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• Published: 17 September 2024

Training healthcare professionals in assessment of health needs in older adults living at home: a scoping review

• Bente Hamre Larsen 1 ,
• Dagrunn Nåden Dyrstad 2 ,
• Helle K. Falkenberg 3 , 4 ,
• Peter Dieckmann 2 , 5 , 6 &
• Marianne Storm 1 , 7 , 8  

BMC Medical Education volume  24 , Article number:  1019 ( 2024 ) Cite this article

Metrics details

Interprofessional assessment and management of health needs for older adults living at home can help prioritize community service resources and enhance health, yet there is a shortage of professionals with the necessary competencies. Therefore, support and training for healthcare professionals in community settings to assess older adults’ health with the aim of for health promotion are needed.

To identify and provide an overview of published papers describing approaches for training healthcare professionals in assessing physical, mental, and social health needs in older adults living at home.

A systematic literature search of the Cinahl, Medline, Academic Search Ultimate, Scopus, Embase, and British Nursing Index databases was performed. We considered studies focusing on the training of healthcare professionals in assessing a single or multiple health needs of older adults aged 65 and above living at home. We considered studies published between 1990 – and March 2024. The review evaluated qualitative, quantitative, and mixed methods studies published in English-language peer-reviewed academic journals. A quality appraisal was conducted via the Mixed Methods Appraisal Tool (MMAT).

Twenty-three studies focused on training healthcare professionals to assess health needs and plan care for older adults living at home were included. The majority of the included studies combined teacher-driven pedagogical approaches consisting of educational sessions, written materials or e-learning, and more participant-engaging pedagogical approaches such as knowledge exchange or various forms of interactive learning. Healthcare professionals were trained to detect and manage single and multiple health needs, and some studies additionally incorporated interprofessional collaboration. Healthcare professionals were satisfied with the training content and it increased their confidence and competencies in health needs assessment and care planning for older adults. Moreover, some studies have reported that training interventions foster the implementation of new and effective ways of working and lead to positive outcomes for older adults.

Healthcare professionals were satisfied with a combination of participant-engaging and teacher-driven pedagogical approaches used to train them in assessing health needs and planning care for older adults living at home. Such training can lead to enhanced assessment skills and facilitate improvements in practice and health promotion for older adults. Future research is recommended on interprofessional simulation training for conducting structured and comprehensive health needs assessments of older adults living at home, as well as on the implementation of such assessments and health-promoting interventions.

Peer Review reports

Introduction

The globally growing and diverse aging population will impact the sustainability of healthcare systems and the independent living of older adults. To support the health needs of older adults, the World Health Organization (WHO) underscores the necessity of effectively training the healthcare workforce [ 1 , 2 ]. However, the complexity of health needs in older adults, coupled with an increased risk of frailty and adverse health outcomes, challenges the provision of tailored care [ 3 ]. Healthcare professionals in homecare settings are well-positioned to assess the health needs of home-living older adults [ 4 , 5 ] and facilitate the interprofessional management of these needs within the community [ 5 ].

Health needs assessment should offer a comprehensive understanding of individuals’ physical, mental, and social health needs, and address the constantly changing needs with increasing age. The assessments aim to identify those who can benefit from healthcare services, such as health education, disease prevention, treatment, and rehabilitation [ 6 ]. The assessment can help set service priorities and allocate service resources effectively, guide clinical decision-making [ 7 ] and design targeted, health promoting interventions [ 4 , 7 , 8 , 9 ] to prevent or delay frailty [ 10 ], enhance overall outcomes for those with complex health needs [ 11 ] and enable them to remain at home for as long as possible [ 12 ]. Given its importance, the task of health needs assessment, is becoming increasingly crucial in homecare settings [ 13 ]. However, there is a scarcity of adequately trained professionals proficient in conducting interprofessional health needs assessments [ 4 , 5 , 9 , 14 , 15 ], including depression [ 16 ], cognitive function [ 17 ], social needs [ 18 ], sensory function (i.e. hearing and vision) [ 19 ], geriatric healthcare [ 20 , 21 ], and multidimensional frailty [ 22 , 23 ]. Frailty, as a dynamic state, affects an individual who experiences losses in one or more domains of human functioning (physical, mental, social) that are caused by the influence of a range of variables, and which increase the risk of adverse outcomes [ 24 ].

A comprehensive understanding of how to train healthcare professionals in health needs assessment of the physical, mental, and social health needs of older adults living at home is crucial. This review understands training as “planned and systematic activities designed to promote the acquisition of the knowledge, skills, and attitudes” [ 25 , p77]. Training can take place as “on-the-job training,” with practicing tasks with a mentor or receiving feedback, or through “off-the-job training,” in a classroom setting with lectures, discussions, and exercises [ 26 ]. It is essential to consistently update and expand knowledge and skills throughout healthcare professionals’ careers [ 27 ]. Mentorship and support are highly valued as pedagogical approaches [ 28 ]. Another approach is implementing interprofessional team-based training [ 29 ] focused on health needs assessment for older adults, which can be complemented by practical, supervised training with a mentor in real-world settings [ 9 ]. Interprofessional simulation training can support healthcare professionals developing communication and collaborative skills and improving patient outcomes [ 2 ]. Additionally, opportunities to share and exchange experiences and new learning with peers and seniors, along with tailored, role-focused teaching, are effective approaches training strategies in community healthcare [ 30 ]. Practical training through simulation, case studies, and role-playing influences skill development by creating experiences that promote individual understanding and learning [ 31 ] and it is based on Vygotsky’s sociocultural learning theory [ 32 ]. Tailored simulation training in use of systematic assessment tools enhanced nurses’ competencies to assess and treat complex symptoms among older adults in long-term care facilities [ 33 ].

Therefore, this scoping review aimed to identify and provide an overview of published papers describing approaches for training healthcare professionals in assessing physical, mental, and social health needs in older adults living at home. Three research questions guided the review: (1) what pedagogical approaches are used when training healthcare professionals to assess the health needs of older adults living at home, (2) what is the content and foci in the health needs assessment training provided in the studies, and (3) what are the outcomes of training reported by healthcare professionals and older adults living at home?

Scoping review design

This study followed the Joanna Briggs Institute (JBI) methodology [ 34 ] for conducting and reporting scoping reviews built on Arksey and O’Malley’s framework [ 35 ]: (1) Define and align the objectives (2) develop and align the inclusion criteria with the objectives (3) describe the planned approach to evidence searching, selection, data extraction, and presentation of the evidence (4) search for the evidence (5) select the evidence (6) extract the evidence (7) analyze the evidence (8) present the results (9) summarize the evidence in relation to the purpose of the review, draw conclusions and note the implications of the findings [ 36 ]. In addition, the PRISMA-ScR [ 37 ] was used as a checklist to report the scoping review data charting, data synthesis and presentation of the data (Additional file 1).

Selection of studies

To be eligible for inclusion in the review, the study had to focus on the training of healthcare professionals in assessing physical, mental and social health needs [ 24 ], specifically assessing frailty, physical function, depression, cognition, social health, and sensory function of older adults aged 65 and above living at home [ 38 ]. Healthcare professionals from diverse fields were included, whether engaging in one-to-one interactions where individual healthcare professionals work directly with patients or working collaboratively in interprofessional teams of members from different professional backgrounds [ 29 ]. The review included qualitative, quantitative, and mixed methods studies published in English-language peer-reviewed academic journals. The inclusion and exclusion criteria are specified in Table  1 below.

Search strategy

The authors and an experienced research librarian collaboratively developed the search strategy and search terms. The search strategy followed the recommendation of JBI [ 34 ]. In June 2022, a limited search of PubMed and CINAHL was conducted to identify relevant articles. To develop a more comprehensive search strategy, we subsequently analyzed the titles and abstracts of the retrieved papers, as well as the index terms used to describe the articles. A systematic literature search was performed on October 6, 2022, in the CINAHL (EBSCO), MEDLINE (EBSCO), Academic Search Ultimate (EBSCO), Scopus (Elsevier), Embase (OVID) and British Nursing Index (ProQuest) databases. The updated search was conducted on the 7th of March 2024. The search terms employed in the different databases to represent training healthcare professionals to assess health needs in older adults living at home are described in Table  2 . We considered studies published between 1990 – and March 2024. Ultimately, the reference lists of all included studies were reviewed to identify any additional studies aligned with the scoping review’s aim.

Identification and selection of studies

The search yielded a total of 2266 records. The study selection process is illustrated in Fig.  1 according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram [ 39 ]. The search results were uploaded into the citation management system EndNote, where duplicates were removed. A total of 1722 records remained for screening. We used the web application Rayyan [ 40 ] to screen studies for inclusion or exclusion. The screening involved all the authors working in pairs, independently assessing eligibility on the basis of the inclusion and exclusion criteria. Discrepancies were resolved through discussions until consensus by all authors in arranged meetings.

All the records were independently screened by the authors (BHL, DND, HKF, PD and MS), and 1452 records were excluded. Two hundred seventy abstracts were reviewed in blinded pairs, leading to the exclusion of 212 records. Next, the full texts of 58 studies were read. This process resulted in the exclusion of 38 studies whose reasons are provided in the flow chart. The remaining 20 studies were included in this review (Fig.  1 ).

The primary reason for exclusion was the lack of content related to training in health needs assessment  ( n  = 13) or incorrect populations ( n  = 12). Eight studies were excluded because they focused on training for medical or bachelor’s degree students. Additionally, four publications were not peer-reviewed studies ( n  = 4).

BHL and MS independently screened the reference lists from the 20 included studies to identify additional eligible studies. After all the blinded titles were read, 28 titles of records were identified for abstract review. Following this, 22 titles were excluded, leaving 6 abstracts included in the full-text examination. The full-text reading further excluded four studies because they did not focus on training in health needs assessment. Finally, two studies [ 41 , 42 ] were added to this scoping review, resulting in a total of 22 included studies.

An updated search was conducted on the 7th of March 2024, including publications from 2022 to 2024, following the procedure above. After removing duplicates, 173 titles and abstracts were screened for eligibility. The full texts of nine articles were read. Six studies were excluded because they did not include training for healthcare professionals. One had incorrect population, and the others were in a language other than English. This led to the inclusion of one new study [ 43 ], bringing the total number of included studies for the scoping review to 23.

Search results, study selection and inclusion process [ 39 ]

Extraction and analysis of the data

In line with the updated JBI methodological guidelines for scoping reviews [ 34 ], we extracted and coded descriptive details from the 23 included records. The extraction table covered the publication year, country of origin, study purpose, research design, study population, context/setting, training intervention content and assessment tools, pedagogical approaches and training duration, and outcomes for healthcare professionals and older adults. A test was conducted to ensure that the coauthors were aligned in their understanding of what type of data to extract for the table. Feedback from the test guided essential refinements to the extraction table before the authors collaborated to extract and organize pertinent information. We applied a basic thematic analysis to code the data and identify, analyze, and interpret patterns, ultimately deriving themes that addressed our research questions [ 44 , 45 ]. The analysis utilized NVivo 12 Pro software [ 46 ].

Quality appraisal

We performed a quality evaluation of the included studies via the Mixed Methods Appraisal Tool (MMAT) in blinded pairs. This tool is designed for a structured and standardized evaluation of methodological quality and risk of bias in systematic reviews that include qualitative, quantitative, and mixed methods studies [ 47 ]. Although quality evaluation is optional in a scoping review, it can provide valuable insights [ 48 ] and enhance the interpretability of the included studies [ 49 ].

All studies were evaluated according to five quality criteria specific to each research design (qualitative, quantitative descriptive, nonrandomized, randomized, and mixed methods studies). Each criterion received a response score of either “Yes,” indicating that the study met the quality criteria, or “No,” indicating that it did not meet the quality criteria or that it was unclear (see Table  4 ). It is discouraged to calculate an overall score. Any disagreements in scoring were resolved through discussion. The quality scores were not used to exclude articles from the review; instead, they were reported and discussed [ 49 ].

In accordance with the JBI scoping review guidance [ 44 ], the extracted data are presented in a table format (Tables  3 and 5 ) and a narrative summary is provided to respond to the three research questions. Table  3 provides a description of the study characteristics, while Table  5 outlines overarching categories along with relevant extracted information [ 44 ].

Characteristics of the included studies

Table  3 shows that the 23 studies were published between 1990- and 2023. Eight studies were conducted in the United States [ 16 , 42 , 43 , 50 , 51 , 52 , 53 , 54 ], three in Canada [ 55 , 56 , 57 ], three in Australia [ 58 , 59 , 60 ], three in the United Kingdom [ 41 , 61 , 62 ], and one each in Ireland [ 63 ], Italy [ 64 ], Brazil [ 65 ], France [ 66 ], Singapore [ 67 ], and Belgium [ 68 ].

Ten studies meticulously examined training interventions tailored for primary nurses [ 43 , 50 , 51 , 54 , 55 , 60 , 61 , 63 , 66 , 68 ], one study specifically targeted the training of community health workers [ 65 ] and another presented an educational session tailored for case managers and agency supervisors [ 42 ]. The remaining studies indicated that training was provided to interprofessional teams or various distinct professions, such as nurses, physical therapists, occupational therapists, general practitioners, social workers and psychologists [ 16 , 41 , 52 , 53 , 56 , 57 , 58 , 59 , 62 , 64 , 67 ]. The study participants were in home healthcare or primary/community care [ 16 , 41 , 43 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 68 ], community and social services [ 42 , 64 ], mental health care [ 61 ], eldercare centers/daycare [ 67 ], residential settings [ 58 , 59 , 64 ], hospitals [ 53 , 56 ], rehabilitation [ 56 ] and acute care [ 61 ].

Quality evaluation results

The quality appraisal procedure revealed variations in the quality of the 23 included studies. The detailed quality evaluation results for each study are presented in Table  4 , and an overview of the methodological quality criteria is presented in Additional file 3.

Each study was evaluated on five criteria appropriate to its study design category. Overall, only one study, which was a mixed methods study, met al.l five quality criteria in the MMAT [ 62 ]. Additionally, one mixed methods study met four criteria [ 61 ], and another met three criteria [ 65 ]. The most common criterion that mixed methods studies failed to meet was 5.2: whether the different components of the study were effectively integrated to answer the research question. Among the quantitative randomized studies, one study met four quality criteria [ 50 ], whereas the other was of low quality, meeting only one criterion [ 59 ]. None of these studies met the quality criterion for proper randomization. In the quantitative nonrandomized studies, six met four criteria [ 41 , 55 , 56 , 58 , 64 , 68 ], one met three [ 63 ], and one met only one criterion [ 16 ], indicating low quality. All studies met the criterion regarding whether the intervention was administered as intended. The most common criteria they failed to meet were 3.3: whether there were complete data and 3.4: whether confounders were accounted for in the study design and analysis. Among the descriptive studies, seven met four criteria [ 42 , 43 , 54 , 57 , 60 , 66 , 67 ], one met three criteria [ 53 ], and two met only one criterion [ 51 , 52 ], demonstrating low quality.

The majority of these studies met the criterion regarding whether the measurements were appropriate. However, the criterion most studies did not meet (only one out of ten) was whether the risk of nonresponse bias was low. Notably, no qualitative methods studies were included in our scoping review.

Training interventions in assessment of older adults living at home

The next section presents a narrative overview of three major themes related to the three research questions. The themes concerned the training provided for healthcare professionals in assessing the physical, mental, and social health needs of older adults living at home: pedagogical approaches, content and foci of health needs assessment training for healthcare professionals and outcomes and evaluation of health needs assessment training for healthcare professionals and older adults living at home. The findings are summarized in Table  5 [ 44 ].

Pedagogical approaches

The included studies employed diverse pedagogical approaches to train healthcare professionals in assessing the health needs of older adults living at home. The spectrum of pedagogical approaches observed in the studies was categorized into teacher-driven and participant-engaging pedagogical approaches. Twenty-one studies [ 16 , 42 , 43 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 67 , 68 ] combined teacher-driven and participant-engaging pedagogical approaches, reflecting a multifaceted training strategy. Mayall et al. [ 41 ] opted for a more singular pedagogical approach, exclusively relying on lecture-based education, whereas the training method used in the Piau et al. [ 66 ] study remained unspecified. The training interventions varied in duration, from one-hour sessions [ 68 ] to an ongoing training program spanning 21 months [ 57 ]. In two studies, the specific duration of the training interventions was not specified [ 53 , 57 ]. The most common duration for training was 4–8 h [ 16 , 43 , 50 , 52 , 54 , 56 , 58 , 59 , 62 , 67 ].

Teacher-driven pedagogical approaches

Almost all studies utilized teacher-driven pedagogical approaches, including educational sessions, written materials or e-learning [ 16 , 41 , 42 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 67 , 68 ]. Educational sessions were evident in 14 studies [ 16 , 41 , 42 , 50 , 51 , 52 , 53 , 56 , 57 , 58 , 59 , 62 , 64 , 65 ], providing healthcare professionals with information about relevant topics through lectures [ 16 , 41 , 42 , 51 , 62 , 64 , 65 ], slides [ 16 , 64 ] and instructions [ 50 , 52 , 53 ], as well as demonstrations of the use of assessment tools [ 41 , 42 , 51 , 56 , 58 , 59 ]. Additionally, Abbasi et al. [ 57 ] and Quijano et al. [ 42 ] offered ongoing sessions during the post training implementation period.

Written materials were provided to the participants in nine studies [ 16 , 42 , 50 , 52 , 54 , 58 , 59 , 63 , 64 ]. This included training manuals containing examples and case studies [ 58 , 59 ], written documents about the training pack and the assessment forms [ 63 ], course textbooks and instruction manuals [ 64 ], educational materials including the program manual and articles [ 42 ], a CD-ROM (a data-disc for computer) containing written educational material [ 52 ] and toolkits derived from the educational material [ 16 , 50 , 54 ]. Brown et al. [ 54 ] reported that toolkits included key intervention components for seamless application of learned concepts [ 54 ]. Furthermore, some described follow-up emails to provide participants with information post training [ 50 , 54 ].

E-learning as a preplaying online module or videoclip appeared in nine studies [ 16 , 42 , 43 , 50 , 53 , 54 , 61 , 64 , 68 ]. Naughton et al. [ 61 ] delivered prerecorded lectures [ 61 ], Landi et al. [ 64 ] used video recordings presenting real cases to test participants’ assessments- and decision-making skills, and Quinlan and Ryer [ 43 ] offered online modules on aging epidemiology, fall risk factors, and age-friendly health systems [ 43 ]. Participants watched video recordings portraying late-life depression [ 42 , 53 , 54 ], and patient interactions illustrating approaches to depression assessment [ 50 , 54 , 68 ] via standardized questions and follow-up questions [ 16 ]. Professional actors were used in three studies [ 16 , 53 , 68 ].

Participant-engaging pedagogical approaches

The majority of the included studies utilized participant-engaging pedagogical approaches involving knowledge exchange or various forms of interactive learning [ 16 , 42 , 43 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 67 , 68 ].

Sixteen studies employed various forms of knowledge exchange such as discussion, questioning and coaching, between training participants and teachers [ 43 , 51 , 52 , 53 , 54 , 55 , 56 , 58 , 59 , 60 , 61 , 63 , 64 , 65 , 67 , 68 ]. Peer-to-peer learning and dialog facilitated the exchange of knowledge and insights [ 65 ], which enriched the overall learning experience [ 61 ]. The participants were included in discussions following lectures [ 55 ], after watching scripted videos [ 53 ], and during patient case reviews [ 56 , 67 ]. Additionally, three studies included both discussions and allowed participants questions [ 52 , 54 , 68 ]. Discussions allowed participants to delve into case management techniques [ 51 ], explore experiences related to assessing the health of older adults [ 54 , 60 , 64 ] and solve problems and discuss alternative strategies regarding depression screening [ 54 ]. A few studies have provided ongoing coaching in the post training phase to support healthcare professionals in applying newly acquired skills [ 42 , 55 , 57 ]. This included three months of feedback and support [ 42 ], mentorship for skill integration [ 57 ], and a six-month collaborative approach between resource staff and case managers involving home visits and clinical consultations [ 55 ].

