{"paper_id":"38805c07-2ba8-4e36-bc54-aa3b6d675af3","body_text":"The Mediating Role of Perceived Stress in the Relationship between Involvement and Academic Performance: A Study on Medical Students | 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 The Mediating Role of Perceived Stress in the Relationship between Involvement and Academic Performance: A Study on Medical Students Yu Jian, Jinping Zhou, Li Pan, Xinyi Liu, Nianchun Shan, Ziju Zhou, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6730157/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background: In contemporary educational settings, \"involution\" has become a core issue impacting students' mental health and academic development. This study aims to explore how perceived academic involution indirectly affects academic performance through perceived stress, and to examine the moderating roles of social support and learning engagement. Methods: A cross-sectional survey combined with a longitudinal study was conducted among 393 third-year medical students. Data were collected using validated scales for perceived involution, perceived stress, coping strategies, social support, and learning engagement. Academic performance was measured via standardized exam scores over four semesters. Statistical analyses included descriptive statistics, independent sample t-tests, binary logistic regression, and moderated mediation modeling using Mplus 8.3. Results: The study reveals that perceived involution indirectly undermines academic performance by increasing perceived stress. Social support and learning engagement significantly moderate this relationship, with family support and peer support playing crucial roles in buffering the negative impact of involution perception on stress and enhancing academic performance. Learning engagement also directly promotes academic achievement. Conclusions: The findings challenge the traditional \"scarcity mindset trap\" assumption in involution research and propose a \"vigilance-strategy transformation\" framework. This study offers insights for developing targeted psychological interventions to mitigate the negative effects of academic involution and provides an evidence-based foundation for mental health support strategies in the context of post-pandemic blended teaching. Academic involution Perceived stress Social support Learning engagement Medical education Figures Figure 1 Figure 2 Introduction In contemporary educational environments, the phenomenon of \"involution\" has emerged as a core issue influencing students' mental health and academic development. The excessive competitive pressures spawned by involution not only lead to student burnout but also have a profound negative impact on academic performance through maladaptive behavioral patterns[ 1] . Existing research indicates that coping strategies adopted by individuals under stress play a crucial mediating role between stressors and outcome variables[ 2][3] . For instance, promotion-focused coping strategies, such as proactive planning and seeking support, can buffer the negative effects of stress on mental health, whereas prevention-focused coping strategies, such as avoidance and emotional suppression, may exacerbate the negative association between stress and academic performance[ 4] . Neurological studies further reveal that specific neuroregulatory systems, such as leucokinin neuropeptides, can promote specific memory expression by modulating dopaminergic neuronal activity under motivational states[ 5][6] . This suggests that the selection of coping strategies under stress may be regulated by similar neurobiological foundations, thereby influencing academic performance. However, the mechanisms underlying coping strategy selection among students under involutionary pressures and their mediating pathways to academic achievement still require systematic validation. Simultaneously, social support, as an important environmental resource, may influence the final outcome by moderating the interactive relationship between stress perception and coping strategies[ 7][8] . For example, emotional and instrumental support from teachers, peers, or family members can enhance students' capacity to employ promotion-focused coping strategies, thereby breaking the vicious cycle of \"stress-negative coping-academic impairment.\" Although this moderating pathway has been partially verified in studies of healthcare workers coping with occupational stress, its applicability and boundaries in educational settings remain to be explored. Additionally, the promoting effect of a school's cultural diversity atmosphere on learning engagement has been confirmed in meta-analytic studies[ 9][10] . Research indicates that multicultural environments that promote intergroup contact can significantly enhance students' academic motivation and classroom participation, providing a cross-cultural perspective for understanding the moderating role of learning engagement in involutionary contexts. Particularly in the context of the COVID-19 pandemic, where blended teaching has become the norm, the forms and efficacy of social support may have undergone structural changes, necessitating a re-examination of their moderating mechanisms in the context of the new educational ecology[ 11][12] . This study aims to construct a mediated effect model of \"perceived involution-perceived stress-academic performance\" and incorporate social support and learning engagement as moderating variables. The study primarily addresses the following research questions: (1) To elucidate the specific pathways through which different dimensions of perceived involution affect academic achievement via perceived stress; (2) To examine the multiple roles of social support and learning engagement in the stress perception stage (moderating the relationship between perceived involution and perceived stress) and the strategy implementation stage (moderating the relationship between perceived stress and academic performance, as well as the relationship between perceived involution and academic performance)[ 13] ; (3) To explore the potential influence of individual difference variables, such as gender and academic background, on the aforementioned mechanisms. The results of this study can provide a theoretical basis for constructing an education support system based on positive psychological interventions and design targeted strategies to mitigate the negative effects of academic involution. Methods Study Design and Participants This study employed a combination of cross-sectional surveys and longitudinal research to construct a mediated effect model of \"perceived involution-perceived stress-academic performance\" and to examine the moderating effects of social support and learning engagement. The study participants included 393 third-year medical students from a medical college, comprising 123 males and 270 females with an average age of 20.41 ± 0.92 years. The participants represented various majors, including radiology, laboratory medicine, stomatology, and clinical medicine, with 66.16% of the students originating from rural areas. The selection of study participants was representative and adequately reflected the overall characteristics of third-year medical students at the college. The study was approved by the ethics review board (approval number: ****), and all participants provided informed consent. Measures Perceived Involvement Scale : The 4-dimensional scale developed by Zhang et al[ 14] . (2024) was used to assess perceived involution, which includes psychological stress, social norms, competitive behavior, and resource scarcity. The scale consists of 17 items scored on a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree). The scale demonstrated good reliability (α = 0.75-0.85) and effectively evaluated students' perceptions of involution. For example, items such as \"most people around me complete tasks beyond the required amount\" precisely reflected the manifestations of involution. Perceived Stress Scale (PSS-10) : The Perceived Stress Scale (Cohen et al., 1983)[ 15] was used to assess perceived stress[ 16] . This scale comprises 10 items scored on a 4-point Likert scale (0 = never, 3 = almost always), including reverse-scored items (e.g., \"I feel that I can control the irritations in my life\"). The internal consistency reliability of the scale was 0.78, effectively evaluating students' perceived stress levels over the past month. Coping Strategies Scale : The Brief COPE scale (Carver, 1997)[ 17] was adapted to assess coping strategies. The scale includes 14 items scored on a 5-point Likert scale (1 = never, 5 = always). It differentiates between promotion-focused coping (e.g., proactive planning, seeking support) and prevention-focused coping (e.g., avoidance, emotional suppression), evaluating students' coping style choices under stress. Social Support Scale : The revised version of the Perceived Social Support Scale (PSSS) by Jiang (1999)[ 18] was used, which includes 12 items scored on a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree). The scale is divided into three dimensions: family support, friend support, and other support. The internal consistency reliability was 0.88, effectively assessing students' perceived levels of social support. Learning Engagement Scale : The Chinese version of the Utrecht Work Engagement Scale for Students (UWES-S) by Fang (2008)[ 19] was used. The scale includes 17 items scored on a 7-point Likert scale (1 = never, 7 = always), divided into three dimensions: vigor, dedication, and absorption. The internal consistency reliability ranged from 0.82 to 0.95, comprehensively evaluating students' engagement in the learning process. Academic Performance : Standardized examination scores over four consecutive semesters were collected. The K-means clustering analysis was used to classify students into two groups: the \"stable high-score group\" (n = 294) and the \"comeback group\" (n = 99). This clustering method effectively revealed the dynamic changes in students' academic performance, providing strong support for subsequent analyses. Quality Control Questionnaires were administered using a unified set of instructions to ensure consistent understanding among participants. After collection, questionnaires with patterned responses (e.g., straight-lining, repetitive answering) were excluded to ensure data authenticity and reliability. Reliability tests were conducted for all scales, ensuring that Cronbach's α coefficients were all > 0.70, indicating good internal consistency. Descriptive statistical analyses were also performed to check for outliers or skewed distributions, ensuring data quality met the requirements for analysis. Data Analysis SPSS 26.0 was used for descriptive statistics, independent samples t-tests, and binary logistic regression analyses to assess differences and associations among variables. Mplus 8.3 was further employed to construct the moderated mediation model, with the Bootstrap method (5,000 resamples) used to test the significance of effects. This approach effectively revealed the complex relationships between perceived involution, perceived stress, social support, learning engagement, and academic performance, and validated the existence of moderated mediation effects. The