Generative artificial intelligence (GenAI) chatbots are increasingly used for mental health support, but trust in these emotionally vulnerable and relationally sensitive interactions remains poorly understood. This study aims to synthesize empirical evidence on how trust is conceptualized, shaped, and associated with outcomes in GenAI-based mental health support, with attention to differences across AI roles. This systematic review was conducted in accordance with the PRISMA 2020 guidelines. Peer-reviewed empirical studies were identified by searching five electronic databases. Two reviewers independently screened records, selected eligible studies, extracted data, and assessed methodological quality using the Mixed Methods Appraisal Tool. Data were synthesized descriptively and thematically. Of 1180 citations retrieved, 28 studies were included. Trust was rarely explicitly defined and was most often operationalized through affective and relational indicators, including emotional comfort, perceived empathy, and psychological safety, rather than technical competence alone. Trust-related antecedents involved user vulnerability and attitudes, system reliability and emotional responsiveness, interactional continuity, and contextual constraints. Trust was associated with engagement and emotional relief, but also with relational and safety concerns, including excessive reliance on AI support, blurred role boundaries, and inadequate responses to crisis-related disclosures. Role-based synthesis suggested that lower-engagement roles (eg, functional assistants and structured facilitators) mainly involved cognitive trust, whereas more emotionally engaging or autonomous roles (eg, empathetic co-therapists and therapeutic companions) involved broader affective and alliance-like trust, together with greater relational and safety risks. Trust in GenAI-based mental health support should not be treated as a uniform or inherently desirable outcome. Role-sensitive evaluation and governance are needed to align user trust with system capability, safety boundaries, and responsibility.

Objective: To evaluate the predictive value of a weighted scoring model based on LASSO logistic regression integrating ultrasound and magnetic resonance imaging (MRI) for severe adverse maternal outcomes (SAMO) in patients with placenta accreta spectrum (PAS). SAMO was defined as hysterectomy and/or postpartum hemorrhage ≥1500 mL within 24 hours. Methods: A total of 133 patients with PAS who delivered at our hospital between January 2020 and December 2022 were retrospectively enrolled. Patients were divided into the SAMO group (n=49) and the non-SAMO group (n=84). Twenty-one prenatal ultrasound and MRI imaging features were evaluated. LASSO logistic regression was used to identify independent predictors and to construct a weighted scoring model. Model performance was assessed using the receiver operating characteristic (ROC) curve. Clinical utility was evaluated using decision curve analysis (DCA) to quantify net benefit across different risk thresholds. Results: LASSO logistic regression initially selected 11 imaging features with non-zero coefficients from the 21 candidate variables. After excluding three features with negligible coefficients (assigned zero weight in the simplified scoring system), eight predictors were retained to construct an 11-point weighted scoring model: anterior placental location, placenta previa, placental thickness ≥5 cm, placental lacunae, cervical length ≤2.5 cm, lower uterine segment myometrial thickness ≤1 mm, intraplacental T2-weighted (T2WI) low-signal bands, and the “tenting sign.” These predictors were assigned weights of 1–2 points to construct an 11-point scoring system. The model achieved an AUC of 0.879 (95% CI: 0.812–0.945) with a sensitivity of 75.51% and a specificity of 88.10% at the optimal cutoff of 7 points. Patients with a score ≥7 had a significantly higher risk of SAMO (OR=22.82, 95% CI: 9.03–57.68). DCA demonstrated a positive net clinical benefit across a wide range of threshold probabilities (approximately 0.05–0.85), substantially outperforming both the “treat-all” and “treat-none” strategies. Conclusion: This internally validated ultrasound–MRI combined scoring system provides a clinically practical tool for early risk stratification of severe maternal outcomes in patients with PAS. The model demonstrates robust predictive performance and clear clinical utility. Future external validation studies are warranted to confirm its generalizability across diverse healthcare settings.

