Factors Contributing to Anxiety in Adolescents Surviving Thalassemia Major in Indonesia

Factors Contributing to Anxiety in Adolescents Surviving Thalassemia Major in Indonesia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Factors Contributing to Anxiety in Adolescents Surviving Thalassemia Major in Indonesia Henny Suzana Mediani, Novitasari Tsamrotul Fuadah This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5330088/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Jan, 2025 Read the published version in BMC Pediatrics → Version 1 posted 4 You are reading this latest preprint version Abstract Background Thalassemia major leads to severe anaemia, necessitating lifelong blood transfusions. Inconsistencies in blood transfusions and iron chelation therapy result in physical changes that can cause psychological issues, with anxiety being the most prominent. This study aimed to examine the factors influencing anxiety levels among adolescent thalassemia major survivors. Methods The research utilized a quantitative approach with a correlational analytic design and cross-sectional method. It included a population of 122 adolescent survivors, all of whom were included using a total sampling technique. Data analysis involved univariate analysis by frequency distribution, bivariate analysis using the chi-square test, and multivariate analysis with logistic regression. Results The study findings revealed that 70.5% of adolescents experienced mild anxiety. Significant correlations were found between body image (p < 0.001), self-esteem, and coping mechanisms with anxiety levels, while social support was not significantly related. Body image emerged as the most influential factor, with poor body image increasing the likelihood of severe anxiety by 11.6 times. Conclusions Adolescents with Thalassemia major in West Java primarily exhibit mild anxiety. These findings highlight the necessity for comprehensive psychological support that addresses body image concerns and boosts self-esteem and coping skills to enhance the mental health of adolescent thalassemia major survivors. Adolescent Anxiety Indonesia Psychological Thalassemia Introduction Thalassemia is a genetic disorder characterized by abnormal production of the α-globin or insufficient production of β-globin chains, the two main components of haemoglobin ( 1 ). Thalassemia major, a severe form of beta thalassemia, typically presents with fetal hemoglobin (HbF) levels ranging from 75–98% and hemoglobin A (HbA) at around 2% ( 2 ). According to statistics from the International Thalassemia Federation, approximately 240 million people worldwide are carriers of beta thalassemia, with around 60,000 new Thalassemia major recorded annually ( 3 ). A significant portion of these cases, around 55 million, are found in the thalassemia belt, particularly in Southeast Asia ( 4 ). Indonesia is among the countries in the 'Thalassemia Belt,' with a β-thalassemia (β-thal) prevalence ranging between 5.0% and 10.0%. It is estimated that there are 1,035 β-thal patients in the country, with approximately 43.0% registered in West Java ( 5 ). According to the Indonesian Thalassemia Foundation, the number of thalassemia survivors reached 7,670 in 2015, with the majority located on Java Island (5,323 people) and a significant portion of them in West Java Province. By January 2016, West Java had 3,300 survivors, the highest number in Bandung City and Regency (670 people). Garut Regency ranked fourth, and Sumedang Regency eighth, in the top ten areas with the highest cases. The government has now set a goal of achieving zero births of individuals with thalassemia major in Indonesia ( 6 ). Medical records from the primary referral hospital and treatment centre for thalassemia survivors in West Java showed that 230 survivors visited the Hemato-Oncology clinic in January 2013, with 70% of them being adolescents aged 14–21 ( 7 ). A 2018 survey revealed that in Sumedang Hospital, out of 165 patients, 48 (29.2%) were adolescents; in Dr. Slamet Hospital Garut, 48 (19.6%) of the 246 patients were adolescents; and in Majalaya Hospital, 26 (26.6%) of the 98 patients were teenagers. The adolescent developmental stage involves forming an ego identity, which is the realization of one's self-identity and life goals ( 8 ). Adolescent survivors of thalassemia major encounter a range of challenges, including physical, psychological, and social issues ( 9 ). Physical appearance is a crucial factor during adolescence, making the physical changes caused by blood transfusions potentially harmful to their body image or self-image. This situation can result in emotional conflict and may lead to psychological issues ( 10 ). Psychological issues in Thalassemia major survivors arise due to their heightened vulnerability to various stressors, including anxiety ( 11 ). Research has shown that these survivors often experience somatic complaints, low self-esteem, and anxiety related to their illness and its potential future implications ( 3 , 10 , 12 – 14 ). If left unaddressed, anxiety can escalate to panic levels. Individuals with panic disorder may become unable to perform tasks even with proper guidance, ultimately leading to a diminished quality of life (QoL) ( 15 ). A qualitative study involving interviews with adolescents diagnosed with Thalassemia major highlighted their concerns about the potential consequences of the condition and the need for frequent blood transfusions. These adolescents voiced fears such as dying at a young age, feeling ashamed due to physical changes that distinguish them from their healthy peers, lacking self-confidence in social situations, and often feeling weak. During the interviews, most adolescents avoided eye contact and gave minimal responses. Nurses need to understand the challenges these individuals face, while parents and families should offer support, collaborate during therapy, and engage in discussions about the emotional impact of the disease, its treatment, and its effects on their lives ( 16 ). Therefore, nurses play a vital role in assessing the severity and frequency of anxiety experienced by survivors, identifying the underlying factors, exploring their coping strategies, and evaluating the overall impact of this anxiety ( 14 , 15 , 17 ). Somatic anxiety factors can be evaluated through psychological anxiety factors, such as body image, self-image, and self-esteem ( 18 ). The psychological aspect of anxiety poses a threat to self-esteem, making individual coping strategies and social support crucial. These elements distinguish this study from previous research. The researchers examined these four factors in relation to anxiety levels. While studies on anxiety in Thalassemia major survivors have primarily been conducted abroad, research on factors contributing to anxiety in adolescents with thalassemia major is still relatively rare in Indonesia. Understanding the factors related to anxiety in adolescents and identifying the most dominant ones is essential for developing interventions to prevent anxiety and panic. Therefore, this study aimed to explore the factors influencing anxiety levels among adolescent thalassemia major survivors. Material and Methods Study Design This study employed a quantitative method with a correlational analytical design using a cross-sectional approach ( 19 – 21 ). The variables examined included independent variables such as body image, self-esteem, coping strategies, and social support, as well as the dependent variable, which was the level of anxiety among adolescent thalassemia major survivors. Participants and Setting This study's population consisted of all adolescent thalassemia survivors who were documented in medical records and regularly received blood transfusions at several referral hospitals in Indonesia, including Sumedang Hospital, Majalaya Hospital, Dr.Slamet Garut Hospital, and Guntur Hospital. This study's minimum required sample size was 91 participants, leading to total sampling as the sampling technique. The final sample included all adolescent survivors of Thalassemia major, aged 13 to 20 years, totaling 122 individuals. Instrument