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The United States Department of Health and Human Services (HHS) regulations for the protection of human subjects (45 CFR 46, the Common Rule) primarily apply to research that is federally funded by U.S. agencies or conducted under the auspices of a U.S. institution. Since this study was conducted independently, without U.S. federal funding or institutional oversight, it does not fall within the mandatory scope of U.S. IRB review under 45 CFR 46. Additionally, under 45 CFR 46.104(d), certain types of research, including anonymous survey studies with minimal risk, may qualify for exemption from full IRB review. This study involved an online survey with no personally identifiable information (PII) collected, no experimental intervention, and no psychological or physiological risk to participants, aligning with the exemption criteria. Furthermore, the Secretary\u2019s Advisory Committee on Human Research Protections (SACHRP) 2013 recommendations emphasize that IRBs should adopt a flexible and context-specific approach to internet-based research. The guidance highlights that additional IRB oversight may not be required for minimal-risk online surveys that do not involve direct intervention or manipulation. Given that this study met these conditions, the HUFS IRB approval sufficiently ensured ethical compliance without requiring additional U.S. IRB approval. All participants provided informed consent before taking part in the study. They were clearly informed of the research objectives, procedures, and potential risks. Participation was entirely voluntary, and participants retained the right to withdraw from the study at any time without penalty. No personally identifiable information (PII) was collected at any stage of the study. All responses were anonymized, and data access was restricted solely to the research team to maintain confidentiality. The study was conducted in accordance with relevant ethical guidelines, including 45 CFR 46 and SACHRP recommendations, and no additional institutional ethics approval was deemed necessary based on these established regulatory frameworks.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"Not applicable.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to participate"}},{"value":"The authors declare no competing interests.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"212"}}