How physical activity and gender moderate the association between parental marital conflict and adolescent depression

Abstract

Adolescent depression is a public development crisis that needs to be paid attention to and addressed under the rapid development of the Internet. It is of great significance to investigate the associations among adolescent depression, family relationship and physical activity (PA) for promoting adolescent mental health. A total of 3990 valid questionnaires were obtained through self-reports from adolescents. Data were collected using measurement tools for adolescent depression, parental marital conflict (PMC), and PA, followed by statistical analysis. Adolescent depression and PMC was significantly positive correlation (β = 0.315, p < 0.001) and PA is significantly negatively correlated (β = − 0.093, p < 0.001). After introducing moderating variables, PMC is still a significant positive correlation and adolescent depression (β = 0.303, p < 0.001). The study provides preliminary support for the association between PMC and adolescent depression, as well as the potential moderating roles of gender and PA in this association. These findings generate hypotheses for future research on the roles of PA and family relationships in adolescent depression, rather than providing direct evidence for prevention or intervention strategies.

Introduction

Depression is a common mental health condition characterized by persistent low mood or loss of interest and pleasure in activities (World Health Organization). Physical symptoms may include fatigue, pain, and sleep disturbances¹. With the advancement of socioeconomic development, mental health issues have emerged as a global concern, with depression exhibiting a notable trend toward younger age groups. Studies indicate that approximately one-fifth of children and adolescents worldwide exhibit symptoms of depression, with this proportion rising over time². Of course, this phenomenon is also very common among children and teenagers in China^3–5. For instance, the study show that globally, the prevalence of self-reported depression among teenagers has increased by 34% (95% CI: 0.30–0.38) over the past 20 years, rising from 24% (95% CI: 0.19–0.28) during 2001–2010 to 37% (95% CI: 0.32–0.42)⁶. Comparisons across geographical regions revealed the highest increases in prevalence in the Middle East, Africa, and Asia. According to a meta-analysis of China youth group (n = 144,060) prevalence of depression was 24.3% (95% CI: 21.3–27.6%), with a gradual increase from 24.5% (95% CI: 17.8–32.8%) in the first year of junior high school to 40.1% (95% CI: 29.4–51.9%) in the final year of high school⁵. Depression poses significant risks to the development of children and adolescents, including health-related issues⁷, psychosocial development⁴, interpersonal relationships⁸, socioemotional and behavioral development, academic performance³, and quality of life⁹. Clarifying the factors and mechanisms underlying adolescent depression is essential for addressing mental health issues in this population.

Factors influencing adolescent depression are multifaceted, with family factors being a crucial aspect of research¹⁰. The development of mental health among teenagers is closely related to family characteristics¹¹. Investigating the relationship between family factors and depression can inform the development of diverse intervention strategies for adolescent depression. Interparental conflict is widely defined as any interaction between primary caregivers involving disagreements, encompassing both positive and negative forms¹². It can be categorized into destructive and constructive interparental conflict, with destructive conflict including verbal disputes, violent behavior, and aggressive actions¹³. Parental marital conflict (PMC) poses significant risks to adolescent development, affecting their emotional, behavioral, and cognitive aspects, and indirectly leading to adverse health behaviors or increased health risks through physiological responses¹⁴. There is a well-established relationship between PMC and the psychological development of children and adolescents^15–18. The impact of PMC on children and adolescents manifests in both externalizing problems, such as behavioral disorders, aggressive behavior, criminality, and antisocial behavior, and internalizing problems, including depression, anxiety, and withdrawal reactions¹⁹. Several studies have demonstrated the significant influence of parental relationships and family dysfunction on the development of adolescent depression^20,21. Early exposure to interparental conflict is closely linked to depression in adolescents^22,23. PMC can significantly predict adolescent depression^18,24, with a positive correlation between interparental conflict and child depression (ρ = 0.214, p < 0.01)²⁵. Despite substantial progress in research on the relationship between PMC and mental health, investigating the factors influencing adolescent mental health is clearly a complex issue, and cross-cultural studies are highly necessary²⁶. This study, based on the link between PMC and depression, aims to uncover the interactive mechanisms of different dimensions of adolescent depression, paying attention to the existence of group differences and attempting to reveal the network mechanism of adolescent depression.

