Physician and Advanced Practice Clinician Burnout in Rural and Urban Settings

Melissa L. Harry; Nancy L. Sudak; Mary J. Engels; Karly K. Horn; Kate Dean; Sara Poplau; Martin J. Stillman; Mark Linzer

doi:10.3122/jabfm.2023.230233R1

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Table 1.

March 2022 Anonymous Clinician Burnout Quality Improvement Survey Respondent Demographics for the Full Sample and Family Practice Clinicians by Clinician Role for the Urban and Rural Subgroups

	Full Sample (n = 1,085)					Family Practice Sample (n = 223)
		Urban Subgroup (n = 736)		Rural Subgroup (n = 349)		Urban Subgroup (n = 86)		Rural Subgroup (n = 137)
	Total (n = 1,085)	Physicians (n = 419)	APCs^* (n = 317)	Physicians (n = 170)	APCs^* (n = 179)	Physicians (n = 47)	APCs^* (n = 39)	Physicians (n = 59)	APCs^* (n = 78)
Demographics	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
Gender^{^†}
Cisgender male assigned at birth	362 (33.4)	193 (46.1)	51 (16.1)	97 (57.1)	21 (11.7)	17 (36.2)	<5	29 (49.2)	6 (7.7)
Cisgender female assigned at birth	609 (56.1)	166 (39.6)	242 (76.3)	64 (37.6)	137 (76.5)	28 (59.6)	31 (79.5)	27 (45.8)	65 (83.3)
Non-binary/Transgender/ Other/Prefer not to answer	69 (6.4)	40 (9.6)	13 (4.1)	<10	13 (7.3)	<5	<5	<5	<10
Missing	45 (4.2)	20 (4.8)	11 (3.5)	<10	8 (4.5)	<5	<5	<5	<10
Race/Ethnicity
White	936 (86.3)	332 (79.2)	297 (93.7)	140 (82.4)	167 (93.3)	45 (95.7)	37 (94.9)	54 (91.5)	75 (96.2)
Black	9 (0.8)	<5	<5	<5	<5	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Latino/a	15 (1.4)	8 (1.9)	<5	5 (2.9)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Asian	30 (2.8)	23 (5.5)	<5	5 (2.9)	<5	0 (0.0)	0 (0.0)	<5	0 (0.0)
Native Hawaiian/Other Pacific Islander	<5	<5	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
American Indian/Alaska Native	<5	0 (0.0)	0 (0.0)	<5	<5	0 (0.0)	0 (0.0)	<5	<5
Middle Eastern/North African	9 (0.8)	5 (1.2)	0 (0.0)	<5	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Other race/Multiple races/ethnicities^{^‡}	43 (4.0)	23 (5.5)	8 (2.5)	9 (5.3)	<5	<5	<5	<5	<5
Missing race/ethnicity	40 (3.7)	24 (5.7)	7 (2.2)	<5	5 (2.8)	<5	<5	<5	<5
Employment type
Full-time	916 (84.4)	353 (84.3)	268 (84.5)	141 (82.9)	154 (86.0)	38 (80.8)	32 (82.0)	49 (83.0)	69 (88.5)
Part-time	169 (15.6)	66 (15.8)	49 (15.5)	29 (17.1)	25 (14.0)	9 (19.2)	7 (18.0)	10 (17.0)	9 (11.5)
Department
Anesthesiology	86 (7.9)	23 (5.5)	39 (12.3)	5 (2.9)	19 (10.6)
Cardiology	51 (4.7)	16 (3.8)	24 (7.6)	<5	7 (3.9)
Elder Care	24 (2.2)	<10	14 (4.4)	<5	<5
Emergency Services	69 (6.4)	30 (7.2)	<10	18 (10.6)	12 (6.7)
Family Practice	223 (20.6)	47 (11.2)	39 (12.3)	59 (34.7)	78 (43.6)
General Internal Medicine	31 (2.9)	10 (2.4)	<10	9 (5.3)	<5
General Pediatrics	26 (2.4)	13 (3.1)	<10	6 (3.5)	<5
General Surgery	32 (3.0)	10 (2.4)	12 (3.8)	7 (4.1)	<5
Hospitalist Services	66 (6.1)	42 (10.0)	<10	15 (8.8)	<5
Neurology	23 (2.1)	<10	13 (4.1)	0 (0.0)	<5
Obstetrics & Gynecology	44 (4.1)	20 (4.8)	12 (3.8)	9 (5.3)	<5
Orthopedic Medicine/Surgery/Urgent Care	42 (3.9)	28 (6.7)	<10	<5	<5
Urgent Care	37 (3.4)	<10	19 (6.0)	5 (2.9)	12 (6.7)
Specialty <2% of Total Respondents	310 (28.6)	150 (35.8)	104 (32.8)	30 (17.6)	26 (14.5)
Missing	21 (1.9)	14 (3.3)	<10	<5	<5

