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Original article
Imposter syndrome and its associated factors in medical students in six Peruvian faculties
Síndrome del impostor y sus factores asociados en estudiantes de Medicina de seis facultades peruanas
Jennifer Vilchez-Cornejoa,b,
Corresponding author
j.vilchezcornejo@gmail.com

Corresponding author.
, Luccio Romanic, Saraí Chávez-Bustamanted, César Copaja-Corzoe, Juan C. Sánchez-Vicentef, Ronald David Viera-Moróng, Benggi Ocampo-Portocarreroa
a Facultad de Medicina, Universidad Nacional de Ucayali, Ucayali, Peru
b Red Asistencial Ucayali, Hospital Essalud II Pucallpa, Ucayali, Peru
c Facultad de Medicina, Universidad San Martín de Porres, Chiclayo, Peru
d Facultad de Medicina, Universidad Continental, Huancayo, Peru
e Facultad de Ciencias de la Salud, Universidad Privada de Tacna, Tacna, Peru
f Facultad de Medicina, Universidad Nacional San Luis Gonzaga Ica, Peru
g Facultad de Medicina, Universidad Nacional del Santa, Chimbote, Peru
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The impostor phenomenon &#40;IP&#41; or impostor syndrome is characterised by feelings of guilt about success experienced by people who are high achievers&#44; and the inability to acknowledge it internally&#44; added to strong feelings of phoniness&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This phenomenon is experienced by individuals who doubt their own abilities&#44; even though they are objectively capable and accomplished&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> People with IP are convinced that they are deceiving those around them about their abilities and are afraid of being exposed as frauds or impostors&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Studies have attempted to determine the causes of IP and there is evidence that race&#44; ethnicity and&#47;or immigrant status can play a role in people who constantly consider themselves unworthy for the environment they find themselves in&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The concept was originally defined with particular reference to women in the fields of science&#44; technology&#44; engineering&#44; mathematics and even medicine&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a> With regard to cultural factors&#44; high levels of IP were found in students who were the first in their families to attend university and&#47;or medical school&#44; in addition to working or studying in another country&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Being part of any higher education programme that included an apprentice level &#40;student&#44; resident intern&#44; fellow&#41;&#44; being surrounded by equally driven&#44; outstanding individuals&#44; and being constantly assessed &#40;medical students during their clinical rotations&#41; were triggers of IP in the different study populations&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">People with IP show a certain inability to delegate functions and make important decisions and tend to procrastinate about delivering projects&#44; which prevents them from being team leaders&#44; or they set impossible goals that end up lowering the morale of other employees&#44; who feel they are being held back by poor leadership&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6&#44;7</span></a> This can make those suffering from IP even more incapable of making decisions or being team leaders&#44; and more likely to develop chronic diseases&#44; adjustment disorders &#40;depression&#44; anxiety&#41; and&#44; in certain cases&#44; even suicidal tendencies&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">IP has now been seen in males and females<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5&#44;8&#8211;11</span></a> and in different professions&#46; Proportionally&#44; however&#44; it is medical professionals who suffer the most from this condition&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> which has also been reported in university students<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;11</span></a> who are studying Human Medicine&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Despite all this&#44; even though IP is considered a psychological construct found in those who underestimate their abilities and skills&#44; it has not yet been widely studied or documented&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It has nonetheless been demonstrated that people affected by IP are incapable of internally acknowledging their accomplishments&#44; while at the same time may magnify their failures&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4</span></a> Accordingly&#44; with this study we sought to quantify the prevalence of IP and determine the main associated factors in medical students at six medical schools in Peru&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design and population</span><p id="par0030" class="elsevierStylePara elsevierViewall">This was an analytical cross-sectional study conducted on students from six medical schools&#58; three of them at public universities&#44; in the regions of Ica &#40;Universidad Nacional San Luis Gonzaga&#41;&#44; Ancash &#40;Universidad Nacional del Santa&#41; and Ucayali &#40;Universidad