Interactive training was employed in fifteen studies through skills training, role-playing, simulations, and hands-on training in real-world settings [ 16 , 42 , 43 , 51 , 52 , 54 , 55 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 ]. Skill training allows nurses to practice patient interviews and assessments and receive instructor feedback [ 54 ]. The participants practiced by assessing their colleagues’ health and responding to assessment [ 16 , 51 ], with faculty staff offering assistance, encouragement, and feedback throughout [ 51 ]. Landi et al. [ 64 ] provided practice exercises followed by presentations, and Quinlan and Ryer [ 43 ] provided a virtual training session in motivational interviewing technique and assessment. Roleplay as a teaching strategy was used to address practical aspects of administering depression screening [ 50 , 52 , 60 ], and Butler and Quayle [ 63 ] incorporated case scenarios, roleplay, and practical skills training for assessing depression in older adults [ 63 ]. Simulation training was used to immerse participants in the experience of living with sight and hearing impairments performing everyday tasks such as filling out forms or managing medications using sight impairment spectacles. Training was followed by a debriefing session [ 62 ]. Hands-on training in the assessment of older adults’ health in real-world settings was conducted in ten studies [ 42 , 51 , 54 , 55 , 57 , 58 , 59 , 60 , 64 , 65 ]. Healthcare professionals gained clinical experience through assessments of home dwelling older adults [ 55 , 58 , 59 , 60 , 64 , 65 ] and through participation in a rotational preceptorship for community health nurses. This enabled them to practice newly acquired assessment skills and collaborate in a real-life setting [ 51 ]. Additionally, two other studies emphasized practical training in communication with other professionals in real-world settings [ 58 , 59 ], while Brown et al. [ 54 ] encouraged participants to practice assessments in a real-world setting between educational sessions.

Content and foci of health needs assessment training for health care professionals

All the included studies offered insights into the content and foci of health neesd assessment training interventions for healthcare professionals. The studies were divided into those aimed at training healthcare professionals to understand and assess either single or multiple physical, mental, and social health needs in older adults living at home. Additionally, some training sessions focused on interprofessional collaboration.

Single health need assessment training

The focus of twelve studies involved enhancing the skills of healthcare professionals in assessing, planning and conducting interventions for a specific, single health need in older adults, with each addressing either the assessment of mental or physical health [ 16 , 41 , 43 , 52 , 53 , 54 , 58 , 59 , 60 , 62 , 63 , 68 ]. Two of these studies [ 43 , 62 ] focused solely on physical health factor training. Smith et al. [ 62 ] emphasized training in assessing and detecting sight and hearing impairments without specifying whether any assessment tools were used [ 62 ]. Quinlan and Ryer [ 43 ] provided fall risk assessment training, which included the use of assessment tools to evaluate the physical function of older adults and to assess their home environments. The other ten studies [ 16 , 41 , 52 , 53 , 54 , 58 , 59 , 60 , 63 , 68 ] focused on training to assess depression in older adults living at home. The training encompassed understanding and detecting the condition, and all of them included the use of assessment tools. Van Daele et al. [ 68 ] included skills such as actively listening to patients and motivating them to seek expert assistance when needed. Delaney et al. [ 16 ] incorporated skills in asking follow-up questions, and Mellor et al. [ 59 ] offered training in appropriate communication with older adults to identify masked, early signs of depression.

Multiple health needs assessment training

Eleven studies [ 42 , 50 , 51 , 55 , 56 , 57 , 61 , 64 , 65 , 66 , 67 ] described training interventions for healthcare professionals aimed at assessing, planning, and conducting interventions for multiple health needs in older adults living at home. The training content ranged from learning to performing a holistic health assessment of older adults encompassing physical, mental, cognitive, and social factors [ 42 , 51 , 55 , 56 , 57 , 61 , 64 , 66 ] to a more nuanced assessment of two or three of these factors [ 50 , 65 , 67 ]. All studies described the use of assessment tools or checklists. A holistic assessment and understanding of older adults’ health context and needs enables interventions to be tailored to their health and care needs, priorities, and levels of frailty [ 57 ]. Within the realm of holistic assessment, only two of these studies addressed alcohol and medication usage [ 55 , 56 ], whereas two other studies focused on evaluating sensory status [ 57 , 66 ]. For studies with more nuanced assessment training, three studies [ 42 , 50 , 67 ] primarily tailored their training to focus on depression assessment and intervention in older adults, but Quijano et al. [ 42 ] also included training in assessing general physical health status, social function, and cognitive function. Sin et al. [ 67 ] included dementia assessment and Bruce et al. [ 50 ] addressed factors that commonly complicate depression in homecare patients, such as health conditions, disability in activities of daily living, and cognitive function. The training included how to ask follow-up questions and observe nonverbal language [ 50 ]. Neto et al. [ 65 ] provided training for healthcare professionals in rural areas to screen for geriatric risk factors such as caregiver overburden, general health, social health, risk of falling, or difficulties in activities of daily living.

Interprofessional collaboration and communication skills in health needs assessment training

Beyond the focus on training for assessing the health needs of older adults, sixteen studies [ 42 , 50 , 51 , 52 , 53 , 54 , 55 , 57 , 58 , 59 , 60 , 61 , 62 , 64 , 65 , 68 ] have incorporated training elements to increase interprofessional collaboration and communication skills among healthcare professionals. Health needs assessment training for interprofessional teams was evident in eight of the included studies [ 51 , 55 , 57 , 58 , 59 , 61 , 64 , 65 ]. Two studies [ 58 , 59 ] outlined an advanced session to teach skills for interacting with other healthcare providers, including general practitioners and mental health specialists, whereas Couser et al. [ 51 ] stressed the importance of effectively communicating the assessment results to physicians and other healthcare providers. Training in writing referrals was emphasized in ten studies [ 42 , 50 , 52 , 53 , 54 , 58 , 59 , 60 , 62 , 68 ]. In addition, Stolee et al. [ 55 ] trained healthcare professionals in writing reports and making recommendations to the referring case manager. Only two studies [ 61 , 65 ] included collaboration with family in their training programs. Naughton et al. [ 61 ] designed training programs to support healthcare professionals in navigating the complexities of collaboration with multidisciplinary teams, older adults, and their families. They also developed a network among nurses to facilitate the exchange of expertise, experience, and innovative ideas [ 61 ]. Neto et al. [ 65 ] aimed to increase the capacity of care workers to effectively collaborate with family caregivers and social services for dependent older adults in rural areas. Stolee et al. [ 55 ] provided training for case managers to extend this knowledge to their teams and strengthen connections with specialized geriatric services. Similarly, Abbasi et al. [ 57 ] emphasized team-based care delivery training, with active and holistic discussions among patients, caregivers, and interprofessional teams. Diverse skill sets within teams can effectively meet the holistic care needs of patients. In parallel, Piau et al. [ 66 ] focused on training nurses to collaborate with general practitioners to develop comprehensive care plans. Landi et al. [ 64 ] trained case managers who collaborated in supervised teams to assess older adults and present care plans. They watched videos of simulated team discussions to enhance their understanding of the assessment process and teamwork [ 64 ].

Evaluation and outcomes of health needs assessment training for healthcare professionals and older adults

All of the studies provided insight into the experiences or outcomes of healthcare professionals participating in the training interventions. This included their satisfaction and experiences with health needs assessment training, improved confidence and competencies in health assessment and care planning and shifts in work practices. Additionally, some studies have reported outcomes for older adults following health needs assessment training, such as appropriate referrals, tailored interventions, fall prevention, symptom reduction, and improved overall function. The evaluation of these outcomes relied to a small extent on models or frameworks, with only three studies incorporating them [ 43 , 61 , 62 ]. Smith et al. [ 62 ] utilized Kirkpatrick’s four-level training evaluation model to assess the relevance and impact of educational intervention. Naughton et al. [ 61 ] adopted Alvarez et al.’s (2004) framework of an integral model of training evaluation and effectiveness. Quinlan and Ryer [ 43 ] presented their findings following the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE) framework.

Healthcare professionals’ satisfaction and experiences with assessment training

Ten studies provided insights into healthcare professionals’ experiences with participating in training interventions [ 16 , 41 , 43 , 54 , 55 , 56 , 60 , 61 , 62 , 65 ], where most of the participants expressed satisfaction with both the content and format of the courses. The participants in Brymer, Cormack and Spezowka [ 56 ] expressed a high level of satisfaction with the presenter’s content, pacing, and format, and in Mayall et al. [ 41 ], the training met the participants’ needs and expectations. The participants in Naughton et al. [ 61 ] particularly valued the peer-to-peer learning aspect, whereas Smith et al. [ 62 ] emphasized the effectiveness of simulations. Neto et al. [ 65 ] rated classroom sessions and supervised home visits very positively and found them useful. Furthermore, participants in four of the studies [ 16 , 60 , 61 , 65 ] offered suggestions to enhance the number of educational sessions. They suggested allocating more time for training [ 16 , 65 ], a greater focus on skills training [ 60 , 61 ], additional training in managing complex and technically challenging issues [ 65 ] and incorporating more time for case studies and discussions [ 16 ].

Improved confidence and competence in health assessment and care planning

Improvements in assessment competencies following training interventions among healthcare professionals were reported in nineteen studies [ 16 , 41 , 42 , 51 , 52 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 , 66 , 67 , 68 ]. Among these, nine studies explicitly reported increased confidence among healthcare professionals in assessing older adults’ health needs [ 16 , 41 , 54 , 55 , 58 , 59 , 63 , 67 , 68 ]. The health need sassessment and use of assessment tools or checklists led to the identification of health needs. Quinlan and Ryer [ 43 ] noted that without screening in a fall prevention program, the identification of fall risk among older adults would be missed. Piau et al. [ 66 ] noted that a high proportion of assessments effectively identified frailty and suggested interventions and referrals. One comment was that they “were previously skirting around the problem, now asked about mental health directly” [ 61 , p. 33]. Naughton et al. [ 61 ] reported that performing a comprehensive geriatric assessment helped when raising issues with general practitioners because they were talking about their language. Nunn, Annells and Sims [ 60 ] acknowledged the use of Geriatric Depression Screening (GDS) tool raised awareness of depression. A total of 62.5% felt that the GDS helped identify depression that might otherwise be overlooked, but some questioned its universal usefulness [ 60 ]. Abbasi et al. [ 57 ] reported that having an evaluation framework helped healthcare professionals guide meaningful measures [ 57 ]. Conversely, some participants also expressed that they relied more on observation than direct questions when assessing depression [ 54 ]. According to Landi et al. [ 64 ], careful assessments is deemed essential for effective care planning, and Stolee et al. [ 55 ] emphasize the critical role of assessment training in identifying health needs and equitably distributing community service resources. Two studies reported one year of retention of knowledge and skills without the inclusion of a refresher course [ 54 , 62 ].

Twenty studies documented a better understanding of appropriate interventions and referrals [ 16 , 41 , 42 , 50 , 51 , 52 , 53 , 55 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 ]. According to Delaney et al. [ 16 ], 50% of the participants noted that a key aspect they learned was understanding the significance of the assessment results and the corresponding interventions [ 16 ]. The participants in the study by Neto et al. [ 65 ] demonstrated significantly improved capacity in responding to the health and care needs of older adults. The participant reported increased confidence in making referrals and consulting resources [ 51 ], increased knowledge about managing depression, making referrals, and accessing available local services [ 41 ] and enhanced self-efficacy in providing care for older adults [ 16 , 58 ]. Nunn, Annells and Sims [ 60 ] reported that 50% of participants felt prepared to address older adults’ depression after training. Smith et al. [ 62 ] observed increased referral practices and improved ability to advise patients about sensory services, whereas Mellor et al. [ 59 ] noted a slight increase over time in specialist referrals, and senior staff reported increased confidence in interacting with health specialists.

Shift in healthcare professionals’ work practices after assessment training

The training intervention resulted in either a change or potential for change in work practices in ten studies [ 16 , 42 , 43 , 52 , 53 , 55 , 57 , 62 , 63 , 64 ]. Butler and Quayle [ 63 ] reported that prior to receiving training, nurses did not utilize any formal assessment measures to screen for depression in older adults. However, following training, some nurses continue to use screening measures for depression in their clinical practice [ 63 ]. Similarly, case managers in Stolee et al. [ 55 ] stated that the major change in their assessment practice was greater consistency in the use of assessment tools. Smith et al. [ 62 ] reported a shift in practice toward incorporating more detailed information about patients’ impairments and implementing supportive strategies, and in Marcus et al. [ 53 ], communication of depression screening results to patients, physicians, or mental health specialists became a standard protocol.

Landi et al. [ 64 ] reported that training was proven feasible and may be implemented on a broader scale, and Luptak et al. [ 52 ] outlined an implementation period of the ADAPT—Assuring Depression Assessment and Proactive Treatment protocol for depression care in rural healthcare—with the potential to achieve the outlined goals in various clinical settings [ 52 ]. Delaney et al. [ 16 ] reported that project participants were interested in implementing the program in their homecare setting and developed a train-the-trainer model. Abbasi et al. [ 57 ] provided results and experiences regarding the Seniors Community Hub (SCH) through the ADKAR (awareness, desire, knowledge, ability, reinforcement) evaluation framework to assist others interested in implementing a similar integrated care model [ 57 ]. Quinlan and Ryer [ 43 ] stated that fall assessment practices are currently implemented and continuous; similarly, Quijano et al. [ 42 ] reported that depression interventions continue to be offered by participating agency offices. On the other hand, Butler and Quayle [ 63 ] noted the challenge of implementing assessment tools due to competing demands such as holidays, working part-time or being too busy, and Sin et al. [ 67 ] outlined one participant with difficulties in applying new knowledge owing to manpower shortages and constraints in time and space.

Outcomes for older adults following the health needs assessment training

Seven studies [ 42 , 43 , 50 , 53 , 57 , 66 , 68 ] detailed outcomes for older adults following health needs assessment training for healthcare professionals. These outcomes included appropriate referrals, tailored interventions, fall prevention, symptom reduction, and improved overall function. Bruce et al. [ 50 ] highlighted that depressed older adults in the intervention group were more likely to receive appropriate referrals for mental health evaluation [ 50 ], aligning with findings where a minimal intervention significantly increased the detection of depression and further referrals to general practitioners [ 68 ]. The findings in two studies demonstrated that patients were referred to tailored resources designed to address their identified problems [ 53 , 57 ]. Furthermore, Quijano et al. [ 42 ] revealed that older adults’ awareness of seeking help and the significance of physical activity for maintaining health improved. Quinlan and Ryer [ 43 ] stated that after providing care plans to 83 older adults, most implemented fall prevention strategies during a two-week follow-up call with 29 older adults, with only one fall reported. Piau et al. [ 66 ] identified the main causes of frailty and reported effective intervention recommendations and referrals [ 66 ]. Most physicians in Stolee et al. [ 55 ] reported better general function for older adults due to comprehensive geriatric assessment. Findings in two studies [ 42 , 57 ] documented reductions in depression severity at the follow-up assessment due to appropriate referrals and interventions [ 42 , 57 ], and significantly more older adults felt better and experienced pain reduction, followed by increased activity [ 42 ]. Additionally, Abbasi et al. [ 57 ] reported a slight improvement in health-related quality of life, including mobility, usual activities, pain/discomfort, and anxiety and depression, suggesting enhanced function [ 57 ].

This scoping review provides insights into training interventions for healthcare professionals assessing the physical, mental, and social health needs of older adults living at home. The analysis of 23 studies revealed that nearly all training interventions used a multifaceted training strategy combining teacher-driven and participant-engaging pedagogical approaches to teach healthcare professionals theoretical and practical knowledge. Health needs assessment training focuses on the skills needed to conduct single or multiple health needs assessments in older adults. Interprofessional collaboration was an essential part of most training interventions. Multiple studies noted that participants were satisfied with the training content and had increased confidence and competencies in health needs assessment and care planning. Studies have also reported a shift in work practices for health care professionals and some included results have shown improved health outcomes for older adults.

Our study revealed that most of the included studies blended the use of teacher-driven and participant-engaging pedagogical approaches [ 16 , 42 , 43 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 67 , 68 ]. These approaches provide participants with confidence and competencies in health needs assessment [ 16 , 41 , 42 , 51 , 52 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 , 66 , 67 , 68 ]. Skilled healthcare professionals are crucial in facilitating the implementation of health assessments for older adults [ 69 ]. Lectures can be highly effective for learning, especially when they stimulate thinking and active engagement. Their effectiveness depends on the lecturer’s skill and can be improved by incorporating learner feedback, performance results, self-reflection, and peer feedback [ 70 ]. Another way to improve lecture quality is by including interactive elements such as practical skill training, following John Dewey’s “learning by doing” philosophy [ 32 ]. In our review, we identified fifteen studies that utilized participant-engaging approaches such as skills training, role-playing, simulations, hands-on training in real-world settings [ 16 , 42 , 43 , 51 , 52 , 54 , 55 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 ], and sixteen studies employed discussion, questioning and coaching [ 43 , 51 , 52 , 53 , 54 , 55 , 56 , 58 , 59 , 60 , 61 , 63 , 64 , 65 , 67 , 68 ]. The integration of teacher-driven sessions, interactive training, and knowledge exchange resembles simulation training, which typically includes briefing, simulation exercises, and debriefing phases. These phases allow participants to reflect, enhance their learning, and deepen their educational experience [ 71 ]. Debriefing is a valuable tool for reflecting on and discussing experiences in training and real-world settings. This helps individuals and teams identify strengths, areas for improvement, and lessons learned, thereby enhancing learning and future performance [ 72 ]. However, effective debriefing relies on facilitators with strong skills to maximize learning outcomes [ 73 ].

The WHO advocates interprofessional simulation training to enhance healthcare professionals’ competencies and improve patient outcomes [ 2 ]. Even if several studies combined teacher-driven approaches, interactive training and knowledge exchange, our review included only one study utilizing simulation training [ 62 ]. Health needs assessment training for interprofessional teams was evident in eight of the studies included in our review [ 51 , 55 , 57 , 58 , 59 , 61 , 64 , 65 ]. Such training has been proven to provide valuable insights into the health of older adults, leading to improved care delivery [ 74 , 75 ], improved patient outcomes [ 76 ] and reduced hospitalization [ 74 ]. It can improve conflict management skills and team functioning [ 76 ] and play a critical role in equitably distributing community service resources [ 55 ]. Interprofessional simulation training is an engaging method for training clinical skills, procedures, teamwork, and communication in a safe, realistic environment [ 77 ]. It promotes critical thinking, reflection [ 78 ], and effective learning [ 79 ] enhancing the application of knowledge in clinical practice [ 80 ]. The use of participant engaging pedagogical approaches aligns with the sociocultural view of training, which emphasizes active engagement and collaboration in the learning process. It enables knowledge exchange and reflection, and participants can integrate their experiences with new information, internalize it, and construct new knowledge [ 32 , 81 ]. Practical training such as simulations, can push participants out of their comfort zones, foster collaborative learning and enrich the educational experience [ 82 ]. However, to achieve optimal learning, it is crucial to balance skill development with an appropriate level of challenge as learners acquire new concepts. At the same time, temporary support from more experienced learners should be available. This balance is known as the zone of proximal development, which represents the space between a learner’s current skill level and their potential skill level with guidance. Tasks within this zone promote growth [ 83 ].

Our review reports a distinction in training content with a focus on assessing single versus multiple health needs in older adults. Ten studies [ 16 , 41 , 52 , 53 , 54 , 58 , 59 , 60 , 63 , 68 ] focused solely on assessing depression. There is a strong correlation between late-life depression and reduced quality of life, as well as comorbidities such as physical illness, disability [ 58 , 84 ] and physical frailty [ 85 , 86 ]. However, single health need assessment training may inadvertently lead to the overlooking of broader health needs among older adults. A multiple health assessment of older adults is recommended [ 7 ], as it can serve as the foundation for developing holistic interventions to enhance overall health [ 10 , 12 , 87 , 88 , 89 ], promote health [ 90 ], foster positive health behaviors [ 91 ], and reduce frailty [ 92 , 93 ]. Our review included eight studies [ 42 , 51 , 55 , 56 , 57 , 61 , 64 , 66 ] providing training in physical, cognitive, mental, and social health needs assessment, alongside care planning on the basis of these assessments. Research indicates that both healthcare professionals and frail older adults participating in an interdisciplinary care approach were satisfied with the improved structure of care and appreciated the emphasis on health promotion [ 94 ]. On the other hand, a comprehensive health needs assessment is a multifaceted and complex intervention, with uncertainties surrounding its effectiveness and underlying mechanisms [ 95 ]. Some research findings indicate that there is no conclusive evidence that it reduces disability, prevents functional decline [ 96 ], impacts mortality, or supports independent living in older adults [ 97 ]. These results underscore the complexity and challenges in conducting and implementing comprehensive health needs assessments and tailoring interventions to promote health in older adults.

