Understanding the psychological drivers of online self-presentation: a survey study on social media exposure, social comparison, social network type and FOMO

Abstract

Background

Social media users can choose how to project their image to make a positive impression on others through social media. Although online self-presentation desire is an emerging phenomenon that engages with the users’ behavior on social media, empirical research and theoretical models on the topic are scarce. This study employs social comparison theory and the fear of missing out as mediators and social network type as a moderator to elucidate the effects of social media exposure on online self-presentation desire.

Methods

A quantitative survey was conducted among 367 social media users in the United States, recruited via Amazon Mechanical Turk. Partial least squares structural equation modelling (PLS-SEM) was used to test the hypothesised relationships among social media exposure, upward social comparison, FOMO, and online self-presentation desire, with social network type examined as a moderating variable.

Results

The findings indicate that frequent exposure to social media is more likely to result in upward social comparisons and experiencing fear of missing out, which motivates the users to self-present online. In addition, the difference between friend-dominated and stranger-dominated networks creates a powerful understanding of how they currently behave on social media platforms.

Conclusions

This study advances theoretical understanding by integrating social comparison theory and FOMO to explain how social media exposure drives online self-presentation desire, highlighting the moderating role of network type. The findings offer practical insights for users to manage their digital behavior and for businesses to tailor marketing strategies that align with users’ self-presentation motivations.

Introduction

Social media networks are characterised by asynchronous communication, enabling users to edit their posts and carefully craft their online image [1]. By affording users control over their online image, social media is a powerful tool for individuals to manage their social interactions and shape their perceived identity. These platforms are designed to facilitate impression management, enabling users to present themselves in a positive light through the information they share [2]. Social media users are often motivated to engage in self-presentation to gain positive feedback and enhance their online social relationships [3]. This phenomenon has important implications for understanding social media’s impact on human psychology and behavior, underscoring the need for further research.

Online self-presentation has emerged as a central issue in social media research. However, existing empirical studies and theoretical models on social media users’ journeys exploring social comparison and social pressure are limited [2–4]. To address this gap, we apply social comparison theory as the theoretical framework to focus on how social media exposure influences online self-presentation desire. Social comparison theory suggests that individuals evaluate their thoughts and actions by comparing them to those of others [5]. Specifically, social media enables social comparison by allowing users access to detailed information about others’ opinions and lives [6]. In this study, we examine the extent to which frequent exposure to social media is associated with upward social comparisons and experiencing fear of missing out (FOMO), which in turn motivates users to self-present online.

FOMO is a pervasive psychological phenomenon that has gained increasing attention in the context of social media. It refers to the feeling of anxiety that individuals experience when they believe they are missing out on rewarding experiences that others are having, particularly through social comparison [7]. Research has shown that individuals who are exposed to social media more frequently are more likely to experience FOMO and engage in social comparison behaviors [8]. However, the role of social network type as a moderator in the relationship between FOMO and online self-presentation desire is still not well understood. While previous studies have found that FOMO has a negative effect on well-being and mental health [9, 10] and impacts consumer behaviors [11, 12], research on how social network type can influence FOMO and the subsequent effects on online self-presentation desire is limited [13]. We aim to fill this gap by examining the interplay between FOMO, social network type, and online self-presentation desire.

Online self-presentation on social media has been widely studied, primarily focusing on individual motivations [14, 15]. However, little attention has been paid to the impact of the type of audience in communication on self-presentation behavior. We propose that the audience with whom they want to communicate on social media can impact an individual’s self-presentation desire. In particular, individuals may be more likely to self-present in front of strangers than their friends [16]. Therefore, social network type plays a moderating role in the relationship between FOMO and self-presentation.

This study is grounded in social comparison theory, which provides a useful framework for understanding how individuals evaluate themselves in relation to others. This theory is particularly relevant in the context of social media, where users are frequently exposed to idealized portrayals of others’ lives. By applying this theoretical lens, this study examines how social media exposure influences the desire for self-presentation through the mediating effects of social comparison and FOMO, and how this relationship is further moderated by the type of social network. Furthermore, we explore the moderating role of social network type in this relationship, highlighting the significance of how social media users formulate self-image on social media platforms. By investigating these factors, we seek to facilitate a comprehensive understanding of the process underlying self-presentation desire. This study not only extends social comparison theory but also reveals the importance of social network type with regard to behavior on social media. These findings have implications for understanding how social media use influences individuals’ self-presentation behavior, significantly contributing to the literature on self-presentation, social comparison, and FOMO on social media.