Purpose: Depression, anxiety and Insomnia are common among middle school students. Non-suicidal self-injury (NSSI) has become an important mental health issue in this group. This study explores the comorbid relationship between depression, anxiety, and insomnia symptoms among junior high school students from a network perspective and investigates the associations between these symptoms and NSSI. Patients and Methods: This study was a cross-sectional design with convenience sampling, and students from junior high schools in Wuhan, China, were selected in October 2023 (N=8244) as survey respondents. An online questionnaire was used to collect data. The Patient Health Questionnaire, Generalized Anxiety Disorder Scale and Insomnia Severity Index were used to assess depression, anxiety and insomnia. Whether NSSI behaviors occurred in the last 1 year was obtained by self-report. Network analysis was used to assess core and bridge symptoms of the depression, anxiety and insomnia co-morbidity network and associations with NSSI. Results: The results revealed that GAD2 "Control Worry", GAD3 "Excessive Worry" (EI = 1.040), ISI2 "SleepMaint" (EI=1.025) and PHQ2 "Hopeless" (EI=1.018) were the central symptoms of the network, exhibiting the highest expected influence values. GAD5 "restlessness" (BEI=0.376) and PHQ4 "Lack of Energy" (BEI=0.351), PHQ6 "self feeling" (BEI=0.325) and GAD1 "Nervous" (BEI=0.296) were the bridge symptoms. PHQ9 "Suicidal Ideation" (edge weight = 0.33) showed the strongest connection to NSSI. The network comparison test results indicated a more densely connected symptom network in the NSH group than in the NSSI group. Conclusion: Symptoms related to worry are core factors in the network of depression, anxiety, and insomnia among junior high school students. Suicidal ideation is directly and closely associated with NSSI. These symptoms may serve as key targets for early screening and intervention, while the strong link between suicidal ideation and NSSI underscores the need for timely prevention efforts in this vulnerable population.

ABSTRACT Background and Aims High fasting blood glucose (FBG) ranks fifth among the global risk factors for disease burden, influenced by both individual and environmental factors. However, the roles of social and neighborhood environmental factors remain underexplored in China. This study aimed to estimate the relationship between neighborhood environment, social factors, and FBG among adult residents, and explore potential interaction. Methods This cross‐sectional study included 440 participants from two public hospitals in China. We collected data on social factors, FBG, and participant characteristics using electronic questionnaires, anthropometric measurements, and physical examination. The neighborhood environment features were measured using the geographic information systems (GIS) methods. Linear regression analysis was used to examine associations between neighborhood environment features and social factors and FBG. Results This study found that marital status (married VS unmarried; β = 0.21, p < 0.001) and the highest quartile of residential housing density (Q4 vs Q1, β = 0.16, p = 0.03) had significant associations with higher FBG levels. The quartiles of the normalized difference vegetation index (NDVI) (Q2, β = −0.14, p = 0.04; Q3, β = −0.19, p = 0.004; Q4, β = −0.21, p = 0.003) and sports facility density (Q2, β = −0.18, p = 0.002; Q3, β = −0.20, p = 0.008; Q4, β = −0.30, p < 0.001) were significantly associated with lower FBG. Furthermore, the second, third, and fourth quartiles of sports facility density and the fourth quartile of residential housing density showed stronger associations with FBG by the interaction with educational level (high vs low). There were also significant interaction effects between residential housing density and subjective economic status, and between NDVI and marital status on FBG. Conclusion This study suggests that marital status, residential greenness, and densities of sports facility and residential housing are associated with FBG, and demonstrates potential interaction. Future research is necessary to further clarify these relationships and explore the underlying mechanisms.

