Prevalence and determinants of nosophobia among medical students of Wah Medical College

Abstract

Background

Fear of developing a serious illness, known as nosophobia, has been reported among medical students-sometimes called the medical student syndrome. The high density of disease-related knowledge may predispose students to ill health anxiety, which can negatively undermine academic performance and mental health. The medical college in Pakistan has little data about nosophobia despite the global studies. This study aimed to determine the prevalence and the factors associated with the students in Wah Medical College.

Methodology

It was a cross-sectional study done among 315 MBBS (Bachelor of Medicine and Bachelor of Surgery), Nursing, and MLT (Medical Laboratory Technology) students at Wah Medical College. Their data were obtained through a structured online questionnaire (Google Forms) containing demographic and behavioral factors, and the Whiteley Index (WI-14) to help examine nosophobia and health-related anxiety. Whiteley Index scores were categorized as 0–4 (no anxiety), 5–7 (subclinical health anxiety), and ≥ 8 (nosophobia). Associations were tested with chi-square (p < 0.05 significant); adjusted odds ratios (ORs) with 95% confidence interval (CI) were computed via multinomial logistic regression controlling for age, gender, and program. Data were collected in May 2025 and analyzed in June 2025.

Results

Nosophobia was found in 16.5% (95% CI 12.4–20.6%) of students, while 28.3% (95% CI 23.3–33.3%) had sub-clinical health anxiety and 55.2% (95% CI 49.7–60.7%) exhibited no anxiety. History of serious illness (adjusted odds ratio [AOR] 2.0, 1.1–3.8 vs. no history) and hostel residence (AOR 3.5, 1.6–7.5) significantly predicted nosophobia; no associations with gender, age, or year of study.

Conclusion

Nosophobia is a relevant mental health concern among medical students, particularly those with personal illness histories and living away from home.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44192-026-00427-2.

Background

Health anxiety disorder, also known as hypochondria or nosophobia, refers to a psychological condition in which a person becomes unduly anxious about their health and develops a fear of illness despite having no serious symptoms [1, 2]. They may have no physical symptoms or misinterpret minor symptoms as signs of serious illness. Hypochondria (also called illness anxiety disorder [IAD] by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-5]) is a persistent fear of having a serious illness despite medical reassurance. On the other hand, nosophobia is characterized as developing a fear of a specific disease [1, 3]. Nosophobia and hypochondriasis are often conflated in casual discourse, but they refer to distinct psychological conditions. In nosophobia, the focus is typically on a particular disease (e.g., cancer or human immunodeficiency virus [HIV]), whereas in hypochondriasis or IAD, the concern may shift between multiple conditions over time. In this study, the term “nosophobia” is used operationally to describe higher levels of health anxiety, as assessed by the Whiteley Index (WI-14), reflecting disease-focused illness fears rather than a formal clinical diagnosis.

When it comes to medical students, nosophobia is referred to as Medical Student Syndrome (MSS), a phenomenon triggered by learning about a disease [4]. It is clear that medical students are exposed to a significant amount of clinical knowledge about various diseases. Although essential to their education, this exposure may be associated with increased illness-related anxiety and disease-related fears [5, 6]. Medicine is a competitive and stressful field, and medical scholars are more subject to depression, psychological diseases, and anxiety when compared to non-medical scholars [7–9].

The topic is debatable because previous studies have reported inconsistent findings regarding nosophobia and health anxiety among medical students. Some investigations have shown higher levels of illness-related anxiety in medical and health-science students compared with their non-medical peers, suggesting a possible influence of medical training and repeated exposure to disease-related content [8, 10, 11]. In contrast, other studies have found no significant differences between medical and non-medical students, or even higher levels of health anxiety among students in non-medical disciplines [1, 7]. Such variation may be due to differences in academic workload, exposure to clinical settings, and cultural attitudes toward health between countries.

In Pakistan, a few studies have been conducted on this topic, supporting the notion that medical students suffer from nosophobia or MSS [1, 12, 13]. In 2023, a cross-sectional study (not peer-reviewed) was conducted by graduates of King Edward Medical University, targeting MBBS (Bachelor of Medicine and Bachelor of Surgery) students from all provinces of Pakistan. The findings of the survey revealed a growing occurrence of nosophobia among medical students in Pakistan [13]. In 2016, the Graduates of Aga Khan Medical University also conducted an analytical cross-sectional study and concluded that about 10% of medical students are somehow suffering from hypochondriasis [12].

