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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 37  |  Issue : 1  |  Page : 82-87

Factors determining psychological stress among Indian adolescents and young adults during the COVID-19 outbreak


1 GROW Society, Growth and Obesity Workforce, Kanpur, Uttarakhand, India
2 Independent Researcher, Rishikesh, Uttarakhand, India
3 Department of Endocrinology, Regency Center for Diabetes Endocrinology and Research, Kanpur, Uttarakhand, India

Date of Submission23-Sep-2020
Date of Decision15-Oct-2020
Date of Acceptance25-Oct-2020
Date of Web Publication31-Mar-2021

Correspondence Address:
Dr. Mandara Muralidhar Harikar
B.4, Divine Residency, Lane 6, Ganesh Vihar, Ganga Nagar, Rishikesh - 249 201, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_246_20

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  Abstract 


Background: Strict isolation measures imposed during the coronavirus disease (COVID-19) pandemic have confined families in their homes, interrupted functioning of schools and colleges, and disrupted play and exploration time. Aim: The aim was to analyze psychological stress and its determinants among Indian adolescents and young adults during the COVID-19 pandemic. Methodology: A cross-sectional, observational study design was adopted. A semi-structured survey including demographic details, COVID-19 awareness, Perceived Stress Scale (PSS-10), and coping methods was distributed among 12–24 year olds, and analyzed to study the determinants of stress. Results: Out of a total of 235 (112 males; 19.4 ± 4.0 years) participants, nearly half of the participants (53%) reported moderate stress; low stress was perceived by 42.3% and severe stress was observed in 4.7%. The mean PSS score was 13.4 ± 8.9. Higher PSS score was associated with age (r = 0.194, P = 0.003), female gender (mean rank = 132.0, P = 0.001), higher education (mean rank = 154.5, P = 0.006), salaried occupation (mean rank = 143.79, P = 0.047), dissatisfaction with the available information (mean rank = 155.64, P = 0.009), and accessing information multiple times a day (mean rank = 133.51, P = 0.041). On multivariate linear regression analysis, age, gender, dissatisfaction with the available information, and higher frequency of accessing information were identified as significant correlates of mean PSS-10 score. Conclusion: Stress was highly prevalent among the Indian adolescents and young adults during the pandemic. Older age, female gender, higher education, salaried job, dissatisfaction toward the available information, and a tendency to view updates frequently were associated with higher stress levels.

Keywords: Adolescents, COVID-19, Perceived Stress Scale-10, psychological stress


How to cite this article:
Agarwal N, Harikar MM, Shukla R, Bajpai A. Factors determining psychological stress among Indian adolescents and young adults during the COVID-19 outbreak. Indian J Soc Psychiatry 2021;37:82-7

How to cite this URL:
Agarwal N, Harikar MM, Shukla R, Bajpai A. Factors determining psychological stress among Indian adolescents and young adults during the COVID-19 outbreak. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Jun 19];37:82-7. Available from: https://www.indjsp.org/text.asp?2021/37/1/82/312872




  Introduction Top


Coronavirus disease (COVID-19), caused by a novel coronavirus SARS-CoV-2, has emerged as an unprecedented challenge for the entire human race.[1] With the first COVID-19 case detected in December 2019 in Wuhan, Hubei province of China,[2] it has spread rampantly, and was officially declared a pandemic by the World Health Organization (WHO) on March 11, 2020.[3]

In an attempt to break the chain of transmission, nations across the globe are following a policy of lockdown. Similarly, a nationwide lockdown was declared by the Government of India, on March 24, 2020.[4] Strict isolation measures have confined families in their homes, interrupted functioning of schools and colleges, and disrupted play and exploration time. In addition, this part of the year is in particular important for adolescents and young adults appearing for various competitive entrance examinations, which in the current scenario are either temporarily suspended or postponed.

