Early perceptions of portfolios in an outcome-based curriculum

Abstract

Background

Despite the widespread use of portfolios in medical education, their outcomes remain variable. This study evaluated students’ perceptions of portfolios at an institution that recently adopted an outcome-based curriculum.

Methods

This descriptive cross-sectional study involved 4th, 5th, and 6th -year medical students (n = 94; response rate = 64.8%) at Prince Sattam Bin Abdulaziz University, Saudi Arabia, during the 2023–2024 academic year. A 13-item Likert-type questionnaire assessed students’ portfolio perceptions across five domains: design, feedback and reflection, benefits in assessment, openness to their broader use in the college, and usefulness. Students’ Grade Point Average (GPA) was also recorded as an index of academic performance. Data were analyzed quantitatively; results were expressed as frequencies, means, medians, and percentages. Correlation analyses were conducted to explore the relationships between overall portfolio perception and other measured domains.

Results

Ninety four students participated in this study. Only 48.9% of students found portfolios useful, with neutral average score of 3.3 ± 1.4 on the Likert scale and 5.66 ± 2.7 on the visual scale. Fewer than half reported positive perceptions across the five assessed domains. Differences in perceptions across academic levels were analyzed using the Kruskal-Wallis test which revealed statistically significant differences (p < 0.05). Post-hoc pairwise comparisons using the Mann-Whitney U test showed that fourth-year students had significantly higher perception scores than both fifth- and sixth-year students (p < 0.05). Although perceptions improved slightly in the sixth year, these differences were not statistically significant. Strong positive correlations were observed among the survey variables (p < 0.001), but no significant correlations were found between portfolio perceptions and academic performance (p > 0.05).

Conclusion

The transition to outcome-based education may be associated with poor portfolio perceptions. Adjusting workload, enhancing feedback, and integrating portfolios into the curriculum may improve portfolio acceptability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-07583-z.

Background

Modern physician training emphasizes achievement of educational outcomes and demonstration of clinical competence [1–4]. Portfolios, which serve as tools for reflection, feedback, and experiential learning, align well with this paradigm of competency-based education [5–7]. In the educational enterprise, portfolios are defined as “purposeful collection of information and digital artifacts that demonstrate learning, skills and competence” [8]. Portfolios encompass different types and formats, and can be used across the continuum of medical training for different purposes, including demonstration of competence, personal development, and readiness to practice [9–11]. In clinical settings, portfolios facilitate the acquisition and assessment of essential skills, and promote professional growth [5, 12, 13]. They foster learner interactions with patients and healthcare teams, aiding the integration of theoretical knowledge into practice and easing the transition to clinical environments [12]. Reflection is pivotal as it helps practitioners learn from experiences and promotes goal-setting and self-regulation [5, 14, 15]. Thus, portfolios support lifelong learning, continuous professional development, and identity formation [16]. However, perceptions of portfolios vary across settings and are potentially influenced by contextual factors such as design, integration in the curriculum, and use in assessment [17]. Learners’ sociocultural backgrounds may also play a role in this process [18, 19]. The perceived value of portfolios affects learners’ engagement, motivation, and outcomes [6, 16]. Additionally, learners’ attitudes towards portfolios are critically determined by their perceived educational benefits [6, 20]. Hence, understanding user satisfaction and acceptability is crucial for designing and implementing portfolio projects [4, 21].

Study context

The Faculty of Medicine at Prince Sattam bin Abdulaziz University has transitioned from a traditional curriculum to a student-centered, competency-based model to enhance learning and meet national accreditation standards. The curriculum incorporates portfolios in various clerkships during the clinical years (4th, 5th, and 6th ) to help students achieve program-learning outcomes. Portfolios were introduced to students at the beginning of each academic year from 2020, employing a paper-based format with a mix of prescriptive and free-writing assignments. Aligned with course learning outcomes, the portfolio tasks include case reports, critical thinking exercises, diagnostic, procedural, and management skills, along with a dedicated section for reflection. Faculty members review students’ submissions and provide timely feedback at regular intervals to enhance and monitor their learning throughout the clerkship period. Marks ranging from 5 to 10 are assigned to the portfolio based on performance criteria, integrating it into formative and summative assessments. Some variations in content, processes, assessments, and markings exist across specialties. Despite these efforts, acceptability and functionality of portfolios have not been critically evaluated. This study aimed to assess students’ perceptions of portfolios and identify their strengths and weaknesses to inform future planning. Specifically, this study aims to answer the following questions.