Nacional de Ucayali&#41;&#59; and three at private universities&#44; in the regions of Lambayeque &#40;Universidad San Martin de Porres Filial Norte&#41;&#44; Jun&#237;n &#40;Universidad Continental&#41; and Tacna &#40;Universidad Privada de Tacna&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The initial sample size of 2819 medical students was calculated with a confidence level of 97&#37; and a margin of error of 3&#37;&#44; which resulted in a sample size of 2348&#59; later adjusted for possible losses of 20&#37;&#46; During the study&#44; 100 surveys &#40;4&#46;3&#37;&#41; were discarded for not having a signed informed consent form and 17 &#40;0&#46;7&#37;&#41; could not be analysed because of incomplete data&#44; leaving a final sample size of 2231 students &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The list of those selected through stratified sampling considered all participants who were enrolled during the 2019-I academic semester corresponding to the first and sixth years of Medicine who did not have any problems for written communication and provided their informed consent&#46; Incomplete surveys or those containing more than two items of data that made it impossible to analyse them were excluded&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">This study was approved by the Ethics Committee of the Universidad Nacional de Ucayali &#40;Ucayali&#44; Peru&#41;&#46; Authorisation to conduct the study was obtained from each of the Medical Schools participating in this study&#59; during data collection&#44; each interviewer proceeded to explain in detail to the selected students the purpose and main aim of the research&#44; stressing its reliability and anonymity&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Instrument and variables</span><p id="par0050" class="elsevierStylePara elsevierViewall">The instrument consisted of a self-administered survey given out to each participant&#46; The first section outlined the main information about the study and their informed consent&#46; The second section concerned the sociodemographic characteristics of the participants&#58; age&#59; gender&#59; marital status&#59; people they are currently living with&#59; and livelihood&#59; as well as the average hours spent working&#46; The academic characteristics assessed included&#58; the academic year&#59; the year of admission&#59; approximate daily hours of study&#59; and extracurricular activities and their type&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The psychological characteristics assessed in the third section were adjustment disorders&#44; with the aim of detecting negative effects of anxiety&#44; depression and stress&#44; which include essential symptoms that make it difficult to relax&#44; nervous tension&#44; hyporexia&#44; irritability and agitation&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> For this&#44; we used the short version of the Depression&#44; Anxiety and Stress Scale &#40;DASS-21&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> which has a validated adaptation to Spanish in a similar university population&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> with Cronbach&#8217;s alpha coefficients of 0&#46;85&#44; 0&#46;73 and 0&#46;83 for the depression&#44; anxiety and stress subscales&#44; respectively&#46; However&#44; overall&#44; the items making up the DASS-21 obtained &#945;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;91&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The scale has 21 items with four alternatives on the Likert scale of 0 &#40;rarely&#41;&#44; 1 &#40;sometimes&#41;&#44; 2 &#40;often&#41; and 3 &#40;almost always&#41; to assess three parameters&#44; including depression &#40;items 3&#44; 5&#44; 10&#44; 13&#44; 16&#44; 17 and 21&#41;&#44; anxiety &#40;items 2&#44; 4&#44; 7&#44; 9&#44; 15&#44; 19 and 20&#41; and stress &#40;items 1&#44; 6&#44; 8&#44; 11&#44; 12&#44; 14 and 18&#41;&#46; The values for the depression scale range from normal &#40;0&#8211;4 points&#41;&#44; to mild depression &#40;5&#8211;6 points&#41;&#44; moderate &#40;7&#8211;10 points&#41;&#44; severe &#40;11&#8211;13 points&#41; and extremely severe &#40;more than 14 points&#41;&#59; anxiety levels range from normal &#40;0&#8211;3 points&#41;&#44; to mild anxiety &#40;4&#8211;5 points&#41;&#44; moderate &#40;6&#8211;7 points&#41;&#44; severe &#40;8&#8211;9 points&#41; and extremely severe &#40;more than 10 points&#41;&#59; and stress levels range from normal &#40;0&#8211;7 points&#41;&#44; to mild stress &#40;8&#8211;9 points&#41;&#44; moderate &#40;10&#8211;12 points&#41;&#44; severe &#40;13&#8211;16 points&#41; and extremely severe &#40;more than 17 points&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Self-esteem was also assessed using the Rosenberg Self-Esteem Scale &#40;RSES&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> which addresses aspects related to feeling competent in various aspects of life&#59; the dimension on self-hatred uses insulting terms associated with sympathy with oneself<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> in its version adapted to Spanish<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;17</span></a> &#40;&#945;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;75&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The