vividly illustrate the effectiveness of our interventions in reducing participants’ fear levels related to COVID-19. The activation of the body’s relaxation response could be a possible explanation for this. Physical activity, like that in the sports games group, releases neurotransmitters, such as dopamine and serotonin, which are known to regulate mood and reduce feelings of fear.⁴⁴ When combined with music, as in the music combined with sports games group, the auditory stimuli might further enhance this effect. Music has the ability to distract individuals from negative thoughts and create a more positive emotional state, thus complementing the physiological benefits of exercise.⁴⁵

The significant between-group differences post-intervention highlight the superiority of the combined music and sports games and sports games interventions over the music-only intervention. The lack of significant impact of the sole music listening intervention in reducing fear levels, despite its positive effects on stress and anxiety, is an interesting finding. This could be due to the complex nature of fear associated with a global pandemic. Fear related to COVID-19 is often multifaceted, involving concerns about health, future uncertainties, and social implications. While music can have a soothing effect, it may not be sufficient on its own to address these deep-rooted fears. In contrast, physical activity provides an outlet for pent-up energy and a sense of control, which might be more directly relevant to reducing pandemic-induced fear. As previous studies have shown, professional music therapy with a therapist’s guidance has been successful in treating emotional disorders during the COVID-19 pandemic,^46,47,48,49 emphasizing the importance of expertise and customization in music-based interventions.

From a practical perspective, schools could incorporate physical education classes with musical accompaniment into their curriculum. This would not only promote physical health but also serve as a means to address students’ mental health concerns, specifically fear related to COVID-19. Community youth centers could also organize similar programs to reach a wider range of adolescents. For future research, it would be beneficial to explore the long-term impact of these interventions on fear reduction. Additionally, studies could focus on identifying the specific elements of music and sports combinations that are most effective in reducing fear. For example, the tempo, rhythm, and genre of music, as well as the type and intensity of sports activities, could be systematically varied to determine the optimal combination.

Some studies, have explored the effects of music therapy on psychological well-being.^50,51 While their results show significant improvements, their interventions were highly structured music therapy sessions. In our study, the music listening intervention was more accessible and less resource-intensive. The differences in the nature of the interventions should be considered when comparing the results. However, similar to music therapy, our music listening intervention also led to positive changes in stress and anxiety levels, as Peters et al. (2024)⁴⁵ has suggested that non-therapeutic music listening can have comparable emotional-regulatory effects. In contrast, our study simply involved participants listening to music without the guidance of a professional music therapist, which may have limited the therapeutic effect. This suggests that passive music listening alone may not be sufficient to alleviate COVID-19-induced fear. The involvement of a trained music therapist can offer expertise and customization to therapy sessions that passive music listening alone may lack. Tailored music selection, interactive techniques, and emotional support can address each patient’s unique needs, enhancing the therapeutic experience.^52,53 In conclusion, while previous research highlights the potential of music therapy in mitigating COVID-19-induced fear and anxiety, our study underscores the limitations of passive music listening alone in achieving similar therapeutic outcomes. The distinction between professional music therapy and passive music listening should be considered when evaluating the effectiveness of different music-based interventions. Our research confirms the consistent efficacy of music combined with sports games and sports games interventions in mitigating COVID-19-induced fear among high school students. Particularly, music combined with sports games emerges as the most effective method, with a straightforward implementation process. These findings suggest its potential for broader dissemination among high school students, offering a promising solution to alleviate mental health challenges in this demographic. Our study uniquely focuses on the impact of a simple and widely applicable music listening intervention. By clearly differentiating it from music therapy, we contribute to the understanding of how basic music listening can be effectively used in non-clinical settings, such as schools, to improve the mental health of students.

SpO₂

Our analysis revealed significant within-group time effects (p < 0.001) in SpO₂ levels, clearly demonstrating that the interventions had a substantial impact on participants’ SpO₂ levels. This indicates that, over time, the participants’ physiological states changed in response to the different interventions. The notable between-group differences in SpO₂ levels before and after the intervention (p < 0.05) further emphasize that the four experimental groups reacted differently to the interventions. The confirmation from the within-between groups (time∗group effect) analysis (p < 0.001) solidifies the significance of these observations.