The measurements used in this research included the Hamilton Anxiety Scale, Body Image Scale, Rosenberg Self-Esteem Scale, Ways of Coping questionnaire, and the Multidimensional Scale of Perceived Social Support. Ethical Considerations The Commission of Research Ethics at Universitas Padjadjaran approved research ethics under reference number 570/UN6.KEP/EC/2018. This study consider to the Five Rights of Human Subjects in Research ( 22 ). Informed consent was implied upon completion of the survey, each participant's data was anonymized, and all information from research participants is kept confidential. Data Analysis The data were analyzed using several methods: univariate analysis through frequency distribution and percentage, bivariate analysis using the chi-square test, and multivariate analysis through logistic regression. The multivariate analysis was employed to examine the impact of the independent factors or variables on the dependent variable. In this research, the dependent variable, the anxiety level, was represented as categorical data, making logistic regression the appropriate multivariate analysis method. Logistic regression is conducted when more than one independent variable has a p-value of less than 0.250 in the bivariate test, qualifying it as a potential predictor. If fewer than two variables meet these criteria, logistic regression analysis cannot be performed. Results Characteristics of Participants More than half of the population, 54.1%, were aged 13-15 years (early adolescence). Additionally, 56.6% of the population were female. The most common level of education was Elementary School, representing 33.6% of the participants. The duration of diagnosis ranged from 1 to 20 years. Nearly all adolescents, 93.4%, did not experience complications (as shown in Table 1). The Anxiety Levels of Adolescent Thalassemia Major Survivors in West Java Most adolescent thalassemia major survivors in West Java, 70.5%, experience mild anxiety (as shown in Table 2). Analysis of the relationship between variables and anxiety levels among adolescent Thalassemia Major survivors in West Java The bivariate analysis of the correlation test between variables and anxiety levels reveals a highly significant relationship between body image, self-esteem, and coping strategies with the anxiety levels of adolescent Thalassemia Major survivors in West Java, all with p-values < 0.05 (p 0.05, indicating no significant relationship between social support and anxiety levels among these adolescents (see Table 3). Factors that the Most Influential on Anxiety Levels of Adolescent Thalassemia Major Survivors in West Java The bivariate analysis results indicate that three independent variables have a p-value of less than 0.250: body image (<0.001), self-esteem (0.002), and coping (0.036). This allows for logistic regression analysis to be performed with these three variables. Using the backwards method, the logistic regression analysis results show that only body image significantly affects anxiety levels, with a p-value of <0.01 (<0.001). In contrast, self-esteem and coping do not significantly influence anxiety levels. According to the adjusted Odds Ratio (OR), the body image variable has an OR of 11.6, suggesting that adolescent Thalassemia Major survivors with poor body image are 11.6 times more likely to experience severe anxiety levels. Discussion Anxiety among Adolescent Thalassemia Major Survivors The descriptive analysis results in this study revealed that all adolescents with Thalassemia Major experienced varying levels of anxiety, ranging from mild to severe. The majority, 70.5%, experienced mild anxiety, while 19.7% faced severe anxiety. This anxiety arises as a response to the identity-threatening effects of Thalassemia Major. The condition is marked by negative emotions, such as worry and fear, and is often accompanied by physical tension. In line with their developmental stage, anxiety in these adolescents is strongly linked to concerns about rejection by peers. During early to middle adolescence, individuals are particularly focused on body changes, acceptance by peers, the struggle to master skills within peer groups, adjusting to changes in body image, and developing attraction to the opposite sex ( 8 ). Severe anxiety levels are influenced by factors such as age, clinical conditions or disease complications, and non-compliance with blood transfusions and iron chelation therapy. In this study, 13.1% of late adolescents (aged 19–20) experienced complications like heart disease, and 6.6% faced other illnesses, which may contribute to their severe anxiety. This finding aligns with research from Iran, where the average anxiety score was higher in Thalassemia patients aged 19 and older. The relationship between complications and anxiety is evident, as patients with complications tend to have higher anxiety scores ( 23 ). Other studies also show that with increasing age, the prevalence of diabetes and hepatitis rises, leading to heightened anxiety in older Thalassemia survivors ( 24 ). Anxiety in adolescents with Thalassemia Major is closely linked to the impact of the condition on their growth and developmental tasks. Several factors contribute to this anxiety, including Cooley's facies, delayed puberty, complications such as diabetes mellitus, heart failure, and hepatitis, as well as physical attributes like bronze-coloured skin, short stature, and splenectomy. Other contributing factors include low self-esteem, non-compliance with chelation therapy, hospitalization, age, gender, and coping mechanisms ( 23 – 26 ). Complications arising from Thalassemia affect the physical, psychological, and social aspects of life, leading to emotional conflicts, including heightened anxiety ( 3 ). Factors Associated with Anxiety Levels in Adolescent Thalassemia Major Survivors. The bivariate analysis results revealed a highly significant relationship between the variables of body image, self-esteem, and coping strategies with anxiety levels. Thalassemia Major impacts physical health in various ways, including the expansion of bone marrow space due to erythroid hyperplasia, nasal bone depression, malocclusion of the jaws, maxillary hypertrophy leading to Cooley's facies, enlarged abdomen from hepatosplenomegaly, delayed puberty, stunted growth, short stature, and skin changes. These alterations in physical condition contribute to a poor body image among individuals with Thalassemia Major ( 9 , 25 , 27 ). Some of these physical issues also lead to psychosocial problems. Previous studies have indicated that people with Thalassemia Major tend to have a poor body image, which is related to their anxiety ( 27 ). Other research shows that anxiety in individuals with Thalassemia is associated with features such as a mongoloid face, bronze skin, and short stature ( 25 ). Thalassemia survivors face various physical, psychological, and social challenges due to the progression of the disease and the routine need for blood transfusions. These circumstances lead to changes in physical conditions, contributing to low self-esteem because of dissatisfaction with their appearance. Self-esteem is a critical factor related to anxiety ( 15 ). Previous studies have shown that 70.7% of individuals with Thalassemia have low self-esteem, which is also linked to their high levels of anxiety ( 27 ). Another study found that anxiety in Thalassemia Major patients was significantly associated with low self-esteem, identifying it as an independent predictor of anxiety ( 25 ). In this research, most adolescents employed problem-focused coping strategies. This approach reduces stressors by learning new skills or methods to adapt to changing situations, circumstances, or challenges. Adolescents are more likely to use this strategy if they believe they can quickly alter the situation, as it focuses on completely resolving problems to alleviate anxiety ( 28 ). A previous study demonstrated that teaching coping strategies effectively enhances the ability to manage stress and other complications in individuals with Thalassemia Major. Moreover, these strategies can increase problem-focused