Treffer: Structural modelling of student volleyball athletes' intimacy, social adjustment, perceived stress, and learning-related anxiety: mediating role of psychological safety.
Title:
Structural modelling of student volleyball athletes' intimacy, social adjustment, perceived stress, and learning-related anxiety: mediating role of psychological safety.
Authors:
Li Y; Department of Common Courses, Changjiang Institute of Technology, Wuhan, 430212, China. liyishuang0826@sina.cn.
Source:
BMC psychology [BMC Psychol] 2025 Jan 07; Vol. 13 (1), pp. 15. Date of Electronic Publication: 2025 Jan 07.
Publication Type:
Journal Article
Language:
English
Journal Info:
Publisher: BioMed Central Country of Publication: England NLM ID: 101627676 Publication Model: Electronic Cited Medium: Internet ISSN: 2050-7283 (Electronic) Linking ISSN: 20507283 NLM ISO Abbreviation: BMC Psychol Subsets: MEDLINE
Imprint Name(s):
Original Publication: London : BioMed Central, [2013]-
MeSH Terms:
Athletes*/psychology , Anxiety*/psychology , Students*/psychology , Students*/statistics & numerical data , Stress, Psychological*/psychology , Volleyball*/psychology , Social Adjustment*, Humans ; Male ; Female ; Young Adult ; Cross-Sectional Studies ; Adult ; China ; Interpersonal Relations ; Universities ; Adolescent ; Models, Structural ; Learning ; Psychological Safety
References:
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Comeaux E, Harrison CK. A conceptual model of academic success for student-athletes. Educ Res. 2011;40(5):235–45. (PMID: 10.3102/0013189X11415260)
Turner TL. Academics and athletics: a phenomenological study of self-advocacy and student involvement in Black student-athletes with disabilities. Pepperdine University; 2023.
Umbach PD, Palmer MM, Kuh GD, Hannah SJ. Intercollegiate athletes and effective educational practices: winning combination or losing effort? Res High Educ. 2006;47(6):709–33. (PMID: 10.1007/s11162-006-9012-9)
Wang MT, Degol JL. School Climate: a review of the Construct, Measurement, and impact on Student outcomes. Educ Psychol Rev. 2016;28(2):315–52. (PMID: 10.1007/s10648-015-9319-1)
Dennehy R, Das M. Balancing Act: the Student-Athlete experience. J Coll Adm. 2019;243:22–7.
Lavelle B, McKenna J. The dual role of Student-Athletes: navigating identity and expectations. J Sport Exerc Psychol. 2018;40:S1.
Diehl K. Transitioning to College: the Student-Athlete experience. J Coll Stud Dev. 2019;60(4):457–61.
Roberts SC, Dunbar RI. The Evolutionary psychology of intimate relationships. The Oxford Handbook of Evolutionary psychology and behavioral endocrinology. Oxford University Press; 2019.
Guzmán PA. Loneliness and social connectedness in Student-Athletes: a qualitative study. J Appl Sport Psychol. 2020;32(4):407–25.
Ferrara K, McMullen J, Krueger P. The impact of social support on mental health in athletes. Int J Sports Med. 2019;40(1):23–30.
Navaneetham P, Kanth B. Effects of Personal relationships on Physical and Mental Health among young Adults-A scoping review. Open Psychol J, 15(1), 2022.
Hanton S, Fletcher D, Coughlan G. Stress in Elite sports performers: a comparative study of competitive and organizational stressors. J Sports Sci. 2005;23(10):1129–41. (PMID: 1619498910.1080/02640410500131480)
Goetz T, Frenzel AC, Stockinger K, Lipnevich AA, Stempfer L, Pekrun R. (2023). Emotions in education. Int Encyclopedia Educ, 149–61.
Etzel EF. Counseling and Psychological Services for College Student-Athletes. Fitness Information Technology; 2006.
Parham WD. Stress and burnout: knowing when to say when. NCAA News. 1993;30(8):16–20.
Misra R, McKean M. College students’ academic stress and its relation to their anxiety, time management, and leisure satisfaction. Am J Health Stud. 2000;16(1):41.
Lazarus RS, Folkman S. Stress, Appraisal, and coping. Springer Publishing Company; 1984.