Background Anxiety is a prevalent mental health issue among junior high students, significantly impacting their physical and psychological well-being. This study aimed to investigate the developmental trajectory of anxiety in this population and its underlying causes and outcomes, providing support for adolescent mental health interventions. Methods A total of 1479 junior high students participated in a three-wave longitudinal study over two years. Latent Growth Curve Modeling was employed to examine the developmental trajectory of anxiety, and analyze the effects of gender and family functioning on the trajectory and the trajectory's predictive role for Non-Suicidal Self-Injury (NSSI). Additionally, Latent Class Growth Modeling was used to explore heterogeneous subgroups within the anxiety trajectory. Multivariate logistic regression analyzed the predictive validity of gender and family functioning for trajectory class membership and the predictive effect of anxiety trajectory classes on NSSI. Results The overall anxiety trajectory exhibited a linear increasing trend. Female students showed higher initial anxiety levels and faster increases. Family functioning significantly negatively predicted anxiety levels. The anxiety trajectory predicted the occurrence of NSSI.Three distinct latent classes of anxiety trajectories were identified: High/ Increasing, Moderate/Increasing, and Low/Decreasing. Gender and family functioning significantly predicted class membership. Individuals in the High/Increasing and Moderate/Increasing classes were more likely to engage in NSSI. Conclusions Anxiety levels in junior high students show an overall linear increase. Gender and family functioning significantly influence the trajectory and predict subgroup membership. The anxiety trajectory predicts subsequent NSSI. Therefore, adolescent mental health interventions should address multiple factors and anxiety-specific risk profiles.

Sleep disturbances have become a pressing public health problem.The association between diet and sleep health has attracted increasing attention in recent years.This study aimed to elucidate the associations of dietary carbohydrate amount and carbohydrate quality with sleep quality.This study was conducted among 4 772 participants with a mean age of(62.4±6.3)years in the Lifestyle and Healthy Aging of Chinese Square Dancer Study.Dietary data were collected using a 64-item food frequency questionnaire.Carbohydrate quality was assessed by the carbohydrate quality index(CQI),which is based on four components:dietary fiber intake,glycemic index,whole grain/total grain ratio,and solid carbohydrate/total carbohydrate ratio.Sleep quality was evaluated by the Pittsburgh sleep quality index.Multivariable logistic regression analysis was performed to analyze the association of carbohydrate amount and quality with sleep quality.After controlling for sociodemographic,lifestyle,and multiple disease-related factors,the odds ratio for the highest vs.the lowest quintile of the CQI was 0.64(95％confidence interval(CI)0.53,0.78;P-trend＜0.000 1).In contrast,no significant associations were observed between carbohydrate amount and sleep quality.The findings suggest that higher dietary carbohydrate quality,rather than carbohydrate amount,was associated with better sleep quality.This study provided a diet-related sleep-improving strategy for the general population.

Adolescent non-suicidal self-injury (NSSI) is a major public health concern. Digital and family-based psychological interventions have shown promise for addressing NSSI; however, evidence for the effectiveness and accessibility of blended family-based interventions that combine face-to-face and digital components remains limited. To evaluate the effectiveness of a family-based blended psychological intervention in reducing NSSI behaviors and improving emotional and family outcomes among adolescents with NSSI. A quasi-experimental controlled design was conducted in the psychiatric inpatient unit of a mental health center in Wuhan, China. Sixty adolescents with NSSI and their primary caregivers were recruited and sequentially assigned to either the intervention or control group according to admission order. The 6-week blended intervention, grounded in cognitive behavioral therapy and dialectical behavior therapy for adolescents, combined therapist-led face-to-face sessions with digital modules delivered via a WeChat mini-program. The control group received routine care and equivalent attention. Primary outcomes were adolescents’ NSSI behaviors; secondary outcomes included emotion regulation, depression, anxiety, family function, and caregivers’ depression and anxiety. Outcomes were assessed at baseline and post-intervention by blinded evaluators. Between-group differences were analyzed using analysis of covariance (ANCOVA), controlling for baseline scores. Forty-eight participants completed the study (intervention n=23; control n=25). Compared with routine care, the blended intervention resulted in significantly greater reductions in adolescents’ NSSI behaviors (adjusted mean difference = −5.16, P = 0.03), emotion regulation difficulties (P = 0.003), depressive symptoms (P = 0.01), and anxiety symptoms (P < 0.001). Caregivers in the intervention group also showed greater improvements in depressive symptoms (P = 0.036) and anxiety symptoms (P = 0.001). The family-based blended intervention demonstrated significant effectiveness in reducing NSSI and emotional symptoms among adolescents, while also improving caregiver emotional states. Findings provide empirical evidence supporting the effectiveness and accessibility of blended family-based interventions for adolescent NSSI in real-world clinical settings. Chinese Clinical Trial Registry ChiCTR2400088438; https://www.chictr.org.cn/showproj.html?proj=205243

