Association of stress and emotional well-being in non-medical college students: A systematic review and meta-analysis.

Stress among college students is a well-explored area with profound implications for their emotional well-being. Despite extensive research, the literature presents inconsistent and mixed findings regarding its relationship with emotional well-being, particularly focusing on medical students. Moreover, there is no meta-analytic study to address this inconsistency. To bridge these gaps, this study conducts a systematic review and meta-analysis to explore the nuanced association between stress among non-medical college students and their emotional well-being. The systematic review utilized databases: PubMed, Scopus, and Web of Science, search engine: Google Scholar, and gray literature sources: ProQuest and Research Gate. The dataset consisted of 46 eligible studies (k), comprising 26,214 participants across 20 countries. The mean age was 21.86 (k = 32), with females constituting 60 % (k = 45). The majority of studies employed a cross-sectional/correlational design. The estimated pooled correlation is found to be -0.27 (95 % CI: -0.33, -0.21, p < .01; I2 = 97.5 %, k = 46). Subgroup analysis revealed significant influences of the type of stress (p < .01), emotional well-being (p < .01), tools (p < .01) used, significance status of findings (p < .001), and demographic factors - country (p < .001) and income level (p < .05). The study found an inversely significant and moderate association between stress and emotional well-being in non-medical college students, consistent with existing literature. Significant moderation by study and demographic variables suggests substantial heterogeneity among studies, highlighting potential influences from demographics, methodologies, and populations.

Social Media Use And Well-Being: A Systematic Review And Meta-Analysis.

Prior research has investigated the link between social media use (SMU) and negative well-being. However, the connection with positive well-being has not been extensively studied, leading to a situation where there are inconsistent and inconclusive findings. This study fills this gap by examining the correlation between excessive and problematic SMU and subjective as well as psychological well-being (PWB). We conducted a systematic search across databases such as PubMed, Scopus, and Web of Science, and gray literature sources such as Research Gate and ProQuest, yielding 51 relevant studies for meta-analysis, encompassing a sample size of 680,506 individuals. Employing the Newcastle-Ottawa Scale, we assessed study quality, whereas statistical analysis was executed using R Studio. Excessive SMU showed no significant association with subjective (ES = 0.003, 95% confidence interval [95% CI]: -0.08, 0.09; p = 0.94, I2 = 95.8%, k =16) and PWB (ES = 0.16, 95% CI: -0.15, 0.45; p = 0.26, I2 = 98%, k = 7). Conversely, problematic SMU showed a negative correlation with subjective (ES = -0.14, 95% CI: -0.20, -0.09; p = 0.00, I2 = 93.3%, k = 25) and PWB (ES = -0.19, 95% CI: -0.31, -0.06; p = 0.01, I2 = 95%, k = 5), with two outliers removed. No publication bias was detected. Subgroup analysis highlighted effects of "sampling method" (p < 0.05), "study quality" (p < 0.05), "developmental status" (p < 0.05), "forms of social media" (p < 0.05), and "type of population" (p < 0.01) on the estimated pooled effect sizes. Although univariate meta-regression showed the effects of "% of Internet users" (p < 0.05) and "male%" (p < 0.05), and multivariate meta-regression showed the combined effect of moderators only on the relationship between problematic SMU and subjective well-being.

Childhood maltreatment is linked to larger preferred interpersonal distances towards friends and strangers across the globe.

Childhood maltreatment (CM) is thought to be associated with altered responses to social stimuli and interpersonal signals. However, limited evidence exists that CM is linked to larger comfortable interpersonal distance (CID) - the physical distance humans prefer towards others during social interactions. However, no previous study has investigated this association in a comprehensive sample, yielding sufficient statistical power. Moreover, preliminary findings are limited to the European region. Finally, it is unclear how CM affects CID towards different interaction partners, and whether CID is linked to social functioning and attachment. To address these outstanding issues, adults (N = 2986) from diverse cultures and socio-economic strata completed a reaction time task measuring CID towards an approaching stranger and friend. Higher CM was linked to a larger CID towards both friends and strangers. Moreover, insecure attachment and less social support were associated with larger CID. These findings demonstrate for the first time that CM affects CID across countries and cultures, highlighting the robustness of this association.

Cross-country assessment of the unique contributions of psychological factors to vaccination: Perspectives on the COVID-19 pandemic.

