|Year : 2019 | Volume
| Issue : 3 | Page : 1082-1089
Effectiveness of holistic group health promotion program on educational stress, anxiety, and depression among adolescent girls – A pilot study
Sreevani Rentala1, Bobo Hi Po Lau2, Rajashree Aladakatti3, Sunanda Govinder Thimmajja1
1 Department of Psychiatric Nursing, Dharwad Institute of Mental Health and Neuroscience, Dharwad, Karnataka, India
2 Department of Counseling and Psychology, Hong Kong Shue Yan University, 10 Wai Tsui Crescent, Braemar Hill Road, North Point, Hong Kong
3 Department of Psychiatric Nursing, Shreya College of Nursing, Dharwad, Karnataka, India
|Date of Web Publication||27-Mar-2019|
Dr. Sreevani Rentala
Department of Psychiatric Nursing, Dharwad Institute of Mental Health and Neurosciences, Dharwad - 580 008, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Academic stress is one of the major stresses among adolescents and it has been associated with poor mental health. Aim: Evaluate effectiveness of holistic intervention on educational stress among adolescent girls. Materials and Methods: Randomized controlled design was adopted and study was conducted at selected colleges of Dharwad city, India. 60 adolescent girls were randomly assigned to either experimental or control group. All subjects were initially assessed for educational stress, depression and anxiety. The experimental group subjects received 8 sessions of holistic intervention. No intervention was given to control group subjects. Post intervention assessments were done at the end of 1st, 2nd and 3rd months. Results: Experimental group subjects showed statistically significant decrease in educational stress, depression and anxiety over 3 months follow-up compared to control group subjects. Conclusion: This study provided evidence of integrating a holistic intervention in reducing stress.
Keywords: Adolescent girls, anxiety, depression, education stress, holistic group health promotion program
|How to cite this article:|
Rentala S, Lau BH, Aladakatti R, Thimmajja SG. Effectiveness of holistic group health promotion program on educational stress, anxiety, and depression among adolescent girls – A pilot study. J Family Med Prim Care 2019;8:1082-9
|How to cite this URL:|
Rentala S, Lau BH, Aladakatti R, Thimmajja SG. Effectiveness of holistic group health promotion program on educational stress, anxiety, and depression among adolescent girls – A pilot study. J Family Med Prim Care [serial online] 2019 [cited 2019 Apr 24];8:1082-9. Available from: http://www.jfmpc.com/text.asp?2019/8/3/1082/254892
| Introduction|| |
In today's world of excellence, almost everyone experiences various degrees of stress in their daily lives. Even children are not an exception to it as they are experiencing greater stress on account of rising expectations at both school and home to perform beyond their natural ability. India accounts for 21% of adolescent population worldwide. Stress resulting from academic schedules though prevalent in adolescents worldwide seems to be more severe among their Asian counterparts. Asian students are pressured with high academic burden, suffer greater academic stress, have low satisfaction relating to their academic performance, and high expectations. Literature shows that academic pressure causes various mental and behavioral disorders such as depression, frustration, anxiety, helplessness, and suicidal behavior; these are more common emotional disorders in adolescents., School related factors that result in depression among adolescents are poor academic performance, stressful events at school, and negative feedback from teachers and parents.,
As adolescent girls of today are mothers of tomorrow, their health is the foundation for future generations. They are more vulnerable to stress than adolescent boys  because of the inherent physiological changes, their social upbringing, and a feeling of greater pressure to achieve good academic grades at an early age. Although anxiety and depression affect boys and girls almost similarly, the adolescent girls are much more vulnerable. Recently, subjective stress related mental health complaints such as pain, sleeping problems, and anxiety have increased among older adolescents, especially girls. Furthermore, depression is more common among adolescent girls. Previous literature has revealed that there is high prevalence of depression, suicidal attempts, anxiety, and stress related symptoms among adolescent girls when compared to boys, which affects the girls health status and accomplishments., Poor psychological health can have several effects on adolescent girls such as poor eating habits, physical health, and coping skills. It also leads to school dropout, drug dependence, unprotected sex, and adolescent pregnancy.
