A cross-sectional study of newly established medical schools in the United States: student body diversity remains an unmet challenge

ABSTRACT

Introduction

The number of medical schools in the United States (US) has rapidly increased over the past two decades, but it is unclear if these newer schools better address the needs of a diversifying population. We hypothesized that newer medical schools might be less encumbered by historical processes and power structures and, therefore, more successful in recruiting students more representative of the US population. This study assesses whether medical schools established since 2000 are advancing diversity compared to their predecessors.

Methods

Between October 1 and 14 December 2023, a cross-sectional study was conducted of all US allopathic and osteopathic medical schools that achieved accreditation and enrolled students by December 2023. School characteristics and matriculant demographics were collected from publicly available sources, including the 2022–2023 Medical School Admission Requirements website provided by the Association of American Medical Colleges and the American Association of Colleges of Osteopathic Medicine website. Descriptive statistics compared schools established before and after 2000.

Results

Sixty new medical schools were identified. Thirty-three (55%) are allopathic and 27 (45%) are osteopathic; 40 (66.7%) are private and 20 (33.3%) are public. Allopathic schools are primarily located in urban areas (21/33; 63.6%); osteopathic schools are in suburban areas (16/27; 59.3%). Mean annual tuition costs are $48,782.82 (standard error (SE) 2201.09) and $56,072.37 (SE: 2120.63) for in-state and out-of-state students, respectively. Out-of-state tuition, matriculant grade point average, and Medical College Admissions Test scores are significantly lower in newly established medical schools. More women entered medical school but the number of underrepresented students by race and ethnicity has not made substantial gains and continues to fail to represent the US population.

Conclusions

Geographic maldistribution, high tuition, and lack of student body diversity persist in newly accredited medical schools. Newly established medical schools are perpetuating many existing obstacles to diversifying the US physician workforce.

Introduction

In the face of racial, geographic, and socioeconomic inequities in healthcare access and outcomes and population demographic changes in the United States (US), many medical education experts and national professional organizations agree that medical schools have not met the needs of a rapidly diversifying population and increasingly complex healthcare system [1,2]. Diversifying the physician workforce provides many critical advantages [3]. Non-White physicians disproportionately care for underserved communities, many of whom are Black, Hispanic, and American Indian [4]. All physicians trained in diverse teams, regardless of race or ethnicity, demonstrate improved cultural competence and provide better care for vulnerable populations [5]. Further, gender and racial concordance of patients with their physicians is associated with improved communication, shared decision-making, participation in screening and preventive services, and adherence to treatment plans [6,7]. Patients with racial-concordant physicians also have better health outcomes, lower emergency department use, decreased hospitalization rates, and lower infant mortality [8,9]. Therefore, a racially and ethnically inclusive physician workforce is necessary to address health disparities and improve care for all communities.

For only the second time in 100 years, many new medical schools are developing, and existing schools are significantly increasing their class size. An earlier period of medical school expansion occurred in the 1960s and early 1970s when 40 new schools were accredited by the Liaison Committee on Medical Education (LCME) (a 50% increase), and the number of graduates doubled [10]. No new allopathic (MD-granting) schools were founded until Florida State University College of Medicine enrolled its charter class in 2001 [11]. Osteopathic (DO-granting) medical schools underwent a similar trend beginning in 2003 after only four new osteopathic schools opened in the preceding 2 decades [12]. The goal of the first major post-Flexnerian expansion of medical schools in the 1960s was to increase the physician workforce, which it did primarily by increasing the number of White men. Over 50 years later, and most recently in the wake of the COVID-19 pandemic, there are wider calls to align the demographics of health professionals more closely with the population.

