Correlation analysis between the use of digital devices and neck and shoulder pain among college students and lifestyle education

doi:10.21203/rs.3.rs-1828299/v1

Background: Musculoskeletal pain (MSP) is frequent complaint among college students, especially neck and shoulder pain (NSP). No study so far has demonstrated a correlation between the use of digital devices and the prevalence of NSP among college students in China. Therefore, a cross-sectional survey investigating this relationship among college students in Shanghai was urgently needed.

Objective: The relationship between digital device usage, lifestyle, and the prevalence of self-reported NSP among college students in Shanghai, and neck muscle activity of different degrees of spinal curvature was investigated to provide suggestions for healthy spinal curvature lifestyle education.

Methods: 6000 students were randomly enrolled, and a self-reported questionnaire was conducted to assess the prevalence and severity of NSP. The students’ demographic characteristics, habits of using digital devices, and lifestyles were recorded. c² tests were used to compare the prevalence of NSP; univariable and multivariable logistic regression analyses were performed to identify potential risk factors for NSP. A musculoskeletal model of the standard human body was established with the AnyBody platform to test the neck muscle activity of different degrees of spinal curvature.

Results: Among the 4848 college students (80.8%) who completed the survey, the prevalence of NSP was 39.1%, with more girls (45.0%) reporting NSP than boys (32.4%). The logistic regression indicated that gender, inappropriate posture and using digital devices for long time had a significant correlation with NSP. Neck muscle activity increased as spinal inclination increased based on the AnyBody platform.

Conclusion: NSP seems to be a common condition among college students in Shanghai. Gender, inappropriate posture and using digital devices for long time are closely associated with NSP. The greater the anterior cervical and lumbar flexion, the higher the activity of cervical muscles. Healthy lifestyle education should be used to decrease the NSP among college students.

Neck and shoulder pain

College students

Use of digital products

Spinal curvature

Education

The goals of a college or university are to produce competent, qualified, professional and healthy candidates who will contribute to the development of society. However, during the course of their college education, students are exposed to stress, academic challenges, and the increasing use of digital products in teaching and learning[1]. These events are considered potential risk factors that may increase the prevalence of musculoskeletal pain/discomfort (MSP/MSD). Musculoskeletal pain (MSP) refers to injuries and disorders of the musculoskeletal system in which exposure to various risk factors may have either contributed to the development of or aggravated a pre-existing condition[2]. MSP is a major cause of chronic pain, injury, illness, and reduced educational attainment; it may affect the quality of productivity and contribute to absenteeism from university classes,[3] which will affect students’ future careers. Therefore, MSP among college students has recently attracted worldwide attention.

Among the different distributions of MSP, neck and shoulder pain (NSP) is the most frequent complaint among college students[4]. Research shows that the use of digital devices such as desktop computers, laptops and smart phones may result in complaints of pain, numbness or tingling in the neck, shoulder and arms, which may be related to loss of productivity, sick leave or even disability[5]. Adebimpe Olayinka Obembe[6] showed that shoulder pain (75.7%) was the most commonly reported type of pain among Nigerian undergraduate laptop users. Katherine Bubric[7] showed that among college laptop users, 28.9% of males and 42.7% of females reported neck discomfort, and 8.9% of males and 24.0% of females reported shoulder discomfort. Meanwhile, the prevalence of NSP has been correlated with postures associated with laptop use. This finding is consistent with Mustafa Ahmed Alshagga, who showed that MSP, and especially NSP experienced in the past year, is significantly associated with daily hours of computer use[8].

More than twenty muscles in the neck are involved in cervical activity and maintaining posture. Among these muscles, significantly activated muscles are more closely related to NSP[9]. There is limited research on the relationship between neck muscle activity and different cervical curvatures, which leads to a lack of education about the relationship between lifestyle and standard healthy cervical curvature. In addition, no study so far has demonstrated a correlation between the use of digital devices and the prevalence of NSP among college students in China. Therefore, a cross-sectional survey investigating this relationship among college students in Shanghai was urgently needed.

In this paper, we investigate the use of digital devices, lifestyle and the prevalence of self-reported NSP among college students in Shanghai. Then, a modified musculoskeletal model based on the Anybody Modeling System is established to analyze the relationship between neck muscle activity and different spinal curvatures.

