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Article History

Received: 8 March 2024

Accepted: 3 March 2025

First Online: 10 April 2025

Competing interests

: The authors declare no competing interests.

: The ethical approval was acquired from the Ethics Committee of Shandong Normal University (sdnu-2021-06-30-07).

: At the time of the first follow-up measurement, all students and their parents or guardians signed a consent form agreeing to participate in the three-year follow-up study. Before data is collected, parents or guardians are informed of the study’s purpose, procedures, risks and benefits in detail, allowing them sufficient time to review and provide written consent. In addition, informed consent was obtained directly from student participants on the day of data collection. The research team explains the study in age-appropriate language to ensure that students fully understand their role and the voluntary nature of their involvement. Students were asked to sign a consent form following this explanation, confirming their intention to participate. They were also reminded that they could withdraw from the study at any time without any negative consequencesc