Are there gender differences in academic medical career aspirations related to research, mentoring and discrimination? A national cross-sectional study of French medical residents.

Are there gender differences in academic medical career aspirations related to research, mentoring and discrimination? A national cross-sectional study of French medical residents - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice BMJ Open . 2026 May 29;16(5):e116972. doi: 10.1136/bmjopen-2026-116972 Are there gender differences in academic medical career aspirations related to research, mentoring and discrimination? A national cross-sectional study of French medical residents Aurore Deledalle 1, ✉ , Anne Congard 1 , Valentine Bour 1 , Élisa Sarda 1, 2 , Fleur Cohen 3 , Pierre-Antoine Gourraud 4 , Patricia Lemarchand 5 Author information Article notes Copyright and License information 1 Nantes Université, Univ Angers, Laboratoire de psychologie des Pays de la Loire, LPPL, UR 4638, F-44000 Nantes, France 2 L-VIS Laboratory of Vulnerabilities and Innovation in Sport (UR 7428), Université Claude Bernard Lyon 1, Lyon, France 3 Assistance publique Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, service de médecine interne 2, centre des maladies infectieuses et immunologique INSERM UMRS 1135, Sorbonne Université, Paris, France 4 Nantes Université, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11: Santé Publique, Clinique des données, CHU de Nantes, Nantes, Pays de la Loire, France 5 Nantes Université, CHU Nantes, CNRS, INSERM, l’institut du thorax, Nantes F-44000, France Supplemental material: Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. ✉ Dr Aurore Deledalle; Aurore.Deledalle@univ-nantes.fr PAG is the founder of Methodomics (2008) and its spin-off Big Data Santé (2018; Octopize brand). He reports consulting activities for pharmaceutical companies and start-ups, all conducted through academic pipelines (including AstraZeneca, Amgen, Biogen, Boston Scientific, Cemka, Cepton, Cook, Docaposte/Heva, Edimark, Ellipses, Elsevier, Grünenthal, Hemovis, Janssen, IAGE, Lek, Merck, Mérieux, Novartis, Sanofi-Genzyme, Lifen, TuneInsight and Aspire UAE). He is also a volunteer board member of AXA, a not-for-profit mutual insurance company Received 2026 Jan 16; Accepted 2026 May 15; Collection date 2026. Copyright © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/ . PMC Copyright notice PMCID: PMC13223669  PMID: 42215261 Abstract Abstract Objectives Academic medical careers remain marked by persistent gender inequalities, despite the growing feminisation of the medical workforce. The objective of this study was to examine whether gender differences exist in key individual and institutional determinants of academic medical career aspirations among medical residents, including research motivation, mentoring, work centrality, self-efficacy, perceived discrimination and stress. Design This was a national cross-sectional online survey. Setting Multicentre study conducted across 36 medical schools in France. Participants A total of 1570 medical residents (997 women and 573 men) voluntarily participated between November 2022 and February 2023. All participants completed validated self-report questionnaires. There were no exclusion criteria beyond being enrolled in a French residency programme. Primary and secondary outcome measures Attitudes towards research (interest, motivation, significance) were measured using the Scale of Attitudes towards Research. Mentoring was assessed with the Mentor–Mentee Perception Questionnaire, work centrality with Hirschfeld and Feild’s scale, self-efficacy with the General Self-Efficacy Scale, perceived discrimination with the Sexual Harassment and Discrimination Experiences of Academic Medical Faculty instrument and stress with the Perceived Stress Scale. Gender differences were analysed using t-tests or χ² tests with Holm-Bonferroni corrections for multiple comparisons. Results Compared with men, women reported lower research motivation (mean (SD) 21.0 (5.5) vs 22.8 (5.5); p adj =0.011), lower research interest (27.1 (5.5) vs 28.1 (5.7); p adj =0.011), lower work centrality (26.7 (7.0) vs 28.2 (8.1); p adj =0.011) and lower self-efficacy (28.3 (5.2) vs 29.9 (5.0); p adj =0.011). Women were less likely to report having a mentor (38.5% vs 44.5%; p adj =0.02). They also reported substantially higher levels of experienced gender discrimination (22.8% vs 3.8%; p adj =0.005), sexual harassment (57.7% vs 18.2%; p adj =0.005) and perceived stress (8.48 (3.29) vs 7.27 (3.43); p adj =0.011) Conclusions Gender differences were observed across several individual and institutional factors associated with academic medical career aspirations. Reduced access to mentoring and greater exposure to discrimination and stress among women may contribute to lower research motivation and self-efficacy. These findings highlight the need for institutional strategies addressing mentoring, workplace culture and equity to support gender parity in academic medicine. Registration