This advocates the need for early and effective identification of depression, stress, and anxiety, which can prevent many psychiatric disorders at their nascent stage. The implementation of stress management strategies such as deep breathing, progressive muscular relaxation, positive self talk, etc., at this stage are not only relevant to manage stress at a very young age but also very significant in improving school achievement and emotional well-being among adolescents. Although school programs targeting stress management are effective in reducing stress among children, only a few are available specifically for adolescent girls.
| Background of the Study|| |
As stress can affect health, emotional state, and academic performance, it is important that students develop effective strategies to manage stressful situations. A systematic review revealed that holistic mental health promotion programs conducted by involving family members, school faculties, and community members result in not only an improvement in their mental health but also the social, academic, work performance, and general health components. These programs provide the adolescents with important life skills, help in achieving their full potential, and overcome difficulties. Such integrative programs deal with multiple student behavioral problems and effectively reduce the burden on schools and teachers. Such integrative programs have also proved to be efficient., The present day adolescents need psychological treatment that goes beyond teaching or talk therapy. These holistic stress management interventions devote on wellness of body, mind, and spirit. Adolescents thrive with a holistic approach to care that not only focuses on individual symptoms or behavior but also on their physical, emotional, and spiritual needs equally. Evidence suggests that conventional stress management that focuses on stress symptoms is of very little benefit as the integrated approach is more ideal to treat the underlying causes of emotional distress. Although there is lot of literature on stress related studies, academic stress, stress adjustment problems, and need for guidance and counseling, management of stress for the students is not addressed sufficiently, especially in India. It is known that earlier the adolescents learn to deal with their stress, the better will be their psychological and physical health as an adult. Several studies demonstrated that only by holistic changes in daily routine one can alleviate multiple emotional sufferings and promote positive psychophysical attributes. Certainly schools or colleges have a vital responsibility in improving student's positive mental health  as it has a bearing on their academic performance.
The present study has been taken up against the above background with a purpose to measure the effectiveness of holistic group health promotion program on the educational stress of adolescent girls. We hypothesized that subjects in the experimental group will experience a greater reduction in academic stress, depression, anxiety, and perceived stress compared to the participants in the control group at follow-up assessments.
| Materials and Methods|| |
The main objective of the study was to assess the effectiveness of holistic group health promotion program in reducing academic stress anxiety and depression among adolescent girls. The present study used experimental pre-post control group design with 3-months follow-up. Study was approved by Institutional Ethics Committee. The ethical considerations were addressed by explaining the participants and their parents their ethical rights both in words and writing. The purpose, nature, time duration of the study, the researchers contact information, confidentiality, and their right not to participate, or to withdraw at any stage were also informed. Subsequent to explanation of the purpose, risks, and benefits of the study, the subjects and their parents gave their written consent.
The age inclusion criteria was 16 to 19 years, and the study excluded subjects who had undergone or were undergoing other forms of counseling or relaxation therapies (psychological counseling and or any other stress reduction programs) and also a significant physical or psychological health problems that could interfere with their participation in the proposed therapy.
After obtaining formal permission from the appropriate institutional authority, recruitment of subjects took place at selected colleges. All these colleges are co-educational institutions with an average of 50 to 60 students per class, 50% of them being girls. Data were collected between June 2017 and October 2017. A total of 130 students were approached of which 14 students expressed their unwillingness as the session timings were not convenient to them. Of the remaining 116 adolescent girls who were initially screened using a stress sub scale of depression, anxiety, and stress scale, 100 adolescent girls met the criteria of cut-off score above 14. From this sample, 60 subjects were randomly selected and assigned to experimental and control groups using computer generated random table method with each group constituting of 30 subjects [Figure 1].
|Figure 1: Flow chart showing distributions of participants in experimental and control group|
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Initially, the data collector approached each participant and assessed them for baseline data using self report methods such as socio-demographic data sheet, personality inventory, IQ assessment, educational stress scale for adolescents, depression, anxiety, and stress scales. Later, the researcher ( first author) randomly assigned 60 subjects to experimental and control groups. Control group subjects did not receive any intervention. Experimental group subjects participated in holistic group health promotion program. The intervention involved a total of eight sessions with 2 weekly sessions for 4 weeks; each session lasting for 90 to 120 min. Intervention was given as a group approach by the first author, who underwent Body-Mind-Spirit practitioner training at center on behavioral health, the University of Hong Kong, Hong Kong. Each group consisted of 8 to15 participants. A total of 3 groups completed the 4 weeks intervention. The holistic group health promotion program was based on Body-Mind-Spirit model originally developed by Chan (2001), which emphasizes a holistic concept of health. This model focuses on establishing a dynamic balance of inter-relationships among mind, body, and spirit through psychoeducational strategies on emotional management; stress reduction techniques such as acupressure exercises, breathing techniques, and meditation; connecting to spiritual; and self-healing resources such as utilizing strengths and appreciating abilities.
