The interplay of grit, resilience, and burnout among medical students during exams: a cross-sectional study in Mansoura University, Egypt

The interplay of grit, resilience, and burnout among medical students during exams: a cross-sectional study in Mansoura University, Egypt | 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 The interplay of grit, resilience, and burnout among medical students during exams: a cross-sectional study in Mansoura University, Egypt Yusof M. Omar, Ahmed Abdelmageed, Omar Shaker, Samir Oransa, Mohamed Nasr, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6380020/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Jan, 2026 Read the published version in Scientific Reports → Version 1 posted 11 You are reading this latest preprint version Abstract Medical students experience significant stress, particularly during exams, contributing to burnout. This study examined the relationships between grit, resilience, and burnout among 653 Mansoura University medical students during exams. Data were collected via an online questionnaire assessing burnout using the Burnout Assessment Tool (BAT-23), grit with the Short Grit Scale (Grit-S), and resilience with the Brief Resilience Scale (BRS). The mean burnout score was 3.62 (SD = 0.67), with exhaustion (M = 3.96, SD = 0.74) and cognitive impairment (M = 3.66, SD = 0.92) as the most prominent symptoms. Female students had lower resilience (M = 2.87 vs. 3.11, p < 0.001) and higher burnout (M = 3.69 vs. 3.55, p = 0.009), while older students showed lower grit (M = 2.86 vs. 3.00, p = 0.008) and higher burnout (M = 3.69 vs. 3.58, p = 0.048). Burnout was negatively correlated with grit (r = -0.595, p < 0.001) and resilience (r = -0.519, p < 0.001), while grit and resilience were positively correlated (r = 0.426, p < 0.001). Multivariate regression identified grit (β = -0.458, p < 0.001) and resilience (β = -0.315, p < 0.001) as protective factors. Strengthening grit and resilience may help students manage academic stress and reduce burnout. Health sciences/Health care/Public health Health sciences/Health care/Quality of life Biological sciences/Psychology Grit Resilience Burnout Medical students Egypt Introduction Medical education is widely recognized for its rigorous and demanding nature, subjecting students to intense academic pressure. This pressure peaks during exams, often considered the most stressful periods in a medical student’s academic journey 1 . As students navigate the challenges and pressures of medical education, they become particularly vulnerable to experiencing burnout—a pervasive issue plaguing medical students and the healthcare workforce worldwide 2,3 . As defined by Schaufeli et al. 4 , burnout in students is characterized by exhaustion due to academic demands, a cynical and detached attitude towards their studies, and pervasive feelings of incompetence. Burnout is alarmingly prevalent among medical students, with global estimates indicating that over half experience burnout, and some studies reporting rates exceeding 88% 5 . In Egypt, burnout is particularly prevalent, with studies among medical students consistently reporting high degrees of emotional exhaustion and depersonalization 6,7 . Compounding this issue, Egyptian medical students often neglect self-care and delay seeking mental health support, citing lack of time or a preference for self-reliance, tendencies exacerbated during exams 8,9 . The demands–resources model suggests that burnout occurs when academic demands exceed students’ available coping resources 10 . During exams, the increased study load and constant pressure due to continuous examinations create an environment where burnout is particularly likely to occur. Alarmingly, burnout during exams has been linked to serious consequences, affecting both cognitive function and ethical decision-making. For one, burnout can impair students’ ability to retain and apply knowledge effectively, potentially leading to worse academic performance 11 . Additionally, studies among U.S. medical students suggest that students experiencing burnout not only perform more poorly on exams, but are also significantly more likely to cheat 12,13 . The impact of burnout on students extends beyond academic performance, contributing to serious mental health consequences such as depression 14 , substance abuse 15 , and suicidal ideation 16 . Moreover, burnout can often persist into professional life, contributing to higher attrition rates and exacerbating healthcare workforce shortages 17 . In Egypt, where a critical physician shortage persists, burnout among medical students exacerbates the healthcare crisis 18 . Indeed, studies indicate that up to 90% of Egyptian medical students express a desire to emigrate, with burnout being a significant driving factor 3,19 . Given the high prevalence and significant consequences of burnout, identifying psychological traits that help students manage exam-related stress and mitigate its negative effects is crucial. Two psychological traits, grit and resilience, might fulfill such a role. Grit, defined as passion and perseverance toward long-term goals 20 , can motivate students to persevere through their exams. Meanwhile, resilience, the ability to recover from adversity and adapt to challenges 21 , may enable students to maintain effort throughout exams despite setbacks. Together, these traits may empower students to navigate the pressures of exams, by sustaining motivation and overcoming academic setbacks 22,23 . Previous research has demonstrated the protective roles of grit and resilience in mitigating burnout across various academic and professional contexts. Grit has been linked to lower burnout rates and better stress management 23 , while resilience has been associated with less emotional exhaustion 24 . However, no studies have specifically examined how these factors influence burnout among Egyptian medical students, particularly during exams. Thus, this study aims to fill this gap by exploring the relationship between grit, resilience, and burnout among medical students in Egypt during exams, providing insights into how these psychological traits influence burnout, and ultimately contributing to a more sustainable medical workforce. Methods Study design and setting A cross-sectional study with descriptive and correlational components was conducted at the Faculty of Medicine, Mansoura University, during the final exam period in January 2025. Pilot study and sample size calculation A pilot study involving 40 students, with a minimum of 5 students from each academic year, was conducted. The standard deviation of the burnout scores was found to be 0.681. Sample size calculations were performed using R programming software with the sampling book package 25,26 . With a 5% margin of error and a 95% confidence level, the required sample size for a finite population of 6,868 individuals was determined to be 646 participants. Study population and data collection approach The study utilized an online, anonymous, self-administered questionnaire in English, hosted on the FormNX platform. The questionnaire was sent out two weeks into the exams month, and remained accessible until the last day of the exams. The questionnaire link was distributed via the official Telegram platform utilized by medical students in their respective academic years, ensuring accessibility to the entire study population. Students could voluntarily participate by completing the questionnaire after reading a message that introduced the study’s aim, reassured participants about their anonymity, and informed them that they could view their grit, resilience, and burnout scores upon completing the survey. All first- through fifth-year students enrolled at the Faculty of Medicine, Mansoura University, were eligible to participate. Interns and postgraduates were excluded. A total of 653 students opted to complete the questionnaire. Data collection tool An anonymous, self-administered English online questionnaire was used to collect data on socio-demographics (such as age, sex, academic year, and residence), grit, resilience, and burnout. Grit was assessed using the Short Grit Scale (Grit-S), an 8-item valid measure for assessing grit 27 . The scale is scored on a 5-point Likert scale (1 = not at all like me, 5 = very much like me), the sum of all items is divided by 8 to produce a final score between 1 and 5, with higher scores reflecting greater grit. The scale comprises two subscales—perseverance of effort and consistency of interest—each consisting of four items, with subscale scores following the same range as the total grit score. The Grit-S has displayed an overall excellent internal consistency reliability, with a Cronbach alpha of 0.82 for the total scale, and subscales of consistency of interest (0.84) and perseverance of effort (0.71) 28 . Resilience was measured using the Brief Resilience Scale (BRS), a 6-item valid