1. What are student perceptions of portfolios, particularly during the transition to outcome-based education?

2. What are the relationships among students’ portfolio perceptions and their academic levels and performance?

Methods

This descriptive cross-sectional study was conducted at Prince Sattam bin Abdulaziz University’s Faculty of Medicine between March and June 2024, and was approved by the university’s Institutional Review Board (SCBR-313/2024). The participants were medical students in clinical years (4th, 5th, and 6th ) using portfolios in their curriculum activities across various clinical subjects. We used convenience sampling by inviting all students in the three classes to participate. A 12-item Likert-type questionnaire from Fida, Hassanien [18] was adapted to assess perceptions across five domains: portfolio design, feedback and reflection, advantages of using portfolio in assessment, receptivity to broader use of portfolios in the college and portfolio usefulness. The latter domain was added through a 13th Likert-type item to assess students’ perceptions of the portfolios’ usefulness in learning, and a visual scale from 1 to 10 to capture students’ overall perception of portfolios, thereby adding a fifth domain to the questionnaire. The visual scale was selected because the actual portfolio grade range was too narrow, which could limit the sensitivity and usefulness of statistical analysis. The Likert-type items were rated on a 5-point scale from: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree. The questionnaire also included a visual scale from 1 to 10 to gauge students’ overall perception of portfolios, and their GPA (grade point average) as an index of academic performance. The online questionnaire was distributed via Google Forms and data analyzed using SPSS (SPSS, Chicago, Illinois, USA) version 16 and expressed as frequencies, means, and percentages. Normality of the domain scores was assessed using the Kolmogorov-Smirnov and Shapiro-Wilk tests. As several variables did not meet the assumptions of normality, non-parametric statistical tests were used: Kruskal-Wallis for comparing scores across academic levels, Mann-Whitney U for pairwise comparisons, and Spearman’s rank correlation for associations with GPA. The internal consistency of the questionnaire was assessed using Cronbach’s alpha coefficient. Comparative studies and correlation analyses were conducted to explore the relationships between overall portfolio perception and the other domains measured to identify significant relationships.

Results

A total of 94 students participated in this study (4th year: 32, 5th year: 37, and 6th year: 25), with a response rate of 64.8%. The questionnaire demonstrated high reliability (Cronbach’s Alpha = 0.92). Table 1 presents the participants’ responses to the questionnaire. Table 2 summarizes the overall responses to the main questionnaire domains. The mean scores of the Likert items were interpreted according to the reference values of a 5-point Likert scale (detailed in Table A) [22]. Less than half of the students had positive perceptions across the following domains: design (31.9%), feedback and reflection (40.3%), assessment (39.5%), and broader use (25.1%), with consistently overall neutral scores across all domains as shown in Table 2. Additionally, only 48.9% of the participants found the portfolio useful with a neutral mean score of 3.28 ± 1.39, and median score of 3, on the Likert scale, and an average usefulness score of 5.66 ± 2.74 (minimum score = 2, maximum score = 9), and median score of 6, on the visual scale. These findings suggest poor overall portfolio perception.

Table 1.

Students’ responses to the questionnaire items (n = 94)