Our review revealed that almost all [ 16 , 41 , 42 , 43 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 63 , 64 , 65 , 66 , 67 , 68 ] health needs assessment training programs included the use of assessment tools or checklists, leading to the identification of health needs. Only one of these studies reported that participants relied more on observation than on direct questioning when assessing depression [ 54 ]. Additionally, another study found that healthcare professionals using assessment tools felt that this approach led to asking overly personal and intrusive questions without first establishing trust or explaining the purpose of the assessment [ 98 ]. On the other hand, some older adults reported that using assessment tools made it difficult to discuss issues outside the predefined domains of the comprehensive health needs assessment [ 99 ]. Research indicates that current assessment practices heavily rely on professional judgment and intuition, and healthcare professionals in community settings often lack adequate knowledge and training regarding the health needs assessment of older adults [ 22 , 100 ]. This can be seen as problematic because these professionals are ideally positioned to assess older adults early in their health trajectories [ 105 ]. Proper assessment in these settings can facilitate the early recognition of functional decline [ 101 , 102 ] and vulnerability, enable timely intervention to mitigate frailty’s adverse effects [ 105 ], and support effective care planning [ 64 ]. Even if several healthcare professionals have endorsed the integration of frailty assessment tools into primary care [ 22 ], they need a simple, efficient assessment tool [ 105 ] that empowers them to identify older adults’ health needs [ 9 , 88 , 103 , 104 ]. This is particularly critical due to the essential role that assessments play in equitably distributing community service resources [ 105 ]. As such, this review underscores the importance of educating healthcare professionals in community care to effectively assess the physical, mental, and social health needs of older adults. Furthermore, understanding the learning process of healthcare professionals [ 78 ], evaluating the effects of training [ 106 ], and establishing evidence-based standards for skills training are crucial for high-quality teaching [ 107 ]. Additionally, further research is necessary to assess the feasibility, effectiveness, and acceptability of interprofessional interventions targeting multiple health needs aimed at health promotion [ 90 ] and experiences using comprehensive health assessment tools [ 108 ].

Methodological considerations

This review included studies employing various methods to obtain comprehensive insights into training healthcare professionals in assessing the health needs of older adults living at home [ 47 ]. We utilized a validated mixed-methods appraisal tool to assess the quality of the included studies [ 47 , 49 ]. We did not include reporting on screening questions regarding the clarity of the research question or whether the collected data addressed the research questions, as our review focused exclusively on empirical studies. Additionally, we chose not to calculate an overall score from the ratings of each criterion, as this practice is discouraged. We provide an overview of each study’s quality by presenting the ratings of each criterion [ 49 ]. Our findings revealed that only one study met all the quality criteria, fifteen studies met four criteria, three studies met three criteria, and four studies met only one criterion. High-quality studies employ rigorous and robust methods, leading to reliable and valid findings [ 109 ]. While most studies met 3–4 quality criteria, they provide a relatively strong evidence base and offer valuable insights, although some concerns remain. Several studies did not meet the quality criteria for nonresponse bias or complete outcome data. It is crucial to describe and evaluate a low response rate for its potential impact, as this can limit the generalizability of findings [ 110 ]. Many studies also failed to account for confounders in their design and analysis. Confounding factors may bias results by distorting the interpretation of findings [ 49 ], masking actual associations or creating false associations, potentially leading to incorrect conclusions [ 111 ]. The randomization of study subjects and rigorous statistical analyses can mitigate the impact of confounding variables [ 112 ]. Nonetheless, conducting a quality assessment increases awareness of these biases and limitations, thereby enhancing our confidence in the study findings.

Strengths and limitations

Our scoping review has several limitations. Initially, our search strategy involved the use of six databases and various relevant search terms related to training healthcare professionals in assessing the health needs of older adults. We excluded gray literature to focus on mapping existing published research and identifying any research gaps. The search was conducted by an experienced librarian. Despite our efforts to comprehensively map the research literature, we may have overlooked some studies. Second, our exclusion criteria, which encompassed, for example, general practitioners, students, and institutional settings, restricted the scope of the study. Additionally, we focused on health needs assessment, excluding studies that assessed the environment, an important factor in enabling older adults to stay at home as long as possible. However, based on the findings and limitations of the included studies, we believe our review provides valuable insights into the research context. These findings can inform future research, practice, policymaking, and the development of training programs for healthcare professionals in community settings to assess older adults’ health needs.

Healthcare professionals require training in assessing physical, mental, and social health needs in older adults living at home to ensure tailored interventions that enhance their health and independence. Our study revealed that healthcare professionals were satisfied with the combination of participant-engaging and teacher-driven pedagogical approaches when training in physical, mental, and social health needs assessment. Such training is beneficial and strengthens healthcare professionals’ confidence and competency in assessment and care planning for older adults living at home. Additionally, some studies reported that following health needs assessment training, there was a shift in work practices and improved health outcomes for older adults. We suggest that health needs assessment training programs are valuable for improving health and care for older adults living at home and contribute to increased sustainability in healthcare.

Furthermore, we propose additional research on interprofessional simulation training for the structured assessment of multiple health needs in older adults, ensuring comprehensive coverage of all significant health issues in these assessments. We also recommend research on the implementation of such assessments and health promoting interventions.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The authors express gratitude to librarian Kari Hølland, Division of Research, Stavanger University Library for performing the systematic literature searches.

This article stems from the research project “More good days at home - Advancing health promoting practices in municipal healthcare services for older recipients of homecare” (HEIME), specifically related to Work Package 3, “Simulation and training for health needs assessment in home-living older adults”. HEIME is funded by the Research Council of Norway (grant 320622), University of Southeastern-Norway, University of Stavanger, Stavanger, Horten, Porsgrunn and Nome municipality (2021–2025). Dr. Grethe Eilertsen is the project director. Drs. Siri Tønnessen, Anette Hansen and Professor Marianne Storm are the principal researchers and work package leaders.

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Helle K. Falkenberg

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All authors (BHL, DND, HKF, PD and MS) contributed to the design and development of the study, research questions, and literature search. BHL conducted the literature search in collaboration with MS and research librarian. All authors participated in the screening and quality assessment processes. Data analysis and manuscript writing and preparation was led by BHL in collaboration with MS. All authors were involved in reading, commenting and reviewing the text, and approving the final manuscript.

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Larsen, B.H., Dyrstad, D.N., Falkenberg, H.K. et al. Training healthcare professionals in assessment of health needs in older adults living at home: a scoping review. BMC Med Educ 24 , 1019 (2024). https://doi.org/10.1186/s12909-024-06014-9

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Efficacy of hepatic arterial infusion chemotherapy in patients with primary liver cancer with portal vein tumor thrombosis: a comparative analysis of different perfusion chemotherapeutic regimens

• Xinxin Tu 1   na1 ,
• Wenfeng Zhang 1   na1 ,
• Sipeng Li 2 ,
• Qi He 1 &

European Journal of Medical Research volume  29 , Article number:  465 ( 2024 ) Cite this article

Metrics details

Portal vein tumor thrombosis (PVTT) commonly occurs in patients with primary liver cancer (PLC). Transarterial chemoembolization (TACE) is a treatment for patients with PLC and PVTT. Some studies have shown that combining TACE therapy with hepatic arterial infusion chemotherapy (HAIC) might improve the survival rate of PLC patients with PVTT. However, few studies have compared the different regimens of PLC with PVTT. We aimed to compare the differences between the oxaliplatin + raltetrexed regimen and FOLFOX regimen.

We divided the 248 patients into two groups. There were 60 patients in the oxaliplatin + ratitetrexed group and 74 patients in the FOLFOX group. The primary endpoints were OS and PFS. The secondary endpoints were ORR and adverse events. We used SPSS software, the Kaplan–Meier method, the t test, and the rank sum test to compare the differences between the two groups.

The median OS was 10.82 months in the oxaliplatin + raltitrexed group and 8.67 months in the FOLFOX group. The median PFS time was greater in the oxaliplatin + raltitrexed group (10.0 months) than that in the FOLFOX group (7.1 months). The ORR was greater in the oxaliplatin + raltitrexed group than that in the FOLFOX group (18.3% vs. 13.5%; P  = 0.445). The DCR in the oxaliplatin + raltitrexed group was higher than that in the FOLFOX group (70.0% vs. 64.8%; P  = 0.529). However, in the subgroup analysis, the difference between them was more significant in the type II PVTT subgroup. The OS was 12.08 months in the oxaliplatin + raltitrexed group and 7.26 months in the FOLFOX group ( P  = 0.008). The PFS was 11.68 months in the oxaliplatin + raltitrexed group and 6.26 months in the FOLFOX group ( P  = 0.014). In the right branch of type II PVTT, the OS was 13.54 months in the oxaliplatin + raltitrexed group and 6.89 months in the FOLFOX group ( P  = 0.015), and the PFS was 13.35 months in the oxaliplatin + raltitrexed group and 6.27 months in the FOLFOX group ( P  = 0.030). The incidence of adverse reactions was similar between the two groups.

Conclusions

Compared with the FOLFOX regimen, the oxaliplatin + raltitrexed chemoembolization regimen had longer OS, PFS time and ORR and DCR and it was safe and tolerable.

Primary liver cancer (PLC) is a common malignancy and the fourth leading cause of cancer-related death worldwide [ 1 ]. There are two types of hepatic vascular invasion: macroscopic and microscopic. Portal vein tumor thrombosis (PVTT) is the most common form of macrovascular invasion of the PLC [ 2 ]. Patients with PVTT usually lose the opportunity for surgery and have an aggressive disease course, decreased liver function reserve, limited treatment options, higher recurrence rates after treatment, and, therefore, worse overall survival [ 3 , 4 , 5 ]. Clinically, PVTT is related to tumor size, tumor number, tumor stage, Child–Pugh score, and serum alpha-fetoprotein (AFP) levels [ 6 ]. Some studies have shown that combining transarterial chemoembolization (TACE) therapy with hepatic arterial infusion chemotherapy (HAIC) might improve the survival rate of patients with PLC with PVTT [ 7 ].

TACE is a treatment in which embolic agents and chemotherapy drugs are mixed together and injected from the hepatic artery to the tumor site, serving to embolize the tumor-feeding arteries and induce ischemic necrosis in the tumor tissue and it is one of the most commonly recommended first-line treatments for PLC, especially combined with PVTT [ 8 , 9 , 10 ]. Many studies have shown that TACE combined with HAIC is superior to TACE alone in terms of overall survival (OS) and progression-free survival (PFS), and the treatment-associated toxicities are generally well tolerated [ 7 , 11 , 12 ]. Other studies have shown that in the unresectable and advanced PLC, compared with those in patients treated with two chemoembolization regimens [oxaliplatin + raltetrexed and oxaliplatin + fluorouracil + leucovorin calcium regimen (FOLFOX)], the disease control rates (DCRs) of patients treated with oxaliplatin and realtitrexed were greater than those in patients in the FOLFOX group, and the incidence of adverse reactions was similar [ 13 , 14 ]. However, the clinical data on the use of raltitrexed in TACE for treating PLC are compared with those on specific chemotherapeutic drug regimens and related effectiveness comparisons [ 15 ]. To date, there are still arguments about the effectiveness of different drug regimens for HAIC combined with TACE in patients with PLC with PVTT.

Therefore, we designed this retrospective study to compare the effectiveness and safety of different drug regimens for patients with PLC with PVTT treated with HAIC combined with TACE.

Section of patients

Patients were recruited from the Second Affiliated Hospital of Chongqing Medical University. The inclusion criteria were as follows: (1) patients aged > 18 years with PLC who were unsuitable for resection or percutaneous ablation, (2) the Barcelona Clinic Liver Cancer (BCLC) stage is the B–C, or Chinese liver cancer (CNLC) stage is Ib, IIa and llb, (3) Eastern Cooperative Oncology Group (ECOG) performance status is less than or equal to 2, (4) preserved liver function (Child–Pugh) class A or B, (5) a life expectancy greater 12 weeks, (6) a leukocyte count of > 3.0 × 10 9 /L, platelet count ≥ 80 × 10 9 /L, hemoglobin (Hb) ≥ 80 g/L; creatinine (Cr) ≤ 2.0 × UNL (upper normal limits), bilirubin (BIL) ≤ 2.0 × UNL, alanine transaminase (ALT) and aspartate transaminase (AST) ≤ 7.0 × UNL and (7) treatment with programmed cell death protein 1 (PD1) or programmed cell death-ligand 1 (PD-L1) before.

All patients were excluded if they had any other primary tumors, severe liver dysfunction, Child–Pugh class C disease, including severe jaundice, hepatic encephalopathy, refractory intraperitoneal effusion, or hepatorenal syndrome. Patients were also excluded if they had coagulation dysfunction that could not be corrected, if the main portal vein was completely embolized by cancer thrombolysis, if the portal vein collateral compensation was insufficient, if the portal vein could not flow back through the portal vein, if it was combined with severe infection and could not be effectively controlled, or if other serious illnesses or medical conditions occurred. In addition to TACE and HAIC, patients receiving other invasive therapies [radiofrequency, liver resection, high-intensity focused ultrasound (HIFU), etc.] were also excluded.

A total of 248 patients with PLC and PVTT were selected from the Department of Hepatobiliary Surgery, Gastroenterology and Hepatic Disease Center from January 2019 to October 2022. All patients underwent contrast-enhanced ultrasound (CEUS) imaging. It represents an important tool for the identification of PVTT, particularly for identifying differentiating neoplastic and nonneoplastic thrombosis through the analysis of the ultrasound enhancement characteristics of the thrombosis (malignant findings are characterized by intraluminal arterial hyperenhancement during the arterial phase and washout in the portal or late phase, while benign thrombosis lacks contrast enhancement in any phase) [ 16 ]. The 248 patients were divided into the oxaliplatin + raltitrexed group and FOLFOX groups. After excluding 26 patients with metastatic tumors from other sites and 88 patients who were lost to follow-up after one treatment session, there were 60 patients in the oxaliplatin + ratitetrexed regimen group and 74 patients in the FOLFOX regimen group were included (Fig.  1 ). The primary endpoints were OS and PFS. The secondary endpoints were ORR and adverse events.

Flow diagram showing patient selection. Abbreviations PLC, primary liver cancer; PVTT, portal vein tumor thrombosis; TACE, transarterial chemoembolization; HAIC, hepatic arterial infusion chemotherapy

Treatment plan

Using the Seldinger technique, we punctured the 5Fr micropuncture into the right femoral artery of patients and placed the 5F vascular sheath. The tumor nourishing arteries were hyperselectively intubated with a microcatheter and a superslip wire. Then, we injected chemicals (3 mg of realtitrexed, 50 mg of loplatin, 20 mg of pyrorubicin mixed with 5–20 ml of iodized oil or loplatin combined with pyrorubicin mixed with iodized oil) into the tumor nourishing arteries. The actual dose was determined based on the size and number of target tumors and the patients’ liver function. Polyvinyl alcohol (PVA) particles were used after embolization of the iodooil emulsions, and digital subtraction angiography (DSA) was performed 5 min after embolization to confirm stagnant blood flow in the feeding artery. We placed an arterial catheter after TACE and performed perfusion chemotherapy in the general ward. We intravenously administered dexamethasone (5 mg i. v) and micropumped oxaliplatin (85 mg/m 2 ) through the catheter sheath artery for 3 h and raltetrexed (3 mg/m 2 ) for 5 h in the oxaliplatin + raltitrexed group. We intravenously administered dexamethasone (5 mg i. v) and micropumped oxaliplatin (85 mg/m 2 ) through the catheter sheath artery for 3 h, calcium folinate (200 mg/m 2 ) for 2 h and fluorouracil (2500 mg/m 2 ) for 46 h in the FOLFOX group. All patients were followed up every 4–6 weeks after the last TACE and then every 1–3 months if there was no significant recurrence or metastasis. If new lesions or residual tumors were identified, TACE was repeated until untreatable progression occurred.

Statement of ethics

This retrospective study was conducted in accordance with the Declaration of Helsinki. This study was approved by the Chongqing Medical University, the Second Affiliated Hospital of Chongqing Medical University. All patients provided written informed consent form.

The data were statistically analyzed using the SPSS 26.0 software. The measurement data were expressed as the mean ± standard deviation (x ± s), with groups compared utilizing the t test and χ 2 test for count data, OS and PFS were analyzed via Kaplan–Meier curves, with statistically significant indicated by P  < 0.05.

Study subject

Between January 2019 and October 2022, 248 patients were received HAIC combined with TACE treatment. After excluding 26 patients with metastatic tumors from other sites and 88 patients who were lost to follow-up after one treatment session, there were 60 patients in the oxaliplatin + ratitetrexed regimen group and 74 patients in the FOLFOX regimen group (Fig.  1 ). The median tumor size was 9.4 cm (range 3.0–18.7 cm). The baseline characteristics of the two groups are summarized in Table  1 ; none of these characteristics differed significantly between the two groups. Most patients were diagnosed with hepatitis B virus (HBV) related PLC, and most of them were male (Table  1 ).

Safety and toxicity

Toxic and adverse reactions were evaluated according to the standards for toxicity and side reactions of World Health Organization (WHO) anticancer drugs [ 17 ]. There were no cases of procedure-related mortality or 30-day mortality. The complications are listed in Table  2 . The most common complications were postembolization syndrome and liver dysfunction. Six of the 60 patients in the oxaliplatin + raltitrexed group and ten of the 74 patients in the FOLFOX group experienced grade 3–4 adverse events. Pain adverse effects occurred in 24 (40.0%) patients in the oxaliplatin + raltitrexed group and 42 (56.7%) patients in the FOLFOX group ( P  = 0.034). The other adverse reactions were similar between the two groups (Table  2 ).

Tumor response

We evaluated the therapeutic efficacy of PLC according to the WHO modified Response Evaluation Criteria in Solid Tumors (mRECEIST) [ 18 ] divided into complete remission (CR) (no enhancement of the intratumoral artery), partial remission (PR) (the tumor was reduced by 30%), stable disease (SD), and progressive disease (PD) (tumor diameter increase of 20% or new tumors). CR + PR was the objective response rate (ORR) and CR + PR + SD was the disease control rate (DCR). Efficacy was evaluated by review after 2 cycles of chemotherapy. A physical examination was performed before the start of each cycle of chemotherapy and routine blood routine, liver and kidney function, AFP, electrocardiogram, computed tomography (CT) or magnetic resonance imaging (MRI), and color ultrasound examinations were performed. Follow-up visits were used to assessed the median survival time. Tumor response was assessed at 4–6 weeks. The results for the two groups are shown in Table  3 . The ORR and DCR were higher in the oxaliplatin + raltitrexed group than that in the FOLFOX group (ORR: 18.3% vs. 13.5%; P  = 0.445; DCR: 70.0% vs. 64.8%; P  = 0.529).

Survival analysis

At the end of the study period, 12 (20.0%) patients in the oxaliplatin + raltitrexed group and 6 (8.1%) patients in the FOLFOX group were still alive. The median follow-up time was 6 months, and the total follow-up time was 20 months. The median OS was 10.82 months in the oxaliplatin + raltitrexed group [95% confidence interval (CI) 8.80, 12.85] and 8.67 months in the FOLFOX group (95% CI 7.11, 10.22; P  = 0.066) (Fig.  2 a). The median PFS time was slightly longer in the oxaliplatin + raltitrexed group (10.02 months, 95% CI 7.69, 12.36) than in the FOLFOX group (7.07 months, 95% CI 5.28, 8.85; P  = 0.102) (Fig.  2 b). The ORR was greater in the oxaliplatin + raltitrexed group than that in the FOLFOX group (18.3% vs. 13.5%; P  = 0.445). The DCR of the oxaliplatin + raltitrexed group was also greater thanthat of the FOLFOX group (70.0% vs. 64.8%; P  = 0.529).

Survival analysis function of the two groups. The median follow-up time was 6 months, and the total follow-up time was 20 months. A Kaplan–Meier curves of OS in patients with unresectable primary liver cancer who underwent TACE in the two groups. B Kaplan–Meier curves of PFS in patients with unresectable primary liver cancer who underwent TACE in the two groups

Univariate and multivariate logistic regression analyses

We used univariate and multivariate logistic regression analyses to assess risk factors for each variable (Table  4 ). We found that age, the type of PVTT, tumor size and extrahepatic metastasis were independent risk factors affecting the prognosis of patients with PLC.

Subgroup analysis

Subgroup analysis by age.

Previous studies have indicated a better protective effect of ralterexed on myocardial function [ 19 ], so our study divided patients into four subgroups by age (< 36 years, 36–50 years, 51–65 years and > 65 years). In the 1st subgroup, the OS was 4.00 months in the oxaliplatin + raltitrexed group (95% CI 2.04, 5.96) and 4.50 months in the FOLFOX group (95% CI 3.90, 5.10; P  = 0.695); the PFS was 1.50 months in the oxaliplatin + raltitrexed group (95% CI 0.00, 4.44) and 3.75 months in the FOLFOX group (95% CI 1.78, 5.72; P  = 0.107). In the 2nd subgroup, the OS was 13.80 months in the oxaliplatin + raltitrexed group (95% CI 10.01, 17.58) and 8.44 months in the FOLFOX group (95% CI 6.65, 10.43; P  = 0.080); the PFS was 13.23 months in the oxaliplatin + raltitrexed group (95% CI 8.98, 17.48) and 6.47 months in the FOLFOX group (95% CI 4.52, 8.41; P  = 0.072). In the 3rd subgroup, the OS was 12.95 months in the oxaliplatin + raltitrexed group (95% CI 10.06, 15.83) and 9.17 months in the FOLFOX group (95% CI 6.12, 12.21; P  = 0.128); the PFS was 12.32 months in the oxaliplatin + raltitrexed group (95% CI 8.93, 15.72) and 7.71 months in the FOLFOX group (95% CI 4.35, 11.07; P  = 0.095). In the 4th subgroup, the OS was 10.03 months in the oxaliplatin + raltitrexed group (95% CI 6.42, 13.64) and 8.27 months in the FOLFOX group (95% CI 5.36, 11.19; P  = 0.951); the PFS was 9.68 months in the oxaliplatin + raltitrexed group (95% CI 5.66, 13.70) and 8.28 months in the FOLFOX group (95% CI 5.36, 11.19; P  = 0.728) (Table  5 ). Overall, the OS and PFS of the oxaliplatin + raltitrexed group were longer than those of the FOLFOX group, but there were no significant differences between the two groups, and the examination indices of myocardial enzyme levels, cardiac color ultrasound results and other indicators did not appear significantly differ among the age groups. Therefore, the cardioprotective effect of raltetrexed needs to be further verified.