Since acceptance into medical school is the first step in a physician’s career, diversifying the physician workforce requires diversifying the national medical student body. Yet, medical school admissions policies have been criticized for perpetuating barriers for non-White applicants and individuals from lower socioeconomic backgrounds [13]. Current admissions practices overvalue grades and standardized test scores, such as the Medical College Admission Test (MCAT), which have been shown to disadvantage low-income and minority students who often lack access to early childhood education opportunities and standardized test preparation resources [14]. Initiatives to improve the diversity of the medical school body over the past several decades have largely failed [15]. Following the 1972 passage of Title IX of the Higher Education Act, the proportion of women entering medical school rose from 6% in the mid-1960s to 50.6% in 2019 [15,16]. During this same time, matriculants from groups historically underrepresented in medicine (URiM; individuals from racial and ethnic backgrounds who are underrepresented in medicine relative to their prevalence in the general population, namely Black or African American, Hispanic or Latino, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander) increased marginally, with the number of Black medical students lagging significantly behind- increasing from 2% of medical students in 1968 to just under 8% in 2019 [17]. Students from low-income households are also under-represented in medical schools, with one study showing that over 50% of medical students were from the top 20% of income levels [18]. Recent studies show that entrenched institutional policies and structures greatly hinder efforts toward inclusion in the admissions process [19,20]. We hypothesized that newer medical schools might be less encumbered by historical processes and power structures and, therefore, more successful in recruiting students more representative of the US population. In this manuscript, we identify all US allopathic and osteopathic medical schools established in the most recent wave of medical school expansion (after 2000) and compare the tuition fees, matriculant standardized test scores, and student body racial and ethnic demographics of these ‘new’ schools with those established earlier.

Materials and methods

In 2009, the Josiah Macy Jr. Foundation consensus panel challenged medical education to better align with the changing needs and expectations of patients and society. The panel provided key recommendations, including mitigating the burgeoning medical student debt and addressing the ongoing underrepresentation of racial and ethnic minorities in medicine [21]. We used the 2009 Josiah Macy Jr. Foundation consensus panel recommendations [21] and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement [22] to guide our reporting.

We received an ethics exemption from the Khalifa University Institutional Review Board in the United Arab Emirates [H23–008]. The study has been performed in accordance with the Declaration of Helsinki. Between 1 October 2023 and 14 December 2023, we conducted a retrospective analysis of secondary data through an internet-based, cross-sectional study. We identified and compared the characteristics of allopathic and osteopathic medical schools that were accredited since 2000 with those established earlier. We used a cross-sectional study design because it allows for the collection and comparison of data across a large number of institutions at a single point in time to identify and describe differences between the characteristics of newer and older medical schools. This provides a snapshot of the current medical school admissions and highlights areas for potential policy reform.

Data sources

We included publicly available data for every medical school in the US that received LCME or Commission on Osteopathic College Accreditation (COCA) accreditation and enrolled students by 1 December 2023 (the full listing of schools is available as Supplementary Table S1). We identified allopathic medical schools listed in the 2022–2023 Medical School Admission Requirements (MSAR) website provided by the Association of American Medical Colleges (AAMC) [23] and the American Association of Colleges of Osteopathic Medicine (AACOM) website for osteopathic schools [24]. Schools currently in development or existing schools that have not received accreditation or enrolled a first cohort of students as of 1 December 2023 were excluded. For schools established after 2000, we included newly established regional medical campuses if all years of education (3 or 4 years) were offered at the site.

Data collection

Data for all schools was collected from the 2022–2023 MSAR and AACOM websites between 1 October 2023 and 14 December 2023. Using a standardized data collection template, two researchers (K.W. and L.A.) independently extracted and charted the data. Discrepancies were discussed with the entire research team and resolved through consensus. For each medical school, we included the name, year of accreditation, degree offered (MD or DO), geographic location, public or private status, annual tuition, duration of enrollment (3 or 4 years), average matriculant GPA and MCAT scores, student demographics (gender, race/ethnicity). We used the student class entering 2022 to identify race and gender distribution as this was the most recent data available.

Data analysis

We categorized the medical schools by MD or DO-granting, public or private, and urban or rural to better understand patterns that may inform education policy reform. R software version 4.2.3 (Vienna, Austria) was used to analyze the data. Means and standard errors were calculated for continuous variables such as GPA, MCAT scores, and tuition. We calculated percentages for categorical variables, including gender distribution. The racial/ethnic distribution was calculated by dividing the total number of students in each racial/ethnic group by the total class sizes. Unpaired T-tests were used to determine significance between schools established before and after 2000. A two-sample test of proportions was employed to assess the significant differences in proportions between each racial group in schools accredited before and after 2000. A p-value of <0.05 was considered statistically significant.

