This study examines bidirectional relationships between academic self-efficacy, family functioning, maladaptive behaviors and depressive symptoms among rural adolescents. Data were collected from 1061 rural adolescents using validated scales. Hierarchical multiple regression and bootstrap mediation analyses were employed. Results indicated that 17.53% of participants reported depressive symptoms (CESD-10 ≥ 10). Academic self-efficacy and family functioning were both negatively related to depressive symptoms. Internet addiction and academic procrastination serially mediated the relationship among them. A bidirectional inverse relationship between academic self-efficacy and family functioning was observed. Participants with low academic self-efficacy or family dysfunction exhibited higher levels of internet addiction and academic procrastination which further exacerbating their depressive symptoms. These findings highlight the importance of enhancing academic self-efficacy and family functioning to reduce maladaptive behaviors and prevent depressive symptoms among rural adolescents.

Purpose:Pandemic fatigue has become a significant public health challenge during the COVID-19 pandemic, but the mechanism of COVID-19 anxiety syndrome on it and its components remains unclear. It has not yet fully clarified whether and how community resilience and personal resilience can play a key role in the post-lockdown context. This study aims to evaluate the association between COVID-19 anxiety syndrome and pandemic fatigue, and to investigate the underlying effects of community resilience and personal resilience. Methods:A cross-sectional online survey was conducted with 1209 participants recruited via stratified sampling in Xi'an. They completed demographic characteristics, Pandemic Fatigue Scale, COVID-19 Anxiety Syndrome Scale, Conjoint Community Resiliency Assessment Measurement, and Connor-Davidson Resilience Scale. Descriptive statistics, t-tests, and ANOVA were used to examine demographic differences in pandemic fatigue. Pearson's correlation and stepwise multiple liner regression were employed to analyze the associations among COVID-19 anxiety syndrome, community resilience, personal resilience, and pandemic fatigue. Results:The mean score of pandemic fatigue was 17.87 (SD = 7.88), with information fatigue (9.51 ± 4.30) higher than behavior fatigue (8.36 ± 4.16). COVID-19 anxiety syndrome was positively associated with pandemic fatigue (β = 0.286, P <0.001). The total effects of community resilience and personal resilience accounted for 28.3% and 30.6% in the model of pandemic fatigue and behavior fatigue. Only community resilience significantly explained the association between COVID-19 anxiety syndrome and information fatigue, accounting for 11.87%. Conclusion:Strategy for enhancing resilience capacity both at the community and individual level should be highlighted to mitigate pandemic fatigue in the context of post-lockdown. Targeted resilience-building interventions should be prioritized for women and middle-aged adults.

Thalassemia is a significant public health issue in many high-prevalence countries. Despite progress in thalassemia management, limited public awareness and engagement continue to hinder early detection and prevention efforts. This study aimed to assess public awareness, knowledge, and attitudes toward thalassemia and its screening in five high-prevalence countries: Azerbaijan, Indonesia, Kuwait, Saudi Arabia, and Thailand. A cross-sectional online survey was conducted among females aged 18–50 residing in the selected countries. The study required each country to include at least 300 participants, with sample size estimated via a simplified normal approximation method. The 31-item questionnaire covered personal information, knowledge and attitude scales, and factors influencing thalassemia screening. Statistical analyses used chi-square test, student t-test, and logistic regression to assess associations, with results expressed as odds-ratios and 95