Item	Strongly agree	Agree	Neutral	Disagree	Strongly disagree	Mean ± SD	Median
Portfolio design
The portfolio has given me a good understanding of the subject.	14* (25.5)†	22 (23.4)	27 (28.7)	13 (13.8)	8 (8.5)	3.44 ± 1.3	3.0
The workload was just right.	19 (20.2)	13 (13.8)	17 (18.1)	27 (28.7)	18 (19.1)	2.87 ± 1.4	3.0
Filling the portfolio’s booklet was appropriate.	17 (18.1)	24 (25.5)	23 (24.5)	22 (23.4)	8 (8.5)	3.2 ± 1.2	3.0
The current version of the portfolio was friendly to use.	20 (21.3)	23 (24.5)	21 (22.3)	22 (23.4)	8 (8.5)	3.3 ± 1.3	3.0
Feedback and reflection
The portfolio helped me to think critically.	23 (24.5)	27 (28.7)	19 (20.2)	16 (17)	9 (9.6)	3.4 ± 1.3	4.0
The portfolio gave me awareness about the required clinical skills.	26 (27.7)	32 (34)	16 (17)	13 (13.8)	7 (7.4)	3.6 ± 1.2	4.0
The writing part on the reflection was enjoyable.	12 (12.8)	14 (14.9)	25 (26.6)	22 (23.4)	21 (22.3)	2.7 ± 1.3	3.0
The portfolio helped me in developing myself awareness.	22 (23.4)	30 (31.9)	25 (26.6)	9 (9.6)	8 (8.5)	3.5 ± 1.2	4.0
The portfolio’s evidence (feedback) was discussed with my mentor.	23 (24.5)	23 (24.5)	16 (17)	15 (16)	17 (18)	3.2 ± 1.4	3.0
Use of portfolio in assessment
My mentor provided me a constructive feedback.	25 (26.6)	22 (23.4)	23 (24.5)	9 (9.6)	15 (16)	3.4 ± 1.4	3.5
I recommend using the portfolio as an assessment tool in medical school.	21 (22.3)	20 (21.3)	20 (21.3)	20 (21.3)	13 (13.8)	3.2 ± 1.4	3.0
Receptivity for broader use of portfolio in the college
I want to use portfolio in other courses too.	17 (18.1)	16 (17)	19 (20.2)	21(22.3)	21 (22.3)	2.9 ± 1.4	3.0
Portfolio usefulness
The portfolio was useful to my learning.	22 (23.4)	24 (25.5)	22 (23.4)	10 (10.6)	16 (17)	3.3 ± 1.4	3.0

*Number of students, †percentage. ‡SD: standard deviation

Table 2.

Overall students’ responses to the main questionnaire variables (n = 94)

Variable	Strongly agree	Agree	Neutral	Disagree	Strongly disagree	Mean	SD‡	Median
Portfolio design	13* (13.8)†	17 (18.1)	32 (34)	26 (27.7)	6 (6.4)	3.05	1.13	3.0
Feedback and reflection	15 (16)	23 (24.5)	34 (36.2)	16 (17)	6 (6.4)	3.27	1.12	3.4
Use of portfolio in assessment	15 (16)	22 (23.4)	24 (25.5)	23 (24.5)	10 (10.6)	3.1	1.25	3.0
Portfolio receptivity	17 (18.1)	16 (17)	19 (20.2)	21 (22.3)	21(22.3)	2.86	1.42	3.0
Portfolio usefulness	22 (23.4)	24 (25.5)	22 (23.4)	10 (10.6)	16 (17)	3.28	1.39	3.0

*Number of students, †percentage. ‡SD: standard deviation

Students’ perceptions of the measured domains were compared to their academic levels using Kruskal-Wallis test (as data were not normally distributed in some of the measured domains) as shown in Table 3. Perceptions varied significantly by academic level. To further explore these variations, the Mann-Whitney U test was used to compare the perceptions of the questionnaire domains among the study cohorts, as shown in Table 4. Fourth-year students consistently perceived the assessed domains significantly better than the fifth year students across all domains. Furthermore, fourth-year students rated feedback and reflection, assessment, and usefulness dimensions significantly better than the sixth-year students, with smaller differences noted in the other domains. Although perceptions in all domains, except for the use of portfolios in assessment, showed an upward trend from the 5th to the 6th year, these variations were not statistically significant. These results suggest that portfolio perception declines significantly between the fourth and fifth years but partially recovers by the sixth year.

Table 3.

Comparisons of the students’ responses to the study variables across the academic years (n = 94)

Variable	Academic level	Mean (SD)	Normality tests	Kruskal Wallis test
			P-value	Mean rank	Chi-Square	df*	P-value
Portfolio design	4th year	3.66 (± 1.14)	0.02	57.5	8.692	2	0.013
	5th year	2.82 (± 1.00)	0.01	38.2
	6th year	3.17 (± 0.93)	0.76	48.46
Feedback and reflection	4th year	3.83 (± 1.00)	0.02	61.53	12.968	2	0.002
	5th year	2.99 (± 0.95)	0.95	39.5
	6th year	3.06 (± 0.95)	0.98	41.38
Use of portfolio in assessment	4th year	3.84 (± 1.12)	0.001	60.56	11.365	2	0.003
	5th year	2.99 (± 1.06)	0.23	41.24
	6th year	2.92 (± 1.2)	0.11	40.04
Portfolio receptivity	4th year	3.34 (± 1.5)	0.001	56.34	6.447	2	0.04
	5th year	2.46 (± 1.33)	0.001	39.97
	6th year	2.84 (± 1.31)	0.02	47.32
Portfolio usefulness	4th year	3.78 (± 1.39)	0.00	57.81	8.719	2	0.013
	5th year	2.84 (± 1.37)	0.002	38.85
	6th year	3.28 (± 1.24)	0.004	47.1
Usefulness scale	4th year	6.78 (± 2.96)	0.003	58.73	8.678	2	0.013
	5th year	4.92 (± 2.63)	0.073	40.04
	6th year	5.32 (± 2.17)	0.327	44.16

