Labor shortage of physicians in rural areas and surgical specialties caused by Work Style Reform Policies of the Japanese government: a quantitative simulation analysis

Abstract

Objective

The Japanese government’s physician workforce reform, which commenced in April 2024, introduced regulations on physicians’ working hours. However, in areas facing physician shortages such as rural regions and surgical medical specialties, healthcare provision relies heavily on the extended working hours of each physician. The anticipated impact of this reform, when implemented, was significant.

Materials and Methods

Using publicly available government data, we estimated the current working hours of physicians in various medical specialties in each prefecture across Japan. Subsequently, we calculated the ratio of surplus or deficit physicians when hypothetically assuming that all physicians adhered to the regulatory upper limit of 58.4 working hours per week nationwide.

Results

Assuming that all physicians work to the regulated maximum, there would be a shortage of doctors in various medical specialties across Japan, such as surgery, neurosurgery, orthopedic surgery, obstetrics and gynecology, and emergency medicine. Geographically, shortages of doctors are observed in rural prefectures such as those in the Tohoku region, particularly in emergency- and surgery-related specialties, indicating a critical shortage of physicians in rural areas. Additionally, it has become evident that even in medical specialties with a calculated surplus of physicians nationwide, the margin of surplus is generally only a few percentage points.

Conclusion

Currently, rural areas and surgical medical specialties in Japan have limited leeway in the physician workforce, and the strict application of workforce reform may lead to a severe shortage of physicians in these areas. It is noteworthy that as similar reforms may subsequently be implemented in other countries, analogous challenges would arise. Thus, the implementation of workforce reform requires a flexible approach to minimize its negative effects, which widen the existing disparity in the workforce.

Introduction

The geographical maldistribution of physicians and disparities in the workforce across medical specialties, including severe shortages in rural areas and clinical fields, are prevalent societal issues in numerous countries worldwide¹⁾. In areas facing physician shortages, healthcare infrastructure often leans heavily on the selfless dedication of current practitioners to maintain its functionality. Regulatory reforms targeting physicians’ working conditions, especially those governing physicians’ working hours, have inherent risks of unsettling the fragile human resource infrastructure of healthcare provision.

Conversely, the challenging working conditions endured by many physicians, characterized by extended working hours and strenuous labor, are widely acknowledged in Japanese society. People’s concerns about this issue extend beyond the individual work-life balance of physicians to potential repercussions for the quality and safety of healthcare. Therefore, establishing appropriate working hours for physicians is of paramount importance in developing a stable and secure healthcare supply system. In light of this backdrop, initiatives are being undertaken by the government to reform work conditions for healthcare workers. These measures, introduced through amendments to the Labor Standards Laws and related regulations, aim to secure compensatory rest, establish substantive upper limits on working hours for physicians, and ensure a conducive working environment²⁾. Specific strategies to address physicians’ overtime work include formulating reduction plans for their working hours at healthcare institutions, creating a special exemption system sanctioned by prefectural governors for healthcare facilities that unavoidably exceed higher-hour limits to maintain regional healthcare, and implementing health assurance measures within such facilities.

Notably, among these measures, significant attention has been drawn to plans to reduce physicians’ working hours. Fundamentally, beginning April 2024, all physicians are allowed annual overtime work of up to 960 hours, provided that monthly hours fall below 100 hours. If these limits are exceeded, healthcare institutions are mandated to conduct face-to-face guidance with the concerned physicians and implement improvements in the working environment. Furthermore, income from compensatory rest is an obligatory requirement²⁾. If we convert the annual working hours of 960 hours into weekly working hours, this is approximately 58.4 hours per week. Some advanced nations, such as the UK and France, have already implemented such restrictions, stipulating that physicians should not exceed 48 hours of work per week²⁾.

However, the reality within Japan’s and probably many other countries’ medical landscapes reveals a notable discord between this ideal and the current state of affairs. As reported, over 40% of physicians are working more than 60 hours per week, and this divergence expected to be more pronounced in areas facing severe physician shortages, such as rural regions and surgical specialties. Additionally, around 90% of university hospitals in Japan, which often house a substantial number of young physicians, have expressed concerns that this reform may influence research productivity and the development of younger medical professionals³⁾.