Before the intervention, the lack of statistically significant differences in SpO₂ levels among the four experimental groups (p > 0.05) validates the randomization process of our study, ensuring that the groups were initially comparable. Post-intervention, the significant increase in SpO₂ levels observed in both the music combined with sports games group and the sports games group, especially the marked superiority of the former over the control group, the music group, and even the sports games group alone, is quite remarkable.

The findings that an individual’s SpO₂ can be enhanced through increased physical activity, as suggested by previous research,^54,55,56 align well with our study’s results. This is because physical activity stimulates the body’s cardiovascular system, increasing blood circulation and oxygen delivery to tissues, thus raising SpO₂ levels. The fact that the music combined with sports games group had a more significant increase in SpO₂ than the sports games group alone may be attributed to the synergistic effect of music. Although there is debate about whether music alone can increase SpO₂,⁵⁷ research has confirmed that music can enhance physical activity.^58,59 In our study, it is likely that the music in the combined intervention motivated participants to engage more actively in sports activities, leading to a greater increase in physical exertion and, consequently, a more substantial rise in SpO₂.

Furthermore, the established negative correlation between SpO₂ and anxiety levels^60,61,62,63 implies important practical implications. Since the music combined with sports games intervention was the most effective in increasing SpO₂ among the three methods we tested, it holds great promise in reducing anxiety levels among participants. This suggests that schools and community centers could consider implementing programs that combine music and sports activities as a means to improve the mental health of adolescents, especially in the context of stress and anxiety related to situations like the COVID-19 pandemic.

For future research, it would be valuable to explore the long-term effects of such combined interventions on SpO₂ and anxiety levels. Additionally, studies could focus on identifying the optimal combination of music characteristics (such as tempo, rhythm, and genre) and sports activities (type, intensity, and duration) to maximize the benefits in enhancing SpO₂ and reducing anxiety. Investigating how individual factors, such as age, fitness level, and musical preference, moderate the relationship between the combined intervention, SpO₂, and anxiety could also provide more personalized and effective intervention strategies.

HR

Our analysis unveiled significant within-group time effects (p < 0.001) in HR, vividly indicating that the interventions induced a notable alteration in participants’ HR. This implies that, as the interventions progressed, the physiological state of the participants, as reflected by their HR, underwent meaningful changes. Although there were no significant between-group differences in HR before and after the intervention (p > 0.05), suggesting a certain similarity in the overall impact on HR across the experimental and control groups, the significant results from the within-between groups (time∗group effect) analysis (p < 0.001) still merit in-depth exploration.

Before the intervention, the lack of significant differences in HR among the four experimental groups (p > 0.05) validates the randomization of our study, ensuring that the groups started on an equal footing. Post-intervention, a remarkable phenomenon emerged. Participants in both the music combined with sports games group and the sports games group experienced a significant reduction in HR. Specifically, the music combined with sports games group showed a more pronounced decrease compared to the music group and the control group. In contrast, the HR changes in the sports games group and the music group were not significantly different from each other.

These results highlight the substantial impact of the interventions on HR. The fact that both the music combined with sports games and sports games interventions led to significant HR reductions indicates the effectiveness of physical activity in regulating HR. The lack of difference between the sports games group and the music group in terms of HR changes implies that the addition of music in the combined intervention played a crucial role in enhancing this effect. Although the direct influence of music on HR remains a subject of debate, previous research has clearly demonstrated its capacity to boost physical activity.^58,59 Additionally, numerous studies have shown that increased physical activity can significantly lower an individual’s HR.^64,65,66 Therefore, it is reasonable to infer that the music in the combined intervention motivated participants to engage in more intense physical activity, thereby leading to a more substantial decrease in HR.

