Abstract
Background
Head trauma is the most common injury from accidents, making rapid and accurate assessment crucial. Incorrect evaluations can lead to serious complications, including brain dysfunction and death. Thus, it is vital to teach nursing students proper assessment techniques. This study evaluates the effectiveness of a digital game-based study guide for enhancing nursing students’ knowledge and practical skills in head trauma assessment.
Methods
This quasi-experimental study involved nursing students in their 8th semester at Shahid Beheshti University of Medical Sciences in 2024, randomly assigned to control and intervention groups. Data collection occurred from May to July 2024. Both groups received two 2-hour face-to-face educational sessions in one week. The intervention group then utilized the digital game-based study guide. Knowledge and practical skills were assessed using a trauma evaluation tool and compared between groups, with data analyzed using SPSS version 20.
Results
Ninety-three nursing students participated (44 males and 49 females), with a mean age of 22.78 years (SD = 1.24). A paired samples t-test showed statistically significant knowledge improvement in both groups (P < 0.05). An independent samples t-test indicated statistically significant differences in knowledge and practical skills between groups post-intervention (P < 0.05).
Conclusion
The study shows that a digital game-based study guide significantly enhances nursing students’ knowledge and skills in head trauma assessment.
Trial registration
This study was registered in the Iranian Registry of Clinical Trials (https://irct.behdasht.gov.ir) with the IRCT ID: IRCT20210131050189N10, and it received approval on July 21, 2024.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12909-025-08122-6.
Keywords: Head trauma, Game-Based education, Nursing student, Study guide, Mobile application, Knowledge and practical skills
Introduction
Trauma is a leading cause of referral, disability, and mortality among emergency room patients [1–4]. Within this context, craniocerebral injuries resulting from head trauma represent the highest incidence of accident-related injuries. Traumatic brain injury (TBI) is recognized as one of the primary causes of death and disability [5–7]. According to the Centers for Disease Control and Prevention, an alarming 190 individuals in the United States die each day from brain damage sustained in accidents, while over ten million individuals experience injuries and complications related to TBI annually [8]. This has led to TBI being described as a silent epidemic [9–11], making its prevention and treatment key priorities for the World Health Organization [9, 12, 13].
In the critical hours following an injury, it is reported that 50% of deaths are linked to brain injuries [14]. Delayed or improper assessments in these cases can result in irreversible brain dysfunction, disability, and death due to ischemia of the brain tissue [14, 15]. Addressing this issue necessitates that clinical decision-making care providers possess adequate training, knowledge, and skills [16, 17]. In the emergency department, nurses are typically the first professionals to arrive at a patient’s bedside [18, 19], thereby playing a crucial role in the care of patients with TBI [8, 20]. As future nurses, nursing students must develop the essential skills required to evaluate head trauma patients effectively [21], ensuring they are equipped to play a significant role in this area in the future [19].
Mobile phone applications can significantly enhance the enjoyment and excitement of the learning process [22]. The integration of gamification has the potential to boost both learning and performance outcomes for educators and learners alike [23]. By embedding game elements into a non-game environment, alongside theoretical and practical education, future health professionals can be better prepared to develop the skills and confidence necessary to tackle the complexities of modern healthcare [24]. For instance, a digital game-based study guide allows learners to gain valuable experience and address clinical problems in risk-free settings, free from the pressures of real patient interactions [25].
Given that traditional educational methods often prove ineffective in learning and management [17, 26], incorporating modern, computerized approaches can significantly enhance educational outcomes [27, 28]. Ghafouri pointed out that, despite the effectiveness of mobile applications, users must have access to programs containing appropriate and relevant content [29]. In introducing a game-based health assessment application, Ghafouri and his colleagues found it to be effective in educational contexts but emphasized that innovative methods tend to have a more profound impact on learners’ education [28]. However, they also acknowledged potential challenges, such as limited resources and varying levels of instructor proficiency, which could impede the achievement of optimal results [28]. Additionally, research conducted by Khaledi and colleagues revealed that the role-playing method outperformed gamification in enhancing learners’ self-efficacy in cardiopulmonary resuscitation training [17].