*Degree of freedom

Table 4.

Comparisons of the students’ responses in the survey domains according to their study level (n = 94)

Variable	Comparison	N (group 1)	Mean rank (group 1)	N (group 2)	Mean rank (group 2)	Mann-Whitney U test	Z	P-value*
Portfolio design	4th vs. 5th Year	32	42.2	37	28.77	361	-2.79	0.01
	4th vs. 6th Year	32	31.8	25	25.42	310.5	-1.45	0.15
	5th vs. 6th Year	37	28.43	25	36.04	349	-1.64	0.10
Feedback and reflection	4th vs. 5th Year	32	43.62	37	27.54	316	-3.33	0.00
	4th vs. 6th Year	32	34.41	25	22.08	227	-2.79	0.01
	5th vs. 6th Year	37	30.96	25	32.3	442.5	-0.29	0.77
Use of portfolio in assessment	4th vs. 5th Year	32	42.72	37	28.32	345	-3.0	0.00
	4th vs. 6th Year	32	34.34	25	22.16	229	-2.78	0.01
	5th vs. 6th Year	37	31.92	25	30.88	447	-0.23	0.82
Portfolio receptivity	4th vs. 5th Year	32	41.27	37	29.58	391	-2.45	0.01
	4th vs. 6th Year	32	31.58	25	25.7	317.5	-1.36	0.17
	5th vs. 6th Year	37	29.39	25	34.62	384.5	-1.15	0.25
Portfolio usefulness	4th vs. 5th Year	32	42.12	37	28.84	364	-2.82	0.01
	4th vs. 6th Year	32	32.19	25	24.92	298	-1.7	0.09
	5th vs. 6th Year	37	29.01	25	35.18	370.5	-1.36	0.18
Usefulness scale	4th vs. 5th Year	32	41.89	37	29.04	371.5	-2.67	0.01
	4th vs. 6th Year	32	33.34	25	23.44	261	-2.25	0.02
	5th vs. 6th Year	37	30.0	25	33.72	407	-0.803	0.42

*P-value is significant if < 0.05

Correlations between the survey domains and students’ academic performance (indicated by their GPAs), and among the survey domains themselves were determined using the Spearman’s correlation coefficient as shown in Table 5. No significant correlations were found between perceptions and academic performance. However, strong positive correlations were identified among survey variables, indicating that students who rated one aspect highly were likely to rate other aspects highly as well. This finding affirms that the measured survey domains represent related constructs in students’ evaluations.

Table 5.

Correlation between the study variables and the GPA, and between the study variables (n = 94)

Variable	GPA	Portfolio receptivity	Portfolio usefulness	Portfolio usefulness scale	Portfolio design	Feedback and reflection	Use of portfolio in assessment
GPA	-	0.14 (0.15)*	0.89 (0.02)	0.77 (0.03)	0.76 (0.03)	0.8 (-0.03)	0.78 (-0.03)
Portfolio receptivity	0.14 (0.15)	-	0.00 (0.78)	0.00 (0.64)	0.00 (0.68)	0.00 (0.66)	0.00 (0.68)
Portfolio usefulness	0.89 (0.02)	0.00 (0.78)	-	0.00 (0.82)	0.00 (0.83)	0.00 (0.75)	0.00 (0.72)
Portfolio usefulness scale	0.77 (0.03)	0.00 (0.64)	0.00 (0.82)	-	0.00 (0.76)	0.00 (0.69)	0.00 (0.63)
Portfolio design	0.76 (0.03)	0.00 (0.68)	0.00 (0.83)	0.00 (0.76)	-	0.00 (0.77)	0.00 (0.69)
Feedback and reflection	0.8 (-0.03)	0.00 (0.66)	0.00 (0.75)	0.00 (0.69)	0.00 (0.77)	-	0.00 (0.83)
Use of portfolio in assessment	0.78 (-0.03)	0.00 (0.68)	0.00 (0.72)	0.00 (0.63)	0.00 (0.69)	0.00 (0.84)	-