Background: Diabetes is associated with poor outcomes in hospitalized patients, but population-level evidence on how in-hospital mortality changed across the pre-pandemic, pandemic, and recovery periods remains scarce. We aimed to assess long-term trends in in-hospital mortality among diabetic inpatients, compare these trends with those in non-diabetic inpatients, and quantify pandemic-attributable excess mortality. Methods: In this large-scale hospital-based cohort study, we analysed administrative hospitalization records from all 207 hospitals in the greater Beijing area, China, from Jan 1, 2012, to Dec 31, 2024, obtained from the Beijing Municipal Health Big Data and Policy Research Center. Diabetes was identified using ICD-10 codes. Joinpoint regression was used to assess temporal trends in in-hospital mortality, Cox proportional hazards models to estimate period-specific mortality risks by diabetes status, and Bayesian structural time-series models to quantify excess mortality attributable to the pandemic. Findings: Among 27,471,563 unique hospitalized patients, 4,571,832 had diabetes and 146,282 died in hospital; among 22,899,731 patients without diabetes, 305,904 died in hospital. In-hospital mortality among diabetic patients was stable during 2012–19, increased during 2019–22, and declined during 2022–24. The increase was concentrated in adults aged 65 years or older. In fully adjusted Cox models, the hazard ratio for in-hospital death in 2022 versus 2012–19 was 14.5 in diabetic patients and 6.4 in non-diabetic patients. Counterfactual analyses showed 15–30% excess mortality among diabetic inpatients during 2020–22. Interpretation: The COVID-19 pandemic was associated with a substantial but transient increase in in-hospital mortality among diabetic inpatients, especially older adults, underscoring the need for targeted protection and continuity of high-quality inpatient care during future public health emergencies.

BackgroundDepressive symptoms and diabetes distress are associated with adverse outcomes in adults with type 2 diabetes mellitus (T2DM). However, no prior studies evaluated the association between healthcare expenditures, utilization, and psychological health in adults with T2DM in rural areas of China. The aim of this study was to explore the association between psychological health—specifically depressive symptoms and diabetes distress—and healthcare utilization and expenditures in this population.MethodsThis cross-sectional study was conducted in 15 rural health clinics in Jiangsu Province, China, and involved 843 adults with T2DM. Psychological health was assessed using the 17-item Diabetes Distress Scale (DDS-17) and the 10-item Center for Epidemiologic Studies Depression Scale (CESD-10). Healthcare utilization and expenditures were evaluated with negative binomial, logistic, and ordinary least squares (OLS) regression models.ResultsOf 843 participants, a total of 32.62% of the sample were comorbid with distress, depression, or both. Each 1-point increase in diabetes distress score was associated with a 44% increase in the expected number of annual outpatient visits (IRR = 1.44, P<0.05), a 52% increase in the odds of inpatient service utilization (OR = 1.52, P <0.05), and a 43.3% increase in outpatient costs (eβ-1 = 0.433, P<0.05). For each point increase in depressive symptom score, the expected number of annual outpatient visits increased by 4% (IRR = 1.04, P<0.01), the odds of inpatient service utilization increased by 4% (OR = 1.04, P <0.01), and total medical expenditures increased by 2% (eβ-1 = 0.02, P<0.05).ConclusionOur study observed that Diabetes distress is associated with higher outpatient costs, while diabetes with depressive symptoms is associated with higher total medical expenditures. These findings suggest that psychological screening and care interventions for adults with diabetes may be essential.

BackgroundFamily caregivers of disabled older adults frequently face significant challenges that are associated with their mental health. Psychological resilience and family functioning may be associated with depressive symptoms among this population. Nevertheless, the mechanisms behind this relationship have received limited attention. In this study, we examined whether caregiver burden serves as a mediating factor and family functioning as a moderating factor in the link between psychological resilience and depressive symptoms among family caregivers of individuals with disabilities.MethodsA community-based cross-sectional survey was conducted in Nantong and Taizhou, eastern China, from December 2023 to May 2024. Data were collected using the 10-item Connor-Davidson Resilience Scale, the 12-item Zarit Burden Interview, the 10-item short form of the Center for Epidemiological Studies Depression Scale, and the Family APGAR Scale. A moderated mediation model was tested using bootstrap and simple slope procedures.ResultsA total of 353 caregivers completed the survey. The prevalence of depressive symptoms was 31.59%. Higher psychological resilience was significantly associated with fewer depressive symptoms. This relationship was partially mediated by caregiver burden. In addition, family functioning moderated the mediated relationship, indicating that the indirect effect of psychological resilience on depressive symptoms via caregiver burden varied across levels of family functioning.ConclusionThese findings suggest that psychological resilience, caregiver burden, and family functioning are jointly associated with depressive symptoms in family caregivers of disabled older adults. Interventions targeting psychological resilience and family functioning may be associated with reduced caregiver burden and depressive symptoms in this population.

