Healthcare managers' perceptions of professional development and organizational support.
Abstract: Purpose: This article explores the participation of healthcare managers in professional development (PD) activities, the reasons for seeking PD and the perceived support of their organizations in terms of reward and recognition.

Methodology: An exploratory survey was emailed to current and past members of three professional associations who share similar missions "to provide educational and networking opportunities" for their members in the southern region of Florida.

Findings: Findings suggest that healthcare managers and healthcare organizations both support and value personal and professional development. Certification by professional organizations appears to be a key credential for upward mobility.

Research limitations: This study serves as an initial attempt to account for the factors that explain differences in pursuing professional development activities. Given the exploratory nature of the study and low response rates, the findings provide direction for further research rather than conclusive judgments.

Practical implications: Continuous learning by managers and organizations should allow the healthcare industry to position itself for future challenges.

Originality: Across all settings, positions, age groups, and perceived organizational support, individuals seek professional certification suggesting recognition of the professional value associated with these certifications. The value attributed to certification and PD by healthcare managers is further demonstrated by our finding that individuals engage in these activities even in the absence of employer reimbursement.

Keywords: Professional development, continuous learning, learning organizations

Article classification: Research
Article Type: Report
Subject: Health services administrators (Practice)
Professional development (Research)
Authors: Gumus, Gulcin
Borkowski, Nancy
Deckard, Gloria J.
Martel, Karen J.
Pub Date: 06/22/2011
Publication: Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2011 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739
Issue: Date: Summer, 2011 Source Volume: 34 Source Issue: 1
Topic: Event Code: 200 Management dynamics; 310 Science & research
Product: Product Code: 8048000 Medical Administrators NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 304050539
Full Text: INTRODUCTION

In today's economic and healthcare environment, healthcare managers and organizations face unprecedented challenges and uncertainty. With increasing demands to redesign the overall U.S. health delivery system to provide accessible, integrated, effective, patient-centered, and error-free services, healthcare leaders must assure that both individuals and organizations possess the requisite traits to adapt and respond. Successful adaptation will require continuous professional and organizational growth. Healthcare managers need to remain current, updating their knowledge, skills and competencies. Likewise, organizations must "learn" to adapt and respond as well as to support the development of managerial staff. For only with a knowledgeable management workforce will healthcare organizations succeed in meeting the demands of today and the future.

The concept of a "learning organization" is not new. Building on the work of Argyris and Schon (1978), Peter Senge described learning organizations as places "where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole (reality) together" (1990, p. 3). The basic rationale for such organizations is that in situations of rapid change only those who are flexible, adaptive and productive will excel and that having a highly skilled and adaptable workforce is fundamental for the organization's survival. A learning organization does not rely on passive or ad hoc processes, but instead actively promotes, facilitates, and rewards collective learning. In other words, a learning organization is viewed as a culture of continuously integrating performance and learning. A learning organization "is not an end in itself, but a route to improved performance, productivity, and profit" (Evans, 1998, p. 203).

Learning organizations are skilled in five main activities: systematic problem solving, experimentation with new approaches, learning from their experiences and past history, learning from the experiences and best practices of others, and transferring knowledge quickly and efficiently throughout the organization (Garvin, 1993, p. 81). To develop these skills, Senge (1990) argues that organizations need to discover how to tap people's commitment and capacity to learn at all levels - at the individual, group, and organizational levels. In a learning organization, the individual's personal and professional development (PD) is viewed as crucial to the organization's success. A learning organization actively promotes, facilitates, and rewards learning.

Individual level PD is also recognized as critical to healthcare management by the American College of Healthcare Executives (ACHE) as well as other professional organizations in the field (e.g., Medical Group Management Association, Healthcare Financial Management Association and American College of Health Care Administrators). For example, attaining certification and earning the status of ACHE Fellow is widely regarded as a symbol of professional commitment and competence. ACHE requires continuing education hours (and other related professionalism activities) over a 3-year period for members to qualify for re-certification.