Assumptions

Several assumptions were made during data collection and analysis that may have affected our findings. We conducted our analysis on publicly available data without verifying the accuracy of the information with the individual schools. Students’ gender and race classifications are recorded as per each school’s reporting. The mechanism and accuracy of this reporting may differ from one institution to the other. Students can designate multiple races or ethnic groups on MSAR and AACOM; students were included in the percentage for a racial or ethnic group category whether it was the only category selected or one of the multiple categories selected. Also, as race was based on self-reports, individuals who identified their origins as Black or African American, Hispanic/Latino, White, or Asian may be of any race and ethnicity. Further, students’ gender identification is presented as binary male or female based on each school’s public reporting. It is unclear if gender is self-reported or based on birth assignment. We did not conduct further searches to extract percentages of transgender or non-binary students. We also did not attempt to stratify students by socioeconomic status, although studies show that students from low-income households are under-represented in medical schools, irrespective of race or ethnicity [25]. Finally, for tuition, we excluded all related costs, including registration fees, books, laboratory fees, insurance, and cost of living, which may vary substantially among schools.

Results

Characteristics of newly established medical schools

Sixty new medical schools received LCME or COCA accreditation and enrolled students since 2000, a 41.4% increase. Thirty-three schools (55%) are allopathic and 27 (45%) are osteopathic. Twenty schools (33.3%) are public (19/33 allopathic and 1/27 osteopathic) and 40 (66.7%) are private (14/33 allopathic and 26/27 osteopathic). The geographic distribution of schools is presented in Figure 1. Using MSAR and AACOM classifications of urban, suburban, or rural, allopathic schools are primarily located in urban areas (21/33; 63.6%), with 10 (30.3%) in suburban areas and 2 (6.1%) in rural areas. Osteopathic schools are predominantly located in suburban areas (16/27; 59.3%), 5 (18.5%) in urban areas, and 6 (22.2%) are rural.

Figure 1.

US medical schools accredited after 2000 (N = 60).

Red- Liaison Committee on Medical Education (LCME) accredited medical schools. Blue- Commission on Osteopathic College Accreditation (COCA) accredited medical schools. The map was adapted from Google maps ©2018 Google Inc.

Table 1 includes tuition and mean matriculant GPAs and MCAT scores in schools accredited before and after 2000. There were two schools with waived or markedly reduced tuition at the time of data collection. Tuition for the New York University Long Island Medical School is $3,950 for both in-state and out-of-state students due to a targeted $100 million donation. The Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena, California waived the $58,052 tuition fee for its first four entering classes.

Table 1.

Comparison of medical schools accredited before and after 2000 for the 2022 class.

	Schools accredited before 2000 (n = 145) Mean (standard error)	Schools accredited after 2000 (n = 60) Mean (standard error)	Total number of schools (n = 205) Mean (standard error)	p value
All schools
GPA	3.80 (0.01)	3.70 (0.02)	3.78 (0.01)	<0.01*
MCAT	512.09 (0.43)	508.43 (0.71)	511.08 (0.38)	<0.01*
Tuition In-State	$47,260.28 (1336.82)	$48,782.82 (2201.09)	$47,705.90 (1142.24)	0.55
Tuition Out-of-State	$61,196.45 (1136.26)	$56,072.37 (2120.63)	$59,684.85 (1026.87)	0.02*
Osteopathic or Allopathic				<0.01*
Allopathic	125 (86.2%)	33 (55.0%)	158 (77.1%)
Osteopathic	20 (13.8%)	27 (45.0%)	47 (22.9%)
Public or Private				<0.01*
Private	65 (44.8%)	40 (66.7%)	105 (51.2%)
Public	80 (55.2%)	20 (33.3%)	100 (48.8%)
Urban or Rural				<0.01*
Rural	9 (6.2%)	8 (13.3%)	17 (8.3%)
Suburban	35 (24.1%)	26 (43.3%)	61 (29.8%)
Urban	101 (69.7%)	26 (43.3%)	127 (62.0%)

Matriculant GPA, MCAT scores, and out-of-state tuition at newer schools are significantly lower than those accredited before 2000 (3.7 vs. 3.8; p < 0.01, 508.4 vs. 512.1; p < 0.01, $56,072.37 vs. $61,196.45; p = 0.02, respectively). Supplementary Table S2 demonstrates a comprehensive breakdown of matriculant GPAs, MCAT scores, and tuition fees in osteopathic, allopathic, private, public, urban, and rural schools, comparing accredited schools before and after 2000.