A study by Chandran et al. examined the effectiveness of smartphone applications in enhancing practical skills and clinical performance among healthcare professionals and students. The findings indicated that smartphone-based applications serve as effective tools for improving knowledge and skills among clinical staff [30]. Given the critical need for nurses to be well-prepared in assessing head trauma patients and recognizing the beneficial impact of dynamic clinical guides, this study was conducted to evaluate the effectiveness of a digital game-based study guide specifically for head trauma assessment on the knowledge and practical skills of nursing students.
Methods
This quasi-experimental study, which included a control group, was conducted to evaluate the effectiveness of a digital game-based study guide for head trauma assessment on the knowledge and practical skills of nursing students. The statistical population for this research comprised all nursing students at Shahid Beheshti University of Medical Sciences in 2024.
Sampling
In this study, the participants were nursing students from Shahid Beheshti University of Medical Sciences in 2024. Sampling was conducted using nonrandom (convenience) methods.
The number of required samples per group was calculated using the following formula:
 |
The effect size was derived from the study by Khaledi and colleagues [17]. Taking into account a 10% potential dropout rate, a minimum of 49 participants was considered for each group.
 |
The inclusion criteria required participants to be willing to install the app on their mobile phones and to have completed at least eight semesters in the nursing program. The exclusion criteria included non-participation in the training session (participants must attend the entire session) and a lack of prior training on how to evaluate head trauma patients.
Out of the 103 students in the eighth semester, 98 met the inclusion criteria and were eligible for the study. They were randomly assigned to two groups: an intervention group with 49 participants and a control group with 49 participants. The allocation was done using the Study Randomizer software (2017), accessible at: https://www.studyrandomizer.com. After registering in the software, the study details, including the number of groups and participants, were entered. In the next step, each participant was assigned a code based on their order of entry into the study, followed by a random assignment to either the intervention or control group using the software.
Research tools
In the research, the ABCDE trauma patient evaluation approach was utilized, a universally accepted method for assessing trauma and critically ill patients [31]. This approach encompasses a comprehensive evaluation of five key areas: airway, breathing, circulation, disability, and exposure [31, 32]. An expert panel, consisting of 12 professors from nursing and emergency medicine, developed a key features questionnaire tailored for assessing head trauma using the ABCDE framework. The questionnaire was divided into two distinct sections: knowledge and practical skills. The knowledge segment featured a clinical scenario accompanied by five multiple-choice items, with each correct answer earning 2 points, leading to a total potential score ranging from 0 to 10 (Additional file 1).
The practical skills assessment consisted of a checklist with 10 items. Based on the scenario presented, students were required to perform specific evaluations. If they completed the tasks independently and without assistance, they received 2 points; if they required reminders or help, they were awarded 1 point; and if they failed to execute the evaluation, they received no points. The scoring for this section ranged from 0 to 20 (Additional file 2).
Ten emergency nurses developed 50 realistic head trauma scenarios based on their clinical experience. An expert panel of six emergency physicians, five experienced emergency nurses, and five nursing faculty reviewed the scenarios for clinical accuracy, clarity, and educational relevance, making revisions as needed. The panel rated the difficulty of embedded questions within each scenario on a 10-point scale and selected the four most difficult questions for formal evaluation. The remaining scenarios, deemed educationally valuable, were incorporated into the gamified situational modules of a mobile application designed to enhance clinical decision-making through scenario-based training.
Reliability and validity of tools
The validity of the questionnaire was evaluated using both qualitative and quantitative methods. Quantitatively, the content validity ratio (CVR) and the content validity index (CVI) calculated from feedback provided by 10 experts (nursing professors, emergency physicians, and experienced emergency nurses). The resulting content validity coefficient was 0.91, exceeding the acceptable Lawshe table value of 0.69 for 10 experts [33]. The content validity index was greater than 0.9 for the instrument, which is accepted [34, 35] (see the result of CVR and CVI in additional file 3).
The test-retest reliability of the knowledge questionnaire showed no significant difference after a two-week interval (n = 25, r = 0.69, p = 0.00). Participants were sixth-semester nursing students who had completed the trauma nursing course and were willing to participate; incomplete questionnaires were excluded. Inter-rater reliability of practical skills, assessed via intraclass correlation coefficient (ICC = 0.59, p < 0.001), showed no significant difference between researcher and emergency department nurse evaluations (n = 14; t = 0.52, df = 26, p = 0.60). Inter-rater reliability samples included hemodynamically stable head trauma patients (Glasgow Coma Scale > 14, age 18–65) without cardiovascular disease, hypertension, or diabetes, hospitalized in the emergency department.