model was constructed in stages to clearly demonstrate the dynamic interactions among variables. Results Sample Characteristics A total of 393 third-year medical students were included in this study, comprising 123 males (31.30%) and 270 females (68.70%) with a mean age of 20.405 ± 0.921 years. Among the participants, 101 (25.70%) held class leadership positions, 42 (10.69%) were from urban areas, 91 (23.16%) from towns, and 260 (66.16%) from rural areas. The distribution across majors included 139 students (35.37%) in radiology, 96 (24.43%) in laboratory medicine, and 158 (40.20%) in stomatology and other clinical specialties. Regarding family structure, 350 participants (89.06%) had parents with normal marital status, while 43 (10.94%) had parents who were divorced, separated, or widowed. There were 49 only children (12.47%) and 344 non-only children (87.53%). In terms of gender differences, no statistically significant differences were observed between males and females in perceived stress, coping strategies, perceived involution, social support, or learning engagement (p > 0.05), indicating limited influence of gender on these variables (Table 1). Academic Performance Cluster Analysis Students were categorized into two clusters using K-means clustering analysis based on standardized exam scores over four semesters: the \"stable high-score group\" (n = 294) and the \"comeback group\" (n = 99). The stable high-score group exhibited consistently high academic performance across semesters with a standard deviation less than 200, indicating minimal fluctuations. In contrast, the comeback group showed a significant improvement from extremely low scores in the first semester (394.80 ± 79.10) to a substantial increase by the fourth semester (1117.60 ± 103.76), demonstrating a marked upward trajectory. The mean scores and standard deviations for each semester, along with the results of variance analysis, are presented in Table 2, with significant differences between the two groups (p < 0.01). Factors Influencing Academic Comeback Binary logistic regression analysis was conducted to identify factors associated with academic comeback. The results indicated that perceived stress was a significant inhibitor of academic comeback, with each unit increase in stress score reducing the odds of academic comeback by 7.0% (OR = 0.930, p = 0.034). Conversely, resource competition vigilance positively influenced academic comeback, with each unit increase in vigilance score raising the odds of academic comeback by 9.1% (OR = 1.091, p = 0.008). Learning engagement also effectively countered involution, enhancing the likelihood of academic comeback (OR = 1.018, p = 0.049). Holding a class leadership position may indirectly promote academic recovery through increased responsibility or resource acquisition, although this requires validation with a larger sample (OR = 1.623, p = 0.104). Other variables, including parents' marital status, major, gender, age, and place of residence, did not significantly influence academic comeback. The regression coefficients, standard errors, z-values, Wald χ² values, p-values, and 95% confidence intervals for each variable are presented in Table 3. The model's explanatory power was limited (McFadden R² = 0.048), suggesting the need to incorporate additional variables such as academic foundation in future studies to improve predictive validity. Moderated Mediation Effect Model Analysis A moderated mediation effect model was constructed to examine the relationships between perceived involution, perceived stress, academic performance, social support, and learning engagement(figure 1). The model explores how these dimensions influence academic performance through perceived stress, and how social support and learning engagement moderate these relationships.The results demonstrated that social support and learning engagement significantly moderated the relationship between perceived involution and perceived stress, as well as between perceived stress and academic performance. Specifically, social support and learning engagement alleviated the positive impact of perceived involution on perceived stress and weakened the negative influence of perceived stress on academic performance. Learning engagement also directly enhanced academic performance, highlighting its protective role in countering involutionary pressures (Figure 2). It also examines how social support and learning engagement moderate these relationships, potentially buffering the negative impacts of stress on academic outcomes. Discussion This study constructed a mediated effect model of \"perceived involution-perceived stress-academic performance\" to elucidate the complex mechanisms underlying educational involution's impact on students' academic development. The findings indicate that perceived involution indirectly undermines academic performance by exacerbating perceived stress, while resource competition vigilance and learning engagement emerge as key protective factors driving academic comeback. Social support (especially from family and peers) and learning engagement (dimensions of vigor and dedication) exhibit dual moderating effects, buffering the positive impact of perceived involution on stress and weakening the negative association between stress and academic performance. Notably, gender and academic background did not significantly influence coping strategy selection or perceived involution, contrasting with prior stereotypical views on gender roles and stress responses and suggesting that involutionary pressures may have universal characteristics across groups[ 20][21] . Adaptive Transformation of Resource Competition Vigilance Resource competition vigilance (OR = 1.091, p = 0.008) significantly promotes academic comeback through cognitive reappraisal (e.g., goal decomposition and strategy optimization), challenging the traditional \"scarcity mindset trap\" assumption in involution research[ 22] . Specifically, when competition intensity is below an individual's cognitive load threshold (e.g., study duration ≤ 8 hours/day), vigilance can activate dopaminergic motivational pathways, driving students to transform perceptions of resource scarcity into structured learning strategies[ 23][24] . This mechanism indicates that under moderate competitive conditions, individual vigilance can be converted into positive learning motivation, thereby enhancing academic performance. Dual-Stage Dynamic Moderation of Social Support Contrary to studies on medical professionals where social support primarily functions in stress alleviation, this study found that social support plays a moderating role in both stress perception and strategy implementation stages[ 25] . Family support (β = 0.24, p < 0.01) significantly weakens the association between perceived involution and stress in the perception stage (β = -0.15), while peer support enhances coping efficacy in the implementation stage (β = 0.19), indirectly improving academic performance. This finding validates the \"resource buffering mechanism\" proposed by Freak-Poli et al[ 26][27] . The dual role likely stems from the continuous nature of support systems in educational settings—teacher guidance, peer collaboration, and family emotional support form a \"stress buffering-strategy empowerment\" complex mechanism, closely related to the development of online support platforms in the context of blended teaching post-COVID-19 [12] . This highlights the importance of multidimensional social support in educational environments and suggests that future research and practice should focus on the synergistic effects of family, peer, and teacher support. Motivational-Behavioral Synergistic Effects of Learning Engagement This study confirmed that learning engagement not only directly promotes academic performance but also indirectly improves grades by enhancing stress-coping efficacy, together forming a psychological resilience system against involutionary erosion. Learning engagement directly counteracts negative stress impacts through its vigor dimension (β = 0.24) and inhibits cognitive distraction through its dedication dimension (β = 0.27). This aligns with the \"feedback design for enhancing academic emotions\" mechanism, where high-engagement students' \"error summarization strategies\" delay knowledge devaluation, breaking the \"involution trap\" of low-effort, high-input learning[ 28] . This finding underscores the crucial role of learning engagement in coping with academic stress and suggests that educators should focus on students' engagement levels and design effective teaching strategies to enhance engagement[ 29][30] . Limitations of This Study This study has several limitations. First, the sample was drawn from a single medical college, limiting the generalizability of the findings to other educational settings. Future research should include diverse institutions to validate these results across different academic contexts. Second, the cross-sectional design prevents conclusions about causality and the dynamic interplay between perceived involution and stress. Longitudinal studies and neuroimaging techniques could elucidate the temporal sequences and neural mechanisms involved. Third, reliance on self-reported measures introduces potential biases. Future studies should incorporate multimodal approaches, combining self-reports with objective behavioral and physiological data, to enhance the robustness of the findings. Addressing these limitations will strengthen the validity and applicability of research on educational involution and its impact on student outcomes. Conclusions This study constructed a mediated effect model of \"perceived involution-perceived stress-academic performance\" to elucidate the core mechanisms underlying educational involution's impact on college students' academic development. The findings challenge the traditional \"unidirectional depletion\" assumption in involution research and propose a \"vigilance-strategy transformation\" framework, emphasizing that individuals can convert competitive pressures into goal-oriented behaviors through cognitive reappraisal in high-stress environments. This study provides a theoretical framework for mitigating educational involution through \"individual-environment-technology\" collaborative interventions, emphasizing a shift from \"passive adaptation\" to \"active empowerment\" in educational ecology reconstruction. It also offers empirical evidence for mental health support strategies in post-pandemic blended teaching contexts. Abbreviations PSS-10: Perceived Stress Scale-10. UWES-S: Utrecht Work Engagement Scale-Student version. McFadden R²: McFadden's pseudo R-squared. Declarations Acknowledgements The authors would like to thank the participating students and staff for their support. Competing Interests The authors declare no competing interests. Authors' Contributions All authors contributed to the study design, data collection, and analysis. The first author drafted the manuscript, and all authors reviewed and approved the final version. Funding No. Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Ethical Approval and Consent to Participate This study was approved by the ethical committee of Xiangya Hospital Central South University and was conducted in accordance with the ethical standards of the responsible committees for human experimentation and with the Helsinki Declaration of 1975. All of participants were asked to provide written informed consent before data collection.Clinical trial number：not applicable. References Zhang, Y., Zhang, Y., Ng, T. W. H., & Lam, S. S. K. (2019). 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Self-regulatory learning theory as a lens on how undergraduate and postgraduate learners respond to feedback: A BEME scoping review: BEME Guide No. 66. Medical teacher, 44(1), 3–18. https://doi.org/10.1080/0142159X.2021.1970732 Graesser, A. C., Sabatini, J. P., & Li, H. (2022). Educational Psychology Is Evolving to Accommodate Technology, Multiple Disciplines, and Twenty-First-Century Skills. Annual review of psychology, 73, 547–574. https://doi.org/10.1146/annurev-psych-020821-113042 Jin, J., & Bridges, S. M. (2014). Educational technologies in problem-based learning in health sciences education: a systematic review. Journal of medical Internet research, 16(12), e251. https://doi.org/10.2196/jmir.3240 Tables Table 1: General characteristics of the study participants. Gender t/χ 2 p Male(n=123) Female(n=270) Age (years old) 20.42±0.87 20.40±0.95 0.264 0.792 perceived pressure score 19.81±4.65 19.89±3.41 -0.154 0.878 Coping style total score 42.98±8.66 41.47±6.24 1.738 0.084 Internal volume perception total 72.91±12.74 71.77±9.79 0.881 0.379 Internal drive anxiety intensity 18.50±3.72 18.50±2.72 0.021 0.983 Implicit rules are internalized 17.28±4.88 16.83±4.23 0.949 0.343 Irrational competitive input 23.55±5.85 23.17±4.62 0.646 0.519 Resource competition alertness 13.57±5.32 13.28±3.93 0.537 0.592 Total perceived Social support 59.57±13.12 58.46±11.06 0.815 0.416 Family support 20.93±4.91 20.08±4.19 1.677 0.095 Friend support 19.74±4.81 20.05±4.12 -0.615 0.539 Others support 18.89±4.78 18.33±4.32 1.153 0.250 Total learning engagement 76.50±20.51 78.04±16.82 -0.783 0.434 Invigoration 25.71±7.73 25.91±6.40 -0.269 0.788 dedicate 23.88±6.54 24.17±5.39 -0.439 0.661 Focus 26.92±7.37 27.96±6.19 -1.454 0.147 First Semester score 817.60±236.20 821.33±278.06 -0.137 0.891 Second Semester score 1165.36±125.68 1196.66±122.69 -2.328 0.020* Third Semester score 933.48±154.27 1025.77±189.11 -5.112 0.000** Fourth Semester score 959.77±159.01 1050.74±171.03 -5.134 0.000** Average score 969.05±120.68 1023.63±134.59 -3.847 0.000** Only child n (%) is 25(20.33) 24(8.89) 10.127 0.001** no 98(79.67) 246(91.11) Parental marital status n (%) normal 112(91.06) 238(88.15) 0.734 0.392 Divorced/separated/widowed 11(8.94) 32(11.85) Residence n (%) city 14(11.38) 28(10.37) 5.362 0.069 towns 37(30.08) 54(20.00) village 72(58.54) 188(69.63) Specialty n (%) image 63(51.22) 76(28.15) 19.685 0.000** inspect 23(18.70) 73(27.04) Clinical and oral 37(30.08) 121(44.81) Class leader n (%) is 30(24.39) 71(26.30) 0.161 0.688 no 93(75.61) 199(73.70) Table 2: Results of cluster analysis for academic performance over four semesters variance analysis of clustering categories (mean±standard deviation) F p stable high-score group (n = 294) comeback group(n=294) The first term 963.40±101.99 394.80±79.10 2557.428 0.000** The second term 1216.35±118.84 1099.29±96.19 78.663 0.000** The third term 1035.79±194.15 881.36±66.40 60.167 0.000** The fourth term 990.17±179.07 1117.60±103.76 44.994 0.000** *p<0.05， **p<0.01. Table 3: Binary logistic regression analysis of factors influencing academic performance improvement Regression coefficient SD Z value Waldχ 2 p OR 95% CI of OR Parents' marital status 0.416 0.370 1.122 1.260 0.262 1.515 0.733 ~ 3.131 profession -0.008 0.147 -0.056 0.003 0.955 0.992 0.744 ~ 1.322 sex 0.385 0.283 1.356 1.840 0.175 1.469 0.843 ~ 2.560 age 0.120 0.125 0.958 0.919 0.338 1.127 0.882 ~ 1.441 Whether to serve as class leader 0.484 0.297 1.627 2.648 0.104 1.623 0.906 ~ 2.907 Place of Residence -0.029 0.192 -0.153 0.023 0.879 0.971 0.666 ~ 1.416 No Only child -0.031 0.391 -0.080 0.006 0.936 0.969 0.451 ~ 2.085 Total perceived stress score -0.073 0.034 -2.117 4.481 0.034 0.930 0.869 ~ 0.995 Total score of learning engagement 0.018 0.009 1.965 3.860 0.049 1.018 1.000 ~ 1.037 Perceived social support score -0.000 0.014 -0.010 0.000 0.992 1.000 0.973 ~ 1.027 Coping style score 0.003 0.021 0.147 0.022 0.883 1.003 0.963 ~ 1.044 Internal drive anxiety intensity -0.013 0.046 -0.273 0.075 0.785 0.987 0.902 ~ 1.081 Implicit rules are internalized -0.005 0.034 -0.156 0.024 0.876 0.995 0.931 ~ 1.063 Irrational competitive input -0.010 0.032 -0.316 0.100 0.752 0.990 0.929 ~ 1.055 Resource competition alertness 0.087 0.033 2.650 7.020 0.008 1.091 1.023 ~ 1.164 intercept -5.690 2.983 -1.908 3.640 0.056 0.003 0.000 ~ 1.168 Note: Dependent variable = Whether the grade is reversed. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 13 May, 2026 Reviewers agreed at journal 09 May, 2026 Reviewers agreed at journal 08 May, 2026 Reviews received at journal 07 May, 2026 Reviewers agreed at journal 07 May, 2026 Reviews received at journal 26 Jun, 2025 Reviewers agreed at journal 25 Jun, 2025 Reviewers invited by journal 24 Jun, 2025 Editor invited by journal 28 May, 2025 Editor assigned by journal 27 May, 2025 Submission checks completed at journal 27 May, 2025 First submitted to journal 23 May, 2025 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. 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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-6730157\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":476098284,\"identity\":\"34455cc4-e2c5-46e1-a7c9-679f4cbd202f\",\"order_by\":0,\"name\":\"Yu Jian\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Central South University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Yu\",\"middleName\":\"\",\"lastName\":\"Jian\",\"suffix\":\"\"},{\"id\":476098285,\"identity\":\"44b02c5c-7d72-4c5d-bcd1-6ddbe73f5c33\",\"order_by\":1,\"name\":\"Jinping 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Zhou\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYFACHiAuYEjgh/CYidViYJAg2UCyFoMDxGqRn5F78MEPgz95xsePP5NgqLBObGA/ewCvFsYZecmGPQYGxWZncswkGM6kJzbw5CXg1cIsDVTJY2CQuO0GD5sEY9vhxAYgF68WNukc859/gFo2z2B/JsH4jwgtPEBbmEG2bJBgMJNgbCBCi4T8G2NpGQPjxBlncowtEo6lG7fx5ODXIt9zxvDjmwq5xP724w9vfKixlu1nP4NfCypIAPmOBPWjYBSMglEwCnAAAM+2PgUzWNOXAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"Central South University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Wei\",\"middleName\":\"\",\"lastName\":\"Zhou\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-05-23 07:08:20\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-6730157/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-6730157/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":85488429,\"identity\":\"492497fd-444d-4923-bf2b-09992ed90a80\",\"added_by\":\"auto\",\"created_at\":\"2025-06-26 12:30:27\",\"extension\":\"jpg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":31922,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eModerated mediation model of perceived involution, perceived stress, social support,learning engagement and academic performance.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6730157/v1/af52a5ca444e5e0651e6bd34.jpg\"},{\"id\":85488428,\"identity\":\"f6ac60b7-bbd7-42b0-add7-14cef2448197\",\"added_by\":\"auto\",\"created_at\":\"2025-06-26 12:30:27\",\"extension\":\"jpg\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":69692,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe model investigates the pathways through which internal drive anxiety intensity (A), internalization of implicit rules (B), irrational competitive input (C), and resource competition alertness (D) affect academic performance by influencing perceived stress.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6730157/v1/dbad9f10c2001e39c69c6341.jpg\"},{\"id\":85489184,\"identity\":\"fa4b583d-c65d-4687-8096-9f2ce3436f33\",\"added_by\":\"auto\",\"created_at\":\"2025-06-26 12:38:28\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":894824,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6730157/v1/49349dd1-2d7c-4a10-a1ca-59c6995127ca.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"The Mediating Role of Perceived Stress in the Relationship between Involvement and Academic Performance: A Study on Medical Students\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eIn contemporary educational environments, the phenomenon of \\u0026quot;involution\\u0026quot; has emerged as a core issue influencing students\\u0026apos; mental health and academic development. The excessive competitive pressures spawned by involution not only lead to student burnout but also have a profound negative impact on academic performance through maladaptive behavioral patterns[\\u003csup\\u003e1]\\u003c/sup\\u003e. Existing research indicates that coping strategies adopted by individuals under stress play a crucial mediating role between stressors and outcome variables[\\u003csup\\u003e2][3]\\u003c/sup\\u003e. For instance, promotion-focused coping strategies, such as proactive planning and seeking support, can buffer the negative effects of stress on mental health, whereas prevention-focused coping strategies, such as avoidance and emotional suppression, may exacerbate the negative association between stress and academic performance[\\u003csup\\u003e4]\\u003c/sup\\u003e. Neurological studies further reveal that specific neuroregulatory systems, such as leucokinin neuropeptides, can promote specific memory expression by modulating dopaminergic neuronal activity under motivational states[\\u003csup\\u003e5][6]\\u003c/sup\\u003e. This suggests that the selection of coping strategies under stress may be regulated by similar neurobiological foundations, thereby influencing academic performance. However, the mechanisms underlying coping strategy selection among students under involutionary pressures and their mediating pathways to academic achievement still require systematic validation.\\u003c/p\\u003e\\n\\u003cp\\u003eSimultaneously, social support, as an important environmental resource, may influence the final outcome by moderating the interactive relationship between stress perception and coping strategies[\\u003csup\\u003e7][8]\\u003c/sup\\u003e. For example, emotional and instrumental support from teachers, peers, or family members can enhance students\\u0026apos; capacity to employ promotion-focused coping strategies, thereby breaking the vicious cycle of \\u0026quot;stress-negative coping-academic impairment.