Psychological Adjustment of Medical Students in Coping with Stress under Chinese Academic Involution: A constructivist grounded theory study

Psychological Adjustment of Medical Students in Coping with Stress under Chinese Academic Involution: A constructivist grounded theory study | 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 Article Psychological Adjustment of Medical Students in Coping with Stress under Chinese Academic Involution: A constructivist grounded theory study Wei Zhang, Zhiyan Cao, Xiaoli Ye, Tong Shen, Fangfang Zhao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4652359/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Academic involutionis highly related to medical students’ mental health. The process of psychological adjustment and the ability to cope with stress affects individual health and personal development for medical students. Aim: To explore the process of psychological adjustment and the experiences of medical students coping with stress under academic involution in China. Method: The interviews data analysis included initial coding, focused coding, and theoretical coding using the constant comparative method and memo writing. Findings: “Physical and mental harmony” was identified as the core category. The following seven categories were conceptualized: enlightening exploration, internal adjustment, seeking social support, emotional support, positive self-awakening, individual degeneration, and asymmetrical resources. Conclusion: The findings showed that under the academic involution the goal of medical students in coping with stress is to achieve and maintain physical and mental harmony, in addition, stress of academic involution can be transformed into a positive driving force for medical students through early identification and intervention. Implications for policy: In a stressful environment, schools should be guided by the psychological needs of medical students and provide mental health services that medical students can choose from. Health sciences/Health care Health sciences/Health occupations Health sciences/Medical research Medical Students Mental Health Academic Involution Stress Coping Grounded Theory Figures Figure 1 1. Introduction Since 2020, involution has suddenly become a popular online term from an academic term to a popular one in China. Educational involution generally refers to a relatively closed teaching environment. In the field of education, education stakeholders continuously increase their time, energy, capital, and other investments in order to achieve their expected goals. Finally, it leads to leading to a decrease in the overall input-output ratio. The education involution has also become one of the most frequently mentioned "pain points", and people's intuitive feelings about it are parents' anxiety, students' hard work, teachers' fatigue, and all education stakeholders are increasing their investment. In this context, a general consensus is that involution as a kind of irrational competition is highly related to mental health, based on more than 100 million quotations on the internet pertaining to both involution and mental health 1 . The negative impact of involution on higher education in universities deserves the attention of educators, as it brings new academic pressure and further threatens the mental health of college students, especially medical students who already face heavy academic pressure. In higher education, medical students deal with many more types of challenging stressors than most students with other majors, including curricular aspects, learning environments, intense academic demands and workloads, personal life events, and psychological pressures that are difficult to cope with 2 , 3 . Medical students’ academic and emotional demands are more prominent than those of any other profession 4 . Research has shown that stress is a double-edged sword for medical students that can either increase their chances of success or prevent them from enhancing their performance 5 . To medical students, stress provides motivation that, to some extent, can be considered an academic stimulation. However, prolonged stress can lower academic performance and lead to health problems 6 . A study in China indicated that, to a certain extent, stress scores might negatively correlate with academic performance among medical students 5 . In addition, many studies have shown evidence of a link between stressful events and physical health in all college students, including medical students 7 , 8 . For example, among several psychosocial factors, emotional stress has been recognized as a modifiable risk factor for cardiovascular disease 9 – 11 and could cause cardiovascular consequences for medical students when long-term stressors are placed on them 7 . Continuous stress further impacts students by negatively affecting their self-concept, such as self-worth, general health, and immune functions 12 . Therefore, researchers have explored factors such as anxiety and depression, which are associated with stress 13 , 14 . The negative emotions caused by these pressures reduce life satisfaction 15 , threaten the mental health of medical students, hinder their self-development 16 , and cause serious socioeconomic burdens 17 . Despite the growing evidence for a positive relationship between involution behavior and stress level among college students, the debate over whether involution causes mental health problem has persisted. A survey by da found that involution does not always have a positive correlation with anxiety among college students in different contexts. No previous studies have considered the psychological adjustment among medical students in coping with stress under Chinese academic involution. Under academic involution, exploring the process of coping with stress and psychological adjustment from medical students’ perspectives can be targeted to identify the adverse consequence caused by stress, and provide a basis for appropriate internal and external interventions to address the mental health problem and stress response for medical students in the future. Hence, this study aims to explore the experiences of medical students coping with stress under academic involution and construct an interpretive understanding from the medical students’ perspective by using constructivist grounded theory. 2. Methods 2.1 Design Based on the interpretive feature of Charmaz’s 18 approach and symbolic interactionism, a constructivist grounded theory approach is adopted. This study is underpinned by symbolic interactionism. All methods were performed in accordance with the relevant guidelines and regulations. 2.2 Participants and Sampling We recruited participants from eight departments of a university in East China. During the initial stage of this study, purposive sampling and snowball sampling were used to recruit participants who could provide rich information. During the sample process, we tried to select medical students with multifield demographics to enrich the original data. No new concepts appeared, indicating that the data achieved theoretical saturation, and the sampling was stopped. 2.3 Data Collection The settings of the campus interviews were quiet and comfortable, which took place in a staircase (n = 27), riverside bench (n = 2), or playground (n = 1), so that subjects could express themselves as fully as possible without affecting their thinking. Before the interview, the researcher carefully designed a semi-structured interview outline. The interviews were conducted in the form of face-to-face in-depth interviews between May 2020 and January 2021. The interviews lasted from 25–50 minutes. After each interview, field notes were written immediately to record the details of the observations and the process of interactions and encounters. The audio-recorded data were transcribed verbatim. Table 1 provides examples of the questions asked during the interviews. Table 1 Interview outline of This study. No. Questions 1 How do you evaluate your general psychological state? 2 What factors do you think affect your psychological health most? 3 Have you ever been depressed for a long time? 4 What factors do you think can promote your mental health? 5 In your view, what resources do schools and surrounding communities have that can help your mental health? 6 How do you evaluate these resources that can help you? 7 How are your interpersonal relationships? 8 What measures and resources do you think can help improve your mental health? 2.4 Data Analysis Data analysis occurred simultaneously with the data collection 19 . After completing the data collection, the researchers used the software MAXQDA2020 to sort the recorded data word by word. Initial coding allowed us to become familiar with the data. We took a fresh look at the data through line-by-line coding as a first step, compared fragments of these data, and asked analytic questions about them. We became aware of potential categories and processes through initial codes grounded in the data 20 . During the following stage, focused coding was used to identify emerging core categories, remaining grounded in the data to some extent but involving some clustering of ideas 18 . Subsequently, theoretical coding was used to enable the saturation of the core categories identified during focused coding. During this stage, we also used constant comparison, allowing the analysis to become much more analytical and interpretive to tell a coherent analytical story. The final core process was the development of the conceptual framework by sorting and integrating memos and writing storylines. 2.5 Theoretical Saturation In this study, 30 data were processed as follows: after 25 data obtained the core concept, the remaining five data were used to test the theoretical saturation. The results of these remaining data showed that, in addition to the seven main categories mentioned above, new categories and concepts were not formed in the three-tiered procedural coding process. Moreover, the relationship between categories and concepts did not change substantially. The model of medical students' stress coping mechanism reached the theoretical saturation state, which has a certain practical explanatory power. The result of coding the overall stress experiences of the participants is depicted in Table 2 . Table 2 Coding Process of Coping Stress Model for Medical Students. Core Category Categories Subcategories Physical and mental harmony Enlightening exploration Exploring helpful resources Developing hobbies Internal adjustment Adapting to stress Self-examination Cognitive restructuring Seeking social support Getting along with friends Talking to parents Communicating with teachers Emotional support Being understood by others Getting respect from others Being encouraged Positive self-awakening Becoming optimistic High self-esteem Individual degeneration Self-denial Escaping from stress Conservative view Asymmetrical resources Popular science knowledge lacks individuality Transparent counseling service 2.6 Ethical Considerations This study was approved by the Ethics Review Committee (2019-17). Before the interviews, the participants’ written informed consent was obtained. The interview data were stored secretly and securely, and only the research team could access them. 2.7 Rigors We ensured the rigor of the study via methodological congruence and procedural transparency 21 – 23 . The reason for the methodological congruence present in this study was that the aim of the research, the philosophical position of the researchers, and the methodological approach employed in the study resonated with each other. 