scale consists of 10 items about the person&#39;s feelings about themselves&#44; with the first five positive statements &#40;items 1&#44; 2&#44; 3&#44; 4 and 5&#41;&#44; on a 4-point Likert scale&#58; 1 &#40;strongly disagree&#41;&#44; 2 &#40;disagree&#41;&#44; 3 &#40;agree&#41; and 4 &#40;strongly agree&#41;&#46; The score is inverted for negative statements &#40;items 6&#44; 7&#44; 8&#44; 9 and 10&#41;&#46; The values on the scale range from low self-esteem &#40;&#60;25 points&#41; to normal &#40;25&#8211;35 points&#41; to high &#40;&#62;35 points&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">IP was assessed using the Clance Impostor Phenomenon Scale &#40;CIPS&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;18</span></a> which determines the clarity of self-concept&#44; components of social self-esteem and concern for having succeeded by chance&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Its original version has &#945;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;96<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#59; the CIPS version adapted to Spanish<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> had a test of sphericity and a significant sampling adequacy measure &#40;0&#46;89&#41;&#59; the reliability of the instrument showed &#945;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;92&#46; However&#44; as the scale was not adapted to a population such as that of our study&#44; the authors carried out a pilot test on 280 students from one of the study sites in the Ucayali region during the 2018 academic year&#46; This enabled us to determine an internal consistency with &#945;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;91&#44; in addition to the permanence of all the items of the instrument&#44; as they did not modify the final construct&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The CIPS is therefore made up of 20 items rated using a 5-point Likert scale&#58; 1 &#40;not at all true&#41;&#44; 2 &#40;rarely true&#41;&#44; 3 &#40;sometimes true&#41;&#44; 4 &#40;often true&#41; and 5 &#40;very true&#41;&#46; The sum of the 20 items provides the score&#59; &#60;62 indicates absence of IP and &#8805;62 is defining of IP&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data analysis</span><p id="par0080" class="elsevierStylePara elsevierViewall">The data collected in the survey were recorded on an Excel 2013 spreadsheet&#44; entered on two separate occasions by different people to verify the quality of the data&#46; Data were analysed with the STATA version 14 statistical package&#59; the qualitative variables are presented as frequency and percentage&#44; and the quantitative variables as median &#91;interquartile range&#93; when distribution is not normal&#44; after checking using the skewness and kurtosis test&#44; with a p-value &#60;0&#46;05&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">With regard to the inferential statistics for the qualitative variables&#44; the DASS-21 variables were dichotomised&#44; considering as affected by the condition those who had some degree of depression&#44; anxiety or stress according to each of the subscales&#46; Lastly&#44; we used this recoding in order to be able to use generalised models&#44; applying logistic regression for both the crude &#40;crude prevalence ratios &#91;PR&#93;&#41; and adjusted &#40;adjusted prevalence ratios &#91;APR&#93;&#41; analysis&#59; a p-value &#60;0&#46;05 was considered significant&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">The study population was made up of 2231 Human Medicine students from six Peruvian universities&#59; median age was 21 years &#91;19&#8211;23&#93;&#59; 96&#37; of the participants &#40;2140&#41; stated that they were single &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">A total of 72&#46;8&#37; &#40;1496&#41; stated that they lived with a family member &#40;parents&#44; siblings and&#47;or aunts and uncles&#41;&#59; 19&#46;2&#37; &#40;394&#41; lived alone&#59; and 3&#46;2&#37; &#40;66&#41; with their partner&#46; Some 12&#46;9&#37; &#40;286&#41; stated that they received money from their relatives and from working&#46; A majority 56&#46;4&#37; &#40;1244&#41; stated that they were not satisfied with their academic performance&#44; and only 43&#46;6&#37; &#40;960&#41; did some type of extracurricular activity as part of their university life&#58; 43&#37; &#40;480&#41; did some type of sport&#59; 24&#46;4&#37; &#40;239&#41; had some involvement in art and&#47;or music&#59; and 21&#37; &#40;234&#41; and 15&#46;7&#37; &#40;176&#41; belonged to the student union or a scientific society&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">According to the DASS-21&#44; 60&#46;7&#37; &#40;1355&#41; did not have any degree of stress&#46; However&#44; 17&#46;8&#37; &#40;398&#41; reported mild levels of stress&#44; 14&#46;2&#37; &#40;316&#41; moderate&#44; 5&#46;6&#37; &#40;125&#41; severe and 1&#46;7&#37; &#40;37&#41; extremely severe&#46; In terms of anxiety&#44; 32&#46;9&#37; &#40;735&#41; had none&#44; but 15&#46;8&#37; &#40;352&#41; reported mild levels of anxiety&#44; 18&#46;9&#37; &#40;422&#41; moderate&#44; 13&#46;8&#37; &#40;307&#41; severe