The Relationship Between Surgical Interest and Performance on a Virtual Reality Surgical Simulator in a Cohort of Untrained First Year Medical Students

doi:10.21203/rs.3.rs-4291135/v1

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Research Article

The Relationship Between Surgical Interest and Performance on a Virtual Reality Surgical Simulator in a Cohort of Untrained First Year Medical Students

https://doi.org/10.21203/rs.3.rs-4291135/v1

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Background:

The intersection of technological advancements and medical education has led to integration of virtual reality (VR) surgical simulators, offering a risk-free environment for trainees to hone clinical decision-making and technical skills. Despite the allure of VR in surgical training, the utility of VR exposure in novice medical trainees remains unclear. Numerous studies aim to decipher the relationship between students’ career preferences and proficiency on VR surgical simulators, but results have been inconclusive, necessitating further exploration. We sought to investigate the correlation between students’ interest in a surgical specialty and performance on a VR surgical simulator, aiming to inform the development of tailored pipeline programs for aspiring surgical students and aid in residency program selection processes.

Methods:

Participants included 134 incoming medical students recruited from a local United States medical school. After an informative session on VR’s impact in surgical medicine, participants completed a pre-interventional questionnaire, engaged in a VR simulation of a slipped capital femoral epiphysis (SCFE) operative procedure, then completed a post-interventional questionnaire. Statistical analysis included Mann-Whitney-Wilcoxon test, Chi-squared test, and Fischer’s exact tests on survey responses and VR simulation markers.

Results:

Descriptive statistics revealed students predominately under 25 years old, nearly equitable gender distribution, and varying levels of interest in surgical specialties. Chi-square tests identified a significant association between sports participation and surgical interest. Nonparametric tests showed no statistically significant differences in VR performance metrics across categories of surgical interest, including the distributions of "number of retries" and "hints" against medical students’ surgical interest.

Discussion:

The findings underscore the potential value of sports participation in shaping students’ inclination towards surgical fields. However, no significant relationship was identified between students' performance in VR surgical simulations and their interest in surgery, challenging assumptions about career interests and practical skills performance. Sample limitations and mitigation strategies were discussed, emphasizing the need for further research to explore additional factors influencing performance in surgical simulations.

Conclusions:

Despite constraints, this study provides valuable insights into factors influencing medical students' career interests and performance in VR surgical simulations. Future investigations should delve into specific aspects of sports engagement and other factors that may shape career aspirations, informing targeted educational strategies and residency selection processes.

virtual reality

medical education

career interest

surgical aptitude

simulation-based learning

The intersection of technological advancements and medical education has witnessed a surge in innovative approaches to surgical training. Among these, the integration of virtual reality (VR) surgical simulators has garnered considerable attention. The allure of VR as an educational tool lies in its ability to provide a risk-free environment for trainees to practice clinical decision-making and technical skills. Notably, it enables the tracking of error rates, success outcomes, and offers instantaneous feedback, contributing to a profound learning experience¹. VR exposure, particularly at the novice level, has been shown to stimulate medical students’ interest in a surgical specialty and influence motivation and confidence during their curriculum training ². Moreover, early exposure to VR surgical simulators potentially reshapes the learning trajectory of surgical training programs, potentially reducing the requisite number of operating hours for trained residents and attending physicians⁴. However, the utility of VR exposure in novice medical trainees is unknown⁵. Studies have also underscored the superiority of VR-assisted training in live surgery compared to conventional methods, highlighting its pivotal role in skill acquisition^5–8.

Numerous investigations attempt to decipher the relationship between students' career preferences and their proficiency demonstrated on VR surgical simulators^3,9,10. The results have been inconclusive, failing to establish a significant connection. Multiple studies aim to find a correlation between video game exposure, sport history, musical instrument talent and VR proficiency^3,7,9,10. Amidst these inconclusive findings, certain investigations have unearthed promising correlations. A 2020 study examined students’ medical specialty preference based on emotional intelligence and perceived self-efficacy markers: male students, who were more extrinsically motivated, prioritized surgical specialties as opposed to female students, who were more intrinsically motivated and preferred general practice¹¹. Other studies attempt to evaluate innate psychomotor and manipulative skills as a predictor for VR performance^12,13. Interest in surgery does not appear to correlate with psychomotor aptitude, however, students with high psychomotor aptitude tend to apply to surgical specialties¹⁴. As far as prior sports involvement, Rahm et.al discovered a positive correlation between frequent prior sports involvement and VR performance⁹. Another recent study found that prior participation in athletics may be a predictor of success in medical school and residency¹⁹.