Apart from an increased risk of mortality, the COVID-19 pandemic is expected to have both short-term and long-term psychological consequences.[5] The desolation caused by COVID-19 is commensurate with the SARS outbreak in 2003, which was considered a “mental health catastrophe.”[6] Adverse mental health impact has also been recorded in other epidemics, such as Middle East respiratory syndrome, H5N1, and Ebola.[7],[8],[9]

Stress is an imminent part of our lives. The way we experience it and cope with it changes throughout life. Adolescents and young adults deal with many new challenges during their phase of transition.[10] An imbalance between the stress-coping methods contributes to a range of developmental disorders, including both internalizing and externalizing challenges.[11] Hence, it is of paramount importance to prepare the teenage brain to deal with life stressors in order to prevent long-term adverse outcomes.

The new coronavirus is affecting the young minds in an obscure way, which is intended to have long-term consequences. Studies have reported increased stress and anxiety among health-care workers, vulnerable population, quarantined individuals, and elderly people during the current COVID-19 pandemic.[5] However, there is scarcity of data regarding the stress among Indian adolescents and young adults who have been rendered unguided during this time of uncertainty.

The present study was, therefore, conducted to analyze the stress and its determinants among the Indian adolescents and young adults and to identify the coping methods adopted by them during the current COVID-19 outbreak.


  Methodology Top


The present study was a cross-sectional, observational study conducted in India. The survey was prepared using Google Forms and distributed among WhatsApp groups. Snowball technique was used for data collection, and the participants were encouraged to forward the link to as many contacts as possible. It was aimed at individuals belonging to 12–24 years' age group. In addition, participants were required to understand English and possess a smartphone device to be eligible to participate. Data collection started on April 30, 2020, at 4 p.m. IST, and was closed on May 10, 2020, at 4 p.m. IST.

The questionnaire was formulated based on expert input, and information was sourced from the websites of WHO[12] and the Ministry of Health and Family Welfare, Government of India.[13]

The questionnaire was tested on a few volunteers prior to distribution to check for ease of understanding. The questionnaire began with an informed consent form, followed by four sections – demographic information, awareness about COVID-19 infection, the 10-item Perceived Stress Scale (PSS-10), and coping methods adopted to tackle stress [Appendix I]. PSS-10 measures the psychological stress estimated over the previous 4 weeks. It consists of ten items measured on a 5-point Likert scale (0: never, 1: almost never, 2: sometimes, 3: fairly often, and 4: very often). The total score is obtained by adding the scores of all the items, with reverse coding for items 4, 5, 7, and 8, as they are positively stated. The total score ranges from 0 to 40, with score 40 depicting the highest perceived stress level. There is no cutoff to differentiate between the stressed and nonstressed individuals. Individuals are categorized into low (PSS score 0–14), moderate (PSS score 15–24), and severe (PSS score 25–40) categories based on the total PSS-10 score.[14]

Based on the correctness of responses to COVID-19-related questions, the participants were allotted scores for their knowledge on the transmission, prevention, and symptoms of COVID-19. Each question was awarded 1 point for correct response and 0 for incorrect response. The scores for transmission, prevention, and symptoms were converted to percentages (%). The survey was completely anonymized in order to address response bias. Ethics committee approval was obtained for the study.

Statistical analysis

The data were compiled using Microsoft Excel, and statistical analysis was performed using IBM Statistical Package for Social Sciences (SPSS version 25.0, SPSS, Inc., Chicago, IL, USA). Continuous variables were expressed as mean (standard deviation); categorical variables were expressed as frequencies (percentages). Chi-square test was performed for categorical variables, whereas Mann–Whitney test was performed for nonparametric, continuous variables. Lastly, Spearman's correlation was performed for nonparametric, ordinal data. The variables found to correlate significantly on univariate analysis were entered into a multiple linear regression model to predict factors predisposing to COVID-19-related stress. P = 0.05 was considered statistically significant.