The appreciation of PD (i.e., lifelong learning) is a characteristic of the "knowledge worker"--a term coined by Peter Drucker (1959) four decades ago. As Drucker remarked, unlike industrial workers, knowledge workers own the means of production: their own brainpower. Their greatest potential limitation is obsolescence. Due to rapid changes not only in the health industry but also in the global environment, the knowledge worker appreciates that learning and work are not distinct. Success in the work of healthcare managers means keeping current with developments in the field and also keeping personal knowledge, skills and competencies current through PD.

HEALTHCARE MANAGER AS A KNOWLEDGE WORKER

PD is one component within the broad definition of professionalism, which encompasses a wide range of individual behaviors. For example, the Healthcare Leadership Alliance (HLA), a consortium of six major professional membership organizations, defines professionalism as "the ability to align personal and organizational conduct with ethical and professional standards that include a responsibility to the patient and community, a service orientation, and a commitment to lifelong learning and improvement." The ACHE categorizes the HLA professionalism definition into three areas: (1) personal and professional ethics, (2) professional and community contribution, and (3) continuing education and lifelong learning. As Garman, Evans, Krause, and Anfossi (2006) point out, a key element of professionalism involves understanding the professional roles and norms expected of ealth managers. This understanding may be obtained through involvement with professional associations that provide both educational programs and networking opportunities for the manager to gain new knowledge of current practices as well as the ability to interact with other professionals (Garman, Evans, Krause, & Anfossi, 2006). Individuals who engage in PD share a common goal--increasing their skills and knowledge for career advancement and personal development. Professional development includes many types of learning opportunities, ranging from membership in professional organizations to obtaining higher education degrees, obtaining certification (e.g., ACHE Fellow) or attending professional conferences.

ORGANIZATIONAL SUPPORT FOR PD

Participation in PD activities by healthcare managers is influenced by both personal/professional and organizational factors. At the individual level, a learning organization needs to provide the leadership and the organizational support that facilitates continuous PD or life-long learning among employees. At the same time, individuals must value, commit and seek opportunities for personal and professional growth.

Over the years, researchers have examined why individuals participate in PD activities such as continuing education. The value an organization places on investing in their employees' personal and professional development has been shown to be a significant factor (Lee & Bruvold, 2003). Incentives and rewards systems signal what is valued by an organization. Organizational support theory or perceived organizational support (POS), describes employees' global beliefs concerning the extent to which the organization values their contributions and cares about their well-being (Eisenberger, Huntington, Hutchison, & Sowa, 1986). If staffs PD is valued and encouraged by an organization, incentives such as paying for continuing education or memberships in professional organizations would be part of an employee's benefit package. When higher learning, skills and competencies have been obtained, salary increases and/or advancement in the organization would be evident to the employee.

In addition to POS, individuals participate in PD based on personal values. If PD is not recognized by payment for such activities or other rewards, the decision to pursue PD activities depends on personal values. Professional affiliation and recognition may play a significant role. Research has determined (Gilley & Maycunich, 2000a, 2000b; Murphy, Cross, & McGuire, 2006; Ray, 1981; Tharenou, 2001) that reinforcement of previous PD by significant others (e.g., employers, other professionals) is a strong motivator for continuing development and educational activities.

In the absence of POS, individuals may also consider economic factors when deciding to pursue PD. Human capital theory suggests that individuals will decide to undertake education or training up to the point the marginal benefits are equal to the marginal costs (Becker, 1964; Mincer, 1993). Two recent studies support this economic approach. The Consultative Committee for Professional Management Organizations represents the eight leading business-related professional associations in the United Kingdom. The Committee's study found that "Individuals with professional qualifications and membership of a professional institution are estimated to achieve both higher earnings, and be more likely to be employed across a lifetime, in comparison to individuals with no professional qualifications" (Chapman, Conlon, & Miller, 2008, p. 7). The Committee estimates that the lifetime benefits of these PD activities equal approximately $220,000, with $120,000 associated with an individual's holding professional qualifications and $100,000 for an individual with membership of a professional institute. The second study by the William E. Smith Institute for Association Research (Brooks, 2008) examined the relationship between association membership and member income and job satisfaction. The study's findings revealed that association members are more successful, earn higher incomes, and report greater job satisfaction, on average, than non-members.

