Fatigue has become a notable public health concern, especially within the population of young adults and university students. It adversely affects daily functioning and overall well-being. Although fatigue has a significant impact, it remains inadequately understood. Fatigue is defined as a sense of tiredness or lack of energy that does not relate to exertion (Brown and Schutte, 2006; Tanaka et al., 2008; de Oliveira Kubrusly Sobral et al., 2022). States of prolonged fatigue are presented as more than a month of living with nonrestorative sleep, headaches, and musculoskeletal and neuropsychiatric symptoms (Dirzyte et al., 2021; Vassend et al., 2018; Findlay, 2008). In the absence of therapeutic intervention, the prognosis for patients experiencing fatigue is typically unfavorable (Farragher et al., 2017; Sasangohar et al., 2020; Harper et al., 2021), as persistent fatigue tends to endure over time and is closely linked to the onset of depressive symptoms (Dirzyte et al., 2021; Vassend et al., 2018; Findlay, 2008; Farragher et al., 2017; Sasangohar et al., 2020; Harper et al., 2021). Among adolescents, there is evidence showing that physical and mental conditions initially come after prolonged fatigue (Dirzyte et al., 2021; Vassend et al., 2018; Findlay, 2008). This suggests that monitoring and alleviating fatigue may be integral to promoting overall well-being and addressing global sustainable development challenges, especially young people whose physical and mental maturation is ongoing.

Higher education fatigue has been a widespread concern among undergraduate students for the past decade (Brown and Schutte, 2006; Tanaka et al., 2008) because it has contributed to learning motivation repression and poor academic outcomes (Brown and Schutte, 2006; Tanaka et al., 2008; de Oliveira Kubrusly Sobral et al., 2022; Dirzyte et al., 2021; Vassend et al., 2018; Findlay, 2008). During the COVID-19 pandemic, videoconferencing was instrumental in maintaining the continuity of education on a global scale (Samara and Monzon, 2021; Kulikowski et al., 2021; Labrague and Ballad, 2021; Mohammed et al., 2022). While online platforms ensured academic continuity, they also increased risks of fatigue through extended screen time, physical inactivity, and reduced in-person interaction. Several studies have indicated that students were highly faced with Zoom fatigue due to online learning (Samara and Monzon, 2021). In the post-pandemic era, online and hybrid classrooms have remained integral to teaching and learning, because of their various advantages. Despite the educational environment has been reshaped, students' perceptions of fatigue within these diverse instructional modalities remain unclear.

Although fatigue has been reported to reduce learning ability (Brown and Schutte, 2006; Tanaka et al., 2008; de Oliveira Kubrusly Sobral et al., 2022; Dirzyte et al., 2021; Vassend et al., 2018; Findlay, 2008), there are not many studies on how to relieve fatigue among students. However, among patients that have experienced high levels of fatigue, intervention through behavioral-based physical activity has been acceptable to target fatigue with self-management (Harper et al., 2021). Regarding health behavior, university students are a vulnerable population group with health risk behaviors, especially in health professional students (Ruiz-Zaldibar et al., 2022; Salameh et al., 2022; Rahman et al., 2022; Tavolacci et al., 2021; Gadi et al., 2022; Xiang et al., 2022). Healthcare undergraduates face unique academic and clinical demands, further compounded by educational disruptions and health risks. However, little is known about higher education-related fatigue in this population, particularly in the post-COVID-19 era. Understanding these factors is essential, as healthcare undergraduates represent future health professionals and role models. By identifying factors associated with fatigue, the present study aimed to fill an important gap in literature and provide evidence to support targeted interventions that promote student well-being and academic success. Specifically, this study examined fatigue and its related symptoms, i.e., musculoskeletal complaints among healthcare undergraduates. Body mass index and sedentary time, which were affected by COVID-19 (Ruiz-Zaldibar et al., 2022; Salameh et al., 2022; Rahman et al., 2022; Tavolacci et al., 2021; Gadi et al., 2022; Xiang et al., 2022; Morgan and Wilson Van Voorhis, 2007), were also assessed in relation to fatigue. Additionally, data from students who were fully engaged in online learning were analyzed and reported to provide further insight into the impact of virtual education on fatigue-related outcomes.

The average age of participants was 21 years, and the majority were female. The distribution across academic years was relatively balanced, with approximately 20–30% in each year (Table 1). About half of the students presented with abnormal BMI and a sedentary lifestyle. A total of 146 students reported a history of musculoskeletal complaints, with a maximum of four affected sites (Table 2). Additional analyses were conducted among students enrolled in online learning during the 2021 academic year. As summarized in Table 3, this subgroup demonstrated health risk patterns, including overweight and prolonged sedentary behavior, which may have contributed to fatigue. However, mean fatigue scores did not differ significantly between this group and other students (Table 3). Students reported fatigue, i.e., most of them felt tired, sleepy, drowsy, fatigued, and worn out at about midpoint or higher. Fatigue behaviors in the students were also reported at higher scores. However, the average scores of Items 14 (moving body) and 16 (carrying on a conversation) were small. Students mostly reported their energy perception at about 5 out of 10 (Table 4).