and 18&#46;6&#37; &#40;415&#41; extremely severe&#46; Last of all&#44; 50&#46;8&#37; &#40;1133&#41; reported some degree of depression&#44; while 14&#46;7&#37; &#40;327&#41; had mild depression&#44; 23&#46;2&#37; &#40;518&#41; moderate&#44; 7&#46;8&#37; &#40;174&#41; severe and 3&#46;5&#37; &#40;79&#41; extremely severe &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">From the RSES&#44; we determined that 22&#46;3&#37; &#40;497&#41; of the participants had normal levels of self-esteem&#44; while 75&#46;3&#37; &#40;1681&#41; had low self-esteem and only 2&#46;4&#37; &#40;53&#41;&#44; high self-esteem &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Of those with low self-esteem&#44; 22&#46;1&#37; &#40;372&#41; were second-year students and 19&#46;5&#37; &#40;328&#41; first-year students&#46; In contrast&#44; 28&#46;3&#37; of fifth-year students &#40;15&#41; had high self-esteem&#46; A statistically significant association &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; was found using the &#967;<span class="elsevierStyleSup">2</span> test between the academic year and the RSES&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The CIPS found that only 30&#46;6&#37; of the students &#40;682&#41; suffered from IP &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; In addition&#44; it was found that during the second&#44; fourth and third years&#44; 20&#46;8&#37; &#40;142&#41;&#44; 19&#46;9&#37; &#40;136&#41; and 19&#46;7&#37; &#40;134&#41;&#44; respectively&#44; suffered from IP &#40;association between academic year and the CIPS by &#967;<span class="elsevierStyleSup">2</span>&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The bivariate analysis found that being female&#44; being in the fourth year and having some degree of depression&#44; anxiety or stress meant a likelihood 1&#46;14 times greater of suffering from IP than those who did not meet any of these conditions &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;14&#59; 95&#37; confidence interval &#91;95&#37; CI&#93;&#44; 1&#46;01&#8722;1&#46;29&#41;&#44; 1&#46;83 &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;83&#59; 95&#37; CI&#44; 1&#46;51&#8722;2&#46;22&#41;&#44; 2&#46;67 &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;67&#59; 95&#37; CI&#44; 2&#46;31&#8722;3&#46;09&#41;&#44; 3&#46;80 &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;80&#59; 95&#37; CI&#44; 3&#46;06&#8722;4&#46;73&#41; and 2&#46;29 &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;29&#59; 95&#37; CI&#44; 2&#46;02&#8722;2&#46;60&#41;&#46; It was also found that those who had high levels of self-esteem were less likely to have IP &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Finally&#44; in the multivariate analysis&#44; after an adjustment was made for the variables described&#44; we were able to determine that the participants who had depression had a 51&#37; higher likelihood of suffering from IP &#40;APR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;51&#59; 95&#37; CI&#44; 1&#46;27&#8722;1&#46;79&#41;&#44; those with anxiety&#44; 125&#37; higher &#40;APR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;25&#59; 95&#37; CI&#44; 1&#46;75&#8722;2&#46;90&#41; and those with stress&#44; 37&#37; higher &#40;APR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;37&#59; 95&#37; CI&#44; 1&#46;19&#8722;1&#46;57&#41;&#46; Females had a 12&#37; greater predisposition to IP &#40;APR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;12&#59; 95 &#37; CI&#44; 1&#46;01&#8722;1&#46;26&#41; than males&#46; Students with high self-esteem and those who were content with their academic performance showed 58&#37; &#40;APR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;42&#59; 95&#37; CI&#44; 0&#46;19&#8722;0&#46;88&#41; and 27&#37; &#40;APR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;73&#59; 95&#37; CI&#44; 0&#46;64&#8722;0&#46;84&#41; less likelihood of IP&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">The prevalence of IP was higher in women&#46; It has been considered that males tend to have more confidence in their intellectual capacity than women&#46; However&#44; adhering to this social concept allows women to be thought of as incapable and&#44; if they show they are not&#44; that they have lost their femininity&#44; thereby devaluing their own success by seeking to reduce this polarity&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> For that reason&#44; &#8220;success&#8221; is more difficult for them to assess and achieve because of different social expectations&#59; women tend to show the need to explain their accomplishments by attributing their intelligence and&#47;or giving credit to external factors beyond their own capabilities&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Previous studies have managed to define certain differences in the prevalence of IP according to gender&#44; and men show a greater tendency to these feelings&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#8211;23</span></a> These studies have also shown that men do not tend to openly acknowledge IP&#44; as they tend to protect themselves from this type of emotion&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> As such&#44; for fear of presenting an atypical