Student demographics

Student gender is listed in Supplementary Table S3. Student race and ethnicity are depicted in Figure 2. Table 2 lists the average racial distribution of students in schools established before and after 2000 by geographic setting, allopathic or osteopathic, and public or private. Among the underrepresented groups, the proportion of American Indian/Alaska Native individuals and Black or African American students was significantly lower in the newer schools (0.009 vs. 0.003; p < 0.001 and 0.09 vs. 0.06; p < 0.001), respectively. However, the Hispanic or Latino student population was significantly higher in newer schools (0.11 vs 0.14; p < 0.001). While there was an overall decrease in the Black or African American student proportion, there was a marginal increase in representation in osteopathic, public, and rural schools.

Figure 2.

Racial/Ethnic distribution of students in United States medical schools ‘class of 2022’, the US general population in 2022, and the projected population in 2060.

Racial categories are in accordance with guidelines provided by the US Office of Management and Budget (OMB) and the US Census Bureau, and these data are based on self-identification [26,27]. The figure was created using Microsoft Excel version 16.77.1.

Table 2.

Racial distribution in medical schools accredited before and after 2000 for the 2022 class.

	Race	Before 2000	After 2000	p value
All schools	White	0.52	0.52	0.48
	American Indian/Alaska Native	0.009	0.003	<0.001*
	Asian	0.28	0.26	<0.001*
	Black or African American	0.09	0.06	<0.001*
	Hispanic or Latino	0.11	0.14	<0.001*
	Native Hawaiian	0.004	0.002	0.08
	Other	0.07	0.07	0.06
Osteopathic
	White	0.53	0.55	0.03
	American Indian/Alaska Native	0.002	0.001	0.12
	Asian	0.29	0.23	<0.001*
	Black or African American	0.04	0.05	0.01*
	Hispanic or Latino	0.07	0.10	<0.001*
	Native Hawaiian	0.001	0.001	0.91
	Other	0.06	0.07	0.37
Allopathic
	White	0.52	0.47	<0.001*
	American Indian/Alaska Native	0.01	0.006	0.02*
	Asian	0.28	0.30	0.03*
	Black or African American	0.10	0.08	<0.001*
	Hispanic or Latino	0.12	0.19	<0.001*
	Native Hawaiian	0.004	0.005	0.88
	Other	0.07	0.08	<0.001*
Private
	White	0.48	0.53	<0.001*
	American Indian/Alaska Native	0.004	0.002	0.05
	Asian	0.30	0.25	<0.001*
	Black or African American	0.10	0.05	<0.001*
	Hispanic or Latino	0.12	0.12	0.12
	Native Hawaiian	0.003	0.001	0.05
	Other	0.06	0.07	0.01
Public
	White	0.56	0.49	<0.001*
	American Indian/Alaska Native	0.01	0.006	0.01*
	Asian	0.27	0.39	0.004*
	Black or African American	0.09	0.10	0.04*
	Hispanic or Latino	0.10	0.17	<0.001*
	Native Hawaiian	0.004	0.005	0.58
	Other	0.07	0.07	0.92
Rural
	White	0.68	0.60	<0.001*
	American Indian/Alaska Native	0.003	0.002	0.55
	Asian	0.20	0.22	0.27
	Black or African American	0.02	0.04	0.01*
	Hispanic or Latino	0.09	0.07	0.02*
	Native Hawaiian	0.004	0	0.02*
	Other	0.05	0.06	0.27
Urban
	White	0.51	0.49	0.12
	American Indian/Alaska Native	0.01	0.005	0.03*
	Asian	0.28	0.26	0.01*
	Black or African American	0.10	0.07	<0.001*
	Hispanic or Latino	0.12	0.19	<0.001*
	Native Hawaiian	0.004	0.004	0.91
	Other	0.07	0.07	0.84

Discussion

This cross-sectional analysis provides a snapshot of enrollment in US medical schools and enables a comparison of ‘older’ schools with those established within the past 2 decades. We found that schools established after 2000 had significantly lower matriculant GPAs, MCAT scores, and out-of-state tuition fees. In the AAMC 2023 Matriculating Student Questionnaire, 77.9% of students reported that reputation was an important factor in their selection of medical school [28]. Whether our findings are an indication of more holistic admissions criteria that de-emphasize grades and standardized test scores or of more lenient admissions criteria in newer schools, primarily osteopathic schools, that have yet to establish a reputation is unclear. Long-term follow-up of admissions trends is needed.