coping and reduce reliance on emotion-focused coping strategies ( 26 ). The study findings did not reveal a significant relationship between social support and the anxiety levels of adolescent Thalassemia survivors in West Java. This may be due to the way individuals perceive support from family, friends, and significant others, as perceptions can vary significantly from person to person. This research evaluated social support based on contributions from family, friends, and special individuals. Social support, as an external factor, does not directly influence anxiety but can enhance self-esteem, body image, and the adoption of effective coping strategies ( 15 ). Adolescents with Thalassemia Major require comprehensive support from family, friends, and significant others as a source of motivation, particularly for adherence to blood transfusions and iron chelation therapy ( 29 ). Social support is crucial for individuals with Thalassemia Major, as they require lifelong psychological support, especially from their families, to improve adherence to therapy, well-being, and treatment outcomes ( 25 ). Key Factors Influencing Anxiety Levels in Adolescent Thalassemia Major Survivors. In this research, body image emerged as the most dominant factor associated with anxiety levels in adolescents with Thalassemia Major, showing a highly significant relationship. According to the OR, adolescents with a poor self-image are 11.6 times more likely to experience severe anxiety. This indicates that severe anxiety is more prevalent among those with a negative self-image. Their physical condition heavily influences their self-image. Since physical appearance plays a crucial role in adolescent development, changes in physical condition contribute to a poor body image, leading to emotional conflicts and psychological issues, including anxiety ( 9 , 10 , 25 ). Strengths and limitations of the study This study has several limitations, including focusing on only four hospitals in West Java, Indonesia. However, it also has notable strengths. The research was conducted in both general and referral hospitals, allowing it to provide a broader picture of anxiety issues among adolescent Thalassemia survivors in West Java and potentially across Indonesia. Additionally, these findings offer valuable insights that can support efforts to address the challenges faced by adolescent Thalassemia survivors in Indonesia." Implications of Study The current study has highlighted several factors that contribute to anxiety in adolescent Thalassemia survivors. These findings carry important implications for both healthcare providers and policymakers. For healthcare workers, understanding these factors can help tailor interventions and provide more personalized care that addresses the specific needs of adolescents struggling with anxiety due to Thalassemia. This might include developing targeted mental health support programs, enhancing communication with patients about their physical and psychological concerns, and integrating anxiety management strategies into routine care for Thalassemia patients. On the policy level, the study's insights can guide the government in formulating comprehensive health policies that prioritize mental health support for Thalassemia patients. This could involve allocating resources for specialized counselling services in hospitals, conducting awareness campaigns about the psychological impact of chronic diseases like Thalassemia, and ensuring that adolescent Thalassemia survivors have access to community-based support systems. Particularly in West Java, where this study was conducted, these strategies could be crucial in addressing the anxiety-related challenges faced by these adolescents. Ultimately, the findings of this study provide a critical evidence base that can help shape effective strategies and interventions aimed at reducing anxiety among adolescent Thalassemia survivors, thereby improving their overall QoL. Conclusion Adolescents surviving Thalassemia Major in West Java predominantly experience mild anxiety levels. The study reveals significant correlations between anxiety levels and factors such as body image and self-esteem, indicating that adolescents' perceptions of their physical appearance and their overall self-worth are crucial to their psychological well-being. Coping mechanisms also show a significant relationship with anxiety, emphasizing the importance of effective strategies for managing stress and emotional challenges. On the other hand, social support does not appear to have a significant impact on anxiety levels in this context. Among these factors, body image stands out as the most dominant, with a poor body image significantly increasing the risk of severe anxiety. These findings highlight the need for comprehensive psychological support that addresses body image concerns, while also fostering self-esteem and developing effective coping skills to improve the mental health of adolescent Thalassemia Major survivors. To build on these insights, further research on a broader scale across Indonesia is recommended, involving representatives from various districts or cities to explore this issue more comprehensively. Abbreviations Fetal hemoglobin (HbF) Hemoglobin A (HbA) β-thalassemia (β-thal) Quality of life (QoL) Odds Ratio (OR) Declarations Ethics approval and consent to participate The Commission of Research Ethics at Universitas Padjadjaran approved research ethics under reference number 570/UN6.KEP/EC/2018. Consent for publication Not applicable Availability of data and materials The research data used to support this study's findings are available from the corresponding author upon reasonable request. Competing interests The authors declare no conflict of interest. Funding This study did not receive any external funding. Authors' contributions Wrote the main manuscript text: HSM, NTF; prepared figures and tables: NTF; Conceptualization: HSM, NTF; Data curation, HSM, and NTF; Official analysis: HSM, and NTF; Funding secured: HSM; Investigation: HSM, and NTF; Methodology: HSM, and NTF; Project administration: NTF and HSM; Resource, HSM, and NTF; Software: NTF; Supervision: HSM; Validation: NTF, HSM; Visualization: HSM, and NTF; Writing – original draft: HSM, NTF; Write - review & editing: HSM, and NTF; All authors reviewed the manuscript. Acknowledgments The authors would like to thank the directors of the Sumedang Hospital, Majalaya Hospital, Dr. Slamet Garut Hospital, Guntur Hospital, and the Universitas Padjadjaran for supporting and facilitating this research and all who have contributed to it. 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Tables Table 1 Characteristics of Adolescents with Thalassemia Based on Age, Gender, Education, Duration of Diagnosis and Disease Complications (n=122) Variable Frequency (n) Percentage (%) Age 13-15 years 16-18 years 19-20 years 66 40 16 54,1 32,8 13,1 Gender Male Female 53 69 43,4 56,6 Last Education Not Educated Elementary School Junior High School Senior High School Perguruan Tinggi 17 41 39 23 2 13,9 33,6 32,0 18,9 1,6 Duration of Diagnose Median (Range in Reays) 13 (1 – 20) Disease Complication Yes No 8 114 6,6 93,4 Table 2 The Anxiety Levels of Adolescent Thalassemia Major Survivors in West Java (n=122) Variable Category Frequency (%) Level of Anxiety Mild 86 (70,5) Medium 12 (9,8) Severe 24 (19,7) Table 3 Correlation test of variables with Anxiety Levels of Adolescent Thalassemia Major Survivors in West Java (n=122) Variable Frequency (n) Level of Anxiety p-value Mild (n=86) Medium -severe (n=36) Body Image Good 105 82 (78,1) 23 (21,9) <0,001 Bad 17 4 (23,5) 13 (76,5) Self Esteem Low 26 12 (46,2) 14 (53,8) 0,002 High 96 74 (77,1) 22 (22,9) Coping Problem 75 58 (77,3) 17 (22,7) 0,036 Emotion 47 28 (59,6) 19 (40,4) Social Support Low/Medium 35 23 (65,7) 12 (34,3) 0,463 High 87 63 (72,4) 24 (27,6) Table 4 The Logistic Regression Analysis of Multivariate Factors that the Most Influential on Anxiety Levels of Adolescent Thalassemia Major Survivors in West Java Independent Variable Adjusted OR (95% CI) p-value Early Model Body Image 8,9 (2,4 – 32,7) 0,001** Self