3. Results Thirty participants were included in the study, and none refused to proceed or quit the study. Table 3 provides information about the interviewees, and their names have been replaced by D01 to D30. Table 3 Demographic Data (N = 30 Participants). No. Gender Age Grade Major Hometown Only child Daily exercise time (hours) D01 Female 18 First Pharmacy Rural No 0.3 D02 Female 20 Second Stomatology Urban Yes 0 D03 Female 19 Second Nursing Urban Yes 1 D04 Female 20 Second Stomatology Urban Yes 0 D05 Female 20 Second Nursing Rural No 1 ~ 2 D06 Female 19 First Clinical Medicine Rural Yes 1 D07 Female 20 First Clinical Medicine Urban Yes 1 D08 Female 20 Second Stomatology Rural Yes 0.3 D09 Female 16 First Medical Imaging Rural Yes 2 D10 Female 18 First Medical Imaging Urban No 0 D11 Female 18 First Medical Imaging Rural Yes 0.5 D12 Female 21 Third Rehabilitation Therapeutics Rural Yes 1 D13 Female 18 Second Pharmacy Urban No 1 D14 Female 20 Second Pharmacy Urban Yes 0.5 D15 Female 20 Second Pharmacy Urban No 1 D16 Female 18 First Stomatology Urban Yes 0.5 D17 Female 19 First Stomatology Rural Yes 0.5 D18 Female 18 First Pharmacy Rural No 0.3 D19 Male 19 First Rehabilitation Therapeutics Urban Yes 0.6 D20 Male 18 First Bioinformatics Urban Yes 2 D21 Female 18 First Bioinformatics Urban No 0.5 D22 Female 18 First Clinical Medicine Urban Yes 2 D23 Female 18 Second Nursing Urban No 0.3 D24 Male 20 First Clinical Medicine Urban Yes 1 D25 Female 19 First Rehabilitation Therapeutics Rural No 1 D26 Male 20 Second Medical Imaging Rural Yes 2 D27 Female 21 Third Clinical Medicine Urban Yes 0.5 D28 Female 18 First Nursing Rural No 1 D29 Female 20 Second Pharmacy Urban No 1 D30 Female 17 First Nursing Urban Yes 2 We obtained 18 subthemes that fit into seven themes to derive the core category. In the conceptual framework constructed, for medical students, physical and mental harmony was the core content and the best outcome of coping with stress under academic involution. From the theoretical model constructed in this study, the negative impact of stress on medical students can be transformed into the reinforcement of their mentality and beneficial gains for individuals through timely and active coping. Figure 1 depicts the final conceptual framework constructed through the data analysis. It provides a visual representation of a process that may be used to inform practical guidance. 3.1 Enlightening Exploration Enlightening exploration is an attempt to obtain help and coping strategies when medical students are aware of the existence of stress from academic involution. It is the guidance of the positive coping of medical students facing stress and means that medical students feel the impact of pressure and respond accordingly. Consequently, enlightening exploration is the beginning of the coping process. 3.1.1 Exploring Helpful Resources Exploring help from valid resources guides active behaviors to cope with stress. When medical students realize continuous stress, some of them seek help from media, books, or music that they think can cheer them up to regulate pressure effectively. D30: “That is, I enjoy watching short films. I feel more warmth in my heart, and then my emotions are improved.” 3.1.2 Developing Hobbies The development of hobbies is a subconscious exploration of dealing with the emotional distress caused by stress among medical students who feel the stress from academic involution. On one hand, they reject passive academic involution and divert their attention from stress, which weakens negative emotions; on the other hand, hobbies can mobilize their positive attitude. D30: “For example, I’ll listen to music or go out for a walk, run, or read some other books. Adjusting slowly, the pressure in my heart will relax. It’s these things that we have to face ourselves and find the solution.” D24:"If you feel a little depressed, you should go out to play ball games, and then find some good friends to chat with and then play a game.” 3.2 Internal Adjustment Internal adjustment is a cognitive alteration that medical students undergo to cope with stress. Under the threat of stress, they clearly recognize cognitive dissonance and re-examine themselves to make correct adjustments to cope with stress from academic involution. 3.2.1 Adapting to Stress Medical students improve their acceptance of stress by adapting to it when they are conscious of the discomfort caused by stress from academic involution. The goal of adapting is to improve their ability to cope with stress. D26: “Because I have experienced a lot, I am indifferent to such things.” D01: “I will try my best to get used to it when I get too many exams, and my mentality will become better and better gradually.” 3.2.2 Self-examination Self-examination is a form of reflection. Medical students discern their shortcomings and effectively improve them through self-examination. This high-level coping style is an important factor in promoting an individual’s ability to adjust internally. D01: “I will first reflect on why this makes me anxious, and then, depending on the situation, see if I can relive the anxiety immediately and decisively.” D16 “ Yes, When I have conflicts with my friends, I will reflect on my own mistakes first, and then slowly propose to him that he may have some problems, and then we can solve them together.” 3.2.3 Cognitive Restructuring The reason for cognitive dissonance among medical students is continuous pressure that requires prompt adjustment. Cognitive restructuring involves adjusting individual shortcomings to improve self-quality, which is an outcome of self-examination. D20: “For example, self-reconstruction can cultivate my self-discipline and some of my own abilities. I think it is very helpful to me now.” 3.3 Seeking Social Support In social support, medical students obtain help from close others to support them in coping with stress from academic involution or daily life. 3.3.1 Getting Along with Friends The purpose of medical students to get along with their peers is to gain an understanding of each other. This type of emotional satisfaction is indispensable for coping with pressure actively and effectively. When encountering pressure, medical students choose to talk with close friends and ask for their opinions. D09: “Friends are people of the same age for us, so we have the same experience in many things, so friends are better to talk to each other.” D05: “I like playing sports with my friends. When I'm in a bad mood, I like playing with my team friends. When I play with my friends, I forget my troubles.” 3.3.2 Talking to Parents The purpose of turning to parents is to gain support and obtain effective advice. Students are willing to communicate with their parents when encountering stressful events based on maintaining good relationships with their parents during their growth. D29: “If I have problems in my studies, such as exams, and I find them difficult, I’ll take the initiative to communicate with my parents and find some solutions.” D27: “I have a good relationship with my parents because I’ve had a good relationship with my father since I was young. Even if I’m lovelorn, I’ll turn to my father.” 3.3.3 Communicating with Teachers Medical students who have established close relationships with their teachers will tell their teachers when they encounter stressful events and are eager to obtain their teachers' suggestions. D20: “Yes, I have a good relationship with my foreign language teacher. He is also very concerned about our lives. He can make friends with students and likes to chat with him.” D16: “My teacher may put forward suggestions on my weak points. If I bother them with something, they’re also willing to help me.” 3.4 Emotional Support Emotional support is based on social support and other factors. It is at the harvest stage for medical students to cope with pressure. Emotional support fills the loss induced by stress and provides a perfect solution to pressure. 3.4.1 Being Understood by Others Understanding by others is an important motivation for medical students to regain confidence. Students facing stress may have self-doubt or even an inferiority complex because of the impact of stress. Being understood by others is a channel for obtaining approval and psychological support from others. D27: “I think it’s a feeling that you are understood and accepted by others.” D24: “Although I got a C in the college entrance examination, the scores of the other three subjects were still OK. Then my parents understood me and encouraged me constantly. They said that I still had the ability.” 3.4.2 Getting Respect from Others Respect is the stage of medical students who face stress to obtain a safe and warm atmosphere, which enables them to feel accepted and obtain a sense of self-worth and power to change themselves. D19: “I get along well with my parents and teachers. They respect me, and I respect them.” D30: “What do you think can promote your mental health?” “My parents’ concern, tolerance, and understanding can promote my mental health. My classmates can also help me.” 3.4.3 Being Encouraged The threat of stress weakens the motivation for medical students to cope. At this time, the encouragement of others constitutes spiritual support, which gives them confidence and provides psychological support. Encouragement is a source of spiritual strength. D30: “It's mainly about the recognition of others and the encouragement of my parents. No matter how effective, it can warm my heart a little, which is also helpful for my mental health.” D16: “I will communicate more with my parents to tell them where my concerns are or where I have no confidence, and then they will encourage me or ask me to stop thinking so much and do my best.” 3.5 Positive Self-awakening The awakening of a positive self is an important indicator of a good mindset for dealing with stress. With the help of strategies and facilitating factors, medical students have achieved positive psychological results in coping with stress. These results reflect that students' self-consciousness is enhanced, and their ability to cope with stress is improved. 3.5.1 Becoming Optimistic Becoming optimistic is the change and strengthening of one's attitudes, the result of coping with stress, and the achievement of emotional gain. D18: “I don’t feel stressed about the exam results, and I’m optimistic. For exam results, it isn’t particularly stressful, and I’ll become optimistic.” D17: “Has this book affected your attitude and mental state since then?” “I’ll be more optimistic and encourage by reading the book.” 3.5.2 High Self-esteem The high self-esteem referred to in this category is the basis for medical students to build self-confidence in coping with pressure and is the category of positive mentality they have gained. When coping with stress reaches this stage, they are good at finding their own values and learning to affirm themselves, which is a notable change in medical students' stress-related events. D24: “I wasn ' t admitted to the ideal school, I was very sad at that time. However, considering that I can become a doctor in the future, my parents are also very supportive of this major. With such a change of mentality, I’ll find myself again and see my profession and value.” D21: “I am a positive person and having more communication with them (friends around me or parents) will also promote my mental health.” 