Data collection
After securing approval from the ethics committee and receiving a letter of introduction from the esteemed Vice President of Research, we reached out to our participants with a heartfelt assurance of the study’s significance and a promise of confidentiality for their personal information. To gather relevant background, we administered a demographic questionnaire that captured details such as age, gender, grade point average (GPA), and prior completion of trauma patient assessment courses.
We then engaged both the intervention and control groups in an interactive face-to-face lecture format, which unfolded over two enriching sessions, each lasting two hours, across one week. Following these enlightening lectures, the intervention group was introduced to an innovative digital game-based study guide designed specifically for head trauma assessment.
A week later, from June 28 to 30, 2024, we conducted a thorough assessment of the knowledge and practical skills of participants in both groups. This evaluation was carried out through an Objective Structured Clinical Examination (OSCE) within a meticulously crafted simulated environment. The OSCE, evaluating head trauma management, was conducted in two days, with all participants completing two stations. Each station simulated a head injury scenario, assessing clinical reasoning, communication, and decision-making skills within a six-minute time constraint. This format ensured consistent assessment and streamlined logistics. Examiners used practical skills assessment checklists for objective and uniform evaluation. The focused trauma scenarios effectively assessed critical skills relevant to emergency and acute care settings.
We ensured rigorous objectivity by maintaining blinding during both the data collection and analysis phases. The entire research process is elegantly depicted in Fig. 1. Once data collection was complete, we excitedly presented the developed application to the control group, further enhancing their learning experience.
Fig. 1.
The research process
Digital study guide design
To implement the intervention, the Digital Game-Based Study Guide for head trauma assessment was developed using the cascade model [36], which includes the following stages: initial analysis, system analysis, design, programming, testing (both alpha and beta), implementation, and modification. In the alpha test, 12 experts participated, including emergency and neurology specialists as well as faculty member nurses, with an average age of 38.43 years (standard deviation = 8.84). They evaluated the application on its content, ease of use, and practicality. Additionally, 5 information technology specialists, with an average age of 33.80 years (standard deviation = 7.22), assessed the application’s structure and ease of execution. The results of the alpha test were shown in Table 1.
Table 1.
Results of the alpha test (opinions of healthcare professionals and IT specialists regarding the application)
| Alpha test Items | Professions | IT Mans | |||
|---|---|---|---|---|---|
| Mean (SD) | Confidence Interval | Mean (SD) | Confidence Interval | ||
| 1 | Do you find the program’s visual appearance appropriate? | 4.57 (0.76) | 4.14- 5.00 | 4.80 (0.45) | 4.24–5.36 |
| 2 | Do you think the program’s design is suitable? | 4.29 (0.83) | 3.81–4.76 | 4.40 (0.55) | 3.72–5.08 |
| 3 | Can the program change users’ attitudes toward the importance of health practices and maintaining well-being? | 4.50 (0.76) | 4.06–4.93 | 4.20 (0.84) | 3.16–5.24 |
| 4 | Can the program create motivation to follow health practices and maintain well-being? | 4.43 (0.85) | 3.94–4.92 | 4.40 (0.89) | 3.28–5.51 |
| 5 | Are the resources used in the program appropriate? | 4.64 (0.63) | 4.27–5.01 | 4.60 (0.55) | 3.92–5.28 |
In the beta test, the completed mobile application was provided to 17 nursing students in their 5th semester and above, with an average age (standard deviation) of 20.71 (1.16) years. They examined the app in terms of usability, convenience, and simplicity. As a result, the program was deemed suitable by both professionals and learners in the alpha and beta tests. The results of the beta test are shown in Table 2.
Table 2.