\\u0026quot; Although this moderating pathway has been partially verified in studies of healthcare workers coping with occupational stress, its applicability and boundaries in educational settings remain to be explored. Additionally, the promoting effect of a school\\u0026apos;s cultural diversity atmosphere on learning engagement has been confirmed in meta-analytic studies[\\u003csup\\u003e9][10]\\u003c/sup\\u003e. Research indicates that multicultural environments that promote intergroup contact can significantly enhance students\\u0026apos; academic motivation and classroom participation, providing a cross-cultural perspective for understanding the moderating role of learning engagement in involutionary contexts. Particularly in the context of the COVID-19 pandemic, where blended teaching has become the norm, the forms and efficacy of social support may have undergone structural changes, necessitating a re-examination of their moderating mechanisms in the context of the new educational ecology[\\u003csup\\u003e11][12]\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003eThis study aims to construct a mediated effect model of \\u0026quot;perceived involution-perceived stress-academic performance\\u0026quot; and incorporate social support and learning engagement as moderating variables. The study primarily addresses the following research questions: (1) To elucidate the specific pathways through which different dimensions of perceived involution affect academic achievement via perceived stress; (2) To examine the multiple roles of social support and learning engagement in the stress perception stage (moderating the relationship between perceived involution and perceived stress) and the strategy implementation stage (moderating the relationship between perceived stress and academic performance, as well as the relationship between perceived involution and academic performance)[\\u003csup\\u003e13]\\u003c/sup\\u003e; (3) To explore the potential influence of individual difference variables, such as gender and academic background, on the aforementioned mechanisms. The results of this study can provide a theoretical basis for constructing an education support system based on positive psychological interventions and design targeted strategies to mitigate the negative effects of academic involution.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003ch3\\u003eStudy Design and Participants\\u003c/h3\\u003e\\n\\u003cp\\u003eThis study employed a combination of cross-sectional surveys and longitudinal research to construct a mediated effect model of \\u0026quot;perceived involution-perceived stress-academic performance\\u0026quot; and to examine the moderating effects of social support and learning engagement. The study participants included 393 third-year medical students from a medical college, comprising 123 males and 270 females with an average age of 20.41 \\u0026plusmn; 0.92 years. The participants represented various majors, including radiology, laboratory medicine, stomatology, and clinical medicine, with 66.16% of the students originating from rural areas. The selection of study participants was representative and adequately reflected the overall characteristics of third-year medical students at the college. The study was approved by the ethics review board (approval number: ****), and all participants provided informed consent.\\u003c/p\\u003e\\n\\u003ch3\\u003eMeasures\\u003c/h3\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePerceived Involvement Scale\\u003c/strong\\u003e: The 4-dimensional scale developed by Zhang et al[\\u003csup\\u003e14]\\u003c/sup\\u003e. (2024) was used to assess perceived involution, which includes psychological stress, social norms, competitive behavior, and resource scarcity. The scale consists of 17 items scored on a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree). The scale demonstrated good reliability (\\u0026alpha; = 0.75-0.85) and effectively evaluated students\\u0026apos; perceptions of involution. For example, items such as \\u0026quot;most people around me complete tasks beyond the required amount\\u0026quot; precisely reflected the manifestations of involution.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePerceived Stress Scale (PSS-10)\\u003c/strong\\u003e: The Perceived Stress Scale (Cohen et al., 1983)[\\u003csup\\u003e15]\\u003c/sup\\u003e was used to assess perceived stress[\\u003csup\\u003e16]\\u003c/sup\\u003e. This scale comprises 10 items scored on a 4-point Likert scale (0 = never, 3 = almost always), including reverse-scored items (e.g., \\u0026quot;I feel that I can control the irritations in my life\\u0026quot;). The internal consistency reliability of the scale was 0.78, effectively evaluating students\\u0026apos; perceived stress levels over the past month.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCoping Strategies Scale\\u003c/strong\\u003e: The Brief COPE scale (Carver, 1997)[\\u003csup\\u003e17]\\u003c/sup\\u003e was adapted to assess coping strategies. The scale includes 14 items scored on a 5-point Likert scale (1 = never, 5 = always). It differentiates between promotion-focused coping (e.g., proactive planning, seeking support) and prevention-focused coping (e.g., avoidance, emotional suppression), evaluating students\\u0026apos; coping style choices under stress.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSocial Support Scale\\u003c/strong\\u003e: The revised version of the Perceived Social Support Scale (PSSS) by Jiang (1999)[\\u003csup\\u003e18]\\u003c/sup\\u003e was used, which includes 12 items scored on a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree). The scale is divided into three dimensions: family support, friend support, and other support. The internal consistency reliability was 0.88, effectively assessing students\\u0026apos; perceived levels of social support.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eLearning Engagement Scale\\u003c/strong\\u003e: The Chinese version of the Utrecht Work Engagement Scale for Students (UWES-S) by Fang (2008)[\\u003csup\\u003e19]\\u003c/sup\\u003e was used. The scale includes 17 items scored on a 7-point Likert scale (1 = never, 7 = always), divided into three dimensions: vigor, dedication, and absorption. The internal consistency reliability ranged from 0.82 to 0.95, comprehensively evaluating students\\u0026apos; engagement in the learning process.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcademic Performance\\u003c/strong\\u003e: Standardized examination scores over four consecutive semesters were collected. The K-means clustering analysis was used to classify students into two groups: the \\u0026quot;stable high-score group\\u0026quot; (n = 294) and the \\u0026quot;comeback group\\u0026quot; (n = 99). This clustering method effectively revealed the dynamic changes in students\\u0026apos; academic performance, providing strong support for subsequent analyses.\\u003c/p\\u003e\\n\\u003ch3\\u003eQuality Control\\u003c/h3\\u003e\\n\\u003cp\\u003eQuestionnaires were administered using a unified set of instructions to ensure consistent understanding among participants. After collection, questionnaires with patterned responses (e.g., straight-lining, repetitive answering) were excluded to ensure data authenticity and reliability. Reliability tests were conducted for all scales, ensuring that Cronbach\\u0026apos;s \\u0026alpha; coefficients were all \\u0026gt; 0.70, indicating good internal consistency. Descriptive statistical analyses were also performed to check for outliers or skewed distributions, ensuring data quality met the requirements for analysis.\\u003c/p\\u003e\\n\\u003ch3\\u003eData Analysis\\u003c/h3\\u003e\\n\\u003cp\\u003eSPSS 26.0 was used for descriptive statistics, independent samples t-tests, and binary logistic regression analyses to assess differences and associations among variables. Mplus 8.3 was further employed to construct the moderated mediation model, with the Bootstrap method (5,000 resamples) used to test the significance of effects. This approach effectively revealed the complex relationships between perceived involution, perceived stress, social support, learning engagement, and academic performance, and validated the existence of moderated mediation effects. The model was constructed in stages to clearly demonstrate the dynamic interactions among variables.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003ch3\\u003eSample Characteristics\\u003c/h3\\u003e\\n\\u003cp\\u003eA total of 393 third-year medical students were included in this study, comprising 123 males (31.30%) and 270 females (68.70%) with a mean age of 20.405 \\u0026plusmn; 0.921 years. Among the participants, 101 (25.70%) held class leadership positions, 42 (10.69%) were from urban areas, 91 (23.16%) from towns, and 260 (66.16%) from rural areas. The distribution across majors included 139 students (35.37%) in radiology, 96 (24.43%) in laboratory medicine, and 158 (40.20%) in stomatology and other clinical specialties. Regarding family structure, 350 participants (89.06%) had parents with normal marital status, while 43 (10.94%) had parents who were divorced, separated, or widowed. There were 49 only children (12.47%) and 344 non-only children (87.53%). In terms of gender differences, no statistically significant differences were observed between males and females in perceived stress, coping strategies, perceived involution, social support, or learning engagement (p \\u0026gt; 0.05), indicating limited influence of gender on these variables (Table 1).\\u003c/p\\u003e\\n\\u003ch3\\u003eAcademic Performance Cluster Analysis\\u003c/h3\\u003e\\n\\u003cp\\u003eStudents were categorized into two clusters using K-means clustering analysis based on standardized exam scores over four semesters: the \\u0026quot;stable high-score group\\u0026quot; (n = 294) and the \\u0026quot;comeback group\\u0026quot; (n = 99). The stable high-score group exhibited consistently high academic performance across semesters with a standard deviation less than 200, indicating minimal fluctuations. In contrast, the comeback group showed a significant improvement from extremely low scores in the first semester (394.80 \\u0026plusmn; 79.10) to a substantial increase by the fourth semester (1117.60 \\u0026plusmn; 103.76), demonstrating a marked upward trajectory. The mean scores and standard deviations for each semester, along with the results of variance analysis, are presented in Table 2, with significant differences between the two groups (p \\u0026lt; 0.01).\\u003c/p\\u003e\\n\\u003ch3\\u003eFactors Influencing Academic Comeback\\u003c/h3\\u003e\\n\\u003cp\\u003eBinary logistic regression analysis was conducted to identify factors associated with academic comeback. The results indicated that perceived stress was a significant inhibitor of academic comeback, with each unit increase in stress score reducing the odds of academic comeback by 7.0% (OR = 0.930, p = 0.034). Conversely, resource competition vigilance positively influenced academic comeback, with each unit increase in vigilance score raising the odds of academic comeback by 9.1% (OR = 1.091, p = 0.008). Learning engagement also effectively countered involution, enhancing the likelihood of academic comeback (OR = 1.018, p = 0.049). Holding a class leadership position may indirectly promote academic recovery through increased responsibility or resource acquisition, although this requires validation with a larger sample (OR = 1.623, p = 0.104). Other variables, including parents\\u0026apos; marital status, major, gender, age, and place of residence, did not significantly influence academic comeback. The regression coefficients, standard errors, z-values, Wald \\u0026chi;\\u0026sup2; values, p-values, and 95% confidence intervals for each variable are presented in Table 3. The model\\u0026apos;s explanatory power was limited (McFadden R\\u0026sup2; = 0.048), suggesting the need to incorporate additional variables such as academic foundation in future studies to improve predictive validity.