Adolescent non-suicidal self-injury (NSSI) is a pressing public health concern, with families playing a pivotal role in its management. Despite this, specific, evidence-based, and accessible family-based blended psychological interventions remain scarce. To develop a family-based blended psychological intervention specifically for NSSI in adolescents and evaluate its feasibility, acceptability, and preliminary effectiveness. A quasi-experimental trial was conducted with 60 adolescents with NSSI and their primary caregivers recruited from a mental health center in Wuhan, China. Participants were assigned to either the intervention or control group based on their admission sequence. The intervention group received a family-based blended psychological intervention, integrating both internet-based and face-to-face components over six weeks, while the control group received routine care. Feasibility measures included recruitment and retention rates, intervention adherence, and acceptability. Primary outcomes included NSSI behavior, and secondary outcomes assessed emotional regulation difficulties, family function, depression, and anxiety. Data were collected at baseline and post-intervention. Among 48 valid participants (intervention: 23, control: 25), recruitment and retention rates were 92.3% and 80.0%, respectively. Compliance rates for offline interventions were 65.2% (adolescents) and 78.3% (caregivers), while online compliance was 87.0% and 69.6%, respectively. Acceptability ratings were 82.6% (adolescents) and 87.0% (caregivers). The intervention group showed significant improvements in NSSI behaviors, emotional regulation, depression, anxiety, and caregiver anxiety (P < 0.05). The family-based blended psychological intervention is feasible, acceptable, and demonstrates preliminary effectiveness, providing a basis for further optimization of clinical interventions for adolescent NSSI behaviors. Chinese Clinical Trial Registry ChiCTR2400088438; https://www.chictr.org.cn/showproj.html?proj=205243

BACKGROUND:This study explores the relationship between family functioning and depressive symptoms, emphasizing the mediating effects of psychological resilience and parent-child interactions. According to Family Systems Theory, interactions and emotional connections within the family have a profound impact on an individual's mental health. Understanding how family dynamics contribute to depressive symptoms and resilience has become a key focus in mental health research. METHODS:A total of 7092 participants, including middle school students and their parents, were selected for the study using cluster sampling. Data were analyzed using the Actor-Partner Interdependence Model extended to mediation (APIMeM). The model tested the effects of family functioning on depressive symptoms and psychological resilience, accounting for both actor and partner effects. RESULTS:Family functioning was negatively associated with depressive symptoms in both parents and children, partially mediated by psychological resilience. The strongest mediation occurred in the student pathway (indirect effect = -0.311, 95 % CI [-0.367, -0.258], 38.6 % of total effect). Mothers' family functioning had a stronger indirect effect on depressive symptoms compared to fathers. Higher parental resilience related to fewer depressive symptoms and positively influenced children's mental health. CONCLUSION:Family functioning significantly relates to depressive symptoms, with notable differences between parental roles. Mothers' family functioning perceptions showed stronger associations with their own and their children's mental health than fathers'. Interventions enhancing family communication and emotional support may be particularly effective when targeting mothers.