3.6 Individual Degeneration Owing to the lack of confidence or competence in facing the threat of pressure, medical students are eager to overcome it. However, their personal abilities were not sufficient to deal with it, resulting in ambivalence. Their inner conflicts led to their degeneration, so they refused to change their conservative views, chose to deny themselves, and escaped pressure. 3.6.1 Self-denial Under the negative effects of stress, some medical students deny their ability and increase their self-doubt. They believe that their value is diminished, and that they cannot cope with their stress, thus losing confidence that they can cope with it. D24: “In my heart, I doubt my own level of excellence. I just feel that I’m not good enough. I feel a little uncomfortable. Nothing else.” 3.6.2 Escaping from Stress Some medical students lack the ability to deal with stress and seek help from others. Therefore, they cannot face the negative impact of stress, refuse to solve these problems, or choose to escape them. D23: “I will avoid the stimulus. Then, I forget and get better.” D28: “I usually choose to avoid conflicts between friends in interpersonal communication.” 3.6.3 Conservative View This category refers to the view that some medical students believe that their stress-induced negative emotions or psychological difficulties are shameful. They are ashamed of others learning about their negative emotions in the face of stigma. D17: “Because of the conservative view, the reason why psychological problems occur and we do not actively seek help is because we feel humiliating.” 3.7 Asymmetrical Resources This study found that the category of asymmetrical resources is another factor hindering the progress of the stress coping process. These asymmetrical resources not only fail to help students face stress but also weaken their willingness to seek valid resources to cope with stress. 3.7.1 Popular Science Knowledge Lacks Individuality In coping with stress, medical students pointed out that the psychological knowledge provided to them did not help them and lacked targeted guidance on the stress they faced. In addition, they considered this kind of popularized science a waste of time. They were unwilling to spend their time on this type of knowledge. D20: “The psychological survey of the school usually sends us a questionnaire, lets us fill it out, and then collects it. There will be no feedback afterwards. I don't think it has any substantial effect, even if it takes a form.” D30: “I think if a real person with mental illness needs one-on-one psychological help. Psychological lectures can’t solve the problem.” 3.7.2 Transparent Counseling Service A transparent counseling service refers to the fact that the psychological counseling service for medical students under stress does not protect their privacy well enough for medical students to trust them. Thus, medical students who value their privacy believe that they may not be protected and that their information may be exposed to others. Faced with this concern, medical students are unwilling to resort to psychological counseling to cope with the pressures they face. D26: “As for psychological counseling, I may not want to open my heart, so they won't really understand me, because I don't trust them.” D27: “Will you tell the doctor truthfully about all the problems?” “I once talked to the doctor and told the truth. But later, I found that some persons talked about it, spread it and the counseling service become stale and meaningless.” 3.8 Core Category: Physical and Mental Harmony Achieving physical and mental harmony confirmed that coping with stress is effective, which is not only a desirable result, but also the purpose of the entire active coping process. This is the effective embodiment of achieving balance in dealing with stressful events, both physically and psychologically. 4. Discussion Physical and psychological conditions are equally important health-related concepts 24 . However, under academic involution, the impact of multiple stress leads to an imbalance between the minds and bodies of medical students. Due to the dearth of existing knowledge relating to the experience and progress of coping with stress from academic involution in medical students, the originality and usefulness of the study were explained by constructing a theoretical framework with stressful events regarding the achievement of "physical and mental harmony" and offering novel insights into medical students' coping with stress. Under the stress from academic involution, the guiding role of enlightening exploration refers to exploratory ways to coping with problems through seeking social support and awakening a positive self 25 . This subcategory of enlightening exploration is consistent with previous studies about coping with stress among medical students that have pointed out that hobbies and interesting activities can help medical students relieve stress and improve their body-mind balance 26 , 27 . In addition to the importance of identifying medical students' enlightening exploration, this study explained the positive role of these behaviors from the students’ perspective, which is of great significance for augmenting medical students' abilities to adapt stress from academic involution. The subcategories of facilitating have noted that adaptive coping can help medical students relieve stress which are consistent with previous studies 28 . The process of internal adjustment and social support can help medical students in their self-reconstruction and with emotional support, which can ameliorate their body mind balance 27 . On one hand, the interviewees in this study expressed self-doubt caused by being suspected and ignored by others during stressful events. This mental condition threatens medical students suffering stress from academic involution further and determines that the purpose of these categories, which play a facilitating role, is to obtain emotional satisfaction. On the other hand, students participating in the study expressed their desire for emotional elements, including encouragement, understanding, recognition, and praise, which reflected the value they want to gain in academic involution and this value is key to transform the stress of academic involution into positive motivation for medical students. Correspondingly, researchers should pay more attention to how to strengthen medical students’ ability for internal adjustment to stress from academic involution and daily life. At the same time, researchers could heighten effective social support systems to cope with stress from academic involution, which may help boost actively stress responses for medical students. This study found that the two categories that hinder medical students from coping with stress are individual degeneration and asymmetrical resources, which provides inspiration for future research to reduce the barriers to medical students coping with stress under the educational environment of academic involution. First, the category of individual degeneration indicates the poor expression of medical students' mental health literacy 29 , so it is necessary to investigate the mental health literacy of medical students who suffer from academic involution to provide targeted assistance and help them resist individual degeneration and improve their ability to cope with stressful events 30 . Second, their ability to cope with stressful events could be improved through mental health services 31 . However, in this study, it was discovered that the mental health services involve another obstacle, asymmetrical resources, which cannot match the personalized psychological health guidance needs of students. Students say that when they encounter stress, they want to obtain effective resources centered on them that help them analyze their difficulties rather than the popular science knowledge of stress prevention for all. In the educational environment of academic involution, researchers should re-examine the psychological dilemma and the psychological health needs of medical students, based on this strengthening mental health services and enriching their forms to reduce the generation of asymmetrical resources and provide accurate mental health services to eliminate obstacles for medical students to cope with stress. It is worth noting that from the theoretical framework and the interviews in this study, personalized and confidential mental health services can become a favorable resource from the perspective of medical students, helping them transform the stress of academic involution into positive motivation. 5. Conclusion This study explored the process of psychological adjustment and the experiences of medical students coping with stress under academic involution in China and develop a theoretical model of medical students coping with stress under the academic involution. The findings showed that under the academic involution the goal of medical students in coping with stress is to achieve and maintain physical and mental harmony, in addition, academic pressure can be transformed into a positive driving force for medical students through early identification and intervention. To achieve physical and mental harmony, it is necessary to provide positive and effective mental health resources and focus on the psychological dilemma of medical students coping with pressure, stimulating their internal efforts to cope with pressure, and taking the initiative to obtain social help and emotional support. In addition, reducing asymmetrical resources and helping medical students facing stress cope with individual degeneration can weaken their barriers to positive coping with stress and help medical students transform the stress of academic involution into positive motivation. Declarations Funding The study was funded by Ministry of Education Humanities and Social Sciences in China (19YJCZH261), National Social Science Foundation (21BSH007). Ethical approval This study was approved by the ethics review committee of Nantong university in the East China (2019-17). Acknowledgements The authors thank Mengyuan Ma and Wenxuan Zhao for their help in recruiting the participants. Finally, we sincerely thank the 30 individual who generously shared their time, experiences, and stories for this research project. Contributions Study design: Wei Zhang, Zhiyan Cao, Fangfang Zhao Data collection: Wei Zhang, Xiaoli Ye, Tong Shen Data analysis: Wei Zhang, Xiaoli Ye, Tong Shen Study supervision: Fangfang Zhao Manuscript writing: Wei Zhang, Fangfang Zhao Critical revisions for important intellectual content: Wei Zhang, Fangfang Zhao Conflicts of interest None Data availability statement The datasets generated during and/or analysed during the current study are not publicly available due to ethical and privacy reasons but are available from the corresponding author on reasonable request. References Yi, D., Wu, J., Zhang, M., Zeng, Q., Wang, J., Liang, J., & Cai, Y. (2022). Does Involution Cause Anxiety? An Empirical Study from Chinese Universities. 