Gender differences are of great significance. Studies have found that there are substantial differences between genders in brain function, behavior, cognition, and emotion²⁷. Gender is also an important factor in mental health^28,29. Adolescent problem behaviors and mental disorders are rooted in biological, cognitive, and socio-emotional factors related to gender³⁰. Therefore, in exploring the relationship between family relationships and adolescent mental health, the important role of gender cannot be ignored. According to the theoretical explanation of the gender intensification hypothesis, the increased pressure of normative gender roles for girls and boys at the onset of adolescence can lead to the emergence of psychological problems such as depression³¹. Other studies have pointed out that there are gender differences in adolescent stress coping, with girls being more likely to internalize stress as emotional disorders³². Thus, in the context of PMC, the impact on girls may be greater. In addition, adolescent females have a higher sensitivity to social relationships³², which may amplify the negative emotional impact of parental conflict. Previous studies have continuously advanced and enriched the evidence of the relationship between adolescent family relationships and depression^33,34. In most studies, gender is generally used as a covariate to explore correlational relationships³⁵, with fewer studies examining the important role of gender in PMC and depression. This study, taking gender as a moderating variable, attempts to explore whether there are differences in the perceived levels of PMC among adolescents of different genders, which in turn affects the levels of adolescent depression.

Physical activity (PA) is an effective means of mental health intervention^36,37, and its role and mechanisms in the physical and mental health development of adolescents are continuously being deepened. Based on the bioecological framework, individual development is closely related to the individual and their environment, as well as the interactions between these environments³⁸. In the development of adolescent mental health, the family, as one of the main factors, has a significant impact on their physical and mental well-being^39–41. To mitigate the negative effects of unhealthy family relationships (PMC), PA can improve stress coping levels, psychological resilience, and enhance peer relationships^42,43. Previous studies have established a conceptual model of PA promoting health, including psychological, psychosocial, and social relationship aspects, which can provide theoretical support for the idea that PA can reduce the negative impact of family relationships through the supplementation of other social relationships⁴⁴. Different types and intensities of PA have different effects on improving and promoting adolescent mental health^45,46. Therefore, it is necessary to investigate whether the interaction between different intensities of PA and PMC has a consistent effect on depression, revealing the dynamic mechanism of how different intensities of PA improve the relationship between PMC and adolescent depression.

Although existing studies have explored the associations between gender, PA and adolescent mental health, most of them focus on the main effects of single variables only. They fail to delve into the interactive moderating roles of PA and gender. Based on Bronfenbrenner’s Ecological Systems Theory⁴⁷, this study examines adolescent mental health from multiple levels, including individual gender differences, family relationship characteristics and physical activity levels. Rather than proposing a novel theoretical framework, it aims to refine existing evidence and clarify associational patterns in a specific cultural context, thereby enriching cross-cultural research by taking Chinese adolescents as the research sample.

The research focuses on the relationship between PMC and adolescent depression, clarifies the regulatory directions of PA and gender in this relationship, and explores the interactive moderating effects as well as the magnitude of such moderation among family relationships, PA, and gender. Therefore put forward the research model (Fig. 1) and following hypothesis: H1, There is a significant positive correlation between PMC and adolescent depression; H2, PA moderates the relationship between PMC and adolescent depression in a negative direction; specifically, higher levels of PA are associated with a weaker link between PMC and adolescent depression. H3, Gender exerts a differential moderating effect on the relationship between PMC and adolescent depression, such that the correlation between PMC and depression is stronger in girls than in boys.

Fig. 1.

Diagram of the research model.

Gender served two distinct roles in the present model: (1) As a covariate: Gender was first entered into the model to control for its baseline confounding effect on the primary association between PMC and adolescent depression. (2) As a moderator: Following covariate adjustment, gender was re-entered into the model as a moderator to examine its regulatory role in the PMC and depression , as well as its interactive moderating effect with PA.

Methods

Participants

Participants were recruited from three provinces in China: Sichuan, Hunan, and Guangdong. A total of 4122 students participated in the survey. Ethical approval was obtained from the Institutional Review Board of Jishou University. Written informed consent was provided by a parent or legal guardian for all participants under 18 years of age, and written assent was obtained from all adolescent participants. Data collection was conducted in Sichuan, Hunan, and Guangdong provinces, all of which were covered by the ethics approval from Jishou University. Students were recruited via schools/classes and that standard errors may be underestimated if clustering exists. After data cleaning, which involved removing patterned responses, missing answers, and participants who exited the study prematurely, the final effective sample size was 3990, yielding a response rate of 96.80%. For example, consistent responses across all items and missing responses on some items were identified and excluded during data cleaning. The sample included 1961 boys and 2029 girls, with a mean age of 14.71 ± 1.43 years. The distribution across educational levels was as follows: 153 elementary school students, 1793 junior high school students, and 2044 senior high school students. Informed consent forms were attached at the beginning of the questionnaire, detailing the study’s purpose, value, and confidentiality measures to ensure participants’ basic right to be fully informed. The inclusion criteria for participants were: being within the adolescent age group (10–19 years), having no severe psychiatric or physical disorders, and voluntarily participating in the study with full awareness.