\\u003c/p\\u003e\\n\\u003ch3\\u003eModerated Mediation Effect Model Analysis\\u003c/h3\\u003e\\n\\u003cp\\u003eA moderated mediation effect model was constructed to examine the relationships between perceived involution, perceived stress, academic performance, social support, and learning engagement(figure 1). The model explores how these dimensions influence academic performance through perceived stress, and how social support and learning engagement moderate these relationships.The results demonstrated that social support and learning engagement significantly moderated the relationship between perceived involution and perceived stress, as well as between perceived stress and academic performance. Specifically, social support and learning engagement alleviated the positive impact of perceived involution on perceived stress and weakened the negative influence of perceived stress on academic performance. Learning engagement also directly enhanced academic performance, highlighting its protective role in countering involutionary pressures (Figure 2). It also examines how social support and learning engagement moderate these relationships, potentially buffering the negative impacts of stress on academic outcomes.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study constructed a mediated effect model of \\u0026quot;perceived involution-perceived stress-academic performance\\u0026quot; to elucidate the complex mechanisms underlying educational involution\\u0026apos;s impact on students\\u0026apos; academic development. The findings indicate that perceived involution indirectly undermines academic performance by exacerbating perceived stress, while resource competition vigilance and learning engagement emerge as key protective factors driving academic comeback. Social support (especially from family and peers) and learning engagement (dimensions of vigor and dedication) exhibit dual moderating effects, buffering the positive impact of perceived involution on stress and weakening the negative association between stress and academic performance. Notably, gender and academic background did not significantly influence coping strategy selection or perceived involution, contrasting with prior stereotypical views on gender roles and stress responses and suggesting that involutionary pressures may have universal characteristics across groups[\\u003csup\\u003e20][21]\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003ch3\\u003eAdaptive Transformation of Resource Competition Vigilance\\u003c/h3\\u003e\\n\\u003cp\\u003eResource competition vigilance (OR = 1.091, p = 0.008) significantly promotes academic comeback through cognitive reappraisal (e.g., goal decomposition and strategy optimization), challenging the traditional \\u0026quot;scarcity mindset trap\\u0026quot; assumption in involution research[\\u003csup\\u003e22]\\u003c/sup\\u003e. Specifically, when competition intensity is below an individual\\u0026apos;s cognitive load threshold (e.g., study duration \\u0026le; 8 hours/day), vigilance can activate dopaminergic motivational pathways, driving students to transform perceptions of resource scarcity into structured learning strategies[\\u003csup\\u003e23][24]\\u003c/sup\\u003e. This mechanism indicates that under moderate competitive conditions, individual vigilance can be converted into positive learning motivation, thereby enhancing academic performance.\\u003c/p\\u003e\\n\\u003ch3\\u003eDual-Stage Dynamic Moderation of Social Support\\u003c/h3\\u003e\\n\\u003cp\\u003eContrary to studies on medical professionals where social support primarily functions in stress alleviation, this study found that social support plays a moderating role in both stress perception and strategy implementation stages[\\u003csup\\u003e25]\\u003c/sup\\u003e. Family support (\\u0026beta; = 0.24, p \\u0026lt; 0.01) significantly weakens the association between perceived involution and stress in the perception stage (\\u0026beta; = -0.15), while peer support enhances coping efficacy in the implementation stage (\\u0026beta; = 0.19), indirectly improving academic performance. This finding validates the \\u0026quot;resource buffering mechanism\\u0026quot; proposed by Freak-Poli et al[\\u003csup\\u003e26][27]\\u003c/sup\\u003e. The dual role likely stems from the continuous nature of support systems in educational settings\\u0026mdash;teacher guidance, peer collaboration, and family emotional support form a \\u0026quot;stress buffering-strategy empowerment\\u0026quot; complex mechanism, closely related to the development of online support platforms in the context of blended teaching post-COVID-19\\u003csup\\u003e[12]\\u003c/sup\\u003e. This highlights the importance of multidimensional social support in educational environments and suggests that future research and practice should focus on the synergistic effects of family, peer, and teacher support.\\u003c/p\\u003e\\n\\u003ch3\\u003eMotivational-Behavioral Synergistic Effects of Learning Engagement\\u003c/h3\\u003e\\n\\u003cp\\u003eThis study confirmed that learning engagement not only directly promotes academic performance but also indirectly improves grades by enhancing stress-coping efficacy, together forming a psychological resilience system against involutionary erosion. Learning engagement directly counteracts negative stress impacts through its vigor dimension (\\u0026beta; = 0.24) and inhibits cognitive distraction through its dedication dimension (\\u0026beta; = 0.27). This aligns with the \\u0026quot;feedback design for enhancing academic emotions\\u0026quot; mechanism, where high-engagement students\\u0026apos; \\u0026quot;error summarization strategies\\u0026quot; delay knowledge devaluation, breaking the \\u0026quot;involution trap\\u0026quot; of low-effort, high-input learning[\\u003csup\\u003e28]\\u003c/sup\\u003e. This finding underscores the crucial role of learning engagement in coping with academic stress and suggests that educators should focus on students\\u0026apos; engagement levels and design effective teaching strategies to enhance engagement[\\u003csup\\u003e29][30]\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003ch3\\u003eLimitations of This Study\\u003c/h3\\u003e\\n\\u003cp\\u003eThis study has several limitations. First, the sample was drawn from a single medical college, limiting the generalizability of the findings to other educational settings. Future research should include diverse institutions to validate these results across different academic contexts. Second, the cross-sectional design prevents conclusions about causality and the dynamic interplay between perceived involution and stress. Longitudinal studies and neuroimaging techniques could elucidate the temporal sequences and neural mechanisms involved. Third, reliance on self-reported measures introduces potential biases. Future studies should incorporate multimodal approaches, combining self-reports with objective behavioral and physiological data, to enhance the robustness of the findings. Addressing these limitations will strengthen the validity and applicability of research on educational involution and its impact on student outcomes.\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eThis study constructed a mediated effect model of \\u0026quot;perceived involution-perceived stress-academic performance\\u0026quot; to elucidate the core mechanisms underlying educational involution\\u0026apos;s impact on college students\\u0026apos; academic development. The findings challenge the traditional \\u0026quot;unidirectional depletion\\u0026quot; assumption in involution research and propose a \\u0026quot;vigilance-strategy transformation\\u0026quot; framework, emphasizing that individuals can convert competitive pressures into goal-oriented behaviors through cognitive reappraisal in high-stress environments. This study provides a theoretical framework for mitigating educational involution through \\u0026quot;individual-environment-technology\\u0026quot; collaborative interventions, emphasizing a shift from \\u0026quot;passive adaptation\\u0026quot; to \\u0026quot;active empowerment\\u0026quot; in educational ecology reconstruction. It also offers empirical evidence for mental health support strategies in post-pandemic blended teaching contexts.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003ePSS-10: Perceived Stress Scale-10.\\u003c/p\\u003e\\n\\u003cp\\u003eUWES-S: Utrecht Work Engagement Scale-Student version.\\u003c/p\\u003e\\n\\u003cp\\u003eMcFadden R\\u0026sup2;: McFadden\\u0026apos;s pseudo R-squared.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eAcknowledgements\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors would like to thank the participating students and staff for their support.\\u003c/p\\u003e\\n\\u003cp\\u003eCompeting Interests\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003eAuthors\\u0026apos; Contributions\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors contributed to the study design, data collection, and analysis. The first author drafted the manuscript, and all authors reviewed and approved the final version.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNo.\\u003c/p\\u003e\\n\\u003cp\\u003eData Availability\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003eEthical Approval and Consent to Participate\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was approved by the ethical committee of Xiangya Hospital Central South University and was conducted in accordance with the ethical standards of the responsible committees for human experimentation and with the Helsinki Declaration of 1975. All of participants were asked to provide written informed consent before data collection.Clinical trial number：not applicable.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eZhang, Y., Zhang, Y., Ng, T. W. H., \\u0026amp; Lam, S. S. K. (2019). Promotion- and prevention-focused coping: A meta-analytic examination of regulatory strategies in the work stress process. The Journal of applied psychology, 104(10), 1296\\u0026ndash;1323. https://doi.org/10.1037/apl0000404\\u003c/li\\u003e\\n\\u003cli\\u003eKleshinski, C. E., Wilson, K. S., Stevenson-Street, J. M., \\u0026amp; Rosokha, L. M. (2024). Coping with work-nonwork stressors over time: A person-centered, multistudy integration of coping breadth and depth. The Journal of applied psychology, 109(11), 1765\\u0026ndash;1793. https://doi.org/10.1037/apl0001207\\u003c/li\\u003e\\n\\u003cli\\u003eHagger, M. S., Koch, S., Chatzisarantis, N. L. D., \\u0026amp; Orbell, S. (2017). 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H., Tracey, I., Wessely, S., Arseneault, L., Ballard, C., Christensen, H., Cohen Silver, R., Everall, I., Ford, T., John, A., Kabir, T., King, K., Madan, I., Michie, S., Przybylski, A. K., Shafran, R., Sweeney, A., Worthman, C. M., \\u0026hellip; Bullmore, E. (2020). Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. The lancet. Psychiatry, 7(6), 547\\u0026ndash;560. https://doi.org/10.1016/S2215-0366(20)30168-1\\u003c/li\\u003e\\n\\u003cli\\u003eKaramihalev, S., Brivio, E., Flachskamm, C., Stoffel, R., Schmidt, M. V., \\u0026amp; Chen, A. (2020). Social dominance mediates behavioral adaptation to chronic stress in a sex-specific manner. eLife, 9, e58723. https://doi.org/10.7554/eLife.58723\\u003c/li\\u003e\\n\\u003cli\\u003eZhang, W., Pan, C., Yao, S., et al. (2024). \\u0026quot;Neijuan\\u0026quot; in China: The psychological concept and its characteristic dimensions. Acta Psychologica Sinica, 56(1), https://doi.org/107-123.10.3724/SP.J.1041.2024.00107.