Literature review

Online self-presentation desire

Social media is used for interaction as it allows users to post images online and engage in the maintenance of their social status and relationship-seeking behavior [17]. It enables communication between individuals, groups, and companies to share and exchange information and ideas interactively [18]. Individuals and organizations are “nodes” tied together for one or more specific purposes. Thus, users can share their experiences and consume others’ information as well [19]. They utilize social media as an essential channel to seek, maintain, and extend their social connections. Social media can enhance users’ self-esteem, support identity expression, and strengthen their sense of belonging within communities [20–23]. In addition to enhancing identity display and belongingness, social media platforms provide psychosocial and hedonic benefits that foster users’ emotional engagement and motivation to remain visible and active online. These perceived benefits contribute to users’ desire to maintain a favorable self-image through self-presentation [24].

Social media sites provide contemporary and convenient functions to present oneself online and manage connections. Self-presentation refers to how one desires to present themselves to influence how others view them on social media [25]. In other words, individuals prefer to convince others to view them through positive images and try to maintain such established favorable impressions. The desire for online self-presentation makes individuals want to highlight their inner selves and display their possessions to prove their social status. In the social media context, online self-presentation is a form of behavior in which users wish to present themselves as part of their community [26, 27]. Messages on such platforms are carefully curated to promote a positive self-image [28]. When individuals are exposed to images of others’ idealized lives and pleasure, it increases their desire to exhibit positive aspects of their own lives to gain or maintain a certain self-image.

Hypothesis 1

Exposure to social media is positively associated with users’ self-presentation desires.

Upward social comparison

Social comparison theory is a well-established socio-psychological framework for understanding individuals’ motivations in society [29]. Social comparison refers to how individuals assess their opinions and abilities by comparing themselves with others who possess similar capacities and status [5]. On social media, upward social comparisons are more frequent [30]. These occur when individuals compare themselves to those they perceive as superior [31]. Social media users tend to share their successes, positive experiences, and highlights of their lives, while omitting unattractive or unfavorable aspects. Regular exposure to such curated content fosters a higher level of social comparison orientation among individuals who are sensitive to others’ opinions [32].

Furthermore, as social comparison theory suggests, individuals engage in self-evaluation by comparing themselves to others [5]. The gap between one’s own experiences and the idealized lives portrayed on social media motivates individuals to restore their self-esteem by emphasizing positive attributes [33]. Research has shown that social comparison, particularly in terms of appearance, leads to self-presentation behavior [32]. Therefore, upward social comparison plays a mediating role between social media exposure and online self-presentation.

Hypothesis 2

Upward social comparison mediates the relationship between exposure to social media and online self-presentation.

Fear of missing out (FOMO)

FOMO is an emerging concept that has attracted significant interest from researchers. It refers to the uneasy feeling of missing out on what one’s peers are doing, or knowing that they own more or better things [34]. It also refers to the anxiety related to losing the opportunity for social interactions, meaningful experiences, and investments [35]. FOMO is a psychological state that affects both the private and public selves, motivating individuals to take actions to maintain or enhance their self-image or social status [36]. This study adopts the widely accepted definition of FOMO as “a pervasive apprehension that others might have rewarding experiences from which one is absent” [7]. FOMO is generally understood as a desire to stay continuously connected to others’ experiences, accompanied by anxiety over being left out. The design of the social media platforms encourages users to stay engaged and connected [37]. This continuous engagement increases users’ exposure to curated content, heightening feelings of FOMO and the pressure to self-present.

Both passive and active use of social media can influence FOMO. Individuals with a high level of social media usage are easily vulnerable due to the ability to control the exposed experiences. Conversely, social media can also feed the feeling of FOMO when users are passively exposed to others’ content and begin thinking that others could receive better rewards. Thus, passive social media users are more likely to experience FOMO [38].

Moreover, FOMO can be understood as the anxiety stemming from missing opportunities to align oneself with others, driven by social comparison [39]. Individuals with a high social comparison orientation are typically sensitive to others’ opinions and tend to experience greater uncertainty and ambiguity regarding their self-concept [40]. It motivates individuals to stay connected and informed about what others are doing [7]. Emotional states such as depressive mood, and behaviors such as self-disclosure, can contribute to social interaction and information seeking [41]. These factors reflect broader psychological strains that, like FOMO, may prompt individuals to actively manage their online self-image to maintain a sense of belonging and relevance. Therefore, social media exposure and social comparison are likely to increase FOMO.