Note: Some small groups were combined and counts less than 5, and in some cases less than 10, were masked to reduce the risk of re-identification. Departments may not add up to 100% due to rounding and masking.
↵*Certified Nurse Practitioner, Physician Assistant, Certified Registered Nurse Anesthetist, Certified Nurse Midwife, Clinical Nurse Specialist.
↵^†While respondents could select more than one gender, none did.
↵^‡Respondents could select more than one race/ethnicity.
Abbreviation: APC, advanced practice clinician.

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Table 2.

Spearman’s Rho Correlation Matrices for the Mini Z 1.0 in Urban (Lower Diagonal) and Rural (Upper Diagonal) Subgroups of Physician and Advanced Practice Clinicians

Items	Burnout	Satisfaction	Stress	Control	EMR Time	Teamwork	Chaotic	Home EMR	Values
Burnout	1.000	0.589^***	0.596^***	0.572^***	0.424^***	0.350^***	0.366^***	0.238^***	0.345^***
Satisfaction	0.613^***	1.000	0.433^***	0.534^***	0.340^***	0.461^***	0.284^***	0.227^***	0.417^***
Stress	0.622^***	0.381^***	1.000	0.456^***	0.387^***	0.278^***	0.244^***	0.308^***	0.116*
Control	0.509^***	0.462^***	0.469^***	1.000	0.610^***	0.347^***	0.397^***	0.221^***	0.308^***
EMR time	0.400^***	0.345^***	0.380^***	0.510^***	1.000	0.192^***	0.378^***	0.375^***	0.225^***
Teamwork	0.327^***	0.418^***	0.205^***	0.313^***	0.223^***	1.000	0.091	0.145**	0.436^***
Chaotic	0.301^***	0.203^***	0.330^***	0.316^***	0.285^***	0.117^**	1.000	0.105	0.123^*
Home EMR	0.170^***	0.158^***	0.218^***	0.222^***	0.463^***	0.193^***	0.100^**	1.000	0.056
Values	0.341^***	0.529^***	0.155^***	0.281^***	0.205^***	0.357^***	0.126^***	0.042	1.000

↵Note: Rounded to nearest thousandth place. *P <.05. **P <.01. ***P <.001.
Abbreviation: EMR, Electronic medical record.

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Table 3.

Survey Responses to Mini Z 1.0 Items, Work Intentions, and Negative Work Experiences Due to Race or Gender: Full Sample and Rural versus Urban Comparisons, Including by Clinician Type

