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Auckley et al
Original Paper
Extracurricular Humanism in Medicine Initiative and Medical
Student Wellness: Retrospective Study
Elizabeth Diane Auckley1*, BA; Jeff Barbee2*, MA, DMA; Nicole Verbeck2*, MPH; Tracie McCambridge3*, MA;
Linda Stone1*, MA, MD; Jennifer Garvin4, MBA, RHIA, PhD
1
The Ohio State University College of Medicine, Columbus, OH, United States
2
Office of Curriculum and Scholarship, The Ohio State University College of Medicine, Columbus, OH, United States
3
Department of Medical Education, The Ohio State University College of Medicine, Columbus, OH, United States
4
Health Information Management and Systems Divisions, Ohio State University, Columbus, OH, United States
*
these authors contributed equally
Corresponding Author:
Elizabeth Diane Auckley, BA
The Ohio State University College of Medicine
370 W 9th Ave
Columbus, OH, 43210
United States
Phone: 1 4402926035
Email: elizabeth.auckley@osumc.edu
Abstract
Background: Humanism in Medicine Initiative (HIMI), an extracurricular program at Ohio State University College of Medicine
(OSUCOM) with 27 subgroups, fosters the humanities. Stress and burnout among first- and second-year medical students are
prevalent across the United States. Solutions for stress among first- and second-year medical students have been proposed, but
no gold standard exists. The relationship of humanism with stress and burnout has yet to be described in the literature.
Objective: This study investigates the relationship between participation in the HIMI and stress, burnout, and academic success
among first- and second-year medical students.
Methods: First- and second-year medical students enrolled at OSUCOM between August 2018 and August 2019 were recruited.
Attendance in the HIMI and membership records were used to measure their participation. Curricular examination scores and
those on Step 1 of United States Medical Licensing Examination (USMLE) were used to measure academic success. Stress and
burnout were measured using the Maslach Burnout Inventory and the Perceived Stress Scale.
Results: In total, 412 students were enrolled with 362 (87%) students participating in HIMI. Those with high participation were
more often Black, Asian, female, or with a humanities undergraduate major compared to the overall study population. There were
significant relationships between Gold Humanism Honors Society (GHHS) induction and participation of first- and second-year
medical students in service- (χ21=5.8, P<.05) or leadership-focused (χ21=19.3, P<.001) HIMI groups. Medium levels of
participation in the HIMI were associated with significantly higher stress. Performance on the Step 1 USMLE was not significantly
associated with participation levels in the HIMI (low=233.7 vs high=238.0; P=.10).
Conclusions: The HIMI is an extracurricular program vastly utilized by first- and second-year medical students at OSUCOM
and did not impact Step 1 USMLE scores. Medium participation in the HIMI was associated with higher stress, and service- and
leadership-focused HIMI participation was associated with a higher level of induction to the GHHS. This study identifies areas
for future studies to understand the relationship of the HIMI with stress and academic success.
(JMIR Form Res 2022;6(9):e37252) doi: 10.2196/37252
KEYWORDS
humanism; extracurricular; stress; burnout; medical student; student; academic success; wellness
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Introduction
Stress and burnout are well known to the majority of medical
students in the United States [1-5]. Stress was first described
as the “nonspecific response of the body to any demand made
upon it” [6] but has since been recognized as a potentially
negative state of being, where the body is threatened by
conditions that create imbalance and endanger homeostasis [7].
Burnout, initially described as excessive burdens of energy,
strength, or resources in work environments, resulting in
malaise, fatigue, cynicism, frustration, and inefficacy [8], is
now well understood as a syndrome of emotional exhaustion,
depersonalization, and decreased personal achievement due to
human interaction at the workplace [2,9]. Stress and burnout
often embody a cyclical, perpetuating relationship [2,10] that
preclinical medical students are uniquely vulnerable to
experiencing [1,10]. In the already hypercompetitive medical
school environment with frequent high-stakes formal
assessments, students cite unanticipated informal verbal
quizzing, feeling useless, and depersonalized preclinical medical
education as specific sources of stress and burnout in addition
to sources from life outside of school [1,11]. Both psychological
conditions are associated with psychological morbidity, anxiety
and depression, alcohol and drug abuse, suicidal ideation, and
suicide in medical students [1,12,13].