In light of this, physician workforce reform has the potential to cause significant upheaval in the healthcare sector. Nevertheless, quantitative reports detailing the extent of disparities in physician working hours by region and medical specialty, and predictions of potential physician shortages under the rigorous application of workforce reform remain scarce. Such research is indispensable for accurately forecasting the impact of physician workforce reform on healthcare practices and planning the implementation of practical policies aligned with reality. Furthermore, this information could prove invaluable to foreign nations contemplating similar reforms.

Consequently, this study utilized government-released data on the number of physicians categorized by region, age, medical specialty, and actual working hours. It aims to determine the extent of the surplus or deficit in physician working hours and the number of physicians calculated from the working hours when applying the working-hour regulations introduced as part of the workforce reform commencing in April 2024. Special focus is placed on physicians’ working hours in underserved areas and surgical specialties, which have long faced the issue of physician shortages. Based on these findings, this study examines the feasibility and potential impact of the proposed workforce reform on rural and surgical healthcare provisions.

Materials and Methods

In this study, by repurposing publicly available government statistical data on the number of physicians and their working hours, we calculated the surplus or deficit in Japanese physicians in various categories. These include medical specialties, prefectures, and medical specialties within each prefecture. The surplus or deficit of physicians was calculated under the assumption that all physicians worked under a weekly working hour limit of 58.4 hours²⁾, and the basis for calculating this is as follows.

In the context of workstyle reform, the annual overtime limit was set at 960 hours, which translates to 80 hours per month. Assuming each physician works up to the maximum of 80 hours of overtime per month, and considering the standard weekly working hours of 40 hours, and an average of 4.34 weeks per month, the weekly working hours (i.e., 58.4 hours) for each physician were calculated by adding the quotient of dividing 80 hours by 4.34 to the 40-hour basic working hours.

Within workforce reform, overtime regulations were established at three different levels²⁾. First, the A-level sets the annual limit for overtime work at 960 hours, with a maximum of 100 hours per month. This level is widely applicable in general healthcare institutions and was thus used as the standard in our study analysis. Second, the B-level serves as a transitional measure to ensure medical care in areas facing physician shortages. At this level, the annual limit for overtime work is 1,860 hours, with a maximum of 100 hours per month. Third, the C-level is aimed at specific healthcare facilities dedicated to educating clinical skills and shares the same overtime regulations as the B-level. Both the B- and C-levels are considered transitional measures, with the expectation that all physicians will eventually be subject to the A-level.

Data on national-level physicians’ working hours, categorized by medical specialty, sex, and age, were drawn from a survey conducted by the Ministry of Health, Labour and Welfare’s Medical Policy Division’s Workstyle Reform Promotion Office, titled “Research on Demand and Supply Based on Working Practices Considering Physician Specialization”⁴⁾. As for the data on physicians’ working hours at the prefecture level, it was extracted from the “Labor Statistics Survey”⁵⁾ conducted by the Ministry of Health, Labour and Welfare. Specifically, data were obtained from the “Medical and Welfare” section of this survey, which reports the average actual working hours per day for each person. It is noteworthy that the results of the Medical and Welfare Survey encompassed the working hours of all healthcare professionals, including physicians. The primary data on the number of physicians by major medical specialty were sourced from the “Physicians, Dentists, and Pharmacists Statistics for the Year”⁶⁾ published by the Ministry of Health, Labour and Welfare.

Using these data, which are publicly available through the Japanese government’s online portal for official statistics, we used Microsoft Excel for spreadsheet calculations. We computed the difference between the weekly working hours of physicians and the upper limit of working hours at both national and regional levels. Further analysis determined the surplus or deficit of physicians, as well as the surplus or deficit of working hours per physician, assuming that all physicians worked under the allowable maximum working hours mentioned above. Additionally, we conducted calculations to determine the surplus or deficit in physician numbers by medical specialty for each prefecture, and the surplus or deficit in working hours per physician in each medical specialty within a single prefecture. These calculations were performed using the following formulas.

Estimated working hours in each medical specialty was calculated as (average physician working hours) × (average working hours for the specialty) / (average working hours for all specialties). The estimated working hours for each specialty in each prefecture were calculated as (estimated working hours for the specialty) × (average working hours for the prefecture) / (average working hours for all prefectures). The surplus or deficit in weekly working hours was computed as (weekly maximum working hours under the reform) × (number of physicians) × (estimated working hours × number of physicians).