measure for assessing resilience 21 . The scale is scored on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), with the sum of all items divided by 6 to produce a final score between 1 and 5, with higher scores reflecting higher resilience. The BRS is a reliable instrument displaying Cronbach’s alpha values ranging from 0.80 to 0.91 across four different samples in previous studies 29 . Burnout was evaluated using the Burnout Assessment Tool Student version (BAT-23), a valid measure for assessing burnout 30,31 . The BAT-23 comprises 23 items across four dimensions: exhaustion (8 items), mental distancing (5 items), cognitive impairment (5 items), and emotional impairment (5 items). Responses were rated on a 5-point Likert scale (1 = never, 5 = always). The total score, as well as the scores for each subscale, is calculated by taking the mean of values of all responses, where a higher score reflects a higher level of burnout (range 1–5). The BAT-23 and its subscales show good reliability with Cronbach’s alpha values ranging from 0.90 to 0.92 for the subscales and 0.95 for the total BAT-23 30 . Convergent validity and discriminant validity were demonstrated with other burnout scales, such as the Maslach Burnout Inventory and the Oldenburg Burnout Inventory. The BAT–23 showed the best overall fit, with the most favorable chi-square to degrees of freedom ratio, the highest comparative fit index and Tucker-Lewis index, and the lowest root mean square error of approximation 31 . Results from the pilot study showed Cronbach’s alpha values of 0.79 for the Grit-S, 0.68 for the BRS, and 0.92 for the BAT, indicating acceptable internal consistency 32 . The slightly lower alpha for the BRS (0.68) was expected given its small number of items, as shorter scales often yield lower reliability estimates. Meanwhile, the BAT’s high alpha (0.92) is consistent with previous studies using the same scale 30 . Statistical Analysis Statistical analyses were performed using Jamovi 2.3.28 software 33 . Categorical variables were summarized as frequencies and percentages, while continuous variables were reported as means and standard deviations (SDs). Normality was assessed visually using Quantile-Quantile (Q-Q) plots. Independent Student t-tests and one-way ANOVA were used to compare mean scores of grit, resilience, and burnout across individual and multiple groups, respectively. Pearson’s correlation coefficient was used to examine associations between grit, resilience, and burnout. To examine the relationship between burnout and its predictors, linear regression analysis was conducted. Multicollinearity was assessed using Variance Inflation Factors (VIFs). A p-value of ≤ 0.05 was considered statistically significant. Results Participant characteristics and differences in grit, resilience, and burnout scores The study included 653 students with a mean age of 20.3 ± 1.7 years, nearly equally distributed by sex and residence. Fourth-year students represented the smallest proportion of participants (8.9%). The overall mean scores for burnout, grit, and resilience were 3.62 (SD = 0.67), 2.95 (SD = 0.68), and 2.99 (SD = 0.68), respectively Among core burnout symptoms, exhaustion had the highest mean score (3.96 ± 0.74), while mental distancing had the lowest (3.21 ± 0.79) (Data not shown in tables). Females reported significantly lower resilience scores (2.87 vs. 3.11, p < 0.001) as well as significantly higher burnout scores (3.69 vs. 3.55, p = 0.009) compared to males. Similarly, older students reported significantly lower grit scores (2.86 vs. 3.00, p = 0.008) and, in turn, significantly higher burnout scores (3.69 vs. 3.58, p = 0.048) than younger students (Table 1). Table 1. Study participants’ sociodemographic characteristics and differences in burnout, grit, and resilience (N=653). Characteristic n (column%) Burnout mean (SD) 1 p-value Grit mean (SD) p-value Resilience mean (SD) p-value Overall 3.62 (0.67) 2.95 (0.68) 2.99 (0.68) Sex Male 335 (51.3%) 3.55 (0.67) 0.009 2.96 (0.72) 0.59 3.11 (0.7) <0.00 1 Female 318 (48.7%) 3.69 (0.66) 2.93 (0.65) 2.87 (0.65) Age 20 and younger 407 (62.3%) 3.58 (0.65) 0.048 3 (0.68) 0.008 3.02 (0.67) 0.15 21 and older 246 (37.7%) 3.69 (0.69) 2.86 (0.68) 2.94 (0.7) Academic year 1st year 88 (13.5%) 3.46 (0.63) 0.102 3.01 (0.57) 0.524 3.08 (0.66) 0.262 2nd year 213 (32.6%) 3.63 (0.67) 2.98 (0.7) 3.03 (0.69) 3rd year 160 (24.5%) 3.62 (0.68) 2.95 (0.72) 2.96 (0.69) 4th year 58 (8.9%) 3.61 (0.67) 2.93 (0.69) 3.02 (0.65) 5th year 134 (20.5%) 3.71 (0.69) 2.87 (0.69) 2.9 (0.69) Residence Rural 288 (44.1%) 3.64 (0.67) 0.418 2.94 (0.67) 0.868 2.97 (0.68) 0.413 Urban 365 (55.9%) 3.6 (0.67) 2.95 (0.7) 3.01 (0.68) Correlation between grit, resilience, and burnout Burnout was negatively correlated with both grit (r = -0.595) and resilience (r = -0.519), indicating that students with higher levels of grit and resilience experienced lower burnout. In terms of grit, consistency of interest correlated more negatively with burnout than persistence of effort (r = -0.576 vs -0.406). Additionally, grit and resilience were positively correlated (r = 0.426), suggesting that students with greater grit also tended to have higher resilience (Table 2). Among the core burnout symptoms, grit showed the strongest negative correlation with cognitive impairment (r = -0.6), followed by exhaustion (r = -0.513). Resilience was most strongly correlated with emotional impairment (r = -0.507), followed by exhaustion (r = -0.439). Table 2. Correlation between burnout, grit, and resilience scores among study participants. All correlations marked with * are statistically significant (p < 0.001). Total burnout Exhaustion Mental distancing Cognitive impairment Emotional impairment Resilience Grit -0.595* -0.513* -0.438* -0.6* -0.354* 0.426* Perseverance -0.406* -0.314* -0.342* -0.452* -0.211* 0.370* Consistency -0.576* -0.530* -0.386* -0.544* -0.37* 0.342* Resilience -0.519* -0.439* -0.311* -0.395* -0.507* — Predictors of Burnout In the linear regression analysis, the VIFs for all predictors ranged from 1 to 2, indicating no significant multicollinearity. The model explained 44.6% of the variance in burnout (R² = 0.446, Adjusted R² = 0.439). Grit (β = -0.458, p < 0.001) and resilience (β = -0.315, p < 0.001) were identified as significant predictors of burnout, with higher levels of both traits associated with lower burnout scores (Table 3). Table 3.Linear regression analysis of factors associated with burnout among the medical students of Mansoura University during exams. Variables β p-value Age (Continuous) 0.008 0.866 Sex (Male=0, Female=1) 0.035 0.249 Academic year (Ordinal) 0.02 0.683 Residence (Urban=0, Rural=1) 0.016 0.588 Grit -0.458 <0.001 Resilience -0.315 <0.001 Discussion Burnout is a widespread challenge in medical education, intensified by the demanding academic pressures, especially during exams. Medical students are particularly vulnerable during these times, underscoring the need to identify factors that could help alleviate burnout. This study sought to explore the relationship between grit, resilience, and burnout, offering insights that could inform strategies to enhance student well-being and foster psychological resilience in future physicians. The students in our study reported significant levels of burnout, with exhaustion and cognitive impairment being the most prevalent symptoms. These findings align with a study among medical students in India 34 , which also identified exhaustion as the most frequently reported symptom, followed by cognitive impairment. Similarly, previous studies among medical students in Egypt have shown that those experiencing a heavy academic burden reported significantly higher levels of burnout, highlighting the impact of academic pressure on student well-being 6,35 . In this study, female students exhibited lower resilience, which was linked to higher burnout, while older students demonstrated lower grit, correlating with increased burnout. These findings align with previous research on Egyptian medical students 29,36 , where female students consistently reported lower resilience, contributing to greater stress and emotional impairment. However, our results contrast with those of a study on Korean medical students 37 , where older students showed lower burnout and greater grit, though the difference compared to younger students was not statistically significant. The lower resilience observed in female students may be influenced by societal and cultural expectations and gender-based stressors, making them more vulnerable to burnout under high-stakes pressure 9,29 . Meanwhile, older students’ lower grit during exams may stem from competing responsibilities, such as family and financial obligations, which can reduce their ability to persist through academic challenges. A study on medical students in the United States similarly found that older students reported lower grit and, consequently, less