Numbers shown are the 2-tailed p-value; correlation is significant at the 0.01 level. GPA: grade point average. *P value (Spearman’s correlation coefficient)

Discussion

This study assessed students’ perceptions of portfolios in five dimensions: design, feedback and reflection, assessment, broader use within the program, and usefulness. The findings revealed poor perceptions across all domains, with a significant decline in perceptions from the 4th to the 5th year, followed by a subsequent increase at the 6th year level. Additionally, students expressed neutrality regarding the perceived value of portfolios in enhancing their learning. Poor perceptions of portfolios have also been reported in other studies [1, 23–25], and have been attributed to various factors including cultural and contextual influences. The discussion of our findings is structured around the main questionnaire domains assessed.

Portfolio design

Nearly half of the students (47.8%) in this study expressed dissatisfaction with the portfolio workload, echoing findings from other studies [1, 20, 26–29]. Excessive paperwork, tight schedules, and variations in the content and structure of clinical disciplines may contribute to this dissatisfaction [2, 30–32]. The current portfolio format, characterized by a predominance of fill-in-the-blanks exercises, may also hinder student engagement and perceived usefulness [2]. A rigid format restricts opportunities for students to demonstrate personal qualities, thereby inhibiting internal motivation [12, 33]. However, a completely unstructured format may be counterproductive, and striking a balance between structure and flexibility is crucial [2, 12, 34]. Sophisticated portfolio designs can be motivational and user-friendly [4, 16], although the medium itself may not significantly impact learning and reflection [16]. A clear structure coupled with a gradual progression from simple to more advanced technological formats may provide an optimal solution [6, 34, 35]. On the other hand, less than half of the students (48.9%) in this study perceived the portfolio as effective in providing a good understanding of the subject. This could be related to a lack of alignment between the portfolio and course learning outcomes, or appropriateness of the portfolio tasks to the students’ academic levels [4, 27, 36]. Evidence suggests that student ownership along with a flexible and balanced format that fosters creativity and competence demonstration is essential for better outcomes [6, 27].

Feedback and reflection

Reflective practice, a core component of portfolios, enhances learning and professional growth [12, 14, 37]. However, only around a quarter of the students (27.2%) in the present study engaged with the reflection component of the portfolio exercise. Students’ dissatisfaction with reflection is likely due to their unfamiliarity with the skill and barriers such as time pressure, inconsistent guidance, and limited narrative and communication skills [38–40]. Reflection develops over time, and requires dedicated teaching, training, and practice [2, 36]. A common pitfall in medical education programs is the assumption that students inherently possess the skills necessary to perform portfolio exercises [38]. Additionally, the curriculum’s recent transition at the study location from a didactic to a competency-based model may contribute to these challenges, as students accustomed to traditional methods may struggle with portfolios [41].

Feedback is central to students’ learning and acceptance of portfolios [42]. However, less than half of the students (49%) in this study reported that feedback was discussed with their mentors. Regular review of students’ work and timely feedback are essential components of successful portfolios. Nevertheless, these aspects are often neglected, leading to student dissatisfaction [43]. Additionally, feedback is frequently perceived as inconsistent, infrequent, of poor quality, and not adequately discussed [6, 17]. Cultural values may further influence how feedback is provided and received. For instance, students may misinterpret feedback messages or perceive criticism as punishment [21]. Effective feedback requires active engagement including seeking, discussing, and interpreting it as an opportunity for development [21, 36, 44]. Introducing portfolios early in the curriculum, establishing effective mentorship systems, and training both students and mentors in reflection and feedback provision can significantly enhance user satisfaction [2, 30, 45, 46].