Despite being recognized as a prevalent issue among medical
students for at least 4 decades [14,15], no gold standard of stress
and burnout reduction for this population has been described
[12]. The focus of improvement has shifted from treating
impacted students individually to changing the environment of
preclinical medical school to be less stressful overall [15].
However, stress and burnout solutions for medical students
remain under investigated, with few studies including empirical
data for specific interventions [12]. Intervention in medical
school is critical, as these psychological conditions in physicians
have been found to originate from early-career training in
medical school [14]. Further, physicians with resilience, an
important phenomenon to fight stress and burnout, are more
prepared to create successful patient-physician relationships
because they are better able to provide hope and empathy to
patients [16].
While stress and burnout are increasingly becoming an important
consideration of medical education reforms, humanism has also
gained the attention of medical educators in recent decades. The
Arnold P. Gold Foundation defines a humanistic health care
practitioner as one with integrity, excellence, collaboration and
compassion, altruism, respect and resilience, empathy, and
service [17]. The Arnold P. Gold Foundation recognizes
humanism in medical students through the national honors
society induction for the Gold Humanism Honors Society
(GHHS). The GHHS selects members based on peer
nominations and individual applications for those with strong
nominations. Induction into GHHS at OSCOM requires strong
peer nominations during the third year of medical school,
followed by an invitation to complete an essay-based
application. GHHS members select new inductees after rigorous
review of deidentified applications and peer nominations. GHHS
induction is intended to be impartial. Local chapters of GHHS
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are limited to inducting a maximum of 15% of each class.
Humanism is often considered the foundation for
professionalism, which is defined as a way of acting to meet
the expectations of the workplace. Professionalism only becomes
authentic when humanism, the morals and values that guide
ones obligation to serve others especially when in need, is
fostered [18]. Calls to protect innate humanism in students [19],
foster growth of humanism in medical school culture [18,20,21],
and add humanism to the top 4 goals of health care [22] are
supported by staff and students alike [23], but specific initiatives
and measurement of humanism has been difficult to describe
[18-20,24]. Further, the impact of humanities and culture of
humanism on preclinical medical students’ stress and burnout
has not been previously reported, based on our review of the
literature.
This study investigates the impact of first- and second-year
medical students’ engagement with HIMI on their stress,
burnout, and academic success. HIMI, a portion of the Linda
C. Stone MD Program for Humanism and the Arts in Medicine,
is a voluntary extracurricular program at the Ohio State
University College of Medicine (OSUCOM), which has been
developed and is led by students with the goal of fostering a
culture of humanism among first- and second-year medical
students. Begun in 2009, it now embodies 27 unique student
organizations that allow students to engage in the arts and
humanities with their peers. Many isolated aspects of HIMI
have been supported as general stress- and burnout-reducing
activities for students in the literature, including animal therapy
[25-27], music [5], peer mentor programs [16,28,29], emotional
expression with peers [29-32], student retreats [29], visual arts
[33], and being student-led [13].
Methods
Ethical Approval
This study was approved by the institutional review board at
the Ohio State University (IRB# 2020B0173) and approved for
waived consent.
Recruitment
The setting for this study was a single-center retrospective study
conducted at OSUCOM (Columbus, Ohio), a large, Midwestern
medical school. The medical school curriculum is structured as
two years of lectures and small group-based classes with
bimonthly clinical experiences. The third year involves clinical
rotations with weekly case discussions, and the fourth year
requires specialty specific rotations, an emergency medicine
clinical rotation, and an advanced elective. Within this
curriculum, Humanism is one option for fourth-year elective
courses, and a Humanism in Medicine extracurricular group
exists to supplement medical student experiences on an optional
basis. This study involved medical students enrolled at
OSUCOM from August 2018 to August 2019. All first- and
second-year [34] medical students were eligible and enrolled
in the study unless they opted out. Students were given the
option to terminate participation by opting out, through an email
notification. Student demographic information was obtained
from internal admissions records for those enrolled.