	Full Sample (n = 1085)		Urban Clinicians (n = 736)		Rural Clinicians (n = 349)			Urban Physicians (n = 419)		Rural Physicians (n = 170)			Urban APCs (n = 317)		Rural APCs (n = 179)
Items	n (%)	Total	n (%)	Total	n (%)	Total	P	n (%)	Total	n (%)	Total	P	n (%)	Total	n (%)	Total	P
High satisfaction^*	765 (73.1)	1047	510 (72.2)	706	255 (74.8)	341	0.385	279 (70.3)	397	122 (73.1)	167	0.507	231 (74.8)	309	133 (76.4)	174	0.681
High stress^*	632 (60.4)	1047	429 (60.8)	706	203 (59.5)	341	0.702	249 (62.7)	397	92 (55.1)	167	0.091	180 (58.3)	309	111 (63.8)	174	0.232
Burnout^†	485 (46.3)	1047	332 (47.0)	706	153 (44.9)	341	0.512	193 (48.6)	397	65 (38.9)	167	0.035	139 (45.0)	309	88 (50.6)	174	0.237
Values alignment^*	728 (71.4)	1020	500 (72.8)	687	228 (68.5)	333	0.153	295 (75.4)	391	117 (72.2)	162	0.428	205 (69.3)	296	111 (64.9)	171	0.334
Lack of workload control^{^‡}	438 (42.9)	1020	300 (43.7)	687	138 (41.4)	333	0.501	183 (46.8)	391	68 (42.0)	162	0.299	117 (39.5)	296	70 (40.9)	171	0.765
EMR time pressure^{^‡}	399 (39.1)	1020	270 (39.3)	687	129 (38.7)	333	0.863	162 (41.4)	391	65 (40.1)	162	0.776	108 (36.5)	296	64 (37.4)	171	0.839
High teamwork^§	881 (86.4)	1020	592 (86.2)	687	289 (86.8)	333	0.788	337 (86.2)	391	145 (89.5)	162	0.289	255 (86.1)	296	144 (84.2)	171	0.567
Chaotic work atmosphere^‖	487 (47.7)	1020	350 (50.9)	687	137 (41.1)	333	0.003	202 (51.7)	391	65 (40.1)	162	0.013	148 (50.0)	296	72 (42.1)	171	0.100
High home EMR^¶	281 (27.5)	1020	183 (26.6)	687	98 (29.4)	333	0.349	110 (28.1)	391	55 (34.0)	162	0.174	73 (24.7)	296	43 (25.1)	171	0.907
Intent to leave practice in 2 years^#	398 (39.0)	1020	263 (38.3)	687	135 (40.5)	333	0.488	152 (38.9)	391	71 (43.8)	162	0.280	111 (37.5)	296	64 (37.4)	171	0.987
Negative work experiences due to:
Race^**	11 (1.1)	1014	8 (1.2)	682	3 (0.9)^††	332	0.489	8 (2.1)	387	3 (1.9)^{^††}	162	0.584	0 (0.0)	295	0 (0.0)	170	^‡‡
Gender^**	69 (6.8)	1012	52 (7.6)	682	17 (5.2)	330	0.143	36 (9.3)	388	11 (6.8)	161	0.351	16 (5.4)	294	6 (3.6)	169	0.357

Note: χ² analyses. P < .05 are bolded. Percentages rounded to nearest tenth decimal place.
↵*Agree/Strongly Agree.
↵^†I am definitely burning out and have one or more symptoms of burnout, e.g. emotional exhaustion/The symptoms of burnout that I’m experiencing won’t go away. I think about work frustrations a lot/I feel completely burned out. I am at the point where I may need to seek help.
↵^‡Poor/Marginal.
↵^§Satisfactory/Good/Optimal.
↵^‖Very Busy/Hectic, Chaotic.
^¶Moderately High/Excessive.
^#Moderate/Likely/Definite.
^**Frequently/Fairly Often.
^††Fisher’s exact test.
^‡‡Not applicable.
Abbreviations: APC, Advanced Practice Clinician; EMR, Electronic medical record; Total, Total responses for the respective item for each group (excludes non-responses).

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Table 4.

Factors Related to Clinician Burnout: Adjusted Binary Logistic Regression Models for Physician and APC Subgroups in the Full Sample