The stronger an individual’s desire for connection, the more likely they are to engage in online self-presentation on social media [26]. Individuals with low self-esteem and a heightened fear of damaging their relationships tend to engage in positive self-presentation to enhance others’ perceptions of them. Research has shown that the more strongly individuals are attached to their group or community, the more they seek to project an online identity that aligns with the group’s expectations [42]. Therefore, individuals with higher levels of FOMO are more likely to exhibit a stronger desire for self-presentation on social media. Based on these discussions, exposure to social media directly and indirectly affects self-presentation desire through the mediating effect of upward social comparison and FOMO.

Hypothesis 3

Social comparison is positively associated with FOMO.

Hypothesis 4

FOMO mediates the relationship between exposure to social media and online self-presentation.

Social network type as a moderator

While individuals strive to present a positive self-image, the audience on the other side of the communication or social network can influence how they post, share, communicate, and construct their online identity. On social media platforms, whether an individual’s online network consists primarily of offline friends or strangers is a key predictor of effective online impression management [16]. A friend-dominated network refers to a relationship network on social media platforms that contains more actual offline friends with strong ties than strangers purely connected through social media. In contrast, a stranger-dominated network is a social media network where most connections are acquaintances with weak or no ties, rather than actual friends [43].

This study conceptualizes social network type based on tie strength, a concept important to distinguish from the architectural connectivity models built into social media platforms. As Bossetta [44]’s research shows, platforms vary in their digital architectures, specifically promoting dyadic or unidirectional connections. These structural differences influence the nature of social interactions, audience perception, and impression management behaviours. Although this study focuses on users’ perceived network composition, these perceptions may interact with platform-specific affordances in meaningful ways.

Previous research has shown that the motivation for online self-presentation often stems from the fear of being left behind or losing social approval [45]. Individuals with low self-esteem often attempt to restore their image to gain social approval. However, while individuals seek to present themselves positively to others, the strategies they employ vary depending on the audience [13]. Owing to friends’ prior knowledge, it is more challenging to manipulate their initial thoughts, and self-enhancing behavior can cause inconsistency and be perceived as conceit [46]. Conversely, when engaging in self-promotional impression management, it is easier to manipulate strangers than friends because they lack the knowledge of one’s actual characteristics and qualities [43]. Figure 1 presents the conceptual framework of this study.

Fig. 1.

Research framework

Hypothesis 5

Social network type moderates the relationship between FOMO and self-presentation desire.

Methods

Participants and procedure

The survey was conducted via Amazon Mechanical Turk (MTurk) in the United States in 2024. Respondents were aged 18 to 49, as this age group represents the most active users of social media [47]. A preliminary screening question asked whether participants had ever used any social media platform (yes/no), ensuring that all participants had at least some prior experience with social media. All participants confirmed prior use of social media platforms.

Participants first indicated their most frequently used social media platform and reported their total number of connections (“friends”) on that platform, as well as the number of those who were actual offline friends. They then completed a structured questionnaire assessing the constructs of this study. A total of 367 valid responses were used for data analysis. The demographic characteristics of the respondents are presented in Table 1.

Table 1.

Demographic characteristics (N = 367)

Item	Characteristics	Frequency	Ratio
Gender	Male	117	31.9
	Female	250	68.1
Age	18–19	3	0.8
	20–29	157	42.8
	30–39	170	46.3
	40–49	37	10.1
Social media platforms	Facebook	151	41.1
	Instagram	133	36.2
	Twitter	16	4.4
	WhatsApp	62	16.9
	TikTok	5	1.4

Measurements

The survey items were measured on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Social media exposure was assessed using items adapted from Ross et al. [48] to measure the frequency of social media use and daily engagement. Upward social comparison was measured using items from Gibbons and Buunk [49], which assessed how participants compared themselves to others in terms of achievements and accomplishments. FOMO was measured using the widely validated scale by Przybylski, Murayama [7], which captures anxiety over missing out on rewarding experiences. Online self-presentation was measured using items from Kim and Chan [42].