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Participation and Leadership in the HIMI
First- and second-year medical student participation in the HIMI
is defined as attending any event hosted by a student group in
the HIMI, organizing an event, leading a group or event, or
nominating a peer for a nomination-based group during August
2018 to July 2019. Participation was measured by internal HIMI
records of attendance, membership, and leadership. Any amount
of participation in a single HIMI group qualified for participation
for that group, and the total number of unique HIMI groups
participated in was measured for each student. In 2018-2019,
HIMI encompassed 27 unique student groups, categorized as
art-focused (eg, Dance in Medicine and Photography/Film,),
service-focused (eg, Life Support Group and Peer Mentoring),
or leadership-focused (eg, Medicine and the Arts Board and
Servant Leadership). Student leaders, who had been nominated
or recognized by the HIMI as a student organizer of the group,
were also recorded.
Academic Outcomes
Academic success was measured on the basis of the Step 1
United States Medical Licensing Examination (USMLE) score
and student Objective Structured Clinical Examination (OSCE)
scores. The OSCEs have been administered at most medical
schools for more than 4 decades [35] with the goal of measuring
communication skills and clinical tasks through directed
interactions with several standardized patients [36]. OSCE
scores are reported as percentages (0%-100%), and the last
OSCE score for the 2018-2019 school year was used for
analysis. Step 1 is the first of 3 examinations in the USMLE
series. This is a nationally standardized examination required
for medical school graduation and licensing that examines
student understanding of basic biomedical principles and clinical
applications. Step 1 is administered after the completion of
didactic coursework and is taken after the second year at
OSUCOM [37]. Scores are reported numerically out of 300 and
correspond to percentiles nationally [38]. OSCE and Step 1
USMLE scores were obtained from the Office of Curriculum
and Scholarship at OSUCOM.
Stress and Burnout
Stress and burnout were measured using the Maslach Burnout
Inventory (MBI), Perceived Stress Scale (PSS), Perceived
Cohesion Scale (PCS) [39], and quality of life (QOL) measure.
These surveys were administered independently by OSUCOM
in a voluntary survey to students in spring 2018. The MBI is
based on a 7-point scale of frequency from “never” to “daily”
responses to 22 statements organized in 3 sections corresponding
to the 3 parts of burnout: emotional exhaustion (9 statements),
depersonalization (5 statements), and reduced personal
accomplishment (8 statements) [9]. The MBI’s items are derived
from the 1996 Maslach Burnout Inventory Manual. The MBI
has been validated as a measure of burnout in preclinical medical
students [40]. The PSS is a measure of how one’s current life
circumstances are interpreted as stressful [41]. A 10-item form
of the Likert-scale–based self-report PSS instrument was used,
and scores were reported between 10 and 50, with lower scores
indicating lower stress. The PSS is validated for populations
with at least junior high school education and has been reported
to have an internal consistency of 0.85 [42]. The PCS measures
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sense of belonging and morale within a population and records
a response from 0=“strongly disagree” to 10=“strongly agree”
to 6 statements, 3 pertaining to sense of belonging and 3 to
morale [43]. The population noted in the statements was
“medical school class” and “medical school” in this survey. A
revised, Bollen and Hoyle form of the Likert-scale self-report
PCS [43] was used, which reported scores between 1 and 60,
and lower scores indicated less perceived cohesion. QOL was
measured using a linear analogue self-assessment, which scores
QOL as 1-5, with 1=“as bad as it can be” and 5=“as good as it
can be”; this QOL measure has been validated in a wide set of
populations [44].
GHHS Induction
Induction into the GHHS was recorded from internal records
of the GHHS. The GHHS was established by the Arnold P.
Gold Foundation in 2002 and recognizes students who embody
humanistic qualities such as empathy and integrity and serve
as role models and advocates for humanism in medicine. The
GHHS has been added as a qualification on the Electronic
Residency Application Service for students to identify
themselves as members, suggesting its importance [45].