While standardized test scores are significantly lower in the schools established after 2000, their student body diversity does not proportionally improve, underscoring that score thresholds alone do not drive inclusion. Moreover, students admitted to these newer institutions still demonstrate high academic achievement. Notably, the average incoming GPA at the newer schools is 3.7, and the mean MCAT score is 508.4. Studies show that undergraduate GPAs and MCAT scores are inadequate predictors of future physician performance and frequently disadvantage URiM students [14,29]. Students in the middle third of MCAT scores of 494–505 have similar academic performance in medical school and are more diverse than those in the upper third [30]. An individualized approach to admissions is needed to address these persistent racial disparities. Specific strategies can be implemented in admissions rubrics with minimal policy changes, such as accepting a broader range of MCAT scores or weighting MCAT scores less than lived experiences or service in underserved areas.

Our findings also highlight an uneven geographic distribution of newly established medical schools. Several states, such as Florida, Texas, and California, have welcomed multiple new schools, while other states, particularly in the Midwest (e.g., North Dakota, South Dakota, Minnesota, Nebraska, Wisconsin, Iowa, Missouri, Wyoming, Ohio, Oregon), have not had any new schools established in the past 50 years. Although population growth trends from 1910–2020 suggest that new medical schools are developed in areas of population expansion [26], this distribution neglects large portions of the country. Rural communities, in particular, have struggled to become sites for medical school development, with only 13.3% of new schools located in rural areas, and are primarily osteopathic schools. Accessibility to healthcare is an established social determinant of health [31]. The physician-to-patient ratio in rural areas is currently 131 physicians per 100,000 persons, compared to 312 physicians per 100,000 individuals in urban areas [32]. The discrepancy is even starker for specialists, where rural areas have 30 specialists per 100,000, compared to 263 specialists per 100,000 persons in urban areas [32]. Studies have associated higher physician-to-population ratios with better self-reported health and higher overall state health rankings [33]. The financial burden of opening a medical school, estimated at $120 million in 2008 [34] (approximately $170 million in 2023 after adjusting for inflation), likely poses a major barrier for many rural communities. While the local economy may benefit in the long term from job creation and increased economic support, the startup financial investment may be cost-prohibitive. The lack of medical schools in rural areas represents a missed opportunity to expose medical students to community medicine, which could foster long-term commitments to practicing in rural settings. Although some existing schools may have rural-oriented missions and are located near rural areas, US and international studies have consistently shown a strong positive correlation between rural backgrounds of students and longer durations of rural training with a higher likelihood of pursuing rural practice [35]. Therefore, the establishment of new schools directly in these underserved regions is crucial to enhance the healthcare workforce and address the healthcare disparities that rural communities face [36].

Tuition in newer schools remains a concern, contributing to increased student debt. Heavy debt burden may steer graduates into more lucrative subspecialties and away from primary care [37]. The most economical option is in-state public schools, though tuition was still $35,385.95 (SE: 3121.37) annually, while annual tuition for private schools exceeds $50,000. We are encouraged by schools that are addressing this important issue by drastically reducing tuition or by offering a three-year degree, thereby decreasing the cost of attendance by 25%. However, two-thirds of the newly established schools are private institutions, which typically have higher tuition costs than public schools, creating a financial barrier that disproportionately affects URiM applicants. Additionally, a substantial proportion of these new schools are osteopathic institutions (45% of schools established after 2000 vs. 13.8% of schools established before 2000). Although DO schools help address physician shortages and provide essential training in holistic care, applicants, including those from URiM backgrounds, may be less familiar with osteopathic training.

Unfortunately, the racial and ethnic diversity of the newly established schools has failed to improve the racial and ethnic diversity of the medical student body nationally. The proportion of URiM students remains below their proportions in the Census, particularly for Black men and women- whose representation is even lower in the schools established after 2000. Between 1997 and 2017, the number of medical school matriculants from underrepresented groups per 100,000 population increased by 20%, while the number of individuals in the population from these groups increased by 63% [38]. A possible contributor to this low representation may be state bans on the use of affirmative action or the use of race and ethnicity in making admission decisions, which are associated with significant decreases in the admission of URiM students [39].