Results of the beta test (nursing students’ opinions as end-users of the application)
| Beta test Items | Mean (SD) | Confidence Interval (95%) | |
|---|---|---|---|
| 1 | How specialized do you think the program’s content is? | 4.59 (0.61) | 4.27–4.90 |
| 2 | Do you think the volume of content in the program is sufficient? | 4.53 (0.62) | 4.20–4.85 |
| 3 | Do you think the program’s visual presentation is appropriate? | 4.76 (0.56) | 4.48–5.05 |
| 4 | Do you think the program is engaging? | 4.59 (0.71) | 4.22–4.95 |
| 5 | Do you think the program effectively conveys its content? | 4.53 (0.72) | 4.16–4.90 |
| 6 | Do you think the program is practical and useful? | 4.71 (0.59) | 4.40–5.01 |
| 7 | Is the program easy and straightforward to use? | 4.94 (0.24) | 4.81–5.06 |
| 8 | Do you think the program’s interface is not confusing? | 4.71 (0.59) | 4.40–5.01 |
| 9 | Would you like to recommend the program to others? | 4.88 (0.49) | 4.63–5.13 |
| 10 | What score would you give the program? | 4.76 (0.56) | 4.76–5.05 |
The application was designed in two parts: a guide for head trauma assessment and game situations. In the training section, the study guide for head trauma assessment is prepared based on the head trauma assessment algorithm, and at each stage (assessment of consciousness level, vital signs, disability, and blood sugar), the person is guided on what action to take based on the patient’s response.
In the game-based situations section, the clinical scenarios of head injury victims are designed and embedded in the application as a game so that the learner first observes the cause of the injury and performs their examinations based on that. Anticipates nursing diagnoses and necessary measures. At each stage, in case of mistakes, feedback is given to him on what things he did not consider and what would have been a better path for the examination. If they choose correctly, they will get a green card, and if they make a mistake, they will receive a red card.
Data analysis
Data analysis was performed using IBM SPSS Statistics, Version 20 (IBM Corp., Armonk, NY) and Psychometrica (Lenhard, W. & Lenhard, A., 2022). Computation of effect sizes. Retrieved from https://www.psychometrica.de/effect_size.html. Normality was assessed using the Kolmogorov-Smirnov test. Group homogeneity was evaluated with independent t-tests and chi-squared tests. Independent samples t-tests compared outcomes between intervention and control groups, while paired samples t-tests compared pre- and post-intervention results within each group. A significance level of p < 0.05 was used for all tests.
Results
This study involved a diverse group of 93 nursing students, all in their final semester, during the vibrant spring of 2024. Among these promising future healthcare professionals, there were 44 men and 49 women, with an average age of 22.78 years (standard deviation = 1.24). The participants were carefully divided into two distinct groups: the control group comprised 44 individuals, while the intervention group included 49 enthusiastic learners. For a deeper insight into the profiles of these participants, please refer to Table 3 below, which eloquently presents their demographic characteristics.
Table 3.
Demographic characteristics of the participants
| Control Group | Intervention Group | Test Result | ||||
|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | |||
| Age | 23.00 | 1.478 | 22.59 | 0.95 |
t = 1.59 df = 91 p = 0.11 |
|
| Grade Point Average (GPA( | 17.09 | 0.83 | 17.39 | 0.65 |
t=−1.91 df = 91 p = 0.05 |
|
| Count | Percentage | Count | Percentage | Test Result | ||
| Gender | Male | 24 | 25.8% | 20 | 21.5% |
ꭓ 2 =1.27 df = 1 p = 0.25 |
| Female | 20 | 21.5% | 29 | 31.2% | ||
| Trauma Course | No | 28 | 30.1% | 33 | 35.5% |
ꭓ 2 =0.14 df = 1 p = 0.70 |
| Yes | 16 | 17.2% | 16 | 17.2% | ||
To assess the homogeneity of age and GPA between the two groups, we employed an independent t-test. Chi-squared tests were conducted to evaluate the homogeneity of gender and trauma course across the groups
Before the intervention, the participants had a mean knowledge score of 2.55 with a standard deviation of 1.10. After the intervention, the mean score increased to 5.25, with a standard deviation of 1.14. A paired samples t-test demonstrated a significant difference in knowledge levels before and after the intervention in both groups (p < 0.05), as shown in Table 4.
Table 4.