In the present study, holistic group health promotion program was implemented over eight sessions: (a) concept of holistic health; (b) understanding my own stress; (c) identifying stressors; (d) how do I respond to stress; (e) emotions and well-being; (f) loving myself; (g) my growth and strength, my support and network, and (h) transformation of self. The details of these sessions are described in [Table 1].
Post assessment was done using educational stress scale, depression, anxiety, and stress scales at 1 month, 2 month, and 3 month intervals. During each follow-up, the experimental group subjects were encouraged and reinforced to practice holistic techniques along with routine follow-up assessments, whereas the control group subjects had only follow-up assessments without any intervention [Table 2].
| Measures|| |
The subjects responded to the Depression, Anxiety and Stress Scale, (DASS-21) and Education Stress Scale for Adolescents (ESSA). The outcome measures were assessed at baseline (T0) and at three follow-up assessments in the 1st (T1), 2nd (T2), and 3rd (T3) months.
- Depression, Anxiety and Stress Scale (DASS-21) was developed by Lovibond, S.H.; Lovibond, P.F. in 1995. It is a short version of a 42-item self-report instrument consisting of three 7-item subscales designed to measure the emotional states of depression, anxiety, and stress. Each scale includes seven items, with a total of 21 items rated on 4-point scale ranging from 0–3 (0-denoting did not apply to me at all and 3-denoting applied to me most of the time). The overall scores for the three subscales are calculated as the sum of scores for the relevant seven items multiplied by two. The Cronbach's alpha for stress subscale is 0.77, depression is 0.77, and anxiety is 0.80 among adolescents 
- Education Stress Scale for Adolescents (ESSA) was developed by Sun, Dunne, Hou, and Xu (2011). It is a self-report instrument containing 16 items designed to measure educational stress on five components that includes study pressure (4 items), workload (3 items), worry on grades (3 items), self expectation (3 items), and despondency (3 items) rated on 5-point scale 1 to 5 (1-strongly disagree to 5-strongly agree) with higher score indicating greater educational stress. Scores range from 16 to 80. The Cronbach's alpha for ESSA five subscales were..81,.74,.71,.66, and.75. indicating moderate to good internal consistency among East Asian adolescents.
The content validity of the intervention module was ensured by a panel of eight subject experts. The appropriateness of each session for use among adolescent girls was rated by the panel members. Their recommendations relating to theme drawing and topics for group discussion were incorporated to better suit the needs of the participants.
Data were analyzed using statistical package for the social sciences software package (Version 23), and results were presented in a table form. Baseline characteristics of the experimental and control groups were compared using one-way ANOVA or independent t tests or χ2 test. The changes in the outcome variables from baseline to 3-month follow-up were compared using two-way RM-ANOVA.
| Results|| |
At pre-intervention level, there were no statistically significant differences between experimental and control group subjects in all baseline variables such as age, residence, religion, type of family, number of siblings, birth order, family income, type of college, percentage of marks in previous class, number of homeworks, study hours per day, percentage of IQ, and type of personality [Table 3]. Both the groups were similar in all the outcome variables [Table 4].
|Table 3: Pre-intervention group comparison of socio-demographic and outcome variables|
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Two-way repeated measures ANOVA were conducted to know the variation in the outcome variables from baseline to 3-month follow-up. There were significant holistic group health promotion intervention effects in all the outcome variables between the experimental and control group subjects [Table 5].
|Table 5: Group comparison of educational stress, depression, anxiety, and stress across the time points between experimental and control group subjects|
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Compared to the control group, the experimental group showed statistically significant decrease in educational stress (F = 500.90, P < 0.001, η2 = 0.90), depression (F = 222.73, P < 0.001, η2 = 0.79), anxiety (F = 224.67, P < 0.001, η2 = 0.80), and stress (F = 277.09, P < 0.001, η2 = 0.82) over 3 months follow-up [Table 4]. The effect size of the holistic group health promotion intervention effects was consistently large for all the outcome variables in experimental group subjects compared to control group subjects.
| Discussion|| |
On the whole, subjects in experimental group showed a marked decreased in educational stress, depression, anxiety, and stress in 3 months follow-up compared to control group which did not receive any intervention. The follow-up results indicated that the effect continued and persisted even after 3 months. This justifies the integration of holistic stress management program for adolescent girls within the school setting to effectively reduce stress levels. These findings are similar to previous research results,,, which highlighted that providing mind-body interventions or mindfulness interventions on adolescents at school setting significantly reduced anxiety, depression, and stress. This study provides research evidence for group based holistic health promotion intervention among adolescent girls and facilitates wider scope for primary care providers to implement these kinds of interventions in school settings.