While increasing research exists exploring various dimensions of VR simulation training, the dearth of studies examining the prognostic value of the career interest of novice medical trainees and performance on a simulated surgical procedure highlights the necessity for further exploration. This current study hopes to bridge these gaps by investigating the correlation between students' interest in a surgical specialty and their performance on a VR surgical simulator. By elucidating this relationship, this study aims to contribute insights that could further enhance the educational development of aspiring surgical students. Furthermore, these findings hold the potential to aid both students and residency program directors in determining the suitability of a specialty, especially considering evolving residency evaluation metrics including the transition of United States Medical Licensing Exam Step 1 to a pass/fail system.

Participants:

In total, 134 incoming first-year medical students (MS1) were voluntarily recruited during two consecutive orientations at a local United States medical school from July 2022 through August 2023. Participants engaged in an informative oral presentation led by the investigating team, exploring the advancements and impact of VR in surgical medicine. Subsequently, participants viewed a demonstration video featuring a post-graduate year three (PGY-3) orthopedic surgery resident illustrating the initial steps of surgical screw fixation of a slipped capital femoral epiphysis (SCFE) using the Osso VR system (San Francisco, CA United States). Following this session, each MS1 was briefed on the study's details, including the opportunity to voluntarily replicate the SCFE VR steps demonstrated by the PGY-3, and provided with a digital consent form via Global Research Electronic Data Capture (REDCap). The confidentiality of all 134 MS1s' consents was maintained through de-identification and secure storage, with each consent assigned a unique REDCap "Record ID #" corresponding to the respective MS1's email address. Group emails were sent using these Record ID #s to ensure privacy and uphold the integrity of this double-blind pilot study.

To be eligible for participation, MS1s needed to be enrolled as medical students at the institution conducting the study. The sole exclusion criterion was a self-reported history of adverse reactions to virtual stimulation or seizure/epileptic behavior, although no MS1s met these criteria for exclusion. Participation was entirely voluntary, with no coercion or incentivization involved, and participants were explicitly informed of their right to withdraw from the study at any point, with their data to be promptly deleted in such instances.

Of the 134 MS1s who initially signed up, 51 successfully completed all aspects of the study, encompassing the consent process, pre-interventional questionnaire, Osso VR SCFE procedure simulation, and post-interventional questionnaire. Five duplicate consents and one dropout during the pre-interventional questionnaire accounted for the reduced number of completions. Of the remaining 128 MS1s, 77 chose not to participate in the SCFE VR simulation. Nevertheless, all 51 MS1s who undertook the OSSO VR SCFE steps also completed the subsequent post-interventional questionnaire. Although this represented fewer than half of the initial 128 MS1s who completed the consent and pre-interventional survey, our sample size of 51 subjects aligns with the average number of participants in prior VR studies, which reported an effect size of 0.80^15–17. This indicates that our sample adequately accounted for projected attrition resulting from students' schedules and VR availability.

Pre-interventional Questionnaire:

Each consent form included a field for the MS1's school email address, accompanied by an explanation detailing its intended use primarily for instruction dissemination. Additionally, a copy of the PGY-3 VR video was provided, allowing participants to review it as many times as desired prior to data collection, alongside their randomly assigned REDCap Record ID number. Upon submitting digital consent, each MS1 proceeded to complete a 22-question pre-interventional questionnaire, exclusively designed for this study by the research team. This questionnaire encompassed inquiries into basic demographics such as age, gender, hand dominance, and history of engagement in hand-eye coordinated activities, video games, or musical instruments (Figs. 1 and 2), serving to evaluate potential confounding variables.

Participants were allotted a time window ranging from 0 to 60 days to decide whether to participate, aimed at mitigating any perceived coercion. 45 out of 128 subjects consented and completed the pre-interventional survey on the day of the orientation presentation, six did so on the same day during their allocated data collection slot.