Study design

This is a cross-sectional study performed in colleges registered in Shanghai from July 2020 to August 2020. Using cluster randomization, a total of 30 colleges were randomly selected, and 200 students aged 18 to 24 were randomly selected from each school.

Exclusion criteria

Pain caused by psychological factors (mental illness diagnosed), pain associated with menstruation in female students, and exercise-induced pain were excluded.

Design and validation of questionnaire

The questionnaire was designed based on the relevant literature[10]. The questions were modified to reflect the characteristics of Chinese college students. To ensure the validity of the questionnaire, a pre-survey was conducted among 200 first year college students before the launch of the formal survey. Based on the results of the pre-survey, the survey questionnaire was modified to eliminate duplication and to remove the factors that had little correlation with disease prevalence (measurement of sampling adequacy MSA <0.50). The study used standard questionnaires with a defined set of questions. Each question had a standard definition to minimize possible misunderstanding. The final Kaiser-Mayer-Olkin (KMO) index of the questionnaire was 0.708. The questionnaire typically took fewer than 20 minutes to complete.

Thirty undergraduates from the Department of Clinical Medicine, College of Medicine in Shanghai Jiao Tong University distributed and retrieved the questionnaires. The undergraduates were trained to give lectures about NSP to college students and to avoid inducing bias. The participants were given a lecture about the specific scope of NSP using diagrams of the human body; details of the characteristics of pain and the differences among post-exercise soreness, menstrual pain in women, and post-traumatic pain were explained before conducting the survey. A pain attack was defined as pain lasting for more than 10 minutes, and “neck and shoulder pain” was defined as “(i) pain over the neck/shoulder region for more than 6 hours each episode or (ii) short-term pain with high frequency more than 2-3 times every day, and (iii) this situation happened more than 3 times in one month”. However, in the questionnaire, we simply described the standard as “in the last 3 months, how often did you feel this type of frequent or continuous pain over the neck/shoulder region?” to differentiate chronic pain from acute pain. Instead of directly using “yes” and “no” to assess the exposure to risk factors, the onset frequency of pain was classified into the following four levels: “almost never”, less than once per month; “occasionally”, 1-3 times per month; “often”, 1-3 times per week; and “always”, more than 3 times per week. General interpretation of the results was as follows: “often" and "always" were treated as "yes"; while the other two levels, "almost never" and "occasionally", were treated as “No”.

Validation and Reliability

Two weeks after the completion of the large-scale questionnaire survey, 50 participants were randomly selected for a two-factor test-retest reliability study. The average of the test-retest reliability was 0.892, measured by Kappa.

Sample size calculation

The minimum sample size required was calculated using the following equation: N=Z²× [P (1-P)]/E², while Z=1.96 (95% confidence interval (95% CI)), and P was 8.6%, as the estimated minimum prevalence was based on the results of a study using a similar survey in Malaysia, and E=0.1×P. Hence, the total minimum sample size was 4086. To ensure enough valid questionnaires, we choose 6000 as our sample size.

Data and analysis

Data were collected in two parts. The first part of the survey included questions pertaining to self-reported NSP. The prevalence of NSP was determined by asking students the following question: "In the past six months, did you feel pain or discomfort in the neck/shoulder region?" Students who answered "yes" completed the second part. Ambiguous answers and other types of pain (described above) were excluded. The second part of the questionnaire included the following potential risk factors: female gender, the habit of using digital products, academic burden and frequent exercise. The habit of using digital products was defined as the gesture associated with using devices, how much the students used digital devices in one day, and whether they were addicted to the devices.

Data analysis was performed with SPSS 21.0 software (SPSS Inc., Chicago, IL). Uncompleted questionnaires and questionnaires completed with answers containing apparent logic errors were excluded. A c²test was used to compare the prevalence of NSP. The associations between different factors and the prevalence of NSP were analyzed using a univariate logistic regression model (OR1). Every specific item was examined using a multivariate logistic regression model (OR2) that included all candidate risk factors. The threshold for variant removal was set at 0.10. The large study sample and randomization limited the selection bias. The results were presented with the odds ratio (OR) and 95% confidence intervals (CI). A p-value less than 0.05 was considered statistically significant. Written informed consents were obtained from all the schools and college students. The study protocol was reviewed and approved by the Ethics Committee of Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine (Approval No. 2017KY212).