Given the contradictory findings regarding the prevalence of nosophobia and the absence of standardized data, developing effective interventions is challenging. Furthermore, while global studies suggest potential risk factors like hostel residence and prior illness history, there is a critical lack of Pakistani data investigating these specific drivers within the unique socio-cultural and academic context of local medical colleges. Therefore, we conducted this study to gain better insights into this issue. Our study aimed to fill this gap by addressing the prevalence of nosophobia and exploring associated factors among students at the Wah Medical College. These findings will help develop interventions to improve students' coping mechanisms and resilience. Moreover, it adds to the existing literature and provides a foundation for future research on psychological challenges in medical training.

Methodology

This was a cross-sectional study, and students of MBBS, MLT (Medical Laboratory Technician), and Nursing across all academic years at Wah Medical College were considered in the standard sample size calculation. The minimum required sample size was 270 students, calculated using Raosoft (https://www.raosoft.com/samplesize.html), with a 95% confidence interval, 5% margin of error, and an estimated response distribution of 50%. To increase the statistical power and minimize the marginal error, we gathered data from 315 students. A non-probability convenience sampling technique was adopted; therefore, participants from different programs and years were included according to their availability rather than fixed quotas. A structured, self-administered online questionnaire with a digital consent form was distributed through Google Forms. The link to the questionnaire was shared among students via WhatsApp. To avoid duplicate responses, only a one-time submission option was enabled, which restricted resubmission from the same device/browser. The questionnaire consisted of two sections: one for socio-demographic and behavioral aspects and the other for measuring nosophobia or health-related anxiety (the Whiteley Index Questionnaire). Data were collected in May 2025 following ethical approval (IRB Approval No. WMC/ERC/IRB/062), and analysis was conducted in June 2025.

Demographics and behavioral aspects

The section encompassed demographic variables—gender, age, year of study, program of study, and lodging status—and health-related behavioral patterns, including exercise status, sleep duration, addiction history (smoking and vaping), frequency of doctor consultations per year, history of serious illness or prolonged hospitalization, and long-term medication use. A detailed summary of all variables and their coding is provided in Tables 1 and 2.

Table 1.

Demographic characteristics of the participants (N = 315)

Variable	Category	Frequency (n)	Percentage (%)
Gender	Male	158	50.2
	Female	157	49.8
Age	17–19 years	97	30.8
	20–22 years	181	57.5
	23–25 years	34	10.8
	26–28 years	3	1.0
Year of study	1st year	118	37.5
	2nd year	97	30.8
	3rd year	58	18.4
	4th year	27	8.6
	Final year	15	4.8
Program	MBBS	201	63.8
	Nursing	64	20.3
	MLT	50	15.9
Lodging	Hostelite	195	61.9
	Day scholar	120	38.1

Table 2.

Health-related behavioral patterns of participants (N = 315)

Variable	Category	Frequency (n)	Percentage (%)
Exercise status	Not at all	117	37.1
	Once a week	81	25.7
	2–4 times a week	75	23.8
	5–7 times a week	42	13.3
Sleep hours per night	Less than 3 h	5	1.6
	3–5 h	76	24.1
	6–8 h	209	66.3
	9–11 h	25	7.9
Addiction	Smoking/Vaping	6	1.9
	Substance abuse	4	1.3
	Not at all	305	96.8
Doctor visits per year	Once a year	49	15.6
	Twice a year	39	12.4
	Three or more times per year	63	20.0
	Not usually	164	52.1
Serious illness/Prolonged hospitalization	Yes	39	12.4
	No	276	87.6
Long-term medication	Yes	23	7.3
	No	292	92.7

The Whiteley index questionnaire

We used the Whiteley index (WI) as a screening tool to detect nosophobia and hypochondriac tendencies [14, 15]. The original version of the Whiteley Index (WI-14), developed by Pilowsky [16] was used in this study. This version has demonstrated good reliability and validity in both clinical and non-clinical populations including medical students. Notably, the internal consistency of the unitary WI-14 has been reported with a Cronbach’s alpha of 0.80, and re-test reliability of 0.90, indicating acceptable reliability [17, 18]. The Whiteley Index comprises 14 dichotomous (“yes”/“no”) items, producing a total score ranging from 0 to 14, with one point assigned for each affirmative response. Scores of 5 or higher indicate a positive screen for health anxiety. For analytic purposes, scores were categorized as 0–4 (no anxiety), 5–7 (subclinical health anxiety), and ≥ 8 (nosophobia), consistent with prior literature [9, 14]. These categories reflect screening-based severity levels of health anxiety rather than formal clinical diagnoses. This threshold has been widely used in prior research to indicate the presence of clinically significant health anxiety or hypochondriasis [9, 19], though cutoffs vary across literature; this threshold was selected to align with validated usage in comparable populations.