In the present study, educational stress decreased considerably among experimental group subjects than in control group subjects at 3 months follow-up (F = 500.9, P < 0.001, η2 = 0.90). This reduction suggests that practicing various health promotion activities may result in decreased negative emotions. Holistic interventions not only help in dealing with the present difficulties but also aim to care for the self balancing abilities of individuals. The present study findings were supported by previous studies ,, which highlighted that holding stress management programs reduce academic stress and improve mental health of the adolescents.
The unresolved stress may cause depression, eating disorders, somatic symptoms, suicidal behavior, anxiety, poor concentration, physical illness, substance abuse, and dissociative disorders. Present study showed that depression scores statistically decreased with a large effect size among experimental group subjects compared to control group subjects. This reduction continued for 3 months, demonstrating that group based holistic approach can facilitate positive emotions among adolescent girls. The present study results are consistent with previous literature ,,, where mindfulness based school programs reported lower depressive scores and stress among students.
The anxiety levels of the experimental subjects exhibited a significant decrease in 3 month follow-up compared to control group subjects. These results were in line with findings of previous studies on adolescents where spirituality oriented stress programs , reduced anxiety and stress symptoms. The present study results demonstrate that spirituality based holistic intervention is an effective approach in bringing down negative emotions among adolescent girls.
The holistic group health promotion is a comprehensive approach in dealing with various dimensions of stress that might have been positively impacted in terms of reducing stress, anxiety, and depression compared to their counterparts in the control group. This intervention mainly focused on empowering participants for self healing. For example, by participating in holistic group sessions, the participants not only acquired comprehensive knowledge on stress and its effects but also recognized the related symptoms. Participants practiced daily log recording on stressful situations to identify stressors, practiced simple relaxation techniques within the class room to handle stress, and appreciated themselves for their growth and for being able to identify their problems and difficulties. These techniques helped the adolescent girls to realize that stress can be reduced by perceiving the situation normally, loving themselves, appreciating their growth and support system, and carrying out self-help role in achieving sense of control over the situations. A group wise intervention seems to be more effective particularly during adolescent period because they are more prone to social influence, peer pressure, and effects of role models. As the adolescents are crucial for individual and societal development, the school curriculum needs to have some scope for promoting holistic practices.
It can be concluded that the use of holistic interventions on managing stress is a useful approach to help students who are having high educational stress. It proved to be highly efficient as it was conducted in groups with less cost and was well accepted by the adolescents. This supports the applicability of the present intervention in Indian context.
As this study was carried out with a small sample, there is a need to substantiate the research results with an adequate sample size. Self-reporting measures were used to assess outcome variables. Including objective measures in the future will strengthen the study validity. Notwithstanding these limitations, it is a maiden study to demonstrate the effectiveness of holistic group health promotion intervention integrating spirituality component in improving outcomes among Indian adolescent girls who are educationally stressed.
The present study findings have several implications for primary health care providers, school counsellors, parents, teachers, and several other stakeholders. Primary health care providers are in better position to implement these interventions, which include mindful meditation, simple relaxation exercises, mirror therapy, and self love techniques to reduce academic stress and anxiety among adolescents.
| Conclusion|| |
Findings demonstrated effectiveness of holistic group health promotion intervention in decreasing the educational stress, depression, anxiety, and stress among educationally stressed adolescent girls. This improvement sustained for 3 months. The present study may provide an avenue for primary health care providers to implement holistic based stress management program so as to promote adolescent mental health in Indian context.
Financial support and sponsorship
This research work was supported by the Indian Council of Social Science Research [Grant number 02/171/2016-17/RPR].
Declaration of conflicting interests
“The Author(s) declare(s) that there is no conflict of interest.”
| References|| |
Tang NY, Westwood P. Worry, general self-efficacy and school achievement: An exploratory study with Chinese adolescents. Aust J Guid Couns 2007;17:68-80.