OSF preregistration for this study is available at https://osf.io/9yseq/?view_only=1c72743f542b402ba67beed6908e597d Keywords: MEDICAL EDUCATION & TRAINING; Schools, Medical; STATISTICS & RESEARCH METHODS; Stress, Psychological STRENGTHS AND LIMITATIONS OF THIS STUDY. Large national sample including residents from 36 medical schools across France. Use of validated instruments covering multiple psychosocial and institutional determinants. This study was a cross-sectional design, and thus, causality cannot be inferred. Voluntary participation may have introduced selection bias. Introduction Many studies show that interest in academic careers in medicine is declining. The most significant indicator of the declining state of academic medicine is the observed decrease in recruitment to clinical academic positions over the past decade. 1 2 Given international concern about the need to revitalise academic medicine, a better understanding of the appeal of and obstacles to choosing a medical career is needed. Alongside this academic decline, the medical profession worldwide continues to become increasingly feminised. This feminisation of the workforce is well documented, yet women remain under-represented in several medical and surgical specialties and among faculty members. 3 4 Several authors have examined factors influencing the choice of an academic career in medicine by gender. 5 , 9 Their results seem to converge on certain factors. For example, women would have fewer opportunities to participate in research activities and publish in useful rank. 10 Additionally, they would less frequently have access to mentors or role models. 11 12 However, the effectiveness of this mentoring is not clearly established. 11 Men express a greater interest in pursuing research than women, partly due to factors such as mentorship and support with research projects. 13 Finally, women would more often experience gender discrimination. 14 15 Academic medicine has traditionally been influenced by male predominance, and beliefs about effective leadership are typically associated with male-related traits. 14 15 A glass ceiling effect is observed despite no difference in scientific output or marital and parental status between male and female academics. 16 However, the results between studies are sometimes more inconsistent on other factors, 5 particularly on women’s interest in research and the importance they attach to their professional lives. Some studies have suggested that women are less likely to express interest in research activities, with men tending to favour object-oriented fields and women being more drawn to people-oriented occupations such as nursing, caregiving or counselling. 17 18 However, such interpretations often reflect enduring gender stereotypes about vocational interests rather than inherent preferences. Other studies have suggested that women may place greater emphasis on achieving work-life balance than men, 19 which could contribute to their lower representation in academic medical careers. These careers are often characterised by long working hours and expectations for productivity and commitment. Work centrality, defined as the importance individuals attach to work as a central life interest, 20 has been proposed as a relevant explanatory variable, with several studies reporting that women tend to place greater importance on family life compared with men. 12 Reasons for these discrepancies in empirical studies are numerous 5 : previous studies had heterogeneous study designs, variables and outcome definitions, precluding production of a quantitative synthesis of the evidence. Most of them had methodological limitations, for example, limited number of participants which could have affected the trustworthiness of the findings. Despite a growing body of literature on gender differences in academic medicine, several limitations remain. Existing studies often focus on a limited number of factors in isolation, use heterogeneous designs and measures and are frequently based on small or single-institution samples. As a result, there is a lack of large-scale, comprehensive analyses simultaneously examining multiple individual and institutional determinants of academic career aspirations, particularly among medical residents. Understanding gender differences in residents’ aspirations towards academic careers may help identify strategies to improve gender diversity in recruitment. In this study, an academic medical career refers to a physician position combining clinical practice with academic responsibilities, including research and/or teaching activities within a university hospital setting (eg, assistant or full professor positions). The objective of our study is to carry out a large-scale quantitative survey (multi-centric, cross-sectional survey) of residents to examine gender differences in several variables identified in the literature but whose relevance remains under debate: attitude to research, perception of mentoring, work centrality and perception of discrimination. Based on knowledge from the psychology of guidance, we also consider self-efficacy, 21 a key construct in career decision-making models, which refers to individuals’ belief in their own ability to achieve desired goals. 