tolerance for uncertainty 38 . These findings underscore the need for targeted interventions. Female students could benefit from resilience-building programs, which have been shown to enhance resilience, grit, and quality of life among Egyptian nursing students 39 . Meanwhile, tailored support systems for older students, particularly during exam periods, could help mitigate the impact of external responsibilities on their academic performance and mental wellbeing. In our study, burnout was significantly negatively correlated with both grit and resilience, suggesting that students with higher levels of these traits experienced lower levels of burnout. This aligns with previous longitudinal studies among medical students, which also found a negative relationship between burnout and grit 22,40 . Moreover, grit has been linked to improved academic performance, underscoring its role in managing stress and maintaining focus during challenging periods 41 . Similarly, a study among pharmacy students reported lower stress levels during exams among more resilient students 42 . Additionally, a quasi-experimental study demonstrated that resilience was negatively associated with depression, stress, anxiety, and burnout, further highlighting its protective role in alleviating the psychological strain often experienced during high-stress situations like exams 43 . The significant negative correlation between burnout and grit/resilience during exams suggests that students with higher levels of these traits are better equipped to cope with the intense pressures of high-stakes assessments. Grit helps students maintain motivation and persistence despite setbacks, while resilience enables them to adapt to stress and recover more effectively from adversity 20,44 . Together, these traits likely act as protective factors, reducing emotional exhaustion and preventing feelings of overwhelm. Conversely, students with lower levels of grit and resilience may struggle to meet the demands of exams, leaving them more susceptible to burnout. This notion is further supported by the positive correlation between resilience and grit observed in our study. Previous research suggests that grit, being a dynamic trait, can be cultivated to enhance resilience and reduce academic stress during challenging periods 45 . While some studies have not found a clear connection between grit and resilience 46 , the broader body of evidence strongly supports their interdependence, especially in the context of managing stress and overcoming adversity 47,48 . These findings underscore the importance of fostering both grit and resilience in students to help them navigate the challenges of medical education and reduce the risk of burnout. In light of the significant challenges facing Egypt’s healthcare system, where many residents and medical students report plans to emigrate upon graduation 3,19 , this study highlights the potential of cultivating resilience and grit as effective strategies to combat burnout and improve academic performance. By fostering these traits, students can develop stronger tools for managing stress and maintaining their well-being, particularly during high-pressure situations like exams. While providing immediate support to medical students during exams may be challenging, fostering grit and resilience early on can better equip them to navigate difficult times, reducing emotional exhaustion and feelings of overwhelm. Integrating targeted interventions to nurture these traits offers a sustainable approach to improving student mental health. In doing so, it would not only help students manage stress but also empower them to excel academically and professionally, ultimately contributing to a healthier, more resilient healthcare workforce in Egypt. Strengths and limitations This study has several strengths, including the validated and reliable tools use to measure burnout, grit, and resilience. Furthermore, the study assesses these traits during exams, a period often understudied due to logistical constraints. Additionally, allowing students to view their burnout scores at the end of the survey may have contributed to raising mental health awareness among participants. However, there are some limitations to consider. The cross-sectional design limits the ability to establish causal relationships between grit, resilience, and burnout. Additionally, reliance on self-reported data may have introduced biases, such as social desirability or inaccurate self-assessment. The sampling method may have excluded students experiencing severe burnout, as they might have been less likely to participate. A more inclusive approach would ensure a broader representation of students, including those facing higher levels of burnout. Moreover, since the study was conducted during exams, the results may not fully capture typical stress levels or coping strategies during less intense academic periods. Future research could address these limitations by employing a longitudinal design to better examine causal relationships between these factors. Conclusion Grit and resilience were associated with significantly less burnout among medical students during exams. The findings suggest that fostering traits like grit and resilience may be effective in mitigating burnout and enhancing students' ability to manage stress, potentially improving both academic performance and well-being. Given the significant levels of burnout medical students experience during exams, interventions aimed at strengthening these traits could provide a sustainable approach to supporting medical students during these periods. However, further research using longitudinal designs and more inclusive sampling methods is needed to better understand the causal relationships between these factors and explore strategies for addressing burnout across different academic contexts. Abbreviations Grit-S – Short Grit Scale BRS – Brief Resilience Scale BAT – Burnout Assessment Tool SD – Standard Deviation STROBE – Strengthening the Reporting of Observational Studies in Epidemiology VIFs – Variance Inflation Factors Declarations Acknowledgments The authors would like to express their sincere gratitude to Ahmed M. Eid, Alaa Abdelmonem Montaser, Basmala Abdelrahman Lashin, Reem Al-Tantawy Mohammed, Aisha Elsayed Mohamed, Noor Eldien Khaled Gadalla, Abdallah Gamal Abdallah, Mohamed Ghazy, and Ahmed Mahmoud Hasan for their invaluable assistance in the pilot study and data collection of this study. Author contributions The conception and design of the study were done by YMO, AA, OS, SO, MV, AAS, and MM. Acquisition of data was done by AA, OS, AAS, and SA. Analysis and interpretation of data were done by YMO and AA. Drafting the manuscript was done by YMO, OS, SO, MN, AAS, and MM. Revising the manuscript critically for important intellectual content was done by YMO and AE. All authors read and approved the final manuscript. Funding No funding or sponsorship was received from any companies, groups, individuals, organizations, or any other entities. Data Availability The dataset supporting the findings of this study has been attached as a supplementary file with this submission. Conflict of interests The authors declare that they have no conflict of interest. Human Ethics and Consent to Participate declarations The study’s aim was explained to each participant, highlighting the confidentiality of the data. All participants provided electronic informed consent prior to enrollment. 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Smith, B. W., Tooley, E. M., Christopher, P. J. & Kay, V. S. Resilience as the ability to bounce back from stress: A neglected personal resource? J. Posit. Psychol. 5 , 166–176 (2010). Ibrahim, N., Mohamad, M., Abdul-Razak, S., Mohamed-Yassin, M.