We have identified the most relevant and significant psychological factors in relation to COVID-19 vaccination attitudes in Ghana, Germany, New Zealand and India. This study recruited 1822 participants from the general populations of India (n = 411), New Zealand (n = 413), Ghana (n = 523) and Germany (n = 475) to participate in a cross-sectional online survey. After controlling for the country of residence, individual psychological factors played a significant role in shaping attitudes towards COVID-19 vaccination. The results also revealed strong direct predictors that explained significant portions of the variance in the COVID-19 vaccination attitudes. Positive affect emerged as the strongest contributor in Ghana (7%), while self-compassion strongly influenced COVID-19 vaccination attitudes in India (66%). Dispositional optimism was the strongest predictor in New Zealand (5%). In Germany, compassion towards others was the strongest positive predictor (2%), while psychological distress had a strong negative impact (3%). Results highlight the importance of promoting emotional well-being to enhance vaccination coverage.

Association of Phubbing Behavior and Fear of Missing Out: A Systematic Review and Meta-Analysis.

Phubbing, a pervasive social behavior linked to smartphone usage, involves users neglecting their conversation partners to engage with their phones. Despite consistent exploration of its association with the concept of fear of missing out (FOMO), findings in the existing literature exhibit notable inconsistency. To address this gap, this study employs a systematic review and meta-analysis to scrutinize the intricate relationship between phubbing behavior and FOMO. A comprehensive systematic review, spanning up to December 10, 2023, encompassed databases such as PubMed, Scopus, Web of Science, ProQuest, and Google Scholar. The resulting dataset comprised 27 eligible studies, incorporating insights from 20,415 participants across 15 countries. Rigorous evaluation of study quality was executed using the Newcastle Ottawa Scale, while statistical analyses were meticulously conducted using R Studio. Revealing a robust positive association, phubbing behavior was significantly linked to FOMO (effect size[ES] = 0.43, 95% CI: 0.36, 0.49, I2: 97.5%, τ2: 0.05). Correcting for detected publication bias using the Trim and Fill method, an additional 16 studies were included, fortifying the robustness of the findings. Moderation analysis uncovered significant influences of location (p < 0.01), income level (p < 0.01), sampling method (p < 0.01), phubbing scale (p < 0.01), and FOMO scale and type (p < 0.01) on the estimated relationship. Univariate meta-regression highlighted the substantial impact of sample size (R2 = 11.81%, p < 0.01), while multivariate meta-regression illuminated the combined effects of publication year, study quality score, sample size, mean age, and female proportion on the estimated relationship (k = 19, R2 = 52.85%, I2 = 93.78%, p < 0.05). Furthermore, post hoc influential analysis, conducted through the leave-one-out method, offered additional depth to the examination.

Association of Childhood Emotional Maltreatment with Adolescents' Psychopathology: A Systematic Review and Meta-Analysis.

Childhood Emotional Maltreatment (CEM) is a significant but under-studied risk factor for impaired mental health, with adolescents being particularly susceptible. This systematic review and meta-analysis, prospectively registered in PROSPERO as CRD42022383005, aims to synthesize the findings of studies investigating the association between CEM and adolescent psychopathology, making it the first attempt to the best of our knowledge. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, a comprehensive search (PubMed, Scopus, PsycINFO, Science Direct, Embase, and ProQuest) yielded 12,224 studies, from which 72 were included in the qualitative synthesis. The meta-analysis was conducted on 76 effect sizes (ranging from 0.01 to 0.57) extracted from 56 studies. The assessment of publication bias utilized funnel plots, Egger's regression test, and the trim and fill method, if required. Additionally, a predictor analysis investigated the influence of study-level variables on the CEM-psychopathology association. Results revealed a significant positive correlation between CEM and adolescent psychopathology (Pooled association: 0.24-0.41) Furthermore, assessment of publication bias indicated no significant bias. The predictor analysis suggested minimal influence of study-level variables. The study underscores the urgent need to address CEM as a crucial risk factor for adolescent psychopathology. The significant positive correlation between CEM and psychopathological outcomes highlights the detrimental effects of CEM on adolescents. Awareness, prevention efforts, and targeted interventions are essential to mitigate these effects. Further studies with culturally diverse and larger sample sizes are required, with emphasis on methodological rigor, given that most of the identified studies showed a high risk of bias.