Measurement tools

Parental marital conflict

The Children’s Perception of Interparental Conflict Scale (CPIC)⁴⁸ was used to measure the perceived level of parental marital conflict among adolescents, and this scale has been verified and used in the Chinese population⁴⁹. There are five items, with a Likert four-point scoring system (strongly disagree, disagree, agree, strongly agree), and the total score ranges from 5 to 20 points. The Cronbach coefficient was 0.777.

Depression

Depression levels among adolescents were evaluated using the Patient Health Questionnaire-2 (PHQ-2)⁵⁰. The main content of the scale focused on a lack of pleasure in activities, decreased sense of enjoyment, and feelings of low mood. On a four-point Likert scale (not at all, a few days, more than half the days, almost every day), the score ranges from 0 to 6, was used to assess depressive symptoms (not to diagnose clinical depression or evaluate symptom severity). The Cronbach coefficient was 0.709.

Physical activity

PA levels were measured using the PA Rating Scale (PARS-3)⁵¹. The questionnaire items included questions such as “How intense is your physical activity?”, “How many minutes do you engage in physical activity at this intensity?”, and “How many times per month do you engage in physical activity at this intensity?”. This scale includes three dimensions: intensity, duration, and frequency. The scoring formula is: PA = Intensity × (Duration − 1) × Frequency, with scores ranging from 0 to 100. The score represents the physical activity level of teenagers. The Cronbach coefficient was 0.606. Previous studies have indicated that a Cronbach coefficient lower than 0.6 is reliable when the number of observed variables in the scale is less than 6⁵². Notably, PARS-3 is a multiplicative composite index designed to quantify overall physical activity levels rather than a reflective latent construct. As such, internal consistency coefficients (e.g., Cronbach’s alpha) are of limited interpretability for this measure and are not presented as evidence of reliability. PARS-3 was selected due to its widespread use and prior validation in adolescent populations, which has demonstrated its suitability for assessing physical activity in this group^53–55. We acknowledge that, as with any composite measure, PARS-3 may be subject to measurement error, which could potentially attenuate observed moderating effects between PA and other study variables.

Data collection and analysis

Convenience sampling was employed in this study. Friends and acquaintances working in middle schools were commissioned to recruit students from their classes. The researchers were primarily responsible for liaising with schools and training survey administrators. The student questionnaires were completed before class in paper form. Subsequently, data were entered, cleaned, organized, and analyzed. The data analysis was conducted using Excel, SPSS 26.0, and Origin 2018 for statistical, organizational, and analytical purposes. The data collection instruments included the Children’s Perception of Interparental Conflict Scale, the Patient Health Questionnaire-2, and the PA Rating Scale. The Cronbach’s alpha coefficients for these scales were 0.777, 0.709, and 0.606, respectively. Although these values suggest adequate reliability, they should be interpreted with caution due to the limitations of alpha (e.g., sensitivity to the number of items). The validity of the scales was assessed through confirmatory factor analysis. For scales with high chi-square to degrees of freedom ratios, residual covariances were allowed to correct for item similarity in the Children’s Perception of Marital Conflict Scale. The final model fit indices were satisfactory (χ²/df = 2.819, RMSEA = 0.021, CFI = 0.994, NFI = 0.990), providing initial support for the factor structure. Future studies should incorporate additional validity tests, such as convergent and discriminant validity. Before the formal data analysis, examine whether there is a common methodological bias in the research. The statistical criterion was that the threshold of the first factor was less than 40%⁵⁶. Gender was coded as a dichotomous variable (0 = boys, 1 = girls) and grade was coded as an ordinal variable (1 = primary school, 2 = middle school, 3 = high school) based on self-report data. Subsequently, all continuous variables (PMC, PA, and depression scores) were standardized (converted to z-scores, M = 0, SD = 1) before analysis. We selected PROCESS Model 2 to test the moderating effects of gender and PA on the association between PMC and adolescent depression, as well as their potential interactive moderating effect. This model is specifically designed for examining two-way interaction effects between two moderators , which matches our research framework⁵⁷. A bootstrapping procedure with 5000 resamples was used to estimate the 95% confidence intervals (CIs) for the moderating effects⁵⁸. Bootstrapping was employed even in this large sample (N = 3990) because it provides more robust CIs for moderation and interaction effects. During analysis, gender, age, and grade were controlled as covariates. The significance level was set at 0.05.