Background Depressive symptoms, loneliness, and social media addiction are commonly reported by medical students, yet their symptom-level interrelationships are not well understood. Objective This study employed network analysis to investigate the connections between these conditions among Chinese medical students. Method A total of 836 Chinese medical students from a university in Nantong were included in this cross-sectional study. Depressive symptoms, loneliness, and social media addiction were assessed using the Patient Health Questionnaire-9, the short-form UCLA Loneliness Scale, and the Bergen Social Media Addiction Scale, respectively. We estimated two complementary networks: a regularized partial correlation network and a Bayesian directed acyclic graph (DAG). Results For the regularized partial correlation network, we found that “Isolation” was not only the most central node but also the primary bridge symptom, with “Sad mood” and “Anhedonia” also emerging as highly central. For the DAG, “Anhedonia” was identified as a key driver of other symptoms within the network, and “Unhappy”, “Fatigue” were terminal symptoms. Conclusion As the first network analysis of depressive symptoms, loneliness, and social media addiction among Chinese medical students, the findings inform multi-level interventions by identifying central, bridge, and upstream symptoms as potential therapeutic targets, with downstream symptoms serving as key clinical indicators.

BackgroundThe elderly with type 2 diabetes mellitus (T2DM) are often affected by mild cognitive impairment (MCI). However, little is known about the potential mechanisms between the psychological and behavioral factors and MCI among rural Chinese elderly with T2DM. This cohort survey explored the effects of changes in self-management behaviors, depressive symptoms, and glycemic control on MCI.MethodsThis study was conducted from 2019 to 2024 in the rural health clinics in China. At baseline and during follow-up in this cohort study, data on changes in self-management behaviors (the Summary of Diabetes Self-Care Activities, Δ SDSCA), depressive symptoms (the 10-item Center for Epidemiologic Studies Depression Scale, Δ CESD-10), cognitive function (the 30-item Mini-Mental State Examination, MMSE), and glycemic control were assessed. MCI was defined as MMSE scores below education-adjusted cutoffs. Hierarchical multiple regression and mediation model analysis were employed to examine the effects of these variables.ResultsAmong 232 participants, 37.07% had MCI at the follow-up stage. Hierarchical multiple regression analysis revealed that improved self-management behaviors (β = 0.233, P < 0.01) significantly predicted better glycemic control. In addition, improved self-management behaviors (increased Δ SDSCA score) (β = 0.220, P < 0.001), less depressive symptoms (decreased Δ CESD-10 score) (β = -0.145, P < 0.05), and better glycemic control (β = 0.143, P < 0.05) were associated with lower risks of MCI. Mediation analysis suggested that better glycemic control partially mediate the effects of improved self-management (increased Δ SDSCA score) on reducing the incidence of MCI (increasing MMSE score) (indirect effect = 0.035, 95% CI [0.006, 0.074]).ConclusionsImproving self-management behaviors may contribute to more favorable cognitive function by controlling glycemic control. Furthermore, alleviating depressive symptoms may reduce the later incidence of MCI.

Objectives This study aimed to evaluate the caregiving burden among primary caregivers of cancer patients, clarify the relationship between family resilience and caregiving burden, and explore the mediation and moderation effects.Design A cross-sectional study design was used.Setting The study was conducted at a specialised tumour hospital in Harbin, China.Participants The study included a sample of 402 primary family caregivers of patients with cancer. Ultimately, 367 participants completed valid questionnaires, yielding a response rate of 91.2%.Outcome measures Participants completed scales evaluating caregiving burden, caring abilities, individual resilience, family resilience and social support. We performed structural equation modelling to analyse mediation and moderation effects.Results Out of 367 responses, approximately 50% of primary family caregivers reported moderate to severe caregiving burden. Family resilience was found to reduce caregiving burden (β=−0.386, p=0.005), while individual resilience fully mediated the relationship between family resilience and caregiving burden (95% CI −0.659 to –0.161). Caring ability moderated both the first and second halves of the mediating path. Furthermore, social support doubly moderated the moderating role of caring ability in both the first and second halves of the mediating path.Conclusions This study demonstrated the mediating role of individual resilience and the moderating roles of caring ability and social support in the relationship between family resilience and caregiving burden. We suggest that medical institutions should enhance caregiving training and psychological counselling services. Additionally, the government should collaborate with medical institutions and social organisations to improve social welfare policies and the medical insurance system.