Lopes Dos Santos M, Uftring M, Stahl CA, Lockie RG, Alvar B, Mann JB, Dawes JJ. Stress in academic and athletic performance in collegiate athletes: a narrative review of sources and monitoring strategies. Front Sports Act Living. 2020;2:42. (PMID: 33345034773982910.3389/fspor.2020.00042)
Storch EA, Storch JB, Killiany EM, Roberti JW. Self-reported psychopathology in athletes: a comparison of intercollegiate student-athletes and nonathletes. J Sport Behav. 2005;28(1):86–98.
Watson JC, Kissinger DB. Athletic participation and wellness: implications for counseling college student-athletes. J Coll Couns. 2007;10(2):153–62. (PMID: 10.1002/j.2161-1882.2007.tb00015.x)
Beaumont E, Maynard I. Examining the efficacy of coping training interventions for reducing competition stress in elite athletes: a systematic review. Int J Sports Exerc Psychol. 2012;10(4):246–63.
Gucciardi DF, Jackson B, Coulter TJ, Mallett CJ. The Connor-Davidson Resilience Scale (CD-RISC): dimensionality and age-related measurement invariance with Australian cricketers. Psychol Sport Exerc. 2011;12(4):423–33. (PMID: 10.1016/j.psychsport.2011.02.005)
Van Dick R, Ketturat C, Häusser JA, Mojzisch A. Two sides of the same coin and two routes for improvement: integrating resilience and the social identity approach to well-being and ill-health. Health Psychol open. 2017;4(2):2055102917719564. (PMID: 29379612577991910.1177/2055102917719564)
Cassady JC, Johnson RE. Cognitive test anxiety and academic performance. Contemp Educ Psychol. 2002;27(2):270–95. (PMID: 10.1006/ceps.2001.1094)
Wang M, Eccles JS. Social support matters: longitudinal effects of social support on three dimensions of school engagement from middle to high school. Child Dev. 2012;83(3):877–95. (PMID: 2250683610.1111/j.1467-8624.2012.01745.x)
Gould D, Dieffenbach K, Moffett A. Psychological characteristics and their development in olympic champions. J Appl Sport Psychol. 2002;14(3):172–204. (PMID: 10.1080/10413200290103482)
Martens MP, Dams-O’Connor K, Beck NC. A systematic review of college student-athlete drinking: prevalence rates, sport-related factors, and interventions. J Subst Abuse Treat. 2006;31(3):305–16. (PMID: 1699639310.1016/j.jsat.2006.05.004)
Ferrante AP, Etzel EF. Counseling college student-athletes: the problem, the need. Quest. 1991;43(1):69–94.
Han L, Gao X, Wang X, Ren W. The relationship between academic stress and educational anxiety: learning anxiety and learning weariness as mediators. Curr Psychol, 2024, 1–12.
Nicholls AR, Polman RC. Coping in sport: a systematic review. J Sports Sci. 2007;25(1):11–31. (PMID: 1712757810.1080/02640410600630654)
Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350–83. (PMID: 10.2307/2666999)
Kozub SA. A comparison of athlete and nonathlete college students’ perceptions of a coach’s leadership style and the presence of a motivational climate. J Appl Sport Psychol. 2004;16(3):214–29.
Edmondson AC. The local and variegated nature of learning in organizations: a group-level perspective. Organ Sci. 2002;13(2):128–46. (PMID: 10.1287/orsc.13.2.128.530)
Newman A, Donohue R, Eva N. Psychological safety: a systematic review of the literature. Hum Resour Manag Rev. 2017;27(3):521–35. (PMID: 10.1016/j.hrmr.2017.01.001)
Carmeli A, Brueller D, Dutton JE. Learning behaviors in the workplace: the role of high-quality interpersonal relationships and psychological safety. Syst Res Behav Sci. 2009;26(1):81–98. (PMID: 10.1002/sres.932)
Paradis KF, Martin LJ, Carron AV. Examining the relationship between social cohesion and team success in elite intercollegiate ice hockey teams. J Sport Behav. 2012;35(4):442–55.
Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000;55(1):68–78. (PMID: 1139286710.1037/0003-066X.55.1.68)
Albritton JA, Fried B, Singh K, Weiner BJ, Reeve B, Edwards JR. The role of psychological safety and learning behavior in the development of effective quality improvement teams in Ghana: an observational study. BMC Health Serv Res. 2019;19:1–12. (PMID: 10.1186/s12913-019-4234-7)
Berscheid E, Snyder M, Omoto AM. The relationship closeness inventory (RCI): assessing the closeness of interpersonal relationships. J Personal Soc Psychol. 1989;57(5):792–807. (PMID: 10.1037/0022-3514.57.5.792)
Weissman MM, Bothwell S, Prieto L. The Social Adjustment Scale-Self-Report (SAS-SR): assessing social functioning. Arch Gen Psychiatry. 1996;53(8):689–98.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385–96. (PMID: 666841710.2307/2136404)
Spielberger CD, Vagg PR, Barker LR, Donham GW, Westberry LG. The learning anxiety scale (LAS): development and validation. J Educ Psychol. 1980;72(4):566–75.
Kline RB. Principles and practice of structural equation modeling. Guilford; 2023.
Hu LT, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equation Modeling: Multidisciplinary J. 1999;6(1):1–55. (PMID: 10.1080/10705519909540118)
Lomax R. Introduction to structural equation modeling. Applied quantitative analysis in education and the social sciences. Routledge; 2013. pp. 245–64.
Galliano DE. (2024). Put Me in Coach! Exploring Associations Between Attachment to Coach and Athletic Coping for High School Athletes (Doctoral dissertation, The Institute for the Psychological Sciences).
Ju L, Ji YP, Wu C, Ning X, He Y. Relationship between abusive supervision and workers’ well-being in construction projects: effects of guanxi closeness and trust in managers. Eng Constr Architectural Manage. 2024;31(8):3429–51. (PMID: 10.1108/ECAM-08-2022-0726)
Hollis-Johnson IA. It’s All About Relationships: A Phenomenological Study of Black Collegiate Student Athletes. University of Dayton; 2023.
Zhang R, Rhim YT. The effect of coach–athlete relationships on motor behaviour in college athletes—mediating effects of psychological needs. Behav Sci. 2024;14(7):579. (PMID: 390624021127394510.3390/bs14070579)
Taylor J, Collins D, Ashford M. Psychological safety in high-performance sport: contextually applicable? Front Sports Act Living. 2022;4:823488. (PMID: 35615347912508110.3389/fspor.2022.823488)
Chen X, Bailey RP, Yin X, Samsudin N. The relationship between teacher–student relationships and academic grades among Chinese rural high school students: the moderating role of mental health symptoms and the conditional moderating effect of academic resilience. Front Psychol. 2024;15:1416783. (PMID: 395393031155732610.3389/fpsyg.2024.1416783)
Leprince C, D’Arripe-Longueville F, Doron J. Coping in teams: exploring athletes’ communal coping strategies to deal with shared stressors. Front Psychol. 2018;9:1908. (PMID: 30356814618951510.3389/fpsyg.2018.01908)
Kaşıkcı F, Öğülmüş S. Adolescent well-being: relative contributions of social emotional learning and microsystem supports. Soc Psychol Educ. 2024;27(3):1097–114. (PMID: 10.1007/s11218-023-09852-5)
Wilson GS, Pritchard ME, Schaffer J. Athletic status and drinking behavior in college students: the influence of gender and coping styles. J Am Coll Health. 2004;52(6):269–73. (PMID: 1513410110.3200/JACH.52.6.269-275)
Trent A, Reed ES. Interpersonal relationships and college adjustment: the roles of relationship direction and emotional support. J Coll Stud Dev. 1998;39(6):643–52.
Comeaux E, Harrison CK. A conceptual model of academic success for student-athletes. Educ Res. 2011;40(5):235–45. (PMID: 10.3102/0013189X11415260)
Turner TL. Academics and athletics: a phenomenological study of self-advocacy and student involvement in Black student-athletes with disabilities. Pepperdine University; 2023.