Following survey completion, participants received an email within 24 hours from the research team, ensuring anonymity. This email included the identical VR video showcased during the orientation session, facilitating further review if desired, along with the corresponding REDCap Record ID number linked to their consent form. Additionally, a Microsoft Excel Spreadsheet (Redmond, WA United States) was provided, enabling subjects to schedule a 15-minute time slot on one of the designated simulation days using their assigned Record ID number.

SCFE Procedure Simulation:

On the day of data collection, each participant entered a spacious room accompanied by two members of the research team. One member assumed the role of data recorder, while the other provided consistent instructions and verbal cues throughout the simulation, with no role-switching occurring. Prior to commencing the procedure, each participant received a comprehensive explanation of the Osso VR system Unit 080, as introduced by the PGY-3 resident during the orientation session.

The initial prompt informed participants of the opportunity to familiarize themselves with the Osso VR system through a tutorial video. They were encouraged to ask questions and seek assistance from the team members, with no time constraints imposed, although the tutorial typically lasted 1–2 minutes. Following the tutorial, participants received further instructions.

Upon initiating the SCFE pinning simulation, participants were informed of a time frame of approximately 10 minutes to complete the procedure, ample time compared to the demonstration by the PGY-3 resident. Participants were assured that exceeding this time limit would not result in termination of their participation. Participants were granted unlimited retries, verbal hints, and the option to discontinue their participation at any point, with a final prompt encouraging adherence to simulator instructions.

During the simulation, participants initially aimed to maneuver the X-ray fluoroscopy C-arm into optimal positions for both anteroposterior (AP) and lateral views. In this step, the OSSO VR system provided standardized prompts as illustrated in Figs. 3 and 4; these prompts were not counted as “hints,” since they were uniformly provided to all participants, irrespective of their performance on the task. The simulation also provided additional verbal cues to correct any misalignments, which were dependent upon participants’ performance. These cues were counted as “retries” to correctly position the C-arm recorded for analysis.

Following C-arm placement, participants proceeded to grasp the drill and drill bit, performing the subsequent steps of drilling the guide wire into the femoral head at designated points while utilizing X-ray fluoroscopy (Fig. 5). Throughout these steps, participants could request verbal hints from the team members, ensuring procedural accuracy.

Upon achieving satisfactory guide wire placement as per ideal X-ray views, participants finalized the procedure, receiving a performance grade of A, B, C, or did not finish (DNF). Performance grade was comprised of the following recommendations: depth placement in millimeters (shallower/deeper), dimension angle in degrees (posterior/anterior and inferior/superior) to the ideal spot (Fig. 6). Both the grade and recommendations were recorded for data analysis, and team members informed the subject that they could remove the VR headset. The time taken, measured in seconds, was recorded for two activities: first, the time it took the MS1 to drill and place the guide wire into the femur, and second, the total time required for the MS1 to perform the entire VR simulation, which included guide wire placement, C-arm operation, and the placement of the drill bit into the drill.

Participants receiving a DNF grade were given the option to retry within the specified time frame or accept the grade. Retries were recorded regardless of DNF status, including voluntary retries initiated by participants. Completion of the simulation allowed participants to proceed to the post-interventional questionnaire. Overall, recorded markers from the VR SCFE Procedure Simulation included total procedure time, C-arm placement time, guide wire insertion time, performance grade, recommendations, number of retries, and verbal hints, facilitating comprehensive data analysis.

Post-Interventional Questionnaire:

Upon completion of the simulation, the subject removed VR headset and scanned a REDCap QR code on a secure device with their personal smartphone in a separate area of the simulation room. There, they answered eight questions pertaining to their VR experience and performance (Fig. 7). While the subject completed the post-interventional survey, one of the proctoring team members entered the subject’s data output from the simulation into REDCap database. When finished, the subject informed one of the proctoring team members and exited the secure room, concluding his or her participation in the study. This was repeated with each subject.

Data Analysis:

Statistical analysis was performed using the Mann-Whitney-Wilcoxon test, Chi-squared test, and Fischer’s exact tests on the pre-/post-interventional survey responses and the VR SCFE procedure simulation markers. Statistical significance was defined as p < 0.05. Data-collected results are presented as means ± standard deviation with confidence intervals for both surgical interest and non-surgical interest. All statistical analysis was performed using IBM SPSS 28 Statistical Software. No prior power analysis to discover a desired sample size was performed due to similar studies having an n-value of approximately 21–24 subjects^15–17. Hindsight power analysis was performed after data was analyzed showing a .80 power equating to approximately 80 subjects.