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Ohrnberger J, Fichera E, Sutton M. The relationship between physical and mental health: A mediation analysis. Soc Sci Med. 2017;195:42-49. doi:10.1016/j.socscimed.2017.11.008 Ashkar PJ, Kenny DT. Views from the inside: young offenders' subjective experiences of incarceration. Int J Offender Ther Comp Criminol. 2008;52(5):584-597. doi:10.1177/0306624X08314181 Fares J, Saadeddin Z, Al Tabosh H, et al. Extracurricular activities associated with stress and burnout in preclinical medical students. J Epidemiol Glob Health. 2016;6(3):177-185. doi:10.1016/j.jegh.2015.10.003 Ramos R, Brauchli R, Bauer G, Wehner T, Hämmig O. Busy yet socially engaged: volunteering, work-life balance, and health in the working population. J Occup Environ Med. 2015;57(2):164-172. doi:10.1097/JOM.0000000000000327 Neufeld A, Malin G. How medical students cope with stress: a cross-sectional look at strategies and their sociodemographic antecedents. BMC Med Educ. 2021;21(1):299. Published 2021 May 25. doi:10.1186/s12909-021-02734-4 Kutcher S, Wei Y, Costa S, Gusmão R, Skokauskas N, Sourander A. Enhancing mental health literacy in young people. Eur Child Adolesc Psychiatry. 2016 Jun;25(6):567-9. doi: 10.1007/s00787-016-0867-9. PMID: 27236662. Nobre J, Oliveira AP, Monteiro F, Sequeira C, Ferré-Grau C. Promotion of Mental Health Literacy in Adolescents: A Scoping Review. Int J Environ Res Public Health. 2021;18(18):9500. Published 2021 Sep 9. doi:10.3390/ijerph18189500xin Jorm AF. Mental health literacy: empowering the community to take action for better mental health. Am Psychol. 2012;67(3):231-243. doi:10.1037/a0025957 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. 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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-4652359","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":329687847,"identity":"ab75e713-5642-489c-9205-c873e7f27c25","order_by":0,"name":"Wei Zhang","email":"","orcid":"","institution":"Nantong University","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Zhang","suffix":""},{"id":329687851,"identity":"b76adeb9-9646-41ff-b1e6-7c58f9f58e74","order_by":1,"name":"Zhiyan Cao","email":"","orcid":"","institution":"Nantong University","correspondingAuthor":false,"prefix":"","firstName":"Zhiyan","middleName":"","lastName":"Cao","suffix":""},{"id":329687853,"identity":"d269224e-af9f-4f51-b554-19e5ca17f620","order_by":2,"name":"Xiaoli Ye","email":"","orcid":"","institution":"Nantong University","correspondingAuthor":false,"prefix":"","firstName":"Xiaoli","middleName":"","lastName":"Ye","suffix":""},{"id":329687854,"identity":"d5bf4582-5c6a-46f6-8444-6da19d9b4737","order_by":3,"name":"Tong Shen","email":"","orcid":"","institution":"Nantong University","correspondingAuthor":false,"prefix":"","firstName":"Tong","middleName":"","lastName":"Shen","suffix":""},{"id":329687855,"identity":"8a56697c-3552-437b-89db-d0239250e98b","order_by":4,"name":"Fangfang Zhao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYDADNobDBx+DWczMDUSoT2Bg4GM8lmzMwGAA1MJIpBY55jNm0mAtDAS06LY3H3v484ddPhvbsbTqgoo/0fztQC0/Krbh1GJ25li6MU9CsmUbz+Fjt2ecMcidcZixgbHnzG3cWm7kAN2TwGzAJnEs7TZvm0FuA1ALM2Mbfi2SPxLqDdjk35gVg7TMJ0aLBE/CYQM2hjNmzCAtGwhqOXMsTZon7ThQy7FkaZ4zxrkbgVoO4vXL8eZjkj9sqg3kGw4f/MxTIZc77/zhgw9+VODWgh0cIFH9KBgFo2AUjAI0AABU71cTk5DnIwAAAABJRU5ErkJggg==","orcid":"","institution":"Nantong University","correspondingAuthor":true,"prefix":"","firstName":"Fangfang","middleName":"","lastName":"Zhao","suffix":""}],"badges":[],"createdAt":"2024-06-28 06:02:52","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4652359/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4652359/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60944521,"identity":"eade0fd9-c619-416e-97a4-fa099e9b54c5","added_by":"auto","created_at":"2024-07-23 22:11:49","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":40833,"visible":true,"origin":"","legend":"\u003cp\u003eMedical Students’ Model for Coping with Stress.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4652359/v1/25dacd5252c79f40d3fb3eae.jpg"},{"id":65820558,"identity":"a65bfedf-20bd-4183-9cc3-bd2b823e724c","added_by":"auto","created_at":"2024-10-03 07:24:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":861546,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4652359/v1/bf48d4da-5cef-403e-bd50-5b85fd3ad677.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychological Adjustment of Medical Students in Coping with Stress under Chinese Academic Involution: A constructivist grounded theory study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eSince 2020, involution has suddenly become a popular online term from an academic term to a popular one in China. Educational involution generally refers to a relatively closed teaching environment. In the field of education, education stakeholders continuously increase their time, energy, capital, and other investments in order to achieve their expected goals. Finally, it leads to leading to a decrease in the overall input-output ratio. The education involution has also become one of the most frequently mentioned \"pain points\", and people's intuitive feelings about it are parents' anxiety, students' hard work, teachers' fatigue, and all education stakeholders are increasing their investment. In this context, a general consensus is that involution as a kind of irrational competition is highly related to mental health, based on more than 100\u0026nbsp;million quotations on the internet pertaining to both involution and mental health \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe negative impact of involution on higher education in universities deserves the attention of educators, as it brings new academic pressure and further threatens the mental health of college students, especially medical students who already face heavy academic pressure. In higher education, medical students deal with many more types of challenging stressors than most students with other majors, including curricular aspects, learning environments, intense academic demands and workloads, personal life events, and psychological pressures that are difficult to cope with \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Medical students\u0026rsquo; academic and emotional demands are more prominent than those of any other profession \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Research has shown that stress is a double-edged sword for medical students that can either increase their chances of success or prevent them from enhancing their performance \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTo medical students, stress provides motivation that, to some extent, can be considered an academic stimulation. However, prolonged stress can lower academic performance and lead to health problems \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. A study in China indicated that, to a certain extent, stress scores might negatively correlate with academic performance among medical students \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. In addition, many studies have shown evidence of a link between stressful events and physical health in all college students, including medical students \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. For example, among several psychosocial factors, emotional stress has been recognized as a modifiable risk factor for cardiovascular disease \u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e and could cause cardiovascular consequences for medical students when long-term stressors are placed on them \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Continuous stress further impacts students by negatively affecting their self-concept, such as self-worth, general health, and immune functions \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Therefore, researchers have explored factors such as anxiety and depression, which are associated with stress \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. The negative emotions caused by these pressures reduce life satisfaction \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, threaten the mental health of medical students, hinder their self-development \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, and cause serious socioeconomic burdens \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite the growing evidence for a positive relationship between involution behavior and stress level among college students, the debate over whether involution causes mental health problem has persisted. A survey by da found that involution does not always have a positive correlation with anxiety among college students in different contexts. No previous studies have considered the psychological adjustment among medical students in coping with stress under Chinese academic involution. Under academic involution, exploring the process of coping with stress and psychological adjustment from medical students\u0026rsquo; perspectives can be targeted to identify the adverse consequence caused by stress, and provide a basis for appropriate internal and external interventions to address the mental health problem and stress response for medical students in the future. Hence, this study aims to explore the experiences of medical students coping with stress under academic involution and construct an interpretive understanding from the medical students\u0026rsquo; perspective by using constructivist grounded theory.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Design\u003c/h2\u003e \u003cp\u003eBased on the interpretive feature of Charmaz\u0026rsquo;s \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e approach and symbolic interactionism, a constructivist grounded theory approach is adopted. This study is underpinned by symbolic interactionism. All methods were performed in accordance with the relevant guidelines and regulations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Participants and Sampling\u003c/h2\u003e \u003cp\u003eWe recruited participants from eight departments of a university in East China. During the initial stage of this study, purposive sampling and snowball sampling were used to recruit participants who could provide rich information. During the sample process, we tried to select medical students with multifield demographics to enrich the original data. No new concepts appeared, indicating that the data achieved theoretical saturation, and the sampling was stopped.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data Collection\u003c/h2\u003e \u003cp\u003eThe settings of the campus interviews were quiet and comfortable, which took place in a staircase (n\u0026thinsp;=\u0026thinsp;27), riverside bench (n\u0026thinsp;=\u0026thinsp;2), or playground (n\u0026thinsp;=\u0026thinsp;1), so that subjects could express themselves as fully as possible without affecting their thinking. Before the interview, the researcher carefully designed a semi-structured interview outline. The interviews were conducted in the form of face-to-face in-depth interviews between May 2020 and January 2021. The interviews lasted from 25\u0026ndash;50 minutes. After each interview, field notes were written immediately to record the details of the observations and the process of interactions and encounters. The audio-recorded data were transcribed verbatim. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides examples of the questions asked during the interviews.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInterview outline of This study.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuestions\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow do you evaluate your general psychological state?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat factors do you think affect your psychological health most?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHave you ever been depressed for a long time?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat factors do you think can promote your mental health?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn your view, what resources do schools and surrounding communities have that can help your mental health?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow do you evaluate these resources that can help you?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow are your interpersonal relationships?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat measures and resources do you think can help improve your mental health?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Analysis\u003c/h2\u003e \u003cp\u003eData analysis occurred simultaneously with the data collection \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. After completing the data collection, the researchers used the software MAXQDA2020 to sort the recorded data word by word. Initial coding allowed us to become familiar with the data. We took a fresh look at the data through line-by-line coding as a first step, compared fragments of these data, and asked analytic questions about them. We became aware of potential categories and processes through initial codes grounded in the data \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. During the following stage, focused coding was used to identify emerging core categories, remaining grounded in the data to some extent but involving some clustering of ideas \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Subsequently, theoretical coding was used to enable the saturation of the core categories identified during focused coding. During this stage, we also used constant comparison, allowing the analysis to become much more analytical and interpretive to tell a coherent analytical story. The final core process was the development of the conceptual framework by sorting and integrating memos and writing storylines.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Theoretical Saturation\u003c/h2\u003e \u003cp\u003eIn this study, 30 data were processed as follows: after 25 data obtained the core concept, the remaining five data were used to test the theoretical saturation. The results of these remaining data showed that, in addition to the seven main categories mentioned above, new categories and concepts were not formed in the three-tiered procedural coding process. Moreover, the relationship between categories and concepts did not change substantially. The model of medical students' stress coping mechanism reached the theoretical saturation state, which has a certain practical explanatory power. The result of coding the overall stress experiences of the participants is depicted in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCoding Process of Coping Stress Model for Medical Students.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCore Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubcategories\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"17\" rowspan=\"18\"\u003e \u003cp\u003ePhysical and mental harmony\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEnlightening exploration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExploring helpful resources\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDeveloping hobbies\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eInternal adjustment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdapting to stress\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-examination\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCognitive restructuring\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSeeking social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGetting along with friends\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTalking to parents\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommunicating with teachers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEmotional support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBeing understood by others\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGetting respect from others\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBeing encouraged\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePositive self-awakening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBecoming optimistic\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh self-esteem\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIndividual degeneration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-denial\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEscaping from stress\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConservative view\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAsymmetrical resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePopular science knowledge lacks individuality\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTransparent counseling service\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Ethical Considerations\u003c/h2\u003e \u003cp\u003e This study was approved by the Ethics Review Committee (2019-17). Before the interviews, the participants\u0026rsquo; written informed consent was obtained. The interview data were stored secretly and securely, and only the research team could access them.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Rigors\u003c/h2\u003e \u003cp\u003eWe ensured the rigor of the study via methodological congruence and procedural transparency \u003csup\u003e\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. The reason for the methodological congruence present in this study was that the aim of the research, the philosophical position of the researchers, and the methodological approach employed in the study resonated with each other.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eThirty participants were included in the study, and none refused to proceed or quit the study. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e provides information about the interviewees, and their names have been replaced by D01 to D30.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Data (N\u0026thinsp;=\u0026thinsp;30 Participants).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGrade\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMajor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHometown\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOnly child\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDaily exercise time (hours)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePharmacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSecond\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStomatology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSecond\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSecond\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStomatology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSecond\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u0026thinsp;~\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinical Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinical Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSecond\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStomatology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedical Imaging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedical Imaging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedical Imaging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThird\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRehabilitation Therapeutics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSecond\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePharmacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSecond\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePharmacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSecond\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePharmacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStomatology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStomatology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePharmacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRehabilitation Therapeutics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBioinformatics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBioinformatics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinical Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSecond\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinical Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRehabilitation Therapeutics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSecond\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedical Imaging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThird\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinical Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSecond\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePharmacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNursing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe obtained 18 subthemes that fit into seven themes to derive the core category. In the conceptual framework constructed, for medical students, physical and mental harmony was the core content and the best outcome of coping with stress under academic involution. From the theoretical model constructed in this study, the negative impact of stress on medical students can be transformed into the reinforcement of their mentality and beneficial gains for individuals through timely and active coping. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts the final conceptual framework constructed through the data analysis. It provides a visual representation of a process that may be used to inform practical guidance.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Enlightening Exploration\u003c/h2\u003e \u003cp\u003eEnlightening exploration is an attempt to obtain help and coping strategies when medical students are aware of the existence of stress from academic involution. It is the guidance of the positive coping of medical students facing stress and means that medical students feel the impact of pressure and respond accordingly. Consequently, enlightening exploration is the beginning of the coping process.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.1.1 Exploring Helpful Resources\u003c/h2\u003e \u003cp\u003eExploring help from valid resources guides active behaviors to cope with stress. When medical students realize continuous stress, some of them seek help from media, books, or music that they think can cheer them up to regulate pressure effectively.