\\u003c/li\\u003e\\n\\u003cli\\u003eCohen, S., Kamarck, T., \\u0026amp; Mermelstein, R.. (1983). A global measure of perceived stress. Journal of health and social behavior, 24(4), 385-96.\\u003c/li\\u003e\\n\\u003cli\\u003eWang, Z., Wang, Y., Wu, Z., et al. (2015). Reliability and validity of the Chinese version of Perceived Stress Scale. Journal of Shanghai Jiao Tong University (Medical Science), 35(10), 1448\\u0026ndash;1451.https://doi.org/10.3969/j. issn.1674-8115.2015.10.004.\\u003c/li\\u003e\\n\\u003cli\\u003eCarver, C. S. (1997). You want to measure coping but your protocol\\u0026rsquo;s too long: Consider the Brief COPE. International Journal of Behavioral Medicine, 4(1), 92\\u0026ndash;100. https://doi.org/10.1207/s15327558ijbm0401_6.\\u003c/li\\u003e\\n\\u003cli\\u003eJiang, Q. J. (1999). Perceived Social Support Scale (PSSS). In Handbook of Mental Health Assessment Scales [M]. Beijing: Chinese Mental Health Journal Press.\\u003c/li\\u003e\\n\\u003cli\\u003eFang, L. T., Shi, K., \\u0026amp; Zhang, F. H. (2008). Research on Reliability and Validity of Utrecht Work Engagement Scale-student. Chinese Journal of Clinical Psychology, 16(6), 618\\u0026ndash;620.\\u003c/li\\u003e\\n\\u003cli\\u003eSpoelma, T. M., \\u0026amp; Fletcher, K. A. (2024). Financial stress and leadership behavior: The role of leader gender. Journal of occupational health psychology, 29(5), 317\\u0026ndash;341. https://doi.org/10.1037/ocp0000387\\u003c/li\\u003e\\n\\u003cli\\u003eLeonard, S. I., Liu, J., Jackman, K. B., \\u0026amp; Bruzzese, J. M. (2024). Sexual and Gender Minority Sleep Health Disparities and Minority Stress in Early Adolescence. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 75(3), 471\\u0026ndash;478. https://doi.org/10.1016/j.jadohealth.2024.05.022\\u003c/li\\u003e\\n\\u003cli\\u003eKindle, P. A. (2015). Scarcity: Why Having Too Little Means So Much, by Sendhil Mullainathan and Eldar Shafir: (2013). New York: Henry Holt and Company (304 pp., $16.80 hardcover, ISBN 978-0805092646). Journal of Human Behavior in the Social Environment, 25(3), 284\\u0026ndash;286. https://doi.org/10.1080/10911359.2014.1003732\\u003c/li\\u003e\\n\\u003cli\\u003eEnriquez-Traba, J., Arenivar, M., Yarur-Castillo, H. E., Noh, C., Flores, R. J., Weil, T., Roy, S., Usdin, T. B., LaGamma, C. T., Wang, H., Tsai, V. S., Kerspern, D., Moritz, A. E., Sibley, D. R., Lutas, A., Moratalla, R., Freyberg, Z., \\u0026amp; Tejeda, H. A. (2025). Dissociable control of motivation and reinforcement by distinct ventral striatal dopamine receptors. Nature neuroscience, 28(1), 105\\u0026ndash;121. https://doi.org/10.1038/s41593-024-01819-9\\u003c/li\\u003e\\n\\u003cli\\u003eJohnson, N. L., Cotelo-Larrea, A., Stetzik, L. A., Akkaya, U. M., Zhang, Z., Gadziola, M. A., Varga, A. G., Ma, M., \\u0026amp; Wesson, D. W. (2025). Dopaminergic signaling to ventral striatum neurons initiates sniffing behavior. Nature communications, 16(1), 336. https://doi.org/10.1038/s41467-024-55644-6\\u003c/li\\u003e\\n\\u003cli\\u003eCohen, S., \\u0026amp; Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological bulletin, 98(2), 310\\u0026ndash;357.\\u003c/li\\u003e\\n\\u003cli\\u003eHtun, H. L., Teshale, A. B., Ryan, J., Owen, A. J., Woods, R. L., Chong, T. T., Murray, A. M., Shah, R. C., Orchard, S. G., \\u0026amp; Freak-Poli, R. (2024). Gender-specific analysis of social connection patterns and risk of dementia in community-dwelling older people. Alzheimer\\u0026apos;s \\u0026amp; dementia : the journal of the Alzheimer\\u0026apos;s Association, 20(7), 4879\\u0026ndash;4890. https://doi.org/10.1002/alz.14055\\u003c/li\\u003e\\n\\u003cli\\u003eMahalingam, G., Samtani, S., Lam, B. C. P., Lipnicki, D. M., Lima-Costa, M. F., Blay, S. L., Castro-Costa, E., Shifu, X., Guerchet, M., Preux, P. M., Gbessemehlan, A., Skoog, I., Najar, J., Sterner, T. R., Scarmeas, N., Yannakoulia, M., Dardiotis, T., Kim, K. W., Riedel-Heller, S., R\\u0026ouml;hr, S., \\u0026hellip; SHARED consortium for the Cohort Studies of Memory in an International Consortium (COSMIC) (2023). Social connections and risk of incident mild cognitive impairment, dementia, and mortality in 13 longitudinal cohort studies of ageing. Alzheimer\\u0026apos;s \\u0026amp; dementia : the journal of the Alzheimer\\u0026apos;s Association, 19(11), 5114\\u0026ndash;5128. https://doi.org/10.1002/alz.13072\\u003c/li\\u003e\\n\\u003cli\\u003eSpooner, M., Duane, C., Uygur, J., Smyth, E., Marron, B., Murphy, P. J., \\u0026amp; Pawlikowska, T. (2022). Self-regulatory learning theory as a lens on how undergraduate and postgraduate learners respond to feedback: A BEME scoping review: BEME Guide No. 66. Medical teacher, 44(1), 3\\u0026ndash;18. https://doi.org/10.1080/0142159X.2021.1970732\\u003c/li\\u003e\\n\\u003cli\\u003eGraesser, A. C., Sabatini, J. P., \\u0026amp; Li, H. (2022). Educational Psychology Is Evolving to Accommodate Technology, Multiple Disciplines, and Twenty-First-Century Skills. Annual review of psychology, 73, 547\\u0026ndash;574. https://doi.org/10.1146/annurev-psych-020821-113042\\u003c/li\\u003e\\n\\u003cli\\u003eJin, J., \\u0026amp; Bridges, S. M. (2014). Educational technologies in problem-based learning in health sciences education: a systematic review. Journal of medical Internet research, 16(12), e251. https://doi.org/10.2196/jmir.3240\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003eTable 1: General characteristics of the study participants.\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" align=\\\"\\\" width=\\\"99%\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 264px;\\\"\\u003e\\n \\u003cp\\u003eGender\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003et/\\u0026chi;\\u003csup\\u003e2\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003eMale(n=123)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003eFemale(n=270)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eAge\\u0026nbsp;(years old)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e20.42\\u0026plusmn;0.87\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e20.40\\u0026plusmn;0.95\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e0.264\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.792\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eperceived pressure score\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e19.81\\u0026plusmn;4.65\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e19.89\\u0026plusmn;3.41\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e-0.154\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.878\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eCoping style total score\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e42.98\\u0026plusmn;8.66\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e41.47\\u0026plusmn;6.24\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e1.738\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.084\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eInternal volume perception total\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e72.91\\u0026plusmn;12.74\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e71.77\\u0026plusmn;9.79\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e0.881\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.379\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n 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\\u003cp\\u003e16.83\\u0026plusmn;4.23\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e0.949\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.343\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eIrrational competitive input\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e23.55\\u0026plusmn;5.85\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e23.17\\u0026plusmn;4.62\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e0.646\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.519\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eResource competition alertness\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e13.57\\u0026plusmn;5.32\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e13.28\\u0026plusmn;3.93\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e0.537\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.592\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eTotal perceived Social support\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e59.57\\u0026plusmn;13.12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e58.46\\u0026plusmn;11.06\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e0.815\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.416\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eFamily support\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e20.93\\u0026plusmn;4.91\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e20.08\\u0026plusmn;4.19\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e1.677\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.095\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eFriend support\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e19.74\\u0026plusmn;4.81\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e20.05\\u0026plusmn;4.12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e-0.615\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.539\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eOthers support\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e18.89\\u0026plusmn;4.78\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e18.33\\u0026plusmn;4.32\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e1.153\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.250\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eTotal learning engagement\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e76.50\\u0026plusmn;20.51\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e78.04\\u0026plusmn;16.82\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e-0.783\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.434\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eInvigoration\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e25.71\\u0026plusmn;7.73\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e25.91\\u0026plusmn;6.40\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e-0.269\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.788\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003ededicate\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e23.88\\u0026plusmn;6.54\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e24.17\\u0026plusmn;5.39\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e-0.439\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.661\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eFocus\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e26.92\\u0026plusmn;7.37\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e27.96\\u0026plusmn;6.19\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e-1.454\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.147\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eFirst Semester