7 22 Finally, we examine whether increased stress, potentially related to the deterioration of working conditions in recent years, 23 may also contribute to understanding gender differences in academic career aspirations. Methods This survey is part of the PULWAR research programme (PUsh and pulL factors to the involvement of young Women physicians in medical Academic caReers), which aims to investigate multiple determinants of academic career choices in medicine ( https://pulwar.hypotheses.org/ ). The present study corresponds to a specific cross-sectional component of this broader project, focusing on gender differences in selected psychosocial and institutional factors (research attitudes, mentoring, work centrality, self-efficacy, perceived discrimination and stress) among French medical residents. While the online supplemental original protocol describes a wider range of research questions and planned analyses, only the variables relevant to the present objectives are reported here . The survey was approved by the Ethics Committee of Nantes University on 1 September 2022 (reference n°26072022). The research has been pre-registered on the OSF platform ( https://osf.io/9yseq/?view_only=1c72743f542b402ba67beed6908e597d ) and the data management plan is public ( https://dmp.opidor.fr/plans/15822 ). The study is reported in accordance with the Consensus-Based Checklist for Reporting of Survey Studies (CROSS) guidelines. The completed checklist is provided as online supplementary file 1 . Survey instrument The questionnaire used in this study is provided as online supplementary file 2 . It was developed by a multidisciplinary team including researchers in psychology, sociology, medicine and epidemiology, based on a review of the literature on determinants of academic medical career choice. The final survey combined socio-demographic and training-related questions specifically developed for this study with several previously published and validated instruments assessing key psychosocial and institutional factors related to academic career aspirations . It covers a range of areas that have been identified in the literature as supporting the choice of an academic medical career (attitude towards research, perception of mentoring, work centrality, perceived self-efficacy) or, on the contrary, as barriers to this career choice (perceived discrimination and stress). The attitudes adopted to research are measured using the Scale of Attitudes towards Research, 24 by selecting only those subscales that are relevant to individuals who may or may not have been involved in research activities (interest (eight items), significance (six items), motivation (seven items)). Each item is scored from 1 (strongly disagree) to 5 (totally agree). Total scores for each subscale were computed, with higher scores indicating more positive attitudes (possible range: interest 8–40, significance 6–30, motivation 7–35). Perception of mentoring is evaluated with the questionnaire capturing mentors’ and mentees’ perceptions and expectations of the mentoring process developed by Heeneman and de Grave, 25 which includes 38 items organised into five dimensions (stimulating reflection, quality of presence, sharing of personal situations, support for change and support for the development of professional identity) and is only completed by participants who answer ‘yes’ to the preliminary question ‘do you have a mentor?’. In this study, mentoring was defined broadly as the presence of a mentor identified by the participant as a knowledgeable and experienced individual who provides guidance, support, or serves as a role model. This definition encompasses both formal and informal mentoring relationships. Items are rated on a Likert scale, with higher scores indicating more positive perceptions of mentoring; no overall composite score was used in the present analysis. To assess work centrality, the survey also includes a 12-item scale derived from the instrument developed by Hirschfeld and Feild 26 ; each item is rated on a Likert scale, yielding a total score ranging from 12 to 60, with higher scores indicating greater work centrality. Self-efficacy beliefs were measured with the General Self-Efficacy Scale 27 in the French-language version. 