Social network type was calculated based on the ratio of actual offline friends to total network size, following Lee-Won, Shim [2], Dinh and Lee [12]. A ratio equal to or greater than 0.5 was classified as friend-dominated, whereas a ratio lower than 0.5 was considered stranger-dominated. During the measurement model evaluation, items across different constructs were removed due to low factor loadings to improve the reliability and validity of the measurement model. This approach aligns with common practices in PLS-SEM analysis to ensure robust construct validity [50].

Data analysis

Structural equation modelling using SmartPLS v4 was employed to analyse the data. This method is well-suited for models involving multiple latent psychological constructs, as it accommodates non-normal data distributions and is effective for exploratory and predictive research contexts [50]. The use of partial least squares SEM (PLS-SEM) is particularly appropriate for the psychological constructs examined in this study, such as self-presentation, social comparison, and FOMO [51]. Accordingly, both the measurement model and the structural model were tested using this approach. Social network type was operationalized as a dummy variable, where a value of 1 indicated a friend-dominated network, and a value of 2 indicated a stranger-dominated network.

Results

Confirmatory factor analysis

As part of the PLS-SEM procedure, confirmatory factor analysis (CFA) was conducted to assess the measurement model, ensuring the reliability, convergent validity, and discriminant validity of the constructs. Key criteria, including factor loadings, composite reliability (CR), average variance extracted (AVE), and the square root of AVE, were examined. The results are presented in Tables 2 and 3.

Table 2.

Constructs’ items, reliability, and validity. (N = 367)

Item	Factor loading
Exposure to social media (CR = 0.838, AVE = 0.509)
Using social media is part of my everyday activity	0.749
I am proud to tell people I’m on social media	0.695
I dedicate a part of my daily schedule to social media	0.726
I feel out of touch when I haven’t logged on to social media for a while	0.640
I feel I am part of the social media community	0.751
Upward social comparison (CR = 0.802, AVE = 0.576)
When using social media, I often compare myself with others with respect to what I have accomplished in life.	0.791
When using social media, if I want to learn more about something, I try to find out what others think about it.	0.714
When using social media, I always pay a lot of attention to how I do things compared with how others do things.	0.769
Fear of missing out (CR = 0.879, AVE = 0.511)
I fear others have more rewarding experiences than me.	0.719
I fear my friends have more rewarding experiences than me.	0.667
I get worried when I find out my friends are having fun without me.	0.754
I get anxious when I don’t know what my friends are up to.	0.768
Sometimes, I wonder if I spend too much time keeping up with what is going on.	0.730
It bothers me when I miss an opportunity to meet up with friends.	0.691
When I have a good time, it is important for me to share the details online	0.665
Self-presentation desire (CR = 0.848, AVE = 0.584)
I want to enhance my online image.	0.796
I want to establish an impressive online image for myself.	0.687
I want to project a desirable impression with my online image.	0.729
I want to give a good impression about myself to others with my online image.	0.758

Table 3.

Discriminant validity and correlations

	1	2	3	4	5
1. Social network type	1	-0.090	-0.129	-0.268	0.102
2. Social media exposure		0.714	0.711	0.582	0.695
3. Upward social comparison			0.759	0.635	0.699
4. FOMO				0.715	0.656
5. Online Self-presentation desire					0.764

Note. Diagonals (ITALICS) represent the square root of the AVE, while the off-diagonals represent correlations. N = 367

As shown in Table 2, all factor loadings exceeded the recommended threshold of 0.60, indicating satisfactory indicator reliability. Internal consistency was confirmed, with CR values exceeding 0.80 for all constructs. Convergent validity was established, as AVE values for all constructs exceeded the 0.50 threshold, indicating that the indicators shared sufficient variance with their corresponding constructs. Discriminant validity was confirmed using the Fornell-Larcker criterion: the square roots of the AVE values were greater than the inter-construct correlations, as shown in Table 3.

Structural model

The structural model was analyzed to test the study’s hypotheses by examining the t-values, p-values, and standardized path coefficients. Additionally, the mediation and moderation effects of social media exposure, social comparison, FOMO, and online self-presentation were examined.

Table 4 shows that all hypotheses were supported. The results show that social media exposure significantly affected online self-presentation desire, with a total effect of b = 0.283, p < 0.001, supporting Hypothesis 1. Furthermore, Hypotheses 2 and 4 were supported, as the indirect effects of social media exposure on self-presentation via social comparison and FOMO were significant (b = 0.171, p < 0.001, b = 0.194, p < 0.01). Table 4 also shows that the direct effect of social comparison on FOMO were significant (b = 0.448, p < 0.001), supporting Hypothesis 3.