masculine image or a position that could question their sexuality&#44; they tend to put on the appearance of indifference so as not to feel inadequate in the society around them&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> This explains why IP&#44; initially observed in women&#44; is now acknowledged to show mixed trends in terms of its distribution by gender&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5&#44;9&#8211;11&#44;25&#8211;27</span></a> However&#44; IP is still considered one of the biggest challenges facing women in medicine&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> in line with research that shows the relationship between IP and less career planning and professional effort&#44; in addition to motivation to pursue and take on leadership roles&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Our study found that only three in 10 students suffered from IP&#44; but that there was an association between being a fourth-year student and a greater tendency towards IP&#46; After consulting different studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;5&#44;8&#44;9</span></a> we are able to conclude that a transition in the academic development of any student&#44; the assignment of new duties&#44; the aim to excel&#44; being part of any programme involving continuous and scaled learning&#44; and being assessed are also determining factors in the development of IP&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Here in Peru&#44; most schools of Human Medicine begin their hospital practices in the fourth year&#44; which means a change in both methodology and teaching and constant assessments for undergraduate students with patients&#44; and this may explain the disproportionate development of IP among fourth-year students&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Being content with academic performance and&#47;or having high levels of self-esteem have a negative correlation with IP&#44; as individuals with high self-esteem attribute their achievements to their own abilities&#44; their own intelligence and&#47;or competence&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#8211;32</span></a> Some authors<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a> recommend having&#44; and even believe it necessary to have&#44; high levels of self-esteem combined with certain IP characteristics&#44; so that future doctors practice medicine in a proper&#44; sustainable and&#44; to a certain extent&#44; healthy manner&#44; as this combination could provide the necessary tools for diagnosing and treating patients with both caution and care&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Depression levels increased the likelihood of having IP by 56&#37;&#46; However&#44; these symptoms are not always concomitant&#44; and various authors have stated that symptoms experienced may be similar to mild depressive disorders&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;34</span></a> Patients with IP and some degree of depression tend to be more critical and harder on themselves and they mask any depressive symptoms&#44; all of which diminishes their performance and their ability to achieve their goals and improve productivity&#44; and leaves them unable to perceive success in their achievements&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">People with IP may not achieve their goals because they are enveloped in a vicious circle of anxiety attacks that manifest on a daily basis&#46; Stress similarly increased the likelihood of suffering IP by 39&#37;&#46; This is due to a persistent struggle to prove that they should be the best in their class&#44; disregarding their own talents and belittling their own ability&#46; Last of all&#44; there is an association between anxiety-related symptoms and IP<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&#59; the constant assessments&#44; the fear of failure&#44; the doubts generated&#44; apprehension&#44; the lack of confidence and the fear of being exposed as a fraud<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#44;37</span></a> provoke and encourage fervent preparation for success and perfectionism&#44; but in the end de-legitimise their accomplishments&#44; and this becomes a never-ending vicious circle&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#8211;37</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Our study has certain limitations&#44; such as access to the different schedules of all the participants selected at the universities&#44; and their commitment to provide their informed consent&#44; in addition to not being able to carry out a case-control and&#47;or longitudinal study to determine the causality of the IP in medical students&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0160" class="elsevierStylePara elsevierViewall">Three in 10 medical students suffer from IP&#46; Suffering some degree of depression&#44; anxiety or stress and being a woman and&#47;or a fourth-year student are all predisposing factors for IP&#46; We also identified that being content with academic performance and having high self-esteem are protective factors against IP among medical students&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">We recommend expanding the