28 It is a 10-item self-reported instrument that asks participants to rate from 1 (not at all true) to 4 (exactly true) the degree of agreement with items reflecting optimistic self-beliefs. The total score ranges from 10 to 40, with higher scores indicating greater self-efficacy. Perception of discrimination is evaluated with the Sexual harassment and discrimination experiences of academic medical faculty instrument, 29 items on gender bias (both perceived in the environment and personally experienced), gender advantage and sexual harassment were included. Items were analysed individually as binary variables (yes/no), and no composite score was computed. Finally, the short-version of the Perceived Stress Scale in the French-language form 30 is used for assessing the degree to which situations in one’s life are appraised as stressful. People are asked to rate on a 5-point scale the extent to which they experienced each of the listed feelings and thoughts, in the past month (from 0=never to 4=very often). A total score of the PSS is obtained by summing the 4 items’ scores. The total score ranges from 0 to a maximum of 16, a higher score indicating a higher level of perceived stress. Socio-demographic data were also collected (gender, age, course year, field of training and university of origin). The questionnaire as a whole was not designed as a single psychometric instrument; rather, it assembled several validated scales alongside study-specific descriptive questions. Validation evidence for each standardised instrument is provided in the corresponding references. Population All residents affiliated to French medical schools were eligible for this study. There were no exclusion criteria beyond not providing informed consent or not completing the questionnaire. Participants were recruited through social media, using online advertisements or email. In addition, the survey was promoted and relayed by 30 of the 36 deans of medical faculties in France. Participants did not receive any remuneration. The survey was conducted from November 2022 to February 2023 and completed anonymously via Lime Survey. Prior to participation, all respondents were provided with an online information sheet and gave informed consent electronically before completing the questionnaire. Sample size was determined pragmatically, based on voluntary participation and wide national dissemination of the survey across French medical schools. No formal a priori sample size calculation was performed. However, the final sample (n=1570) provided sufficient statistical power to detect small effect sizes in gender comparisons, given the use of two-sided tests and correction for multiple comparisons. Due to the open recruitment strategy and the absence of reliable national data on the total number of residents by gender during the study period, a response rate could not be calculated. Patient and public involvement statement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research. Participants were medical residents, and no specific patient or public involvement framework was implemented in this study. Statistical analysis Analysis codes and a synthetic dataset 31 are available at https://osf.io/cmeb8/?view_only=994c4caf23c744858f00a1260469395a The dataset was generated with Octopize.Avatar (V.1.0.3Octopize, 2023) to replicate the original data structure while ensuring anonymity. 32 Descriptive analysis was assessed for all collected variables. The enrolled residents were described according to the main socio-demographic variables (gender, age, parental status, etc). Then, gender comparisons of means (t-test) or of frequencies (χ²) were made for each of the variables studied in the survey. Effect sizes were also computed to compare genders: For Cohen’s d, a value around 0.2 was considered to indicate a weak effect, around 0.5 a moderate effect and around 0.8 a large effect. 33 For Cramer’s V, the closer the value is to 1, the stronger the association between the variables. We applied the Holm-Bonferroni correction 34 to adjust for multiple comparisons. Adjusted p values (p adj ) are reported accordingly. Corrections were conducted separately for t-tests and χ 2 analyses, as they represented distinct families of tests. Results Participants A total of 1570 residents participated voluntarily in the study, including 997 women and 573 men ( table 1 ). Participants’ ages ranged from 22 to 48 years (mean (SD), 27.3 (2.61) years). Most respondents reported not having children (93.6%). Participants from different years of residency were represented. Geographically, more than one-quarter of respondents were based in the Île-de-France region (26.6%), which refers to the area around Paris. Table 1. Main characteristics of the sample (n=1570). Variables Frequency (%) Gender Women=63.5% Men=36.5% Parental status No children=93.6% One or more=4.1% Medical school location Other=73.4% Paris area=26.6% Year of residency 1=18.7% 2=21.0% 3=22.9% 4=23.9% 5=13.6% Age Mean (SD) Min–max Skewness Kurtosis 27.3 (2.61) 22–48 2.31 11.1 Open in a new tab Our objective was to examine gender differences in variables potentially predictive of pursuing an academic career in medicine. Men and women similarly recognised the importance of research (mean (SD), 19.9 (4.76) vs 19.4 (4.53); p adj =0.39), but men reported higher motivation (22.8 (5.52) vs 21.0 (5.54); p adj =0.011) and greater interest in research (28.1 (5.67) vs 27.1 (5.45); p adj =0.011). Mentoring perception scores did not differ significantly between women and men (all adjusted