Study design and setting
The study had a cross-sectional study design and was conducted among school-going adolescents with ages ranging from 15 to 19 years (late adolescence). The study was conducted in one administrative unit of district Srinagar of the Kashmir valley. The administrative unit has a total population of around 1 Lakh with an adolescent population of around 17,000. The area is predominantly urban with few pockets of rural and hilly areas.
Selection of participants
The adolescents were contacted through their school teachers who had the contact numbers of all students as classes were being conducted online owing to pandemic related lockdown. The study area is divided into 12 subcentre areas, and one school was selected randomly from each subcentre area. The teachers of selected schools were contacted, and the link for online questionnaire shared was shared. The teacher then shared the link with the adolescent students. The data was collected online using Google Forms.
Sample size calculation
Sample size was calculated using the formula for prevalence studies (1.96)2 *p*(1-p)/L2. The prevalence of depression was estimated at 20%. A precision level of 0.01 was used, and the sample required was estimated to be 381 subjects.
Inclusion criteria
Adolescents aged between 15 and 19 years and studying in the selected schools were included in the study.
Exclusion criteria
As the questionnaire was shared online with all the students in the eligible age group, no specific exclusion criteria were predetermined.
Assessment tools and procedure
Data collection was done between January and February 2021. The questionnaire consisted of three parts; the first part contained questions for socio-demographic profile, past personal diagnosis of COVID-19, history of quarantine, history of COVID-19 diagnosis and hospital admission in the family. Self-reported weight, height and duration of physical activity were also recorded. The second part consisted of English version of Patient Health Questionnaire for Adolescents (PHQ-9A), and the third part consisted of English version of Generalised Anxiety Disorder questionnaire (GAD-7). PHQ-9A is a modified version of PHQ-9 to be developmentally appropriate for adolescents. The tool is freely available and consists of nine items. Adolescents are asked to rate the frequency of symptoms they experienced in the past 2 weeks. The responses are recorded on a four-point Likert scale ranging from 0 (not at all) to 3 (nearly every day). The scores of individual items are summed with a maximum possible score of 27. In this study, an elevated score was defined as a total score of 10 or higher. This scale has been validated for use in adolescents. GAD-7 was used to assess the anxiety symptoms. This tool has seven items and asks participants to describe the frequency of each symptom during the last 2 weeks. The responses are recorded on a four-point Likert scale ranging from 0 (not at all) to 3 (nearly every day). Like for the PHQ-9A scale, a score of 10 or more was considered to be positive for anxiety. Since the target population was school-going children and the primary medium of education in this part of the world is English, the English version of the same was used. Face and construct validity of the questionnaire was assessed by independent experts after which the tool pretested on 30 subjects. Cronbach alpha was estimated to be 0.73 which suggested good internal consistency for the questionnaire.
Main outcome measures
The total scores for both PHQ-9A and GAD-7 were calculated for each subject. A score of 10 or more was labelled as positive for both. BMI was calculated from self-reported weight and height and socioeconomic scale as per the Kuppuswamy scale for 2021 [9].
Statistical analysis
Means, percentages and quartiles were calculated for a description of the subjects. Fisher exact test and chi-square test were used for univariate data analysis. Variables that had a p-value of less than 0.02 were further analysed using logistic regression. Subjects whose responses had more than one missing value were excluded from the study. Data imputation using the average for that specific question was used if there was a single missing response in PHQ-9A or GAD-7 scales.
Ethical consideration
The study protocols were reviewed by one mental health and one public health expert. Informed consent was sought from all participants and additionally from their guardians as the study population belonged to adolescent’s age group. Approval was obtained in the institutional review committee.