Musculoskeletal model building and muscle activity analysis.

In this paper, the basic musculoskeletal model was adopted from the AnyBody 6.05 Modeling System[11]. The basic model is a standing model including a rigid skeleton of the upper body, joints, and a combination of muscles and tendons with physiological properties. The model is able to analyze the whole musculoskeletal system under various conditions and calculate muscle activities, joint movement, co-contraction, etc.[12, 13] The basic musculoskeletal model adopted from the Anybody Modeling System was in the standard standing posture with lumbar curvature of 0, 15, 30, 45 and 60 degrees; we then investigated neck muscle activity at different cervical curvature postures ranging from 0 to 45 degree (Fig. 1). Muscle activity in AnyBody refers to the ratio of muscle force to maximal voluntary contractions (MVC)[14, 15], which is the most accurate indicator of whether muscle is overworked.

In this study, a total of 6,000 questionnaires were distributed, out of which 5,622 questionnaires (93.7%) were successfully retrieved and 4,848 questionnaires (86.2%) were confirmed to be valid (any questionnaire with more than 15% incomplete answers was regarded as invalid). Among the 774 unfinished questionnaires, nine were excluded because key items were missing, and three were not completed because the participant was on sick leave (Fig. 2). An analysis of the remaining 762 incomplete questionnaires revealed no significant difference in the prevalence of NSP when compared with the other 4,848 questionnaires (37.7% vs. 39.1%, P=0.568).

NSP prevalence and demographic factors

The overall prevalence of self-reported NSP among college students in Shanghai was 39.1%. Female students are more likely than male students to experience this discomfort according to both univariable and multivariable logistic regression analysis. There was no significant difference among college majors in the prevalence of NSP, although arts were the highest (45.1%) and engineering the lowest (35.9%) (Table 1).

Table 1 Demographic Factors and the Prevalence of NSP in College School Students

	N	% With NSP	P Value	OR1 (95%CI)	P Value	OR2 (95%CI)
Gender
Male	2259	32.4%	/	1	/	1
Female	2589	45.0%	＜0.001	1.710 (1.521-1.923)	＜0.001	1.462 (1.243-1.720)
College major
Arts	886	45.1%	/	1	/	1
Science	976	39.0%	0.008	0.778 (0.647-0.936)	0.315	1.053 (0.816-1.360)
Engineering	1786	35.9%	0.409	0.682 (0.579-0.803)	/	/
Medicine	679	36.8%	0.491	0.708 (0.577-0.869)	/	/
Business	470	43.2%	0.400	0.924 (0.737-1.157)	/	/
NSP = neck and shoulder pain; OR1= ORs after univariate logistic regression; OR2 = ORs in backward multivariable logistic regression model with all mentioned factors of NSP included; CI = confidence interval;

NSP prevalence and postures when using digital products

Our data show that there is a significant correlation between the different postures adopted when using digital devices and the prevalence of NSP (Table 2). We find that college students who use digital products at school with only a neck bending posture (Posture A) have the lowest prevalence of NSP (35.2%), which is significantly different from the students who used only a back bending posture (Posture B, OR1=1.297, 95%CI: 1.096-1.535, P=0.002; OR2=1.369, 95%CI: 1.135-1.651, P=0.011). However, the correlation between Posture A and both neck and back bending (Posture C) vanished when multivariable logistic regression was applied. Interestingly, using devices without back bending or head lowering is not a protective factor for NSP, though this was not significant. Moreover, whatever posture students choose when using digital devices, maintaining one single posture for more than 1 hour seems to be a risk factor for NSP. When at home, the students who used a smart phone while lying on their side in bed were more likely to have NSP. Meanwhile, maintaining one single posture for more than 2.0 hours increased the risk of NSP. Surprisingly, using digital devices in public transport vehicles seems not to be a risk factor, although there is a significant difference in NSP prevalence between “＜ 0.5 h” group and other groups.