-S. & Baharudin, N. Predictors of grit among medical students: a study at a Malaysian Public University. BMC Med. Educ. 24 , 791 (2024). Hayden, D. Coping with being cut from the team: examining grit, resilience and optimism in response to failure in college athletes. Psychology Master’s Theses (2018). Schimschal, S. E., Visentin, D., Kornhaber, R. & Cleary, M. Grit: A concept analysis. Issues Ment. Health Nurs. 42 , 495–505 (2021). Stoffel, J. M. & Cain, J. Review of Grit and Resilience Literature within Health Professions Education. Am. J. Pharm. Educ. 82 , 6150 (2018). Additional Declarations No competing interests reported. Supplementary Files BurnoutstudyData.xlsx Cite Share Download PDF Status: Published Journal Publication published 29 Jan, 2026 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 20 Oct, 2025 Reviewers agreed at journal 06 Oct, 2025 Reviews received at journal 06 Aug, 2025 Reviews received at journal 05 Aug, 2025 Reviewers agreed at journal 04 Aug, 2025 Reviewers agreed at journal 02 Aug, 2025 Reviewers invited by journal 02 Aug, 2025 Editor invited by journal 05 May, 2025 Editor assigned by journal 05 Apr, 2025 Submission checks completed at journal 05 Apr, 2025 First submitted to journal 05 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Omar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYLCCCjDJfABISMgQp+UMmGRLAGnhIUULjwGYJKja4Eb6wwcHc2yi+Wef+fzqRo0FDwP74aMb8GvJMTY4uC0td8a53G3WOceADuNJS7tBQAub9Mdth3MbzvBuM85hA2qR4DEjoCX9mcRBoJb5Z3ieGef8I0pLghlYy4YzPMyPc9uI0CJ55g3ELxvPsJkx5/ZJ8LAR8gvfcVCIbbPJnXeG+fHnnG91cvzsh4/h1aJwAMFmkwCT+JSDgHwDgs38gZDqUTAKRsEoGJkAAFkdTks+3LwpAAAAAElFTkSuQmCC","orcid":"","institution":"Faculty of Medicine, Mansoura University","correspondingAuthor":true,"prefix":"","firstName":"Yusof","middleName":"M.","lastName":"Omar","suffix":""},{"id":522632859,"identity":"1ddd903d-e7c7-48d9-80e2-1313152930ef","order_by":1,"name":"Ahmed Abdelmageed","email":"","orcid":"","institution":"Faculty of Medicine, Mansoura University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Abdelmageed","suffix":""},{"id":522632860,"identity":"47abca01-583d-4857-a8eb-4de688902a34","order_by":2,"name":"Omar Shaker","email":"","orcid":"","institution":"Faculty of Medicine, Mansoura University","correspondingAuthor":false,"prefix":"","firstName":"Omar","middleName":"","lastName":"Shaker","suffix":""},{"id":522632861,"identity":"3df1441c-f89b-4605-9fe3-061c73c80414","order_by":3,"name":"Samir Oransa","email":"","orcid":"","institution":"Faculty of Medicine, Delta University","correspondingAuthor":false,"prefix":"","firstName":"Samir","middleName":"","lastName":"Oransa","suffix":""},{"id":522632862,"identity":"6f28b617-c462-40f9-a117-63fa0c06896e","order_by":4,"name":"Mohamed Nasr","email":"","orcid":"","institution":"Faculty of Medicine, Delta University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Nasr","suffix":""},{"id":522632863,"identity":"dd347867-f3a7-4c3a-a283-2a1039117a45","order_by":5,"name":"Abdelrahman A. Senbel","email":"","orcid":"","institution":"Faculty of Medicine, Mansoura University","correspondingAuthor":false,"prefix":"","firstName":"Abdelrahman","middleName":"A.","lastName":"Senbel","suffix":""},{"id":522632864,"identity":"cf2f52a5-2867-43f6-be51-4fd2219a7e9a","order_by":6,"name":"Mark Messak","email":"","orcid":"","institution":"Faculty of Medicine, Helwan University","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"","lastName":"Messak","suffix":""},{"id":522632865,"identity":"78f0c8ac-1c4e-404f-b6e0-f249f499fb2d","order_by":7,"name":"Shady Aboheif","email":"","orcid":"","institution":"Faculty of Medicine, Mansoura University","correspondingAuthor":false,"prefix":"","firstName":"Shady","middleName":"","lastName":"Aboheif","suffix":""},{"id":522632866,"identity":"97e39415-b824-4a71-8a6b-f270455159a2","order_by":8,"name":"Abdel-Hady El-Gilany","email":"","orcid":"","institution":"Public Health and Community Medicine Department, Faculty of Medicine, Mansoura University","correspondingAuthor":false,"prefix":"","firstName":"Abdel-Hady","middleName":"","lastName":"El-Gilany","suffix":""}],"badges":[],"createdAt":"2025-04-05 05:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6380020/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6380020/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-026-35125-0","type":"published","date":"2026-01-29T15:58:02+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":101692379,"identity":"0a54612f-b049-49b4-8612-930691c10210","added_by":"auto","created_at":"2026-02-02 16:18:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1089331,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6380020/v1/bbae5e59-3c50-4db6-b3fb-24f7306307a6.pdf"},{"id":92558038,"identity":"7ddf6410-0692-49a2-8e81-a02e26301c8c","added_by":"auto","created_at":"2025-10-01 03:45:07","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":135720,"visible":true,"origin":"","legend":"","description":"","filename":"BurnoutstudyData.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6380020/v1/13474d92ee08fa64210f1683.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The interplay of grit, resilience, and burnout among medical students during exams: a cross-sectional study in Mansoura University, Egypt","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMedical education is widely recognized for its rigorous and demanding nature, subjecting students to intense academic pressure. This pressure peaks during exams, often considered the most stressful periods in a medical student\u0026rsquo;s academic journey \u003csup\u003e1\u003c/sup\u003e. As students navigate the challenges and pressures of medical education, they become particularly vulnerable to experiencing burnout\u0026mdash;a pervasive issue plaguing medical students and the healthcare workforce worldwide \u003csup\u003e2,3\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAs defined by Schaufeli et al. \u003csup\u003e4\u003c/sup\u003e, burnout in students is characterized by exhaustion due to academic demands, a cynical and detached attitude towards their studies, and pervasive feelings of incompetence. Burnout is alarmingly prevalent among medical students, with global estimates indicating that over half experience burnout, and some studies reporting rates exceeding 88% \u003csup\u003e5\u003c/sup\u003e. In Egypt, burnout is particularly prevalent, with studies among medical students consistently reporting high degrees of emotional exhaustion and depersonalization \u003csup\u003e6,7\u003c/sup\u003e. Compounding this issue, Egyptian medical students often neglect self-care and delay seeking mental health support, citing lack of time or a preference for self-reliance, tendencies exacerbated during exams \u003csup\u003e8,9\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe demands\u0026ndash;resources model suggests that burnout occurs when academic demands exceed students\u0026rsquo; available coping resources \u003csup\u003e10\u003c/sup\u003e. During exams, the increased study load and constant pressure due to continuous examinations create an environment where burnout is particularly likely to occur. Alarmingly, burnout during exams has been linked to serious consequences, affecting both cognitive function and ethical decision-making. For one, burnout can impair students\u0026rsquo; ability to retain and apply knowledge effectively, potentially leading to worse academic performance \u003csup\u003e11\u003c/sup\u003e. Additionally, studies among U.S. medical students suggest that students experiencing burnout not only perform more poorly on exams, but are also significantly more likely to cheat \u003csup\u003e12,13\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe impact of burnout on students extends beyond academic performance, contributing to serious mental health consequences such as depression \u003csup\u003e14\u003c/sup\u003e, substance abuse \u003csup\u003e15\u003c/sup\u003e, and suicidal ideation \u003csup\u003e16\u003c/sup\u003e. Moreover, burnout can often persist into professional life, contributing to higher attrition rates and exacerbating healthcare workforce shortages \u003csup\u003e17\u003c/sup\u003e. In Egypt, where a critical physician shortage persists, burnout among medical students exacerbates the healthcare crisis \u003csup\u003e18\u003c/sup\u003e. Indeed, studies indicate that up to 90% of Egyptian medical students express a desire to emigrate, with burnout being a significant driving factor \u003csup\u003e3,19\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eGiven the high prevalence and significant consequences of burnout, identifying psychological traits that help students manage exam-related stress and mitigate its negative effects is crucial. Two psychological traits, grit and resilience, might fulfill such a role. Grit, defined as passion and perseverance toward long-term goals \u003csup\u003e20\u003c/sup\u003e, can motivate students to persevere through their exams. Meanwhile, resilience, the ability to recover from adversity and adapt to challenges \u003csup\u003e21\u003c/sup\u003e, may enable students to maintain effort throughout exams despite setbacks. Together, these traits may empower students to navigate the pressures of exams, by sustaining motivation and overcoming academic setbacks \u003csup\u003e22,23\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrevious research has demonstrated the protective roles of grit and resilience in mitigating burnout across various academic and professional contexts. Grit has been linked to lower burnout rates and better stress management \u003csup\u003e23\u003c/sup\u003e, while resilience has been associated with less emotional exhaustion \u003csup\u003e24\u003c/sup\u003e. However, no studies have specifically examined how these factors influence burnout among Egyptian medical students, particularly during exams. Thus, this study aims to fill this gap by exploring the relationship between grit, resilience, and burnout among medical students in Egypt during exams, providing insights into how these psychological traits influence burnout, and ultimately contributing to a more sustainable medical workforce.