Use of portfolios in assessment

While portfolios are considered suitable tools for evaluating several skills in clinical practice, their use in assessment remains controversial [12, 30]. Less than half of the students in this study (43.6%) recommended using the portfolio as an assessment tool in the college, and only half reported receiving constructive feedback from their mentors. Students’ poor perceptions of portfolio assessment in this study may stem from inadequate feedback experiences, minimal portfolio scores, and cultural factors that influence critical incident recording [4, 17]. Negative feedback experiences, particularly the lack of discussion around feedback, may exacerbate these perceptions. Learning to interpret and utilize constructive criticism effectively is essential to enhance portfolio acceptance. Conversely, perceptions of assessment play a critical role in determining the feasibility of feedback within a learning context [21]. Furthermore, the low weight assigned to the portfolio in the overall assessment may have reduced its perceived value, especially among students who are predominantly focused on examinations. For portfolios to be effective, students must feel that the effort invested is adequately rewarded [4, 37]. Inconsistent assessment approaches may also contribute to these challenges [26]. Standardizing assessment protocols and integrating portfolios into both formative and summative evaluations can significantly enhance their acceptability and effectiveness [14, 32, 42, 45, 46].

Study level and the academic performance

Junior students in the present study perceived the portfolio significantly better than their senior counterparts. Williams, Park [47] explained similar findings in their setting, suggesting that junior students may be more idealistic and resilient than senior students when adapting to new learning approaches. Conversely, they argued that senior students may be more adept at picking up negative cues from their learning environment, making them more vulnerable to negative portfolio experiences [24, 27, 47]. Similarly, McMullan [39] reported that senior students were less positive about portfolios due to their perceived lack of value in fostering learning and growth. By contrast, Contreras-Higuera, Martínez-Olmo [45] reported contradicting findings, linking students’ frustration during early portfolio experiences to the difficulty of the exercises and a lack of understanding of portfolio objectives. Likewise, other studies suggest that novice students face the greatest challenge with portfolio exercises due to unfamiliarity, unclear goals, and an ambiguous purpose [14, 17, 27]. Strikingly, the initial decline and subsequent improvement in students’ perceptions of portfolios as they progress in their studies, noted in this research, aligns with the phenomenon of “the implementation dip” observed during the introduction phase of portfolio projects [48]. Improved perceptions may reflect increased familiarity and acceptance of the portfolio over time, but they may also underscore the importance of commitment and buy-in required from all stakeholders [15]. Interestingly, and in contrast to other studies, no significant correlation was found between students’ portfolio perceptions and their academic performance [23, 30]. Further longitudinal and qualitative studies are required to validate these findings.

Limitations

The findings of this study are specific to the context in which they were conducted and may not be applicable to other settings. Additionally, the study assessed students’ perceptions of portfolios, which are situated at the lowest level of Kirkpatrick’s hierarchy, and thus may be inherently subjective. Future qualitative research could provide a more comprehensive exploration of students’ perspectives on portfolio-based learning.

Moreover, the study had a small sample size, which was a constraint imposed by the limited number of students enrolled in the program. Nonetheless, the preliminary results offer an insight into the acceptability of portfolios within active student learning environments and could inform the development of strategies to enhance portfolio-based outcomes.

Conclusion

Portfolios are essential tools for reflective learning in clinical practice, but their acceptability varies significantly. This study identified relatively poor portfolio perceptions among students transitioning from traditional to outcome-based education, which could be potentially influenced by contextual factors such as workload, portfolio design, and the use of portfolios in assessment. Junior students demonstrated better perceptions than their senior counterparts, highlighting the role of portfolio implementation in shaping portfolio outcomes. However, perceptions appear to improve with practice, underscoring the importance of maintaining consistency and continuity in the process. Recommendations for enhancing the value of portfolios arising from this study include establishing a clear purpose, adopting a flexible format, implementing standardized assessments, and providing consistent feedback. Contextual adaptation of portfolios is required for achieving better outcomes, as a good fit within the educational environment is essential. Further research is required to examine the longitudinal impact of portfolios on student learning outcomes and to incorporate faculty perspectives.

Electronic supplementary material

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Author contributions

“AO conducted data collection and analysis. All authors contributed to the study’s conceptualization, interpretation of results, and co-authored the final manuscript”.

Funding

None.

Data availability

“The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request”.

Declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board at Prince Sattam bin Abdulaziz University (SCBR-313/2024). All participants were provided with detailed information about the study and gave their informed consent prior to enrollment. This study followed the ethical guidelines approved by the Helsinki declaration 2013 (https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.