Attachment orientation and depression: A moderated mediation model of self-silencing and gender differences.

BACKGROUND: While the effect of insecure attachment on depression is well established, findings pertaining to the relationship between specific attachment dimensions (anxious and avoidant) and depression are inconsistent. The role of interpersonal factors underlying this effect has been little explored. 'Silencing the Self', a socio-cognitive construct may provide important insights as a mediating pathway from insecure attachment to depression and help resolve the inconsistencies. AIMS: The present study explored the mediating effect of self-silencing and the role of gender as a moderator in the relation between insecure attachment orientation (i.e. avoidant and anxious) and depressive symptoms. METHOD: Data was collected via an online survey, from 121 adults who were in a relationship. The participants were asked to complete three self-report questionnaires, assessing attachment orientation, silencing the self and depressive symptoms. Moderated mediation analysis was performed using conditional process analysis. RESULTS: The results indicated that the effect of both insecure attachment dimensions on depressive symptoms was mediated by silencing the self. In addition, gender moderated the association between insecure attachment and self-silencing. CONCLUSIONS: This study adds to the literature on mediating pathways between insecure attachment and depression, and provides a new perspective for therapeutic interventions in the context of depression. It indicates that professionals should focus on current social context and relational schemas of individuals with an insecure attachment, especially women, while treating cases of depression in clinical settings.

Assessing COVID-19 Booster Hesitancy and Its Correlates: An Early Evidence from India.

The emergence of SARS-CoV-2 mutants, waning immunity, and breakthrough infections prompted the use of booster doses of the COVID-19 vaccine to fight against the pandemic. India started booster doses in January 2022 and it is critical to determine the intention of booster dose uptake and its correlates. Therefore, the current cross-sectional study aimed to investigate booster dose acceptability and associated predictors among the Indian population. A convenience sampling technique was utilized to recruit a sample of 687 Indian residents. A 55-item psychometric validated survey tool was used to assess booster dose acceptability, vaccine literacy and vaccine confidence. Univariate, bivariate, and multivariate statistical methods were used to analyze the data. Over 50% of participants reported their willingness to take the booster dose. Among the group not willing to take the booster dose (n = 303, 44.1%), a significantly larger proportion of respondents were unvaccinated with the primary series (12.2% vs. 5.2%, p < 0.001), had an annual income below 2.96 lacs/annum (52.8% vs. 33.1, p < 0.001), were residents of rural areas (38.0% vs. 23.2%, p < 0.001), were not living with vulnerable individuals (78.5% vs. 65.2%, p < 0.001) and did not have family/friends who had tested positive for COVID-19 (54.6% vs. 35.1%, p = 0.001). Demographic, vaccine variables and multi-theory model subscales to predict the initiation of booster dose among hesitant participants were statistically significant, R2 = 0.561, F (26, 244) = 11.978, p < 0.001; adjusted R2 = 0.514. Findings of this study highlight the need to develop evidence-based interventions to promote vaccine uptake, particularly among hard-to-reach communities living in developing countries.

Cross-Cultural Measurement of Positive and Negative Emotions in Adolescence: Evidence from Three Countries.

Cross-cultural assessment of affective well-being among adolescents has received scarce attention in positive psychological research. The present study investigated cross-cultural measurement invariance of the Scale of Positive and Negative Experience (SPANE) among adolescents from three countries (India, Poland, and Serbia). The sample included a total of 1080 adolescents (53.6% female; M age = 16.75, range = 15-19 years). Surveys were administered online in each country. Measurement invariance testing provided evidence for partial scalar invariance of the SPANE across cultures, with item "afraid" showing nonivariance across the three countries. Latent factor correlations between positive and negative emotions were stronger in Serbia compared to Poland and India. Positive emotions and life satisfaction had strong positive associations in all three countries (ranging from 0.68 to 0.75). The inverse correlations between negative emotions and life satisfaction were - 0.27, - 0.54, - 0.69 in India, Poland, and Serbia, respectively. Polish adolescents demonstrated the lowest levels of affective well-being, whereas Indian and Serbian adolescents did not differ substantially in levels of positive and negative emotions. The present study demonstrated that the SPANE is a reliable and useful tool for the assessment of positive and negative emotions among adolescents from different cultural settings. Supplementary Information: The online version contains supplementary material available at 10.1007/s10902-022-00521-6.