Owing to space constraints, this study exclusively presents the prefecture-level working hours in each specialty for three prefectures: Aomori, which boasts the longest average working hours; Kyoto, which features the shortest working hours; and Hiroshima, where the results are on an average level among all the prefectures.

The data regarding the number of physicians categorized by gender, age group, and medical specialty were sourced from the “Medical, Dental, and Pharmacist Statistics”⁶⁾. However, to simplify the analysis and consolidate certain medical specialties, the following aggregates were made in the dataset: Respiratory medicine, cardiology, gastroenterology, nephrology, neurology, endocrinology, and hematology were combined into a single category referred to as “internal medicine”. Psychiatry and psychosomatic medicine were grouped into the category “psychiatry”. Pulmonary surgery, cardiac surgery, breast surgery, thoracic and esophageal surgery, gastrointestinal surgery, and coloproctology were consolidated into the category “surgery”. Obstetrics, gynecology, and perinatology were combined into the category “obstetrics and gynecology”.

Results

Table 1 presents the number of physicians in various medical specialties nationwide, their working hours, and whether there is a surplus or shortage of physicians and working hours.

Table 1. Number of physicians by specialty, working hours, and the shortage or excess of physicians and working hours.

Specialty	Number of physicians	Working hours	Shortage/Excess of hours (%)	Shortage/Excess of personnel (%)
Internal medicine	61,514	56.22	0.04	0.04
Dermatology	9,869	53.85	0.09	0.08
Pediatrics	17,997	54.25	0.08	0.07
Psychiatry	16,490	47.83	0.22	0.18
Surgery	13,211	61.9	−0.06	−0.06
Urology	7,685	56.98	0.03	0.02
Neurosurgery	7,349	61.87	−0.06	−0.06
Orthopedic surgery	22,520	58.83	−0.01	−0.01
Plastic surgery	3,003	54.48	0.07	0.07
Ophthalmology	13,639	50.47	0.16	0.14
Otorhinolaryngology	9,598	55.03	0.06	0.06
Obstetrics and gynecology	11,219	58.78	−0.01	−0.01
Rehabilitation medicine	2,903	50.4	0.16	0.14
Radiology	7,112	52.9	0.1	0.09
Anesthesiology	10,277	54.1	0.08	0.07
Pathology	2,120	52.81	0.11	0.1
Clinical laboratory	631	46.17	0.27	0.21
Emergency medicine	3,950	60.95	−0.04	−0.04

Assuming that all physicians worked up to the maximum limit allowed by the workstyle reform, there was a shortage of the medical workforce in specialties such as surgery, neurosurgery, orthopedic surgery, obstetrics and gynecology, and emergency medicine. In contrast, other specialties, such as internal medicine and urology, do not show a shortage of workforce with the current number of physicians but enjoy only a few percentage points of surplus regarding both physician numbers and working hours, indicating minimal flexibility of work style in these specialties.

Table 2 presents the surplus or shortage of physicians and working hours in each prefecture. The shortage in the total number of physicians in the Aomori Prefecture was the worst among all prefectures, and some prefectures in the Tohoku, northern Kanto, and Hokuriku regions also suffered shortages. Even in prefectures with a surplus of physicians and working hours, the surplus was only a few percentage points.

Table 2. Number of physicians, working hours, and the shortage or excess of physicians and working hours by prefecture.