Subgroup analysis by PVTT classification

The more conventional and better-known classification of PVTT was proposed by the Liver Cancer Study Group of Japan (LCSGJ) [ 20 , 21 ]. Chen et al. proposed Cheng's classification type: Type I0: microscopic tumor thrombosis formation; Type I: tumor thrombosis involving secondary level and above portal vein branch (type Ia: tumor thrombosis involving portal vein grade i and j level and above branch; type Ib: tumor thrombosis involving portal vein secondary branch); Type II: tumor thrombosis involving primary portal branch [type IIa: primary portal branch (such as left or right portal stem); type IIb: secondary primary portal branch (involving left and right portal stem)]; Type III: tumor thrombolysis involving the main portal vein (type IIIa: tumor thrombolysis involving the main portal vein, portal vein trunk confluence below no more than 2 cm; type IIIb: tumor thrombolysis involving the main portal vein, portal vein trunk trunk confluence below more than 2 cm); Type IV: tumor thrombolysis involving superior mesenteric vein or inferior vena cava (type IVa: tumor thrombolysis involving superior mesenteric vein; type IVb: cancer thrombolysis involving inferior vena cava) [ 22 ].

We subjected all patients to PVTT subgroup analysis by Cheng's classification type. In the type II PVTT subgroup, the OS was 12.08 months in the oxaliplatin + raltitrexed group (95% CI 9.18, 14.98) and 7.26 months in the FOLFOX group (95% CI 5.79, 8.72; P  = 0.008) (Fig.  3 a); the PFS was 11.68 months in the oxaliplatin + raltitrexed group (95% CI 8.46, 14.90) and 6.26 months in the FOLFOX group (95% CI 4.80, 7.73; P  = 0.014) (Fig.  3 b). The ORR and DCR were greater in the oxaliplatin + raltitrexed group than in the FOLFOX group (ORR: 24.1% vs. 15.2%; P  = 0.357; DCR: 75.8% vs. 60.9%; P  = 0.221) (Table  6 ).

Survival analysis function of patients in the type II PVTT subgroup. A Kaplan–Meier curves of OS in patients with type II PVTT who underwent TACE in the two groups. B Kaplan–Meier curves of PFS in patients with type II PVTT who underwent TACE in the two groups

Subgroup analysis by tumor number

In the baseline comparison, there were significant differences between the number of tumors in the two groups, so we performed Cox multivariate regression analysis. All patients were divided into two subgroups: a single-tumor subgroup and a multiple-tumor subgroup. In the single-tumor subgroup, the OS was 11.25 months in the oxaliplatin + raltitrexed group (95% CI 8.58, 13.91) and 7.81 months in the FOLFOX group (95% CI 5.27, 10.35; P  = 0.044) (Fig.  4 a); the PFS was 10.66 months in the oxaliplatin + raltitrexed group (95% CI 7.53, 13.80) and 5.95 months in the FOLFOX group (95% CI 3.34, 8.56; P  = 0.041) (Fig.  4 b). In the multiple-tumor subgroup, the OS was 12.96 months in the oxaliplatin + raltitrexed group (95% CI 9.83, 16.08) and 9.10 months in the FOLFOX group (95% CI 7.10, 11.09; P  = 0.046) (Fig.  4 c); the PFS was 12.54 months in the oxaliplatin + raltitrexed group (95% CI 9.10, 15.87) and 8.24 months in the FOLFOX group (95% CI 5.90, 10.57; P  = 0.047) (Fig.  4 d) (Table  7 ).

Survival analysis function of subgroups by tumor numbers. A Kaplan–Meier curves of OS in patients with a single tumor who underwent TACE in the two groups. B Kaplan–Meier curves of PFS in patients with a single tumor who underwent TACE in the two groups. C Kaplan–Meier curves of OS in patients with a multiple tumor who underwent TACE in the two groups. D Kaplan–Meier curves of OS in patients with a multiple tumor who underwent TACE in the two groups

Subgroup analysis by the position of type II PVTT

In the type II PVTT subgroup, the oxaliplatin + raltitrexed regimen showed better efficacy than FOLFOX, and we again divided all patients into left, right and bilateral type II PVTT groups according to the location of the PVTT.In the right group, the OS was 13.54 months in the oxaliplatin + raltitrexed group (95% CI 9.52, 17.56) and 6.89 months in the FOLFOX group (95% CI 5.17, 8.60; P  = 0.015) (Fig.  5 a); the PFS was 13.35 months in the oxaliplatin + raltitrexed group (95% CI 9.08, 17.63) and 6.27 months in the FOLFOX group (95% CI 4.48, 8.07; P  = 0.030) (Fig.  5 b). These two drug treatment modalities were significant different (Table  8 ).

Survival analysis of subgroups stratified by the location of type II PVTT. A Kaplan–Meier curves of OS in patients with type II PVTT in the right branch who underwent TACE in the two groups. B Kaplan–Meier curves of PFSS in patients with type II PVTT in the right branch who underwent TACE in the two groups

In our study, after a 20-month follow-up time, the OS and PFS in the oxaliplatin + raltitrexed group were slightly longer than those in the FOLFOX group. However, neither of the two groups exhibited statistically significant differences. The ORR was 18.3% in the oxaliplatin + raltitrexed group and 13.5% in the FOLFOX group ( P  = 0.445). The DCR was 70.0% in the oxaliplatin + raltitrexed group and 64.8% in the FOLFOX group ( P  = 0.529). Pain adverse effects occurred in 24 (40.0%) patients in the oxaliplatin + raltitrexed group and 42 (56.7%) patients in the FOLFOX group ( P  = 0.034). However, the other adverse reactions were almost the same between the two groups.

The FOLFOX treatment modality was previously used to treat gastrointestinal tumors (including primary and metastatic liver cancer, biliary tract system tumors, pancreatic tumors, and colorectal tumors.) [ 23 , 24 ]. According to previous reports, FOLFOX-HAIC significantly improved OS compared with TACE in patients with unresectable large hepatocellular carcinoma [ 25 , 26 ]. However, fluorouracil should be administered intra-arterially for approximately 44 h, and a higher incidence of pain, catheter thrombosis and catheter-associated infection has been reported [ 27 ]. The oxaliplatin + raltitrexed regimen had been gradually used for HAIC treatment after TACE due to its advantages of less cardiotoxicity and shorter perfusion time in recent years [ 28 ]. The OS and PFS were longer than those of the FOLFOX group in previous studies not only for HCC but also for colorectal cancer (CRC) liver metastasis (CRCLM) [ 29 , 30 ]. There are few studies on perfusion chemotherapy for liver cancer combined with PVTT. Cui et al. proposed that the PFS of patients treated with raltitrexed was longer in unresectable hepatocellular carcinoma complicated with PVTT, but no significant statistical difference was observed between the two groups [ 13 ]. However, this finding did not further explain the reason for the longer PFS of the oxaliplatin + raltitrexed regimen. OS and PFS were also longer in the oxaliplatin + raltitrexed group than those in the FOLFOX group, but there was no significant difference between the two groups in our study. Unlike previous studies, our drug dose was calculated by body weight in order to obtain the best results for each patient and decrease toxic side effects. In addition, we also conducted subgroup analysis through age, type of PVTT, and the number of tumors and still concluded that oxaliplatin + raltitrexed was superior to FOLFOX, and there were significant differences in the subgroups of type II PVTT and the number of tumors. Moreover, the sample size was somewhat larger than that in previous studies. It can be seen that oxaliplatin + raltitrexed regimen has beneficial advantages and safety for PLC in combination with PVTT.

According to our subgroup analysis by PVTT classification, oxaliplatin + raltitrexed showed better efficacy than FOLFOX in the type II PVTT subgroup. The OS was 12.08 months in the oxaliplatin + raltitrexed group (95% CI 9.18, 14.98) and 7.26 months in the FOLFOX group (95% CI 5.79, 8.72; P  = 0.008); the PFS was 11.68 months in the oxaliplatin + raltitrexed group (95% CI 8.46, 14.90) and 6.26 months in the FOLFOX group (95% CI 4.80, 7.73; P  = 0.014). Moreover, oxaliplatin + raltitrexed was more effective for type II PVTT located in the right branch in our study. Theoretically speaking, there may be two reasons for this. First, the efficacy of chemotherapy drugs may be related to the location of the PVTT. When the PVTT is located in the right branch of the portal vein and the tumor is located on the same side, the drug can be better transported to the target vessel through the right hepatic artery, while when the PVTT is located in the left or bilateral or even the main portal vein (MPV), the perfusion effect of the drug through the arteriae hepatica propria (AHP) may be slightly attenuated. On the other hand, this is due to the pharmacokinetic difference between ratitetrexed and fluorouracil. Raltitrexed can directly or specifically cause DNA chain breakage and apoptosis by inhibiting thymidylate synthase (TS), a key enzyme in the synthesis of deoxythymidine 5-triphosphate (TTP). However, fluorouracil was first converted to a 5-fluorine-deoxyuracil nucleotide at first in vivo after which TS was inhibited to inhibit DNA. Nevertheless, further prospective studies are needed to determine the possible advantages of the right-branch type II PVTT will in the oxaliplatin + raltitrexed group.

Previous studies reported that fluorouracil has some cardiotoxic effects, such us fluoropyrimidine-induced cardiotoxicity (FIC), including coronary artery vasospasm, endothelial or cardiomyocyte damage, toxic metabolites, and dihydropyrimidine dehydrogenase deficiency and so on [ 31 ]. Compared with fluorouracil, raltitrexed is less cardiotoxic [ 32 ]. According to our subgroup analysis by age, the OS and PFS of the oxaliplatin + raltitrexed group were longer than those of the FOLFOX group in every subgroup, but neither the OS nor PFS of the two groups in the subgroups were significantly different. All patients in our study underwent accessory examinations including myocardial enzyme spectrum, type B natriuretic peptide precursor (BNP), cardiac color ultrasound and electrocardiogram before and after TACE, and none of the findings showed significant cardiac damage. Therefore, the cardioprotective effect of raltetrexed needs to be further verified. According to the subgroup analysis by tumor number, the OS and PFS in the oxaliplatin + raltitrexed group were grater than those in the FOLFOX group and there were significant differences regardless of the number of tumors. The study of Rong et al. noted that as the number of tumors increased, the OS decreased [ 33 ], while the OS of our study was slightly longer in multiple tumor groups than in a single tumor group. Therefore, further studies on the impact of tumor number on patient prognosis are needed, but these studies did not reveal an obvious prognostic benefit of raltitrexed.

Our study also evaluated the safety and tolerability of these two treatments. We found that the incidence of major complications was not significantly different between the two groups. Only a greater proportion of pain response in the FOLFOX group may be associated with a longer drug perfusion time, but all complications were reversible and adequately controlled by medical treatment. These results indicate that the combination of raltitrexed and oxaliplatin in TACE in patients with unresectable PLC is safe and tolerable.

Our study also had some limitations. First, because it was retrospective, some selection biases were unavoidable. Second, this study was conducted at a single center with a relatively small number of patients, a large number of whom carried hepatitis B (82.8%), and the proportion of males was high (89.5%). Third, the included subjects in this study had no type IV PVTT. Currently, the treatment of type IV PVTT for TACE + HAIC is still being explored currently, and further studies on this topic may be needed. Finally, the sample size of the oxaliplatin + raltitrexed group was small. If we increase the sample size, reduce the loss to follow-up and extend the follow-up time, we can obtain better results. Moreover, the number of TACE procedures differed among individuals, which may also have affected the results of our study. Larger prospective trials are needed to confirm this conclusion.

Despite no significant difference between the oxaliplatin + raltitrexed group and the FOLFOX group, the oxaliplatin + raltitrexed chemoembolization regimen had a longer OS, PFS, ORR and DCR than the FOLFOX regimen. This regimen was safe and tolerable, especially for PLCs with type II PVTT. Our findings suggest that the combination therapy of TACE and HAIC bvia oxaliplatin plus raltitrexed regimen confers more benefits to patients with unresectable PLC than other regimens.

Availability of data and materials

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

Portal vein tumor thrombosis

• Primary liver cancer
• Transarterial chemoembolization
• Hepatic arterial infusion chemotherapy

Overall survival

Progression-free survival

Oxaliplatin + fluorouracil + leucovorin calcium

Objective remission rate

Disease control rate

Transarterial chemoembolization plus hepatic arterial infusion chemotherapy

Confidence interval

Alpha-fetoprotein

Barcelona clinic liver cancer

Eastern Cooperative Oncology Group

Upper normal limits

Aminotransferase

Programmed cell death protein 1

Programmed cell death-ligand 1

High intensity focused ultrasound

Polyvinyl alcohol particles

Digital subtraction angiography

Hepatitis B surface antigen

Carbohydrate antigen 125

Carbohydrate antigen 199

Carbohydrate antigen 242

Carbohydrate antigen 50

Carbohydrate antigen 724

International normalized ratio

White blood cell

Alkaline phosphatase

γ-Glutamyl transferase

World Health Organization

Modified response evaluation criteria in solid tumors

Complete remission

Partial remission

Stable disease

Progressive disease

Objective response rate

Computed tomography

Magnetic resonance imaging

Liver Cancer Study Group of Japan

Colorectal cancer

Colorectal cancer liver metastasis

Main portal vein

Arteriae Hepatica Propria

Thymidylate synthase

Deoxythymidine 5-triphosphate

Fluoropyrimidine-induced cardiotoxicity

B naturetic peptide precursor

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Acknowledgements

We are grateful to the Department of Hepatobiliary Surgery at the Second Affiliated Hospital of Chongqing Medical University. This study was supported by the National Natural Science Foundation of China (No. 82173117), Natural Science Foundation of Chongqing (No. CSTB2023NSCQ-MSX0214) and Kuanren Talents Program of the Second Affiliated Hospital of Chongqing Medical University (NO. kryc-yq-2209).

This study was supported by the National Natural Science Foundation of China (No. 82173117), Natural Science Foundation of Chongqing (No. CSTB2023NSCQ-MSX0214) and Kuanren Talents Program of the Second Affiliated Hospital of Chongqing Medical University (NO. kryc-yq-2209).

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Xinxin Tu and Wenfeng Zhang have contributed equally to this work.

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Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, No. 74, Linjiang Road, Yuzhong District, Chongqing Municipality, 400010, People’s Republic of China

Xinxin Tu, Wenfeng Zhang, Qi He & Yue Li

Department of Hepatobiliary Pancreatic Tumor Center, Chongqing University Cancer Hospital, Chongqing, No. 181, Hanyu Road, Shapingba District, Chongqing Municipality, 400010, People’s Republic of China

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Study conception and experimental design, collection and analysis of data, and manuscript writing, Xinxin Tu; collection and analysis of data, Xinxin Tu, Wenfeng Zhang, Sipeng Li, Qi He; study conception, design, and supervision, Wenfeng Zhang, Yue Li; supervision, manuscript writing, and final approval of the manuscript; Yue Li. All authors read and approved the final manuscript.

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Tu, X., Zhang, W., Li, S. et al. Efficacy of hepatic arterial infusion chemotherapy in patients with primary liver cancer with portal vein tumor thrombosis: a comparative analysis of different perfusion chemotherapeutic regimens. Eur J Med Res 29 , 465 (2024). https://doi.org/10.1186/s40001-024-02053-6

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Investigating academic dishonesty and its relationship with moral competence and professional identity of nursing students: a cross-sectional study

• Leila Homayouni   ORCID: orcid.org/0000-0001-7776-4496 1 , 2 ,
• Azam Zare   ORCID: orcid.org/0009-0005-1645-9558 3 ,
• Zahra Padam 5 &
• Armin Fereidouni   ORCID: orcid.org/0000-0003-0089-2638 4  

BMC Nursing volume  23 , Article number:  662 ( 2024 ) Cite this article

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Academic dishonesty as a fundamental challenge in adherence of ethical principles in providing care to patients has caused concern to the scientific community of nurses. In addition, positive professional identity and high moral competence are important for nurses to perform multiple care roles in high quality care of patients. The purpose of the present study is of investigating academic dishonesty and its relationship with moral competence and professional identity of master’s and PhD nursing students.

This descriptive-analytical study was conducted by census method on 65 master’s and PhD nursing students in Shiraz University of Medical Sciences, Iran in 2023. Data collection tools included 4 questionnaires (Demographic information, Academic Dishonesty Scale (DAS), Nurses’ moral competence and Professional Identity Scale for Nursing Students (PISNS)). Data collection was done within 2 months. Descriptive and inferential analyzes including independent t-test, Pearson correlation coefficient and linear regression were used to analyze the data. The collected data were analyzed by SPSS.V.22 software. P -value less than 0.05 was considered significant.

The average age of 65 participants was 31.5 ± 5.61 years. The majority of the participants in this study were women 48 (73.8%). There is a significant and negative correlation between academic dishonesty and moral competence ( r =-0.260, P -value = 0.036). There is no significant correlation between academic dishonesty and professional identity ( r  = 0.154, P -value = 0.22). Also, a significant positive correlation was found between moral competence and professional identity ( r  = 0.294, P -value = 0.018).

Therefore, considering that the fact that students have a great impact on patient care, Researchers suggest that educational institutions should prevent the increase of academic dishonesty among students by establishing new rules and regulations.

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One of the important issues in the health system is providing ethical care. Ethical care is an essential part of the nursing profession The actual academic dishonesty is a fundamental challenge in adherence to ethical principles in providing care to the patient [ 1 ]. Honesty is considered a fundamental moral value in all educational environments, and academic honesty is of unquestionable importance in educational environments, academic dishonesty and theft have been one of the most challenging and controversial ethical issues in academic debates for years [ 2 , 3 ]. Academic dishonesty is defined as the use of illegal aid to deceive an instructor or professor, a deliberate attempt by a student to falsify data, or any other fraud on campus. Globally, more than 80% of students agree that cheating is necessary to progress at higher levels [ 4 ] And more than 70% of students admit that they have been involved in various forms of academic dishonesty [ 2 ]. The study of Alotaibi and et al., (2024) showed that the prevalence of dishonesty among nursing students is at a high level [ 5 ] This is a concern for the scientific community of nurses, because there is a positive correlation between academic dishonesty and ethical behavior in the future [ 6 , 7 ]. Students who engage in academic immorality will have difficulty in acquiring the necessary skills for their future jobs [ 8 ] and these inefficient and unskilled people will cause irreparable problems in the clinical environment. In addition, paying attention to ethical competence in the nursing profession is essential, because the quality of patient care depends on the ethics of nurses [ 9 ].

Ethical competence is an ethical imperative that health care professionals must embody in their day-to-day functioning in order to identify ethical dimensions in their decisions. Ethical competence helps healthcare professionals find the best solution for their patients. Therefore, it is an essential component for providing high-quality care [ 10 , 11 ]. Moral competence is an abstract concept that consists of cognitive, emotional and behavioral components [ 12 ]. The results of a qualitative study in Iran showed that the ethical competence of nursing includes wide dimensions such as moral character, moral decision-making and moral care [ 9 ]. Since most of the decisions and procedures that are made in the nursing profession have an ethical dimension [ 13 ], developing students’ ethical competence is of great importance. Today’s students are future nurses who will make decisions about human health and life. Therefore, these students should attain an appropriate level of moral competence during their studies, which is a good opportunity for learning and both ethical and professional development [ 14 ] In this regard, the study of Haghighat, et al. stated there is a significant relationship between the formation of professional identity and the development of ethics in nursing students, so that by strengthening the professional values ​​of students, their moral competences grow [ 12 ]. In addition to individual effects, unethical acts can have a negative impact on both the patient and the profession. Therefore, investing in nursing students’ moral competency improves professional identity and quality of nursing services [ 15 ].