Table 2 Postures to Use Digital Products and the Prevalence of NSP in College School Students

	N	% With NSP	P Value	OR (95%CI)	P Value	OR2 (95%CI)
Use digital devices at desk
Neck bending and back straight	1120	35.2%	/	1	/	1
Neck straight and back bending	1191	41.3%	0.002	1.297 (1.096-1.535)	0.011	1.369 (1.135-1.651)
Neck bending and back bending	937	44.1%	＜0.001	1.452 (1.216-1.735)	0.272	1.408 (1.102-1.800)
Neck straight and back straight	1600	37.3%	0.255	1.097 (0.935-1.286)	/	/
Use digital devices in bed
Doesn’t use	135	27.4%	/	1	/	1
Lie on one’s back	870	38.9%	0.011	1.683 (1.126-2.515)	0.125	1.579 (0.944-2.643)
Lie on one’s stomach	436	39.4%	0.012	1.726 (1.129-2.637)	0.062	1.845 (1.075-3.168)
Lie on one’s side	1936	42.6%	0.001	1.967 (1.333-2.901)	0.029	1.737 (1.056-2.855)
Semi-reclining posture	1002	35.9%	0.051	1.486 (0.998-2.211)	/	/
Sit in bed	369	34.7%	0.124	1.407 (0.911-2.173)	/	/
Keep one single posture at desk
＜1h	1406	32.6%	/	1
1-2h	1908	40.1%	＜0.001	1.384 (1.198-1.599)	0.005	1.252 (1.074-1.461)
2-3h	908	42.7%	＜0.001	1.539 (1.296-1.829)	0.012	1.277 (1.056-1.544)
3-4h	335	39.4%	0.019	1.324 (1.049-1.716)	0.782	1.038 (0.797-1.352)
＞4h	291	51.9%	＜0.001	2.225 (1.723-2.873)	0.004	1.513 (1.137-2.013)
Keep one single posture in bed
＜ 0.5 h	1214	34.70	/	1	/	1
0.5-1 h	2193	38.70	0.020	1.190 (1.028-1.377)	0.580	1.036 (0.856-1.255)
1 - 2 h	1082	39.60	0.016	1.233 (1.040-1.461)	0.824	0.941 (0.732-1.21)
＞ 2 h	355	55.20	＜0.001	2.322 (1.826-2.953)	0.001	1.269 (0.788-2.043)
Keep one single posture in public transport vehicles
＜ 0.5 h	2470	36.50	/	1	/	1
0.5-1 h	1774	41.70	＜0.001	1.243 (1.097-1.409)	0.068	1.079 (0.903-1.288)
1 - 2 h	457	41.40	0.048	1.228 (1.002-1.505)	0.594	0.976 (0.725-1.312)
＞ 2 h	144	46.50	0.016	1.515 (1.081-2.124)	0.914	0.866 (0.496-1.510)
NSP = neck and shoulder pain; OR1= ORs after univariate logistic regression; OR2 = ORs in backward multivariable logistic regression model with all mentioned factors of NSP included; CI = confidence interval;

Spinal flexion increased neck muscle activity

According to the analysis of the basic musculoskeletal model from the AnyBody 5.2 Modeling System, we can see that cervical and lumbar flexion can both increase total cervical muscle activity. The greater the curvature of cervical and lumbar flexion, the higher total cervical muscle activity. Total cervical muscle activity is lowest (8.33%) when cervical flexion is at 10 degree and lumbar flexion is at 0 degrees, which means the cervical muscle is most relaxed in this position. Total cervical muscle activity of only the cervical flexion position was lower than that same neck bending position with different lumbar flexion. When the lumbar flexion exceeds 30 degrees, slight cervical flexion has little effect on total cervical muscle activity (Fig. 3). The lower the spinal flexion, the lower the neck muscle activity. The results of the AnyBody analysis can explain the relationship between spinal flexion and neck muscle activity based on the skeletal and muscular mechanics of the spine, for which the data are similar to NSP prevalence and postures when using digital products.

NSP prevalence and the duration of use of digital products

During the survey, we also studied the duration of use of digital products (Table 3). Our data shows that there is an increasing prevalence of NSP among students who use desktop computers or laptops for more than 4 hours (OR=1.689, 95%CI: 1.336-2.135, P＜0.001), while the use of handheld digital devices (e.g., smart phones or iPads) for more than 4 hours in one day seems not to be a risk factor for NSP, as the significance vanished through multivariable regression. Meanwhile, our survey also shows that college students regard handheld digital devices as a necessity in their daily lives, and 33.8% of them reported being dependent on smart phones or iPads. Unfortunately, the data show that the students who are dependent on digital products are more likely to suffer from NSP (OR1=1.828, 95%CI: 1.493-2.237; P<0.001; OR2=1.503, 95%CI: 1.165-1.938, P<0.001).