	Physicians		APCs
	Mini Z	Mini Z + Independent Variables	Mini Z	Mini Z + Independent Variables^*
Variables	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
High satisfaction	0.16 (0.09-0.29)^***	0.16 (0.08-0.32)^***	0.28 (0.14-0.56)^***	0.46 (0.21-0.99)^*
High stress	7.11 (4.11-12.28)^***	6.36 (3.60-11.24)^***	6.63 (3.85-11.42)^***	6.32 (3.63-11.02)^***
Values aligned	0.64 (0.34-1.21)	0.65 (0.33-1.26)	0.44 (0.24-0.78)^**	0.48 (0.26-0.88)^*
Lack of workload control	2.68 (1.62-4.42)^***	2.42 (1.43-4.09)^**	2.02 (1.18-3.46)^*	1.98 (1.14-3.45)^*
EMR time pressure	1.42 (0.81-2.49)	1.53 (0.86-2.71)	1.35 (0.77-2.34)	1.30 (0.74-2.30)
High teamwork	0.61 (0.26-1.43)	0.66 (0.27-1.62)	1.16 (0.57-2.39)	1.18 (0.57-2.46)
Chaos in work atmosphere	1.24 (0.76-2.01)	1.12 (0.67-1.86)	1.57 (0.96-2.56)	1.54 (0.92-2.59)
High home EMR time	1.17 (0.65-2.08)	1.28 (0.71-2.33)	1.37 (0.75-2.52)	1.47 (0.79-2.74)
High intent to leave in 2 years		2.36 (1.39-4.02)^**		2.38 (1.32-4.28)^**
Negative work experiences:
Gender		1.94 (0.74-5.07)		2.61 (0.62-10.96)
Race		0.12 (0.02-0.74)^*
Part-time^{^†}		0.53 (0.26-1.08)		0.53 (0.25-1.12)
Rural clinician		0.62 (0.36-1.05)		1.32 (0.79-2.21)
Gender^{^‡}
Female	0.96 (0.59-1.58)	0.94 (0.55-1.61)	1.40 (0.71-2.78)	1.42 (0.70-2.87)
Other^§	0.86 (0.31-2.35)	0.83 (0.28-2.42)	1.02 (0.24-4.39)	0.88 (0.18-4.28)
BIPOC/multiracial^‖	0.57 (0.28-1.14)	0.58 (0.27-1.22)	1.10 (0.30-3.97)	1.36 (0.37-5.02)
N	517	516	446	444
Likelihood Ratio χ² (df)	266.84 (11)^***	286.23 (16)^***	199.00 (11)^***	212.30 (15)^***
Pearson’s χ² Model Fit (df)	241.88 (216)	346.07 (337)	162.06 (154)	266.65 (262)
McKelvey & Zavoina’s pseudo R²	0.548	0.591	0.484	0.515

Note: Models adjusted for gender (male, female, or other/prefer not to answer) and race (white or BIPOC/multiple race/ethnicity). ***P < .001, **P < .01, *P <.05.
↵*Negative experiences at work due to race was omitted due to collinearity.
↵^†Compared with full-time employment.
↵^‡Compared with males.
↵^§Includes other, prefer not to answer, binary, transgender.
^‖Compared with white.
Abbreviations: APC, advanced practice clinician; BIPOC, black, Indigenous, and people of color; CI, confidence interval; df, degrees of freedom; n/a, not applicable; OR, odds ratio; EMR, Electronic medical record.

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Table 5.

Factors Related to Clinician Burnout: Adjusted Binary Logistic Regression Models for the Rural and Urban Subgroups of Physician and Advanced Practice Clinician Survey Respondents

	Rural Subgroup		Urban Subgroup
	Mini Z	Mini Z + Independent Variables	Mini Z	Mini Z + Independent Variables
Variables	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
High satisfaction	0.22 (0.10-0.51)^***	0.26 (0.11-0.65)^**	0.19 (0.11-0.34)^***	0.24 (0.13-0.44)^***
High stress	9.97 (4.89-20.29)^***	8.53 (4.09-17.78)^***	7.50 (4.63-12.13)^***	7.55 (4.60-12.41)^***
Values alignment	0.38 (0.18-0.80)^*	0.42 (0.19-0.90)^*	0.57 (0.33-0.98)^*	0.63 (0.36-1.09)
Lack of workload control	3.11 (1.54-6.29)^**	3.06 (1.47-6.36)^**	1.97 (1.28-3.04)^**	1.81 (1.15-2.83)^*
EMR time pressure	1.44 (0.68-3.02)	1.45 (0.67-3.13)	1.28 (0.79-2.06)	1.29 (0.80-2.11)
High teamwork	1.64 (0.63-4.34)	1.67 (0.61-4.57)	0.69 (0.35-1.35)	0.75 (0.37-1.51)
Chaotic work atmosphere	2.45 (1.29-4.67)^**	2.53 (1.29-4.99)^**	1.09 (0.71-1.65)	0.98 (0.63-1.52)
High home EMR time	0.79 (0.37-1.69)	1.01 (0.45-2.27)	1.46 (0.87-2.42)	1.50 (0.89-2.52)
High intent to leave in 2 years		2.18 (1.06-4.45)^*		2.48 (1.54-3.98)^***
Negative work experiences:
Gender		0.95 (0.15-5.84)		2.34 (0.97-5.64)
Race		0.25 (0.01-7.75)		0.09 (0.01-0.67)^*
APC^*		1.31 (0.60-2.89)		1.01 (0.63-1.62)
Part-time^{^†}		0.30 (0.11-0.81)^*		0.67 (0.36-1.25)
Gender^{^‡}
Female	1.55 (0.80-3.02)	1.81 (0.79-4.15)	1.06 (0.69-1.63)	0.97 (0.59-1.59)
Other^§	1.19 (0.18-8.08)	0.81 (0.08-8.15)	0.73 (0.29-1.81)	0.72 (0.28-1.88)
BIPOC/multiracial^‖	0.10 (0.02-0.46)^**	0.11 (0.02-0.58)^**	1.12 (0.56-2.24)	1.34 (0.63-2.86)
N	317	315	646	645
Likelihood Ratio χ² (df)	180.49 (11)^***	190.25 (16)^***	301.64 (11)^***	324.51 (16)^***
Pearson’s χ² Model Fit (df)	159.94 (150)	211.44 (212)	257.63 (228)	421.65 (386)
McKelvey & Zavoina’s pseudo R²	0.609	0.643	0.502	0.537