Research has established a positive correlation between HR and anxiety levels, suggesting that a decrease in HR can effectively alleviate the negative mental state associated with COVID-19.^67,68 Given that the music combined with sports games intervention was the most effective among the three in reducing HR, it is highly likely to have a distinct advantage in alleviating the negative mental state caused by COVID-19, an advantage that the other intervention methods may lack.

From a practical perspective, schools, and fitness centers could incorporate music-enhanced sports activities into their programs. For example, offering group exercise classes with carefully selected music could help individuals better manage their HR and, in turn, reduce anxiety. In future research, it would be beneficial to explore the long-term impact of these interventions on HR and anxiety. Additionally, studies could focus on optimizing the combination of music and sports activities. For instance, determining the most suitable music tempo, genre, and the optimal type and intensity of sports activities to achieve the best results in HR reduction and anxiety alleviation. Moreover, investigating how individual factors, such as age, fitness level, and musical preference interact with these interventions could lead to more personalized and effective strategies for promoting mental and physical health.

Limitations of the study

While this study provides valuable insights into the effects of music and sports game interventions on adolescent stress and anxiety during the COVID-19 pandemic, several limitations should be acknowledged. First, the sample was drawn exclusively from schools in Lanzhou, China, which may limit the generalizability of findings to other cultural or socioeconomic contexts. Second, the 8-week intervention period may not capture long-term sustainability of observed effects, warranting longer follow-up studies. Third, reliance on self-reported psychological measures (SAVE-6, FCV-19) introduces potential response biases, despite supplementing with physiological indicators. Fourth, the study did not control for participants’ prior music/sports experiences which might influence outcomes. Finally, the fixed music tempo (120–130 bpm) and exercise intensity (142 ± 2 bpm) may not represent optimal parameters for all individuals. Future research should employ multi-center designs with extended observation periods and personalized intervention dosing to address these limitations.

Resource availability

Lead contact

The lead contact for this study is Garry Kuan. He can be reached at garry@usm.my. Dr. Kuan is responsible for responding to all reagent and resource requests related to this research. In case of any further inquiries regarding the study, researchers, and interested parties are encouraged to contact him via the provided email address. He will also serve as the main communication point for the journal, both during the publication process and after the article is published, ensuring seamless communication and handling of any issues or requests that may arise.

Materials availability

This study did not generate new unique reagents. The questionnaires and measurement devices are commonly available through standard channels.

Data and code availability

Data: The complete dataset and analysis scripts for this study have been deposited in the Open Science Framework repository and can be accessed at https://www.scidb.cn/s/qMrQ3y.

Code: Analysis scripts are available from the lead contact upon request.

Other Items: Any additional information required to reanalyze the data reported in this paper is available from the lead contact upon request.

Acknowledgments

We sincerely thank all participating adolescents, schools, and parents in Lanzhou for their cooperation and support throughout this study. We are grateful to the physical education teachers and research assistants who facilitated intervention implementation and data collection. Special thanks to the Universiti Sains Malaysia Ethics Committee for their guidance on research protocols.

Funding: The present study is free from any disputes regarding attribution and intellectual property rights. This research is funded by the Social Sciences and Humanities Research grant, University of Guizhou (2024RW280) with the main title: “research on the impact mechanism and intervention strategies of minors’ mental health”.

Author contributions

J.W. designed the study, interpreted the results, drafted and edited the manuscript, coordinated the study activities. G.K. and Y.C.K. designed the study, prepared the material, analyzed the data, interpreted the results, drafted and edited the manuscript. G.K. and Y.C.K. critically revised the draft of the manuscript. All authors reviewed and approved the manuscript.

Declaration of interests

The authors declare no competing interests.