p values>0.05), although fewer women reported having a mentor than men (384 (38.5%) vs 255 (44.5%); p adj =0.02). Women placed less emphasis on work centrality (26.7 (6.97) vs 28.2 (8.09); p adj =0.011) and reported lower self-efficacy (28.3 (5.17) vs 29.9 (5.01); p adj =0.011) than men. They also reported higher levels of discrimination, including gender bias (227 (22.8%) vs 22 (3.8%); p adj =0.005) and harassment (575 (57.7%) vs 104 (18.2%); p adj =0.005), as well as greater stress during residency (8.48 (3.29) vs 7.27 (3.43); p adj =0.011). All comparisons are shown in table 2 . Table 2. Research attitudes, mentoring perceptions, job centrality and career stressors by gender. Measure Women mean (SD) Men mean (SD) P adj holm Effect size Research attitude Interest 27.1 (5.45) 28.1 (5.67) 0.011 d =0.19 Motivation 21.0 (5.54) 22.8 (5.52) 0.011 d =0.33 Work centrality 26.7 (6.97) 28.2 (8.09) 0.011 d =0.21 Self-efficacy 28.3 (5.17) 29.9 (5.01) 0.011 d =0.32 Stress 8.48 (3.29) 7.27 (3.43) 0.011 d =−0.36 Mentoring Has mentor? No (%) 384 (38.5) 255 (44.5) 0.02 V =0.06 Discrimination Perceived gender bias No (%) 587 (58.9) 232 (40.5) 0.005 V =0.18 Experienced bias No (%) 227 (22.8) 22 (3.8) 0.005 V =0.25 Experienced harassment No (%) 575 (57.7) 104 (18.2) 0.005 V =0.38 Open in a new tab n=997 women, 573 men. Only variables with significant adjusted p values are shown. Discussion This study identified factors associated with gender differences in intentions to pursue an academic career. Female residents reported less support and more obstacles than men, including differences in mentoring, perceived discrimination, work centrality, research interest, self-efficacy and stress, with effect sizes ranging from small to medium. The most salient results concern perceived discrimination, with female residents reporting particularly high and worrying levels. Such experiences may play a critical role in career choice, as everyday sexism has been shown to reduce self-esteem and self-efficacy, 35 an effect reflected in our sample, where women reported lower self-efficacy than men. However, given the cross-sectional design of the study, these findings should be interpreted as associations rather than causal relationships. Lower self-efficacy may reflect the impact of repeated exposure to discrimination rather than constituting a causal factor influencing career aspirations. An earlier study conducted in 2006–2009 on a sample of 1066 new K-awards recipients, 29 in which 30.4% of women reported sexual harassment, 57.7% of women in our study reported similar experiences. While these findings highlight a substantial prevalence, it remains unclear whether the rate has increased over the past decade or whether the situation in France is particularly alarming. These results warrant further exploration through qualitative research and should inform initiatives aimed at promoting academic careers in medicine among women. Similarly, women in our study reported having a mentor less often than men. Previous studies have demonstrated the positive impact of role models on various career outcomes. 36 According to social learning theory, 37 individuals seek role models similar to themselves, assuming that the experiences of these models are also applicable to them. With fewer women in leadership positions, there are consequently fewer female role models and mentors available, which may contribute to lower self-efficacy in demonstrating research skills among women. These results align with a recent study of medical school deans 38 which documented clear gender disparities in career advancement. Men often received early mentorship and structured opportunities that guided them toward leadership roles and fast-tracked their progress. In contrast, women rarely benefited from such support, with advancement dependent largely on personal effort rather than sponsorship. Research on the development of professional interests often invokes gender socialisation to explain the persistence of gendered occupations. 39 Such socialisation can foster implicit gender biases. 40 These biases refer to the automatic, unconscious association of gender with specific traits, roles, or career paths. For example, a recent study on postgraduate training shows that women and residents have internalised these biases more than men and clinical trainers. 41 Looking at implicit biases can help improve conditions for women in residency programmes, but this approach has limitations. 