study nationwide and&#44; given the hostile environment they have to deal with in hospitals&#44; including all students of health sciences&#46; Moreover&#44; sampling techniques should be applied that allow data to be extrapolated to the real situations experienced by these Peruvian health science students&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">We propose expanding the research to a case-control study to determine the risk factors for IP more accurately&#44; as well as a longitudinal study to detect possible causality between other variables in addition to the association with the number of years at university&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">As a result of our study&#44; we recommend providing advice&#44; counselling and psychological support to students throughout their university course&#44; to enable early detection of psychological conditions that may affect their performance&#44; prevent them from fulfilling their full academic potential and end up triggering the development of IP&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0180" class="elsevierStylePara elsevierViewall">This research was self-financed by all the authors&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">The pilot for this study was part of Dr Jennifer Vilchez-Cornejo&#39;s thesis entitled &#34;Factores asociados al s&#237;ndrome del impostor en estudiantes de medicina de la Universidad Nacional de Ucayali&#44; 2018&#34; &#91;&#34;Factors associated with impostor syndrome in medical students at the National University of Ucayali&#44; 2018&#34;&#93;&#44; defended in 2019 at Universidad Nacional de Ucayali&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">To determine the factors associated with impostor syndrome in medical students from six regions of Peru&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A multicentre&#44; cross-sectional study was conduced on students from first to the sixth year in six Peruvian regions&#46; Sociodemographic&#44; academic&#44; and psychological characteristics were included through the Depression&#44; Anxiety&#44; and Stress Scale-21&#44; the Rosenberg Self-Esteem Scale and the Clance Imposter Phenomenon Scale&#46; Generalised linear models were performed using crude and adjusted estimated prevalence ratios&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Of 2&#44;231 medical students&#44; 54&#46;3&#37; were female and 30&#46;6&#37; had the impostor phenomenon&#46; An association was found between the PI and those who suffered from depression &#40;aPR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;51&#59; 95&#37;CI&#44; 1&#46;27&#8211;1&#46;79&#41;&#44; anxiety &#40;aPR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;25&#59; 95&#37;CI&#44; 1&#46;75&#8211;2&#46;90&#41;&#44; stress &#40;aPR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;37&#59; 95&#37;CI&#44; 1&#46;19&#8211;1&#46;57&#41;&#44; and being female &#40;aPR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;12&#59; 95&#37;CI&#44; 1&#46;01&#8211;1&#46;26&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Three out of 10 medical students suffer from PI&#59; having some level of depression&#44; anxiety&#44; stress&#44; being a woman&#44; and&#47;or attending the fourth academic year were predisposing factors for their development&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Determinar los factores asociados con el s&#237;ndrome del impostor &#40;IP&#41; en estudiantes de Medicina de 6 facultades peruanas&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Material y m&#233;todos Estudio multic&#233;ntrico transversal anal&#237;tico realizado en estudiantes del primer al sexto a&#241;o en 6 regiones peruanas&#46; Se incluyeron caracter&#237;sticas sociodemogr&#225;ficas&#44; acad&#233;micas y psicol&#243;gicas mediante la escala de depresi&#243;n&#44; ansiedad y estr&#233;s&#44; la escala de autoestima de Rosenberg y la escala del Fen&#243;meno del Impostor de Clance&#46; Los modelos lineales generalizados se construyeron mediante razones de prevalencia estimada brutas y ajustadas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">De 2&#46;231 estudiantes de Medicina&#44; el 54&#44;3&#37; eran mujeres y el 30&#44;6&#37; padec&#237;a IP&#46; Se encontr&#243; asociaci&#243;n entre el IP y la depresi&#243;n &#40;RPa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;51&#59; IC95&#37;&#44; 1&#44;27-1&#44;79&#41;&#44; la ansiedad &#40;RPa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44;25&#59; IC95&#37;&#44; 1&#44;75-2&#44;90&#41;&#44; el estr&#233;s &#40;RPa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;37&#59; IC95&#37;&#44; 1&#44;19-1&#44;57&#41; y el sexo mujer &#40;RPa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;12&#59; IC95&#37;&#44; 1&#44;01-1&#44;26&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">De cada 10 estudiantes de Medicina&#44; 3 sufren IP&#59; tener depresi&#243;n&#44; ansiedad o estr&#233;s&#44; ser mujer y&#47;o cursar el cuarto a&#241;o fueron los factores predisponentes&#46;</p></span>"