Umbach PD, Palmer MM, Kuh GD, Hannah SJ. Intercollegiate athletes and effective educational practices: winning combination or losing effort? Res High Educ. 2006;47(6):709–33. (PMID: 10.1007/s11162-006-9012-9)
Wang MT, Degol JL. School Climate: a review of the Construct, Measurement, and impact on Student outcomes. Educ Psychol Rev. 2016;28(2):315–52. (PMID: 10.1007/s10648-015-9319-1)
Dennehy R, Das M. Balancing Act: the Student-Athlete experience. J Coll Adm. 2019;243:22–7.
Lavelle B, McKenna J. The dual role of Student-Athletes: navigating identity and expectations. J Sport Exerc Psychol. 2018;40:S1.
Diehl K. Transitioning to College: the Student-Athlete experience. J Coll Stud Dev. 2019;60(4):457–61.
Roberts SC, Dunbar RI. The Evolutionary psychology of intimate relationships. The Oxford Handbook of Evolutionary psychology and behavioral endocrinology. Oxford University Press; 2019.
Guzmán PA. Loneliness and social connectedness in Student-Athletes: a qualitative study. J Appl Sport Psychol. 2020;32(4):407–25.
Ferrara K, McMullen J, Krueger P. The impact of social support on mental health in athletes. Int J Sports Med. 2019;40(1):23–30.
Navaneetham P, Kanth B. Effects of Personal relationships on Physical and Mental Health among young Adults-A scoping review. Open Psychol J, 15(1), 2022.
Hanton S, Fletcher D, Coughlan G. Stress in Elite sports performers: a comparative study of competitive and organizational stressors. J Sports Sci. 2005;23(10):1129–41. (PMID: 1619498910.1080/02640410500131480)
Goetz T, Frenzel AC, Stockinger K, Lipnevich AA, Stempfer L, Pekrun R. (2023). Emotions in education. Int Encyclopedia Educ, 149–61.
Etzel EF. Counseling and Psychological Services for College Student-Athletes. Fitness Information Technology; 2006.
Parham WD. Stress and burnout: knowing when to say when. NCAA News. 1993;30(8):16–20.
Misra R, McKean M. College students’ academic stress and its relation to their anxiety, time management, and leisure satisfaction. Am J Health Stud. 2000;16(1):41.
Lazarus RS, Folkman S. Stress, Appraisal, and coping. Springer Publishing Company; 1984.
Lopes Dos Santos M, Uftring M, Stahl CA, Lockie RG, Alvar B, Mann JB, Dawes JJ. Stress in academic and athletic performance in collegiate athletes: a narrative review of sources and monitoring strategies. Front Sports Act Living. 2020;2:42. (PMID: 33345034773982910.3389/fspor.2020.00042)
Storch EA, Storch JB, Killiany EM, Roberti JW. Self-reported psychopathology in athletes: a comparison of intercollegiate student-athletes and nonathletes. J Sport Behav. 2005;28(1):86–98.
Watson JC, Kissinger DB. Athletic participation and wellness: implications for counseling college student-athletes. J Coll Couns. 2007;10(2):153–62. (PMID: 10.1002/j.2161-1882.2007.tb00015.x)
Beaumont E, Maynard I. Examining the efficacy of coping training interventions for reducing competition stress in elite athletes: a systematic review. Int J Sports Exerc Psychol. 2012;10(4):246–63.
Gucciardi DF, Jackson B, Coulter TJ, Mallett CJ. The Connor-Davidson Resilience Scale (CD-RISC): dimensionality and age-related measurement invariance with Australian cricketers. Psychol Sport Exerc. 2011;12(4):423–33. (PMID: 10.1016/j.psychsport.2011.02.005)
Van Dick R, Ketturat C, Häusser JA, Mojzisch A. Two sides of the same coin and two routes for improvement: integrating resilience and the social identity approach to well-being and ill-health. Health Psychol open. 2017;4(2):2055102917719564. (PMID: 29379612577991910.1177/2055102917719564)
Cassady JC, Johnson RE. Cognitive test anxiety and academic performance. Contemp Educ Psychol. 2002;27(2):270–95. (PMID: 10.1006/ceps.2001.1094)
Wang M, Eccles JS. Social support matters: longitudinal effects of social support on three dimensions of school engagement from middle to high school. Child Dev. 2012;83(3):877–95. (PMID: 2250683610.1111/j.1467-8624.2012.01745.x)
Gould D, Dieffenbach K, Moffett A. Psychological characteristics and their development in olympic champions. J Appl Sport Psychol. 2002;14(3):172–204. (PMID: 10.1080/10413200290103482)
Martens MP, Dams-O’Connor K, Beck NC. A systematic review of college student-athlete drinking: prevalence rates, sport-related factors, and interventions. J Subst Abuse Treat. 2006;31(3):305–16. (PMID: 1699639310.1016/j.jsat.2006.05.004)
Ferrante AP, Etzel EF. Counseling college student-athletes: the problem, the need. Quest. 1991;43(1):69–94.