Note: Models adjusted for gender (male, female, or other/prefer not to answer) and race (white or BIPOC/multiple race/ethnicity). ***P < .001, **P < .01, *P <.05.
↵*Compared with physicians.
↵^†Compared with full-time employment.
↵^‡Compared to males.
↵^§Includes other, prefer not to answer, binary, transgender.
↵^‖Compared to white.
Abbreviations: APC, advanced practice clinician; BIPOC, black, Indigenous, and people of color; CI, confidence interval; df, degrees of freedom; n/a, not applicable; OR, odds ratio; EMR, electronic medical record.

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Table 6.

Factors Related to Clinician Burnout: Adjusted Binary Logistic Regression Models for Family Practice Physicians and Advanced Practice Clinicians

	Mini Z	Mini Z + Independent Variables
Variables	OR (95% CI)	OR (95% CI)
High satisfaction	0.18 (0.06-0.52)^**	0.18 (0.05-0.62)^**
High stress	16.40 (6.42-41.90)^***	13.43 (4.90-36.79)^***
Values aligned	0.39 (0.14-1.09)	0.44 (0.15-1.31)
Lack of workload control	1.83 (0.81-4.13)	1.75 (0.73-4.20)
EMR time pressure	1.46 (0.63-3.40)	1.46 (0.60-3.56)
High teamwork	1.42 (0.51-3.94)	1.31 (0.44-3.92)
Chaos in work atmosphere	2.25 (1.06-4.78)^*	2.02 (0.90-4.52)
High home EMR time	1.13 (0.46-2.77)	1.85 (0.68-5.04)
High intent to leave in 2 years		2.11 (0.84-5.30)
Negative work experiences due to gender^*		0.92 (0.11-8.09)
APC^{^†}		2.53 (0.99-6.42)
Part-time^{^‡}		0.24 (0.07-0.81)^*
Rural clinician		0.60 (0.27-1.36)
Gender^§
Female	0.65 (0.25-1.69)	0.55 (0.17-1.72)
Other^‖	1.36 (0.15-12.62)	0.52 (0.04-6.51)
BIPOC/multiracial^¶	0.16 (0.03-1.02)	0.22 (0.03-1.74)
N	212	209
Likelihood Ratio χ² (df)	113.68 (11)^***	123.93 (16)^***
Pearson’s χ² Model Fit (df)	100.84 (103)	150.47 (164)
McKelvey & Zavoina’s pseudo R²	0.586	0.645

Note: Models adjusted for gender (male, female, or other/prefer not to answer) and race (white or BIPOC/multiple race/ethnicity). ***P < .001, **P < .01, *P <.05.
↵*Negative experiences at work due to race was omitted due to collinearity.
↵^†Compared to physicians.
↵^‡Compared to full-time employment.
↵^§Compared to males.
↵^‖Includes other, prefer not to answer, binary, transgender.
↵^¶Compared to white.
Abbreviations: APC, advanced practice clinician; BIPOC, black, Indigenous, and people of color; CI, confidence interval; df, degrees of freedom; n/a, not applicable; OR, odds ratio; EMR, electronic medical record.