BACKGROUND:The number of college students in need of treatment for depressive symptoms far outweighs the resources of most counseling centers due to rising health needs. It is necessary to establish prevention and intervention strategies for college students. This study aimed to explore the associations between self-efficacy, e-health literacy, and depressive symptoms to guide college students in adopting preventive measures and potential interventions for managing depressive symptoms. METHODS:This cross-sectional study randomly recruited 1500 students from two universities in Nantong City from May to December 2020. Participants' demographic characteristics, self-efficacy, e-health literacy, and depressive symptoms were collected. The mediating effect of e-Health literacy was evaluated using the bootstrap resampling technique. RESULTS:A total of 1388 valid questionnaires were collected. The prevalence of depressive symptoms among the sample was 50.29%. Higher self-efficacy and e-health literacy were all significantly associated with lower depressive symptoms. e-Health literacy partially mediated the association between self-efficacy and depressive symptoms, accounting for 26.6% of the total effect. CONCLUSION:Improving self-efficacy and e-health literacy was associated with reducing depressive symptoms, with e-health literacy partially mediating the relationship between self-efficacy and depressive symptoms. Interventions for college students should focus on enhancing both self-efficacy and e-health literacy to help alleviate depressive symptoms.

The global aging process is accelerating, and the demand for long-term care is increasing. Although there is abundant research on the demand for long-term care insurance, studies on the factors affecting its service supply are relatively scarce. This study employed a cross-sectional research design, utilizing a questionnaire survey conducted across 3,315 long-term care facilities in China. The survey aimed to identify the fundamental, operational, policy, economic and demographic factors that affect the supply of long-term care services in China. Most of the 3,315 designated long-term care facilities were non-profit, independent and privately owned, concentrated in residential communities in East China. Facilities located in areas with better economic support, and larger elderly populations showed greater service capacity. Moreover, factors such as treatment payments for severely disabled individuals, regional GDP, the proportion of the population aged 60 and above, facility ownership, whether the facility is part of a chain, geographic location, the presence of digital tools and talent incentive mechanisms, as well as the implementation of professional staff training, were all significantly associated with actual operational performance. This study reflects the service supply of LTCFs from three dimensions, namely service provision capacity, practical operational performance, and service items. The analysis indicates that LTCI financing design, the level of economic development, the proportion of the elderly population, the presence of digital tools and talent incentive mechanisms, the implementation of professional staff training, etc., affect service supply outcomes across various dimensions differently. Not applicable.

Empty nesters represent a unique group that deserves focused attention. Internet usage is becoming increasingly prevalent among older people. This study preliminarily discussed the differences in life satisfaction between empty nesters who used the Internet and those who did not. This study also provided insight into how Internet use interacted with social participation to improve their life satisfaction. A face-to-face survey was conducted in Yangzhou City, China, from July to August 2022. Covariates related to life satisfaction, such as sociodemographic characteristics and participants’ health behaviors, were collected. Propensity Score Matching (PSM) was used to match Internet users with non-Internet users. Binomial logistic regression was employed to analyze the association between Internet use and life satisfaction, and the KHB method was used to examine the mediating effect. 1,177 respondents aged 60 and above were ultimately matched for analysis in this study. The results showed that Internet use was significantly correlated with higher levels of both social participation (β = 0.276, P < 0.05) and life satisfaction (β = 0.433, P < 0.05). Social participation partially mediated the relationship between Internet use and life satisfaction, with a mediating effect of 0.112 accounting for 21

Public health physicians are experiencing increased work stress and workload, leading to heightened negative emotions and presenteeism. This study investigates the relationship between job burnout and presenteeism among primary public health physicians in China and explores the potential mediating effect of depressive symptoms, and moderating effects of coping styles and organizational support on these associations. 955 primary public health physicians were surveyed from September to December 2022 in China. Presenteeism was assessed using the Stanford Presenteeism Scale (SPS-6). A moderated mediation model was used to understand the moderating relationship between job burnout (X), depressive symptoms (M) mediated presenteeism (Y), coping styles (W1), and organizational support (W2), controlling for all possible covariates. 69.95

