Caspian Journal of

1. Introduction
COVID-19 has swept the globe and has now been considered a global health issue. As of January 2022, over 350 million people have been infected and at least 5 million have died since the disease emerged in China in November 2019 [1]. To prevent the possibility of infection, medical clinics have restricted access due to the COVID-19 pandemic. Hence, the routine care of patients with chronic diseases such as diabetes has become a major challenge in this context. During the COVID-19 pandemic, several strategies were implemented to assist patients with type 1 and type 2 diabetes and to prevent exacerbations [2, 3, 4, 5]. A healthy lifestyle consisting of a nutritious diet and regular physical activity is recommended for patients with diabetes to reduce the risk of infection, monitor blood sugar levels, take medication, inject insulin and noninsulin drugs adequately, and maintain a healthy weight [6]. As a result of the experience of physical and social isolation, the COVID-19 pandemic also impacted the pediatric population psychologically. Many children and adolescents with Type 1 Diabetes (T1D) didn’t follow up on scheduled outpatient follow-up visits, and they encountered numerous obstacles that forced them to change their diabetes management approach [7].
Self-efficacy is an important component in improving diabetes self-management skills. Adolescents with T1D with better self-efficacy reported a higher probability of reaching target diabetes control [8]. Studies have shown that self-efficacy is effective at reducing stress and generating coping strategies for individuals dealing with stressful life events [9]. In the COVID-19 pandemic, self-efficacy was associated with positive outcomes [10]. Even though self-efficacy plays a positive role in managing stressful events, these events can also undermine self-efficacy [11]. According to Alexander and Ward, people dealing with disasters have low coping abilities and physiological responses such as sweat and pain, which reduces self-efficacy [12].
The authors reported that diabetes patients are four times more likely to die from COVID-19 [13]. In a study by Bonora et al. published in 2020, patients with Type 1 diabetes who were locked up during lockdowns were better able to control their blood sugar levels [14]. Due to the COVID-19 pandemic, health care professionals make unprecedented changes to health care systems, social services, as well as how to manage children with diabetes [15].
Although countries and communities have reacted differently to the pandemic and lockdown, many households and individuals have used idiosyncratic approaches to overcome their peculiar challenges. The characteristics of individuals’ coping strategies have influenced their coping strategies, such as gender, pre-existing health conditions, work status, and other sociodemographic factors [16, 17, 18]. Additionally, earlier studies indicate that the utility of coping strategies varies depending on the situation [19, 20]. 
It is therefore critical for public health policy and interventions to identify which coping mechanisms work in particular settings, such as the ongoing COVID-19 pandemic Thus, the purpose of this study was to examine the effectiveness of coping skills training on self-efficacy among adolescents with type 1 diabetes during the COVID-19 pandemic lockdown.

2. Materials and Methods
Study type and study population
The current research was conducted as a pilot study using pre-test, post-test design with a control group from June to August 2021. The study was implemented in collaboration with the Tehran Diabetes Center in Iran. Two diabetes experts and a pediatric endocrinologist verified the T1D diagnosis of the patients in the diabetes center. A total of 16 participants were selected through a purposeful sampling process when referred to the Tehran Diabetes Center. They were non-randomly allocated to the intervention (n=9) and control (n=7) groups. The inclusion criteria were age between 12-18 years old, at least six months since diabetes diagnosis, and satisfaction with participating in the study. Those patients who had recently received coping strategies training or currently participating in coping strategies programs, were unwilling to continue the sessions or missed more than two training sessions were excluded from the study. The parents and guardians of the participants received an online presentation of the study objectives, design, duration, and how they could withdraw from the study. Then they were taken informed consent. The information of the participants was kept confidential and anonymous. 

Intervention protocol
Due to quarantine conditions and the health risk of infection transmission, training sessions was held through online education in Whats App. The contents of coping skills training were designed based on Grey et al.’s [21] and are presented in Table 1.

Online training sessions were held for eight weeks and last for 90 minutes. Both groups completed General Self-efficacy (GSE) scale and submitted it via a link before and after the training sessions. 

Study instrument
Self-efficacy was measured using GSE that was developed by Sherer et al. in 1982 [22]. The purpose of this scale is to measure “a general set of expectations that an individual brings with him or her into new situations”. The questionnaire consisted of 17 items scored from strongly disagree (score=1) to strongly agree (score=5) on a 5-point Likert scale. GSE scores ranged from 17 to 85, with higher scores indicating higher self-efficacy. Other Iranian studies have also used the Persian version of GSE. The Persian version of GSE reported internal consistency of 0.78 [23]. GSE was found to exhibit an internal consistency reliability coefficient (Cronbach’s) and test-retest reliability that was assessed via Pearson correlation coefficients to be 0.91 and 0.93, respectively.