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and setting\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional study with descriptive and correlational components was conducted at the Faculty of Medicine, Mansoura University, during the final exam period in January 2025.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePilot study\u003c/strong\u003e \u003cstrong\u003eand sample size calculation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA pilot study involving 40 students, with a minimum of 5 students from each academic year, was conducted. The standard deviation of the burnout scores was found to be 0.681. Sample size calculations were performed using R programming software with the sampling book package \u003csup\u003e25,26\u003c/sup\u003e. With a 5% margin of error and a 95% confidence level, the required sample size for a finite population of 6,868 individuals was determined to be 646 participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population and data collection approach\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study utilized an online, anonymous, self-administered questionnaire in English, hosted on the FormNX platform. The questionnaire was sent out two weeks into the exams month, and remained accessible until the last day of the exams. The questionnaire link was distributed via the official Telegram platform utilized by medical students in their respective academic years, ensuring accessibility to the entire study population. Students could voluntarily participate by completing the questionnaire after reading a message that introduced the study\u0026rsquo;s aim, reassured participants about their anonymity, and informed them that they could view their grit, resilience, and burnout scores upon completing the survey.\u003c/p\u003e\n\u003cp\u003eAll first- through fifth-year students enrolled at the Faculty of Medicine, Mansoura University, were eligible to participate. Interns and postgraduates were excluded. A total of 653 students opted to complete the questionnaire.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection tool\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn anonymous, self-administered English online questionnaire was used to collect data on socio-demographics (such as age, sex, academic year, and residence), grit, resilience, and burnout.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGrit was assessed using the Short Grit Scale (Grit-S), an 8-item valid measure for assessing grit \u003csup\u003e27\u003c/sup\u003e. The scale is scored on a 5-point Likert scale (1 = not at all like me, 5 = very much like me), the sum of all items is divided by 8 to produce a final score between 1 and 5, with higher scores reflecting greater grit. The scale comprises two subscales\u0026mdash;perseverance of effort and consistency of interest\u0026mdash;each consisting of four items, with subscale scores following the same range as the total grit score. The Grit-S has displayed an overall excellent internal consistency reliability, with a Cronbach alpha of 0.82 for the total scale, and subscales of consistency of interest (0.84) and perseverance of effort (0.71) \u003csup\u003e28\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResilience was measured using the Brief Resilience Scale (BRS), a 6-item valid measure for assessing resilience \u003csup\u003e21\u003c/sup\u003e. The scale is scored on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), with the sum of all items divided by 6 to produce a final score between 1 and 5, with higher scores reflecting higher resilience. The BRS is a reliable instrument displaying Cronbach\u0026rsquo;s alpha values ranging from 0.80 to 0.91 across four different samples in previous studies \u003csup\u003e29\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBurnout was evaluated using the Burnout Assessment Tool Student version (BAT-23), a valid measure for assessing burnout \u003csup\u003e30,31\u003c/sup\u003e. The BAT-23 comprises 23 items across four dimensions: exhaustion (8 items), mental distancing (5 items), cognitive impairment (5 items), and emotional impairment (5 items). Responses were rated on a 5-point Likert scale (1 = never, 5 = always). The total score, as well as the scores for each subscale, is calculated by taking the mean of values of all responses, where a higher score reflects a higher level of burnout (range 1\u0026ndash;5). The BAT-23 and its subscales show good reliability with Cronbach\u0026rsquo;s alpha values ranging from 0.90 to 0.92 for the subscales and 0.95 for the total BAT-23 \u003csup\u003e30\u003c/sup\u003e. \u0026nbsp;Convergent validity and discriminant validity were demonstrated with other burnout scales, such as the Maslach Burnout Inventory and the Oldenburg Burnout Inventory. The BAT\u0026ndash;23 showed the best overall fit, with the most favorable chi-square to degrees of freedom ratio, the highest comparative fit index and Tucker-Lewis index, and the lowest root mean square error of approximation \u003csup\u003e31\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eResults from the pilot study showed Cronbach\u0026rsquo;s alpha values of 0.79 for the Grit-S, 0.68 for the BRS, and 0.92 for the BAT, indicating acceptable internal consistency \u003csup\u003e32\u003c/sup\u003e. The slightly lower alpha for the BRS (0.68) was expected given its small number of items, as shorter scales often yield lower reliability estimates. Meanwhile, the BAT\u0026rsquo;s high alpha (0.92) is consistent with previous studies using the same scale \u003csup\u003e30\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003cbr\u003e\u003c/strong\u003eStatistical analyses were performed using Jamovi 2.3.28 software \u003csup\u003e33\u003c/sup\u003e. Categorical variables were summarized as frequencies and percentages, while continuous variables were reported as means and standard deviations (SDs). Normality was assessed visually using Quantile-Quantile (Q-Q) plots. Independent Student t-tests and one-way ANOVA were used to compare mean scores of grit, resilience, and burnout across individual and multiple groups, respectively. Pearson\u0026rsquo;s correlation coefficient was used to examine associations between grit, resilience, and burnout. To examine the relationship between burnout and its predictors, linear regression analysis was conducted. Multicollinearity was assessed using Variance Inflation Factors (VIFs). A p-value of \u0026le; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant characteristics and differences in grit, resilience, and burnout scores\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study included 653 students with a mean age of 20.3 \u0026plusmn; 1.7 years, nearly equally distributed by sex and residence. Fourth-year students represented the smallest proportion of participants (8.9%). The overall mean scores for burnout, grit, and resilience were 3.62 (SD = 0.67), 2.95 (SD = 0.68), and 2.99 (SD = 0.68), respectively Among core burnout symptoms, exhaustion had the highest mean score (3.96 \u0026plusmn; 0.74), while mental distancing had the lowest (3.21 \u0026plusmn; 0.79) (Data not shown in tables).\u003c/p\u003e\n\u003cp\u003eFemales reported significantly lower resilience scores (2.87 vs. 3.11, p \u0026lt; 0.001) as well as significantly higher burnout scores (3.69 vs. 3.55, p = 0.009) compared to males. Similarly, older students reported significantly lower grit scores (2.86 vs. 3.00, p = 0.008) and, in turn, significantly higher burnout scores (3.69 vs. 3.58, p = 0.048) than younger students (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Study participants\u0026rsquo; sociodemographic characteristics and differences in burnout, grit, and resilience (N=653).\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"733\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 17.1896%;\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.779%;\"\u003e\n \u003cp\u003en (column%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.824%;\"\u003e\n \u003cp\u003eBurnout mean (SD)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.5962%;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.0969%;\"\u003e\n \u003cp\u003eGrit mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.45839%;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.6876%;\"\u003e\n \u003cp\u003eResilience mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.3683%;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e3.62 (0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e2.95 (0.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e2.99 (0.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e335 (51.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e3.55 (0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.009\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e2.96 (0.