Results

Common method bias test

To assess potential common method bias (CMB), we conducted Harman’s single-factor test via exploratory factor analysis (EFA) on all measurement items. Among the three factors with eigenvalues greater than 1, the first common factor is 26.57%, which is lower than the threshold of 40%. However, we acknowledge that Harman’s single-factor test is a relatively crude and conservative method with limited sensitivity, and thus this result cannot conclusively rule out the potential impact of CMB in the current study.

Descriptive analysis

As shown in Table 1, significant differences were observed between genders and grades in terms of PA (t = 8.779, p < 0.001; F = 30.766, p < 0.001), depression (t = − 4.006, p < 0.001; F = 17.485, p < 0.001), and PMC (t = − 3.221, p < 0.01; F = 14.735, p < 0.001).

Table 1.

Descriptive statistics by gender and grade.

Variables	PA		Depression		PMC
	mean	Sd	mean	Sd	mean	Sd
Boys	19.36	21.88	1.92	1.55	10.36	3.48
Girls	13.96	16.46	2.11	1.50	10.72	3.44
t	8.779***		− 4.006***		− 3.221**
Primary school	14.40	20.91	2.19	1.67	10.39	3.50
Middle school	19.28	19.33	1.86	1.52	10.23	3.40
High school	14.45	19.26	2.14	1.51	10.83	3.40
F	30.766***		17.485***		14.735***

**: p < 0.01; ***: p < 0.001; PA, Physical activity; PMC, Parental marital conflict.

Correlation analysis

The results of the correlation analysis (Table 2) showed that PMC was significantly positively correlated with adolescent depression (r = 0.315, p < 0.001) and significantly negatively correlated with PA (r = − 0.039, p < 0.05). Additionally, depression was significantly negatively correlated with PA (r = − 0.093, p < 0.001).

Table 2.

Correlation analysis.

Variables	1	2	3	4
1. Age	–
2. PMC	0.075***	–
3. Depression	0.117***	0.315***	–
4. PA	− 0.047**	− 0.039*	− 0.093***	–

***: p < 0.001; PA, Physical activity; PMC, parental marital conflict.

Moderation model analysis

After controlling for demographic variables, the results presented in Table 3 indicated that PMC remained significantly positively associated with adolescent depression (β = 0.303, p < 0.001) even after the inclusion of moderating variables. Moreover, both PA (β = − 0.074, p < 0.001) and gender (β = 0.037, p < 0.05) were significantly associated with adolescent depression. The interaction terms of PA × PMC (β = − 0.036, p < 0.05) and gender × PMC (β = 0.035, p < 0.05) were also significantly associated with adolescent depression, but very small in magnitude. The associations between the interaction terms and depression, reflecting the moderating pattern are illustrated in Figs. 2 and 3.

Table 3.

Moderation model analysis.

Outcome variable	Predictor variable	β	SE	t	R2	F
Depression	PMC (A)	0.303	0.015	20.197***	0.118	75.768***
	PA (B)	− 0.074	0.015	− 4.853***
	A × B	− 0.036	0.016	− 2.302*
	Gender (C)	0.037	0.015	2.440*
	A × C	0.035	0.015	2.318*
	Grade	− 0.005	0.015	− 0.304
	Age	0.093	0.016	5.669***

*: p < 0.05; ***: p < 0.001.

Fig. 2.

Testing of moderating effects (*: p < 0.05; ***: p < 0.001).

Fig. 3.

Simple slope diagram.

Additionally, the results of the moderation analysis for different levels of PA across genders are presented in Table 4. The findings indicated that, for both boys and girls, different levels of PA were significantly related to differences in the strength of the association between PMC and depression. Moreover, the degree of difference in the association strength was stronger in girls than in boys across all levels of PA.

Table 4.