Prefecture	Number of physicians	Adjusted working hours	Shortage/Excess of hours (%)	Shortage/Excess of personnel (%)
Hokkaido	13,129	53.9	0.08	0.08
Aomori	2,631	61.6	−0.05	−0.05
Iwate	2,509	58.2	0	0
Miyagi	5,669	59.1	−0.01	−0.01
Akita	2,328	60.8	−0.04	−0.04
Yamagata	2,448	59.9	−0.02	−0.03
Fukushima	3,770	60.8	−0.04	−0.04
Ibaraki	5,555	59.9	−0.02	−0.03
Tochigi	4,580	59.1	−0.01	−0.01
Gunma	4,534	59.9	−0.02	−0.03
Saitama	13,057	55.6	0.05	0.05
Chiba	12,935	53.9	0.08	0.08
Tokyo Metropolis	45,078	57.4	0.02	0.02
Kanagawa	20,596	58.2	0	0
Niigata	4,497	59.1	−0.01	−0.01
Toyama	2,706	54.8	0.07	0.06
Ishikawa	3,302	57.4	0.02	0.02
Fukui	1,978	59.9	−0.02	−0.03
Yamanashi	2,026	53.9	0.08	0.08
Nagano	4,994	57.4	0.02	0.02
Gifu	4,442	51.4	0.14	0.12
Shizuoka	7,972	57.4	0.02	0.02
Aichi	16,925	57.4	0.02	0.02
Mie	4,100	59.1	−0.01	−0.01
Shiga	3,340	56.5	0.03	0.03
Kyoto	8,576	50.5	0.16	0.14
Osaka	25,253	58.2	0	0
Hyogo	14,540	52.2	0.12	0.11
Nara	3,670	58.2	0	0
Wakayama	2,840	54.8	0.07	0.06
Tottori	1,742	56.5	0.03	0.03
Shimane	1,994	59.1	−0.01	−0.01
Okayama	6,045	54.8	0.07	0.06
Hiroshima	7,478	52.2	0.12	0.11
Yamaguchi	3,491	55.6	0.05	0.05
Tokushima	2,435	53.1	0.1	0.09
Kagawa	2,756	55.6	0.05	0.05
Ehime	3,693	56.5	0.03	0.03
Kochi	2,227	55.6	0.05	0.05
Fukuoka	15,915	59.9	−0.02	−0.03
Saga	2,356	59.1	−0.01	−0.01
Nagasaki	4,187	57.4	0.02	0.02
Kumamoto	5,162	55.6	0.05	0.05
Oita	3,227	57.4	0.02	0.02
Miyazaki	2,733	58.2	0	0
Kagoshima	4,504	57.4	0.02	0.02
Okinawa	3,775	60.8	−0.04	−0.04
Average	6,887	57.4	0.02	0.02

Table 3 presents the surplus or shortage of physicians and working hours by medical specialty in Aomori Prefecture (with the most severe shortage), Hiroshima Prefecture (at the medium between shortage and surplus), and Kyoto Prefecture (with the highest surplus). In Kyoto Prefecture, a surplus was observed across all medical specialties, and the extent of the surplus exceeded 10% in many of them; however, in Aomori Prefecture, more than half of the specialties showed a shortage. In particular, surgery, neurosurgery, and emergency medicine faced shortages of over 10%. Hiroshima Prefecture showed a surplus in all specialties, but the degree of surplus was marginal in specialties such as surgery, neurosurgery, and emergency medicine.

Table 3. Number of physicians, adjusted working hours, and the shortage or excess of physicians and working hours by selected prefectures and specialties.

Prefecture		Number of physicians	Adjusted working hours	Shortage/Excess of hours (%)	Shortage/Excess of personnel (%)
Aomori prefecture
	Total	2,631	61.6	−0.05	−0.05
	Internal medicine	936	61.5	−0.05	−0.05
	Dermatology	79	58.9	−0.01	−0.01
	Pediatrics	145	59.3	−0.01	−0.02
	Psychiatry	156	52.3	0.1	0.11
	Surgery	256	67.7	−0.15	−0.16
	Urology	96	62.3	−0.06	−0.07
	Neurosurgery	52	67.6	−0.15	−0.16
	Orthopedic surgery	200	64.3	−0.1	−0.1
	Plastic surgery	18	59.6	−0.02	−0.02
	Ophthalmology	87	55.2	0.05	0.06
	Otorhinolaryngology	83	60.2	−0.03	−0.03
	Obstetrics and gynecology	105	64.3	−0.09	−0.1
	Rehabilitation medicine	15	55.1	0.05	0.06
	Radiology	43	57.8	0.01	0.01
	Anesthesiology	75	59.1	−0.01	−0.01
	Pathology	11	57.7	0.01	0.01
	Clinical laboratory	8	50.5	0.13	0.14
	Emergency medicine	34	66.6	−0.13	−0.14
	Clinical residents	165	62.6	−0.07	−0.07
Kyoto prefecture
	Total	8,576	50.5	0.16	0.14
	Internal medicine	3,027	50.4	0.16	0.14
	Dermatology	244	48.2	0.2	0.17
	Pediatrics	460	48.6	0.19	0.17
	Psychiatry	386	42.9	0.31	0.27
	Surgery	783	55.5	0.06	0.05
	Urology	214	51	0.15	0.13
	Neurosurgery	183	55.4	0.06	0.05
	Orthopedic surgery	549	52.7	0.11	0.1
	Plastic surgery	66	48.8	0.19	0.16
	Ophthalmology	360	45.2	0.26	0.23
	Otorhinolaryngology	285	49.3	0.18	0.16
	Obstetrics and gynecology	318	52.7	0.11	0.1
	Rehabilitation medicine	82	45.2	0.26	0.23
	Radiology	240	47.4	0.22	0.19
	Anesthesiology	272	48.5	0.2	0.17
	Pathology	54	47.3	0.22	0.19
	Clinical laboratory	14	41.4	0.34	0.29
	Emergency medicine	112	54.6	0.08	0.07
	Clinical residents	490	51.3	0.14	0.12
Hiroshima prefecture
	Total	7,478	52.2	0.12	0.11
	Internal medicine	2,769	52.1	0.12	0.11
	Dermatology	213	49.9	0.16	0.15
	Pediatrics	373	50.3	0.16	0.14
	Psychiatry	398	44.3	0.27	0.24
	Surgery	757	57.3	0.02	0.02
	Urology	158	52.8	0.11	0.1
	Neurosurgery	195	57.3	0.02	0.02
	Orthopedic surgery	545	54.5	0.08	0.07
	Plastic surgery	42	50.5	0.15	0.14
	Ophthalmology	310	46.7	0.22	0.2
	Otorhinolaryngology	223	51	0.14	0.13
	Obstetrics and gynecology	268	54.4	0.08	0.07
	Rehabilitation medicine	56	46.7	0.23	0.2
	Radiology	157	49	0.18	0.16
	Anesthesiology	248	50.1	0.16	0.14
	Pathology	32	48.9	0.18	0.16
	Clinical laboratory	11	42.8	0.3	0.27
	Emergency medicine	71	56.5	0.04	0.03
	Clinical residents	339	53	0.1	0.09