The purpose of the study presented here was to explore the participation of healthcare managers in PD, the associated reasons for seeking PD, and the perceived support of their organizations in terms of reward and recognition. As noted previously, organizations that value PD offer incentives and benefits, including bonuses and salary increases, encouraging their employees to engage in such activities. Organizational benefits and rewards are reported by the study participants and, thus, represent their perceptions. In addition, we explore differences across healthcare managers in terms of participation and POS by setting, position, and age. Gender differences using these data are reported elsewhere (see Gumus, Borkowski, Deckard, & Martel, 2009).

METHODS

In order to assess healthcare managers' participation and perceived organizational support, an electronic survey was emailed to current and past members of three professional healthcare management associations with similar missions "to provide educational and networking opportunities" in the southern region of Florida. The survey was exploratory in nature and was designed for the organizations to collect information concerning PD needs of their members. While theoretical underpinnings were considered, the questionnaire was designed to serve practical needs rather than to empirically test the theoretical relationships.

The survey included limited demographic characteristics in order to allow for more detailed information on participation in PD activities in the past year and the type of activities undertaken, as well as whether their employers reimbursed for expenses associated with the respondent's PD activities. In addition, respondents were asked if their employer rewarded PD activities by advancement and/or increased compensation. The questionnaire is available from the authors upon request.

Of the three associations' 675 current and past members, 108 completed the survey, for a response rate of 16%. Respondents employed in non-management positions were excluded, limiting the study sample to healthcare managers and executives. Table 1 reflects the demographic information of the study's final sample respondents (N = 93). Using the associations' member data available to us, we were able to include summary statistics for the general member population as well. Despite the low response rate, a comparison of the descriptive statistics between our sample and the member population provided in this table reveals consistency in terms of the observable characteristics. Nevertheless, generalization is limited and the findings suggest the need for further research.

DATA ANALYSIS AND RESULTS

Data were analyzed using descriptive statistics, t-tests and Kruskal-Wallis tests to examine differences in means and mean proportions. The t-tests are based on the assumption that independent samples with equal variances are being compared. Participants were categorized by age, gender, educational level (highest degree obtained), position (senior versus middle/entry level management), and employer group (hospital versus non-hospital). As displayed in Table 1, 49% of the respondents were 50 years of age or older and 46% were men. A high majority (89%) reported holding either a master's degree or doctorate, which may indicate that a master's degree is the standard credential for today's healthcare manager (Bureau of Labor Statistics, 2010). Approximately 53% of the respondents have a degree in healthcare administration while the remaining portion holds degrees in business or other fields. Senior managers represent 55% of the respondents with the remaining 45% of respondents in middle/entry level management positions. Most of the individuals (62%) work in hospitals, and the rest (38%) are in non-hospital settings such as managed care organizations, outpatient facilities, or home health care centers.

Table 1 also presents the descriptive statistics for the sample by employment setting and by respondent's organizational position. None of the differences across types of facility are statistically significant (p>.10), indicating that the respondents in hospital versus non-hospital settings are similar in terms of the listed characteristics. Those in senior level positions are older and more likely to be male than middle/entry level managers (p<.01). Among those in senior management, 65% are men whereas only 22% among the middle/entry level managers are men.

First, our analysis focuses on the proportion of respondents who indicated that they currently hold professional certifications. Overall 73% of the individuals in the sample responded yes to the question, "Do you hold certification(s) in your field?" These data were further analyzed by age, position, and employment setting. The certification status is positively correlated with age, which suggests that older individuals (presumably those individuals who have been in the field for a longer time) are more likely to a hold certification. While 52% of those under age 40 hold a certification, 73% of those aged 40-49 and 83% of those above age 50 have a certification. Males (88%) are more likely to hold certifications compared to females (62%); this difference is statistically significant (p<.01). However, this may be an artifact of the higher percentage of senior positions among men, as previously noted. When the sample is further analyzed by position, we find that those in senior level management are more likely to hold a certification compared to those in middle/entry level positions (p<.10), 80% and 64%, respectively. Although those in non-hospital settings are slightly more likely to hold certifications compared to those employed by hospitals (77 % and 71%, respectively), the difference is not statistically significant.