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e3.11 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.00\u003c/strong\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e318 (48.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e3.69 (0.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e2.93 (0.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e2.87 (0.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003e20 and younger\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e407 (62.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e3.58 (0.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.048\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e3 (0.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.008\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e3.02 (0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003e21 and older\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e246 (37.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e3.69 (0.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e2.86 (0.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e2.94 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAcademic year\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003e1st year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e88 (13.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e3.46 (0.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e3.01 (0.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e0.524\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e3.08 (0.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e0.262\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003e2nd year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e213 (32.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e3.63 (0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e2.98 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e3.03 (0.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003e3rd year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e160 (24.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e3.62 (0.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e2.95 (0.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e2.96 (0.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003e4th year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e58 (8.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e3.61 (0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e2.93 (0.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e3.02 (0.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003e5th year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e134 (20.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e3.71 (0.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e2.87 (0.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e2.9 (0.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003eRural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e288 (44.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e3.64 (0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e2.94 (0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e0.868\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e2.97 (0.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e0.413\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1896%;\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.779%;\"\u003e\n \u003cp\u003e365 (55.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.824%;\"\u003e\n \u003cp\u003e3.6 (0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.5962%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.0969%;\"\u003e\n \u003cp\u003e2.95 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.45839%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.6876%;\"\u003e\n \u003cp\u003e3.01 (0.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3683%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelation between grit, resilience, and burnout\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBurnout was negatively correlated with both grit (r = -0.595) and resilience (r = -0.519), indicating that students with higher levels of grit and resilience experienced lower burnout. In terms of grit, consistency of interest correlated more negatively with burnout than persistence of effort (r = -0.576 vs -0.406). Additionally, grit and resilience were positively correlated (r = 0.426), suggesting that students with greater grit also tended to have higher resilience (Table 2). Among the core burnout symptoms, grit showed the strongest negative correlation with cognitive impairment (r = -0.6), followed by exhaustion (r = -0.513). Resilience was most strongly correlated with emotional impairment (r = -0.507), followed by exhaustion (r = -0.439).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Correlation between burnout, grit, and resilience scores among study participants. All correlations marked with * are statistically significant (p \u0026lt; 0.001).\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"687\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 16.4483%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.2082%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal burnout\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.8282%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExhaustion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.1004%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMental distancing\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.0116%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCognitive impairment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16.4483%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmotional impairment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12.9549%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResilience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.4483%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.2082%;\"\u003e\n \u003cp\u003e-0.595*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8282%;\"\u003e\n \u003cp\u003e-0.513*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1004%;\"\u003e\n \u003cp\u003e-0.438*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.0116%;\"\u003e\n \u003cp\u003e-0.6*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.4483%;\"\u003e\n \u003cp\u003e-0.354*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.9549%;\"\u003e\n \u003cp\u003e0.426*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.4483%;\"\u003e\n \u003cp\u003ePerseverance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.2082%;\"\u003e\n \u003cp\u003e-0.406*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8282%;\"\u003e\n \u003cp\u003e-0.314*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1004%;\"\u003e\n \u003cp\u003e-0.342*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.0116%;\"\u003e\n \u003cp\u003e-0.452*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.4483%;\"\u003e\n \u003cp\u003e-0.211*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.9549%;\"\u003e\n \u003cp\u003e0.370*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.4483%;\"\u003e\n \u003cp\u003eConsistency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.2082%;\"\u003e\n \u003cp\u003e-0.576*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8282%;\"\u003e\n \u003cp\u003e-0.530*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1004%;\"\u003e\n \u003cp\u003e-0.386*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.0116%;\"\u003e\n \u003cp\u003e-0.544*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.4483%;\"\u003e\n \u003cp\u003e-0.37*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.9549%;\"\u003e\n \u003cp\u003e0.342*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.4483%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResilience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.2082%;\"\u003e\n \u003cp\u003e-0.519*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8282%;\"\u003e\n \u003cp\u003e-0.439*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1004%;\"\u003e\n \u003cp\u003e-0.311*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.0116%;\"\u003e\n \u003cp\u003e-0.395*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.4483%;\"\u003e\n \u003cp\u003e-0.507*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.9549%;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ePredictors of Burnout\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the linear regression analysis, the VIFs for all predictors ranged from 1 to 2, indicating no significant multicollinearity. The model explained 44.6% of the variance in burnout (R\u0026sup2; = 0.446, Adjusted R\u0026sup2; = 0.439). Grit (\u0026beta; = -0.458, p \u0026lt; 0.001) and resilience (\u0026beta; = -0.315, p \u0026lt; 0.001) were identified as significant predictors of burnout, with higher levels of both traits associated with lower burnout scores (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.Linear regression analysis of factors associated with burnout among the medical students of Mansoura University during exams.