Table 3 the Use Time of and Dependence on Digital Products and the Prevalence of NSP in College School Students

		N	% With NSP	P Value	OR (95%CI)	P Value	OR2 (95%CI)
The use time of handheld digital devices one day
＜4h		2989	36.5	/	1	/	1
≥4h		1859	43.4	<0.001	1.334(1.185-1.501)	0.384	0.900 (0.760-1.066)
The use time of computers one day
＜4h		4415	42.9%	/	1	/	1
≥4h		433	49.7%	<0.001	1.689(1.336-2.135)	<0.001	1.589 (1.245-2.028)
What do you regard handheld digital device as?
Just a social tool		576	30.70	/	1	/	1
Very important for me		2655	37.40	0.003	1.348 (1.110-1.636)	0.029	1.203 (0.963-1.504)
Dependence on them		1637	44.80	<0.001	1.828 (1.493-2.237)	<0.001	1.503 (1.165-1.938)
	NSP = neck and shoulder pain; OR1= ORs after univariate logistic regression; OR2 = ORs in backward multivariable logistic regression model with all mentioned factors of NSP included; CI = confidence interval;

This study is a regionally representative survey, conducted in Shanghai, China, investigating the prevalence of NSP and the impact of digital devices on NSP among college students in different majors. The results showed a high prevalence of NSP among college students (39.1%) in Shanghai, which is slightly higher than the findings of a study conducted in 2005 by Derek Smith[16] about Chinese medical students (for whom the prevalence of neck and shoulder pain was 33.8% and 21.7%, respectively), and also higher than we found in our previous research on Chinese adolescents aged 14-17 years (for whom the prevalence of NSP was 32.8%)[17]. Compared with similar studies in both Asian and non-Asian countries[5, 7, 18], the prevalence of NSP in the 18-24 year-old age group is 20-40%. Additionally, our survey covers a large number of undergraduates ranging from 18-22 years old in five common majors. Meanwhile, we also use more detailed definition on NSP and more stringent criteria to define NSP. Therefore, we expect our results to be more representative and compelling.

Consistent with other similar surveys[8], we also found that the prevalence of NSP among females is higher than among males (45.0% vs. 32.4%, OR=1.710, 95%CI: 1.521-1.923, P<0.001). There are several possible mechanisms that could explain this phenomenon. Firstly, females may have a lower pain threshold and experience particular hormonal changes throughout their lives [19]. Secondly, girls tend to be more sensitive to stress, which was found to be correlated with NSP[20]. Thirdly, females have a smaller skeletal system and a shorter reach distance than males, on average; thus, they may be required to adopt awkward postures more often, especially for configurations that manipulate the position of digital devices[21]. Moreover, there has been some discussion of whether differences in bone mass result in greater skeletal integrity in males than females, making females more susceptible to injury[22].

In this study, we have found that the use of digital devices is significantly correlated with the prevalence of NSP among college students, which is consistent with other similar studies[6]. With the development of cyber networks and the spread of digital products, people around the world are spending more and more time using digital devices; this is especially true for adolescents and young adults[2]. According to our previous study in 2013, the increasing time spent on personal laptops and handheld digital devices such as iPads was a risk factor for musculoskeletal disorders among adolescents in Shanghai, China[23]. In this study, we also find that among young adults, more time spent engaged with computers and smart phones has a significant correlation with NSP prevalence, which can be reflected by NSP prevalence among different college majors (e.g., students majoring in arts and business need to devote more time to research on their digital devices, while students majoring in science, engineering and medicine have to arrange more time for practical work and may spend less time on devices), and we further realize that remaining in a single posture for a long time when using digital devices may also be a risk factor of NSP. We believe that digital device users sometimes remain in static postures while playing games, reading digital books or searching for information for long periods of time; thus, as a recent study showed, a static posture can increase bone and muscle stress around the waist and neck and is closely related to NSP[24]. According to the result of AnyBody, we find that the spine (including the neck and lumbar) leaning forward caused neck muscle activity to increase. Relatedly, staying in a single posture for a long time can lead to increased neck muscle activity, especially to keep the spine leaning forward. Prolonged neck muscle activity can increase NSP prevalence. Interestingly, while our cross sectional study found that students who adopt a back-bending posture are more likely to suffer from NSP, we speculate that this is due to the waist and back muscles not contracting to support and protect the spinal skeleton. Bio-mechanical measurements should be used to study the protective effect of waist and back muscles on NSP prevalence.