Han L, Gao X, Wang X, Ren W. The relationship between academic stress and educational anxiety: learning anxiety and learning weariness as mediators. Curr Psychol, 2024, 1–12.
Nicholls AR, Polman RC. Coping in sport: a systematic review. J Sports Sci. 2007;25(1):11–31. (PMID: 1712757810.1080/02640410600630654)
Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350–83. (PMID: 10.2307/2666999)
Kozub SA. A comparison of athlete and nonathlete college students’ perceptions of a coach’s leadership style and the presence of a motivational climate. J Appl Sport Psychol. 2004;16(3):214–29.
Edmondson AC. The local and variegated nature of learning in organizations: a group-level perspective. Organ Sci. 2002;13(2):128–46. (PMID: 10.1287/orsc.13.2.128.530)
Newman A, Donohue R, Eva N. Psychological safety: a systematic review of the literature. Hum Resour Manag Rev. 2017;27(3):521–35. (PMID: 10.1016/j.hrmr.2017.01.001)
Carmeli A, Brueller D, Dutton JE. Learning behaviors in the workplace: the role of high-quality interpersonal relationships and psychological safety. Syst Res Behav Sci. 2009;26(1):81–98. (PMID: 10.1002/sres.932)
Paradis KF, Martin LJ, Carron AV. Examining the relationship between social cohesion and team success in elite intercollegiate ice hockey teams. J Sport Behav. 2012;35(4):442–55.
Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000;55(1):68–78. (PMID: 1139286710.1037/0003-066X.55.1.68)
Albritton JA, Fried B, Singh K, Weiner BJ, Reeve B, Edwards JR. The role of psychological safety and learning behavior in the development of effective quality improvement teams in Ghana: an observational study. BMC Health Serv Res. 2019;19:1–12. (PMID: 10.1186/s12913-019-4234-7)
Berscheid E, Snyder M, Omoto AM. The relationship closeness inventory (RCI): assessing the closeness of interpersonal relationships. J Personal Soc Psychol. 1989;57(5):792–807. (PMID: 10.1037/0022-3514.57.5.792)
Weissman MM, Bothwell S, Prieto L. The Social Adjustment Scale-Self-Report (SAS-SR): assessing social functioning. Arch Gen Psychiatry. 1996;53(8):689–98.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385–96. (PMID: 666841710.2307/2136404)
Spielberger CD, Vagg PR, Barker LR, Donham GW, Westberry LG. The learning anxiety scale (LAS): development and validation. J Educ Psychol. 1980;72(4):566–75.
Kline RB. Principles and practice of structural equation modeling. Guilford; 2023.
Hu LT, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equation Modeling: Multidisciplinary J. 1999;6(1):1–55. (PMID: 10.1080/10705519909540118)
Lomax R. Introduction to structural equation modeling. Applied quantitative analysis in education and the social sciences. Routledge; 2013. pp. 245–64.
Galliano DE. (2024). Put Me in Coach! Exploring Associations Between Attachment to Coach and Athletic Coping for High School Athletes (Doctoral dissertation, The Institute for the Psychological Sciences).
Ju L, Ji YP, Wu C, Ning X, He Y. Relationship between abusive supervision and workers’ well-being in construction projects: effects of guanxi closeness and trust in managers. Eng Constr Architectural Manage. 2024;31(8):3429–51. (PMID: 10.1108/ECAM-08-2022-0726)
Hollis-Johnson IA. It’s All About Relationships: A Phenomenological Study of Black Collegiate Student Athletes. University of Dayton; 2023.