Descriptive Statistics:

In the examination of 128 students, a comprehensive analysis of demographic and interest-related variables from pre-interventional questionnaire was conducted (Figs. 1 and 2). The data illustrated a predominant presence of students under 25 years old, constituting 79.8% of the cohort. Gender distribution was nearly equal, with 53.5% identifying as male and 45.7% as female (Table 1).

Table 1

Descriptive statistics based on Pre-interventional Questionnaire:
Variables	Category	Frequency	Percent
Age	< 25 yrs	103	79.8%
	> 25 yrs	25	19.4%
Gender	Male	69	53.5%
	Female	59	45.7%
Interest in Surgery	Yes	60	46.5%
	No	68	52.7%
Students who play sports	Yes	53	41.1%
	No	75	58.1%
Students who play Music	Yes	36	27.9%
	No	92	71.3%

Variables related to interests:

Regarding surgical aspirations, 46.5% of students expressed interest, while 52.7% did not (Fig. 8). A similar pattern was observed in sports involvement, with 41.1% displaying interest and 58.1% not participating. On the musical front, a majority of 71.3% of students did not engage in musical activities, contrasting with 27.9% who did (Table 1).

Chi-Squared Tests:

Further exploration through Chi-Square tests (Table 2) aimed to establish associations between demographic factors and surgical interest. The results unveiled no significant relationships with age, gender, or handedness. However, a noteworthy revelation emerged regarding sports participation, with a statistically significant association found (p = .036). Conversely, no substantial association was identified for musical engagement (p = .961). This suggests that while most demographic factors do not exert influence on surgical interest, active involvement in sports may play a role in shaping a student's inclination towards surgical fields.

Table 2

Chi-Square Test Results:
Variables	P-value
Age vs. Interest in Surgery	.224
Gender vs. Interest in Surgery	.345
Plays Sports vs. Interest in Surgery	.036
Plays Music vs. Interest in Surgery	.961

Nonparametric tests:

The nonparametric tests, specifically the Independent-Samples Mann-Whitney U Tests, were conducted to assess the relationship between various VR simulation performance metrics and students' interest in surgery in a subset of 51 students who completed the study (Table 3). The results of the Mann-Whitney U tests revealed that there were no statistically significant differences in the distribution of VR performance metrics across categories of surgery interest. The p-values for procedure total time, c-arm placement, and guide wire insertion were 0.263, 0.483, and 0.311, respectively. The Independent-Samples Mann-Whitney U Tests were also conducted to compare the distributions of "number of retries" and "hints" across various categories of "surgical interest (Figs. 9 and 10).” For the "number of retries" variable, the Mann-Whitney U statistic was 366.000, with a Standardized Test Statistic of 1.288 and an asymptotic significance of .198; similarly, for "hints," the Mann-Whitney U statistic was 360.500, with a Standardized Test Statistic of 1.123 and an asymptotic significance of .261 (Tables 4 and 5).

Table 3

Mann-Whitney U Test Results for OSSO VR Simulation Performance Metrics
Variable	Test	p-value	Statistical sig.
Procedure Total Time	Mann-Whitney U Test	.263	Not significant
C-arm Placement Time	Mann-Whitney U Test	.483	Not significant
Guide Wire Insertion Time	Mann-Whitney U Test	.311	Not significant

Asymptotic Significance

Table 4

Number of Retries across Surgical Interest Independent-Samples Mann-Whitney U Test Summary
Total N	51
Min./Max	0/4
Mean	.9
Std. Dev	1.06
Mann-Whitney U	366.000
Wilcoxon W	894.000
Test Statistic	366.000
Standard Error	48.119
Standardized Test Statistic	1.288
Asymptotic Sig. (2-sided test)	.198

Table 5

Hints across Surgical Interest Independent-Samples Mann-Whitney U Test Summary
Total N	51
Min/max	0/10
Mean	2.5
St. Dev	1.98
Mann-Whitney U	360.500
Wilcoxon W	888.500
Test Statistic	360.500
Standard Error	50.297
Standardized Test Statistic	1.123
Asymptotic Sig. (2-sided test)	.261
Nonparametric Tests

All p-values exceeded the conventional significance threshold of 0.05, leading to the retention of the null hypothesis for each test, including the distributions of "number of retries" and "hints" against surgical interest (Table 6). Consequently, it can be inferred that interest in surgery may not significantly impact students' performance in VR simulations of medical procedures.

