Study On The Mediating Role Of Self-esteem In The Relationship Between Maladaptive Perfectionism And Academic Burnout Among Undergraduate Medical Students And The Intervention

Objective:The current study recruited undergraduate medical students as subjects to examine the relationship between maladaptive perfectionism and academic burnout and to explore the mediating role of self-esteem in this relationship.Based on theories of positive psychology and cognitive behavioral therapy,a quasi-experiment was conducted to explore the effective measure of raising medical students'self-esteem levels while reducing their academic burnout levels.This study provided both theoretical and practical implications for promoting medical students'mental health.Methods:1.By exploratory factor analysis(EFA)and confirmatory factor analysis(CFA),the reliability and validity of Chinese College Student Academic Burnout Inventory(CCSABI)were examined among undergraduate medical students.With reference to Maslach Burnout Inventory(MBI),Lian developed CCSABI based on Chinese college students'psychological characteristics.The study sample was first-year medical students from two medical universities and statistical analyses included principal component extraction,varimax rotation,structural equation modeling,convergent validity,discriminate validity and intra-class correlation analysis.2.With a quantitative analysis research method and in a sample of 1499 undergraduate medical students from1^st-4^th grades,the correlations among the three psychological variables of maladaptive perfectionism,self-esteem and academic burnout were examined,and the mediating role of self-esteem was explored.Statistical analyses included descriptive statistical analysis,Pearson correlation analysis,hierarchical linear regression analysis and bootstrap mediation analysis.3.With mixed methods of both quantitative analysis and qualitative analysis,a quasi-experimental study was conducted among 374 first-year undergraduate medical students to test the effectiveness of the intervention,i.e.College Student Mental Health Education Course(CSMHEC)with cognitive behavioral theory as its basis.For quantitative analyses,independent samples t-tests and paired samples t-tests were used to examine whether CSMHEC could effectively raise medical students'self-esteem levels and reduce their academic burnout levels;Analysis of variance(ANOVA)and post hoc LSD tests were employed to examine the enduring effect of the intervention CSMHEC;descriptive statistical analysis was adopted to gain insights from investigating medical students'overall satisfaction with CSMHEC and their feelings after taking the course.For qualitative analysis,thematic analysis was used to extract themes and subthemes based on students'answers to open-ended questions,which provided feedback on the course delivery,helped discover the existing problems and shed light on implementing similar mental health education courses in other medical universities.Results:1.Results of examination of reliability and validity of Chinese College Student Academic Burnout Inventory(CCSABI)among medical students were:for exploratory factor analysis,the extracted three principal components of CCSABI(i.e.Low Mood,Improper Behavior,Low Achievement)together explained 42.595%of the total variance in academic burnout and the factor loadings of 20 items in CCSABI were all larger than0.30.The three factors of“Low Mood”,“Improper Behavior”and“Low Achievement”accounted for 28.783%,7.957%and 5.855%,respectively in the total variance of academic burnout.For confirmatory factor analysis,both the first-order factor structural equation modeling and the second-order factor structural equation modeling showed good fit(?²/df=2.240,CFI=0.919,TLI=0.907,GFI=0.935,AGFI=0.918,RMSEA=0.047,SRMR=0.049);CCSABI demonstrated good convergent validity(each item significantly correlated with its corresponding subscale:all rs>0.45),good discriminate validity(the Pearson correlation coefficient of each item with its corresponding subscale was higher than that with the other two subscales)and good test-retest reliability(ICC?0.70)among undergraduate medical students.2.Undergraduate medical students'academic burnout was significantly associated with students'gender and maternal education levels:males were more likely to suffer from academic burnout than their female counterparts(53.90±12.49 vs.52.45±11.70,P=0.024);compared with medical students whose mothers held college and above qualifications,students whose mothers'education levels were primary school and below had more tendency to have academic burnout problems(54.95±10.84 vs.52.02±13.01,P=0.003);compared with medical students whose mothers held secondary school qualifications,students whose mothers'education levels were primary school and below were also more likely to suffer from academic burnout(54.95±10.84 vs.53.01±11.68,P=0.035).Medical students'self-esteem was significantly negatively related to both maladaptive perfectionism(r=-0.38,P<0.001)and academic burnout(r=-0.48,P<0.001).On the other hand,medical students'maladaptive perfectionism was significantly positively associated with academic burnout(r=0.30,P<0.001).Maladaptive perfectionism had a significantly negative effect on self-esteem(a=-0.385,95%CI:-0.433,-0.338,P<0.001);self-esteem had a significantly negative effect on academic burnout(b=-0.417,95%CI:-0.465,-0.369,P<0.001);the total effect of maladaptive perfectionism on academic burnout was significantly positive(c=0.306,95%CI:0.257,0.355,P<0.001);the direct effect of maladaptive perfectionism on academic burnout was still significantly positive after adding self-esteem as a mediator(c'=0.145,95%CI:0.097,0.194,P<0.001);self-esteem played a partial mediating role in the relationship between maladaptive perfectionism and academic burnout among undergraduate medical students(a*b=c-c'=0.161,BCa 95%CI:0.132,0.191,P<0.001).3.Results of the intervention-control quasi-experimental study were:after taking the8-week College Student Mental Health Education Course(CSMHEC),subjects in the experiment group had significantly higher levels of self-esteem than their pre-intervention base-line levels of self-esteem(31.13±3.90 vs.29.81±3.85,t=-5.997,P<0.001,Cohen's d=0.44),but significantly lower levels of academic burnout than their pre-intervention base-line levels of academic burnout(42.85±9.94 vs.51.16±8.26,t=19.997,P<0.001,Cohen's d=1.46);compared with subjects in the control group,subjects in the experiment group had significantly higher levels of self-esteem(31.13±3.90 vs.29.23±3.61,t=4.909,P<0.001,Cohen's d=0.51)but significantly lower levels of academic burnout(42.85±9.94 vs.50.08±10.64,t=-6.792,P<0.001,Cohen's d=0.70)in the post tests;a majority of medical students in the experiment group were satisfied with CSMHEC and expressed the idea that CSMHEC was helpful in regulating emotions effectively,promoting a healthy mental state and increasing mental health literacy;thematic analysis of qualitative data showed that there was still room for improvement regarding the course content and the teaching method of CSMHEC.The results of the follow-up test show that the effectiveness of the intervention CSMHEC was long-lasting.Conclusion:1.Chinese College Student Academic Burnout Inventory,which was developed by Lian with reference to Maslach Burnout Inventory,showed good reliability and good validity among medical students and thus can be used as an effective instrument to measure medical students'academic burnout levels.2.Undergraduate medical students'academic burnout was significantly associated with students'gender and maternal education levels.Self-esteem played a partial mediating role in the relationship between maladaptive perfectionism and academic burnout among medical students.3.Developed based on positive psychology and cognitive behavioral theories,College Student Mental Health Education Course was demonstrated to be an effective intervention in raising medical students'self-esteem levels and reducing their academic burnout levels.However,there was still room for improvement in terms of course content and course delivery.