Additional questions

Three additional exploratory, self-constructed questions (A, B, C) were included as separate variables. These are neither validated measures nor the part of the Whiteley index (WI-14) scoring. These questions assessed whether participants (A) worry about having diseases they are currently studying, (B) check their own body for symptoms when learning about diseases, and (C) perceive that their exposure to medical knowledge has increased their health-related fears since entering medical school. These items were included to explore context-specific aspects of health anxiety that are particularly relevant to medical students, and to provide supplemental insight into the cognitive patterns associated with nosophobia beyond what is measured by the Whiteley Index.

Statistical analysis

We used IBM SPSS Statistics Version 30.0 and Microsoft Excel (2016) for data analysis. Descriptive statistics, including means, standard deviations, frequencies, and percentages, were used to summarize the demographic and behavioral aspects of the participants and determine the prevalence. The chi-square test was applied to determine the association between qualitative variables. We considered a p value less than 0.05 significant. Effect sizes (Cramer’s V) were calculated for all chi-square associations to indicate the strength of relationships. Multinomial logistic regression was used to compute adjusted odds ratios (OR) with 95% confidence intervals (CI), controlling for age, gender, and program of study, and using “no anxiety” group as the reference category.

Results

A total of 315 students participated in the study (all responses were complete; no cases were excluded for missing data), and their demographic characteristics and health-related behavioral patterns are provided in Tables 1 and 2.

Prevalence of nosophobia

Overall, 16.5% of students scored above the threshold for nosophobia, 28.3% exhibited subclinical health anxiety, and 55.2% reported no health anxiety. Prevalence varied across academic programs: 20.3% in Nursing, 17.4% in MBBS, and 8.0% in MLT. However, these differences were not statistically significant (χ² = 4.53, p = 0.339, Cramer’s V = 0.085) and should be interpreted as exploratory. Table 3 shows the percentage (%), frequency, standard deviation (SD), mean (), and median interquartile range (IQR) of the different groups of students based on positive responses.

Table 3.

Prevalence of nosophobia and health anxiety among students (N = 315)

Status	WI range	Frequency (n)	Percentage (%)	Mean ± SD	Median (IQR)
Nosophobia	≥ 8	52	16.5	10.06 ± 1.76	10 (8–12)
Subclinical health anxiety	5–7	89	28.3	5.98 ± 0.78	6 (5–7)
No anxiety	0–4	174	55.2	2.09 ± 1.40	2 (1–3)

Nosophobia severity was categorized based on total Whiteley Index scores.

Significant association between nosophobia and other factors

Significant predictors of nosophobia were identified in the adjusted analyses. Students residing in hostels had 3.5 times the odds of nosophobia compared to day scholars (AOR 3.5, 95% CI 1.6–7.5; χ² = 15.84, p < 0.001). Likewise, participants with a history of serious illness or prolonged hospitalization had twice the odds relative to those without such histories (AOR 2.0, 95% CI 1.1–3.8; χ² = 6.98, p = 0.030). These associations are summarized in Table 4, while Figs. 1 and 2 provide visual representations of group differences and chi-square contributions.

Table 4.

Association between predictor variables and nosophobia categories

Variable	χ2	df	p value	Cramer’s V	Adjusted OR (95% CI)
Gender	0.445	2	0.800	0.038	1.0 (0.6–1.8)
Age	9.230	6	0.161	0.121	1.1 (0.9–1.3)
Program of study	4.527	4	0.339	0.085	1.3 (0.7–2.4)
Year of study	13.440	8	0.098	0.146	1.5 (0.9–2.6)
Lodging (Hostel)	15.835	2	< 0.001*	0.224	3.5 (1.6–7.5)
Exercise frequency	6.385	6	0.382	0.082	1.4 (0.9–2.1)
Sleep duration	4.745	6	0.577	0.070	1.2 (0.7–2.0)
Addiction history	3.154	4	0.532	0.071	0.8 (0.3–2.1)
Doctor visits/year	8.306	6	0.216	0.094	1.3 (0.8–2.0)
Serious illness	6.984	2	0.030*	0.149	2.0 (1.1–3.8)
Long-term medication	3.070	2	0.218	0.099	1.9 (0.7–5.2)

Bold entries and asterisks (*) indicate statistically significant associations (p < 0.05)

Fig. 1.