Of note, 3 new medical schools that were not yet accredited and, thereby, not included in our study should be mentioned for their dedication to diversity. The College of Osteopathic Medicine at the Cherokee Nation, Tahlequah campus, the first tribally affiliated medical school in the US, opened in August 2020 and has enrolled 159 students, 1/5th of whom are Native American representing more than 11 of the federally recognized tribes. In addition, approximately half the students come from rural backgrounds [40]. Morgan State University, a Historically Black College and University (HBCU), is opening a new osteopathic medical school, the Maryland College of Osteopathic Medicine, in Baltimore- the first HBCU partnership with an osteopathic school. It plans to matriculate its first class in 2024 [41]. In January 2023, Xavier, an HBCU, and Ochsner Health announced the creation of a new allopathic medical school [42]. The latter two schools are important in focusing on expanding the Black physician population [17]. Studies have shown that while HBCUs comprise less than 2% of US medical colleges, they educate approximately 20% of the nation’s medical students, thereby playing a pivotal role in increasing the representation of Black physicians in the medical community [43].

Our findings have educational policy implications. First, medical schools can accept a broader range of academic metrics and implement holistic admissions practices that prioritize qualitative attributes, such as lived experiences, community engagement, and overcoming adversity. Pathway or pipeline programs have also shown success in recruiting URiM students, with a recent study showing that pathway students perform well on standardized tests during medical school despite having significantly lower GPAs and MCAT scores prior to admission [44,45]. A bridge program at Florida State University increased the enrollment of URiM students and doubled the number of Black students in the school [46]. Further, policymakers should support the development of medical schools in underserved rural areas. Providing incentives and financial support to communities to overcome the initial investment barriers could enhance healthcare access and outcomes in these regions. To alleviate some of the financial burden, medical schools can implement tuition reduction strategies, such as offering three-year degree programs. Other strategies to decrease student debt include capping tuition at current or reduced levels and providing additional funding for needs-based scholarships through endowments. Federal programs that provide tuition relief in exchange for public service commitments should also be expanded. In the wake of recent changes to affirmative action laws, institutions can develop race-neutral strategies that promote an equitable admissions process for all aspiring students, such as emphasizing socioeconomic background.

Limitations

Our study has several limitations. The cross-sectional design does not account for temporal changes or trends. Longitudinal studies are needed to examine how these characteristics evolve and to better understand the long-term impact of new medical schools on workforce diversity. Our analysis focused on the geographic distribution of newly established medical schools without considering population per state, which can influence the need for medical schools in specific regions. We reported matriculant demographics but could not access applicant standardized test scores or race information. We acknowledge that admissions processes are complex and vary substantially between schools. Moreover, we did not consider each school’s unique mission. Further, we used tuition to estimate the cost of attendance, excluding all related costs, including registration fees, books, laboratory fees, insurance, and cost of living. We also do not know what students paid- after scholarships or other adjustments. Older schools may have greater scholarship endowments and financial aid packages that decrease the actual tuition students pay. Finally, publicly available data may not provide a comprehensive picture of the medical schools, such as curricular innovations, faculty backgrounds, quality of the clinical learning environments, and the learner experience.

Conclusion

Rapid medical school expansion offers an opportunity to better align medical education with the public’s health needs. However, geographic maldistribution, high tuition, and a persistent lack of racial, ethnic, and geographic diversity persist in newly established US medical schools. There are encouraging individual examples, with some schools offering tuition-free or substantially discounted education. We are also heartened by the model provided by some of the most recent schools, with a focus on prioritizing Native American, Alaska Native, and Black students and those who wish to care for vulnerable populations. However, the number of students in these programs is small and they alone will not improve the diversity of the future physician workforce. We believe our findings are a call for action for educational leaders and policymakers. More medical students alone will not fulfill medicine’s social contract with society unless even more robust efforts are made to recruit students who will likely improve health equity for all.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

All of the data is available in the manuscript or supplementary material.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10872981.2025.2487660