Lee M, Larson R. The Korean 'examination hell': Long hours of studying, distress, and depression. J Youth Adolesc 2000;29:249-71.
Huan VS, See YL, Ang RP, Har CW. The impact of adolescent concerns on their academic stress. Edu Rev 2008;60:169-78.
Crystal DS, Chen C, Fuligni AJ, Stevenson HW, Hsu CC, Ko HJ. Psychological maladjustment and academic achievement: A cross-cultural study of Japanese, Chinese, and American high school students. Child Dev 1994;65:738-53.
Ang RP, Huan VS. Relationship between academic stress and suicidal ideation: Testing for depression as a mediator using multiple regressions. Child Psychiatry Hum Dev 2006;37:133-43.
Verma S, Gera M. Stress management strategies for adolescents to improve mental health. Int J Curr Res 2013;4:2319-7064.
Liu Y, Lu Z. Chinese high school students' academic stress and depressive symptoms: Gender and school climate as moderators. Stress Health 2012;28:340-6.
Gray-Stanley S. Work stress and depression among direct support professionals: The role of work support and locus of control. J Intellect Disabil Res 2010;54:749-61.
Saleem A, Ahmed G, Ali AS, Fawwad HS, Saleem B, Farrukh T. Psychiatric in Pakistan: Focus on child mental health. Asian J Psychiatr 2013;6:618-9.
Schraml K, Perski A, Grossi G, Simonsson-Sarnecki M. Stress symptoms among adolescents: The role of subjective psychosocial conditions, lifestyle, and self-esteem. J Adolesc 2010;34:987-96.
Bouma EM, Ormel J, Verhulst FC, Oldehinkel AJ. Stressful life events and depressive problems in early adolescent boys and girls: The influence of parental depression, temperament and family environment. J Affect Disord 2008;105:185-93.
Rosvall P, Nilsson S. Gender-based generalisations in school nurses' appraisals of and interventions addressing students' mental health. BMC Health Serv Res 2016;16:451.
Wiklund M, Malmgren-Olsson EB, Bengs C, Öhman A. He messed me up: Swedish adolescent girls' experiences of gender-related partner violence and its consequences over time. Violence Against Women 2010;16:207-32.
Saluja G, Lachan R, Scheidt CP, Overpeck DM, Sun W, Giedid NJ. Prevalence of and risk factors for depressive symptoms among young adolescents. Arch Pediatr Adolesc Med 2004;158:760-65.
Desouky Del-S, AbdellatifIbrahem R, Salahomar M. Prevalence and comorbidity of depression, anxiety and obsessive compulsive disorders among Saudi secondary school girls, Taif Area, KSA. Arch Iran Med 2014; 18:234-238.
Mundy LK, Simmons JG, Allen NB, Viner RM, Bayer JK. Study protocol: The Childhood to Adolescence Transition Study (CATS). J BMC Pediatr 2013;13:160.
Qidwai W, Ishaque S, Shah S, Rahim M. Adolescent lifestyle and behavior: A Survey from a developing country. PLoS One 2010;5:e12914.
Petanidov D, Daskaeianni E, Dinnitrakaki C, Kolaitis G, Tountas Y. The role of perceived wellbeing in the family, school and peer context in adolescent's subjective health complaints evidence from Greek cross sectional study. Biopsychosoc Med 2013;7:2-9.
Sandal RK, Goel NK. Prevalence of depression, anxiety and stress among school going adolescent in Chandigarh. J Family Med Prim Care 2017;6:405-10.
] [Full text]
Durlak JA, Wells AM. Primary prevention mental health programs for children and adolescents: A meta-analytic review. Am J Community Psychol 1997;25:115-52.
Wells J, Barlow J, Stewart-Brown S. A systematic review of universal approaches to mental health promotion in schools. Health Educ 2003;4:197-220.
Prochaska JJ, Spring B, Nigg CR. Multiple health behaviour change research: An introduction and overview. Prev Med 2008;46:181-8.
Paulussen T, Panis R, Peters L, Buijs G, Wijnsma P. Stand van zaken schoolgezondheidsbeleid in Nederland [State of the art of school health policy in the Netherlands]. Woerden: NIGZ; 1998.