Esteem 0,6 (0,2 – 1,9) 0,376 Coping 1,9 (0,8 – 4,7) 0,161 Last Model Body Image 11,6 (3,4 – 38,9) <0,001** Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 31 Jan, 2025 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 28 Oct, 2024 Editor assigned by journal 26 Oct, 2024 Submission checks completed at journal 26 Oct, 2024 First submitted to journal 25 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5330088","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":371049353,"identity":"cb7ee55a-8466-48a2-9783-19cec6a82ace","order_by":0,"name":"Henny Suzana Mediani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYBACAzjrMBAnVCAEeRgOEKXlDElaQAoY25AFcWgxZ+899piHYZsc33HmZw8ezjucZ85+eAPDjxoGGT4cWix7zqUb8zDcNpY8zGZukLjtcLFlT1oBY88xBh5JXA67kWMmDdSSuOEwg5kEUEvihgM5Bgy8DQw8Bri03H8D1lK/4TD7N4nEOUAt598YMP7Fp+UGD1hLgsFhHqAtDUAtN3IMmPHacibHTHKOwW3DmYd5yiQSjqUn7pzxrOCwzDEJ3H45fsZM4k3FbXm+88e3Sf6osU7czp+88eGbGht7XCEGAkw8Bkg8EBuoWAK3eiBg/IFiL161o2AUjIJRMBIBAP+9XvAw2NbUAAAAAElFTkSuQmCC","orcid":"","institution":"Universitas Padjadjaran","correspondingAuthor":true,"prefix":"","firstName":"Henny","middleName":"Suzana","lastName":"Mediani","suffix":""},{"id":371049354,"identity":"0ea14a82-c215-4d51-8c7d-50d1c79c6dc6","order_by":1,"name":"Novitasari Tsamrotul Fuadah","email":"","orcid":"","institution":"Bhakti Kencana University","correspondingAuthor":false,"prefix":"","firstName":"Novitasari","middleName":"Tsamrotul","lastName":"Fuadah","suffix":""}],"badges":[],"createdAt":"2024-10-25 06:53:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5330088/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5330088/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12887-025-05403-3","type":"published","date":"2025-01-31T15:57:34+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":75351426,"identity":"423074fe-1b19-4042-839b-3d286b28e8b6","added_by":"auto","created_at":"2025-02-03 16:11:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":910013,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5330088/v1/9bfa77ec-3bae-4104-8091-638f6c8069b3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factors Contributing to Anxiety in Adolescents Surviving Thalassemia Major in Indonesia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThalassemia is a genetic disorder characterized by abnormal production of the α-globin or insufficient production of β-globin chains, the two main components of haemoglobin (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Thalassemia major, a severe form of beta thalassemia, typically presents with fetal hemoglobin (HbF) levels ranging from 75\u0026ndash;98% and hemoglobin A (HbA) at around 2% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). According to statistics from the International Thalassemia Federation, approximately 240\u0026nbsp;million people worldwide are carriers of beta thalassemia, with around 60,000 new Thalassemia major recorded annually (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). A significant portion of these cases, around 55\u0026nbsp;million, are found in the thalassemia belt, particularly in Southeast Asia (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIndonesia is among the countries in the 'Thalassemia Belt,' with a β-thalassemia (β-thal) prevalence ranging between 5.0% and 10.0%. It is estimated that there are 1,035 β-thal patients in the country, with approximately 43.0% registered in West Java (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). According to the Indonesian Thalassemia Foundation, the number of thalassemia survivors reached 7,670 in 2015, with the majority located on Java Island (5,323 people) and a significant portion of them in West Java Province. By January 2016, West Java had 3,300 survivors, the highest number in Bandung City and Regency (670 people). Garut Regency ranked fourth, and Sumedang Regency eighth, in the top ten areas with the highest cases. The government has now set a goal of achieving zero births of individuals with thalassemia major in Indonesia (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Medical records from the primary referral hospital and treatment centre for thalassemia survivors in West Java showed that 230 survivors visited the Hemato-Oncology clinic in January 2013, with 70% of them being adolescents aged 14\u0026ndash;21 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). A 2018 survey revealed that in Sumedang Hospital, out of 165 patients, 48 (29.2%) were adolescents; in Dr. Slamet Hospital Garut, 48 (19.6%) of the 246 patients were adolescents; and in Majalaya Hospital, 26 (26.6%) of the 98 patients were teenagers.\u003c/p\u003e \u003cp\u003eThe adolescent developmental stage involves forming an ego identity, which is the realization of one's self-identity and life goals (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Adolescent survivors of thalassemia major encounter a range of challenges, including physical, psychological, and social issues (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Physical appearance is a crucial factor during adolescence, making the physical changes caused by blood transfusions potentially harmful to their body image or self-image. This situation can result in emotional conflict and may lead to psychological issues (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePsychological issues in Thalassemia major survivors arise due to their heightened vulnerability to various stressors, including anxiety (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Research has shown that these survivors often experience somatic complaints, low self-esteem, and anxiety related to their illness and its potential future implications (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). If left unaddressed, anxiety can escalate to panic levels. Individuals with panic disorder may become unable to perform tasks even with proper guidance, ultimately leading to a diminished quality of life (QoL) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA qualitative study involving interviews with adolescents diagnosed with Thalassemia major highlighted their concerns about the potential consequences of the condition and the need for frequent blood transfusions. These adolescents voiced fears such as dying at a young age, feeling ashamed due to physical changes that distinguish them from their healthy peers, lacking self-confidence in social situations, and often feeling weak. During the interviews, most adolescents avoided eye contact and gave minimal responses. Nurses need to understand the challenges these individuals face, while parents and families should offer support, collaborate during therapy, and engage in discussions about the emotional impact of the disease, its treatment, and its effects on their lives (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Therefore, nurses play a vital role in assessing the severity and frequency of anxiety experienced by survivors, identifying the underlying factors, exploring their coping strategies, and evaluating the overall impact of this anxiety (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSomatic anxiety factors can be evaluated through psychological anxiety factors, such as body image, self-image, and self-esteem (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The psychological aspect of anxiety poses a threat to self-esteem, making individual coping strategies and social support crucial. These elements distinguish this study from previous research. The researchers examined these four factors in relation to anxiety levels. While studies on anxiety in Thalassemia major survivors have primarily been conducted abroad, research on factors contributing to anxiety in adolescents with thalassemia major is still relatively rare in Indonesia. Understanding the factors related to anxiety in adolescents and identifying the most dominant ones is essential for developing interventions to prevent anxiety and panic. Therefore, this study aimed to explore the factors influencing anxiety levels among adolescent thalassemia major survivors.