Discussion

Assuming that all physicians work equally up to the maximum limit of working hours, there is a shortage of physicians in the emergency medicine and surgical specialties across Japan, whereas other specialties exhibit a surplus of small percentage points. However, the extent of the surplus is highly dependent on the geographic area and medical specialty. It is evident that in rural prefectures such as those in the Tohoku region, particularly in surgical specialties and emergency medicine, there is a severe shortage of physicians, and the existing physicians in such areas are not able to fulfil the current workload under the upcoming reform regulations. These findings indicate that if work-style reform is implemented as it stands, it could lead to significant disruptions, especially in these regions and specialties.

Prior research has reported that over 40% of physicians work more than the maximum limit defined by the work-style reform, which is 60 hours per week²⁾. This substantial discrepancy between harsh working conditions and the surplus of the physician workforce calculated in this study should be given due attention. Physicians’ working patterns vary widely, from those working significantly more than the maximum hourly limit to part-time or even nonclinical roles. It is noteworthy that this study simplifies these individual variations and calculate the working hours as “average”. It is likely that the results of this study underestimated the working hours of full-time physicians on the clinical frontlines. Furthermore, the calculation of physicians’ working hours by prefecture was based on the inter-prefecture gap in working hours for all healthcare professionals, not just physicians, which might not accurately reflect the geographic disparities in physicians’ working hours.

It is speculated that if there had been available data indicating regional disparities in physicians’ working hours, these working hours in each prefecture would have resulted in a more severe shortage than the results of this study. Additionally, the analysis relied on a survey that did not necessarily account for the time spent on research or self-study as part of working hours. Therefore, this study’s findings may underestimate the harshness of the actual working conditions of hospital-based physicians.

However, this study did not consider the potential reduction in physician workload owing to technological advancements or institutional reforms. In the future, advancements and the widespread adoption of artificial intelligence in healthcare settings and task delegation to healthcare assistants may reduce the burden on physicians, leading to a reduction in working hours.

According to a previous survey⁷⁾, efforts are being made in labor hour management optimization and streamlining, task simplification for physicians, assistance or substitution of medical tasks by physicians, realization of telehealth, promotion of team-based healthcare, and effective utilization of online learning and training. Currently, systems such as appointment scheduling, web-based questionnaires, and AI-based optical character recognition (Aiocr) services are widely implemented, with some facilities adopting technologies such as AI-based patient interviews.