Peters LWH, Kok G, Ten Dam GTM. Effective elements of school health promotion across behavioral domains: A systematic review of reviews. BMC Public Health 2009;9:182.
Roger D, Jarvis P, Najarian B. Detachment and coping: The construction and validation of a new scale for measuring coping strategies. Pers Individ Dif 1993;15:619-26.
Gupta A, Harjai S. Stress management for adolescents: A review. Int J Rec advanc Multidisc Res 2016;03: 1913-1918.
Romeo RD. Adolescence: A central event shaping stress reactivity. J Dev Psychobiol 2010;52:244-53.
Suldo S, McMahan M, Chappel A, Loker T. Relationships between perceived school climate and adolescent mental health across genders. J Sch Men Health 2012;4:69-80.
Leaver CA. Subjective well-being of children in elementary school and repeated visits to school health nurses. J Sch Health 2014;84:294-301.
Chan CLW, Ho PSY, Chow E. A body-mind-spirit model in health: An eastern approach. Soc Work Health Care 2001;34:261-82.
Lovibond SH, Lovibond PF. Manual for the Depression Anxiety & Stress Scales. 2nd
ed. Sydney: Psycho Fon; 1995.
Hítalo AS, Muana HPP. Short version of the depression anxiety stress scale-21: Is it valid for Brazilian adolescents? Einstein J Biol Med 2016;14:486-93.
Sun J, Dunne MP, Hou XY, Xu A. Educational stress scale for adolescents: Development, validity and reliability with Chinese students. Int J Sch Educ Psychol 2011;29:534-46.
Gloria R. The evaluation of a mind/body intervention to reduce psychological distress and perceived stress in college students. J Sch Health 2016;50:220-88.
Johnstone JM, Roake C, Sheikh I, Mole A, Nigg TJ, Oken B. School-based mindfulness intervention for stress reduction in adolescents: Design and methodology of an open-label, parallel group, randomized controlled trial. Contemp Clin Trials Commun 2016;4:99-104.
Gallegos AM. Mindfulness-based stress reduction to enhance psychological functioning and improve inflammatory biomarkers in trauma-exposed women: A pilot study. Psychol Trauma 2015;7:525-32.
Rentala S, Fong TC, Nattala P, Chan CL, Konduru R. Effectiveness of body-mind-spirit intervention on well-being, functional impairment and quality of life among depressive patients – A randomized controlled trial. J Adv Nurs 2015;71:2153-63.
Nikitha S, Tessy TJ, Blessy PV. Effectiveness of academic stress management programme on academic stress and academic performance among higher secondary students in selected schools of Udupi District. Nitte University. J Health Sci 2015;5:9-12.
Chinaveh M, Ishak MN, Salleh MA. Improving mental health and academic performance through multiple stress management intervention: Implication for diverse learners. Procedia Soc Behav Sci 2010;7:311-6.
Yazdani M, Rezaei S, Pahlavanzadeh S. The effectiveness of stress management training program on depression, anxiety and stress of the nursing students. Iran J Nurs Midwifery Res 2010;15:208-15.
Bhola P, Kapur M. Prevalence of emotional disturbance in Indian adolescent girls. Indian J Clin Psychol 2000;27:217-22.
Kuyken W, Weare K, Ukoumunne OC, Vicacy R, Motton N, Burnett R, et al.
Effectiveness of the mindfulness in schools program: Non-randomised controlled feasibility study. Br J Psychiatry 2013;203:126-31.
Raes F, Griffith JW, Van der Gucht K, Williams JM. School-based prevention and reduction of depression in adolescents: A cluster randomized controlled trial of a mindfulness group program. Mindfulness (N
Lau N, Hue M. Primary outcomes of a mindfulness based programs for Hong Kong adolescents in schools: Wellbeing stress and depressive symptoms. Int J Child Spiritual 2011;16:315-30.
Schonert-Reichl KA, Lawlor MS. The effects of a mindfulness-based education program on pre- and early adolescents' well-being and social and emotional competence. Mindfulness (N
Ebrahimi M, Jalilabadi ZK, Amini F, Arkian F. Effectiveness of training of spiritual intelligence components on depression, anxiety, and stress of adolescents. J Med Life 2015;8:87-92.
Niloufar M, Hamidreza S. The relationship between self-efficacy and self-esteem with spiritual health in patients with diabetes mellitus. J Chronic Dis Manag 2015;4:219.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]