Comparison of the results of participants’ knowledge before and after the intervention
| Control Group | Intervention Group | Total | ||||
|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | Mean | SD | |
| Knowledge (Before) | 2.59 | 1.14 | 2.51 | 1.06 | 2.55 | 1.10 |
| Knowledge (After) | 4.86 | 1.40 | 5.59 | 0.67 | 5.25 | 1.14 |
| Test Result |
t=−7.39 df = 43 p = 0.001 |
t=−17.18 df = 48 p = 0.001 |
t=−15.20 df = 92 p = 0.001 |
|||
The paired t-test was used for comparison the result of participants’ knowledge before and after the intervention
Effect size dppc2 sensu Morris (2008) = 0.73
Effect size dKorr sensu klaauer (2001) = 0.75
The results of the independent sample t-test showed that there was no significant difference in the knowledge of participants between the control and intervention groups before the intervention (p = 0.72). However, after the intervention, a significant difference was observed (P < 0.05). Additionally, the independent samples t-test revealed a significant difference in the practical skills of participants between the two groups following the intervention (p < 0.05) (Table 5).
Table 5.
Comparison of the results of participants’ knowledge and practical skills between two groups
| Control Group | Intervention Group | Test Result | Effect Size dCohen resp.gHedgesd |
Confident Interval 95% | |||
|---|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | ||||
| Knowledge (Before) | 2.59 | 1.14 | 2.51 | 1.06 |
t = 0.35 df = 91 p = 0.72 |
−0/07 | −0.48-0.34 |
| Knowledge (After) | 4.86 | 1.40 | 5.59 | 0.67 |
t =−3.23 df = 91 p = 0.002 |
0/68 | 0.26–1.10 |
| Practical Skills | 18.65 | 1.11 | 19.32 | 0.87 |
t =−3.22 df = 91 p = 0.002 |
0/67 | 0.26–1.10 |
The independent samples t-test was used for comparison of the results of participants’ knowledge and practical skills between two groups
Effect size was estimated with Cohen’s d (dCohen resp.gHedges)
Discussion
The present research aims to investigate the effectiveness of a digital game-based study guide on head trauma assessment on the knowledge and practical skills of nursing students. The research findings indicated a significant difference between the knowledge and the practical skills of the participants after using a digital game-based learning for head trauma assessment. Inangil and colleagues in 2022 also concluded, based on the findings of their research, that the use of technology and new technologies such as animations and web and multimedia tools can be effective in improving knowledge and increasing the motivation and satisfaction of learners, and suggested using new technologies to improve learning [37]. Arias-Calderón and colleagues evaluated the use of digital games as a positive learning strategy that can improve students’ motivation, participation, and learning experience [38]. Castro and colleagues also found in their results that digital games have an effect on the competence of nursing students and emphasize their use in nursing education [39].
Game-based learning activities can provide an attractive learning environment for learners and improve the effectiveness of education [27]. Other benefits of game-based learning for learners include increasing their collaborative awareness, providing opportunities for active learning, and improving clinical reasoning and clinical decision-making skills [40]. Sanz-Martos and colleagues reported that after participating in gamified sessions, students described the experience as fun, motivating, and highly focused, showing greater satisfaction and improved theoretical knowledge. The researchers recommended using this approach for all nursing courses [41].
Sailer and colleagues found that gamification can serve as an effective educational strategy for interventions aimed at enhancing cognitive, motivational, and behavioral learning outcomes. Additionally, creating a gamified environment that fosters both competitive and collaborative interactions among learners can be particularly advantageous. The opportunity for students to form teams and compete with one another has been shown to elevate the quality of performance and enhance learner skills [42]. Further supporting this, Wang and colleagues conducted a study on the impact of serious games on undergraduate nursing students, revealing positive effects on their knowledge and skills [43]. This research provides compelling evidence for the effectiveness of serious games in improving nursing students’ competencies compared to traditional educational methods, particularly in the development of technical skills.
Building on these insights, Arias-Calderón and colleagues assessed digital games as a valuable learning strategy, noting their ability to boost student motivation, engagement, and overall learning experience [38]. Likewise, Lee and colleagues highlighted that these games not only enhance student knowledge, performance, and confidence but also present a robust alternative to conventional methods, aligning closely with the evolving demands of modern healthcare education. Serious digital games that focus on practical application offer a promising approach to enriching educational experiences and improving outcomes. By incorporating this strategy, nursing education can significantly increase its quality while equipping students with the competencies essential for success in real clinical environments, thereby preparing them for the dynamic challenges of the healthcare sector [44].