Second, respondents were asked whether they typically attend any PD activities such as educational programs, workshops, or conferences and pay for any portion of these activities out-of-pocket. Two thirds of the sample of managers responded yes with no difference between senior and middle/entry level managers. Those employed in a non-hospital setting were more likely to have answered this question affirmatively compared to those employed by hospitals (p<.10, 79% and 60%, respectively). This finding may reflect that hospitals are larger organizations and may be more likely to fund employees' PD activities. Employees whose organizations do not reimburse for PD expenses are more likely to attend such activities by paying out-of-pocket compared to those employees whose employer provides this reimbursed benefit (p<.10, 83% versus 63%, respectively).

Third, respondents who attended PD activities for which they were not reimbursed by their employers were asked their reasons for doing so (Table 2). The major reasons for attendance included personal PD (87%), staying current in the field (54%), and networking with associates (43%). Note that the percentages do not total 100% because respondents reported more than one reason. When the data were analyzed by position, a higher percentage of middle/entry level managers cited networking as the reason than senior level managers. Although the difference is not statistically significant, it may reflect the fact that networking plays an important role in leader and leadership development. Networking "develops leaders beyond merely knowing what and knowing how, to knowing who in terms of problem-solving resources" (Day, 2000, p. 597). Enhancing individual networks is believed to be an effective way to increase managers' innovation and problem-solving capacities.

Comparisons across settings yield some statistically significant differences in reasons for attendance. Managers in non-hospital settings are more likely to cite PD (p<.10, 96% versus 80%, respectively) while managers working for hospitals are more likely to cite staying current in the field (p<.01, 69% versus 35%, respectively). Our findings are consistent with a recent study which reported that hospital CEOs value continuing education for keeping themselves abreast of and understanding current industry changes (Walston & Khaliq, 2010). The percentage reporting personal PD as the reason for attending educational programs is higher among those who pay themselves (93% versus 84%), although not statistically significant. Interestingly, while the numbers are small and the difference is not statistically significant, individuals for whom the organization reimburses expenses are more like to cite combining with a personal vacation than those paying out of pocket (20% versus 7%).

Fourth, professional certification holders were examined according to whether their current employer reimburses for PD activities or not. The proportion with certifications is identical between those managers whose employers reimburse (either fully or partially) for certification and/or licensure fees and those managers whose employers do not (73%). Similarly, the proportion of those with certifications does not statistically differ according to the status of employer's reimbursement for continuing education courses, although the proportion is slightly higher if the employer does pay (75% versus 69%). This same pattern holds when the sample is divided according to the status of employer's reimbursement for recertification fees. These findings reinforce the previous benefit/cost discussion that managers perceive value of professional certification even in the absence of employer reimbursement.

The survey included four questions on the perceived recognition for obtaining licensure/certification and advanced degrees. Only 23% of the managers believed that obtaining an advanced degree is associated with a salary increase in their institution (Table 3). An even smaller proportion of managers, 11%, perceive that earning an advanced degree is recognized with a promotion in their organizations. When the managers were asked whether obtaining licensure/certification is recognized with a salary increase, almost half of them answered yes. Recognition of such an achievement with a promotion, on the other hand, is perceived to be very unlikely. In general, although senior level managers are more likely to perceive recognition for such achievements in their workplaces compared to middle/entry level managers, the differences are not significant. The differences by facility, on the other hand, reveal statistically significant differences. With the exception of the first question listed in Table 3, managers working in a hospital are more likely to positively perceive recognition for PD compared to their counterparts working in non-hospital settings. This finding may result from the size of hospitals and a higher number of opportunities for advancement and recognition compared to non-hospital settings.

Table 4 presents the current employer's reimbursement for different types of PD activities (either fully or partially) based on participants' responses, and how these differ by facility and position. Seventy-five percent of the individuals say their employer provides tuition for college level courses in their benefit package, 69% say continuing education courses are covered, and 71% related that attendance at annual conferences or meetings of their professional organizations are covered by their employers. The proportion who list licensure/certification fees and membership in professional organizations as being covered by their employers are smaller (48% and 56%, respectively). Dividing the sample by type of setting indicates that managers in hospitals are more likely to receive funding benefits from their employers compared to those working in non-hospital settings. These differences are statistically significant for tuition for college level courses, continuing education courses, and licensure/certification fees. The difference in funding benefits may be a result of hospitals being, in general, larger entities with higher acuity patients, complex structures, and greater variation of employed professionals than non-hospital organizations (e.g., physician practices, long-term care facilities). As such, hospitals may allocate a greater amount of their financial resources for their employees' PD. There are no significant differences by position with the exception of membership in professional organizations. Senior managers are more likely to receive this benefit from their employers compared to middle/entry level managers (p<.01, 69% versus 40%, respectively).