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study employed a quantitative method with a correlational analytical design using a cross-sectional approach (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The variables examined included independent variables such as body image, self-esteem, coping strategies, and social support, as well as the dependent variable, which was the level of anxiety among adolescent thalassemia major survivors.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and Setting\u003c/h3\u003e\n\u003cp\u003eThis study's population consisted of all adolescent thalassemia survivors who were documented in medical records and regularly received blood transfusions at several referral hospitals in Indonesia, including Sumedang Hospital, Majalaya Hospital, Dr.Slamet Garut Hospital, and Guntur Hospital. This study's minimum required sample size was 91 participants, leading to total sampling as the sampling technique. The final sample included all adolescent survivors of Thalassemia major, aged 13 to 20 years, totaling 122 individuals.\u003c/p\u003e\n\u003ch3\u003eInstrument\u003c/h3\u003e\n\u003cp\u003eThe measurements used in this research included the Hamilton Anxiety Scale, Body Image Scale, Rosenberg Self-Esteem Scale, Ways of Coping questionnaire, and the Multidimensional Scale of Perceived Social Support.\u003c/p\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e The Commission of Research Ethics at Universitas Padjadjaran approved research ethics under reference number 570/UN6.KEP/EC/2018. This study consider to the Five Rights of Human Subjects in Research (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Informed consent was implied upon completion of the survey, each participant's data was anonymized, and all information from research participants is kept confidential.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe data were analyzed using several methods: univariate analysis through frequency distribution and percentage, bivariate analysis using the chi-square test, and multivariate analysis through logistic regression. The multivariate analysis was employed to examine the impact of the independent factors or variables on the dependent variable. In this research, the dependent variable, the anxiety level, was represented as categorical data, making logistic regression the appropriate multivariate analysis method. Logistic regression is conducted when more than one independent variable has a p-value of less than 0.250 in the bivariate test, qualifying it as a potential predictor. If fewer than two variables meet these criteria, logistic regression analysis cannot be performed.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eCharacteristics of Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMore than half of the population, 54.1%, were aged 13-15 years (early adolescence). Additionally, 56.6% of the population were female. The most common level of education was Elementary School, representing 33.6% of the participants. The duration of diagnosis ranged from 1 to 20 years. Nearly all adolescents, 93.4%, did not experience complications (as shown in Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Anxiety Levels of Adolescent Thalassemia Major Survivors in West Java\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost adolescent thalassemia major survivors in West Java, 70.5%, experience mild anxiety (as shown in Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis of the relationship between variables and anxiety levels among adolescent Thalassemia Major survivors in West Java\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe bivariate analysis of the correlation test between variables and anxiety levels reveals a highly significant relationship between body image, self-esteem, and coping strategies with the anxiety levels of adolescent Thalassemia Major survivors in West Java, all with p-values \u0026lt; 0.05 (p \u0026lt; 0.001, p = 0.002, and p = 0.036, respectively). However, the correlation test for social support and anxiety levels yielded a p-value \u0026gt; 0.05, indicating no significant relationship between social support and anxiety levels among these adolescents (see Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors that the Most Influential on Anxiety Levels of Adolescent Thalassemia Major Survivors in West Java \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe bivariate analysis results indicate that three independent variables have a p-value of less than 0.250: body image (\u0026lt;0.001), self-esteem (0.002), and coping (0.036). This allows for logistic regression analysis to be performed with these three variables. Using the backwards method, the logistic regression analysis results show that only body image significantly affects anxiety levels, with a p-value of \u0026lt;0.01 (\u0026lt;0.001). In contrast, self-esteem and coping do not significantly influence anxiety levels. According to the adjusted Odds Ratio (OR), the body image variable has an OR of 11.6, suggesting that adolescent Thalassemia Major survivors with poor body image are 11.6 times more likely to experience severe anxiety levels.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAnxiety among Adolescent Thalassemia Major Survivors\u003c/h2\u003e \u003cp\u003eThe descriptive analysis results in this study revealed that all adolescents with Thalassemia Major experienced varying levels of anxiety, ranging from mild to severe. The majority, 70.5%, experienced mild anxiety, while 19.7% faced severe anxiety. This anxiety arises as a response to the identity-threatening effects of Thalassemia Major. The condition is marked by negative emotions, such as worry and fear, and is often accompanied by physical tension. In line with their developmental stage, anxiety in these adolescents is strongly linked to concerns about rejection by peers. During early to middle adolescence, individuals are particularly focused on body changes, acceptance by peers, the struggle to master skills within peer groups, adjusting to changes in body image, and developing attraction to the opposite sex (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSevere anxiety levels are influenced by factors such as age, clinical conditions or disease complications, and non-compliance with blood transfusions and iron chelation therapy. In this study, 13.1% of late adolescents (aged 19\u0026ndash;20) experienced complications like heart disease, and 6.6% faced other illnesses, which may contribute to their severe anxiety. This finding aligns with research from Iran, where the average anxiety score was higher in Thalassemia patients aged 19 and older. The relationship between complications and anxiety is evident, as patients with complications tend to have higher anxiety scores (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Other studies also show that with increasing age, the prevalence of diabetes and hepatitis rises, leading to heightened anxiety in older Thalassemia survivors (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnxiety in adolescents with Thalassemia Major is closely linked to the impact of the condition on their growth and developmental tasks. Several factors contribute to this anxiety, including Cooley's facies, delayed puberty, complications such as diabetes mellitus, heart failure, and hepatitis, as well as physical attributes like bronze-coloured skin, short stature, and splenectomy. Other contributing factors include low self-esteem, non-compliance with chelation therapy, hospitalization, age, gender, and coping mechanisms (\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Complications arising from Thalassemia affect the physical, psychological, and social aspects of life, leading to emotional conflicts, including heightened anxiety (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFactors Associated with Anxiety Levels in Adolescent Thalassemia Major Survivors.