Nosophobia prevalence by lodging type with 95% confidence intervals. An asterisk (*) indicates a significant difference between groups (p < 0.01)

Fig. 2.

Chi-square contribution heatmap for serious illness versus nosophobia category. Values in cells are χ² contributions; dark red > 3.84 (p < 0.05), light red < 3.84

Non-significant association between nosophobia and other variables

Several factors, including gender, age, year of study, academic program, exercise, sleep, addiction, doctor consultations, and long-term medication, showed no significant association with nosophobia (all p > 0.05). Table 4 indicates the association between predictor variables and nosophobia categories—using chi-square tests and adjusted odds ratios from multinomial logistic regression.

Nosophobia indicators related to medical education

All three nosophobia indicators (A, B, C) were assessed for their association with prevalence. Two indicators—A and C—showed significant associations, with small-to-moderate effect sizes (Cramer's V = 0.237–0.249), while B was not statistically significant. Worry about studying diseases (A) emerged as the strongest predictor, followed by fear due to medical knowledge (C), with adjusted odds ratios indicating substantial increases in risk compared to students without these concerns. Multicollinearity diagnostics indicated no concern, with VIF (Variance Inflation Factor) values for all predictors below 1.2 (A: 1.17, B: 1.07, C: 1.17) (Table 5).

Table 5.

Association between nosophobia indicators and nosophobia prevalence

Variable	χ2 Value	df	p value	Cramer's V	AOR (95% CI)
Worry about studying disease (A)	17.65	1	< 0.001*	0.237	2.69 (1.37–5.25)
Checking own body for symptoms (B)	0.60	1	0.440	0.044	0.86 (0.43–1.71)
Fear due to medical knowledge (C)	19.48	1	< 0.001*	0.249	3.16 (1.57–6.32)

*Represents p value is less than 0.05

Discussion

The prevalence of nosophobia in our sample was substantial, echoing concerns raised in the literature about “medical students’ disease.” For context, earlier reports documented extremely high rates (70–79%) of transient illness fears among medical students [7], though these were based on small samples. More recent surveys show more moderate rates. In Pakistan, for example, Zahid et al. found about 11.9% of medical students with significant health anxiety [12]. whereas Mehmood et al. [13] reported that 36.1% of Pakistani medical students scored above the clinical cutoff on a health-anxiety inventory. In our study, we similarly found a notable proportion of students with elevated nosophobia scores. Globally, results vary: a Greek study found 18.1% of health‐science students had high anxiety (Short Health Anxiety Inventory [SHAI] > 14) and that health‐science majors were twice as likely as other students to report excessive health worries [20]. In contrast, a Polish investigation found medical and non-medical students did not differ on nosophobia scores [7], and a recent Saudi study actually observed higher mean nosophobia in other health-science students than in medical students (mean 2.40 vs. 2.05, p = 0.016) [10]. Thus, our findings fit into a mixed international picture: some studies report higher illness anxiety in medical/health students, while others report little difference or even higher anxiety in peers. In our sample, the overall pattern of nosophobia was broadly comparable to other Pakistani studies, but direct comparisons are difficult given different instruments and cutoffs. Importantly, whether medical students exhibit higher nosophobia than non-medical peers remains unsettled. For example, Szczurek et al. found no significant difference in nosophobia between Polish medical and law students [7], whereas Papadopoulou et al. found a significant excess in Greek health-science students [20], and Hussein et al. (Saudi Arabia) reported modestly higher scores in non-medical health fields [10]. These discrepancies may reflect differences in curricula, cultural factors, or definitions of “health anxiety,” but they underline that studying medicine per se is not universally a risk factor for nosophobia [7].