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD30: \u0026ldquo;That is, I enjoy watching short films. I feel more warmth in my heart, and then my emotions are improved.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.1.2 Developing Hobbies\u003c/h2\u003e \u003cp\u003eThe development of hobbies is a subconscious exploration of dealing with the emotional distress caused by stress among medical students who feel the stress from academic involution. On one hand, they reject passive academic involution and divert their attention from stress, which weakens negative emotions; on the other hand, hobbies can mobilize their positive attitude.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD30: \u0026ldquo;For example, I\u0026rsquo;ll listen to music or go out for a walk, run, or read some other books. Adjusting slowly, the pressure in my heart will relax. It\u0026rsquo;s these things that we have to face ourselves and find the solution.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eD24:\"If you feel a little depressed, you should go out to play ball games, and then find some good friends to chat with and then play a game.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Internal Adjustment\u003c/h2\u003e \u003cp\u003eInternal adjustment is a cognitive alteration that medical students undergo to cope with stress. Under the threat of stress, they clearly recognize cognitive dissonance and re-examine themselves to make correct adjustments to cope with stress from academic involution.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Adapting to Stress\u003c/h2\u003e \u003cp\u003eMedical students improve their acceptance of stress by adapting to it when they are conscious of the discomfort caused by stress from academic involution. The goal of adapting is to improve their ability to cope with stress.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD26: \u0026ldquo;Because I have experienced a lot, I am indifferent to such things.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eD01: \u0026ldquo;I will try my best to get used to it when I get too many exams, and my mentality will become better and better gradually.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Self-examination\u003c/h2\u003e \u003cp\u003eSelf-examination is a form of reflection. Medical students discern their shortcomings and effectively improve them through self-examination. This high-level coping style is an important factor in promoting an individual\u0026rsquo;s ability to adjust internally.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD01: \u0026ldquo;I will first reflect on why this makes me anxious, and then, depending on the situation, see if I can relive the anxiety immediately and decisively.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eD16\u003c/strong\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eYes, When I have conflicts with my friends, I will reflect on my own mistakes first, and then slowly propose to him that he may have some problems, and then we can solve them together.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e3.2.3 Cognitive Restructuring\u003c/h2\u003e \u003cp\u003eThe reason for cognitive dissonance among medical students is continuous pressure that requires prompt adjustment. Cognitive restructuring involves adjusting individual shortcomings to improve self-quality, which is an outcome of self-examination.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD20: \u0026ldquo;For example, self-reconstruction can cultivate my self-discipline and some of my own abilities. I think it is very helpful to me now.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Seeking Social Support\u003c/h2\u003e \u003cp\u003eIn social support, medical students obtain help from close others to support them in coping with stress from academic involution or daily life.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Getting Along with Friends\u003c/h2\u003e \u003cp\u003eThe purpose of medical students to get along with their peers is to gain an understanding of each other. This type of emotional satisfaction is indispensable for coping with pressure actively and effectively. When encountering pressure, medical students choose to talk with close friends and ask for their opinions.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD09: \u0026ldquo;Friends are people of the same age for us, so we have the same experience in many things, so friends are better to talk to each other.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eD05: \u0026ldquo;I like playing sports with my friends. When I'm in a bad mood, I like playing with my team friends. When I play with my friends, I forget my troubles.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Talking to Parents\u003c/h2\u003e \u003cp\u003e The purpose of turning to parents is to gain support and obtain effective advice. Students are willing to communicate with their parents when encountering stressful events based on maintaining good relationships with their parents during their growth.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD29: \u0026ldquo;If I have problems in my studies, such as exams, and I find them difficult, I\u0026rsquo;ll take the initiative to communicate with my parents and find some solutions.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eD27: \u0026ldquo;I have a good relationship with my parents because I\u0026rsquo;ve had a good relationship with my father since I was young. Even if I\u0026rsquo;m lovelorn, I\u0026rsquo;ll turn to my father.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003e3.3.3 Communicating with Teachers\u003c/h2\u003e \u003cp\u003eMedical students who have established close relationships with their teachers will tell their teachers when they encounter stressful events and are eager to obtain their teachers' suggestions.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD20: \u0026ldquo;Yes, I have a good relationship with my foreign language teacher. He is also very concerned about our lives. He can make friends with students and likes to chat with him.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eD16: \u0026ldquo;My teacher may put forward suggestions on my weak points. If I bother them with something, they\u0026rsquo;re also willing to help me.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Emotional Support\u003c/h2\u003e \u003cp\u003eEmotional support is based on social support and other factors. It is at the harvest stage for medical students to cope with pressure. Emotional support fills the loss induced by stress and provides a perfect solution to pressure.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1 Being Understood by Others\u003c/h2\u003e \u003cp\u003eUnderstanding by others is an important motivation for medical students to regain confidence. Students facing stress may have self-doubt or even an inferiority complex because of the impact of stress. Being understood by others is a channel for obtaining approval and psychological support from others.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD27: \u0026ldquo;I think it\u0026rsquo;s a feeling that you are understood and accepted by others.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eD24: \u0026ldquo;Although I got a C in the college entrance examination, the scores of the other three subjects were still OK. Then my parents understood me and encouraged me constantly. They said that I still had the ability.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2 Getting Respect from Others\u003c/h2\u003e \u003cp\u003eRespect is the stage of medical students who face stress to obtain a safe and warm atmosphere, which enables them to feel accepted and obtain a sense of self-worth and power to change themselves.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD19: \u0026ldquo;I get along well with my parents and teachers. They respect me, and I respect them.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eD30: \u0026ldquo;What do you think can promote your mental health?\u0026rdquo; \u0026ldquo;My parents\u0026rsquo; concern, tolerance, and understanding can promote my mental health. My classmates can also help me.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003e3.4.3 Being Encouraged\u003c/h2\u003e \u003cp\u003eThe threat of stress weakens the motivation for medical students to cope. At this time, the encouragement of others constitutes spiritual support, which gives them confidence and provides psychological support. Encouragement is a source of spiritual strength.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD30: \u0026ldquo;It's mainly about the recognition of others and the encouragement of my parents. No matter how effective, it can warm my heart a little, which is also helpful for my mental health.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eD16: \u0026ldquo;I will communicate more with my parents to tell them where my concerns are or where I have no confidence, and then they will encourage me or ask me to stop thinking so much and do my best.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Positive Self-awakening\u003c/h2\u003e \u003cp\u003eThe awakening of a positive self is an important indicator of a good mindset for dealing with stress. With the help of strategies and facilitating factors, medical students have achieved positive psychological results in coping with stress. These results reflect that students' self-consciousness is enhanced, and their ability to cope with stress is improved.\u003c/p\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003e3.5.1 Becoming Optimistic\u003c/h2\u003e \u003cp\u003eBecoming optimistic is the change and strengthening of one's attitudes, the result of coping with stress, and the achievement of emotional gain.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD18: \u0026ldquo;I don\u0026rsquo;t feel stressed about the exam results, and I\u0026rsquo;m optimistic. For exam results, it isn\u0026rsquo;t particularly stressful, and I\u0026rsquo;ll become optimistic.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eD17: \u0026ldquo;Has this book affected your attitude and mental state since then?\u0026rdquo; \u0026ldquo;I\u0026rsquo;ll be more optimistic and encourage by reading the book.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section3\"\u003e \u003ch2\u003e3.5.2 High Self-esteem\u003c/h2\u003e \u003cp\u003eThe high self-esteem referred to in this category is the basis for medical students to build self-confidence in coping with pressure and is the category of positive mentality they have gained. When coping with stress reaches this stage, they are good at finding their own values and learning to affirm themselves, which is a notable change in medical students' stress-related events.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD24: \u0026ldquo;I wasn\u003c/em\u003e'\u003cem\u003et admitted to the ideal school, I was very sad at that time. However, considering that I can become a doctor in the future, my parents are also very supportive of this major. With such a change of mentality, I\u0026rsquo;ll find myself again and see my profession and value.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eD21: \u0026ldquo;I am a positive person and having more communication with them (friends around me or parents) will also promote my mental health.