Table 6

Hypothesis Test Summary
	Null Hypothesis	Test	Sig.^a,b	Decision
1	The distribution of number of retries is the same across categories of surgical interest.	Independent-Samples Mann-Whitney U Test	.198	Retain the null hypothesis.
2	The distribution of hints is the same across categories of surgical interest.	Independent-Samples Mann-Whitney U Test	.261	Retain the null hypothesis.
a. The significance level is .050.
b. Asymptotic significance is displayed.

Moreover, these findings suggest that the level of "number of retries" and "hints" did not vary significantly among individuals with different levels of interest in medical topics.

The findings from this study contribute to understanding the factors that influence medical students' career interests and performance in virtual surgical environments. The correlation between sports participation and surgical interest underscores the potential value of physical and cognitive skills gained from sports, such as hand-eye coordination and decision-making under pressure, in surgical practice. This aligns with previous research suggesting that activities requiring precise motor skills and strategic thinking can enhance performance in tasks requiring similar competencies²⁰, implying the potential transferability of skills from sports to surgical tasks. Furthermore, this study is the first where each participant was from the same stage of medical training at the beginning of their first year and was not composed of a cohort with medical students, residents, and attendings with significantly more experience and exposure to the orthopedic surgery field.

Contrary to our initial hypothesis, we found no significant relationship between students' performance in the VR surgical simulator and their interest in surgery. However, there is a strong inclination for further studies based on the student's performance. In our data findings, we discovered a strong trend between students with surgical interest versus no interest pertaining to the mean values of guide wire placement, C-arm placement, and total procedural time. Students declaring surgical interest tended to have decreased time needed for the prior metrics when compared to the non-surgical interest students. This suggests that interest may have an intricate influence on the skills necessary for proficient performance, especially in a simulated environment. This finding is crucial for medical educators and curriculum developers, indicating the need for a broad range of training and assessment methods to identify and nurture the diverse skills required for surgical proficiency.

Sample Limitations and Mitigation Strategies:

In conducting this study on the relationship between student demographics, interests, and performance in virtual surgical simulations, several limitations were encountered. One notable limitation encountered was the challenge of attaining the desired sample size. Despite concerted efforts to recruit a larger cohort of participants, logistical constraints within the medical student population limited our ability to achieve a larger sample size. To address this concern, we focused our investigation on specific cohorts of medical students within our institution, supported by a pilot study aimed at refining our methodology. While the sample size remained relatively modest, it is noteworthy to report that after reviewing pertinent literature the n-values for similar studies often fell below the projected n = 80 to reach power. A recently published study by Orland et al. (2020) investigating VR simulation training in an orthopedic context had an average of 23 to 24 participants across 18 different studies, and a prior power analysis estimated that 21 participants were needed for their study¹⁵.

This study could address many constraints and limitations by continuing data collection to eventually become an annual longitudinal study. This would improve sample size as well as provide an opportunity to follow up with previous participants and determine whether implications found in this study in fact lead to the pursuit of a surgical or procedure-heavy specialty.

As far as methodological considerations, it is important to recognize that the use of chi-square tests and Mann-Whitney U tests, while informative, may have inherent limitations in capturing the confounders, and full complexity of the relationships under investigation. The categorical nature of some variables and the relatively small sample size may impact the statistical power of our analyses.

The outcomes derived from our descriptive statistics and nonparametric tests provide valuable insights into the factors influencing medical students' career interests and their manifestation in virtual surgical simulations. Notably, the significant association found between sports participation and an interest in surgery adds nuance to our understanding of the interplay between extracurricular activities and professional inclinations among students.

Future Directions and Implications:

Future studies could explore additional factors that may influence performance in surgical simulations, such as medical knowledge, cognitive abilities, learning styles, and previous exposure to VR technologies. Expanding the diversity of the participant pool and incorporating a wider range of simulation tasks could also provide a more comprehensive understanding of the skills and interests that predict success in surgical careers.