Although the introduction of such technologies may lead to a reduction in physician workload, especially in outpatient services and waiting time management, the benefits may not be as significant for emergency care, inpatient care, on-call shifts, and day shifts, which are most affected by physician shortages. Moreover, although task sharing and task shifting are being developed, many tasks still require physician supervision. Therefore, it is necessary to evaluate this study’s results considering both the possibility of underestimating and overestimating physicians’ workload, considering these factors.

The study revealed shortages in the physician workforce in certain rural areas, such as prefectures in the Tohoku region, and in specific medical specialties, with a particular focus on surgery. Considering that this study likely underestimated the physician workforce shortage on the clinical frontline, it can be concluded that these areas and medical fields face severe shortages and overwork. However, resolving these critical situations is challenging because they are influenced by variables that are not easily modifiable in the short term, such as the number of physicians and patient population. Whether work-style reforms can be successfully implemented depends on the extent to which geographical and specialty disparities among physicians can be addressed. These improvements require long-term and sustained policy interventions.

Efforts have been made to address geographical disparities in physician distribution in Japan, such as the introduction of the “regional quota system” for medical schools. This system, which began approximately ten years ago, allocates a portion of medical school admissions to students from regions with physician shortages. Consequently, graduates from this system are more likely than usual physicians to work in rural areas. This approach has been effective and the percentage of medical school students admitted through the regional quota system now accounts for approximately 16% of all medical students. However, it is important to note that this is a short-term outcome, and that the effectiveness of these policies may continue to grow as more students graduate⁸⁾.

In contrast, policies aimed at addressing disparities in medical specialties appear to lag. The establishment of the maximum number of specialist physicians by the Japanese Medical Specialty Board began only recently. More proactive implementation of policies, such as strict regulations on the number of specialist physicians by region and medical specialty, is necessary. With the impending implementation of work-style reforms in 2024, the role of the Japanese Medical Specialty Board will be crucial.

Workstyle reforms for physicians will be implemented by April 2024. As is evident from this study’s findings, aligning the current situation with the system is challenging in many regions and specialties. Therefore, as a transitional measure, the B- and C-levels, with annual maximum overtime and holiday working hours set at 1,860 hours, have been introduced for medical facilities that meet certain criteria¹⁾. This provides an exception that allows extended overtime and holiday work, and many medical facilities are striving to comply with the current situation and systems using these criteria. According to one survey, 34.1% of physicians wished to apply for this special exception⁹⁾. However, this is a temporary measure that will be phased out by 2035, at which point A-level working conditions will apply uniformly to all physicians. Nevertheless, adapting to this system within such a short timeframe in regions or medical specialties facing severe physician shortages is challenging. Furthermore, medical institutions in areas with severe workforce shortages often rely on the dispatch of external physicians, especially from medical facilities in major cities with relatively more physicians. If the work-style reform is strictly applied, the situation could become even more critical because some facilities in major cities are no longer able to send physicians because of regulations. Hence, it is necessary to ensure flexible operation of the regulations based on the actual situation in medical institutions to prevent confusion on the clinical frontline and maintain stable healthcare services for the public. In addition, it is important for other countries to introduce physician working-hour regulations to anticipate similar issues. Our findings can serve as a reference for implementing the necessary measures in regions with physician shortages before introducing reforms in many societies worldwide.

Conclusion

Even in a scenario where all physicians work up to the maximum allowable number of hours, a critical shortage of physicians is already evident in rural areas and some specific medical specialties. Given the challenging working conditions faced by these physicians, Work Style Reform should be implemented with flexibility tailored to the realities of clinical frontlines. The issues revealed by the simulation analyses in this study may provide insights for other countries contemplating the integration of physician workstyle reforms.

Conflict of interest

The authors declare no conflicts of interest regarding this study.

Funding information

This study was conducted as part of a medical research practicum in the Hiroshima University curriculum. No funding was received for this study.

Ethics approval and consent to participate

This study did not require an ethical review or participant consent because of its research design, in which no individualized data were used.

Consent for publication

: All authors have reviewed the final version of the manuscript and consented to its submission for publication in the Journal of Rural Medicine.

Data availability statement

In this study, we utilized publicly available data provided by the government and accessible from sources such as e-statistics and survey conference documents. The data can be obtained from the corresponding author upon reasonable request.

Author contributions

YM played a central role throughout the study, taking charge of the research design, data collection, statistical analysis, and other essential aspects. MM assumed a leadership role in the early stages of the research design, providing literature, offering diverse advice on the study direction, and contributing significantly.