People experienced significant disruptions in their daily lives due to COVID-19, leading to pandemic fatigue, however the underlying mechanisms have rarely been investigated. This study explored the relationship between COVID-19’s disruptions to daily life and pandemic fatigue by examining the potential role of perceived stress and perceived social support. A cross-sectional questionnaire survey via the Wenjuanxing online platform using a convenience sampling approach was conducted from April to May 2022 in Shanghai Municipality, Jiangsu Province, and Zhejiang Province, China. Of the 2112 initial participants, 88 invalid questionnaires were excluded due to missing key variables or logical errors, yielding 2024 valid samples included (efficiency rate of 95.8

AIM:This study aims to evaluate the impact of a pay-for-performance (P4P) program on health outcomes for patients with type 2 diabetes mellitus in Chinese primary care settings. METHODS:Conducted from February to March 2019, this trial involved 1,085 participants from 19 rural villages in China. Family physicians in the intervention group received P4P incentives. We collected clinical health outcomes, including fasting blood glucose, blood pressure, and lipid levels, at baseline and after one year. A differences-in-differences model was employed to assess the P4P program's effects on these health outcomes. Additionally, a multiple regression analysis was performed to evaluate the influence of P4P on patients' health behaviors, such as self-management, doctor-patient trust, and self-rated health. RESULTS:Following the intervention, the intervention group showed significant reductions in fasting plasma glucose (0.88 mmol/L), systolic blood pressure (11.10 mmHg), and total cholesterol (0.50 mmol/L) compared to the control group. The P4P program also improved control rates for fasting glucose (OR = 2.34, 95 % CI:1.57-3.48), blood pressure (OR = 7.57, 95 % CI: 4.98-11.50), and total cholesterol (OR = 2.47, 95 % CI:1.61-3.79), while enhancing self-management behaviors (OR = 0.21, 95 % CI: 0.08-0.34) and doctor-patient trust (OR = 0.75, 95 % CI: 0.39-1.11). CONCLUSIONS:The P4P incentive effectively improved glycemic control and diabetes management in rural China.

Academic procrastination is a concerning behavior that could have detrimental effects on students. The rising prevalence of Internet overuse, or Internet addiction, among adolescents has intensified psychological issues, including depressive symptoms and loneliness, thereby contributing to academic procrastination. However, environmental factors, such as family functioning and teacher support, may play crucial roles in alleviating the effects of Internet addiction on procrastination. This study aims to explore the mediating effects of psychological disorders and the moderating effects of environmental factors on the relationship between Internet addiction and academic procrastination. A cross-sectional study involving 3219 Chinese rural junior high school students was conducted. Data were collected using several instruments, including the Internet Addiction Questionnaire, the Academic Procrastination Scale, the Center for Epidemiologic Studies Depression Scale, the UCLA Loneliness Scale, the Family Adaptation Partnership Growth Affection Resolution Scale, and the Perceived Teacher Support Scale. Hierarchical multiple regression and moderated mediation analyses were employed to examine the relationships among Internet addiction (X), psychological disorders (M), environmental factors (W), and academic procrastination (Y). Among the 3219 participants, 14.23% had academic procrastination behaviors. Hierarchical linear regression results indicated that higher Internet addiction scores were related to more severe academic procrastination (β = 0.30, 95% CI [0.27, 0.33]). Mediation analysis confirmed that depressive symptoms (indirect effect = 0.12, 95% CI [0.10, 0.14]) and loneliness (indirect effect = 0.06, 95% CI [0.04, 0.08]) had indirect effects on this relationship. Moderated mediation analysis showed that better family functioning moderated the effect of Internet addiction on academic procrastination by attenuating the severity of psychological disorders, whereas higher levels of teacher support could moderate the effect of Internet addiction on psychological disorders. Psychological disorders may exacerbate the negative effect of Internet addiction on academic procrastination, whereas improved family functioning and increased levels of teacher support could help moderate this effect.