OBJECTIVE:To explore the concurrent trajectories of depressive symptoms and insomnia among adolescents and to analyse the individual, familial and social predictors of the concurrent trajectories. STUDY DESIGN:This study tracked depressive symptoms and insomnia in eight secondary schools annually from 2021 to 2023. We also collected data on individual, familial and social factors that may influence these conditions. Group-based multi-trajectory (GBMT) modelling was used to categorise adolescents into depressive-insomnia severity subgroups. RESULT:This study included 2822 adolescents, who were categorised into four groups, including the no symptom group, mild symptom group, symptom relief group and symptom increase group. Compared with the no symptom group, predictors of the mild symptom group were gender (OR = 1.30), academic performance (OR = 1.57), subjective well-being (OR = 0.78), anxiety (OR = 1.14), economic status (OR = 1.23) and relationship with teachers (OR = 1.46). Predictors of the symptom relief group were personality (OR = 1.75), academic performance (OR = 2.28), subjective well-being (OR = 0.69) and anxiety (OR = 1.25). Predictors of the symptom-increasing group were personality (OR = 2.45), academic performance (OR = 1.96), subjective well-being (OR = 0.69), anxiety (OR = 1.20), maternal education level (OR = 1.58), family function (OR = 0.93), parental relationship (OR = 2.07) and relationship with teachers (OR = 1.54). CONCLUSION:This study provided a comprehensive understanding of the concurrent trajectories of depressive symptoms and insomnia among adolescents, revealing distinct subgroups and identifying predictors across individual, familial and social levels. IMPLICATIONS FOR PATIENT CARE:This study emphasises the importance of a multi-faceted approach involving family, school and society to promote adolescent mental health and also highlights the need for conducting precise interventions according to adolescents' features. IMPACT:The identification of four distinct symptom trajectories and their predictors advances the understanding of adolescent mental health development, informing precision prevention strategies. REPORTING METHOD:STROBE checklist. PATIENT OR PUBLIC CONTRIBUTION:None.

Parenting styles (PSs) are significant risk factors for major depressive disorder (MDD) in young adults. Understanding the common features of these parenting styles and their specific effects on depression is crucial for effective intervention. To assess the profiles of paternal and maternal parenting styles and their impact on depression-related symptoms in young Chinese adults with MDD. This study involved 717 young adult outpatients (24.20 ± 3.84 years) with MDD, diagnosed at Renmin Hospital of Wuhan University between April and December 2019. Participants completed the Egna Minnen av Barndoms Uppfostran (EMBU) questionnaire and scales measuring depression (PHQ-9), anxiety (GAD-7), anhedonia (SHAPS), and physical symptoms (PHQ-15). Latent profile analysis (LPA) was used to identify PS profiles. The effects of different parenting style profiles on depression, anxiety, and anhedonia were assessed using stepwise linear regression. LPA identified three profiles for both paternal and maternal PSs. For fathers: 'Warm-Preference PS' (27.2%), 'moderate PS' (65.3%), and 'Harsh-Controlling PS' (7.53%). For mothers: 'Warm-Preference PS' (34.7%), 'moderate PS' (12%), and 'Harsh-Controlling PS' (53.3%). Regression analyses revealed that punitive and overprotective parenting significantly affected depression and anxiety, while emotionally warm parenting correlated with better mental health. This study applied LPA to classify PS in MDD patients and revealing maternal-specific effects, addressing gaps in prior research. It underscores three distinguished PSs and the significant correlations between PSs and the severity of depression, anxiety, and somatic symptoms in young adults with MDD. Specific patterns of parenting influence mental health outcomes, highlighting the importance of early intervention.

Objectives To explore the chained mediating role of self-efficacy and e-health literacy in the association between social support and technophobia in older adults in urban communities.Design A cross-sectional study conducted from June 2023 to April 2024.Setting This study was conducted in three districts of Taiyuan City, Shanxi Province, China.Participants The study enrolled 1658 older adults (> 60 years old) in urban communities in Taiyuan.Methods The analyses included assessments using the technophobia, e-health, self-efficacy and social support scales, and the mediating effects of these indices were investigated using Model 6 in SPSS V.26.Results The level of technophobia in older adults was found to be moderately high. Technophobia was negatively correlated with social support, self-efficacy and e-health literacy. Stepwise regression analysis showed that age, residential situation, health and the frequency of electronic device use were risk factors for technophobia (p<0.05). Social support could influence technophobia directly (β=−0.266). In addition, self-efficacy (β=−0.080) and e-health literacy (β=−0.098) significantly mediated the relationship between social support and technophobia.Conclusion Social support was found to affect technophobia in older adults via the independent or chained mediating effects of self-efficacy and e-health literacy.