42 While it raises awareness and promotes self-reflection on unconscious discrimination, focusing primarily on individual biases may obscure the structural, cultural and institutional roots of gender inequality. Taken together, these findings provide a nuanced understanding of the gendered mechanisms that shape residents’ career aspirations in academic medicine. They highlight the role of both individual and institutional factors in shaping career aspirations. These findings have important implications for policies aimed at promoting gender equity in academic medicine. The observed gender differences point to the central role of institutional factors. In particular, the high levels of reported gender discrimination and harassment suggest that workplace culture and climate may discourage women from engaging in academic careers. Addressing these issues requires institutional efforts to reduce discriminatory practices and foster more inclusive and supportive environments. Ensuring equitable access to mentoring also appears critical, as fewer women reported having a mentor despite similar levels of perceived mentoring support. This highlights the need for structured and transparent mentoring systems to reduce inequalities in access. This study has several limitations. Its cross-sectional design prevents any causal inference, and the observed relationships should be interpreted as associations rather than causal effects. Voluntary participation may have introduced selection bias, as residents more sensitive to gender issues might have been more likely to respond. All data were self-reported, which may entail social desirability bias. While validated instruments were used, complex constructs such as mentoring or discrimination may not be fully captured through quantitative measures alone; qualitative research could help contextualise these findings. Although more complex modelling could further explore relationships between variables, we prioritised a comprehensive and transparent descriptive approach. Future studies using multivariate analyses would be valuable to better understand the mechanisms underlying these associations. Finally, further research could benefit from a more detailed characterisation of mentoring relationships, including mentor gender and the distinction between formal and informal mentoring, to better understand their role in shaping career aspirations. In conclusion, our results indicate that gender inequities in academic career aspirations persist despite the feminisation of the medical workforce. Women residents report lower research motivation and self-efficacy, less access to mentoring and higher exposure to discrimination and stress. These findings underscore that improving gender equity requires more than individual awareness—it calls for systemic interventions such as structured mentoring programmes, transparent recruitment and promotion processes and institutional initiatives that support work–life balance. Advancing gender equity in academic medicine is not only a matter of fairness but also essential for sustaining innovation, excellence and diversity in medical education and research. Original protocol for the study The original study protocol, including the study objectives, design, instruments and planned analyses, is available as a supplementary file and was preregistered on the Open Science Framework ( https://osf.io/9yseq/?view_only=1c72743f542b402ba67beed6908e597d ). Supplementary material online supplemental file 1 bmjopen-16-5-s001.docx (20.2KB, docx) DOI: 10.1136/bmjopen-2026-116972 online supplemental file 2 bmjopen-16-5-s002.docx (18.9KB, docx) DOI: 10.1136/bmjopen-2026-116972 online supplemental file 3 bmjopen-16-5-s003.docx (41.3KB, docx) DOI: 10.1136/bmjopen-2026-116972 Acknowledgements The authors would like to thank Sandrine Garin for her valuable support throughout the project. We also sincerely thank all the medical residents who participated in this study. Footnotes Funding: This work was supported by the French National Research Agency (ANR-21-CE41-0028). Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online ( https://doi.org/10.1136/bmjopen-2026-116972 ). Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent for publication: Not applicable. Ethics approval: This study involves human participants. The survey was approved by the Ethics Committee of Nantes University on 1 September 2022 (reference n°26072022). Participants gave informed consent to participate in the study before taking part. Data availability free text: In line with principles of transparency, openness and reproducibility, de-identified synthetic data and statistical analysis code supporting the findings of this study are publicly available on the Open Science Framework (OSF) at https://osf.io/cmeb8/overview . 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Supplementary Materials online supplemental file 1 bmjopen-16-5-s001.docx (20.2KB, docx) DOI: 10.1136/bmjopen-2026-116972 online supplemental file 2 bmjopen-16-5-s002.docx (18.9KB, docx) DOI: 10.1136/bmjopen-2026-116972 online supplemental file 3 bmjopen-16-5-s003.docx (41.3KB, docx) DOI: 10.1136/bmjopen-2026-116972 Data Availability Statement Data are available in a public, open access repository. Articles from BMJ Open are provided here courtesy of BMJ Publishing Group ACTIONS View on publisher site PDF (480.0 KB) Cite Collections Permalink RESOURCES Similar articles Cited by other articles Links to NCBI Databases Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top

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