Another factor that has a significant impact on the quality of patient care is professional identity. In fact, professional identity is a fundamental element in nursing [ 16 ]. The professional identity of “perception of the professional self” is based on attitudes, beliefs, feelings, values, motivations and experiences related to a particular profession [ 16 , 17 , 18 ]. Professional identity is a part of the care structure and is the main consequence of the education and socialization of nurses [ 19 , 20 ]. Positive and flexible professional identity is important for performing multiple roles of nurses in quality care of patients and reducing workplace stress [ 19 , 20 ]. It is also one of the most important factors affecting employees’ commitment to their profession [ 16 ]. The formation of professional identity is a dynamic process that starts from the time of training students for a future job and continues throughout one’s professional life [ 21 , 22 , 23 ]. Positive professional identity will ultimately increase the quality of care and negative professional identity and decrease the quality of care and motivation for professional learning of nursing students [ 20 ]. The results of a systematic review study showed that the most important factors related to the formation of nursing professional identity include poor team and communication activities, role of clinical instructors, educational methods, individual characteristics (age, sex, self-confidence, job satisfaction, etc.) and the role of culture and media [ 24 ]. In another study, the gap and lack of coordination between theoretical and clinical education, the amount of support that students receive from the educational system and lack of a clear and acceptable picture of nursing profession in the community are the factors affecting the development of professional identity [ 25 ].

On the other hand, academic dishonesty affects the formation of professional identity in nursing students, so the results of the study of the Krueger(2014) study reported that more than half of the nursing students reported academic dishonesty in the classroom and almost the same number of cheating in the clinical environment, which reflects the unprofessional behavior of the students in the clinical environment [ 26 ]. Also, in Bloomfield et al.(2021)’s study, the participants stated that academic dishonesty is a violation of the code of conduct, and a high percentage of them stated that academic dishonesty should be considered as a professional offense [ 27 ].

Considering the importance of academic honesty and the negative consequences of engaging in academic dishonesty, as well as the importance of moral competence and professional identity in nursing students, so far no study has investigated the relationship between academic dishonesty and the moral competence and professional identity of nursing students. Most of the studies conducted in the field of academic dishonesty have investigated its situation and methods [ 6 , 28 , 29 ] and the effective factors in creating academic dishonesty and cheating [ 2 , 29 ]. Therefore, this study aimed to determining the relationship between academic dishonesty with moral competence and professional identity of nursing students was accomplished.

Study design and subjects

In The present study 70 students (Master and PhD) participated in the study. Five students were excluded from the study due to the failure to complete the questionnaire and the analysis was done on the data of 65 students of Shiraz School of Nursing and Midwifery, Iran from June to November 2023. The Sampling method used in this study was census and all nursing students in master and PhD nursing students with inclusion and exclusion criteria were enrolled. Inclusion criteria included at least one semester of study. Exclusion criteria were deficiency in filling out the questionnaire, unwillingness to participate in the study and presence of self-reported mental illness. The current study was designed based on the STROBE guidelines for observational studies.

The present study has been approved by the ethics committee of Shiraz University of Medical Sciences with the Code of Ethics (IR). SUMS. NUMIMG. REC.1401.054 and access link (B2n.ir/z74571). After receiving the code of ethics, the researcher received a list of names along with the contact numbers of MS and PhD nursing students who met the inclusion and exclusion criteria. In the next step, the link of online questionnaires (all questionnaires were designed in one link) was sent to the target group via short message service (a system used for sending text messages to and from mobile phones).

The online questionnaire link was sent up to 3 times. In the design of the online questionnaire, IP filtering was used to prevent repeated responses, and the participants could refuse to complete the questionnaire at any time.

Before completing the questionnaire, participants were informed of the objectives of the study and informed written consent was obtained from each participant electronically before completing the questionnaire. There are 80 students nursing (master’s and PhD degree) in college. Finally, 70 of 80 nursing students participated in the study and after collecting questionnaires, 5 questionnaires were excluded due to failed to completion. Finally, data from 65 participants were analyzed.

Data collection tools

In this study, 4 questionnaires were used, including: Demographic information questionnaire (age, gender, grade point average), Academic Dishonesty Scale (DAS) [ 30 ], Nurses’ moral competence [ 9 ]and Professional Identity Scale for Nursing Students (PISNS) [ 16 ].

Academic dishonesty scale

The scale was designed by Bashir & Bala in 2018 in 23 items and 6 dimensions. Dimensions of the scale include Cheating in examination (items 1 to 5), Plagiarism (items 6 to 9), Outside help (items 10 to 13), Prior cheating (14 to 16), Falsification (items 17 to 19), and lying about academic assignments (items 20 to 23). The items of this scale are scored on a 5-degree Likert range from never (score 0) to always (score 4) [ 31 ]. The upper limit of the score in this questionnaire is 92 and the lower limit is 0. (Low range: 0–30, Intermediate range: 31–60, High range: 61–90) This scale has been Translation and validated in Iran. Validity and reliability of the questionnaire were confirmed by face, content and construct validity (confirmatory factor analysis and internal consistency) and Cronbach’s alpha. Confirmatory factor analysis with fitting indices (2X = 317, 1.63 × 2/df, 0.81 NFI, 0.93 TLI:, 0.89 GFI:, 0.95 CFI:, 0.05 RMR:, 0.68 PNFI:, 0.73 PCFI:, 0.63 PGFI:, 0.86 AGFI:, 0.95 IFI:, 0.06 RMSEA:, 0.19 PCLOSE: ) showed the fit of academic dishonesty scale with the data. In order to investigate the internal consistency of academic dishonesty scale, correlation between the scores of academic dishonesty dimensions with each other and with the total score of the scale was used [ 30 ]. Cronbach’s alpha was 0.93 in the version Translation and validated in Iran.

Nurses’ moral competence

This questionnaire was designed in 2017 by Zafarnia et al. in Iran. The questionnaire consists of 46 items, including 6 domains including Responsible Behavior (item 1 to 15), Reliability (16 to 23), Service Enthusiasm (24 to 28), Utility (29 to 33), Client-centered (4 to 42) and Ethical Knowledge (43 to 46). The questionnaire is based on a 4-point Likert scale with always (score 4), often (score 3), sometimes (score 2) and never [ 1 ]. Therefore, the minimum score on this scale is 46 and its maximum is 184 (Low range: 46–92, Intermediate range: 93–138, High range: 139–184). A higher score indicates greater moral competence. The content validity of this questionnaire was 92% by researchers [ 9 ]. Internal consistency was used to determine the reliability and Cronbach’s alpha was 0.93. To determine the reliability of the test-retest with a two-week interval, the nurses’ moral competency scale was administered again. Test-retest reliability was found to be 0.84 with CI 0.71–0.92 [ 9 ].

Professional identity scale for nursing students

The scale was created by Hufang Hao in 2011 and consists of 17 questions and 5 dimensions. Professional self-image, benefit of retention and risk of turnover, social comparison and self-reflection, independence of career choice, and social modeling. Items were graded from 1 (completely disagree) to 5 (completely agree), with scores ranging from 17 to 85. (Low range:17–39, Intermediate range: 40–62, High range:63–85) A high score denoted a high professional identity. In his study, the reliability coefficient of the total scale was 0.926 and the reliability coefficients of all subscales were more than 0.7 [ 32 , 33 ]. Translation and validated of tools in Iran has been confirmed by Haghighat et al. in 2017 with Cronbach’s alpha (α: 0.787) [ 16 ].

Statistical analysis

Data were analyzed using descriptive analysis including frequency, percentage, mean and standard deviation. Pearson correlation coefficient was used to determine the relationship between academic dishonesty and professional competence and academic dishonesty with students’ professional identity. Independent t-test was used to determine the relationship between demographic variables and academic dishonesty. Linear regression model was used for modeling. In this model, the dependent variable was professional competency and predictor variable were academic dishonesty, gender, grade, and grade point average. The collected data were analyzed using SPSS software version 22. P -value less than 0.05 was considered statistically significant.

The average age of 65 participants was 31.5 ± 5.61 years. The majority of the participants in this study were women (48, 73.8%). The mean GPA for nursing PhD students was18.09 ± 0.63 and 17.09 ± 1.15 in MS students. The details of frequency, percentage, mean and standard deviation of variables based on demographic information are reported in Table  1 .

According to the findings of this study, the mean and standard deviation for academic dishonesty was 7.82 ± 8.84, which is lower than average. Also, the mean and standard deviation for total moral competency was 158 ± 19.1 (High average) and total professional identity was 58 ± 11.5 (Intermediate average). The mean and standard deviation of the dimensions of all three variables are given in Table  2 .

The results of data analysis showed that there was a significant and negative correlation between academic dishonesty and moral competence ( r =-0.260, P -value = 0.036, df = 63). On the other hand, there was no significant correlation between academic dishonesty and professional identity ( r  = 0.154, P -value = 0.22). Also, there was a significant positive correlation between moral competence and professional identity ( r  = 0.294, P -value = 0.018). The analytical results of the relationship between academic dishonesty, moral competence and professional identity are shown in Table  3 .

In the linear regression model, first, the relationship between each independent variable (academic dishonesty, gender, grade, average) with the dependent variable (moral competence) was measured by simple linear regression. If the p -value was below 0.2, the variable was included in the multiple model.

In this model, a significant relationship was found between moral competence and academic dishonesty ( P -value = 0.002). The model shows that for every increase in academic dishonesty, moral competence decreases by an average of 0.829 points. Details are shown in Table  4 .

The aim of this study was to investigate academic dishonesty and its relationship between moral competence and professional identity of nursing students. In this study, less than half of these nursing students reported academic dishonesty. By comparison, the results of the Amutairi et al.study also -found that more than half of nursing students had academic integrity and a smaller percentage of them reported academic dishonesty with half of them saying that they participated in more than two cases of academic dishonesty during their education [ 34 ]. Maracle et al.‘s study stated that nursing students got used to doing dishonest behaviors and they think those behaviors are acceptable and normal, and this has caused an increase in dishonest behaviors among them [ 6 ]. Conversely, the results of the Alotaibi et al. study, contradicted the results of the current study, They found that a high percentage of students cheated on exams and assignments, and reported that more than three-quarters of students cheated before and during exams [ 5 ]. A study conducted in Saudi Arabia by Alnjjar et al. also found that a high percentage of nursing students reported at least one case of academic dishonesty in exams and homework [ 35 ].

In the other part of the study, the results showed that the moral competency of nursing students was moderate to high. In this regard, in the study of Alnajjar et al., it also indicated that nursing students had a moderate level of academic moral awareness and moral sensitivity [ 35 ]. On the other hand, Choi’s study emphasized that it is necessary for students to be given reasonable explanations about academic ethical standards at the same time as the beginning of academic enrollment to ensure that they are aware of their responsibilities and adherence these principles during their studies [ 36 ]. Therefore, ethical principles should be institutionalized during nursing students’ education in order to ensure safe and optimal care for patients in the future.

The results of another study indicate that professional identity of nursing students is higher than average. In this regard, the Amutairi study was similar to the results of the current study, with more than half of the students having a high professional understanding [ 34 ]. The Gilvari study showed that students had a high professional identity [ 37 ]. The study in Iran also showed the professional identity score of nursing students was higher than half of the expected score [ 16 ].

The correlation between variables showed that there is a significant and negative relationship between academic dishonesty and moral competence of nursing students. That is, the less academic honesty students had, the less moral competency they showed. In this regard, Chang’s study is in line with the results of this study. This study showed that students with high ethical attitude were less involved in academic dishonesty, In this study the ethical behavior of participants showed a significant relationship with academic dishonesty [ 38 ]. Therefore, doing unethical activities may lead to normalization of this behavior and nursing students’ interest in ethical behaviors after graduation decreases. Academic honesty is usually an issue earlier in life than being specifically taught about ethical behavior. In the course of their training and clinical practice , nursing students like other professionals will encounter ethical dilemmas in professional life. Therefore, universities should plan to promote students’ culture of academic honesty in order to prevent unethical activities, and take necessary measures and inform students of existing policies.

In another part of the study, no significant relationship was found between academic dishonesty and professional identity. Bloomfield et al.‘s study stated that high percentage of participants stated that academic dishonesty should be attended as a Professional misconduct [ 27 ]. Also, a study showed that there is a positive relationship between academic dishonesty and professional dishonesty [ 39 ]. On the other hand, most of the available studies are in the field of professional identity formation and ethical growth [ 40 , 41 ], which considering that academic dishonesty can have adverse effects on ethical and professional behaviors, therefore, with the help of professional identity formation, it can be expected that ethical competencies can be developed in students. In this regard, nursing education has an important impact on the development of nursing students’ professional identity and values [ 12 ]. Professional values are one of the important parts of professional identity. In the process of forming professional identity, a system of norms and values is formed in students and nurses. Nursing students learn these values from educators and other nurses as well as from other students. Their experiences of faculty and hospitals also play an important role in the development of professional values [ 42 ]. Therefore, it seems that by forming professional identity, indirectly the desire for students’ moral performance will be formed, and ultimately students will not go to unethical acts such as academic dishonesty.

Ethical values in nursing students are affected by different factors in a process [ 40 ]. Perhaps this is because in this study no significant relationship was found between academic dishonesty and professional identity and on the other hand, nursing schools and educational system have an important role in the formation of professional identity if educational centers focus solely on increasing knowledge and skills, graduate nurses may be able to Do not have appropriate internalized professional values, which include moral and ethical values. The emphasis on professional values from the beginning of the study helps students develop the competencies they need to work in accordance with ethical and professional values.

The study by Alnajjar et al. showed that academic dishonesty has adverse effects on workplace honesty and health care system quality [ 35 ] Therefore, given that academic honesty is a serious issue in nursing and nursing students who are involved in academic dishonesty have the potential to conduct deceptive and unethical behaviors in clinical settings [ 43 ]. Nursing requires high professional and ethical standards for protecting people’s lives and a reliable profession is known, so lack of academic honesty such as cheating in exams in nursing students can have inappropriate consequences in developing unethical behaviors and have adverse effects on the future of the profession [ 27 ].

Therefore, the academic honesty of students should be examined from different dimensions, and nursing teachers will be effective in reducing academic dishonesty by implementing specific educational programs in this field, therefore they will provide a basis for patient safety and will prevent dishonest behaviors in the professional future of students.

This study has limitations. One of the limitations of the study is that due to the fact that the sampling was done from a nursing school, the number of samples is small, so the generalizability of the data should be taken into account. Therefore, it is suggested that future studies be conducted with a higher sample size and sampling from several nursing schools. It is also suggested to conduct studies considering the variables of the current research in undergraduate nursing and various levels of other medical fields. It is also recommended to conduct qualitative studies in this field.

In the present study, there is a significant relationship between academic dishonesty and moral competencies, but there is no relationship between academic dishonesty and professional identity. Therefore, considering that students will work as nurses and nursing instructors in the future, if it becomes a habit for students to do dishonest things during their studies, it can cause harm to the patient and reduce the quality of nursing care. Researchers suggest that educational institutions should prevent the increase of academic dishonesty among students by establishing new rules and regulations, and professors should try to focus more on moral issues and honest academic activities in addition to increasing the level of knowledge and skills of students.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.

Abbreviations

Academic Dishonesty Scale

Nurses’ moral competence and Professional Identity Scale for Nursing Students

Doctor of Philosophy

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Acknowledgements

The authors would like to thank all nursing students who voluntarily participated in the study.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Leila Homayouni

Department of E-Learning in Medical Sciences, Virtual School and Center of Excellence in E-Learning, Shiraz University of Medical Sciences, Shiraz, Iran

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Department of Operating room technology, Community Based Psychiatric Care Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Fatemeh (PUBH) Nursing Midwifery School, Nemazee Square, Shiraz, 71936-13119, Iran

Armin Fereidouni

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Study conception and design: L.H and AF, Data collection: Z.P, Statistical analysis: A.F.M and Z.P and A.Z, Interpretation of results: A.Z and LH, Drafting of the manuscript: All authors, Revision of the final manuscript: A.F, L.H.

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Homayouni, L., Zare, A., Padam, Z. et al. Investigating academic dishonesty and its relationship with moral competence and professional identity of nursing students: a cross-sectional study. BMC Nurs 23 , 662 (2024). https://doi.org/10.1186/s12912-024-02335-8

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Exploring the trend of age-standardized mortality rates from cardiovascular disease in Malaysia: a joinpoint analysis (2010–2021)

• Wan Shakira Rodzlan Hasani 1 ,
• Kamarul Imran Musa 1 ,
• Kueh Yee Cheng 2 &
• Sarat Chandra Dass 3  

BMC Public Health volume  24 , Article number:  2519 ( 2024 ) Cite this article

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Introduction

Cardiovascular disease (CVD) is a major health concern worldwide, particularly in low- and middle-income countries. The COVID-19 pandemic that emerged in late 2019 may have had an impact on the trend of CVD mortality. This study aimed to investigate the trend and changes in CVD mortality rates in Malaysia, using age-standardized mortality rates (ASMR) from 2010 to 2021.

The Malaysian population and mortality data from 2010 to 2021 were obtained from the Department of Statistics Malaysia (DOSM). ASMRs from CVD per 100,000 population were calculated based on the World Health Organization (2000–2025) standard population using the direct method. The ASMRs were computed based on sex, age groups (including premature mortality age, 30–69 years), and CVD types. The annual percent change (APC) and average annual percent change (AAPC) of the ASMR with corresponding 95% confidence intervals (95% CI) were estimated from joinpoint regression model using the Joinpoint Regression Program, Version 4.9.1.0.

Throughout the study period (2010–2021), ASMRs for CVD exhibited an increase from 93.1 to 147.0 per 100,000, with an AAPC of 3.6% (95% CI: 2.1 to 5.2). The substantial increase was observed between 2015 and 2018 (APC 12.6%, 95% CI: 5.4%, 20.3%), with significant changes in both sexes, and age groups 50–69, 70 years and over, and 30–69 (premature mortality age). Notably, the ASMR trend remained consistently high in the premature mortality age group across other age groups, with males experiencing higher rates than females. No significant changes were detected before or after the COVID-19 pandemic (between 2019 and 2021), except for females who died from IHD (10.3% increase) and those aged 0–4 (25.2% decrease).

Overall, our analysis highlights the persistently high burden of CVD mortality in Malaysia, particularly among the premature mortality age group. These findings underscore the importance of continued efforts to address CVD risk factors and implement effective prevention and management strategies. Further research is needed to fully understand the impact of the COVID-19 pandemic on CVD mortality rates and to inform targeted interventions to reduce the burden of CVD in Malaysia.

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Cardiovascular disease (CVD) is the leading cause of death worldwide, responsible for approximately one-third of all deaths globally [ 1 , 2 ]. Low- and middle-income countries (LMICs) bear a disproportionate burden of CVD, accounting for 32% of all CVD deaths [ 3 ]. Despite declining age-standardized mortality rates (ASMR) in high-income regions, most LMICs have not experienced similar reductions [ 4 , 5 ]. Instead, there has been an increase in premature mortality (deaths that occur at a younger age than expected) from CVD in LMICs [ 6 ]. Recognizing this alarming trend, there is a global commitment to reducing premature CVDs by 25% by the year 2025 [ 7 ]. While significant progress has been made in preventing and treating CVD, there are notable disparities among different subpopulations, and the trend for CVD mortality has been inconsistent globally [ 5 , 8 , 9 , 10 , 11 , 12 ]. Malaysia, classified as an LMIC, also faces a significant burden of CVD, particularly ischemic heart disease (IHD) and stroke [ 13 ].

Changes in CVD mortality trends can be attributed to several factors. Adverse conditions or behaviours related to modifiable risk factors such as diabetes, obesity, lack of physical activity, hypertension, an unhealthy diet, smoking, and excessive alcohol consumption are associated with an increase in CVD mortality trends [ 4 , 14 , 15 , 16 ]. Without reducing these risk factors, it is predicted that almost 23.6 million people will die from CVDs by 2030 [ 17 ]. Other factors, including an aging population [ 18 ], environmental factors [ 19 ], and changes in healthcare access and quality [ 15 ], may contribute to these disparities in the trend for CVD mortality.

In addition to these factors, the COVID-19 pandemic, which began in late December 2019 [ 20 ] has had a significant impact on the healthcare system and may have affected the trend for CVD mortality. For example, the pandemic resulted in excess all-cause mortality in the USA [ 21 ] and in a multi-country study using data from 74 countries worldwide [ 22 ]. In Poland, in-hospital mortality for acute heart failure increased [ 23 ], whereas in Sweden, CVD mortality, particularly from IHD and myocardial infarction, decreased substantially during 2020 [ 24 ]. Several countries reported a decrease in hospitalizations and percutaneous coronary interventions during the COVID-19 pandemic, likely leading to a reduction in recorded mortality from cardiac events [ 25 , 26 , 27 ]. Lockdowns and prioritization of COVID-19 care may have indirectly affected diseases like CVDs that require a functional healthcare system [ 28 , 29 ]. Thus, analysing mortality trends allows for understanding the indirect impacts of the pandemic on health outcomes, identifying gaps in healthcare delivery, and developing strategies to mitigate these impacts.