  Results Top


A total of 235 (112 males; 19.4 ± 4.1 years) volunteers participated in the study. The baseline sociodemographic characteristics of the participants are depicted in [Table 1].
Table 1: Baseline sociodemographic characteristics of the study participants

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All the participants had either heard or read about COVID-19. Most people cited their main source of information as television (73.2%; n = 172) [Figure 1]a. There was a significant difference between the source of information and the employment status, with students preferring television and online resources over print media, compared to other professional peers (χ2 {15,235} = 31.85, P = 0.007). Nearly two-thirds of the total participants (77%; n = 181) reported being satisfied with the available information. Around 88.9% (n = 209) of the participants had not experienced any COVID-19-related symptoms, such as dry cough, fever, tiredness, cold, or diarrhea in the last 14 days.
Figure 1: (a) Proportion of study participants who opted for various sources of accessing information regarding coronavirus disease 2019, *GAA=Governmentauthorized application, (b) proportion of study participants who opted for various modes of coronavirus disease 2019 transmission, (c) proportion of study participants who opted for various preventive measures against coronavirus disease 2019, (d) proportion of study participants who opted for various symptoms of coronavirus disease 2019

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The mean percentage score for knowledge regarding transmission, prevention, and symptoms was 65.9% ± 24.9%, 92.8% ± 20.2%, and 68.8% ± 24.7%, respectively. The proportion of the study participants who opted for different ways of COVID-19 transmission, prevention, and symptoms is represented in [Figure 1]b,[Figure 1]c,[Figure 1]d. Those viewing information multiple times a day had statistically significantly higher prevention (mean rank = 125.0, P = 0.005) and symptoms (mean rank = 133.46, P = 0.042) score %.

Nearly, half of the participants (53%; n = 124) reported moderate stress; low stress was perceived by 42.3% (n = 99) and severe stress was observed in 4.7% (n = 12). The mean PSS score was 13.4 ± 8.9. Higher mean PSS score was associated with age (r = 0.194, P = 0.003), female gender (mean rank = 132.0, P = 0.001), higher education (mean rank = 154.5, P = 0.006), salaried occupation (mean rank = 143.79, P = 0.047), as shown in [Table 2], dissatisfaction with the available information (mean rank = 155.64, P = 0.009), and accessing information multiple times a day (mean rank = 133.51, P = 0.041), as shown in [Table 3]. No significant association of mean PSS-10 score was observed with the type of residence; source of information; presence of symptoms over the last 14 days; and the percentage scores for knowledge regarding the transmission, prevention, and symptoms of COVID-19.
Table 2: Univariate analysis of Perceived Stress Scale-10 against demographic variables

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Table 3: Univariate analysis of Perceived Stress Scale-10 against information-related and knowledge-related variables

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The variables found significant on univariate analysis (gender, education, occupation, dissatisfaction with the available information, frequency of accessing information, and age), were analyzed by linear regression with step-wise backward elimination of variables. Finally, age, gender, dissatisfaction with the available information, and frequency of accessing information were identified to be significant correlates of mean PSS-10 score [Table 4].
Table 4: Linear multiple regression analysis of Perceived Stress Score-10 against sociodemographic and other related variables

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In order to cope with stress, the participants reportedly spent time with their family and friends (76.0%), indulged in hobbies (61.9%), acknowledged praying as a means of dissipating stress (47.5%), had anger outbursts (17.1%), and increased sleep duration (29.8%). No significant difference was seen in the coping methods adopted across the PSS-10 categories, gender, and other sociodemographic variables.


  Discussion Top


The direct physical effects of COVID-19 on children are known to be less severe as compared to that of the adults.[15] However, the indirect and unseen psychological impact of the current pandemic is likely to have a pernicious and sustained effect on the young minds. The stress-induced psychological disturbances such as anxiety, depression, and anger are more marked in adolescents and young adults because of the immaturity of stress-related limbic and cortical areas.[16] In addition, childhood stress is known to be associated with an increased risk of adulthood anxiety and other psychiatric illnesses.[17]

In this study, we found that a significant proportion (95.3%) of the study participants were dealing with low-to-moderate stress. Stress correlated positively with age in our study. On the same line, Gao et al.[18] showed higher odds of combined anxiety and depression among individuals aged 21–30 years and 31–40 years compared to those aged <20 years. The positive correlation of stress with increasing age could be explained by a better understanding of the impact of the pandemic and professional uncertainty for an age group that has recently entered job markets. We observed that females were significantly more stressed as compared to males. This is in agreement with previous studies.[19],[20] Similar to the findings reported by Du et al.,[21] a higher stress score was noted among those with the highest educational level in our study. This could simply be attributed to their older age, or a result of apprehensions stemming from the increased awareness regarding the pandemic, or both. In contrast to Wang et al.,[20] who reported more stress among students, we observed that salaried individuals perceived significantly more stress compared to students and self-employed or unemployed individuals, which, too, is concurrent with the present fall in employment opportunities for young people.