Statistical Analysis
To understand the potential relationship between participating
in an HIMI group (ie, arts, leadership-, or service-focused
organization) and induction into the GHHS, second-year
students, who were eligible to be inducted into GHSS the
following year, were grouped dichotomously as having
participated in at least one activity, or not at all. A chi-square
goodness-of-fit test was conducted for each category of the
HIMI group to determine if the proportions of students who
participated in at least one group and inducted into the GHHS
was similar to those of students who did not participate in any
HIMI groups.
Examining the HIMI program and wellness constructs such as
burnout and perceived stress, student participation was
demarcated into 3 levels of participation: low (0-1 groups),
medium (2-3 groups), and high (4 or more groups). This
grouping was performed to better differentiate potential effects
and attempt to obtain evenly balanced groups. ANOVA was
performed to identify any significant differences. All
assumptions were checked to ensure this was the appropriate
analysis technique.
When studying the perceptions of belonging and morale from
a cohort and school viewpoint, the limited data required the
participation variable to be collapsed to a dichotomous grouping.
The low participation group attended 1 or 0 HIMI groups, while
the high participation group attended ≥2 groups. Owing to failure
of the assumption of normality, the nonparametric
Kruskal-Wallis test was applied. These survey instruments were
optional for students to complete and required additional consent
for research.
Dichotomous grouping into low and high group participation
groups was also used to test for significant relationships with
the Step 1 USMLE scores of second-year students. An
independent samples t test was performed for this analysis. This
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analytical approach was continued to examine the
Professionalism OSCEs during the last second-year evaluation.
Results
The final relationship studied was between participation in the
HIMI and the Interpersonal-Communication Skills OSCE scores
of first-year students. This OSCE was conducted during the
Endocrine-Reproduction block. These data allowed for the use
of the trichotomous grouping of low, middle, and high
participation levels. ANOVA was performed for this analysis
with no assumption violations. All statistical analyses were
performed using RStudio (version 1.3.959; RStudio Team).
Recruitment and Demographics
In total, 419 first- and second-year students were enrolled at
OSUCOM during the study period, and 412 met inclusion
criteria for analysis (Figure 1). Regarding race and ethnicity,
the study population comprised 48.8% White (n=201), 8.5%
Black (n=35), and 19.9% Asian (n=82) students, and 22.8% of
participants did not respond (n=94), and regarding gender, the
study population comprised 45.4% females (n=188) and 41.7%
males (n=172), and 12.8% of participants did not respond
(n=52). Most participants did not have a humanities
undergraduate major (n=338, 82.0%) as opposed to 8.4% (n=35)
of participants who had a humanities major, and 9.6% (n=39)
of participants did not respond (Table 1).
Figure 1. Recruitment of participants. There were 419 first- and second-year students enrolled in Ohio State University College of Medicine (OSUCOM)
in 2018-2019. After an email invitation to opt out of the study, 1 student opted out of the study. Six students did not provide consent to the Office of
Curriculum and Scholarship (OCS) for the use of demographic and academic data. The analysis included the remaining 412 students. Surveys were
optional for students and some data were incomplete.
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Table 1. Demographic information regarding participants in the Humanism in Medicine Initiative (HIMI) between 2018-2019 (N=412).
Low participation in the
HIMI (n=180), n (%)
Medium participation in
the HIMI (n=147), n (%)
High participation in the
HIMI (n=85), n (%)
Total, n (%)
Asian
30 (16.7)
30 (20.4)
22 (25.8)
82 (19.9)
Black
19 (10.6)
8 (5.4)
8 (9.4)
35 (8.5)
White
86 (47.8)
80 (54.4)
35 (41.2)
201 (48.8)
No response
45 (24.9)
29 (19.8)
20 (23.6)
94 (22.8)
Female
59 (32.7)
75 (50.7)
54 (63.5)
188 (45.4)
Male
90 (50.0)
61 (41.5)
21 (24.7)
172 (41.7)
No response
31 (17.3)
11 (7.8)
10 (11.8)
52 (12.8)
Humanities
11 (6.1)
16 (10.8)
8 (9.4)
35 (8.4)
Other
142 (78.8)
125 (85.0)
71 (83.5)
338 (82.0)
No response
27 (14.8)
6 (4.2)
6 (7.1)
39 (9.6)
Race
Gender
Undergraduate major
Race, gender, and undergraduate major of the participants were
obtained from the Office of Curriculum and Scholarship internal
records, which were optionally self-reported by students. No
response indicates the percentage of students who did not opt
to self-report their information.