Since there are various items in the VAS-F, factor analysis was performed to classify items in determining fatigue among undergraduates. It was found that Item 11 (bushed) was classified the same as Items 6 to 10 (energy) (Supplementary Table S1), whereas Items 13, 14, 15, and 16 were classified to other items rather than the items of fatigue, energy, and fatigue behaviors (Supplementary Table S1). It was found that BMI was associated with the daily sedentary time and fatigue behavior score but negatively related to Item 11 (bushed). It implied that feeling bushed may be related to exertion in the students. Negative associations between sedentary time and the number of musculoskeletal complaint sites were observed. The number of musculoskeletal complaint sites was associated with fatigue behaviors. Nonetheless, the present study demonstrated that statistically significant associations were observed even with the correlation coefficients being quite low. The VAS-F showed that higher fatigue severity (Items 1–5) correlated positively with fatigue behaviors (Items 13–16), but negatively with Item 11. Perceived energy (Items 6–10) was negatively linked to both fatigue severity and related behaviors (Table 5).

This study examined subjective fatigue among undergraduates in the post-COVID-19 era across various teaching and learning strategies, including face-to-face, online, and hybrid classrooms, which continue to be utilized today and in the future. The effects of fatigue among undergraduates were supported by the number of musculoskeletal complaint sites (Vassend et al., 2018), it was found that around 20% of the participants reported a history of musculoskeletal complaints. Besides fatigue, musculoskeletal pain among students also has been reported to be associated with postural habits, which were changed by distance learning (Labrague and Ballad, 2021). University students experience significant levels of study-related fatigue (Brown and Schutte, 2006; Tanaka et al., 2008; de Oliveira Kubrusly Sobral et al., 2022). Regarding face-to-face learning, it was reported that fatigue levels among students correlated with psychological health, academic demands, and conflicts between studies and other activities (Kizhakkeveettil et al., 2017). In contrast, fatigue from online learning was caused by the overuse of videoconferencing (Olasina, 2019; Dumford and Miller, 2018; Assareh and Hosseini Bidokht, 2011). The failing technological aspects of online courses among both students and teachers also frustrated students (Olasina, 2019; Dumford and Miller, 2018; Assareh and Hosseini Bidokht, 2011; Rattanawan and Pakdee, 2024). Regarding the learning process during the COVID-19 global pandemic, Mohammed et al. (2022) reported that students from tertiary institutions in Iraq (n = 819, electronic respondents) had a high level of fatigue due to lockdown measurements. Lower levels of lockdown fatigue were shown to be associated with higher levels of personal resilience and coping abilities (Mohammed et al., 2022).

The present study found no significant differences in fatigue levels between students engaged in online learning and those in other modalities, including face-to-face instruction. This may be due to students' accumulated experience with online learning since the pandemic, which likely enabled them to adapt and mitigate the potential impact of virtual modalities on fatigue. It has been observed that fatigue was quite high among students, even with improvements in the COVID-19 situation. This suggests that fatigue is a common occurrence among undergraduates across all educational approaches (i.e., face-to-face, online, and hybrid learning) and may be influenced by multiple factors. A lack of structured, multifaceted teaching methods could contribute to student fatigue both post-pandemic and in the future. Therefore, prioritizing the development of effective teaching strategies and student support policies is essential to alleviate and prevent prolonged fatigue among university students.

Although subjective fatigue is one of the significant factors contributing to the inhibition of learning motivation, the paths and contributing factors of fatigue are under-researched. The present study revealed the associations between the fatigue items from the VAS-F and health reports among undergraduates. Items 1–5 showed that greater fatigue severity correlated positively with fatigue behaviors (Items 13–16), while Items 6–10 demonstrated that higher perceived energy was negatively associated with both fatigue severity and fatigue behaviors among students. The fatigue behavior score was also associated with BMI as related with daily sedentary time; however, no direct correlation was observed between daily sedentary time and any of the individual VAS-F items. This may reflect the relatively uniform sedentary patterns among participants, which limited variability and reduced the ability to detect associations. In relation to fatigue interventions, it is therefore essential to further investigate fatigue management strategies in higher education to establish a stronger foundation for promoting students' well-being and supporting their academic achievement (Compton et al., 2020; Räisänen et al., 2021; Cosentino et al., 2024; Buneviciene et al., 2021).

In agreement with previous studies, the present study revealed that half of the students had abnormal BMI and a sedentary lifestyle (Ruiz-Zaldibar et al., 2022; Salameh et al., 2022; Rahman et al., 2022; Tavolacci et al., 2021; Gadi et al., 2022; Xiang et al., 2022). Weight gain during the COVID-19 pandemic had been reported to be associated with higher baseline BMI, mental symptoms, maladaptive eating behaviors, less sleep, and physical inactivity (Buneviciene et al., 2021; Almandoz et al., 2022). Together, obesity and prolonged sedentary time are of particular concern among health sciences students. With multiple learning modalities and other educational disruptions persisting beyond the pandemic, these patterns are likely to continue, underscoring the need for sustainable strategies that foster healthy behaviors in this population.

Our study highlights the importance of systematically monitoring fatigue among undergraduates. Implementing effective interventions such as lifestyle modifications and advancing teaching methods through research and policy development may help alleviate fatigue and, in turn, support both student well-being and academic performance.