Conditional regression coefficients for the moderating roles of PA level and gender.

Moderating variable		Conditional regression coefficient	SE	t	Lower limit 95%CI	Upper limit 95%CI
PA Levels	Gender
Low	Boys	0.298	0.025	11.807	0.249	0.348
	Girls	0.368	0.024	15.103	0.320	0.415
Medium	Boys	0.267	0.021	12.611	0.226	0.309
	Girls	0.337	0.021	15.948	0.295	0.378
High	Boys	0.231	0.026	8.800	0.180	0.283
	Girls	0.300	0.027	11.079	0.247	0.353

***: p < 0.001; PA, Physical activity.

Discussion

The interaction terms between PA and PMC and between gender and PMC were also significantly associated with adolescent depression. Specifically, the degree of difference in the strength of the association between PMC and depression (reflecting the gender-related moderating pattern) was more pronounced in girls than in boys across all levels of PA (high, medium, and low). These findings confirm the correlation between PMC and adolescent depression and highlight the patterns of how gender and PA relate to the strength of the association between PMC and depression. This study provides preliminary insights to inform future longitudinal or intervention research, emphasizing the need to further explore the association between adolescent depression and factors such as family dynamics and PA to lay a foundation for understanding and supporting adolescent psychological well-being.

Empirical evidence has corroborated the association between PMC and depression, a finding that aligns with existing research^{18,22,23,59,60}. This underscores the potential relevance of the family to the psychological development of adolescents. Parental conflict has been identified as significantly associated with adolescent depression in prior studies^61–63. Building on this foundation, the current study not only provides cross-cultural validation but also expands the scope of research on the close link between PMC and depression. The adverse associations of PMC on adolescents are multifaceted, encompassing sleep disturbances, externalizing and internalizing problems, academic issues, social and interpersonal difficulties, physical health problems, and the quality of future intimate relationships⁶⁴. Internalizing problems specifically include negative emotions such as depression, anxiety, and stress⁶⁵. Regarding the proposition of “how PMC affects adolescent depression”, various theoretical explanations have been proposed in existing research. The emotional security hypothesis⁶⁶ posits that children’s emotional security is threatened in the context of PMC, leading to the development of negative emotions. Attachment theory⁶⁷ suggests that destructive and poorly managed conflict between parents can impact children’s emotional functioning. Additionally, research on the neurobiological and psychophysiological regulatory mechanisms of children’s adaptation to parental conflict⁶⁸ provides further theoretical support. These findings highlight the potential relevance of family relationships to adolescent mental health, offering informative clues for future longitudinal investigations into family dynamics and adolescent depression—rather than supporting direct prevention or intervention strategies.

Findings from the present study provide preliminary support for a moderating role of PA in the link between PMC and depression. It should be stated that the observed moderation effects may have been attenuated by measurement imprecision in PA, contributing to their small magnitude. The correlation between PA and depression has been established in numerous studies^69–74. Building on the relationship between PMC and depression, the current study demonstrates that PA is associated with differences in the severity of adolescent depression related to PMC. The moderating effect of PA can be explained through various biological mechanisms, such as Brain-Derived Neurotrophic Factor (BDNF)⁷⁵, monoamine imbalance, inflammation, altered stress responses, and oxidative stress⁷⁶, as well as psychosocial mechanisms, including self-esteem, social support, and self-efficacy⁷⁷. Furthermore, studies have identified psychological resilience, social support, and stress as mediating variables between PMC and depression^18,78. The association of PA with these aspects can provide insights for understanding adolescent depression. The significant relevance of PA to understanding adolescent depression warrants continuous attention and further investigation, with additional exploration of the correlative patterns between different types, durations, and intensities of PA and depression.

Similarly, the current results offer tentative evidence for a moderating effect of gender on the association between PMC and depression, though the magnitude of this moderation was small. Studies have shown that across all levels of PA (high, medium, and low), girls exhibit a stronger moderating effect between PMC and adolescent depression than boys. Gender research is extensive, with the physiological mechanisms of gender frequently mentioned in adolescent depression studies^79–81. The higher prevalence of depression in girls compared to boys has long been noted^28,82. In the context of PMC, biological factors such as neuroticism and stress reactivity⁸³, as well as power dynamics such as female silencing, marginalization, and gender oppression⁸⁴, provide explanations for the gender differences in depression. The findings that girls have a stronger moderating effect at all levels of PA may be related to gender differences in stress coping^80,85, emotional expression⁸⁶, sensitivity to distress/stress⁸⁷, and rumination⁸⁸. Therefore, PA may show stronger positive associations with girls’ emotional well-being and stress reduction, which could contribute to a larger effect size for girls in the association between PMC and depression. However, it is also possible that biases may arise from single PA data. Although the moderating effect of gender is statistically significant, its effect size is small, which may be related to sample size, changes in gender concepts, and interactions between gender variables and other factors.