Joinpoint analysis is a statistical method that is commonly used to detect changes in trends or patterns in data over time, and it has been used in many previous studies to investigate the burden of various diseases, including CVD [ 30 , 31 , 32 , 33 ]. Investigating the trend for CVD mortality within a country is crucial, particularly in LMICs like Malaysia. However, to date, the trend and any change in trend of ASMR from CVD in Malaysia have not been investigated over the past decade, including the impact of COVID-19 on CVD mortality rates. Using joinpoint analysis to analyse Malaysian data will provide valuable insights into the temporal patterns of CVD mortality occurrence in Malaysia and help inform policy and intervention strategies to reduce the burden of CVD in the country. Moreover, it will contribute to the literature on CVD mortality trends and change point analysis, particularly in LMICs, and provide a basis for future studies on CVD mortality in the region. Therefore, this study aims to explore the change in trend of ASMR from CVD in Malaysia from 2010 to 2021. Specifically, we aim to identify any changes in trends according to sex, major CVD types, and age group, including premature mortality. Furthermore, we aim to assess any changes in the CVD mortality trend within each subgroup before and after the COVID-19 pandemic.

Source of data

Data on CVD mortality and Malaysian population (census and inter-census years) were obtained from the Department of Statistics Malaysia (DOSM) for the period 2010–2021. Malaysian law mandates that all deaths be registered with the National Registration Department (NRD), which issues death certificates [ 34 ]. Deaths in Malaysia are categorized into medically certified deaths, which occur in health facilities and are determined by medical officers based on symptoms and examination, and non-medically certified deaths, which occur outside health facilities. While death registration quality is an issue in many countries [ 35 ]. Malaysia stands out as one of the few Asian countries with a functioning vital registration system. Analysing trends from 1995 to 2010, medically certified deaths increased over time, while non-medically certified deaths remained stable [ 36 ]. In 1995, non-medically certified deaths were 55%, surpassing medically certified deaths at 45% [ 36 ]. In 2021, DOSM reported an improvement, with medically certified deaths at 70.0% and non-medically certified deaths at 30.0% [ 37 ]. In Malaysia, death certificates document a clear sequence of events leading to death. The cause of death listed on the lowermost line of the sequence, which initiated the train of events leading to death, is defined as the underlying cause of death. All other causes listed on the lines between the underlying cause (on the lowermost line) and the immediate cause (on the topmost line) are referred to as antecedent causes of death [ 38 ]. DOSM is responsible for cleaning and classifying cause-of-death information for all medically certified deaths obtained from the NRD, coding them based on the 10th International Classification of Diseases (ICD-10) [ 39 ]. This process is carried out by specialized coders at DOSM. To ensure the study’s quality and enhance the accuracy of cause-of-death information, only medically certified deaths for CVD as indicated by ICD-10 (code I01-I99) were used for this analysis. The unknown cause of death and missing information on age and sex were excluded.

Statistical analysis

We estimated ASMRs per 100,000 population for all medically certified deaths from CVD. The World (WHO 2000–2025) Standard population [ 40 ] was used as the reference population to calculate ASMR, based on the direct method of age-standardization. The use of a standard population is important to enable comparability between relevant years and rates from other countries. To calculate the ASMR using direct standardization, we first aggregated the number of CVD deaths into 5-year age intervals (0–4, 5–9, 10–14, 15–19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–49, 50–54, 55–59, 60–64, 65–69, 70–74, 75–79 and 80+) for each year of study. Next, we calculated the age-specific mortality rates by dividing the number of deaths in a specific age group by the number of people in that age group and then multiplying the result by 100,000. Finally, the ASMR was calculated by multiplying the age-specific death rate by the weight of that age group in the standard population [ 40 ]. This direct standardization method was applied to calculate the overall ASMR, and stratified by gender (male and female), CVD type (IHD and stroke), and selected specific age ranges (e.g., 0–1, 30–49, 50–59 years). To explore the trend for premature CVD mortality, we also selected a specific age group of 30–69 years, in accordance with the WHO definition of premature mortality [ 41 ]. The descriptive statistics of ASMR and trend plots were analysed using R software.

Joinpoint regression analysis was utilized to detect the significant changes in annual ASMR for CVD mortality from 2010 to 2021 according to sex, age groups and CVD types. A joinpoint regression model was employed to estimate the magnitude of change in the trend of CVD mortality rates over time. This model allows us to identify points in time, where significant changes occur in the trend. Additionally, the model provides a confidence measure around these estimated changes. We used the Joinpoint Regression Program, Version 4.9.1.0 for this analysis [ 42 ]. The Joinpoint program fits a series of straight lines to the ASMRs on a log scale and detects the best fitting points, called ‘joinpoints’ [ 43 ]. This program selects the final model using two methods; the Monte Carlo permutation tests and the Bayesian Information Criterion (BIC) [ 43 ]. The analysis starts with the minimum number of joinpoints (e.g., zero joinpoints, which is a straight line), and tests whether one or more joinpoints are significant and must be added to the model. Based on the recommendation of the Joinpoint program, a maximum of two joinpoints can be selected for the given 12 data points [ 42 ]. Permutation tests determine the number of joinpoints by comparing different hypotheses until the final number is reached. Starting with ka = minimum number of joinpoint and kb = maximum number of joinpoint, each test compares the null hypothesis H0: number of joinpoints = ka against the alternative Ha: number of joinpoints = kb, where ka < kb. If the null hypothesis is rejected, ka is increased by 1; otherwise, kb is decreased by 1. This process continues until ka = kb, and the final value is the selected number of joinpoints. Then, models with this number of joinpoints are compared using BIC, and the model with the minimum BIC value is selected as the optimal model [ 44 ].

To describe changes in CVD mortality rates, the annual percent change (APC) of the ASMR between the trend-change point and the average annual percent change (AAPC) in the whole period studied was calculated with corresponding 95% confidence intervals (95% CI). We applied the log transformation to calculate the APC. This approach assumes that CVD mortality rates change at a constant percentage relative to the rate of the previous year, and the log transformation allows for linear changes on a logarithmic scale. To derive the APC for a given data series, the following regression model is employed [ 45 ];

where \(\text{log}\left({R}_{y}\right)\) is the natural log of the rate in year \(y\) . \({b}_{0}\) is the intercept, representing the value of the natural log of the rate when \(y=0,\) and ​ \({b}_{1}\) is the slope, indicating the rate of change in the natural log of the rate per year.

The APC from year \(y\) to year \(y\) + 1 is derived from this formula

The formula is further transformed to represent an annual percent change;.

The AAPC was calculated to summarize the trend over a specific fixed interval (2010–2021), allowing for the use of a single number to describe the APCs over multiple years. The AAPC is computed by taking a weighted average of the APCs from the joinpoint model, with the weights determined by the length of each APC interval. The AAPC over any fixed interval is calculated by taking a weighted average of the slope coefficients of the underlying joinpoint regression model, where the weights correspond to the length of each segment within the interval [ 46 ].

APC i = {exp(b i ) − 1} x 100.

where b i is the slope coefficient for the i th segment (within the desired range of years).

In the calculation, the weighted average of slope coefficients is further transformed to represent an average annual percent change [ 46 ];

where w i is the length of each segment within that range.

The Joinpoint Regression Program performs a series of hypothesis tests. These tests compare the null hypothesis (the assumption of no trend or no joinpoints) against alternative hypotheses with different numbers of joinpoints. A small p -value indicates strong evidence against the null hypothesis, suggesting significant trends or joinpoints. The trend was considered to be significantly increasing (positive change) or decreasing (negative change) when the p -value was below 0.05 ( p  < 0.05).

Table  1 shows the demographic structure of the Malaysian population and the age standardized mortality rate from CVD. The Malaysian population is systematically increasing for the period 2010–2021 from 28.6 million to 32.6 million [ 47 ]. During the observed period, 1.9 million deaths (from all causes) were recorded in Malaysia, of which 318,268 deaths (16.6%) were caused by CVD.

Age standardised mortality rate

The ASMR ranged from 88.1 to 147.0 per 100,000 population (Table  1 ). The overall ASMR showed an increase trend from 93.1 to 147.0 deaths per 100,000 population from 2010 to 2021, but with small variation between years. During the study period, the rates were almost twice as high in men as in women. The trend shown increases in both sexes and the main CVD types (IHD and stroke). Although all of the rates increased over the period of study, the pattern of increase varied across age groups. Figure  1 shows that the ASMR trend in males was highest among those aged 30–69 years (defined as premature mortality), whereas in females, the highest rate was observed in those over 70 years of age. We detected that the trend for both sexes was rising and peaking in 2018, particularly among the premature mortality age group and those over 50. Meanwhile, the mortality trend among adolescents and children below the age of 15 for both sexes has almost plateaued over the years.

The ASMR trend from CVD in Malaysia from 2010 to 2021; ( A ) Overall population by age group; ( B ) Male by age group and ( C ) Female by age group

Joinpoint regression model

Table  2 shows the joinpoint regression analysis of ASMR for total CVD and the model for both sexes stratified by age group and CVD type. The jointpoint model demonstrated a statistically significant increase in ASMR for CVD, with an AAPC of 3.6% (95% CI: 2.1, 5.2) during the entire study period (2010 to 2021). However, when we looked at a specific segment, the trend was slightly decreasing between 2010 and 2015, with an APC of -2.2% (95% CI: -3.6, -0.7), and a substantial increase between 2015 and 2018, with an APC of 12.6% (95% CI: 5.4, 20.3). Between 2018 and 2021, the rate increased slightly (APC: 5.0%, 95% CI: 1.6%, 8.6%), and no significant changes were detected before or after the COVID-19 pandemic (2019–2021). These changes in ASMRs exhibited similar patterns in both men and women, with large increments occurring between 2015 and 2018.

The analysis of trends by age strata (Table  2 ) demonstrated the large increase between 2015 and 2018 was contributed by the age groups 50–59, ≥ 70 years, and premature mortality group, with APCs of 9.5%, 16.7%, and 9.3%, respectively. Meanwhile, the reduction in trend between 2010 and 2015 was notable among females aged 50–69 (reduced by -2.3%) and both male and female aged ≥ 70 age groups (reduced by -3.6% in females and − 3.9% in males). Interestingly, among premature CVD mortality (age 30–69), the trend was systematically increasing throughout the study period, where the reduction slopes between 2010 and 2015 were not statistically significant. In addition, the AAPC during the observed study (2010–2021) only significantly increased among the aged group over 30 years. Meanwhile, the mortality rate in the age group below 30 years was nearly constant, and the trend in this subgroup was not statistically significant, except for those aged 0–4 years, who showed a significant decline in trend (reduced by 25.5%) from 2019 to 2021. Figures  2 and 3 present the joinpoint model plots illustrating the overall ASMR trend from CVD, as well as the trends by sex and age group.

In terms of CVD subtype, both IHD and stroke showed an upward trend between 2010 and 2021, with AAPC rates of 3.9% and 3.4%, respectively (Table  2 ). Although females reported lower ASMR from IHD and stroke than males, females had a greater increase in trend for IHD and stroke. Specifically, the AAPC for females was 4.5% for IHD and 3.6% for stroke, whereas for males it was 3.8% for IHD and 3.3% for stroke.

During the period from 2019 to 2021, which encompasses the pre- and post-COVID-19 pandemic eras, our joinpoint analysis revealed significant changes in CVD mortality rates among females. Specifically, there was a notable increase in the mortality rate due to IHD among females, with an APC of 10.3%. Additionally, there was a significant decrease in mortality among female children aged 0–4, with an APC of -25.2%. However, it’s important to note that significant changes among males were detected between 2018 and 2021, which falls outside the defined pre- and post-COVID-19 pandemic period of 2019–2021.

Joinpoint regression model of age standardised mortality rate (ASMR) per 100,000 from CVD in Malaysia, 2010–2021 for overall CVD ( a ) and by sex ( b )

Joinpoint regression model of age standardised mortality rate (ASMR) per 100,000 from CVD in Malaysia, 2010-2021by age group in male ( a ) and female ( b )

In this study, we conducted joinpoint analysis to identify and measure temporal patterns of ASMR on CVD mortality in Malaysia from 2010 to 2021. These analytical methods proved useful in understanding the underlying drivers of the observed trends and their implications for policies and interventions. Our findings indicated an overall increase in ASMR from CVD over the study period (AAPC of 3.6%) with a large increment occurring between 2015 and 2018 (APC of 12.6%). Interestingly, we detected a slight decrease in the trend between 2010 and 2015 (APC of -2.2%). This descending trend in CVD mortality aligns with other reports worldwide. For example, the findings from the GBD Study 2017 reported that nearly all countries, including developing countries and regions like Southeast Asia, experienced a significant declining trend in age-standardized CVD mortality rates from 1990 to 2017 [ 48 ]. A study by Khan et al. revealed that the global mortality trend of IHD decreased slowly but progressively from 1990 to 2017 [ 49 ]. They suggested that this reduction may be partly due to increasing global awareness of lifestyle factors. Another study showed that the ASMR of stroke decreased sharply by 33.4% over the same period [ 50 ].

However, several epidemiological studies have reported a global trend of age-standardized CVD mortality rates either slightly declining or increasing in most LMICs, while high-income regions have experienced a significant reduction [ 4 , 18 ]. For example, a study in Central Asia (comprising LMICs) found that CVD mortality trends have risen over the past two decades [ 51 ]. The researchers attributed this rise to factors such as inadequate preventive care, low awareness of disease signs and symptoms, reduced physical activity, elevated blood pressure, and insufficient utilization of healthcare services.

Although a slight reduction occurred before 2015, our joinpoint model suggests that the ASMR for CVD in Malaysia increased throughout the study period (2010–2021). The observed increase in ASMR from CVD in this country may be attributed to a combination of factors, including urbanization, changes in lifestyle and dietary habits, and a shift towards more sedentary lifestyles [ 52 , 53 , 54 ]. These factors have contributed to unhealthy, high-calorie diets, leading to the development of metabolic disorders like obesity and diabetes, which are well-known risk factors for CVD. Over the past decade, Malaysia has experienced a significant increase in the prevalence of several metabolic disorders, including obesity, diabetes, hypertension, and hypercholesterolemia. According to the National Health and Morbidity Survey (NHMS), the prevalence of obesity among adults in Malaysia has risen from 14.0% in 2006 [ 55 ] to 17.7% in 2019 [ 56 ], while the prevalence of diabetes has increased from 11.6% in 2006 [ 55 ] to 18.3% in 2019 [ 56 ]. The survey also showed that the prevalence of hypertension and hypercholesterolemia among adults in Malaysia has been increasing from 32.2% and 20.6% in 2006 [ 55 ] to 43.5% and 47.7% in 2019 [ 56 ], respectively. These trends are concerning, as these metabolic disorders are significant risk factors for CVD, which could contribute to the observed increase in ASMR from CVD in Malaysia. Additionally, Malaysia is experiencing a demographic transition due to an increasing aged population ≥ 60 years and increased life expectancy [ 57 ]. Population aging is becoming the most important driver of the CVD epidemic [ 58 ]. On the other hand, increased access to healthcare and better medical treatment for CVD [ 59 , 60 ] may have also led to higher reported CVD mortality rates. Firstly, increased access to healthcare can lead to better detection and diagnosis of CVD cases, including previously undiagnosed or asymptomatic cases. As a result, more individuals with CVD are identified and included in mortality statistics, thus contributing to higher reported mortality rates. Secondly, better medical treatment for CVD can prolong the lives of individuals with the condition. While this is beneficial for improving individual health outcomes, it can also increase the pool of individuals living with CVD, who are at risk of dying from CVD-related complications in the long term. This, in turn, can lead to higher reported mortality rates.

While there has been an overall upward trend in CVD mortality rates, our joinpoint regression analysis only identified significant changes pre- and post-COVID-19 outbreak (2019–2021) among females who died from IHD and females aged 0–4 years, with no significant changes detected in other subgroups during this period (2019–2021). It is important to note that the impact of COVID-19 on CVD mortality rates during the early phases of the pandemic is inconsistent, with some countries reporting a decrease in CVD mortality [ 61 , 62 , 63 ] and others having observed an increase or excess mortality [ 64 , 65 , 66 ]. While our data is limited to one-year post-COVID-19 pandemic (2021), the study by Jayaraj et al. [ 67 ] on all-cause mortalities in Malaysia between January 2016 and September 2021 also utilized similar post-COVID data points up to 2021. Their results show a reduction in all-cause mortality in 2020, especially during the first Movement Control Order, followed by a significant increase between July and September 2021. This pattern supports our findings and might explain why the APC did not show significant changes between 2019–2021 in our study, despite an overall significant increase in the APC between 2018–2021. Additionally, the use of monthly data points with all causes of death in their study might have allowed for more precise detection of changes in trends during the COVID-19 pandemic compared to our study, which used yearly data points with specific causes of death.

On the other hand, our study highlights the persistent burden of premature CVD mortality (age 30–69) in Malaysia, which is in line with the trend of increasing global premature CVD mortality observed in LMICs [ 1 ]. Furthermore, there are notable sex disparities, with higher rates of premature CVD mortality among males compared to females. This finding is consistent with the results of Zhang et al. (2021) [ 68 ], who reported a 35.6% higher overall premature CVD mortality rate among men than women, based on global data from the WHO Global Health Estimates (GHE). Other studies [ 69 , 70 , 71 ] have also highlighted sex disparities related to premature CVD mortality.

In addition, our study revealed that while males had a higher overall ASMR than females, the magnitude of increase during the entire study period (2010–2021) was greater among females (AAPC 3.8% in females versus 3.5% in males). Notably, females aged over 70 years exhibited the highest ASMR over time compared to other age groups. These findings are consistent with the observations of Roth et al. [ 1 ], who reported a rapid increase in the proportion of CVD-related deaths among women after the age of 70, surpassing that among men. However, Roth et al. found that this trend is driven predominantly by stroke mortality, whereas our findings show that IHD had a higher increment among Malaysian females. These findings highlight the importance of targeted interventions and policies to address sex-specific CVD types and age-related disparities in ASMR from CVD mortality in Malaysia.

Study limitations

The study had some limitations that should be taken into consideration when interpreting the results. Firstly, the use of yearly data points and the lack of post-COVID-19 outbreak observation may have contributed to the insignificant findings of changes in the overall CVD mortality trend and most of the subgroup during the pre- and post-COVID-19 outbreak period (2019–2021). Therefore, the true burden of the effect of COVID-19 on CVD deaths should be interpreted with caution. Despite this limitation, our intention to examine the potential impact of the early COVID-19 pandemic on CVD mortality remains relevant, as evidenced by the significant APC detected during the pre- and post-COVID-19 period (2019–2021) in certain groups (e.g., females with IHD). Additionally, the study was limited by the variables available in the death registry, which did not include information on other modifiable risk factors such as diabetes, hypertension, and alcohol use, as well as important sociodemographic factors such as ethnic group, regional area, income level, and employment status. These variables may have been important to adjust or stratify in the joinpoint regression analysis. Furthermore, the study may not have represented the total CVD deaths in Malaysia, as it relied only on medically certified deaths. However, the use of the most complete and accurate data on CVD death, with ICD-10 coding conducted by specialist coders from DOSM and validated by independently certified coders, is a strength of the study.

In conclusion, this study highlights the increasing trend in ASMR from CVD in Malaysia, with a substantial increase observed between 2015 and 2018. The findings also underscore the ongoing burden of premature CVD mortality in the country, particularly among males. Efforts to address CVD risk factors and implement effective prevention and management strategies should be continued, including public health campaigns to raise awareness about healthy lifestyle behaviours, enhancing access to affordable and quality healthcare services, strengthening primary healthcare systems, investing in community-based interventions, and promoting multi-sectoral collaboration. Further research is warranted to explore the specific impact of the COVID-19 pandemic on CVD mortality rates in Malaysia and to guide the development of targeted interventions to mitigate its effects.

Data availability

The mortality data used in this study were obtained from a restricted source (Department of Statistics Malaysia). The population structure in Malaysia is available online ( https://pqi.stats.gov.my ). We confirm that all methods were carried out in accordance with the relevant guidelines and regulations.

Abbreviations

the average annual percent change.

the annual percent change.

Ischemic heart disease (ICD-10 code: I20-I25).

including all cerebrovascular disease.

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Acknowledgements

We thank the Department of Statistics Malaysia (DOSM) for providing the mortality data with ICD-10 codes for cause of death and population structure.