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"398\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61.0553%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.5829%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.3618%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 61.0553%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u0026nbsp;\u003c/strong\u003e(Continuous)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.5829%;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.3618%;\"\u003e\n \u003cp\u003e0.866\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 61.0553%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u0026nbsp;\u003c/strong\u003e(Male=0, Female=1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.5829%;\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.3618%;\"\u003e\n \u003cp\u003e0.249\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 61.0553%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAcademic year\u0026nbsp;\u003c/strong\u003e(Ordinal)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.5829%;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.02\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.3618%;\"\u003e\n \u003cp\u003e0.683\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61.0553%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u0026nbsp;\u003c/strong\u003e(Urban=0, Rural=1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.5829%;\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.3618%;\"\u003e\n \u003cp\u003e0.588\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61.0553%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.5829%;\"\u003e\n \u003cp\u003e-0.458\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.3618%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61.0553%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResilience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.5829%;\"\u003e\n \u003cp\u003e-0.315\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.3618%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eBurnout is a widespread challenge in medical education, intensified by the demanding academic pressures, especially during exams. Medical students are particularly vulnerable during these times, underscoring the need to identify factors that could help alleviate burnout. This study sought to explore the relationship between grit, resilience, and burnout, offering insights that could inform strategies to enhance student well-being and foster psychological resilience in future physicians.\u003c/p\u003e\n\u003cp\u003eThe students in our study reported significant levels of burnout, with exhaustion and cognitive impairment being the most prevalent symptoms. These findings align with a study among medical students in India \u003csup\u003e34\u003c/sup\u003e, which also identified exhaustion as the most frequently reported symptom, followed by cognitive impairment. Similarly, previous studies among medical students in Egypt have shown that those experiencing a heavy academic burden reported significantly higher levels of burnout, highlighting the impact of academic pressure on student well-being \u003csup\u003e6,35\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn this study, female students exhibited lower resilience, which was linked to higher burnout, while older students demonstrated lower grit, correlating with increased burnout. These findings align with previous research on Egyptian medical students \u003csup\u003e29,36\u003c/sup\u003e, where female students consistently reported lower resilience, contributing to greater stress and emotional impairment. However, our results contrast with those of a study on Korean medical students \u003csup\u003e37\u003c/sup\u003e, where older students showed lower burnout and greater grit, though the difference compared to younger students was not statistically significant.\u003c/p\u003e\n\u003cp\u003eThe lower resilience observed in female students may be influenced by societal and cultural expectations and gender-based stressors, making them more vulnerable to burnout under high-stakes pressure \u003csup\u003e9,29\u003c/sup\u003e. Meanwhile, older students\u0026rsquo; lower grit during exams may stem from competing responsibilities, such as family and financial obligations, which can reduce their ability to persist through academic challenges. A study on medical students in the United States similarly found that older students reported lower grit and, consequently, less tolerance for uncertainty \u003csup\u003e38\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThese findings underscore the need for targeted interventions. Female students could benefit from resilience-building programs, which have been shown to enhance resilience, grit, and quality of life among Egyptian nursing students \u003csup\u003e39\u003c/sup\u003e. Meanwhile, tailored support systems for older students, particularly during exam periods, could help mitigate the impact of external responsibilities on their academic performance and mental wellbeing.\u003c/p\u003e\n\u003cp\u003eIn our study, burnout was significantly negatively correlated with both grit and resilience, suggesting that students with higher levels of these traits experienced lower levels of burnout. This aligns with previous longitudinal studies among medical students, which also found a negative relationship between burnout and grit \u003csup\u003e22,40\u003c/sup\u003e. Moreover, grit has been linked to improved academic performance, underscoring its role in managing stress and maintaining focus during challenging periods \u003csup\u003e41\u003c/sup\u003e. Similarly, a study among pharmacy students reported lower stress levels during exams among more resilient students \u003csup\u003e42\u003c/sup\u003e. Additionally, a quasi-experimental study demonstrated that resilience was negatively associated with depression, stress, anxiety, and burnout, further highlighting its protective role in alleviating the psychological strain often experienced during high-stress situations like exams \u003csup\u003e43\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe significant negative correlation between burnout and grit/resilience during exams suggests that students with higher levels of these traits are better equipped to cope with the intense pressures of high-stakes assessments. Grit helps students maintain motivation and persistence despite setbacks, while resilience enables them to adapt to stress and recover more effectively from adversity \u003csup\u003e20,44\u003c/sup\u003e. Together, these traits likely act as protective factors, reducing emotional exhaustion and preventing feelings of overwhelm. Conversely, students with lower levels of grit and resilience may struggle to meet the demands of exams, leaving them more susceptible to burnout.\u003c/p\u003e\n\u003cp\u003eThis notion is further supported by the positive correlation between resilience and grit observed in our study. Previous research suggests that grit, being a dynamic trait, can be cultivated to enhance resilience and reduce academic stress during challenging periods \u003csup\u003e45\u003c/sup\u003e. While some studies have not found a clear connection between grit and resilience \u003csup\u003e46\u003c/sup\u003e, the broader body of evidence strongly supports their interdependence, especially in the context of managing stress and overcoming adversity \u003csup\u003e47,48\u003c/sup\u003e. These findings underscore the importance of fostering both grit and resilience in students to help them navigate the challenges of medical education and reduce the risk of burnout.\u003c/p\u003e\n\u003cp\u003eIn light of the significant challenges facing Egypt\u0026rsquo;s healthcare system, where many residents and medical students report plans to emigrate upon graduation \u003csup\u003e3,19\u003c/sup\u003e, this study highlights the potential of cultivating resilience and grit as effective strategies to combat burnout and improve academic performance. By fostering these traits, students can develop stronger tools for managing stress and maintaining their well-being, particularly during high-pressure situations like exams. While providing immediate support to medical students during exams may be challenging, fostering grit and resilience early on can better equip them to navigate difficult times, reducing emotional exhaustion and feelings of overwhelm. Integrating targeted interventions to nurture these traits offers a sustainable approach to improving student mental health. In doing so, it would not only help students manage stress but also empower them to excel academically and professionally, ultimately contributing to a healthier, more resilient healthcare workforce in Egypt.