Availability of adequate information is the key to mitigate the prevailing stress. A significantly higher PSS-10 score was seen among those who were reportedly dissatisfied with the available information. The need for more information could be a means to cope with the fears and uncertainties due to the pandemic. Paradoxically, those viewing information multiple times a day also had significantly higher PSS-10 score compared to others. Accessing information frequently, in addition to providing knowledge about the pandemic, also adds to the level of anxiety and stress.[22] In contradiction to the past studies,[18] no difference in perceived stress was observed with the source of information. This could be because of smaller sample size in our study.

We observed a remarkably good level of knowledge regarding COVID-19 among the study participants. This is in contrast to previous studies that have reported inadequate levels of knowledge about the measures of prevention toward the H1N1 influenza pandemic among the general public.[23] This could be attributed to the fact that most of our participants possessed at least high school level education and also to the untiring measures taken by the government and the media to spread reliable information.

We found that majority of the participants cited television as an important source of information. This is in agreement to previous studies which reported the Internet and television as prime sources of information during infectious outbreaks.[22],[24] Furthermore, students preferred television to newspaper for viewing updates. This is also in agreement with previous studies which have reported an upsurge in digital media use compared to traditional ways, such as newspaper and magazines, among children and adolescents.[25]

Majority of the participants adopted positive coping strategies to deal with the outbreak. Spending more time with friends and family members was the most common strategy used. This is similar to the findings reported in previous studies where participants reported increased felt need to talk with someone to vent out their distress.[26]

The limitation of our study is that it was designed for patients with access to smartphones and those possessing the ability to understand English. Therefore, the results of this study cannot be extrapolated across all the sections of the society. In addition, data regarding COVID-19 status of the participants and their family members or friends, were not collected. Use of a subjective tool (PSS-10) to determine the level of stress has its own inherent limitations. However, given the current scenario of lockdown, this was the most feasible method to assess the mental health of the study participants. Notwithstanding the above limitations, our study provides valuable information on the perceived stress among Indian adolescents and young adults, approximately 5 weeks after the announcement of the nationwide lockdown. It highlights the possible factors contributing to increased stress among the participants.


  Conclusion Top


An increased prevalence of stress was seen among the Indian adolescents and the young adults in our study. Older age, female gender, higher education level, salaried individuals, dissatisfaction with the available information, and accessing information multiple times a day, contributed to an increased risk of stress. Future measures for psychological support could, therefore, be focused more on these priority groups.

Acknowledgments

The authors would like to thank the participants of the study for kindly taking their time out to answer the questionnaire.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Appendix I: Questionnaire used in the survey Top


We invite you to participate in this study conducted by a group of doctors to understand the various challenges faced by young adults in the COVID-19 scenario. We are concerned that children and young adults are especially at risk for stress and anxiety during these times, and we want to help them.

This will be a 10-min online survey in the form of simple yes/no questions.

Participation will be entirely voluntary, the information collected shall be kept strictly confidential, and the identities of the students shall not be revealed at any time.

Thank you for your support.

Hope we can all come together to fight this crisis collectively.

For further questions, please do not hesitate to contact Dr. Mandara at [email protected]

Section 0 – Informed consent

I have read the above information and agree to participate in this research project:

  1. Yes
  2. No


If no, survey terminates.

Is your age between 12 and 24 years of age? If yes, to continue with Section 1.1.

If no, survey terminates.

Section 1.1 – Demographic details

  1. Age (in completed years):
  2. Gender: Male/female
  3. Are you married? Yes/no
  4. Which country do you reside in?
  5. State of residence?
  6. Resident type: Independent house/apartment/hostel
  7. Education: Less than high school/high school/intermediate/graduation/postgraduation
  8. Occupation: Student/employed/business/unemployed.