STAR★Methods

Key resources table

REAGENT or RESOURCE	SOURCE	IDENTIFIER
Deposited data
Original Data	Science DataBank	https://www.scidb.cn/s/qMrQ3y
Software and algorithms
SPSS	IBM	https://www.ibm.com/analytics/spss-statistics-software
Other
Questionnaires - SAVE - 6	Chung et al., 2021	https://doi.org/10.3389/fpsyg.2021.669606.
Questionnaires - FCV - 19	Ahorsu et al., 2022	https://doi.org/10.1007/s11469-020-00270-8.
Physiological measurement device - for SpO2	ChoiceMMed	OX200
Physiological measurement device - for HR	ChoiceMMed	OX200

Experimental model and study participant details

This was a prospective, randomized study. All 200 participants, aged between 14 and 18 years old, were middle school students from Lanzhou Cansu province, China. They were recruited from multiple local secondary schools. All participants provided written informed consent. Ethical approval was obtained from the Human Research Ethics Committee of Universiti Sains Malaysia (USM/JEPeM/22040247) and adhered to the principles outlined in the Declaration of Helsinki. The RCT study is registered at ClinicalTrials.gov with the identifier NCT05930015. ClinicalTrials.pdf, Human Research Ethics Committee USM - related documents, and Data. sav files were all compressed into Data S1 and uploaded to Supplemental Items. In the Supplemental Items, Data S1 can be accessed to view these related materials. Additionally, the “PARTICIPANT INFORMATION SHEET AND CONSENT FORM (JEPeM)” was marked as Data S2 and included in the supplemental PDF file. Data S2: Participant information sheet and informed consent form.

Participants with special educational needs from special schools, and those with visual, auditory, or other significant physical or mental disabilities were excluded. The final sample consisted of 140 boys (70.0%) and 60 girls (30%), with an average age of 15.5 years.

Study design

This study employed a prospective, randomized controlled trial design. The primary objective was to investigate the effects of different intervention methods (music - only, sports games - only, and music combined with sports games) on alleviating stress, anxiety, and fear among adolescents during the COVID - 19 pandemic. The randomization process was crucial to ensure that participants had an equal chance of being assigned to any of the four groups (music - only group, sports games - only group, music combined with sports games group, and control group). By randomly selecting three secondary schools in Lanzhou City and then randomly choosing one class as the intervention group and another as the control group within each school, we aimed to minimize selection bias.

The choice of the control group is crucial for accurately assessing the effectiveness of the experimental interventions. We selected traditional moderate - intensity exercise as the control group because it reflects the standard physical education curriculum in schools. By maintaining the normal physical education routine as the control, we established a baseline against which we could measure the additional benefits of the music - only, sports - only, and music - sports combination interventions. This approach allows for a clear comparison between the novel interventions and the existing standard practice, helping us determine whether the integration of music or specific sports game designs can lead to greater stress and anxiety reduction than regular school - based physical activity.

The intervention groups received specific treatments as described in the “Interventions” section, while the control group adhered to the traditional school physical education standards without any additional interventions. The pre - and post - intervention measurements of psychological and physiological variables allowed for an assessment of the impact of each intervention. This design enabled us to compare the effectiveness of the three intervention methods and determine whether they were more effective than the control condition in improving the mental and physical well - being of adolescents in the context of the pandemic.

Method details

Randomization

Participants were randomly assigned to one of four groups: music - only group, sports games - only group, music combined with sports games group, and control group, with 50 students in each group. The randomization was carried out using a computer - generated random number table.

Interventions and intervention fidelity

Music - Only group

Intervention Details: Music Only Intervention (120–130 bpm): This involved playing selected music during regular school physical education classes. Due to the potential association of electronic music with a decline in emotional states, classical music has shown promise in enhancing emotional well-being.^69,70 Additionally, fast-paced music can evoke a sense of happiness in listeners and influence emotions.⁷¹ Therefore, we chose fast-paced classical music with a tempo of 120–130 bpm for the intervention. In the music - only group, participants engaged in music listening activities. They listened to fast - paced classical music (120–130 bpm) twice a week, with each session lasting 45 min. This music listening intervention, was designed to evoke positive emotional responses and potentially reduce stress levels. It differs from music therapy in that it lacks the therapeutic goal - setting and individualized treatment planning characteristic of music therapy sessions. Previous research by Kim & Stegemann (2016) has demonstrated the positive effects of music listening on stress reduction among adolescents. Their findings support our decision to incorporate music listening as an intervention in this study.