Antenatal depression (AND) is a common complication during pregnancy, particularly in rural China, where access to mental health resources is limited. This study aimed to examine the relationship between positive psychological capital (PsyCap) and AND, and to explore the mediating roles of maternal health literacy (MHL) and social support (SS). A cross-sectional survey was conducted among 1,683 pregnant women from seven rural regions in China. Participants completed validated instruments measuring PsyCap, SS, MHL, and AND. Data were analyzed using Pearson correlations, hierarchical regression, and structural equation modeling. Mediation effects were tested with 5,000 samples bootstrapping. A total of 51.1

Background: Chemotherapy and transplantation can impact fertility in hematologic disease patients. Implementing fertility preservation could protect their reproductive capabilities and improve overall quality of life. We aimed to understand the awareness and clinical practice of fertility preservation in hematologic disease patients from the perspectives of healthcare providers (HCPs) in hematologic and reproductive medicine and to explore suggestions.Methods: Empirical phenomenological approach was used in this study. HCPs were recruited from the hematologic and reproductive medicine department at one of the affiliated general hospitals of Wuhan University using purposive sampling. They participated in semi-structured, in-depth face-to-face individual interview between Aug 20, 2023 and Oct 15, 2023. Interviews were transcribed verbatim and analyzed using Colaizzi’s phenomenological method.Findings: A total of 14 HCPs were recruited, including 6 hematologic physicians, 3 hematologic nurses, 3 reproductive medicine physicians, and 1 reproductive medicine nurse. The analysis revealed three major theme and associated subthemes: (1) recognition of the importance and feasibility of fertility preservation in hematologic patients; (2) prioritization of disease treatment and fertility preservation in initial stage; and (3) challenges from multi-levels and recommendations.Interpretation: HCPs recognize the importance and feasibility of fertility preservation in hematologic patients, but its implementation encounters challenges at various levels, including the medical system, patient, and societal dimensions. To promote early discussions and informed decision-making on fertility preservation, it is necessary to enhance multidisciplinary collaboration, provide better support for patients and their families, and improve legal and policy frameworks.Funding: This study was supported by the funds from the National Natural Science Foundation of China (No. 82103025) and Project HOPE Educational Program (No. 250071424). Declaration of Interest: The authors have declared no conflicts of interest.Ethical Approval: This study was reviewed by Biomedical Ethics Committee of Wuhan University (Ethical approval No.: WHU-LFMD-IRB2023034). Prior to each face-to-face interview, the objectives and voluntary nature of study were thoroughly explained to the participants, and their informed consent was obtained. To ensure confidentiality, participants’ identities were anonymized using numerical codes (e.g., physician P1, P2, etc.; nurse N1, N2, etc.), and all potentially identifying information was removed from the transcripts. Additionally, audio recordings and transcripts were securely stored on a password-protected computer. This study adhered to the guidelines outlined in the consolidated criteria for reporting qualitative research (COREQ) to maintain methodological rigor throughout the research process.

Background Cardiovascular disease (CVD) is the leading cause of death worldwide, particularly affecting low- and middle-income countries. Food environments may be linked with the risk of CVD; however, current study findings regarding their relationship are inconsistent. A systematic review of their associations is needed to guide interventions to improve cardiovascular health. Objective This systematic review aimed to comprehensively assess the relationship between food environments and CVD outcomes, including incidence, hospitalization, mortality, and recurrence rates. Method According to PRISMA guidelines, a systematic search was conducted until 28th March 2024, using eight databases, including PubMed, Embase, Ovid, CINAHL, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang Data. The review quality was assessed according to the Agency for Healthcare Research and Quality (AHRQ) and Newcastle-Ottawa Scale (NOS). The included studies were categorized based on their exposure factors into unhealthy, healthy, and comprehensive food environments, encompassing facilities that offer healthy and unhealthy foods. The findings were narratively synthesized according to this classification. Result A total of 23 studies, encompassing 13 cross-sectional studies and 10 cohort-longitudinal studies, were included in this review. Among the 20 studies on unhealthy food environments, 13 found a positive association with CVD outcomes. Of the seven studies on healthy food environments, 3 found a negative association with CVD outcomes. Additionally, 4 out of 8 studies on comprehensive food environments found a significant but inconsistent association with CVD outcomes. Conclusion This study suggested that unhealthy food environments are probably associated with CVD outcomes. At the same time, there is currently no conclusive evidence to indicate a relationship between healthy food environments or comprehensive food environments and CVD outcomes.