DISCUSSION

Healthcare managers demonstrate commitment to the profession through personal and professional development as noted by Garman, Evans, Krause, and Anfossi (2006). Across all settings, positions, and age groups, the vast majority (73%) held certification(s), suggesting recognition of the associated professional value. Of the study's respondents holding a certification, nearly half (49%) indicated that he/she was either board certified in healthcare management through the American College of Healthcare Executives (ACHE) and/or held the designation of Fellow with the organization. Since certifications are generally granted through the manager's relevant professional association, we can assume that the individual continues to hold membership in that association for continuing education and re-certification.

Senior level managers are more likely to hold certification compared to those in middle/entry level positions. This finding may suggest that certification is an important credential for healthcare managers who desire to move up the organizational ladder. The value attributed to certification and PD by healthcare managers is further demonstrated by our finding that individuals engage in these activities even in the absence of employer reimbursement. This finding supports the characterization of healthcare managers as knowledge workers (Drucker, 1959) as PD assures their means of production, that is, brainpower, and prevents obsolescence. Continued PD by these individuals builds their "brainpower" and credentials for promotion opportunities or for obtaining positions in organizations that actively promote, facilitate and reward learning as described by Senge (1990).

Given the exploratory nature of our survey, our findings cannot be regarded as conclusive but indicative of the need to further study PD and its impact on career advancement. Our study data was self-reported and reflected the perception of healthcare managers regarding their organizations' support of PD activities. No assessment was made as to whether these types of activities actually lead to career advancement. In future research, more comprehensive analysis is needed to examine the healthcare managers' participation in PD while controlling for other contributing factors such as age, race and ethnicity, educational attainment, experience, and seniority within the institution. Healthcare organizations that demonstrate a commitment to learning are rewarded with a managerial staff who seek development opportunities and, thereby, improve the effectiveness of their own performance as well as that of the organizations (Senge, 1990). The commitment to professionalism and life-long learning demonstrated by our sample suggests that healthcare managers stay current in the field and seek to continuously develop the knowledge, skills and competencies required for today's challenges and tomorrow's unknowns.

ACKNOWLEDGEMENTS

The authors would like to thank the two anonymous referees for their constructive feedback.

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GULCIN GUMUS

Florida Atlantic University

NANCY BORKOWSKI

Florida International University

GLORIA J. DECKARD

Florida International University

KAREN J. MARTEL

Alere, Inc.
Table 1
Descriptive statistics
                           Member      Entire Study

                             %         %       StDev
Age
20-39                       0.26      0.23      0.42
40-49                       0.22      0.28      0.45
50+                         0.52      0.49      0.50
Sex
Male                        0.42      0.46      0.50
Female                      0.58      0.54      0.50
Highest degree obtained
Doctorate                   0.10      0.11      0.31
Master's                    0.73      0.78      0.41
Bachelor's or other         0.17      0.11      0.31
Field for the highest
  degree
Health administration                 0.53      0.50
Business                              0.24      0.43
Other field                           0.24      0.43
Position
Senior level management     0.60      0.55      0.50
Middle/entry management     0.40      0.45      0.50
Facility
Hospital                    0.59      0.62      0.49
Non-hospital                0.41      0.38      0.49
N                           597                  93

                                      Non-
Study Sample              Hospital   hospital  Senior   Mid/Ent
                             %          %        %         %
Age
20-39                       0.19      0.29      0.10     0.38
40-49                       0.33      0.20      0.20     0.38
50+                         0.48      0.51      0.71     0.24
Sex
Male                        0.46      0.46      0.65     0.22
Female                      0.54      0.54      0.35     0.78
Highest degree obtained
Doctorate                   0.12      0.09      0.14     0.07
Master's                    0.78      0.80      0.78     0.79
Bachelor's or other         0.10      0.11      0.08     0.14
Field for the highest
  degree
Health administration       0.53      0.51      0.59     0.45
Business                    0.22      0.26      0.18     0.31
Other field                 0.24      0.23      0.24     0.24
Position
Senior level management     0.53      0.57      0.61     0.64
Middle/entry management     0.47      0.43      0.39     0.36
N                            58        35        51       42

Notes: The percentages may not sum up to one due to rounding.