Section 1.2

  1. Age of your child (in years):
  2. Gender of your child: Male/female
  3. Which country do you reside in?
  4. State of residence:
  5. Family type: Nuclear/joint
  6. Residence type: Independent house/flat
  7. Have you heard about coronavirus infection? Yes/no.



  Section 2 – Knowledge and awareness about COVID-19 Top


  1. Are you aware of the current COVID-19 pandemic: Yes/no
  2. Major source of information regarding the COVID-19 pandemic: WhatsApp/Facebook or other social media/Google or other online sources/newspaper/television/government-authorized applications
  3. Are you satisfied with the information available to you: Yes/no/maybe
  4. How often are you tracking the information about COVID-19: Never/occasionally/daily/multiple times a day
  5. How does coronavirus spread? (check all that apply): Direct contact with infected person or object/droplets (spreads when you come within 1 m of someone coughing/sneezing)/airborne (the infection remains in the air for long periods of time, even when people have moved away)/don't know
  6. How can you protect yourself from coronavirus infection? (check all that apply): Frequent hand washing/social distancing/wearing face mask when outdoor/avoiding contact with person coughing/sneezing/don't know
  7. What are the signs and symptoms of coronavirus infection? (check all that apply) Fever/dry cough/tiredness/cold/diarrhea/sometimes no symptoms/don't know
  8. Have you experienced any of these symptoms in the last 14 days? (check all that apply): Fever/dry cough/tiredness/cold/diarrhea/None.



  Section 3 – Psychological impact of the COVID-19 pandemic Top


PSS-10

  1. In the last month, how often have you felt upset because of something that happened unexpectedly: Never/almost never/fairly often/often/very often
  2. In the last month, how often have you felt unable to control important things in your life: Never/almost never/fairly often/often/very often
  3. In the last month, how often have you felt nervous and “stressed”: Never/almost never/fairly often/often/very often
  4. In the last month, how often have you felt confident about your ability to handle personal problems: Never/almost never/fairly often/often/very often
  5. In the last month, how often have you felt that things were going your way: Never/almost never/fairly often/often/very often
  6. In the last month, how often have you found that you could not cope with all the things that you had to do: Never/Almost never/Fairly often/Often/Very often
  7. In the last month, how often have you been able to control irritations in your life: Never/almost never/fairly often/often/very often
  8. In the last month, how often have you felt that you were on top of things: Never/almost never/fairly often/often/very often
  9. In the last month, how often have you been angered because things were out of your control? Never/almost never/fairly often/often/very often
  10. In the last month, how often have you felt that difficulties were piling up so high that you could not overcome them: Never/almost never/fairly often/often/very often.
  11. What are you doing to decrease your anxiety/stress? Engaging in recreational activities/talking with friends or family/accepting it as an unchangeable problem/praying to God/often feel angry or frustrated with others/increased sleep time




 
  References Top

1.
Paules CI, Marston HD, Fauci AS. Coronavirus infections-more than just the common cold. JAMA 2020;323:707-8.  Back to cited text no. 1
    
2.
Nishiura H, Jung SM, Linton NM, Kinoshita R, Yang Y, Hayashi K, et al. The extent of transmission of novel coronavirus in Wuhan, China, 2020. J Clin Med 2020;9:330.  Back to cited text no. 2
    
3.
Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed 2020;91:157-60.  Back to cited text no. 3
    
4.
The Lancet. India under COVID-19 lockdown. Lancet 2020;395:1315.  Back to cited text no. 4
    
5.
Vindegaard N, Benros ME. COVID-19 pandemic and mental health consequences: Systematic review of the current evidence. Brain Behav Immun 2020;89:531-42.  Back to cited text no. 5
    
6.
Mak IW, Chu CM, Pan PC, Yiu MG, Chan VL. Long-term psychiatric morbidities among SARS survivors. Gen Hosp Psychiatry 2009;31:318-26.  Back to cited text no. 6
    