Fidelity Measures: A pre - set playlist ensured music consistency. Trained assistants monitored sessions, noting and rectifying equipment or environmental issues for continuous playback.

Sports games - Only group

Intervention Details: Sports games such as basketball, badminton, and group relay races, chosen for cooperation, enjoyment, and competition, were held twice a week for 45 min, supervised by trained P.E. teachers.

Fidelity Measures: Standard game rules were established prior to the intervention. Teachers received training on standardizing instructions and decisions. Weekly reports were submitted, and non - compliance was addressed through additional training.

Music combined with sports games group

Intervention Details: During sports games, the same fast - paced classical music from the music - only group was played at 50% of max volume via JBL Charge 5 speakers to enhance enjoyment and motivation.

Fidelity Measures: Music timings were synchronized with game activities. Research assistants monitored both sports and music to prevent interference, and participant feedback was collected to improve the combination.

Control group: Participants in the control group maintained the original school physical education teaching mode, having P.E. classes twice a week, 45 min per class, without any additional interventions (see Figure 5).

All participants from the four groups were required to complete a set of questionnaires, and physiological measurements were taken before and after the intervention phase. For the intensity and duration of the sports game intervention, we deliberately selected a moderate-intensity exercise intervention, i.e., exercising at 40% of the maximum oxygen consumption and maintaining a heart rate of 142 ± 2 beats per minute. The intervention took place during the regular school physical education class, lasting 45 min each, twice a week. This design aligns with the intensity and duration proposed by paolucci et al. (2018) to significantly reduce depression levels. The intervention spanned 8 weeks, with a total of 16 intervention sessions.

The flow chart in Figure 5 depicts the overall process of participant allocation. It shows how students were randomly assigned to one of the four groups (music - only, sports games - only, music combined with sports games, and control). The chart also details the sequence of events, from the baseline measurements, through the 8 - week intervention period for the three intervention groups, and finally to the post - intervention measurements for all groups.

These measures were taken to ensure that the interventions were implemented as designed, enhancing the reliability and validity of the study results.

Measurements

Psychological questionnaires

The SAVE - 6 and FCV - 19 questionnaires were utilized to measure stress, anxiety, and fear levels related to COVID - 19 among participants. The SAVE-6, developed by South Korean researchers Chung et al. (2021), is a unidimensional six - question survey designed to evaluate stress and anxiety responses in the general population during the pandemic. Participants indicate their feelings using a Likert scale from "1 = Never" to "5 = Always", and it has demonstrated robust internal consistency (Cronbach’s Alpha = 0.817) and validity (CFI = 0.910, TLI = 0.850) in its application in Korea (Park et al., 2021). The FCV-19, created by Ahorsu et al. (2022), is a seven - item questionnaire that measures the fear related to COVID - 19, with participants using a Likert scale from "1 = strongly disagree" to "5 = strongly agree". It exhibits robust psychometric properties, including an internal consistency of 0.82 (Cronbach’s Alpha), a composite reliability of 0.88, and an Average Variance Extracted (AVE) of 0.51, along with a test - retest reliability (ICC) of 0.72.⁷²

These questionnaires were administered face - to - face by trained research assistants. Before distribution, assistants provided a detailed introduction, explaining the study’s purpose, assuring confidentiality, and demonstrating how to complete the Likert - scale questions. During the process, assistants were present to answer questions without influencing responses. This face - to - face approach, as per Gever (2024), enables direct interaction with participants, allowing for the observation of non - verbal cues and better data quality. Despite the finding by Monday & Gever (2024) that most research participants prefer digital media for research participation, in our study involving adolescents, face - to - face communication helped build trust, which we believe enhanced response accuracy. Questionnaires were administered at baseline, before the intervention, and after the 8 - week intervention period.

Physiological measurements

Blood oxygen saturation (SpO2) and heart rate (HR) were measured using the ChoiceMMed OX200 device. Trained medical personnel conducted these measurements in a quiet area within the school, such as an empty classroom set up for this purpose. Participants were asked to sit quietly for 5 min before the measurements to ensure stable physiological states. Each measurement was repeated three times, and the average value was recorded. Measurements were taken at the same time of day, both before and after the 8 - week intervention period.