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several strengths, including the validated and reliable tools use to measure burnout, grit, and resilience. Furthermore, the study assesses these traits during exams, a period often understudied due to logistical constraints. Additionally, allowing students to view their burnout scores at the end of the survey may have contributed to raising mental health awareness among participants.\u003c/p\u003e\n\u003cp\u003eHowever, there are some limitations to consider. The cross-sectional design limits the ability to establish causal relationships between grit, resilience, and burnout. Additionally, reliance on self-reported data may have introduced biases, such as social desirability or inaccurate self-assessment. The sampling method may have excluded students experiencing severe burnout, as they might have been less likely to participate. A more inclusive approach would ensure a broader representation of students, including those facing higher levels of burnout. Moreover, since the study was conducted during exams, the results may not fully capture typical stress levels or coping strategies during less intense academic periods. Future research could address these limitations by employing a longitudinal design to better examine causal relationships between these factors.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eGrit and resilience were associated with significantly less burnout among medical students during exams. The findings suggest that fostering traits like grit and resilience may be effective in mitigating burnout and enhancing students\u0026apos; ability to manage stress, potentially improving both academic performance and well-being. Given the significant levels of burnout medical students experience during exams, interventions aimed at strengthening these traits could provide a sustainable approach to supporting medical students during these periods. However, further research using longitudinal designs and more inclusive sampling methods is needed to better understand the causal relationships between these factors and explore strategies for addressing burnout across different academic contexts.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eGrit-S \u0026ndash; Short Grit Scale\u003c/p\u003e\n\u003cp\u003eBRS \u0026ndash; Brief Resilience Scale\u003c/p\u003e\n\u003cp\u003eBAT \u0026ndash; Burnout Assessment Tool\u003c/p\u003e\n\u003cp\u003eSD \u0026ndash; Standard Deviation\u003c/p\u003e\n\u003cp\u003eSTROBE \u0026ndash; Strengthening the Reporting of Observational Studies in Epidemiology\u003c/p\u003e\n\u003cp\u003eVIFs \u0026ndash; Variance Inflation Factors\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their sincere gratitude to Ahmed M. Eid, Alaa Abdelmonem Montaser, Basmala Abdelrahman Lashin, Reem Al-Tantawy Mohammed, Aisha Elsayed Mohamed, Noor Eldien Khaled Gadalla, Abdallah Gamal Abdallah, Mohamed Ghazy, and Ahmed Mahmoud Hasan for their invaluable assistance in the pilot study and data collection of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe conception and design of the study were done by YMO, AA, OS, SO, MV, AAS, and MM. Acquisition of data was done by AA, OS, AAS, and SA. Analysis and interpretation of data were done by YMO and AA. Drafting the manuscript was done by YMO, OS, SO, MN, AAS, and MM. Revising the manuscript critically for important intellectual content was done by YMO and AE. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding or sponsorship was received from any companies, groups, individuals, organizations, or any other entities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset supporting the findings of this study has been attached as a supplementary file with this submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study\u0026rsquo;s aim was explained to each participant, highlighting the confidentiality of the data. All participants provided electronic informed consent prior to enrollment. The study was approved by the Institutional Research Board (IRB) at the Faculty of Medicine, Mansoura University (R.24.12.2969) and adheres to the Declaration of Helsinki for Medical Research Involving Human Subjects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eFritz, J., Stochl, J., Kievit, R. A., van Harmelen, A.-L. \u0026amp; Wilkinson, P. O. Tracking Stress, Mental Health, and Resilience Factors in Medical Students Before, During, and After a Stress-Inducing Exam Period: Protocol and Proof-of-Principle Analyses for the RESIST Cohort Study. \u003cem\u003eJMIR Formativ. 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Coping with being cut from the team: examining grit, resilience and optimism in response to failure in college athletes. \u003cem\u003ePsychology Master\u0026rsquo;s Theses\u003c/em\u003e (2018).\u003c/li\u003e\n \u003cli\u003eSchimschal, S. E., Visentin, D., Kornhaber, R. \u0026amp; Cleary, M. Grit: A concept analysis. \u003cem\u003eIssues Ment. Health Nurs.\u003c/em\u003e \u003cstrong\u003e42\u003c/strong\u003e, 495\u0026ndash;505 (2021).\u003c/li\u003e\n \u003cli\u003eStoffel, J. M. \u0026amp; Cain, J. Review of Grit and Resilience Literature within Health Professions Education. \u003cem\u003eAm. J. Pharm. Educ.\u003c/em\u003e \u003cstrong\u003e82\u003c/strong\u003e, 6150 (2018).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Grit, Resilience, Burnout, Medical students, Egypt","lastPublishedDoi":"10.21203/rs.3.rs-6380020/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6380020/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Medical students experience significant stress, particularly during exams, contributing to burnout. This study examined the relationships between grit, resilience, and burnout among 653 Mansoura University medical students during exams. Data were collected via an online questionnaire assessing burnout using the Burnout Assessment Tool (BAT-23), grit with the Short Grit Scale (Grit-S), and resilience with the Brief Resilience Scale (BRS). The mean burnout score was 3.62 (SD = 0.67), with exhaustion (M = 3.96, SD = 0.74) and cognitive impairment (M = 3.66, SD = 0.92) as the most prominent symptoms. Female students had lower resilience (M = 2.87 vs. 3.11, p \u003c 0.001) and higher burnout (M = 3.69 vs. 3.55, p = 0.009), while older students showed lower grit (M = 2.86 vs. 3.00, p = 0.008) and higher burnout (M = 3.69 vs. 3.58, p = 0.048). Burnout was negatively correlated with grit (r = -0.595, p \u003c 0.001) and resilience (r = -0.519, p \u003c 0.001), while grit and resilience were positively correlated (r = 0.426, p \u003c 0.001). Multivariate regression identified grit (β = -0.458, p \u003c 0.001) and resilience (β = -0.315, p \u003c 0.001) as protective factors. Strengthening grit and resilience may help students manage academic stress and reduce burnout.","manuscriptTitle":"The interplay of grit, resilience, and burnout among medical students during exams: a cross-sectional study in Mansoura University, Egypt","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-01 03:45:03","doi":"10.21203/rs.3.rs-6380020/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-20T06:10:21+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"178545739612980724895823285071148709437","date":"2025-10-06T08:36:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-06T10:38:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-05T10:24:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6345527111678727706280038981548653594","date":"2025-08-04T19:33:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"334985070623845398801535362750295409088","date":"2025-08-02T18:31:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-02T18:06:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-05T04:26:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-05T07:54:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-05T07:53:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-04-05T05:41:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1930e53c-220c-49c8-8014-0234c9754146","owner":[],"postedDate":"October 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":55549420,"name":"Health sciences/Health care/Public health"},{"id":55549421,"name":"Health sciences/Health care/Quality of life"},{"id":55549422,"name":"Biological sciences/Psychology"}],"tags":[],"updatedAt":"2026-02-02T16:18:46+00:00","versionOfRecord":{"articleIdentity":"rs-6380020","link":"https://doi.org/10.1038/s41598-026-35125-0","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2026-01-29 15:58:02","publishedOnDateReadable":"January 29th, 2026"},"versionCreatedAt":"2025-10-01 03:45:03","video":"","vorDoi":"10.1038/s41598-026-35125-0","vorDoiUrl":"https://doi.org/10.1038/s41598-026-35125-0","workflowStages":[]},"version":"v1","identity":"rs-6380020","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6380020","identity":"rs-6380020","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}