There are some limitations for this study. First, this study was limited by the fact that it relied on participant memory of events that occurred in the past. Previous studies have shown that people tend to overestimate durations in self-reported data[25]. Consequently, it could have been difficult for respondents to estimate precisely and accurately how long they spend in each configuration. The limitations of this survey originate from the following perspectives. Second, as a cross-sectional study, the present investigation was only focused on correlation rather than causation. Third, only a limited number of college school in Shanghai were surveyed; thus, our results might not be reflective of other regions. However, our investigation was based on a large random sample (6,000) to reduce bias and ensure it was representative. Fourth, the questionnaire was designed based on the relevant literature[17]. While the questions were modified to reflect the characteristics of Chinese college students, which had been used without a complete validation through a publication in a peer review journal. Finally, students suffering from NSP might be more willing to complete this questionnaire than other students, which could result in a certain degree of respondent bias[26].

In summary, the prevalence of NSP among college students in Shanghai, China is 39.1%, which is closely correlated to gender, inappropriate posture and the use of digital devices for long periods of time. We recommend that college students reduce unnecessary time spent on digital devices, adopt appropriate postures while using them and interrupt their work with a break or exercise every 0.5-1 hour such as McKenzie exercise and Kinesio taping[27] for the prevention of NSP. Appropriate posture should avoid cervical and lumbar flexion. In addition, individualized digital device use should be possible given the different characteristics of college students. Weight of digital device (mobile phones/tablets) may also play an important role in determining prevalence of NSP, which will be considered in future research. Cohort studies to explore the causation between various candidate risk factors and young adult NSP are needed and are in progress.

MSP: Musculoskeletal Pain; NSP: Neck and Shoulder Pain; MSD: Musculoskeletal Discomfort; KMO: Kaiser-Mayer-Olkin; OR: Odds Ratio; CI: Confidence Intervals; MVC: Maximal Voluntary Contractions.

Acknowledgements

The authors acknowledge the college students who participated in this research.

Authors’ contributions

All authors contributed to the study conception and design. XY, GD and GX were the principal investigator. YL, XB and YX performed the preparation and analysis. XWand CL distributed and collected questionnaires data. The first draft of the manuscript was written by WW, YZ and YL. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

This project was supported by the National Key R and D Program of China (2020YFC2008404), the National Natural Science Foundation of China (No. 82102605), Post Graduation Innovation subject of Shanghai Jiao Tong University (BXJ201734); Construction of Trauma Center of Shanghai first people's hospital (No.1304).

Availability of data and materials

All data relevant to the study are included in the article. Please contact the corresponding author if additional information is required.

Ethics approval and consent to participate

The study protocol was reviewed and approved by the Ethics Committee of Shanghai General Hospital, Shanghai Jiaotong University, School of Medicine (Approval No. 2017KY212).

Consent for publication

Not applicable.

Competing interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author details

¹ Department of Orthopaedics, Second Affiliated Hospital of Naval Medical University, NO.415 Fengyang Road, Shanghai, P.R.China. ² Department of Orthopedics, Second Affiliated Hospital of Zhejiang University, NO.88 Jiefang Road, Hangzhou, P.R.China. ³ Shanghai Jiaotong University School of Medicine, NO.227 South Chongqing Road, Shanghai, P.R.China. ⁴Trauma Center, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, NO.650 Xin Songjiang Road, Shanghai, P.R.China. ⁵Department of Orthopaedics, Tongren Hospital, Shanghai Jiaotong University, No. 1111, Xianxia Road, Shanghai, P.R. China.

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Correlation analysis between the use of digital devices and neck and shoulder pain among college students and lifestyle education

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