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Individual Degeneration\u003c/h2\u003e \u003cp\u003eOwing to the lack of confidence or competence in facing the threat of pressure, medical students are eager to overcome it. However, their personal abilities were not sufficient to deal with it, resulting in ambivalence. Their inner conflicts led to their degeneration, so they refused to change their conservative views, chose to deny themselves, and escaped pressure.\u003c/p\u003e \u003cdiv id=\"Sec30\" class=\"Section3\"\u003e \u003ch2\u003e3.6.1 Self-denial\u003c/h2\u003e \u003cp\u003eUnder the negative effects of stress, some medical students deny their ability and increase their self-doubt. They believe that their value is diminished, and that they cannot cope with their stress, thus losing confidence that they can cope with it.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD24: \u0026ldquo;In my heart, I doubt my own level of excellence. I just feel that I\u0026rsquo;m not good enough. I feel a little uncomfortable. Nothing else.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec31\" class=\"Section3\"\u003e \u003ch2\u003e3.6.2 Escaping from Stress\u003c/h2\u003e \u003cp\u003eSome medical students lack the ability to deal with stress and seek help from others. Therefore, they cannot face the negative impact of stress, refuse to solve these problems, or choose to escape them.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD23: \u0026ldquo;I will avoid the stimulus. Then, I forget and get better.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eD28: \u0026ldquo;I usually choose to avoid conflicts between friends in interpersonal communication.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section3\"\u003e \u003ch2\u003e3.6.3 Conservative View\u003c/h2\u003e \u003cp\u003eThis category refers to the view that some medical students believe that their stress-induced negative emotions or psychological difficulties are shameful. They are ashamed of others learning about their negative emotions in the face of stigma.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD17: \u0026ldquo;Because of the conservative view, the reason why psychological problems occur and we do not actively seek help is because we feel humiliating.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec33\" class=\"Section2\"\u003e \u003ch2\u003e3.7 Asymmetrical Resources\u003c/h2\u003e \u003cp\u003eThis study found that the category of asymmetrical resources is another factor hindering the progress of the stress coping process. These asymmetrical resources not only fail to help students face stress but also weaken their willingness to seek valid resources to cope with stress.\u003c/p\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003ch2\u003e3.7.1 Popular Science Knowledge Lacks Individuality\u003c/h2\u003e \u003cp\u003eIn coping with stress, medical students pointed out that the psychological knowledge provided to them did not help them and lacked targeted guidance on the stress they faced. In addition, they considered this kind of popularized science a waste of time. They were unwilling to spend their time on this type of knowledge.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD20: \u0026ldquo;The psychological survey of the school usually sends us a questionnaire, lets us fill it out, and then collects it. There will be no feedback afterwards. I don't think it has any substantial effect, even if it takes a form.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eD30: \u0026ldquo;I think if a real person with mental illness needs one-on-one psychological help. Psychological lectures can\u0026rsquo;t solve the problem.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec35\" class=\"Section3\"\u003e \u003ch2\u003e3.7.2 Transparent Counseling Service\u003c/h2\u003e \u003cp\u003eA transparent counseling service refers to the fact that the psychological counseling service for medical students under stress does not protect their privacy well enough for medical students to trust them. Thus, medical students who value their privacy believe that they may not be protected and that their information may be exposed to others. Faced with this concern, medical students are unwilling to resort to psychological counseling to cope with the pressures they face.\u003c/p\u003e \u003cp\u003e \u003cem\u003eD26: \u0026ldquo;As for psychological counseling, I may not want to open my heart, so they won't really understand me, because I don't trust them.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eD27: \u0026ldquo;Will you tell the doctor truthfully about all the problems?\u0026rdquo; \u0026ldquo;I once talked to the doctor and told the truth. But later, I found that some persons talked about it, spread it and the counseling service become stale and meaningless.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec36\" class=\"Section2\"\u003e \u003ch2\u003e3.8 Core Category: Physical and Mental Harmony\u003c/h2\u003e \u003cp\u003eAchieving physical and mental harmony confirmed that coping with stress is effective, which is not only a desirable result, but also the purpose of the entire active coping process. This is the effective embodiment of achieving balance in dealing with stressful events, both physically and psychologically.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003ePhysical and psychological conditions are equally important health-related concepts \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. However, under academic involution, the impact of multiple stress leads to an imbalance between the minds and bodies of medical students. Due to the dearth of existing knowledge relating to the experience and progress of coping with stress from academic involution in medical students, the originality and usefulness of the study were explained by constructing a theoretical framework with stressful events regarding the achievement of \"physical and mental harmony\" and offering novel insights into medical students' coping with stress.\u003c/p\u003e \u003cp\u003eUnder the stress from academic involution, the guiding role of enlightening exploration refers to exploratory ways to coping with problems through seeking social support and awakening a positive self \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. This subcategory of enlightening exploration is consistent with previous studies about coping with stress among medical students that have pointed out that hobbies and interesting activities can help medical students relieve stress and improve their body-mind balance \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. In addition to the importance of identifying medical students' enlightening exploration, this study explained the positive role of these behaviors from the students\u0026rsquo; perspective, which is of great significance for augmenting medical students' abilities to adapt stress from academic involution.\u003c/p\u003e \u003cp\u003eThe subcategories of facilitating have noted that adaptive coping can help medical students relieve stress which are consistent with previous studies \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. The process of internal adjustment and social support can help medical students in their self-reconstruction and with emotional support, which can ameliorate their body mind balance \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. On one hand, the interviewees in this study expressed self-doubt caused by being suspected and ignored by others during stressful events. This mental condition threatens medical students suffering stress from academic involution further and determines that the purpose of these categories, which play a facilitating role, is to obtain emotional satisfaction. On the other hand, students participating in the study expressed their desire for emotional elements, including encouragement, understanding, recognition, and praise, which reflected the value they want to gain in academic involution and this value is key to transform the stress of academic involution into positive motivation for medical students. Correspondingly, researchers should pay more attention to how to strengthen medical students\u0026rsquo; ability for internal adjustment to stress from academic involution and daily life. At the same time, researchers could heighten effective social support systems to cope with stress from academic involution, which may help boost actively stress responses for medical students.\u003c/p\u003e \u003cp\u003eThis study found that the two categories that hinder medical students from coping with stress are individual degeneration and asymmetrical resources, which provides inspiration for future research to reduce the barriers to medical students coping with stress under the educational environment of academic involution. First, the category of individual degeneration indicates the poor expression of medical students' mental health literacy \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e, so it is necessary to investigate the mental health literacy of medical students who suffer from academic involution to provide targeted assistance and help them resist individual degeneration and improve their ability to cope with stressful events \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Second, their ability to cope with stressful events could be improved through mental health services \u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. However, in this study, it was discovered that the mental health services involve another obstacle, asymmetrical resources, which cannot match the personalized psychological health guidance needs of students. Students say that when they encounter stress, they want to obtain effective resources centered on them that help them analyze their difficulties rather than the popular science knowledge of stress prevention for all. In the educational environment of academic involution, researchers should re-examine the psychological dilemma and the psychological health needs of medical students, based on this strengthening mental health services and enriching their forms to reduce the generation of asymmetrical resources and provide accurate mental health services to eliminate obstacles for medical students to cope with stress. It is worth noting that from the theoretical framework and the interviews in this study, personalized and confidential mental health services can become a favorable resource from the perspective of medical students, helping them transform the stress of academic involution into positive motivation.