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Table A1.

Quality Improvement Survey Questions and Response Options Used in This Study

Survey Questions	Response Options
Please tell us with which gender you identify, optional (select all that apply)	Cisgender Male (assigned male at birth) Cisgender Female (assigned female at birth) Non-binary Transgender Other/Prefer not to answer
Are you a (select only one)…	Physician Psychologist Chiropractor Certified Nurse Practitioner Physician Assistant Certified Registered Nurse Anesthetist Certified Nurse Midwife Clinical Nurse Specialist Other Clinician
Please describe your race/ethnicity, optional (select all that apply)	White Black or African American Latino/a Asian Native Hawaiian or Other Pacific Islander Native American or Alaska Native Middle Eastern or North African Other
Using your own definition, are you full time or part time?	Full time Part time
In which clinical site do you practice most?	[healthcare system facilities by market]
Mini Z 1.0 Items The Mini Z was developed by Dr. Mark Linzer and team at Hennepin Healthcare, Minneapolis MN. The Mini Z survey tools can be used for research, program evaluation and education capacities without restriction. Permission for commercial or revenue-generating applications of the Mini Z must be obtained from Mark Linzer, MD or the Hennepin Healthcare Institute for Professional Worklife before use: Available at: www.professionalworklife.com. Questions drawn mainly from the Physician Worklife Study, MEMO study, and the Healthy Workplace study.
Overall I am satisfied with my job^*	Strongly agree = 1 Agree = 1 Neither agree nor disagree = 0 Disagree = 0 Disagree strongly = 0
I feel a great deal of stress because of my job	Strongly agree = 1 Agree = 1 Neither agree nor disagree = 0 Disagree = 0 Disagree strongly = 0
Using your own definition of “burnout,” please select one of the answers below	I enjoy my work. I have no symptoms of burnout. = 0 I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out. = 0 I am definitely burning out and have one or more symptoms of burnout, e.g. emotional exhaustion. = 1 The symptoms of burnout that I’m experiencing won’t go away. I think about work frustrations a lot. = 1 I feel completely burned out. I am at the point where I may need to seek help. = 1
My control over my workload is	Poor = 1 Marginal = 1 Satisfactory = 0 Good = 0 Optimal = 0
My sufficiency of time for documentation is	Poor = 1 Marginal = 1 Satisfactory = 0 Good = 0 Optimal = 0
Which number best describes the atmosphere in your primary work area?	Calm = 0 Not too busy = 0 Busy, but reasonable = 0 Very busy = 1 Hectic, chaotic = 1
My professional values are well aligned with those of my department leader / immediate supervisor^*	Strongly agree = 1 Agree = 1 Neither agree nor disagree = 0 Disagree = 0 Disagree strongly = 0
The degree to which my patient care team works efficiently together is^*	Poor = 0 Marginal = 0 Satisfactory = 1 Good = 1 Optimal = 1
The amount of time I spend on the electronic medical record (EMR) at home is	Excessive = 1 Moderately high = 1 Satisfactory = 0 Modest = 0 Minimal/none = 0
What is the likelihood that you will leave your current practice within TWO YEARS?	None = 0 Slight = 0 Moderate = 1 Likely = 1 Definite = 1
How often do you encounter negative experiences at work due to your gender (e.g. being denied work opportunities, being isolated or treated as if you were not competent, experiencing repeated, small slights at work, or other forms of discrimination)?	Frequently = 1 Fairly Often = 1 Infrequently = 0 Rarely = 0 Never = 0
How often do you encounter negative experiences at work due to your race (e.g. being denied work opportunities, being isolated or treated as if you were not competent, experiencing repeated, small slights at work, or other forms of discrimination)?	Frequently = 1 Fairly Often = 1 Infrequently = 0 Rarely = 0 Never = 0

Note: Bolded versus non-bolded response options indicate responses that were combined to create binary variables, denoted “1” or “0.”
↵*Reverse coded.