Consistent with some prior work, we found no significant gender differences in nosophobia scores. This aligns with Zahid et al., who observed comparable rates in male and female Pakistani students [12] and a Nigerian survey, which reported that gender did not significantly influence illness fears [21]. However, other studies have noted female predominance: for instance, Papadopoulou et al. found higher health anxiety scores among women [20], and Szczurek et al. found women scored higher on nosophobia overall [7]. The absence of a gender gap in our sample may reflect a relatively uniform stress environment at our college or cultural attitudes toward health; it suggests that anxiety about disease affects male and female students similarly in this setting. In short, gender did not emerge as a driver of nosophobia in our study, in contrast to some international reports, but in agreement with others [7, 12]. We observed that nosophobia (severe health anxiety) varied across students’ programs of study but these differences were not statistically significant and should therefore be interpreted cautiously as exploratory patterns rather than confirmed effects. This pattern is plausible, as curricula and clinical exposure differ by program. Papadopoulou et al. found that students in health-related majors (medicine, nursing, etc.) had significantly higher health anxiety than peers in other fields [20], likely reflecting intense exposure to medical knowledge and stress. Similarly, Hussein et al. reported that other health-science students had higher mean nosophobia scores than medical students [22]. In contrast, Szczurek et al. found no difference between medical and non-medical students [7]. Our finding of program-related variation thus mirrors a broader trend: some health curricula (especially those that emphasize clinical training or emergency care) may heighten awareness of disease and foster anxiety, whereas others may not. Interpretively, students in more clinically intensive programs may experience greater nosophobia if their coursework constantly exposes them to pathology, whereas students in less medicalized tracks may have lower baseline anxiety. This deserves further study, but our results suggest that differences in training and expectations likely underlie the program variation we observed.

We found significantly higher nosophobia among students living in hostels compared to those living at home. While literature on lodging per se is sparse, this pattern may reflect the added stressors of hostel life, such as academic pressure, unfamiliar environments, and separation from family support. For example, a residential setting was a significant correlate of health anxiety in a large Pakistani survey (p = 0.000) [13, 23]. Students away from home may feel more vulnerable or isolated, potentially amplifying the fear of illness. This suggests that campus living conditions and peer influences can affect health anxieties. Although direct comparisons are few, our findings resonate with research showing higher overall stress and anxiety among students living away from home. Universities may need to consider the support structures for hostelites, as their living situation itself appears linked to elevated nosophobia.

In contrast to some previous findings, our study did not find a statistically significant association between the frequency of doctor consultations and nosophobia. This suggests that, in our cohort, frequent healthcare visits were not necessarily driven by illness anxiety. While reassurance-seeking is a known behavior among individuals with health anxiety, our results imply that students may visit doctors for routine or unrelated reasons rather than out of nosophobic concerns. This finding diverges from international studies that have linked high consultation rates with underlying health anxiety [21], and it aligns more closely with Zahid et al.’s findings, where no strong correlation was observed between doctor visits and hypochondriac tendencies in medical students [12]. It may also reflect differing healthcare access patterns, cultural perceptions of medical care, or institutional factors that normalize doctor visits irrespective of anxiety levels.

Finally, students reporting a history of serious illness or hospitalization had significantly higher nosophobia. This aligns with cognitive models of health anxiety: personal experience with illness or trauma can create lasting hypervigilance to bodily symptoms [24]. A study in Public Health and Community Medicine found that early traumatic experiences, including emotional abuse and neglect, were significantly linked to lower self-esteem in medical students, underscoring how past health-related stressors can shape current psychological vulnerabilities like nosophobia [25]. Thus, students who have endured major illness may perceive themselves as more vulnerable, sensitizing them to innocuous symptoms. While formal studies on this variable are rare, the finding is intuitive: prior health scares likely make future disease fears more salient. Altogether, the patterns we observed—no gender gap, program-related differences, hostel effect, and prior illness—provide a coherent picture. They suggest that nosophobia among our students is multifactorial, influenced by environment (living arrangements), educational context (field of study), and personal history, rather than by gender alone. Our study identified two specific behaviors that were strongly linked to nosophobia in medical students. These behaviors reflect classic features of health anxiety: for example, nosophobic individuals often “repetitively and persistently” scan their body for signs of illness, and medical training itself can amplify fear by prompting students to apply learned disease information to themselves [7]. In other words, constant exposure to serious disease concepts appears to fuel students’ tendency to over-interpret minor symptoms and to fear having a serious illness. The robust chi-square associations suggest that these behaviors could serve as practical “red flags” for identifying students at risk: frequent disease-focused worrying, obsessive symptom checking, or knowledge-driven fear should alert educators and clinicians to the possibility of underlying nosophobia. Recognizing these behavioral cues provides a valuable early-warning signal, indicating when a student’s health concerns may warrant further attention or support.