Participation in the HIMI
First- and second-year students vastly participated in HIMI
student groups. The HIMI participation rate was 95% (n=199
students) among first-year students and 81% (n=163) among
second-year students, accounting for a total participation rate
of 87% (n=362). First-year students averaged participating in
3.0 unique student groups, and second-year in 1.6 unique student
groups (Figure 2). Of the HIMI groups, Peer Mentoring (n=333),
Somali Health Initiative for Nutrition Education (n=62), Visual
Arts (n=49), M1 Fall Retreat (n=43), and Dance in Medicine
(n=39) were those most participated in.
Figure 2. Medical student participation in the Humanism in Medicine Initiative (HIMI) groups, displayed by minimum participation levels. Each HIMI
group includes all students who participated in the minimum amount stated or more. Medical student participation in HIMI groups was defined as
attending any event hosted by a student group in the HIMI, organizing an event, leading a group or event, and nominating a peer for a nomination-based
group between August 2018 and July 2019 and collected from internal HIMI records.
Student participation was categorized as low (0-1 groups),
medium (2-3 groups), or high (≥4 groups). When compared
with the total study population, high participation was observed
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to a larger extent among Black or Asian (Black: n=35, 8.5% vs
n=8, 9.4%; Asian: n=82, 19.9% vs 22, 25.8%), among female
participants (n=188, 45.4% vs n=54, 63.5%) and those who
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have majored in humanities during their undergraduate studies
(n=35, 8.4% vs n=8, 9.4%).
participation in the HIMI had no significant impact on Step 1
USMLE scores.
Academic Outcome Results
Comparison With Prior Work
Step 1 USMLE scores were analyzed for second-year students.
HIMI participation had no significant relationship with the
OSCE outcomes. When comparing low and high participation,
the high participation group averaged higher scores (238.0, SD
14.6) than the low participation group (233.7, SD 19.3) (P=.10),
though the difference was not significant.
Humanities content during undergraduate medical education
has also been a topic of debate for decades. Most recent concerns
seek to determine how to balance the need for humanistic
training and diverting students’ time from rigorous basic science
study to accomplish this. Moreover, the success of humanities
content as part of the curriculum versus as an extracurricular
program has similarly been debated. Our results suggest that
students highly utilize the HIMI as a voluntary opportunity to
engage with the humanities. This study found first-year students
to engage with HIMI to a greater degree than second-year
students, possibly owing to the increased demands on
second-year students to study for the Step 1 USMLE. HIMI
membership was also more commonly observed among students
who are female, Black, Asian and had a humanities background
than the overall medical school population. One possible reason
for this result could be that students with an identity
underrepresented in medicine (female, Black, or Asian students
and those with a humanities education) sought out the HIMI as
a community of support.
Stress and Burnout
Perceived stress was found to be a significant factor by
participation level (F2,193=3.85; P<.05; ηp2=0.038). A post hoc
analysis was conducted given the significance of the omnibus
test. The Tukey honestly significant difference multiple
comparison test was used to examine all pairwise relationships.
A significant difference was found between the students with
medium participation (18.5, SD 6.6) and students with low
participation (15.7, SD 5.58; P=.02). This finding indicates that
medium participation in the HIMI was significantly associated
with higher levels of perceived stress than those with low
participation in the HIMI. Participation in the HIMI was not
significantly associated with burnout, sense of belonging, or
QOL.
GHHS Induction
GHHS induction was significantly associated with participation
in a HIMI service (χ21=5.8, P<.05) and leadership focused group
(χ21=19.3, P<.001).
Discussion
Principal Findings
This study investigated the short-term impact of first- and
second-year students’ participation in the HIMI on their stress,
burnout, and academic success. We found that the HIMI is
utilized by the majority of first- and second-year students (95%
vs 81% participation, respectively), and those who participated
in ≥4 HIMI groups were more often female, Black, Asian, or
had a humanities undergraduate major compared to the total
study population.