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe bivariate analysis results revealed a highly significant relationship between the variables of body image, self-esteem, and coping strategies with anxiety levels. Thalassemia Major impacts physical health in various ways, including the expansion of bone marrow space due to erythroid hyperplasia, nasal bone depression, malocclusion of the jaws, maxillary hypertrophy leading to Cooley's facies, enlarged abdomen from hepatosplenomegaly, delayed puberty, stunted growth, short stature, and skin changes. These alterations in physical condition contribute to a poor body image among individuals with Thalassemia Major (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Some of these physical issues also lead to psychosocial problems. Previous studies have indicated that people with Thalassemia Major tend to have a poor body image, which is related to their anxiety (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Other research shows that anxiety in individuals with Thalassemia is associated with features such as a mongoloid face, bronze skin, and short stature (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThalassemia survivors face various physical, psychological, and social challenges due to the progression of the disease and the routine need for blood transfusions. These circumstances lead to changes in physical conditions, contributing to low self-esteem because of dissatisfaction with their appearance. Self-esteem is a critical factor related to anxiety (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Previous studies have shown that 70.7% of individuals with Thalassemia have low self-esteem, which is also linked to their high levels of anxiety (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Another study found that anxiety in Thalassemia Major patients was significantly associated with low self-esteem, identifying it as an independent predictor of anxiety (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this research, most adolescents employed problem-focused coping strategies. This approach reduces stressors by learning new skills or methods to adapt to changing situations, circumstances, or challenges. Adolescents are more likely to use this strategy if they believe they can quickly alter the situation, as it focuses on completely resolving problems to alleviate anxiety (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). A previous study demonstrated that teaching coping strategies effectively enhances the ability to manage stress and other complications in individuals with Thalassemia Major. Moreover, these strategies can increase problem-focused coping and reduce reliance on emotion-focused coping strategies (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study findings did not reveal a significant relationship between social support and the anxiety levels of adolescent Thalassemia survivors in West Java. This may be due to the way individuals perceive support from family, friends, and significant others, as perceptions can vary significantly from person to person. This research evaluated social support based on contributions from family, friends, and special individuals. Social support, as an external factor, does not directly influence anxiety but can enhance self-esteem, body image, and the adoption of effective coping strategies (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Adolescents with Thalassemia Major require comprehensive support from family, friends, and significant others as a source of motivation, particularly for adherence to blood transfusions and iron chelation therapy (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Social support is crucial for individuals with Thalassemia Major, as they require lifelong psychological support, especially from their families, to improve adherence to therapy, well-being, and treatment outcomes (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eKey Factors Influencing Anxiety Levels in Adolescent Thalassemia Major Survivors.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn this research, body image emerged as the most dominant factor associated with anxiety levels in adolescents with Thalassemia Major, showing a highly significant relationship. According to the OR, adolescents with a poor self-image are 11.6 times more likely to experience severe anxiety. This indicates that severe anxiety is more prevalent among those with a negative self-image. Their physical condition heavily influences their self-image. Since physical appearance plays a crucial role in adolescent development, changes in physical condition contribute to a poor body image, leading to emotional conflicts and psychological issues, including anxiety (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations of the study\u003c/h2\u003e \u003cp\u003eThis study has several limitations, including focusing on only four hospitals in West Java, Indonesia. However, it also has notable strengths. The research was conducted in both general and referral hospitals, allowing it to provide a broader picture of anxiety issues among adolescent Thalassemia survivors in West Java and potentially across Indonesia. Additionally, these findings offer valuable insights that can support efforts to address the challenges faced by adolescent Thalassemia survivors in Indonesia.\"\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eImplications of Study\u003c/h2\u003e \u003cp\u003eThe current study has highlighted several factors that contribute to anxiety in adolescent Thalassemia survivors. These findings carry important implications for both healthcare providers and policymakers. For healthcare workers, understanding these factors can help tailor interventions and provide more personalized care that addresses the specific needs of adolescents struggling with anxiety due to Thalassemia. This might include developing targeted mental health support programs, enhancing communication with patients about their physical and psychological concerns, and integrating anxiety management strategies into routine care for Thalassemia patients. On the policy level, the study's insights can guide the government in formulating comprehensive health policies that prioritize mental health support for Thalassemia patients. This could involve allocating resources for specialized counselling services in hospitals, conducting awareness campaigns about the psychological impact of chronic diseases like Thalassemia, and ensuring that adolescent Thalassemia survivors have access to community-based support systems. Particularly in West Java, where this study was conducted, these strategies could be crucial in addressing the anxiety-related challenges faced by these adolescents. Ultimately, the findings of this study provide a critical evidence base that can help shape effective strategies and interventions aimed at reducing anxiety among adolescent Thalassemia survivors, thereby improving their overall QoL.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAdolescents surviving Thalassemia Major in West Java predominantly experience mild anxiety levels. The study reveals significant correlations between anxiety levels and factors such as body image and self-esteem, indicating that adolescents' perceptions of their physical appearance and their overall self-worth are crucial to their psychological well-being. Coping mechanisms also show a significant relationship with anxiety, emphasizing the importance of effective strategies for managing stress and emotional challenges. On the other hand, social support does not appear to have a significant impact on anxiety levels in this context. Among these factors, body image stands out as the most dominant, with a poor body image significantly increasing the risk of severe anxiety. These findings highlight the need for comprehensive psychological support that addresses body image concerns, while also fostering self-esteem and developing effective coping skills to improve the mental health of adolescent Thalassemia Major survivors. To build on these insights, further research on a broader scale across Indonesia is recommended, involving representatives from various districts or cities to explore this issue more comprehensively.