Table 4.

Results of hypothesis testing for key relationships in the structural model

Hypothesis	β	t	p	Result
H1. Social media exposure → Online self-presentation	0.283	3.748	0.000	Accepted
H2. Social media exposure → Upward social comparison → Online self-presentation	0.171	3.905	0.000	Accepted
H3. Upward social comparison → FOMO	0.448	5.763	0.000	Accepted
H4. Social media exposure → FOMO → Online self-presentation	0.194	2.971	0.003	Accepted
H5. FOMO × Social network types → Online self-presentation	-0.425	3.181	0.001	Accepted

Finally, Hypothesis 5, which posited that social network type moderates the effect of FOMO on self-presentation desire, was supported (b = -0.425, p < 0.01). In other words, individuals in stranger-dominated networks exhibited stronger sharing behavior than those in friend-dominated networks. This finding is illustrated in Fig. 2. The overall structural relationships among the study variables are summarized in Fig. 3.

Fig. 2.

Moderation effect of social network type

Fig. 3.

Final structural path model

Discussion and conclusion

This study utilized social comparison theory to provide insights into the underlying processes when individuals are exposed to social media. The desire for online self-presentation, along with social comparison and FOMO, emerged as key variables in this context.

Social media exposure is significantly associated with social comparison, which in turn influences self-presentation. The findings indicate that frequent exposure to social media content leads to social comparison with others’ lives, consistent with previous research [52, 53]. Information about others’ lives is accessible anytime and anywhere; therefore, social media users can readily update this information and connect it, either consciously or unconsciously, to their own status. Users compare themselves with others on social media and notice the gaps. To fill these gaps, they engage in self-presentation online to protect their self-image.

Furthermore, this study revealed that FOMO serves as a mediator in the relationship between social media use and self-presentation desire. Social media exposure increases the desire to stay connected to what others own and experience [7]. Individuals with lower life satisfaction are more likely to browse social media feeds to monitor the activities of others. FOMO arises from social comparison following exposure to others’ status on social media [54].

This study is grounded in social comparison theory, which highlights the role of social comparison in motivating individuals to connect with others and stay informed about their status [5]. When individuals incorporate social media into their daily routines, social comparison occurs more frequently [39]. Frequent social media use leads to social comparison and heightens social exclusion anxiety. After comparing themselves with others on social media, users become aware of their absence from certain activities and experience anxiety as a result. The mediating roles of social comparison and FOMO indicate that social media exposure influences individuals’ desire for self-presentation.

Furthermore, social media use within a stranger-dominated network is associated with higher levels of online self-presentation desire compared to a friend-dominated network. When an individual’s friend list on social media consists primarily of offline friends who know them personally, self-promotional posts can damage their self-image and may be perceived as conceited [43]. Therefore, they are more likely to limit their posting behavior on social media to maintain a consistent self-image. In contrast, when the audience primarily consists of online acquaintances who have little knowledge of the user’s real-life circumstances, individuals are more likely to flaunt their wealth and success in an effort to impress others and boost their self-esteem [55].

Theoretical contributions

This study offers several theoretical implications by using social comparison theory as a framework to propose a model that explains the pathway from social media exposure to online self-presentation. Although social comparison theory has been applied in previous studies on well-being, social media engagement, and consumer contexts [30, 52, 54], its use in explaining self-presentation desire remains rare. Furthermore, while FOMO is an emerging concept that explores individual motivations across various domains [56–58], few studies have empirically examined its effect on self-presentation desire within the context of social media exposure.

This study advances the literature by integrating social comparison and FOMO to examine the mediating role of social media exposure in shaping self-presentation desire. By addressing this gap, the current study provides a new direction for researchers to apply social comparison theory in understanding how individuals seek to present themselves on social media today. To further understand these relationships, the moderating effects of social network types were examined, and they demonstrated the significant difference between friend- and stranger-dominated networks. This finding provides further insight into why some individuals are more motivated to engage in online self-presentation than others.