Based on the above research, attention should be paid to the associations between family relationships, PA and adolescent mental health. This study generates hypotheses for exploring a dual approach involving understanding family relationship dynamics and enhancing PA participation. Such an approach may inform future research on supporting the holistic development of adolescents, rather than serving as direct evidence for intervention strategies. Attention should also be given to the relevance of gender differences in mental health-related research and future intervention design. In particular, future exercise programs could be designed with consideration of gender differences. For instance, promoting team sports, and integrating mindfulness into yoga and Pilates programs for girls, may be explored as potential avenues for strengthening the associations between PA and positive mental health outcomes. Coordinated efforts among communities, families, and schools are important. Communities and families could prioritize understanding and monitoring PMC in future longitudinal or intervention studies. Schools could explore the development and implementation of PA curricula as part of future research agendas. These collective efforts may inform a better understanding of how to support the long-term mental health of adolescents, rather than providing direct guidance for immediate prevention or intervention.

This study has certain limitations. The cross-sectional design precludes causal inferences between variables. It cannot clarify the specific mechanisms and pathways linking PMC to adolescent depression. Based on extensive evidence from existing studies, causal research on adolescent depression is needed. Such research may inform targeted practices related to adolescent depression. Confounding variables were not fully controlled. Adolescent depression is associated with multiple factors. The study did not fully account for other confounding variables. These variables include family socioeconomic status, parenting practices, parental education, and family structure. Future studies should control for extraneous variables. They should also refine variables in greater detail. Examples include types and intensities of PA, as well as specific forms of PMC. This refinement will help better explore the correlates of depression. Measures need further optimization. The measures used in this study were relatively brief. Their reliability, validity and acceptability were verified through multiple approaches. However, the limitations of these measures cannot be ignored. For instance, the Cronbach’s alpha of the PARS-3 was below 0.7, there may be measurement errors. Yet, statistical results indicate this issue requires further attention and resolution. Moreover, the PHQ-2 offers convenience for large-scale surveys. It cannot assess depression severity or support clinical diagnosis. Future work may use multi-informant measures or temporal separation / objective PA, such as accelerometers. This step will strengthen the validity of study findings. The sample scope was limited. The study adopted convenience sampling. It did not cover a broader geographical range. The generalizability of the findings needs to be confirmed by replication studies with larger and more diverse samples. We should to note that the nested structure of the data was not modeled and that this may have influenced statistical inference (standard errors may be underestimated due to unmodeled nesting).

Conclusion

Gender and PA moderated the association between PMC and depression, effects were statistically significant but small. Adolescent depression is linked to multiple factors in its development. This study provides insights for understanding adolescent depression. For example, attention to family relationships and increased PA participation may be relevant to adolescent mental health.

Author contributions

Conceptualization, Methodology, Formal analysis, Data curation, Visualization, Writing—original draft, Writing—review & editing: Lei Xu.

Funding

This work was supported by Youth Foundation Project of Humanities and Social Sciences, Ministry of Education of China (Grant No. 22YJC890040); Postgraduate Scientific Research Innovation Project of Hunan Province (Grant No. CX20231066); and National and Ethnic Traditional Sports Research Base (Grant No. MZTY2206).

Data availability

Data are not publicly available due to ethical restrictions and the inclusion of ongoing research components that have not yet been fully finalized. However, data can be made available from the corresponding author upon reasonable request.

Decalarations

Competing interests

The authors declare no competing interests.

Ethics approval

The study was approved by the Biomedicine Ethics Committee of Jishou University before the initiation of the project (Grant number: JSDX-2024-0086). We confirm that all experiments comply with the relevant guidelines and regulations, such as the Declaration of Helsinki.

Consent to participate

The research ensures that participants are aware of and agree to participate in the study. The informed consent form is attached to the front of the questionnaire to help participants understand the purpose and content of the study. Only after agreeing and signing can they fill out the questionnaire.