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eFetal hemoglobin (HbF)\u003c/p\u003e\n\u003cp\u003eHemoglobin A (HbA)\u003c/p\u003e\n\u003cp\u003e\u0026beta;-thalassemia (\u0026beta;-thal)\u003c/p\u003e\n\u003cp\u003eQuality of life (QoL)\u003c/p\u003e\n\u003cp\u003eOdds Ratio (OR)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Commission of Research Ethics at Universitas Padjadjaran approved research ethics under reference number 570/UN6.KEP/EC/2018.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research data used to support this study's findings are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWrote the main manuscript text: HSM, NTF; prepared figures and tables: NTF; Conceptualization: HSM, NTF; Data curation, HSM, and NTF; Official analysis: HSM, and NTF; Funding secured: HSM; Investigation: HSM, and NTF; Methodology: HSM, and NTF; Project administration: NTF and HSM; Resource, HSM, and NTF; Software: NTF; Supervision: HSM; Validation: NTF, HSM; Visualization: HSM, and NTF; Writing – original draft: HSM, NTF; Write - review \u0026amp; editing: HSM, and NTF; All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the directors of the Sumedang Hospital, Majalaya Hospital, Dr. Slamet Garut Hospital, Guntur Hospital, and the Universitas Padjadjaran for supporting and facilitating this research and all who have contributed to it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Pediatric Nursing,\u0026nbsp;Faculty of Nursing,\u0026nbsp;Universitas Padjadjaran, Sumedang,\u0026nbsp;West Java, 45363, Indonesia.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eFaculty of Nursing, Bhakti Kencana University, West Java, Indonesia.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOikonomidou PR, Rivella S. 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Peranan Relasi Keluarga Pada Psikopatologi Remaja Penderita Talasemia. Damianus J Med. 2014;13(2):137\u0026ndash;47. \u003c/li\u003e\n\u003cli\u003eKaheni S, Yaghobian M, Sharefzadah GH, Vahidi A, Ghorbani H, Abderahemi A. Quality of life in children with \u0026beta;-thalassemia major at center for special diseases. Iran J Pediatr Hematol Oncol [Internet]. 2013;3(3):108\u0026ndash;13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24575281%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC3921875\u003c/li\u003e\n\u003cli\u003eYengil E, Acipayam C, Kokacya MH, Kurhan F, Oktay G, Ozer C. Anxiety, depression and quality of life in patients with beta thalassemia major and their caregivers. Int J Clin Exp Med. 2014;7(8):2165\u0026ndash;72. \u003c/li\u003e\n\u003cli\u003eHamilton M. The Assessment of Anxiety States By Rating. Br J Med Psychol. 1959;32(1):50\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eMulyana AM, Rakhmawati W, Adistie F, Maulana S. 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J Xi\u0026rsquo;an Shiyou Univ [Internet]. 2023;65(11):60\u0026ndash;9. Available from: https://www.researchgate.net/publication/368958213_APPLICATION_OF_CORRELATIONAL_RESEARCH_DESIGN_IN_NURSING_AND_MEDICAL_RESEARCH\u003c/li\u003e\n\u003cli\u003ePolit D, Beck C. Essentials of Nursing Research: Appraising Evidence for Nursing Practice. 7th ed. Wolters Kluwer Lippincot Williams \u0026amp; Wilkins; 2010. \u003c/li\u003e\n\u003cli\u003eAdib-Hajbaghery M, Ahmadi M, S P. Health Related Quality of Life, Depression, Anxiety and Stress in Patients with Beta-Thalassemia Major. Iran J Pediatr Hematol Oncol [Internet]. 2015;5(4):193\u0026ndash;205. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26985352%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4779154\u003c/li\u003e\n\u003cli\u003eSeyedifar M, Dorkoosh FA, Hamidieh AA, Naderi M, Karami H, Karimi M, et al. Health-Related Quality of Life and Health Utility Values in Beta Thalassemia Major Patients Receiving Different Types of Iron Chelators in Iran. Int J Hematol stem cell Res. 2016 Oct;10(4):224\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eYahia S, El-Hadidy MA, El-Gilany A-H, Anwar R, Darwish A, Mansour AK. Predictors of anxiety and depression in Egyptian thalassemic patients: A single center study. Int J Hematol. 2013 May;97(5):604\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eHashemi F, Naderi Darshori A, Sharif F, Karimi M, Zare N. Effect of coping strategies training on its use by thalassemia major adolescents: a randomized controlled clinical trial. Int J community based Nurs midwifery [Internet]. 2015;3(1):67\u0026ndash;74. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25553336%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4280559\u003c/li\u003e\n\u003cli\u003eYildiz D, Suluhan D, Fidanci BE, Kiziler E, Boyraz G. Determining the Relationship Between Self-Esteem, Body Image, and Anxiety Levels of Children With Thalassemia. J Am Acad Child Adolesc Psychiatry. 2016;55(10):S209. \u003c/li\u003e\n\u003cli\u003eLazarus RS, Folkman S. Transactional theory and research on emotions and coping. Eur J Pers. 1987 Sep;1(3):141\u0026ndash;69. \u003c/li\u003e\n\u003cli\u003ePouraboli B, Abedi HA, Abbaszadeh A, Kazemi M. Living in a misty marsh : A qualitative study on the experiences of self-care suffering of patients with thalassemia. Iran J Nurs Midwifery Res |. 2014;19(7):S77\u0026ndash;82. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Characteristics of Adolescents with Thalassemia Based on Age, Gender, Education, Duration of Diagnosis and Disease Complications (n=122)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"612\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.6078%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.0392%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3529%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.6078%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e13-15 years\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16-18 years\u003c/p\u003e\n \u003cp\u003e19-20 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.0392%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3529%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e54,1\u003c/p\u003e\n \u003cp\u003e32,8\u003c/p\u003e\n \u003cp\u003e13,1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.6078%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.0392%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3529%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e43,4\u003c/p\u003e\n \u003cp\u003e56,6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.6078%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLast Education\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNot Educated\u003c/p\u003e\n \u003cp\u003eElementary School\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eJunior High School\u003c/p\u003e\n \u003cp\u003eSenior High School\u003c/p\u003e\n \u003cp\u003ePerguruan Tinggi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.0392%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3529%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13,9\u003c/p\u003e\n \u003cp\u003e33,6\u003c/p\u003e\n \u003cp\u003e32,0\u003c/p\u003e\n \u003cp\u003e18,9\u003c/p\u003e\n \u003cp\u003e1,6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.6078%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of Diagnose \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMedian (Range in Reays)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.0392%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13 (1 \u0026ndash; 20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3529%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.6078%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisease Complication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.0392%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3529%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6,6\u003c/p\u003e\n \u003cp\u003e93,4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e The Anxiety Levels of Adolescent Thalassemia Major Survivors in West Java (n=122)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"496\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31.4516%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30.4435%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38.1048%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Frequency (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.4516%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of Anxiety\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4435%;\"\u003e\n \u003cp\u003eMild\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38.1048%;\"\u003e\n \u003cp\u003e86 (70,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.4516%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4435%;\"\u003e\n \u003cp\u003eMedium\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38.1048%;\"\u003e\n \u003cp\u003e12 (9,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31.4516%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.4435%;\"\u003e\n \u003cp\u003eSevere\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38.1048%;\"\u003e\n \u003cp\u003e24 (19,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Correlation test of variables with Anxiety Levels of Adolescent Thalassemia Major Survivors in West Java (n=122)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"540\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of Anxiety\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eMild\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMedium -severe\u003c/p\u003e\n \u003cp\u003e(n=36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBody Image\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eGood\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e82 (78,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e23 (21,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eBad\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e4 (23,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e13 (76,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf Esteem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e12 (46,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e14 (53,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e0,002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e74 (77,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e22 (22,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoping\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eProblem\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e58 (77,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e17 (22,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e0,036\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eEmotion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e28 (59,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e19 (40,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial Support\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eLow/Medium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e23 (65,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e12 (34,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e0,463\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e63 (72,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e24 (27,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e The Logistic Regression Analysis of Multivariate Factors that the Most Influential on Anxiety Levels of Adolescent Thalassemia Major Survivors in West Java\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"550\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8182%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30.5455%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndependent Variable\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.6364%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted OR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8182%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEarly Model\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.5455%;\"\u003e\n \u003cp\u003eBody Image\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6364%;\"\u003e\n \u003cp\u003e8,9 (2,4 \u0026ndash; 32,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16%;\"\u003e\n \u003cp\u003e0,001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8182%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.5455%;\"\u003e\n \u003cp\u003eSelf Esteem\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6364%;\"\u003e\n \u003cp\u003e0,6 (0,2 \u0026ndash; 1,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16%;\"\u003e\n \u003cp\u003e0,376\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8182%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.5455%;\"\u003e\n \u003cp\u003eCoping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.6364%;\"\u003e\n \u003cp\u003e1,9 (0,8 \u0026ndash; 4,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16%;\"\u003e\n \u003cp\u003e0,161\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21.8182%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLast Model\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30.5455%;\"\u003e\n \u003cp\u003eBody Image\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31.6364%;\"\u003e\n \u003cp\u003e11,6 (3,4 \u0026ndash; 38,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16%;\"\u003e\n \u003cp\u003e\u0026lt;0,001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescent, Anxiety, Indonesia, Psychological, Thalassemia","lastPublishedDoi":"10.21203/rs.3.rs-5330088/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5330088/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThalassemia major leads to severe anaemia, necessitating lifelong blood transfusions. Inconsistencies in blood transfusions and iron chelation therapy result in physical changes that can cause psychological issues, with anxiety being the most prominent. This study aimed to examine the factors influencing anxiety levels among adolescent thalassemia major survivors.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe research utilized a quantitative approach with a correlational analytic design and cross-sectional method. It included a population of 122 adolescent survivors, all of whom were included using a total sampling technique. Data analysis involved univariate analysis by frequency distribution, bivariate analysis using the chi-square test, and multivariate analysis with logistic regression.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study findings revealed that 70.5% of adolescents experienced mild anxiety. Significant correlations were found between body image (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), self-esteem, and coping mechanisms with anxiety levels, while social support was not significantly related. Body image emerged as the most influential factor, with poor body image increasing the likelihood of severe anxiety by 11.6 times.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAdolescents with Thalassemia major in West Java primarily exhibit mild anxiety. These findings highlight the necessity for comprehensive psychological support that addresses body image concerns and boosts self-esteem and coping skills to enhance the mental health of adolescent thalassemia major survivors.\u003c/p\u003e","manuscriptTitle":"Factors Contributing to Anxiety in Adolescents Surviving Thalassemia Major in Indonesia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-06 06:18:07","doi":"10.21203/rs.3.rs-5330088/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-28T05:55:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-26T09:23:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-26T09:23:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2024-10-25T06:37:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"96ca4feb-ff94-48f7-b0ea-174d0dd61f57","owner":[],"postedDate":"November 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-03T16:06:03+00:00","versionOfRecord":{"articleIdentity":"rs-5330088","link":"https://doi.org/10.1186/s12887-025-05403-3","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2025-01-31 15:57:34","publishedOnDateReadable":"January 31st, 2025"},"versionCreatedAt":"2024-11-06 06:18:07","video":"","vorDoi":"10.1186/s12887-025-05403-3","vorDoiUrl":"https://doi.org/10.1186/s12887-025-05403-3","workflowStages":[]},"version":"v1","identity":"rs-5330088","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5330088","identity":"rs-5330088","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}