The face - to - face nature of these physiological measurements, as emphasized by Gever (2024), provides better control over the data collection process. It allows for immediate addressing of any technical issues, ensuring accurate readings. Since research results from questionnaires often suffer from limitations such as social desirability bias (Prasad et al., 2004) and self - perception biases (He & van, 2013; John & Robins, 1994), Moreover, relying solely on self-reports can introduce self-perception biases, potentially skewing data accuracy and leading to biases in experimental outcomes (John & Robins, 1994), the inclusion of these objective physiological measurements, which are closely related to psychological states,^73,74,75 aims to mitigate biases. By examining changes in SpO2 and HR before and after the intervention, we sought to elucidate shifts in psychological states, enhancing data stability and accuracy through this multifaceted approach.

Quantification and statistical analysis

Sample size calculation

In this study, the sample size calculation was conducted using G∗Power 3.1.9.7 (Heinrich Heine University, Dusseldorf, Germany) based on Analysis of Variance (ANOVA): within-between interaction (repeated measures between intervention and control groups; group effect), within-subjects (time effect), and between-subjects (interaction effect). This section describes the maximum sample size. With a medium effect size of 0.25, an alpha value of 0.05, a power of 0.80, a group size of 4, and a number of measurements of 2, the calculated sample size was 156. After accounting for a 20% dropout rate, a minimum of 188 participants was required. To facilitate grouping, 200 students were selected, with 50 students in each group.

Statistical analysis

All statistical analyses were performed using SPSS version 27.0. Our choice of this software is supported by the research of Asogwa et al. (2024). SPSS, being a widely - utilized digital software in statistical analysis, offers a comprehensive range of statistical procedures that are well - suited for our study.

We carried out analyses based on the collected data from 200 middle school students who were divided into four groups: music group, sports games group, music combined with sports games group, and the control group. For the data obtained from the SAVE - 6 questionnaire (used to measure stress and anxiety levels) and the FCV - 19 questionnaire (used to measure fear levels related to COVID - 19), as these are likely categorical or ordinal data representing different levels of psychological states:

We used the chi - square test to analyze differences in the distribution of scores among the four groups both before and after the 8 - week intervention period.

For the physiological data of blood oxygen saturation (SpO2) and heart rate (HR):

First, we conducted a normality test on these continuous variables. If the data of SpO2 and HR were normally distributed, we used the independent samples t - test to compare the means between each intervention group (music group, sports games group, music combined with sports games group) and the control group at baseline and after the intervention. We also used paired samples t - test to analyze the changes within each group before and after the intervention.

In case the data did not follow a normal distribution, the Mann - Whitney U test was applied to compare the differences between groups, and the Wilcoxon signed - rank test was used for within - group comparisons.

For the overall analysis of changes in variables over the 8 - week period within each group and differences between groups:

We used a mixed factors analysis of variance (ANOVA) to assess the main effects of the intervention type (music, sports games, music combined with sports games, control) and the time factor (before and after the intervention), as well as their interaction effects. When necessary, we adjusted for potential confounding factors such as the gender of the participants (since there were 140 boys and 60 girls in the sample), and age (with an average age of 15.5 years).

All statistical analyses were two - sided tests, and a significance level of p < 0.05 was considered as the criterion for statistical significance.

Additional resources

The RCT study is registered at ClinicalTrials.gov with the identifier NCT05930015 (https://clinicaltrials.gov/search?term=NCT05930015&viewType=Table).

ClinicalTrials.pdf, Human Research Ethics Committee USM-related documents, and data files were compressed into a single ZIP file (Data S1). Data S1: Clinical trial registration and ethics committee documents.

Additionally, the “PARTICIPANT INFORMATION SHEET AND CONSENT FORM (JEPeM)” was marked as Data S2 and included in the supplemental PDF file. Data S2: Participant information sheet and informed consent form.

Published: May 28, 2025