Table 2

Reasons for attending educational programs by paying
out-of-pocket

                                    Professional     To stay current
                                     development      in the field

All (N=61)                              87 %               54%
By position
Senior level management                  91%               55%
Middle or entry level management         82%               54%
By facility
Hospital                                80% *            69% ***
Non-hospital                            96% *            35% ***
Employer reimburses expenses
Yes                                      84%               56%
No                                       93%               47%

                                     To network          Combine
                                   with associates    with vacation

All (N=61)                              43 %              16 %
By position
Senior level management                  33%               18%
Middle or entry level management         54%               14%
By facility
Hospital                                 51%               23%
Non-hospital                             31%               8%
Employer reimburses expenses
Yes                                      47%               20%
No                                       27%               7%

Notes: *, **, *** indicate statistically significant differences
between groups at 10%, 5%, and 1% significance levels, respectively.
Differences between groups are tested using a t-test. The percentages
do not sum up to one since the respondents were allowed to pick
multiple answers.

Table 3
Perceived recognition for obtaining licensure/certification
and advanced degrees

When an employee in your organization                  Yes   No

  earns an advanced degree, is this achievement
  recognized with a salary increase? (N=90)            23%   77%

By facility

                                           Hospital    24%   76%
                                       Non-hospital    22%   78%

By position

                            Senior level management    29%   71%
                   Middle or entry level management    17%   83%

  earns an advanced degree, is this achievement
  recognized with a promotion? (N=91)                  11%   89%

By facility *

                                           Hospital    16%   84%
                                       Non-hospital    3%    97%

By position

                            Senior level management    12%   88%
                   Middle or entry level management    10%   90%

  obtains licensure/certification, is this
  achievement recognized with a salary increase?       45%   55%
  (N=89)

By facility **

                                           Hospital    54%   46%
                                       Non-hospital    30%   70%

By position

                            Senior level management    47%   53%
                   Middle or entry level management    43%   57%

  obtains licensure/certification, is this
  achievement recognized with a promotion? (N=90)      17%   83%

By facility *

                                           Hospital    21%   79%
                                       Non-hospital    9%    91%

By position

                            Senior level management    16%   84%
                   Middle or entry level management    17%   83%

Notes: Differences between groups are tested using a t-test.
*, **, *** indicate statistically significant differences at 10%, 5%,
and 1% significance levels, respectively.

Table 4
PD activities reimbursed by the current employer

                                                      Yes   No
Does your current employer provide the
following in your

Tuition for college level courses (N=93)              75%   25%

                  By facility ***

                                          Hospital    88%   12%
                                      Non-hospital    54%   46%

                  By position

                           Senior level management    73%   27%
                  Middle or entry level management    79%   21%

Continuing education courses (N=93)                   69%   31%

                  By facility **

                                          Hospital    78%   22%
                                      Non-hospital    54%   46%

                  By position

                           Senior level management    73%   27%
                  Middle or entry level management    64%   36%

Certification and/or licensure fees (N=93)            48%   52%

                  By facility *

                                          Hospital    55%   45%
                                      Non-hospital    37%   63%

                  By position

                           Senior level management    57%   43%
                  Middle or entry level management    38%   62%

Attendance at annual conference/meeting
of professional organization(s) (N=93)                71%   29%

                  By facility

                                          Hospital    74%   26%
                                      Non-hospital    66%   34%

                  By position

                           Senior level management    75%   25%
                  Middle or entry level management    67%   33%

Membership in professional organization(s)            56%   44%
(N=93)

                  By facility

                                          Hospital    62%   38%
                                      Non-hospital    46%   54%

                  By position ***

                           Senior level management    69%   31%
                  Middle or entry level management    40%   60%

Notes: Differences between groups are tested using a t-test.
*, **, *** indicate statistically significant differences at
10%, 5%, and 1% significance levels, respectively.
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