Social Functioning in Individuals Affected by Childhood Maltreatment: Establishing a Research Agenda to Inform Interventions.

Childhood maltreatment (CM) is linked to impairments in various domains of social functioning. Here, we argue that it is critical to identify factors that underlie impaired social functioning as well as processes that mediate the beneficial health effects of positive relationships in individuals exposed to CM. Key research recommendations are presented, focusing on: (1) identifying attachment-related alterations in specific inter- and intrapersonal processes (e.g., regulation of closeness and distance) that underlie problems in broader domains of social functioning (e.g., lack of perceived social support) in individuals affected by CM; (2) identifying internal (e.g., current emotional state) and external situational factors (e.g., cultural factors, presence of close others) that modulate alterations in specific social processes; and (3) identifying mechanisms that explain the positive health effects of intact social functioning. Methodological recommendations include: (1) assessing social processes through interactive and (close to) real-life assessments inside and outside the laboratory; (2) adopting an interdisciplinary, lifespan perspective to assess social processes, using multi-method assessments; (3) establishing global research collaborations to account for cultural influences on social processes and enable replications across laboratories and countries. The proposed line of research will contribute to globally develop and refine interventions that prevent CM and further positive relationships, which - likely through buffering the effects of chronic stress and corresponding allostatic load - foster resilience and improve mental and physical health, thereby reducing personal suffering and the societal and economic costs of CM and its consequences. Interventions targeting euthymia and psychological well-being are promising therapeutic concepts in this context.

Motors of COVID-19 Vaccination Acceptance Scale (MoVac-COVID19S): Evidence of Measurement Invariance Across Five Countries.

Purpose: The percentage of individuals who were fully vaccinated against COVID-19 was 53% worldwide, 62% in Asia, and 11% in Africa at the time of writing (February 9, 2022). In addition to administrative issues, vaccine hesitancy is an important factor contributing to the relatively low rate of vaccination. The Motors of COVID-19 Vaccination Acceptance Scale (MoVac-COVID19S) was developed to assess COVID-19 vaccination acceptance levels. However, it has only been tested among Taiwanese, mainland Chinese, and Ghanaian populations (Chen et al, 2021; Fan et al, 2021; Yeh et al, 2021). Therefore, the present study examined the construct validity and measurement invariance of the MoVac-COVID19S among individuals from five countries (ie, Taiwan, mainland China, India, Ghana, and Afghanistan). Participants and Methods: A cross-sectional survey study recruited 6053 participants across five countries who completed the survey between January and March 2021. Confirmatory factor analysis (CFA) fit indices were used to examine factor structure and measurement invariance across the five countries. Results: The fit indices of the CFA were relatively good across the countries except for the root mean square error of approximation (RMSEA). Moreover, the four-factor structure (either nine or 12 items) had a better fit than the one-factor structure. However, the four-factor model using nine MoVac-COVID19S items was the only model that had measurement invariance support for both factor loadings and item intercepts across the five countries. Conclusion: The present study confirmed that the MoVac-COVID19S has acceptable psychometric properties and can be used to assess an individual's willingness to get COVID-19 vaccination.

The Satisfaction with Life Scale in Adolescent Samples: Measurement Invariance across 24 Countries and Regions, Age, and Gender.

Measurement of adolescent life satisfaction across cultures has not received much attention in previous empirical research. The present study evaluated measurement invariance of the Satisfaction with Life Scale (SWLS) among adolescents in 24 countries and regions (N = 22,710; age range = 13-19 years; 53% female). A single-factor model with residual covariance between a pair of items tapping past life satisfaction fitted well in 19 countries and regions and showed a partial metric invariance. In a subset of nine countries and regions, partial scalar invariance was supported. Partial metric invariance across all 24 countries and regions was achieved when custom model modifications in five countries and regions were included. Three SWLS items showed evidence of noninvariance across cultures. The measurement model was found to operate similarly across gender and age. Our findings suggest that caution is needed when using the SWLS for measuring life satisfaction among adolescents from different cultures. Supplementary Information: The online version contains supplementary material available at 10.1007/s11482-021-10024-w.

COVID-19 related fear and mental health in Indian sample: The buffering effect of support system.