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Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, 16150, Malaysia

Wan Shakira Rodzlan Hasani & Kamarul Imran Musa

Biostatistics and Research Methodology Unit, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, 16150, Malaysia

Kueh Yee Cheng

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Conceptualization: Wan Shakira Rodzlan Hasani, Kamarul Imran Musa, Kueh Yee Cheng, Sarat Chandra Dass. Data curation: Wan Shakira Rodzlan Hasani, Kamarul Imran Musa. Formal analysis: Wan Shakira Rodzlan Hasani. Investigation: Wan Shakira Rodzlan Hasani, Kamarul Imran Musa, Kueh Yee Cheng. Methodology: Wan Shakira Rodzlan Hasani, Kamarul Imran Musa, Sarat Chandra Dass. Project administration: Wan Shakira Rodzlan Hasani. Resources: Wan Shakira Rodzlan Hasani, Kamarul Imran Musa. Software: Wan Shakira Rodzlan Hasani. Writing – original draft: Wan Shakira Rodzlan Hasani. Writing – review & editing: Wan Shakira Rodzlan Hasani, Kamarul Imran Musa, Kueh Yee Cheng, Sarat Chandra Dass. All authors read the manuscript and approved the submission.

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Correspondence to Kamarul Imran Musa .

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The study was conducted in accordance with the Declaration of Helsinki and ethical approval was obtained from the Medical Research and Ethics Committee (MREC), Ministry of Health Malaysia and the Human Research Ethics Committee of USM (USM/JEPeM/22,030,181). Mortality data was obtained with approval from the Department of Statistics Malaysia (DOSM). All data was anonymized prior to use in this study. Due to the using of DOSM database (vital registration data), the requirement for informed consent was waived.

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Hasani, W.S.R., Musa, K.I., Cheng, K.Y. et al. Exploring the trend of age-standardized mortality rates from cardiovascular disease in Malaysia: a joinpoint analysis (2010–2021). BMC Public Health 24 , 2519 (2024). https://doi.org/10.1186/s12889-024-19103-7

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Received : 11 July 2023

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Published : 16 September 2024

DOI : https://doi.org/10.1186/s12889-024-19103-7

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Experience in Using an Echo Meter Touch Ultrasonic Module in Studies of the Species Composition, Occurrence, and Biotopic Preferences of Bats (Chiroptera, Vespertilionidae) in Voronezh Oblast

• Published: 23 November 2023
• Volume 50 , pages 1511–1524, ( 2023 )

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• D. G. Smirnov 1 ,
• A. S. Klimov 2 ,
• A. D. Numerov 2 &
• E. I. Trufanova 2  

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The results of surveying echolocation signals of bats, performed using an Echo Meter Touch 2 PRO ultrasonic detector, are given. The signals were recorded in the time–expansion mode and identified manually in the BatSound program. The surveys were made in June–August 2019–2020 in the northwestern part of Voronezh oblast within the Federal Voronezh State Nature Reserve. Four types of biotopes were used as model territories to identify the species composition, occurrence, and biotopic confinement: a river bank, a forest lake, the expanse of a former burnt area, and a village. A total of 2332 audio recordings of ultrasonic signals were made. After manual verification, 1615 records (69.3%) belonging to 13 bat species were identified with a high probability (located in descending order according to the number of occurrences): N. noctula > N. leisleri > P. pygmaeus > V. murinus > P. nathusii > M. dasycneme > M. daubentonii > N. lasiopterus > P. auritus > P. pipistrellus > M. brandtii > E. nilssonii . The habitat of E. nilssonii was established for the first time in the territory studied. Biotopically, near-water areas, where the greatest diversity was noted, were the most attractive for bats. However, the distribution of species here was not the same. M. brandtii , P. pygmaeus , E. nilssonii , and M. dasycneme preferred river biotopes predominantly and were almost absent above the forest lake or were indifferent to this space. M. daubentonii , V. murinus , P. nathusii , and E. serotinus gave the greatest preference to the lake territory. Burnt areas were unattractive to most species, except for N. noctula and E. serotinus . An indifferent attitude to the territory of the village or its avoidance was noted for all species. Alpha diversity increased in the following series of biotopes: burnt area–village–river bank–forest lake, over which the largest number of species was noted with greater evenness according to the index of relative occurrence. The detected differences in biotopic confinement are discussed in connection with the spatial location of biotopes.

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Penza State University, 440026, Penza, Russia

D. G. Smirnov

Voronezh State University, 394018, Voronezh, Russia

A. S. Klimov, A. D. Numerov & E. I. Trufanova

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Smirnov, D.G., Klimov, A.S., Numerov, A.D. et al. Experience in Using an Echo Meter Touch Ultrasonic Module in Studies of the Species Composition, Occurrence, and Biotopic Preferences of Bats (Chiroptera, Vespertilionidae) in Voronezh Oblast. Biol Bull Russ Acad Sci 50 , 1511–1524 (2023). https://doi.org/10.1134/S1062359023070245

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Received : 20 August 2021

Revised : 22 March 2022

Accepted : 23 March 2022

Published : 23 November 2023

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DOI : https://doi.org/10.1134/S1062359023070245

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Voronezh State Medical University Russia 2024-25: Admission, Courses, Fees, Eligibility, Ranking etc.

Voronezh State Medical University (VSMU), founded in 1930, is a prestigious institution in Voronezh, Russia, offering programs in medicine, dentistry, and pharmacy. The university combines theoretical knowledge with practical skills and features modern facilities, including advanced labs, a large library, and well-equipped lecture halls. With a focus on international collaboration, VSMU attracts students from around the world and offers exchange programs, creating a multicultural learning environment. Located in Voronezh, a city rich in history and culture, VSMU provides a balanced academic and cultural experience. The university is renowned for its excellence in medical education and its contributions to healthcare advancements both in Russia and globally.

In this article, we cover all the important details about Voronezh State Medical University. You will find information on the admission process, courses offered, fee structure, and eligibility criteria. We also discuss the pros and cons of studying MBBS in Russia, as well as the university’s ranking and other relevant details.

[Page Index]

College summary.

Before we go through Voronezh State Medical University detailed information, let’s look at the College’s essential details.

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Affiliation and Recognition

These are the renowned bodies who’ve given recognition to the Voronezh State Medical University.

• National Medical Commission of India.
• World Health Organization.
• Ministry of Science & Higher Education of the Russian Federation.

Below is the list of faculties that Voronezh State Medical University Russia has to offer:

Courses Offered

Voronezh State Medical University offers quality medical programs under highly qualified faculty and state-of-the-art infrastructure. The College is famous for its undergraduate medical programs (MBBS).

Why Study MBBS at Voronezh State Medical University?

• Voronezh State Medical University consists of international students from about 56 countries. Hence students can experience a multicultural environment at this university.
• Seminars and practicals are also given importance rather than giving just theoretical knowledge to students.
• No donation and no entrance exam are required for admission into Voronezh State Medical University.
• At this university, there are graduate, postgraduate, PhD and secondary courses.
• The classrooms and laboratories at the university are equipped with internet, audio-video systems, modern equipment and modern software.
• Student life is quite beautiful in Russia due to its university making an effort to make student life in Russia better.

Admission Procedure

If you want to take Voronezh State Medical University Admission, you must qualify for the National Eligibility Entrance Exam (NEET) for Indian students.

To get admission to Voronezh State Medical University, one should follow these steps:

• First of all, you will need to fill out the application form provided by the university on their website.
• Take a printout of the application form and send a signed copy of the form to the university and do not forget to attach all the documents mentioned below.
• Selected international students would receive their admission letter within a week.
• Admission will be determined based on the candidate’s application forms, eligibility, and marks obtained.
• You will need to apply for visa at the immigration department of the Russian embassy in your country once you receive your invitation letter.
• You should notify the university about your arrival date.

Eligibility Criteria

If you want to study MBBS at Voronezh State Medical University, check out the eligibility criteria of this university mentioned below:

Graphical Representation of Eligibility Criteria

Documents Required

Before taking admission at Voronezh State Medical University, please do not forget to carry all these related documents.

• Passport (Minimum 18 months validity).
• 10th Certificate & Mark sheet.
• 12th Certificate & Mark sheet.
• Birth Certificate.
• 10 passport-size Photographs
• Official Invitation letter from the Medical University of Russia.
• Authorization of all documents from the Ministry of External Affairs, New Delhi.
• Legalization of all documents from the Russian Embassy.
• Bank receipt of 1st Year of the Voronezh State Medical University Tuition fee (required for some Universities).
• HIV test documents.

Fee Structure 2024-25

This section shows Voronezh State Medical University MBBS fees are given below:-

Cost of Living at Voronezh

The cost of living at Voronezh city is as follows:

Ranking 2024-25

According to Unirank, the Voronezh State Medical University ranking in Russia and all over the world:

Advantages of MBBS in Russia

About Voronezh City

• Voronezh City is located in the European part of Russia. It is the capital of the Voronezh region and is situated on the banks of the Voronezh water reservoir of the Voronezh River, which is about 520 km south of Moscow.
• Voronezh City is a cultural, scientific, and industrial centre of the region. The area of Voronezh City is 596 sq. km. and the population of Voronezh is about 1,032,000, according to the 2015 census.
• Voronezh City is the administrative centre of Voronezh Oblast. Voronezh City lies 93m above sea level. Generally, it is cold and temperate in Voronezh city.

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• Research Note
• Open access
• Published: 17 September 2024

The economic burden of prostate cancer in Iran: a cross-sectional cost-of-illness study

• Banafshe Darvishi Teli 1 ,
• Aziz Rezapour 1 ,
• Meysam Behzadifar 2 ,
• Samad Azari 3 ,
• Seyed Jafar Ehsanzadeh 4 &
• Masoud Behzadifar 2  

BMC Research Notes volume  17 , Article number:  268 ( 2024 ) Cite this article

Metrics details

This study aims to assess the economic burden of prostate cancer in Iran by analyzing direct medical costs, direct non-medical costs, and indirect costs. We conducted a cross-sectional cost-of-illness study in Khorramabad, located in western Iran, during 2023, using a prevalence-based, bottom-up approach. Data were collected from 285 prostate cancer patients using questionnaires, interviews, and patient records.

Our study estimated the economic burden of prostate cancer at $744,990. Direct medical costs accounted for 63.50% of this, totaling $153,330, with therapy being the largest component. Direct non-medical costs were $62,130, and indirect costs from productivity losses were $209,760. The calculated overall cost per patient was $2,614.88. Extrapolating from the 2021 Global Burden of Disease data, which reported approximately 83,000 prostate cancer patients in Iran, the national economic burden is estimated at $217,034,040. This substantial burden highlights the need for improved insurance coverage and early detection. The findings suggest that policymakers and healthcare providers in Iran should develop standardized cost analysis methods and enhance financial protection to alleviate economic strain and improve healthcare outcomes and sustainability.

Peer Review reports

Introduction

Prostate cancer ranks as the second most prevalent cancer among men worldwide, with approximately 1.4 million new cases diagnosed in 2020. This disease significantly contributes to the overall cancer burden in men [ 1 , 2 ]. The incidence of prostate cancer has exhibited a concerning upward trend, particularly in high-income regions such as Europe and North America. This increase can be attributed to factors such as population aging and the widespread adoption of prostate-specific antigen (PSA) screening [ 3 ]. However, mortality rates associated with prostate cancer follow a more intricate pattern. While high-income countries have witnessed a decline in mortality rates, low- and middle-income countries (LMICs) continue to grapple with higher mortality rates due to limited access to early diagnostic and treatment services [ 4 , 5 ].

In Iran, prostate cancer stands as the third most common cancer among men, with an estimated 8,937 new cases reported in 2020 [ 6 ]. Projections indicate that the prevalence of prostate cancer in Iran will escalate significantly by 2040, posing substantial challenges to the healthcare system [ 6 ]. This rise can be attributed to demographic shifts, including population aging, urbanization, and changes in lifestyle and dietary patterns. Consequently, there is an urgent need to comprehensively understand the economic impact of prostate cancer on the Iranian healthcare system [ 7 ].

The economic burden of prostate cancer encompasses both direct costs (such as diagnosis, treatment, and follow-up care) and indirect costs (including lost productivity and income) [ 8 ]. Studies conducted across various regions consistently highlight the substantial financial strain that prostate cancer imposes on healthcare systems and patients alike [ 9 ]. For instance, in the United States, the annual costs associated with managing prostate cancer were estimated at $11.85 billion in 2010, making it one of the costliest cancers to treat. Similarly, in Europe, annual healthcare costs related to prostate cancer reach €8.5 billion [ 10 ].

This study aims to fill the gap in understanding the economic burden of prostate cancer in Iran, driven by unique socio-economic and healthcare challenges. The mixed public-private healthcare system in Iran exhibits significant disparities in access to care, with high out-of-pocket expenses exacerbating the financial strain on families [ 9 ]. Rapid urbanization and lifestyle changes have led to an increased incidence of non-communicable diseases, including cancer. By analyzing direct medical costs, indirect costs, and the broader societal impact, this research provides essential insights for policymakers and healthcare providers to develop effective strategies for managing prostate cancer and mitigating its financial repercussions.

Study Design and Data Collection

We conducted a cross-sectional cost-of-illness study to assess the economic burden of prostate cancer in Khorramabad, western Iran, in 2023. Utilizing a prevalence-based, bottom-up approach from a societal perspective, we included all prostate cancer patients who visited or were hospitalized at Rahimi Hospital during the year [ 11 ]. Out of 338 identified patients, 53 were excluded due to lack of access, inaccurate diagnostic data, and mortality, leaving 285 patients for the final analysis. The study was approved by the relevant ethics committee, and informed consent was obtained from all participants. A subset of patients could not be reached or contacted despite repeated attempts, resulting in incomplete data collection. Some patients had incomplete or inaccurate diagnostic records, affecting the reliability of cost estimates. Additionally, some patients had passed away before data collection could be completed, necessitating their exclusion. This introduces potential bias, as the remaining cohort may not fully represent the broader population of prostate cancer patients in Khorramabad. The exclusion of these patients could impact the generalizability of the cost estimates. Future research with more comprehensive data collection and a larger sample size is recommended to mitigate these biases and provide a more accurate assessment of the economic burden of prostate cancer.

Cost estimation approach

Data were collected through questionnaires, interviews, and a review of patient documents to estimate costs, categorized into three domains: direct medical costs (DMC), direct non-medical costs (DNMC), and indirect costs.

Direct Medical Costs (DMC): These included diagnostic services, laboratory and pathology tests, inpatient and outpatient care, rehabilitation, medical devices, physician visits, therapies, and consultations. Costs were based on tariffs from the Ministry of Health and Medical Education (MOHME) and gathered retrospectively via patient and specialist interviews, and examination of healthcare records and financial documents. Each cost was calculated individually, considering both patient files and specialist input.

Direct Non-Medical Costs (DNMC): These encompassed transportation, accommodation, and food costs. Estimates were derived from interviews with patients and their families.

Indirect Costs: These were based on productivity losses from absenteeism and presenteeism, calculated using monthly income data from questionnaires and direct inquiries. This included work and daily activity absences by patients and their caregivers, with costs estimated using average salary data for 2023 from Iranian Statistics.

This approach ensured comprehensive cost analysis by integrating multiple data sources and cost categories.

In this study, all reported costs are annual and specific to a cohort of 285 prostate cancer patients from Rahimi Hospital in Khorramabad for the year 2023. These costs do not represent lifetime costs or the total economic burden for Iran but reflect the financial impact on this specific group. The findings are not immediately applicable to a broader national context, and future research should include multiple centers and regions for a comprehensive national estimate. Extrapolation to national costs should be done cautiously, and additional analyses are recommended. The study employed a one-way sensitivity analysis, varying the prevalence rate of prostate cancer in Iran to calculate the disease population and economic burden, assuming constant cost components per patient. To facilitate international comparisons, all costs were converted into US dollars using the exchange rate of 420,000 Iranian Rials per US dollar in 2023. The collected data underwent rigorous analysis using R software version 4.3.2.

The mean age of the patients was 71.53 years, with a standard deviation of 16.18 years. Demographic characteristics are detailed in Table  1 . The highest percentage of patients fell within the 60 to 69 age group, comprising 39.64%, followed by the 70 to 79 age group at 29.82%. Among the patients, 67.36% were employed, while 18.24% were unemployed. Additionally, 88.07% of the patients were married. Regarding insurance status, 3.88% of patients had no insurance, and 4.57% had a family history of prostate cancer. The calculated costs are categorized as follows (see Table  2 A): The direct medical cost amounts to $473,100, with the bulk of this being attributed to therapy costs. The direct non-medical cost is $62,130, largely driven by accommodation costs. The indirect costs reach $209,760, primarily due to patients being absent from work and their usual daily activities. The calculated overall cost per patient was $2,614.88.

Figure  1 represents the total costs across all three categories. The economic burden of prostate cancer in this study amounted to $744,990. Direct medical costs accounted for 63.50% of the total costs, indirect costs for 8.33%, and non-medical costs for 28.17%. Based on the disease stage, the economic burden was calculated as follows: $138,377 for patients in stage 1, $189,623 for patients in stage 2, $314,194 for patients in stage 3, and $102,796 for patients in stage 4. The detailed table breaking down costs by cancer stage is provided in Table  2 B. Based on the number of patients in each stage, the total cost per patient was calculated as follows: $4,463.77 for stage 1, $1,841 for stage 2, $2,513.55 for stage 3, and $3,953.65 for stage 4.

Costs of prostate cancer by category. The plot shows that direct medical costs constitute 63.50% of the total costs, non-medical costs make up 28.17%, and indirect costs account for 8.33%

Based on the sensitivity analysis, the range of costs is as follows: direct medical costs are between $425,790 and $520,410; direct non-medical costs range from $55,917 to $68,343; indirect costs vary from $188,784 to $230,736; and total costs are calculated to be between $670,491 and $819,489. Detailed costs for sensitivity analysis are provided in supplementary file 1.

To estimate the national economic burden of prostate cancer in Iran, we extrapolated our data using prevalence statistics from the 2021 Global Burden of Disease (GBD) ( https://vizhub.healthdata.org/gbd-results/ ), which reported approximately 83,000 prostate cancer patients in the country. With a calculated cost per patient of $2,614.88, the estimated total economic burden for prostate cancer in Iran amounts to $217,034,040.

The aggregate direct medical costs in our investigation amounted to $473,100, predominantly influenced by the costs of therapy. Similar studies in other in other countries and studies conducted in Iran, direct medical costs had the largest share of the economic burden of prostate cancer [ 6 , 7 , 9 ]. This discrepancy can be ascribed to variations in methodologies, treatment patterns, and cost conversion practices.

Our study discovered that indirect costs, primarily due to patients’ absence from work, totaled $209,760, representing 28.17% of the total costs. This is in line with the findings from the US study by Gustavsen et al., where productivity losses were a significant component of the economic burden, although they observed that high-risk patients incurred greater costs over time due to disease progression [ 11 ].

Although patients with metastatic disease incur significant medical costs, the higher number of patients with localized disease (approximately 91% compared to those with metastatic disease) results in a greater overall share of costs for patients with localized disease. This finding is consistent with studies conducted in Iran and other countries [ 6 , 7 , 12 , 13 ]. Given that many of the services received at different stages, such as radiotherapy, hormone therapy, and chemotherapy, are expensive; this can explain why these patients incur the highest costs. This finding is consistent with studies conducted in other countries [ 13 , 14 , 15 , 16 ]. More severe stages of the disease can be very expensive for patients. Due to the higher costs and financial pressure on families, patients often reported having to use their savings, rely on family members, or borrow money to pay for their medical expenses [ 7 , 17 ].

The substantial costs associated with prostate cancer, particularly in terms of direct medical expenses, highlight the necessity for financial support for patients. The findings from Eswatini by Ngcamphalala et al., [ 18 ] indicate that advanced cancer stages significantly augment healthcare costs, a trend also observed in our study. This suggests that early detection and treatment are pivotal in managing overall costs and enhancing patient outcomes.

This study highlights significant variation in stage-specific costs of prostate cancer treatment, with the highest cost per patient in stage 1 at $4,463.77 and the lowest in stage 2 at $1,841. These differences emphasize the importance of early detection and tailored treatment strategies [ 16 ]. The higher cost in stage 1 likely reflects intensive initial treatments, while stage 2’s lower cost suggests a more stable management period [ 10 ]. The estimated national economic burden of prostate cancer in Iran is approximately $217 million, underlining the need for effective public health initiatives. However, this estimate should be interpreted cautiously due to potential generalizability issues, as regional data may not fully represent the entire country.

Our study provides a comprehensive analysis of the economic burden of prostate cancer in Iran, highlighting critical areas for policy intervention and patient support. By refining cost classification methodologies, enhancing the generalizability of our findings, and ensuring clear and detailed reporting, our research aims to offer more reliable insights into the financial challenges faced by patients and the healthcare system. Addressing gaps in insurance coverage, emphasizing early detection and treatment, and improving healthcare infrastructure are essential strategies to alleviate the economic impact of prostate cancer on individuals and society. These findings can inform policymakers and healthcare providers in making evidence-based decisions to improve patient outcomes and financial protection.