In summary, this study makes several meaningful contributions to the literature on social media psychology. First, it introduces a new mediation model, demonstrating that the desire for online self-presentation is influenced not only by social media exposure but also by the combined effects of upward social comparison and FOMO. Second, it extends social comparison theory by applying it to the context of self-presentation, an area that has received less attention in prior research. Third, it identifies the moderating role of social network type, demonstrating that users behave differently in stranger-dominated networks compared to friend-dominated networks. These findings contribute to our understanding of how social media affects users’ psychological responses and provide valuable directions for future research on digital identity and online behavior.

Practical implications

The findings of this study offer several practical implications for individuals and businesses that use social media platforms. For social media users, it is important to recognize that frequent exposure may heighten the desire for online self-presentation. This desire is often driven by FOMO and social comparison. Therefore, it is essential to maintain a balance between online and offline activities to avoid excessive exposure to social media. Moreover, social media users should recognize the differences between friend-dominated and stranger-dominated networks and adjust their online self-presentation strategies accordingly. They may choose to present themselves in a more casual and informal manner on friend-dominated networks, while adopting a more professional and curated tone in stranger-dominated networks.

In the business context, brands can apply the insights from this study to design more effective social media marketing strategies, including advertising campaigns tailored to the self-presentation desires of their target audience. Brands can target consumers who are more likely to engage in online self-presentation and create tailored content that appeals to their desire to project a positive image. They can develop ads that highlight the benefits of their products or services in enhancing the user’s image or social status.

Limitations and future research

A potential limitation of this study is that the sample was drawn from Amazon Mechanical Turk in the U.S., with respondents aged 18–49 years. Therefore, the findings may not be generalizable to individuals outside the U.S., younger age groups who are highly active on social media, or older adults. Additionally, although the sample size of 367 participants was adequate for the PLS-SEM analysis, it remains relatively small, which may limit the generalizability of the findings. Future research with larger and more diverse samples is encouraged to validate and extend these results. This study is cross-sectional and relies on self-reported data. Future research could evaluate these findings using longitudinal designs to provide more robust conclusions.

In addition, it is important to note that not all social media platforms operate similarly in terms of self-presentation and social comparison. For instance, WhatsApp functions primarily as a private messaging app with smaller, close-knit audiences, differing from more public platforms like Facebook or Instagram. Prior research suggests that users experience different social pressures on private versus public platforms [59]. Future research could further explore these platform-specific dynamics. Another limitation of this study is that “prior use” was defined broadly as having ever used social media, without considering the frequency or recency of use. This may have included participants with varying levels of engagement, which could influence the generalizability of the findings.

Moreover, while our study focused on the perceived network type, future research may explore how these perceptions interact with platform-level connectivity architectures. For example, platforms vary in whether they encourage dyadic versus unidirectional connections, which may influence users’ sense of audience and shape self-presentation strategies in different ways [44]. Integrating platform architecture with user-level network perceptions could offer a richer framework for understanding digital impression management. Finally, future research could assess self-presentation desire across different social media platforms rather than by social network type, to further examine the impact of social media exposure on online self-presentation desire.

Abbreviations

FOMO

Fear of missing out

PLS-SEM

Partial least squares structural equation modelling

CFA

Confirmatory factor analysis

CR

Composite reliability

AVE

Average variance extracted

Author contributions

T.C.T.D. conceptualized the study, designed the methodology, administered the project, and wrote the original draft. Y.L. contributed to the conceptual development, supervised the project, and revised the manuscript through critical review and editing. All authors reviewed and approved the final manuscript.

Funding

This work was supported by the 2024 Yeungnam University Research Grant.

Data availability

Data are available on Figshare at https://figshare.com/s/c15a296f3a015d4af5f5

Declarations

Ethical approval and consent to participate

This study was conducted in accordance with the ethical standards of the institutional and/or national research committee and adhered to the principles outlined in the 1964 Helsinki Declaration and its subsequent amendments or comparable ethical standards. Approval for this study was granted by the Yeungnam University Institutional Review Board (Approval No. 7002016-A-2024-111). Prior to participation, informed written consent was obtained from every participant. All participants first received detailed information about the study’s purpose, procedures, potential risks and benefits, confidentiality safeguards, and their right to withdraw at any time without penalty.

Consent for publication

Written informed consent was obtained from all participants at the time of data collection, and this consent included permission to publish anonymized aggregate study results. Because the manuscript contains only deidentified data with no individual level identifying information, no additional consent was required.

Competing interests

The authors declare no competing interests.