Further, students who participated in a service- or
leadership-focused group were significantly more likely to be
inducted into the GHHS than those who did not participate in
these groups.
Medium participation (defined as participation in 2-3 HIMI
groups), compared with low participation (0-1 groups), was
associated with significantly higher stress. Medical student
stress and burnout have been a concern in recent decades with
no gold-standard solution described. The association of medium
HIMI participation with high stress warrants future study at our
institution, with more medical students, and at other institutions
with similar programs. Perhaps students with higher baseline
stress seek out HIMI for reduction, but it is difficult to determine
the cause of stress, as a complex multidimensional variable,
and the results of this study cannot infer causation. Furthermore,
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The association of HIMI leadership and service engagement
with GHHS membership suggests that participation in the HIMI
makes students more competitive for GHHS membership,
possibly either by characterizing time spent on valued activities
or identification of intrinsic interest in humanities. While the
GHHS and HIMI appear to share several values, the GHHS
selection process requires strong peer nominations as the first
step for consideration. HIMI involvement may therefore add
holistic review of applicants.
However, students’ time spent in the HIMI did not significantly
impact Step 1 USMLE scores in our study, and these findings
may be evidence for including humanities content in the medical
students’ schedule without concern for detracting from basic or
clinical science education.
Limitations
This study was completed at a single medical school in an
academic institution with a small sample size of students,
compared to the population of medical students in the United
States. The results of the study are therefore limited in
generalizability within the United States and internationally.
The study constituted a secondary data analysis and was limited
in analysis by existing data. Further variables could be analyzed
in future, experimentally designed studies. Participation data
were collected internally by students and may be limited by
program design. Further, participation was classified binarily
and thus did not discriminate difference in volume of
participation within each group. Some student group
participation may be underrepresented in the study owing to
these limitations. Student demographic and some outcome data
were optional to report, which may have led to bias in our
results. The analysis had a cross-sectional design and did not
account for longitudinal outcomes of participation in the HIMI.
The study utilized solely quantitative data, which may limit the
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ability to capture the full impact of humanism on medical
students [46]. Finally, the study was observational by design.
Conclusions
The HIMI is an extracurricular program vastly utilized by firstand second-year medical students at OSUCOM and did not
impact Step 1 USMLE scores. Medium participation in the
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HIMI was associated with higher stress, and service- and
leadership-focused HIMI participation was associated with a
higher level of induction to the GHHS. This study identified
areas for future studies to understand the association of
participation in the HIMI with stress, academic success,
potentially important activities for social support and resilience
in medical school.
Acknowledgments
The authors wish to thank OSUCOM, the Office of Curriculum and Scholarship at Ohio State University College of Medicine,
and the Humanism in Medicine Research Team.
Conflicts of Interest
None declared.
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Auckley et al
Abbreviations
GHHS: Gold Humanism Honors Society
HIMI: Humanism in Medicine Initiative
MBI: Maslach Burnout Inventory
OSCE: Objective Structured Clinical Examination
OSUCOM: Ohio State University College of Medicine
PCS: Perceived Cohesion Scale
PSS: Perceived Stress Scale
QOL: quality of life
USMLE: United States Medical Licensing Examination
Edited by A Mavragani; submitted 12.02.22; peer-reviewed by KH Tan, L Puljak; comments to author 25.04.22; revised version
received 11.08.22; accepted 15.08.22; published 16.09.22
Please cite as:
Auckley ED, Barbee J, Verbeck N, McCambridge T, Stone L, Garvin J
Extracurricular Humanism in Medicine Initiative and Medical Student Wellness: Retrospective Study
JMIR Form Res 2022;6(9):e37252
URL: https://formative.jmir.org/2022/9/e37252
doi: 10.2196/37252
PMID:
©Elizabeth Diane Auckley, Jeff Barbee, Nicole Verbeck, Tracie McCambridge, Linda Stone, Jennifer Garvin. Originally published
in JMIR Formative Research (https://formative.jmir.org), 16.09.2022. This is an open-access article distributed under the terms
of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly
cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this
copyright and license information must be included.
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