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;0&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Academic year</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>First year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">475 &#40;21&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Second year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">515 &#40;23&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Third year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">414 &#40;18&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fourth year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">278 &#40;12&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fifth year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">232 &#40;10&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sixth year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">317 &#40;14&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Universidad Continental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">522 &#40;23&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Universidad de San Mart&#237;n de Porres &#40;North Campus&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">393 &#40;17&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Universidad Nacional de Ucayali&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">298 &#40;13&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Universidad San Luis Gonzaga&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">558 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Universidad Privada de Tacna&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">274 &#40;12&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Universidad Nacional de Santa&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">186 &#40;8&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;815 &#40;81&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Working&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">114 &#40;5&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">286 &#40;12&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#91;5&#8211;24&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Hours of study per week</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#91;5&#8211;19&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;01&#8211;1&#44;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#44;045&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;01&#8211;1&#44;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;047&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Depression</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;31&#8211;3&#44;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;27-1&#44;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Anxiety</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No anxiety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anxiety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;06&#8211;4&#44;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;75&#8211;2&#44;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Stress</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No stress&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Stress&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;02&#8211;2&#44;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;19&#8211;1&#44;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Self-esteem</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;79&#8211;1&#44;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;300&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;72&#8211;0&#44;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;023&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;13&#8211;0&#44;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;19&#8211;0&#44;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;023&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="7" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="7" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Academic year</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>First year&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Second year&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;84&#8211;1&#44;27&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;768&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;76&#8211;1&#44;11&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;397&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;21&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;99&#8211;1&#44;48&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;066&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1&#44;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;85&#8211;1&#44;24&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;805&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;51&#8211;2&#44;22&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;20&#8211;1&#44;73&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sixth year&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;91&#8211;1&#44;42&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;82&#8211;1&#44;29&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Content with academic performance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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ISSN: 25303120
Original language: English
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