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study explored the process of psychological adjustment and the experiences of medical students coping with stress under academic involution in China and develop a theoretical model of medical students coping with stress under the academic involution. The findings showed that under the academic involution the goal of medical students in coping with stress is to achieve and maintain physical and mental harmony, in addition, academic pressure can be transformed into a positive driving force for medical students through early identification and intervention. To achieve physical and mental harmony, it is necessary to provide positive and effective mental health resources and focus on the psychological dilemma of medical students coping with pressure, stimulating their internal efforts to cope with pressure, and taking the initiative to obtain social help and emotional support. In addition, reducing asymmetrical resources and helping medical students facing stress cope with individual degeneration can weaken their barriers to positive coping with stress and help medical students transform the stress of academic involution into positive motivation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by Ministry of Education Humanities and Social Sciences in China (19YJCZH261), National Social Science Foundation (21BSH007).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical\u003c/strong\u003e\u003cstrong\u003eapproval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the ethics review committee of Nantong university in the East China (2019-17).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors thank Mengyuan Ma and Wenxuan Zhao for their help in recruiting the participants. Finally, we sincerely thank the 30 individual who generously shared their time, experiences, and stories for this research project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy design: Wei Zhang, Zhiyan Cao,\u0026nbsp;Fangfang Zhao\u003c/p\u003e\n\u003cp\u003eData collection: Wei Zhang, Xiaoli Ye, Tong Shen\u003c/p\u003e\n\u003cp\u003eData analysis: Wei Zhang, Xiaoli Ye, Tong Shen\u003c/p\u003e\n\u003cp\u003eStudy supervision: Fangfang Zhao\u003c/p\u003e\n\u003cp\u003eManuscript writing: Wei Zhang, Fangfang Zhao\u003c/p\u003e\n\u003cp\u003eCritical revisions for important intellectual content:\u0026nbsp;Wei Zhang, Fangfang Zhao\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are not publicly available due to ethical and privacy reasons but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYi, D., Wu, J., Zhang, M., Zeng, Q., Wang, J., Liang, J., \u0026amp; Cai, Y. (2022). Does Involution Cause Anxiety? An Empirical Study from Chinese Universities. International journal of environmental research and public health, 19(16), 9826. https://doi.org/10.3390/ijerph19169826\u003c/li\u003e\n\u003cli\u003eThoits, P. A. (2010). Stress and health: Major findings and policy implications. Journal of health and social behavior, 51, 41-53. https://doi.org/10.1177/0022146510383499\u003c/li\u003e\n\u003cli\u003ePark, N. (2004). The role of subjective well-being in positive youth development. The Annals of the American Academy of Political and Social Science, 591(1), 25-39. https://doi:10.1177/0002716203260078\u003c/li\u003e\n\u003cli\u003eJ. Aleccia, \u0026ldquo;Teens more stressed-out than adults,\u0026rdquo; NBC News, http://www.nbcnews.com/health/kids-health/teens-more-stressed-outadults-survey shows-n26921, 2014.\u003c/li\u003e\n\u003cli\u003eLin XJ, Zhang CY, Yang S, Hsu ML, Cheng H, Chen J, Yu H. Stress and its association with academic performance among dental undergraduate students in Fujian, China: a cross-sectional online questionnaire survey. BMC Med Educ. 2020 Jun 3;20(1):181. doi: 10.1186/s12909-020-02095-4. PMID: 32493378; PMCID: PMC7271445.\u003c/li\u003e\n\u003cli\u003eSilverstein ST, Kritz-Silverstein D. A longitudinal study of stress in first-year dental students. J Dent Educ. 2010;74(8):836-848.\u003c/li\u003e\n\u003cli\u003eCrestani CC. Adolescent vulnerability to cardiovascular consequences of chronic emotional stress: Review and perspectives for future research. Neurosci Biobehav Rev. 2017 Mar;74(Pt B):466-475. doi: 10.1016/j.neubiorev.2016.03.027. Epub 2016 Apr 1. PMID: 27044451.\u003c/li\u003e\n\u003cli\u003eHsu T, Raposa EB. Effects of stress on eating behaviours in adolescents: a daily diary investigation. Psychol Health. 2021 Feb;36(2):236-251. doi: 10.1080/08870446.2020.1766041. Epub 2020 May 18. PMID: 32419507.\u003c/li\u003e\n\u003cli\u003eInoue N. Stress and atherosclerotic cardiovascular disease. J Atheroscler Thromb. 2014;21(5):391-401. doi:10.5551/jat.21709\u003c/li\u003e\n\u003cli\u003eSteptoe A, Kivim\u0026auml;ki M. Stress and cardiovascular disease. Nat Rev Cardiol. 2012;9(6):360-370. Published 2012 Apr 3. doi:10.1038/nrcardio.2012.45\u003c/li\u003e\n\u003cli\u003evon K\u0026auml;nel R. Psychosocial stress and cardiovascular risk : current opinion. Swiss Med Wkly. 2012;142:w13502. Published 2012 Jan 20. doi:10.4414/smw.2012.13502\u003c/li\u003e\n\u003cli\u003eLargo-Wight E, Peterson PM, Chen WW. Perceived problem solving, stress, and health among college students. Am J Health Behav. 2005;29(4):360-370. doi:10.5993/ajhb.29.4.8\u003c/li\u003e\n\u003cli\u003eAloufi MA, Jarden RJ, Gerdtz MF, Kapp S. Reducing stress, anxiety and depression in undergraduate nursing students: Systematic review. Nurse Educ Today. 2021 Jul;102:104877. doi: 10.1016/j.nedt.2021.104877. Epub 2021 Mar 18. PMID: 33905898.\u003c/li\u003e\n\u003cli\u003eGardani M, Bradford DRR, Russell K, Allan S, Beattie L, Ellis JG, Akram U. A systematic review and meta-analysis of poor sleep, insomnia symptoms and stress in undergraduate students. Sleep Med Rev. 2022 Feb;61:101565. doi: 10.1016/j.smrv.2021.101565. Epub 2021 Nov 2. PMID: 34922108.\u003c/li\u003e\n\u003cli\u003eLayard R, Clark A, Cornaglia F, Powdthavee N, Vernoit J (2014) What predicts a successful life? A lifecourse model of wellbeing. Econ J 124:F720\u0026ndash;F738\u003c/li\u003e\n\u003cli\u003eWoodward LJ, Fergusson DM (2001) Life course outcomes of young people with anxiety disorders in adolescence. J Am Acad Child Adolesc Psychiatry 40:1086\u0026ndash;1093\u003c/li\u003e\n\u003cli\u003eFineberg NA, Haddad PM, Carpenter L, Gannon B, Sharpe R, Young AH et al (2013) The size, burden and cost of disorders of the brain in the UK. J Psychopharmacol 27:761\u0026ndash;770\u003c/li\u003e\n\u003cli\u003eCharmaz, K. (2014). Constructing Grounded Theory. 2nd Edn. London. Sage.\u003c/li\u003e\n\u003cli\u003eTurner C, Astin F. Grounded theory: what makes a grounded theory study?. Eur J Cardiovasc Nurs. 2021;20(3):285-289. doi:10.1093/eurjcn/zvaa034\u003c/li\u003e\n\u003cli\u003eCharmaz, K. (2006). Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis. London: Sage.\u003c/li\u003e\n\u003cli\u003eBirks, M., Mills, J., 2015. Grounded Theory: a Practical Guide, 2nd ed. Sage Publications, London.\u003c/li\u003e\n\u003cli\u003eChiovitti, R.F., Piran, N., 2003. Rigour and grounded theory research. J. Adv. Nurs. 44 (4), 427\u0026ndash;435.\u003c/li\u003e\n\u003cli\u003eSandelowski, M., 1986. The problem of rigor in qualitative research. ANS Adv. Nurs. Sci. 8 (3), 27\u0026ndash;37.\u003c/li\u003e\n\u003cli\u003eOhrnberger J, Fichera E, Sutton M. The relationship between physical and mental health: A mediation analysis. Soc Sci Med. 2017;195:42-49. doi:10.1016/j.socscimed.2017.11.008\u003c/li\u003e\n\u003cli\u003eAshkar PJ, Kenny DT. Views from the inside: young offenders\u0026apos; subjective experiences of incarceration. Int J Offender Ther Comp Criminol. 2008;52(5):584-597. doi:10.1177/0306624X08314181\u003c/li\u003e\n\u003cli\u003eFares J, Saadeddin Z, Al Tabosh H, et al. Extracurricular activities associated with stress and burnout in preclinical medical students. J Epidemiol Glob Health. 2016;6(3):177-185. doi:10.1016/j.jegh.2015.10.003\u003c/li\u003e\n\u003cli\u003eRamos R, Brauchli R, Bauer G, Wehner T, H\u0026auml;mmig O. Busy yet socially engaged: volunteering, work-life balance, and health in the working population. J Occup Environ Med. 2015;57(2):164-172. doi:10.1097/JOM.0000000000000327\u003c/li\u003e\n\u003cli\u003eNeufeld A, Malin G. How medical students cope with stress: a cross-sectional look at strategies and their sociodemographic antecedents. BMC Med Educ. 2021;21(1):299. Published 2021 May 25. doi:10.1186/s12909-021-02734-4\u003c/li\u003e\n\u003cli\u003eKutcher S, Wei Y, Costa S, Gusm\u0026atilde;o R, Skokauskas N, Sourander A. Enhancing mental health literacy in young people. Eur Child Adolesc Psychiatry. 2016 Jun;25(6):567-9. doi: 10.1007/s00787-016-0867-9. PMID: 27236662.\u003c/li\u003e\n\u003cli\u003eNobre J, Oliveira AP, Monteiro F, Sequeira C, Ferr\u0026eacute;-Grau C. Promotion of Mental Health Literacy in Adolescents: A Scoping Review. Int J Environ Res Public Health. 2021;18(18):9500. Published 2021 Sep 9. doi:10.3390/ijerph18189500xin\u003c/li\u003e\n\u003cli\u003eJorm AF. Mental health literacy: empowering the community to take action for better mental health. Am Psychol. 2012;67(3):231-243. doi:10.1037/a0025957\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Medical Students, Mental Health, Academic Involution, Stress Coping, Grounded Theory","lastPublishedDoi":"10.21203/rs.3.rs-4652359/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4652359/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Academic involutionis highly related to medical students’ mental health. The process of psychological adjustment and the ability to cope with stress affects individual health and personal development for medical students.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim: \u003c/strong\u003eTo explore the process of psychological adjustment and the experiences of medical students coping with stress under academic involution in China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e The interviews data analysis included initial coding, focused coding, and theoretical coding using the constant comparative method and memo writing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings: \u003c/strong\u003e“Physical and mental harmony” was identified as the core category. The following seven categories were conceptualized: enlightening exploration, internal adjustment, seeking social support, emotional support, positive self-awakening, individual degeneration, and asymmetrical resources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The findings showed that under the academic involution the goal of medical students in coping with stress is to achieve and maintain physical and mental harmony, in addition, stress of academic involution can be transformed into a positive driving force for medical students through early identification and intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for policy:\u003c/strong\u003e In a stressful environment, schools should be guided by the psychological needs of medical students and provide mental health services that medical students can choose from.\u003c/p\u003e","manuscriptTitle":"Psychological Adjustment of Medical Students in Coping with Stress under Chinese Academic Involution: A constructivist grounded theory study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-23 22:11:45","doi":"10.21203/rs.3.rs-4652359/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cd5f6f21-b454-4c19-81dc-d27cc5bd087a","owner":[],"postedDate":"July 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":34899335,"name":"Health sciences/Health care"},{"id":34899336,"name":"Health sciences/Health occupations"},{"id":34899337,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2024-10-03T07:23:47+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-23 22:11:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4652359","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4652359","identity":"rs-4652359","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}