These findings suggest that while interest may guide career choices, it does not necessarily equate to skill or aptitude in related tasks, especially in a simulated environment. This finding is crucial for medical educators and curriculum developers, indicating the need for a broad range of training and assessment methods to identify and nurture the diverse skills required for surgical proficiency. The goal of a surgical residency is to stimulate critical thinking and problem-solving strategies along with developing surgical skills necessary to proficiently execute surgical procedures. The motivation to pursue a surgical specialty is unable to be measured directly therefore indirect measures of aptitude can be assessed as in this study. The intriguing findings regarding sports participation prompt consideration of the potential transferable skills and attributes developed through sports involvement that may contribute to an interest in surgical fields.

Previous studies have indicated that VR simulation improves the surgical skills of PGY-1 orthopedic residents, especially in technical skills, and is expected to become an indispensable part of orthopedic surgical education¹⁸. If this indication is expanded into medical student education before the curriculum’s clinical clerkships, significant decreases in medical student error could be a potential outcome. However, further study is needed to determine the most beneficial use for VR within the constraints of a medical student curriculum.

The prevalence of students under 25 years old in our cohort aligns with broader trends observed in medical education. While age, gender, and handedness did not exhibit significant associations with surgical interest, the marked influence of sports engagement suggests potential avenues for further exploration. The absence of a substantial association between musical activities and surgical interest highlights the complexity of individual preferences and the need for a nuanced examination of diverse interests among medical students.

Moreover, the Mann-Whitney U tests conducted on a subset of students in the study shed light on the performance of individuals with varying degrees of interest in surgery in VR simulations. The lack of statistically significant differences in procedure total time, c-arm placement, and guide wire insertion suggests that, despite variations in career aspirations, students demonstrated comparable proficiency in these specific simulation parameters. These findings challenge conventional assumptions about the direct translation of career interests into practical skills performance in virtual environments.

In conclusion, despite these constraints and resource limitations, this study provides valuable awareness into the distinct factors influencing medical students' career interests and their performance in virtual surgical simulations. While the study highlights interesting correlations between sports participation and surgical interest, it also raises questions about the relationship between interest in surgery and actual performance in surgical tasks. These findings are invaluable for the development of targeted educational strategies that can better prepare medical students for the demands of surgical careers, emphasizing the importance of a holistic approach to medical education that values a variety of skills and interests. These limitations of the study help to illuminate the path for future investigations to build upon these findings and address the persistent challenges in this field.

Virtual Reality (VR); post-graduate year three (PGY-3); slipped capital femoral epiphysis (SCFE); first-year medical student (MS1); Global Research Electronic Data Capture (REDCap); anteroposterior (AP); did not finish (DNF)

Ethics approval and consent to participate:

Ethical approval for this study was obtained from the Institutional Review Board at Marshall University. All participants provided informed consent prior to their participation in the study. The study adhered to ethical standards outlined by the Institutional Review Board.

Consent for publication:

Consent for publication was obtained from all individual participants included in the study. Participants were provided with detailed information regarding the publication of study findings, and their consent was obtained prior to the dissemination of any data.

Availability of data and materials:

The datasets generated and analyzed during the current study are not publicly available due to restrictions regarding participant confidentiality. However, anonymized data may be available from the corresponding author upon reasonable request.

Competing interests:

The authors declare that they have no competing interests.

Funding:

This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements:

The authors thank Dr. Kamal Sodhi, Laura Christopher and Mary Beth Cordle for their assistance in developing this project.

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No competing interests reported.

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The Relationship Between Surgical Interest and Performance on a Virtual Reality Surgical Simulator in a Cohort of Untrained First Year Medical Students

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Abstract

Background:

Methods:

Results:

Discussion:

Conclusions:

Figures

INTRODUCTION

METHODS

Participants:

Pre-interventional Questionnaire:

SCFE Procedure Simulation:

Post-Interventional Questionnaire:

Data Analysis:

RESULTS

Descriptive Statistics:

Variables related to interests:

Chi-Squared Tests:

Nonparametric tests:

DISCUSSION

Sample Limitations and Mitigation Strategies:

Future Directions and Implications:

Conclusions

Abbreviations

Declarations

References

Additional Declarations

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