Limitations

Our study exhibits several limitations that warrant consideration. These include the potential for misreporting of costs and income, as well as the restricted generalizability of our findings due to the metropolitan focus of our patient cohort. Similar to the observations made by Alinezhad et al., [ 6 ] the bottom-up approach employed in our study, while valuable for obtaining direct patient information, may inadvertently lead to a higher likelihood of missing values. To address these limitations, future research endeavors should strive to incorporate a more diverse patient population and explore the utilization of top-down approaches to gather more comprehensive data. Since the data were collected from a single center, Rahimi Hospital, in one city, the results may not be representative of the entire country. The socioeconomic, demographic, and healthcare infrastructure variations across different regions of Iran could influence the economic burden of prostate cancer in ways that our study does not capture. To enhance the generalizability of future research, it is recommended that similar studies be conducted in multiple centers across diverse regions of Iran. This would provide a more comprehensive understanding of the economic burden of prostate cancer nationwide. Despite these limitations, we believe our study contributes valuable preliminary data that can serve as a foundation for broader analyses. Reporting the estimated economic burden for Iran as a whole, even with the acknowledged limitations, can still be beneficial for a wider audience, providing a useful starting point for policymakers and healthcare planners. while the national burden estimate offers valuable context, it should be interpreted with caution. The extrapolation is based on regional data that may not fully represent the entire Iranian population. Therefore, the estimated national burden might not be entirely accurate due to potential generalizability issues.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Low- and middle-income countries

Direct Medical Costs

Ministry of Health and Medical Education

Direct Non-Medical Costs

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Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran

Banafshe Darvishi Teli & Aziz Rezapour

Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran

Meysam Behzadifar & Masoud Behzadifar

Hospital Management Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran

Samad Azari

English Language Department, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran

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Contributions

Conceptualization: BDT, MaB, AR. Data curation: MeB, BDT, SA, And SJE. Formal analysis: MaB, AR, SA. Investigation: BDT, SJE, Methodology: MaB, BDT, Project administration: MeB, AR, SA. Supervision: MaB, AR. Validation: BDT, MaB. Writing – original draft: MaB, SA, BDT. Writing – review & editing: SJE, MaB, AR, BDT. The author(s) read and approved the final manuscript.

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Correspondence to Masoud Behzadifar .

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The study was approved by Ethics Committee of the Iran University of Medical Sciences (IR.IUMS.REC.1402.698). All participants provided written informed consent to participate in this study.

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Darvishi Teli, B., Rezapour, A., Behzadifar, M. et al. The economic burden of prostate cancer in Iran: a cross-sectional cost-of-illness study. BMC Res Notes 17 , 268 (2024). https://doi.org/10.1186/s13104-024-06913-6

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• Published: 16 September 2024

Response is increased using postal rather than electronic questionnaires – new results from an updated Cochrane Systematic Review

• Phil Edwards 1 &
• Chloe Perkins 1  

BMC Medical Research Methodology volume  24 , Article number:  209 ( 2024 ) Cite this article

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Metrics details

A decade ago paper questionnaires were more common in epidemiology than those administered online, but increasing Internet access may have changed this. Researchers planning to use a self-administered questionnaire should know whether response rates to questionnaires administered electronically differ to those of questionnaires administered by post. We analysed trials included in a recently updated Cochrane Review to answer this question.

We exported data of randomised controlled trials included in three comparisons in the Cochrane Review that had evaluated hypotheses relevant to our research objective and imported them into Stata for a series of meta-analyses not conducted in the Cochrane review. We pooled odds ratios for response using random effects meta-analyses. We explored causes of heterogeneity among study results using subgroups. We assessed evidence for reporting bias using Harbord’s modified test for small-study effects.

Twenty-seven trials (66,118 participants) evaluated the effect on response of an electronic questionnaire compared with postal. Results were heterogeneous (I-squared = 98%). There was evidence for biased (greater) effect estimates in studies at high risk of bias; A synthesis of studies at low risk of bias indicates that response was increased (OR = 1.43; 95% CI 1.08–1.89) using postal questionnaires. Ten trials (39,523 participants) evaluated the effect of providing a choice of mode (postal or electronic) compared to an electronic questionnaire only. Response was increased with a choice of mode (OR = 1.63; 95% CI 1.18–2.26). Eight trials (20,909 participants) evaluated the effect of a choice of mode (electronic or postal) compared to a postal questionnaire only. There was no evidence for an effect on response of a choice of mode compared with postal only (OR = 0.94; 95% CI 0.86–1.02).

Conclusions

Postal questionnaires should be used in preference to, or offered in addition to, electronic modes.

Peer Review reports

Introduction

When collecting information from large, geographically dispersed populations, a self-administered questionnaire is usually the only financially viable option [ 1 ]. Non-responses to questionnaires reduce effective sample sizes, reducing study power, and may introduce bias in study results [ 2 ]. The Cochrane Methodology Review of methods to increase response to self-administered questionnaires has provided a much-used scientific evidence base for effective data collection by questionnaire since the publication of the first version of the review in 2003 which focused on postal questionnaires [ 3 ].

A decade ago paper-and-pencil administration of questionnaires in epidemiological studies was twenty times more common than electronic administration [ 4 ], but increased Internet access and decreasing volumes of mailed letters suggests that electronic administration has gained favour [ 5 , 6 , 7 ]. Researchers planning to collect data from participants using a self-administered questionnaire need to know how will the proportion of participants responding to a questionnaire administered electronically compare with one administered by post? We conducted further analyses of the trials included in the recently updated Cochrane Review [ 8 ] to answer this question.

To assess whether response rates to questionnaires administered electronically differ to those of questionnaires administered by post.

Data sources/measurement

We exported data of randomised controlled trials included in the updated Cochrane Review [ 8 ] from RevMan and imported them into Stata for a series of meta-analyses not conducted in the Cochrane review.

Comparisons

We focused on data from trials included in three comparisons in the Cochrane Review that had evaluated hypotheses relevant to our research objective:

Postal vs. electronic questionnaire (Cochrane Comparison 81).

Electronic questionnaire only vs. choice (postal or electronic) (Cochrane Comparison 84).

Choice (electronic or postal) vs. postal questionnaire only (Cochrane Comparison 82).

These comparisons assess: response to questionnaires administered by post compared with questionnaires administered electronically, response to a questionnaire administered electronically compared with response when including a postal response option, and response when including an electronic response option compared with response to a questionnaire administered by post only, respectively.

Outcome measures

The data obtained from each trial included the numbers of participants randomised to each arm of the trial with the numbers of completed, or partially completed questionnaires returned after all mailings (for trials including a postal questionnaire), and the numbers of participants randomised to each arm of the trial with the numbers of participants submitting the completed, or partially completed online questionnaires after all contacts (electronic questionnaire).

Other variables

Additional data were also extracted on the:

Year of publication of the study.

Risk of bias in each included study (a judgment - high, low, or unclear); we assessed the overall risk of bias in each study using the Cochrane Collaboration’s tool [ 9 ].

Effect measures and synthesis

For each of the three comparisons (2.1.1 above), we pooled the odds ratios for response in each included study in a random effects meta-analysis (to allow for heterogeneity of effect estimates between studies) using the metan command in Stata [ 10 ]. This command also produced a forest plot (a visual display of the results of the individual studies and syntheses) for each comparison. We quantified any heterogeneity using the I 2 statistic that describes the percentage of the variability in effect estimates that is due to heterogeneity [ 11 ].

Subgroup analyses

We explored possible causes of heterogeneity among study results by conducting subgroup analyses according to two study-level factors: Year of study publication, and risk of bias in studies. We used a statistical test of homogeneity of the pooled effects in subgroups to assess evidence for subgroup differences. The statistical test of homogeneity used is Cochran’s Q test, where the Q statistic is distributed as a chi-square statistic with k-1 degrees of freedom, where k is the number of subgroups. If there was evidence for subgroup differences provided by the test of homogeneity, we chose the ‘best estimate of effect’ as the estimate from the subgroup of studies with low risk of bias, or the subgroup of studies published after 2012. If there was no evidence for subgroup differences, we chose our best estimate of effect based on the synthesis of all studies.

Year of study publication

From 2012, household access to a computer exceeded 40%: [ 5 ] As the odds ratios for response to questionnaires administered electronically may be associated with household access to a computer, we analysed trial results in two subgroups – before 2012 and after 2012, where we used the year of publication as an approximation of the year of study conduct.

Risk of bias

The odds ratios for response estimated in the included studies may be associated with trial quality. [ 12 , 13 ] For this reason we analysed trial results in two subgroups – trials judged to be at low and at high risk of bias.

Reporting bias assessment

We assessed evidence for reporting bias using Harbord’s modified test for small-study effects implemented in Stata using the metabias command [ 14 ]. This test maintains better control of the false-positive rate than the test proposed by Egger at al [ 14 ].

Study characteristics

Thirty-five studies [ 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ] reported 45 independent trials included in one or more of the three comparisons (Table  1 ). The studies were conducted in the US ( n  = 20), Europe ( n  = 13), and Australasia ( n  = 2). The studies included between 133 and 12,734 participants and were published between 2001 and 2020. Eight studies were judged to be at high risk of bias [ 16 , 19 , 33 , 34 , 42 , 43 , 45 , 46 ].

Results of syntheses

Comparison 1 - postal vs. electronic questionnaire.

Twenty-seven trials (66,118 participants) evaluated the effect on questionnaire response of postal administration compared with electronic. [ 15 , 16 , 17 , 18 , 19 , 20 , 23 , 24 , 25 , 26 , 27 , 28 , 31 , 32 , 33 , 34 , 35 , 36 , 38 , 39 , 40 , 41 , 43 , 44 , 46 , 47 , 48 ] The odds of response were increased by over half (OR 1.76; 95% CI 1.34 to 2.32) using a postal questionnaire when compared with an electronic one (Fig.  1 ). There was considerable heterogeneity between the trial results (I-squared = 98%), but most of the studies showed response was greater with postal questionnaires than with electronic questionnaires, and the high I-squared is due to differences in the size of the benefit for postal questionnaires, rather than being due to an even spread of results between those favouring postal and those favouring electronic questionnaires.

Effect on response of mode of administration

Comparison 2 - electronic questionnaire only vs. choice (postal or electronic)

Ten trials (39,523 participants) evaluated the effect on questionnaire response of providing a choice of response mode (postal or electronic) compared to an electronic questionnaire only [ 20 , 21 , 27 , 29 , 30 , 35 , 37 , 40 , 42 , 45 ]. The odds of response were increased by over half when providing a choice of response mode (OR 1.63; 95% CI 1.18 to 2.26; Fig.  2 ). There was considerable heterogeneity between the trial results (I-squared = 97.1%), but again, most of the studies favoured giving people the choice of response mode rather than electronic questionnaire only, and the high I-squared is due to differences in the size of the benefit for choice, rather than being due to an even spread of results between those favouring choice and those favouring electronic only.

Effect on response of choice of response mode compared with electronic only

Comparison 3 - choice (electronic or postal) vs. postal only

Eight trials (20,909 participants) evaluated the effect of providing a choice of response mode (electronic or postal) compared to postal response only [ 20 , 22 , 27 , 29 , 34 , 35 , 40 , 49 ]. There was no evidence for an effect on response of providing a choice (OR 0.94; 95% CI 0.86 to 1.02; Fig.  3 ). There was moderate heterogeneity among the trial results (I-squared = 50.9%).

Effect on response of choice of response mode compared with postal only

Results of subgroup analyses

Table  2 presents the results of subgroup analyses according to the two study-level factors (forest plots of these subgroup analyses are included in supplementary figures).

Comparison 1 - postal vs. electronic questionnaire

Year of publication.

A third of studies were published before 2012 [ 15 , 16 , 17 , 23 , 24 , 33 , 35 , 40 , 47 , 48 ]. In this subgroup of studies the odds of response were 85% greater (OR 1.85; 95% CI 1.12 to 3.06) with a postal questionnaire compared with an electronic one. In the subgroup of studies published after 2012 the effect was lower (OR 1.70; 1.19 to 2.43), consistent with our concern (Sect.  2.4.1 ) that higher household access to a computer from 2012 may have improved preference for electronic questionnaires, however the statistical test of homogeneity of the pooled effects in these two subgroups was not significant ( p  = 0.788), indicating no evidence from these studies for different effects by year of study (Supplementary Fig.  1 a).

Seven of the trials [ 16 , 17 , 26 , 33 , 34 , 43 , 46 ] were judged to be at high risk of bias and for these trials the odds of response were more than tripled (OR 3.24; 95% CI 1.68 to 6.25) using a postal questionnaire when compared with an electronic one. There was considerable heterogeneity between the trial results (I-squared = 99%).

When only the 20 trials deemed to be at low risk of bias were synthesised, the odds of response were increased by two-fifths (OR 1.43; 95% CI 1.08 to 1.89). There was also considerable heterogeneity between these trial results (I-squared = 96.8%).

The statistical test of homogeneity of the pooled effects in these two subgroups ( p  = 0.025) provides some evidence for greater effect estimates in studies at high risk of bias (Supplementary Fig.  1 b). Our best estimate of the effect on response of mode of administration is hence from a synthesis of the studies at low risk of bias (OR 1.43; 95% CI 1.08 to 1.89). Results overall were thus confounded by risk of bias, but this did not explain the between study heterogeneity.

Year of study

Half of studies were published before 2012 [ 35 , 40 , 42 , 45 ]. In this subgroup of studies there was no evidence for an effect on response of providing a postal response option (OR 1.22; 95% CI 0.93 to 1.61). In the subgroup of studies published after 2012 there was evidence for an effect on response of providing a postal response option (OR 2.02; 95% CI 1.30 to 3.13). The statistical test of homogeneity of the pooled effects in these two subgroups was significant ( p  = 0.057), indicating some evidence from these studies for different effects by year of study (Supplementary Fig.  2 a). This apparent preference for a postal response option in studies published after 2012 was counter to our concern (Sect.  2.4.1 ) that higher household access to a computer from 2012 would improve preference for electronic questionnaires. There was considerable heterogeneity between the trial results (I-squared = 98.2%), but most of the studies favoured giving people the choice of response mode rather than electronic questionnaire only, and the high I-squared is due to differences in the size of the benefit for choice, rather than being due to an even spread of results between those favouring choice and those favouring electronic only.

Two of the trials were judged to be at high risk of bias [ 42 , 45 ]. There was no evidence for an effect on response of a postal option in these studies (OR 1.08; 95% CI 0.43 to 2.71). When only the 8 trials deemed to be at low risk of bias were synthesised, there was evidence that the odds of response were increased when providing a postal response option (OR 1.77; 95% CI 1.23 to 2.55). There was considerable heterogeneity between these trial results (I-squared = 97.7%). The statistical test of homogeneity of the pooled effects in these two subgroups ( p  = 0.326) provides no evidence for different effects by risk of bias (Supplementary Fig.  2 b). Our best estimate of the effect on response of providing a postal response option is hence from a synthesis of all of these studies (OR 1.63; 95% CI 1.18 to 2.26).

Comparison 3 - choice (electronic or postal) vs. postal questionnaire only

In the subgroup of studies published before 2012 there was very weak evidence that the odds of response were lower with an electronic option (OR 0.85; 0.73 to 0.98), whereas in studies published after 2012 there was no evidence for a difference between an electronic option and postal only – perhaps due to electronic methods being more acceptable with increased computer access. The results in both subgroups were more homogeneous (I-squared = 48.5% and 7.0% respectively). The statistical test of homogeneity of the pooled effects in these two subgroups ( p  = 0.04) provides some evidence for different effects by year of study (Supplementary Fig.  3 a). If we consider the most recent trials to better represent the situation today (i.e., greater access to computers than prior to 2012), then our best estimate of the effect on response of providing an electronic response option is from a synthesis of the studies published after 2012 (OR 1.01; 95% CI 0.93 to 1.08), i.e., no evidence for an effect.

There was one study at high risk of bias [ 34 ]. Its results were entirely consistent with the results of the seven studies at low risk of bias (the statistical test of homogeneity of the pooled effects in these two subgroups was not significant ( p  = 0.454), Supplementary Fig.  3 b).

Results of assessments of evidence for reporting bias

There was no evidence for small study effects (Harbord’s modified test p  = 0.148).

There was no evidence for small study effects (Harbord’s modified test p  = 0.841).

There was no evidence for small study effects (Harbord’s modified test p  = 0.139).

General interpretation of the results in the context of other evidence

This study has shown that response to a postal questionnaire is more likely than response to an electronic questionnaire. It has also shown that response is more likely when providing the option for postal response with an electronic questionnaire. It has further shown that providing an electronic response option with a postal questionnaire has no effect on response. Response is thus increased using postal rather than electronic questionnaires.

A previous meta-analysis of 43 mixed-mode surveys from 1996 to 2006 also found paper and postal administration produced greater response than electronic administration [ 50 ]. Our result that providing an electronic response option to postal administration does not increase response is consistent with a previous meta-analysis of randomised trials that found that mailed surveys that incorporate a concurrent Web option have significantly lower response rates than those that do not [ 51 ].

We suggest two possible reasons for these results:

Paper questionnaires are more  accessible  than electronic questionnaires .

Although access to the Internet increased over the period during which the studies included in this study were conducted [ 5 , 52 ], a ‘digital divide’ [ 53 ] persists in many populations where completion of a paper questionnaire may be possible, but completion of an electronic one may not.

Paper questionnaires are more  personal  than electronic questionnaires .

Personalised materials have been shown to increase response [ 54 ]. If participants perceive a paper questionnaire with a return envelope to be more ‘personal’ than a request to go to a website to answer some questions, we should expect a higher response with paper.

Strengths and limitations

The main strengths of this study are that our results are based on syntheses of the results of 45 randomised controlled trials that span two decades, and most of which were judged to be at low risk of bias.

There was, however, considerable heterogeneity between the results of the included studies. Our subgroup analyses did not identify any causes of heterogeneity among study results, but they did reveal confounding of the pooled result for postal versus electronic questionnaires. The unexplained heterogeneity means that we cannot be confident about the magnitude of the effects on response using postal rather than electronic questionnaires. However, from inspection of the forest plots we can be confident about the direction of these effects.

The evidence included in this review addresses ‘unit’ non-response only (i.e., return of questionnaires). ‘Item’ response (i.e., completion of individual questions) may be greater with electronic methods, but this was not addressed in this review and requires investigation in the future.

We assessed evidence for reporting bias using Harbord’s modified test for small-study effects and found no evidence for bias. This test may not be reliable given the substantial heterogeneity between the results of the included trials [ 55 ].

Due to the nature of this study (secondary analysis of a published review), there is no pre-registered protocol for the subgroup analyses provided in this study.

Implications for practice, policy, and future research

These results will help researchers and healthcare providers to improve data collection from study participants and patients, helping to maintain study power and reduce bias due to missing data in research studies. In addition to the methods already known to be effective in increasing questionnaire response [ 8 , 56 ], postal questionnaires should be used in preference to, or offered in addition to, electronic modes as this will help to increase the proportion of participants that responds. It should be noted, however, that the evidence upon which this recommendation is based is from studies published between 2001 and 2020, and this may change in the future as access to the Internet increases and more people become ‘tech-savvy’. Furthermore, we consider that the certainty of the evidence provided in this study is “Moderate”, due to the unexplained heterogeneity between the results of the included studies.

Future research

Evidence on effective data collection in low- and middle-income settings is needed. Research centres such as LSHTM can embed studies within trials (SWATs) in their research in these settings to help to increase the evidence base [ 57 ].

Participation rates for epidemiologic studies have been declining [ 58 ]. Our study has presented evidence that postal questionnaires are preferable to electronic questionnaires to improve participation, but it does not tell us why . Research is still needed to advance sociological and psychological theories of participation in data collection procedures [ 59 ].

Electronic administration provides benefits for researchers over paper administration which have not been addressed by this study: A well-designed Web questionnaire can control skip patterns, check for allowable values and ranges and response consistencies, and it can include instructions and explanations about why a question is being asked [ 60 ]. These options could help to improve the completeness and quality of self-administered data collection, maintaining study power, reducing the risk of bias in study results, and saving study resources. Further research into the cost-effectiveness of electronic administration compared with postal administration in different settings will be needed to inform practice [ 61 ].

Data availability

Data extracted from included studies will be available in the forthcoming update on the Cochrane Library.

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This work was supported by the NIHR Evidence Synthesis Programme [Grant NIHR133238]. Conduct of the work was entirely independent of the funder.

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PE independently screened the search results and the full-text reports, and extracted data from eligible studies. He assisted with data entry into RevMan 5. He exported data into Stata and he conducted the meta-analyses and other statistical analyses. He drafted the manuscript. PE is guarantor for the paper.CP ran the electronic searches, independently screened the search results and the full-text reports, and extracted data from eligible studies. CP assisted with data entry into RevMan 5, and commented on the manuscript.

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Edwards, P., Perkins, C. Response is increased using postal rather than electronic questionnaires – new results from an updated Cochrane Systematic Review. BMC Med Res Methodol 24 , 209 (2024). https://doi.org/10.1186/s12874-024-02332-0

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