BACKGROUND:Social anxiety has been shown to affect college students' academic performance. However, the role of social media addiction and academic engagement in this association is unclear.METHODS:A total 2661 college students completed a self-report questionnaire including Liebowitz Social Anxiety Scale, the Bergen Social Media Addiction Scale, the Utrecht Student Work Engagement Scale for Students, and the grade point average. Hayes' PROCESS macro for SPSS was employed to test the serial mediation effect.RESULTS:Results indicated that social anxiety was negatively related to academic performance, only academic engagement played a single mediating role in the relationship between social anxiety and academic performance, meanwhile social media addiction and academic engagement acted as serial mediators between social anxiety on academic performance.CONCLUSIONS:Social media addiction and academic engagement can explain the potential mechanisms of the association between social anxiety and academic performance, which have implications for devising intervention strategies to enhance the mental health and academic outcomes of college students.

Objectives This study was to use the Kano model to explore inpatients’ medical service demands better, as satisfactory services for inpatients in public hospitals could effectively increase their compliance with services, ultimately enhancing the medical service quality and patient loyalty in public hospitals. Methods The survey was conducted from January to June 2023 among patients from 15 departments discharged from a tertiary hospital. Through the collected data of hospitalized patients, we introduced traditional Kano model analysis, important-satisfaction matrix analysis as well as an "in-line-of-sight" approach to explore the effect of different services on inpatients’ satisfaction. Results Our study adopted the method of convenient sampling and selected 336 inpatients from a public hospital in China for investigation. The analysis revealed that five of the 28 services were classified as “must-be attributes” (visit process, consistent information, privacy protection, informed consent, clear sign), 12 as “one-dimensional attributes” (appointment, convenient process, timely disposal, attention feelings, initiative, communication, etc.), 9 as “attractive attributes” (coordination service, convenient multidisciplinary coordination, timely service, patient participation, active care, dietary service), and 2 as “indifferent attributes” (personalized service, collaborative service). Optimized method results of Kano show that healthcare professional active care boosts satisfaction, and it is no need for major improvement; Disrespect would lead to dissatisfaction among inpatients.. For males, top concern is informed consent realization, then continuous information service from medical staff. Female patients have a medical service demand hierarchy, top is informed consent respect, then privacy protection and consistent team work. Conclusions From the traditional Kano attribute classification perspective, attractive and expected services are crucial as they maximize patients' service experience. The optimized classification method enables us to identify the service items that public hospitals should prioritize for improvement, achieving the best results.

Abstract Background Social media addiction (SMA) is an increasing problem, especially among young adults. Little is known about university students’ SMA and family functioning. This study aimed to explore the mediating effect of depressive symptoms and the moderating effect of peer support in the relationship between family functioning and SMA among young adults. Methods A sample of 1862 Chinese university students completed an online survey including the Bergen Social Media Addiction Scale (BSMAS), Family APGAR, the Patient Health Questionnaire (PHQ-9), peer support, and demographic characteristics. Hierarchical regression and moderated mediation analysis were used to test the effects and pathways among them. Results Of the 1840 participants, 30.11% experienced SMA, 38.80% had family dysfunction and 15.98% had depressive symptoms. Hierarchical multiple regression showed better family functioning significantly predicted less SMA (β = -0.26, p < 0.001) and lower depressive symptoms (β = -0.58, p < 0.001), after adjusting for covariates. Mediation analysis verified that depressive symptoms mediated the effect of family functioning on SMA (indirect effect = -0.22, 95%CI[-0.28, -0.17]). Furthermore, the interaction of family functioning and peer support was negatively related to depressive symptoms (β= -0.03, 95% CI[-0.05, -0.01]) and the interaction of depressive symptoms and peer support was positively related to SMA (β = 0.01, 95%CI[0.004, 0.02]). Additional analysis further confirmed that peer support decreased depressive symptoms among young adults from dysfunctional families, and increased SMA behaviors in individuals with depressive symptoms. Conclusion Better family functioning and lower depressive symptoms may contribute to less social media addiction among Chinese university students. Peer support could moderate the mediating role of depressive symptoms on social media addiction in individuals with family dysfunction.