The scientific world witnessed a surge of researches, from all corners of the world, regarding the humanitarian crisis precipitated by COVID-19 pandemic, more specifically its impact on people's mental health. However, researchers exploring the association between COVID-19 related fear and mental health are yet to understand the conditions through which potential benefits may occur. Many factors could buffer the effects of COVID-19 related fear on mental health; support system is probably the predominant one. Thus, the present study examined the moderating effects of support system in the association between COVID-19 related fear and mental health outcomes - somatic symptoms, generalized anxiety disorder (GAD), and depression. Using a web-based cross-sectional survey, we collected data from 163 volunteers assessed with demographic information, COVID-19 related fear, support system, and mental health outcomes. Hierarchical multiple regression analysis and simple effect tests revealed that high levels of support from family, friends, and significant others might buffer/lessen the psychological sequelae (e.g., somatic symptoms, anxiety, and depression during public health emergencies, such as COVID-19 pandemic. Given the potential for negative mental health outcomes following pandemics, such as COVID-19, efforts to enhance peoples' support system may be especially important.

Gender Differences in Childhood Maltreatment: A Comparative Study of Nightmare Sufferers and Non-sufferers.

Child maltreatment has been identified as a significant problem, both within India and outside. According to UNICEF, over the last decade, there has been a growing recognition about this, but the problem has remained unresolved largely due to being underreported and undocumented. Previous research in this area has reported inconsistent gender differences across the world. Besides, there are shreds of evidence to suggest that childhood maltreatment would be associated with nightmares later in life, but a handful of studies exist in this context. Moreover, there is a paucity of research concerning the interaction effect of gender and group (nightmare sufferer vs non-sufferer) on childhood maltreatment. Owing to the insufficient research and inconsistent findings, the present study aimed to investigate gender differences in childhood maltreatment among nightmare sufferers as compared to non-sufferers. A total of 120 participants were selected from New Delhi. The results of two-way ANOVA suggest that the nightmares later in life would be associated with the abuse and neglect experienced during childhood as nightmare sufferer group reported having higher rates of child abuse and neglect than non-sufferers. It also suggests that male participants in general experience childhood maltreatment more than females; however, emotional abuse was experienced by males only if they belonged to the nightmare sufferer group.

Lived Experiences of Women with Dissociative Disorder: An Interpretative Phenomenological Analysis.

BACKGROUND: In the Indian setting, several studies have documented that dissociative disorders (DDs) are more common in females, and the most commonly elicited stressors are interpersonal. However, much of the research up to now has been quantitative. There is a notable paucity of qualitative studies exploring the subjective experiences of women with DD. Therefore, the present study sought to explore and gain an in-depth understanding of the lived experiences of women diagnosed with DD. METHODS: Five women were recruited who were seeking psychological treatment for dissociative symptoms at a tertiary care neuropsychiatric institute in North India. In-depth interviews were conducted with each, and the transcripts were analyzed using the analytic method of interpretative phenomenological analysis. RESULTS: Three superordinate themes that emerged were: patients' illness perspectives, the salience of relationships, and dealing with relationship conflicts. CONCLUSIONS: Our findings highlight the role of culture in influencing the participants' illness perspectives. Women with DD tend to define their self in relational terms and, thus, inhibit the expression of one's needs and opinions, to avoid conflict and to maintain harmony in relationships.

Lived experiences of Indian Youth amid COVID-19 crisis: An interpretative phenomenological analysis.

BACKGROUND: COVID-19 and the resultant lockdowns have caused a global discomposure. Out of a plethora of ramifications of this unusual state, mental health problems are becoming a serious concern. Considering the peculiarity of the situation, encapsulation of the lived experiences of people affected by COVID-19 may lead us towards a better understanding and control of the situation. AIM: The aim of the present study was to get an in-depth analysis of the lived experiences of Indian youth amid COVID-19 crisis and its impact on their mental health. METHOD: Ten college going students were telephonically interviewed using a semi-structured interview schedule to elicit participants' experiences with COVID-19 and the impact it has posed on their mental health. Transcripts were analysed using Interpretative Phenomenological Analysis (IPA). RESULTS: The analysis revealed three master themes: (1) 'Impact on mental health', (2) 'Positive experiences' and (3) 'Ways of coping amid the crisis'. CONCLUSION: The study draws attention to the mental health concerns of Indian youth amid the current crisis. The findings also highlight the positive outcomes of the crisis as well as the different ways of coping adopted by young individuals in India.