score\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e817.60\\u0026plusmn;236.20\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e821.33\\u0026plusmn;278.06\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e-0.137\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.891\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eSecond Semester score\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e1165.36\\u0026plusmn;125.68\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e1196.66\\u0026plusmn;122.69\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e-2.328\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.020*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eThird Semester score\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e933.48\\u0026plusmn;154.27\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e1025.77\\u0026plusmn;189.11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e-5.112\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.000**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eFourth Semester score\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e959.77\\u0026plusmn;159.01\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e1050.74\\u0026plusmn;171.03\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e-5.134\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.000**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eAverage score\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e969.05\\u0026plusmn;120.68\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e1023.63\\u0026plusmn;134.59\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e-3.847\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.000**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eOnly child n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eis\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e25(20.33)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e24(8.89)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e10.127\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.001**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eno\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e98(79.67)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e246(91.11)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eParental marital status n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003enormal\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e112(91.06)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e238(88.15)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e0.734\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.392\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eDivorced/separated/widowed\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e11(8.94)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e32(11.85)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eResidence n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003ecity\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e14(11.38)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e28(10.37)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e5.362\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.069\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003etowns\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e37(30.08)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e54(20.00)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003evillage\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e72(58.54)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e188(69.63)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eSpecialty n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eimage\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e63(51.22)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e76(28.15)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e19.685\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.000**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003einspect\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e23(18.70)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e73(27.04)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eClinical and oral\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e37(30.08)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e121(44.81)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eClass leader n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eis\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e30(24.39)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e71(26.30)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e0.161\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\u003e\\n \\u003cp\\u003e0.688\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 177px;\\\"\\u003e\\n \\u003cp\\u003eno\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e93(75.61)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 132px;\\\"\\u003e\\n \\u003cp\\u003e199(73.70)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 52px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 61px;\\\"\\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\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eTable 2: Results of cluster analysis for academic performance over four semesters\\u0026emsp;\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"100%\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 109px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 300px;\\\"\\u003e\\n \\u003cp\\u003evariance analysis of clustering categories\\u003c/p\\u003e\\n \\u003cp\\u003e(mean\\u0026plusmn;standard deviation)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 79px;\\\"\\u003e\\n \\u003cp\\u003eF\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003ep\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 163px;\\\"\\u003e\\n \\u003cp\\u003estable high-score group (n = 294)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 136px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;comeback group(n=294)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 109px;\\\"\\u003e\\n \\u003cp\\u003eThe first term\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 163px;\\\"\\u003e\\n \\u003cp\\u003e963.40\\u0026plusmn;101.99\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 136px;\\\"\\u003e\\n \\u003cp\\u003e394.80\\u0026plusmn;79.10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 79px;\\\"\\u003e\\n \\u003cp\\u003e2557.428\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e0.000**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 109px;\\\"\\u003e\\n \\u003cp\\u003eThe second term\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 163px;\\\"\\u003e\\n \\u003cp\\u003e1216.35\\u0026plusmn;118.84\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 136px;\\\"\\u003e\\n \\u003cp\\u003e1099.29\\u0026plusmn;96.19\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 79px;\\\"\\u003e\\n \\u003cp\\u003e78.663\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e0.000**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 109px;\\\"\\u003e\\n \\u003cp\\u003eThe third term\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 163px;\\\"\\u003e\\n \\u003cp\\u003e1035.79\\u0026plusmn;194.15\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 136px;\\\"\\u003e\\n \\u003cp\\u003e881.36\\u0026plusmn;66.40\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 79px;\\\"\\u003e\\n \\u003cp\\u003e60.167\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e0.000**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 109px;\\\"\\u003e\\n \\u003cp\\u003eThe fourth term\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 163px;\\\"\\u003e\\n \\u003cp\\u003e990.17\\u0026plusmn;179.07\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 136px;\\\"\\u003e\\n \\u003cp\\u003e1117.60\\u0026plusmn;103.76\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 79px;\\\"\\u003e\\n \\u003cp\\u003e44.994\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e0.000**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\" style=\\\"width: 554px;\\\"\\u003e\\n \\u003cp\\u003e*p\\u0026lt;0.05，\\u0026nbsp;**p\\u0026lt;0.01.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eTable 3: Binary logistic regression analysis of factors influencing academic performance improvement\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"100%\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003eRegression coefficient\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003eSD\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003eZ value\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003eWald\\u0026chi;\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ep\\u0026nbsp;\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003eOR\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e95% CI of OR\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003eParents\\u0026apos; marital status\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e0.416\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e0.370\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e1.122\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e1.260\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.262\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e1.515\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e0.733 ~ 3.131\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003eprofession\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-0.008\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e0.147\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-0.056\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e0.003\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.955\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e0.992\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e0.744 ~ 1.322\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003esex\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e0.385\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e0.283\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e1.356\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e1.840\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.175\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e1.469\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e0.843 ~ 2.560\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003eage\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e0.120\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e0.125\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e0.958\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e0.919\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.338\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e1.127\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e0.882 ~ 1.441\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003eWhether to serve as class leader\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e0.484\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e0.297\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e1.627\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e2.648\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.104\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e1.623\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e0.906 ~ 