Objectives: This study was conducted to investigate the stigma status of infertile women in China and to determine the influencing factors. Methods: 366 infertile women from the gynecological and reproductive departments of two tertiary hospitals completed socio-demographic questionnaires, the Infertility Stigma Scale (ISS) and the Mandarin Fertility Problem Inventory (M-FPI). Results: The scores of stigma and infertility-related stress in infertile women were (52.51 ± 17.74) and (150.03 ± 17.51), respectively. Multiple regression analysis found that location of residence, regarding children as the most important thing in life, talking to others about infertility and infertility-related stress were the main influencing factors of stigma in infertile women, which explained 17.3% of the total variance. Conclusions: In the current study, the level of stigma in women with infertility was at the middle range. Location of residence, regarding children as the most important thing in life, whether to talk with others about infertility and infertility-related stress were the four main influencing factors of stigma.

This study aimed to understand the current state of adolescent mental health, explore the mediating effect of bullying victimization and resilience in the relationship between adolescent family functioning and mental health, and investigate gender differences in this association. A total of 4319 students (2347 boys and 1972 girls) completed the questionnaire. Mediating effects were analyzed using the framework of structural equation modeling and bootstrapping. The results revealed that family functioning is significantly associated with adolescent mental health, and that bullying victimization and resilience have significant independent and chain mediating effects on this relationship. Multiple group analysis revealed that the independent mediating role of resilience was more significant for male adolescents. Furthermore, the chain-mediated effects of bullying victimization and resilience were observed only in the relationship between family functioning and mental health in male adolescents. To improve the mental health of adolescents, special attention should be given to the impact of family life on adolescents’ school life. Early detection and intervention for adolescents with poor family functioning are also important to effectively prevent bullying victimization and reduce the emergence of mental health problems.

Background Virtual simulation and face-to-face simulation are effective for clinical judgment training. Rare studies have tried to improve clinical judgment ability by applying virtual simulation and face-to-face simulation together. This study aimed to evaluate the effect of an integrated non-immersive virtual simulation and high-fidelity face-to-face simulation program on enhancing nursing students’ clinical judgment ability and understanding of nursing students’ experiences of the combined simulation. Methods A sequential exploratory mixed-methods study was conducted in a nursing simulation center of a university in Central China. Third-year nursing students ( n = 122) taking clinical training in ICUs were subsequentially assigned to the integrated non-immersive virtual simulation and high-fidelity face-to-face simulation program arm ( n = 61) or the face-to-face simulation-only arm ( n = 61) according to the order in which they entered in ICU training. Clinical judgment ability was measured by the Lasater Clinical Judgment Rubric (LCJR). Focus group interviews were conducted to gather qualitative data. Results Students in both arms demonstrated significant improvement in clinical judgment ability scores after simulation, and students in the integrated arm reported more improvement than students in the face-to-face simulation-only arm. The qualitative quotes provided a context for the quantitative improvement measured by the LJCR in the integrated arm. Most of the quantitative findings were confirmed by qualitative findings, including the domains and items in the LJCR. The findings verified and favored the effect of the combination of non-immersive virtual simulation and high-fidelity face-to-face simulation integrated program on enhancing nursing students’ clinical judgment ability. Conclusions The integrated virtual simulation and face-to-face simulation program was feasible and enhanced nursing students’ self-reported clinical judgment ability. This integrated non-immersive virtual simulation and high-fidelity face-to-face simulation program may benefit nursing students and newly graduated nurses in the ICU more than face-to-face simulation only.