The Curvilinear Association Between Posttraumatic Distress and Posttraumatic Growth Among Pellet Gun Victims: The Moderating Roles of Time Since Trauma and Age.

Since 2010, the use of pellet guns in Indian-administered Kashmir has led to serious physical and psychological consequences among a growing number of victims. However, no research to date has examined the association between posttraumatic distress and posttraumatic growth (PTG) within this population. Previous research conducted on other types of trauma exposure has yielded inconsistent findings regarding the nature and directionality of this association; namely, whether it is linear or curvilinear. Moreover, this inconsistency may also be due to the effects of other variables, such as time since trauma and age. In the present study, we investigated whether the association between posttraumatic distress and PTG among pellet gun victims is best explained as linear or curvilinear and tested whether this association was moderated by time since trauma and/or age. Using purposive sampling, 120 pellet gun victims were recruited from Indian-administered Kashmir. The results of quadratic hierarchical regression suggested that an inverted U-shaped curvilinear association, sr2 = 0.07 (medium effect), was a better fit over and above a linear term, sr2 = 0.06 - 0.08 (medium effect). The moderation test further revealed that this effect was present across time but became apparent, as an inverted U-shape, 18 to 24 months posttrauma, sr2 = 0.04 (small effect); age, however, was not found to influence this association. These findings held even after controlling for the effects of confounding variables. The present findings suggest that across time, moderate levels of posttraumatic distress are associated with the highest levels of PTG.

Coronavirus disease (COVID-19) pandemic: Furnishing experiences from India.

The current work seeks to address the issues and ramifications of the rapid spread of the coronavirus disease (COVID-19) in India. Ever since COVID-19 was declared a pandemic, leading to a nationwide lockdown, a majority of people in India have faced a myriad of hardships, with mental health crisis being the most prominent one. The evidence at hand points toward an array of mental health issues in people that include a sense of uncertainty, anxiety, depression, sleep disturbances, panic attacks, and loneliness. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

'Silencing the self' and women's mental health problems: A narrative review.

In the context of women's mental health several propositions have been made to account for their increased susceptibility to certain psychiatric illnesses. However, given the topic's multifacetedness, no single explanation is found sufficient in itself. 'Silencing the Self' theory sheds new light on this issue because it acknowledges the importance of social and cultural processes. Besides with its relational perspective, it centers on the primacy of core relationships and its influence on a woman's mental health. Even though, since its inception three decades ago, the theory has been studied in relation to various psychological and physical disorders; it has hitherto received inadequate attention by scholars. Nonetheless, it has the potential to inform our understanding when formulating women's mental health issues. The aim of this review is to provide a comprehensive narrative account of the extant work on 'silencing the self' in relation to psychiatric illnesses like depression, eating disorder and premenstrual dysphoric disorder. It attempts to synthesize the work done till date, as a starting point for further investigation of unexamined areas.

Beyond linear evidence: The curvilinear relationship between secondary traumatic stress and vicarious posttraumatic growth among healthcare professionals.

Insufficient and inconsistent research exists regarding the relationship between secondary traumatic stress (STS) and vicarious posttraumatic growth (VPTG). Some authors suggest that the STS-VPTG relationship can be linear, whereas others suggest that the relationship can best be represented as curvilinear. Therefore, the purpose of the current study was to examine whether the relationship between STS and VPTG is essentially linear or curvilinear. A cross-sectional correlational research design was employed, and a total of 258 surgeons, psychiatrists, and physicians who deal with victims of the ongoing conflict were selected. After controlling for the effects of vicarious and direct traumatic exposure and experience, results of hierarchical regression provide support for the curvilinear association between STS and VPTG among the overall sample (the curvilinear model explained 4.6% of the variance in Posttraumatic Growth Inventory (PTGI) scores beyond the variance explained by the linear model) and among professional groups of surgeons and physicians (the curvilinear model explained 4.3% of the variance in PTGI scores among surgeons and 3.5% of the variance in PTGI scores among physicians over and above variance explained by the linear models, respectively). Findings suggest that moderate levels of STS are most associated with the highest levels of VPTG.