The substantial prevalence of nosophobia and its association with identifiable risk factors highlight important implications for medical education and student well-being. Our findings suggest that medical colleges should recognize nosophobia as a real concern and respond with proactive strategies. Routine screening for health anxiety could be integrated into student health services, with referrals to confidential counseling or cognitive-behavioral support groups to help students reframe excessive worries and distinguish normal sensations from illness. Awareness campaigns and peer-support initiatives can destigmatize health anxiety, encourage healthy coping, and reassure students that such fears are common and manageable. Figure 3 summarizes proposed strategies at the institutional, curricular, and student-support levels, including routine screening, confidential counseling, psychosomatic education, stress management training, and improved hostel support systems. The proposed roadmap is author-developed conceptual framework derived from the study findings and prior literature rather than a validated intervention model [26–31].

Fig. 3.

Policy roadmap for institutions to support medical students’ mental health and reduce nosophobia

Limitations

Our study has a few limitations that should be acknowledged. As a single-center, cross-sectional survey, the findings may not be fully generalizable to students in other institutions or regions. This cross-sectional design of the study precludes any causal inference between identified factors and nosophobia. The reliance on self-reported data could introduce response bias, as participants may have underreported or overestimated their symptoms. A non-probability convenience sampling approach was used, which may have resulted in unequal representation across programs and years; however, the overall sample size was sufficient for the main analyses. Additionally, while the Whiteley Index is a validated tool, it does not capture the full clinical complexity of nosophobia, and a structured clinical interview might provide deeper insights. Despite adjusting for demographics, three additional items may overlap conceptually with WI-14 constructs. While these questions provide curriculum-specific insights, their overlap may increase shared variance between predictors and outcome. Future studies should validate them as standalone tools with broader sampling and a longitudinal design could offer a more comprehensive understanding.

Conclusion

Our study revealed that nosophobia affects a significant portion of medical students, with 16.5% meeting the criteria for high illness anxiety. Importantly, nosophobia was not significantly associated with gender, age, or academic year, suggesting that it is a broad-based concern across the student population. However, it was significantly linked to a history of serious illness or hospitalization and lodging status, with hostelites reporting greater health anxiety than day scholars. In addition, students who frequently worried about diseases they studied or reported increased fear due to medical knowledge were more likely to experience nosophobia. These behaviors point to cognitive and environmental triggers that may intensify health-related anxiety during medical training. In light of our findings, medical institutions could implement proactive policies to address nosophobia. This may include incorporating routine health-anxiety screening within student health services, ensuring access to confidential counseling and group-based interventions, and embedding stress-management and psychosomatic education into the curriculum. Institutions may also prioritize supportive residential environments by facilitating peer support, strengthening family communication, and promoting healthy lifestyle practices. Future interventional studies are warranted to evaluate the effectiveness of these strategies in reducing health anxiety among medical students.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contribution

MO designed the study, analyzed the data, and drafted the manuscript. MU and RZ contributed to data collection and literature review. MHY and MUM assisted with data interpretation, statistical analysis, and manuscript editing. SG supervised the project and critically revised the manuscript. All authors read and approved the final manuscript.

Funding

Self-funded.

Data availability

The data supporting the findings of this study are available as a supplementary file in the submission system.

Declarations

Ethics approval and consent to participate

The study was commenced after approval from the Institutional Review Board (IRB) of Wah Medical College (IRB Approval No. WMC/ERC/IRB/062). Participation in the study was voluntary, and no one was forced to take part in data collection. Ethical standards set by the Helsinki Declaration [32] and the Institutional Review Board of Wah Medical College were taken into consideration throughout the entire process. All participants were aged 18 years or older. Digital informed consent was obtained from each participant prior to their inclusion in the study. Participation was voluntary, and participants could withdraw at any time without consequence.

Consent for publication

Not applicable. The submission of the questionnaire was anonymous, and no personal questions were asked of the participants that could reveal their identity. The privacy and confidentiality of the responses were ensured.

Competing interests

The authors declare no competing interests.