Chandran and colleagues explored the impact of mobile applications on medical education, finding that these tools significantly enhance the knowledge and skills of healthcare professionals. They noted the effectiveness of both online and offline programs across Android and iOS platforms. As mobile phone use rises, there is a growing trend in education toward e-learning opportunities over traditional methods, with mobile apps serving as low-cost, adaptable resources that provide online and offline access [30]. In a related study, George et al. highlighted that smartphone applications ensure secure access to current healthcare information, allowing learners to review lessons anytime and anywhere. The availability of many free clinical apps makes them cost-effective, prompting recommendations for their early integration into nursing curricula to foster active, evidence-based learning [45].
Guo and colleagues also emphasized that mobile technologies enhance information access, improve care quality, reduce medical errors, foster engagement, and support evidence-based decision-making in clinical settings. These benefits are driving their increased adoption among healthcare professionals [46]. The improvement in knowledge and performance among learners in the current study aligns with prior research highlighting the effectiveness of mobile apps in education.
Game-based study guides provide learners with the opportunity to gain experience and solve clinical problems in safe, simulated environments without involving actual patients. This makes them appropriate for clinical education as well. In conclusion, mobile applications can enhance learning outcomes, especially when they are developed using game-based, interactive approaches that promote active engagement. Therefore, it is recommended that nursing education incorporate mobile applications designed as game-based study guides.
One of the strengths of our study was evaluating the impact of skill-based applications on students; however, this evaluation was conducted in a simulation environment. It is advisable to assess the effectiveness of these applications in clinical settings to make more informed judgments regarding their role in reducing clinical errors and enhancing patient safety. Decreasing clinical errors among learners can contribute to improved patient safety. Additionally, examining the application’s impact over a longer follow-up period could provide further insights, as the lack of follow-up was a limitation in our current study.
Conclusion
This study demonstrates that a digital game-based study guide enhances nursing students’ knowledge and practical skills in assessing head trauma. Therefore, incorporating such guides into nursing education could enhance students’ competence in this area.
Research limitations
The digital game-based study guide for head trauma assessment was designed for Android phones. This led to non-random allocation of participants with iPhones (14.28%) to the control group, potentially affecting the results. Therefore, we recommend developing the application for both Android and iOS. Some participants (4.08%) were hesitant to install the program; So, Information regarding the security of the program and the need for no worries about installation was provided to the participants in writing and verbally.
Another limitation was the absence of follow-up to assess long-term effects in a clinical setting. Future studies should investigate the impact of the game-based guide on students’ clinical errors in real-world scenarios, with more comprehensive follow-up and analysis of learner errors.
Supplementary Information
Additional File 1: Knowledge questionnaire.
Additional File 2: Practical questionnaire.
Additional File 3: Result of CVR and CVI.
Acknowledgements
The authors also wish to thank all the participants and those who helped us carry out the research, especially all the staff of the Department of Medical Surgical Nursing of the School of Nursing & Midwifery of Shahid Beheshti University of Medical Sciences.
Author contributions
• EB and RG formulate the research question that represents the systematic review objective.• EB, SM, and RG provided proposals and reports.• EB, SM, and RG collected the data.• MN: Data analysis.
Funding
The authors received no specific funding for this work.
Data availability
The datasets used and analyzed during the current study are available as supplementary files.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the Declaration of Helsinki and approved by the ethics committee of Shahid Beheshti University of Medical Science (IR.SBMU.PHARMACY.REC.1403.022) and the Iranian National Committee for Ethics in Biomedical Research. The online research ethical code certificate is available at https://ethics.research.ac.ir/ProposalCertificateEn.php?id=468273&Print=true&NoPrintHeader=true&NoPrintFooter=true&NoPrintPageBorder=true&LetterPrint=true.
The study was registered with the Iranian Registry of Clinical Trials (IRCT20210131050189N10) and approved on July 21, 2024. The School of Nursing & Midwifery of Shahid Beheshti University of Medical Sciences approved participation, and all participants provided informed written consent after understanding the research goals, procedures, anonymity, and confidentiality. Participation was voluntary, with the right to withdraw at any time.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Conflict of interest
The authors declare no conflicts of interest with respect to the research, authorship, and/or publication of this article.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Additional File 1: Knowledge questionnaire.
Additional File 2: Practical questionnaire.
Additional File 3: Result of CVR and CVI.
Data Availability Statement
The datasets used and analyzed during the current study are available as supplementary files.