Statistical analysis
Data were described using Mean±SD frequency and percent. Normal distribution of continuous variable was assessed using Shapiro-Wilk test. Analysis of covariance (ANCOVA) was conducted to find out whether coping skills training could improve the self-efficacy of adolescents with type 1 diabetes during the COVID-19 pandemic lockdown. All Statistical analysis was performed using SPSS software, v. 23.

3. Results
The Mean±SD age of participants with T1D in the intervention and control groups were 13.87±1.34 and 13.46±1.76 years old, respectively (P=0.16). Furthermore, 49% of the participants in the intervention group and 51% of the participants in the control group were female (P=0.11).
Baseline self-efficacy Mean±SD was not significantly different between the intervention (45.44±13.377) and the control group (46.49±14.174) (P<0.05). In the posttest, the result of covariance analysis adjusted for the baseline self-efficacy score showed that self-efficacy score significantly improved in the intervention (71.52±13.86) compared to the control group (48.13±12.96) (F=18.97, P=0.001, η2=0.59).

4. Discussion
Study results indicated that coping skills training helped adolescents with type 1 diabetes become more self-confident during the COVID-19 pandemic lockdown. Problem-solving skills can help resolve or accelerate the resolution of a problem. During a pandemic, individuals need to develop coping skills in order to cope with the effects to ease and to support their mental health [24, 25]. It was self-efficacy that was essential to maintaining mental health and optimism in the course of the COVID-19 pandemic [10, 11].
It is argued, however, that these strategies may exhibit varying effectiveness depending on context [20]. According to the results of this study, self-efficacy was improved among adolescents with diabetes after coping skills training, which was consistent with other studies [23, 24, 25, 26, 27, 28]. In a study on school-aged children with type 1 diabetes, coping skills training significantly improved psychosocial adaptation [26] and improved psychosocial and diabetes self-management outcomes [27]. 
Moreover, Edraki et al. [8] showed coping skills training improved the patients’ self-efficacy, they suggested that the use of this intervention could be a part of community-based nursing practice for adolescents with diabetes. Guo et al. [27] demonstrated that improving self-efficacy is an important strategy to improve diabetes self-management in adolescents with T1D. In another research, they showed the coping skills training program had no significant effect on primary outcomes of perceived stress, coping, and self-efficacy and secondary outcomes of diabetes self-management, quality of life, and glycated Hemoglobin A1c (HbA1c) over 12 months. However, there was a significant increase in positive coping, self-efficacy, diabetes problem-solving and goals of diabetes self-management, and quality of life of school-aged children in the intervention group compared with the control group [28]. 
Coping skills training may enhance the ability of adolescents with diabetes to cope with their daily issues and to be more effective in achieving the therapeutic goals, especially when this intervention is accompanied by ongoing follow-up care. Furthermore, training such patients regarding problem-solving helps them think of new, less differentiating behaviors that allow them to adhere to a diabetes diet [8].
This was a pilot study with inherent limitations in terms of small sample size and non-random allocation. There was a lack of long-term follow-ups after the intervention, which indicates the necessity for another longitudinal study. In addition, generalizing the results of this study is difficult due to its non-random sample method (purposeful). Another limitation in this study is the lack of assessment of important intervention variables like the duration of diabetes and socioeconomic conditions. Further studies should take into account this demographic variable. Study participants were recruited exclusively from one diabetes center in Tehran, which was a limitation of the study. Accordingly, it is vital to conduct similar studies in other parts of our country and abroad.

5. Conclusion 
Study results indicated that adolescents with type 1 diabetes who received coping skills training improved significantly in self-efficacy. It is essential to examine these research areas in future studies to evaluate the benefits, sustainability, safety, and optimization strategies for telemedicine and other digital approaches as key elements of modern healthcare delivery. 

Ethical Considerations
Compliance with ethical guidelines
We followed the Helsinki declaration of 1964 and its later amendments or similar ethical standards in all procedures involving human participants (IRSHUMS.REC.1400.077.).

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
All authors have equally contributed in preparing the article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
It is the authors’ pleasure to express their full appreciation to the staff and management of the Tehran Diabetes Center for their perfect cooperation in advancing this research.



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