Zhang R, Rhim YT. The effect of coach–athlete relationships on motor behaviour in college athletes—mediating effects of psychological needs. Behav Sci. 2024;14(7):579. (PMID: 390624021127394510.3390/bs14070579)
Taylor J, Collins D, Ashford M. Psychological safety in high-performance sport: contextually applicable? Front Sports Act Living. 2022;4:823488. (PMID: 35615347912508110.3389/fspor.2022.823488)
Chen X, Bailey RP, Yin X, Samsudin N. The relationship between teacher–student relationships and academic grades among Chinese rural high school students: the moderating role of mental health symptoms and the conditional moderating effect of academic resilience. Front Psychol. 2024;15:1416783. (PMID: 395393031155732610.3389/fpsyg.2024.1416783)
Leprince C, D’Arripe-Longueville F, Doron J. Coping in teams: exploring athletes’ communal coping strategies to deal with shared stressors. Front Psychol. 2018;9:1908. (PMID: 30356814618951510.3389/fpsyg.2018.01908)
Kaşıkcı F, Öğülmüş S. Adolescent well-being: relative contributions of social emotional learning and microsystem supports. Soc Psychol Educ. 2024;27(3):1097–114. (PMID: 10.1007/s11218-023-09852-5)
Wilson GS, Pritchard ME, Schaffer J. Athletic status and drinking behavior in college students: the influence of gender and coping styles. J Am Coll Health. 2004;52(6):269–73. (PMID: 1513410110.3200/JACH.52.6.269-275)
Trent A, Reed ES. Interpersonal relationships and college adjustment: the roles of relationship direction and emotional support. J Coll Stud Dev. 1998;39(6):643–52.
Contributed Indexing:
Keywords: Intimacy; Learning anxiety; Perceived stress; Psychological safety; Social Adjustment; Student athletes
Entry Date(s):
Date Created: 20250108 Date Completed: 20250108 Latest Revision: 20250108
Update Code:
20250114
DOI:
10.1186/s40359-024-02299-z
PMID:
39773753
Database:
MEDLINE
Weitere Informationen
Background: Psychological safety is crucial for student-athletes, impacting their stress levels and academic anxiety. Understanding how interpersonal factors like intimacy and social adjustment impact psychological safety can guide interventions to enhance student-athlete well-being.
Objectives: This study investigates the relationships between intimacy, social adjustment, psychological safety, perceived stress, and learning-related anxiety among student-athletes. It tests explicitly whether psychological safety mediates the effects of intimacy and social adjustment on perceived stress and learning-related anxiety.
Methodology: A cross-sectional design was employed, involving 300 student-athletes from various universities in Wuhan, China. Participants completed measures of intimacy (RCI), social adjustment (SAS-SR), perceived stress (PSS), learning-related anxiety (LAS), and psychological safety (PSS). Structural Equation Modeling (SEM) was used to analyze direct and indirect relationships among the variables.
Results/discussion: The results revealed that intimacy and social adjustment positively impact psychological safety. In turn, psychological safety negatively affects perceived stress and learning-related anxiety. The mediation analysis showed that psychological safety significantly mediates the relationships between both intimacy and social adjustment with perceived stress and learning-related anxiety. Specifically, the study found that higher intimacy and social adjustment levels increased psychological safety, subsequently reducing perceived stress and anxiety levels. These findings underscore the importance of fostering a psychologically safe environment to mitigate stress and anxiety among student-athletes. The study's implications suggest that coaches and educators should build supportive relationships and enhance social integration to improve psychological safety and overall athlete well-being.
Conclusion: This study highlights the critical role of psychological safety in student athletes' mental health. By promoting intimacy and social adjustment, institutions can enhance psychological safety, reduce stress and anxiety, and improve athletes' academic and personal experiences. Future research should explore longitudinal effects and potential moderators to understand these relationships further.
(© 2024. The Author(s).)
Declarations. Ethics approval and consent to participate: The study was conducted in accordance with the Declaration of Helsinki, and “the protocol was approved by Institutional Review Board of Changjiang Institute of Technology. All subjects gave their informed consent for inclusion in the study before they participated in the study. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.