2.907\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003ePlace of Residence\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-0.029\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e0.192\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-0.153\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e0.023\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.879\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e0.971\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e0.666 ~ 1.416\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003eNo Only child\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-0.031\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e0.391\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-0.080\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e0.006\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.936\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e0.969\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e0.451 ~ 2.085\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003eTotal perceived stress score\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-0.073\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e0.034\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-2.117\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e4.481\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.034\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e0.930\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e0.869 ~ 0.995\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003eTotal score of learning engagement\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e0.018\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e0.009\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e1.965\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e3.860\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.049\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e1.018\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e1.000 ~ 1.037\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003ePerceived social support score\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-0.000\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e0.014\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-0.010\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e0.000\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.992\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e1.000\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e0.973 ~ 1.027\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003eCoping style score\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e0.003\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e0.021\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e0.147\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e0.022\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.883\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e1.003\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e0.963 ~ 1.044\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003eInternal drive anxiety intensity\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-0.013\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e0.046\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-0.273\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e0.075\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.785\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e0.987\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e0.902 ~ 1.081\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003eImplicit rules are internalized\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-0.005\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e0.034\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-0.156\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e0.024\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.876\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e0.995\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e0.931 ~ 1.063\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003eIrrational competitive input\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-0.010\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e0.032\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-0.316\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e0.100\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.752\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e0.990\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e0.929 ~ 1.055\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003eResource competition alertness\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e0.087\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e0.033\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e2.650\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e7.020\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.008\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e1.091\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e1.023 ~ 1.164\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 155px;\\\"\\u003e\\n \\u003cp\\u003eintercept\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-5.690\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 42px;\\\"\\u003e\\n \\u003cp\\u003e2.983\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 62px;\\\"\\u003e\\n \\u003cp\\u003e-1.908\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 68px;\\\"\\u003e\\n \\u003cp\\u003e3.640\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 34px;\\\"\\u003e\\n \\u003cp\\u003e0.056\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e0.003\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e0.000 ~ 1.168\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"8\\\" style=\\\"width: 554px;\\\"\\u003e\\n \\u003cp\\u003eNote: Dependent variable = Whether the grade is reversed.\\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\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-medical-education\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"meed\",\"sideBox\":\"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/meed/default.aspx\",\"title\":\"BMC Medical Education\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Academic involution, Perceived stress, Social support, Learning engagement, Medical education\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6730157/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6730157/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eBackground: In contemporary educational settings, \\\"involution\\\" has become a core issue impacting students' mental health and academic development. This study aims to explore how perceived academic involution indirectly affects academic performance through perceived stress, and to examine the moderating roles of social support and learning engagement.\\u003c/p\\u003e\\n\\u003cp\\u003eMethods: A cross-sectional survey combined with a longitudinal study was conducted among 393 third-year medical students. Data were collected using validated scales for perceived involution, perceived stress, coping strategies, social support, and learning engagement. Academic performance was measured via standardized exam scores over four semesters. Statistical analyses included descriptive statistics, independent sample t-tests, binary logistic regression, and moderated mediation modeling using Mplus 8.3.\\u003c/p\\u003e\\n\\u003cp\\u003eResults: The study reveals that perceived involution indirectly undermines academic performance by increasing perceived stress. Social support and learning engagement significantly moderate this relationship, with family support and peer support playing crucial roles in buffering the negative impact of involution perception on stress and enhancing academic performance. Learning engagement also directly promotes academic achievement.\\u003c/p\\u003e\\n\\u003cp\\u003eConclusions: The findings challenge the traditional \\\"scarcity mindset trap\\\" assumption in involution research and propose a \\\"vigilance-strategy transformation\\\" framework. This study offers insights for developing targeted psychological interventions to mitigate the negative effects of academic involution and provides an evidence-based foundation for mental health support strategies in the context of post-pandemic blended teaching.\\u003c/p\\u003e\",\"manuscriptTitle\":\"The Mediating Role of Perceived Stress in the Relationship between Involvement and Academic Performance: A Study on Medical Students\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-06-26 12:30:23\",\"doi\":\"10.21203/rs.3.rs-6730157/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"reviewerAgreed\",\"content\":\"316189506711761668902645645181203183933\",\"date\":\"2026-05-13T10:46:12+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"298028452048953439919410984913000592613\",\"date\":\"2026-05-09T04:09:04+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"318948564939251838705739283430961098621\",\"date\":\"2026-05-08T13:49:08+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-07T15:40:47+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"124021153634800997349893393199876186986\",\"date\":\"2026-05-07T09:38:28+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-06-26T04:53:05+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"317233460656222268619975597983578297079\",\"date\":\"2025-06-26T03:34:13+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-06-24T08:15:52+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2025-05-28T10:28:03+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-05-27T09:31:58+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-05-27T09:30:19+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Medical Education\",\"date\":\"2025-05-23T06:59:45+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-medical-education\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"meed\",\"sideBox\":\"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/meed/default.aspx\",\"title\":\"BMC Medical Education\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"0308a117-4558-483b-9a7e-13de70e752e5\",\"owner\":[],\"postedDate\":\"June 26th, 2025\",\"published\":true,\"recentEditorialEvents\":[{\"type\":\"reviewerAgreed\",\"content\":\"316189506711761668902645645181203183933\",\"date\":\"2026-05-13T10:46:12+00:00\",\"index\":96,\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"298028452048953439919410984913000592613\",\"date\":\"2026-05-09T04:09:04+00:00\",\"index\":94,\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"318948564939251838705739283430961098621\",\"date\":\"2026-05-08T13:49:08+00:00\",\"index\":93,\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-07T15:40:47+00:00\",\"index\":92,\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"124021153634800997349893393199876186986\",\"date\":\"2026-05-07T09:38:28+00:00\",\"index\":91,\"fulltext\":\"\"}],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-06-26T12:30:23+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-06-26 12:30:23\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6730157\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6730157\",\"identity\":\"rs-6730157\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}