7.
Li L, Wan C, Ding R, Liu Y, Chen J, Wu Z, et al. Mental distress among Liberian medical staff working at the china Ebola treatment unit: A cross sectional study. Health Qual Life Outcomes 2015;13:156.  Back to cited text no. 7
    
8.
Lau JT, Tsui HY, Kim JH, Chan PK, Griffiths S. Monitoring of perceptions, anticipated behavioral, and psychological responses related to H5N1 influenza. Infection 2010;38:275-83.  Back to cited text no. 8
    
9.
Kim HC, Yoo SY, Lee BH, Lee SH, Shin HS. psychiatric findings in suspected and confirmed Middle East respiratory syndrome patients quarantined in hospital: A retrospective chart analysis. Psychiatry Investig 2018;15:355-60.  Back to cited text no. 9
    
10.
Arnett JJ. Adolescent storm and stress, reconsidered. Am Psychol 1999;54:317-26.  Back to cited text no. 10
    
11.
Skinner EA, Zimmer-Gembeck MJ. The development of coping. Annu Rev Psychol 2007;58:119-44.  Back to cited text no. 11
    
12.
Advice for the Public on COVID-19 – World Health Organization; 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public. [Last accessed on 2020 Apr 24].  Back to cited text no. 12
    
13.
MoHFW Home; 2020. Available from: https://mohfw.gov.in/. [Last accessed on 2020 Apr 24].  Back to cited text no. 13
    
14.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.  Back to cited text no. 14
    
15.
Yavuz S, Kesici S, Bayrakci B. Physiological advantages of children against COVID-19. Acta Paediatr 2020;109:1681.  Back to cited text no. 15
    
16.
Eiland L, Romeo RD. Stress and the developing adolescent brain. Neuroscience 2013;249:162-71.  Back to cited text no. 16
    
17.
Lähdepuro A, Savolainen K, Lahti-Pulkkinen M, Eriksson JG, Lahti J, Tuovinen S, et al. The impact of early life stress on anxiety symptoms in late adulthood. Sci Rep 2019;9:4395.  Back to cited text no. 17
    
18.
Gao J, Zheng P, Jia Y, Chen H, Mao Y, Chen S, et al. Mental health problems and social media exposure during COVID-19 outbreak. PLoS One 2020;15:e0231924.  Back to cited text no. 18
    
19.
ízdin S, Bayrak ízdin Ş. 'Levels and predictors of anxiety, depression and health anxiety during COVID-19 pandemic in Turkish society: The importance of gender. Int J Soc Psychiatry 2020;66:504-11.  Back to cited text no. 19
    
20.
Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health 2020;17:1729.  Back to cited text no. 20
    
21.
Du J, Dong L, Wang T, Yuan C, Fu R, Zhang L, et al. Psychological symptoms among frontline healthcare workers during COVID-19 outbreak in Wuhan. Gen Hosp Psychiatry 2020;67:144-5.  Back to cited text no. 21
    
22.
Chandrasekaran N, Gressick K, Singh V, Kwal J, Cap N, Koru-Sengul T, et al. The utility of social media in providing information on Zika virus. Cureus 2017;9:e1792.  Back to cited text no. 22
    
23.
Johnson EJ, Hariharan S. Public health awareness: Knowledge, attitude and behaviour of the general public on health risks during the H1N1 influenza pandemic. J Public Health 2017;25:333-7.  Back to cited text no. 23
    
24.
Fung IC, Duke CH, Finch KC, Snook KR, Tseng PL, Hernandez AC, et al. Ebola virus disease and social media: A systematic review. Am J Infect Control 2016;44:1660-71.  Back to cited text no. 24
    
25.
Reid Chassiakos YL, Radesky J, Christakis D, Moreno MA, Cross C, Council on Communications and Media. Children and adolescents and digital media. Pediatrics 2016;138:e20162593.  Back to cited text no. 25
    
26.
Lee AA, Piette JD, Heisler M, Rosland AM. Diabetes distress and glycemic control: The buffering effect of autonomy support from important family members and friends. Diabetes Care 2018;41:1157-63.  Back to cited text no. 26
    


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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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