Quantitative research methodologies, qualitative research methodologies, mixed method methodologies, selecting a methodology.
According to Dawson (2019),a research methodology is the primary principle that will guide your research. It becomes the general approach in conducting research on your topic and determines what research method you will use. A research methodology is different from a research method because research methods are the tools you use to gather your data (Dawson, 2019). You must consider several issues when it comes to selecting the most appropriate methodology for your topic. Issues might include research limitations and ethical dilemmas that might impact the quality of your research. Descriptions of each type of methodology are included below.
Quantitative research methodologies are meant to create numeric statistics by using survey research to gather data (Dawson, 2019). This approach tends to reach a larger amount of people in a shorter amount of time. According to Labaree (2020), there are three parts that make up a quantitative research methodology:
Once you decide on a methodology, you can consider the method to which you will apply your methodology.
Qualitative research methodologies examine the behaviors, opinions, and experiences of individuals through methods of examination (Dawson, 2019). This type of approach typically requires less participants, but more time with each participant. It gives research subjects the opportunity to provide their own opinion on a certain topic.
Examples of Qualitative Research Methodologies
A mixed methodology allows you to implement the strengths of both qualitative and quantitative research methods. In some cases, you may find that your research project would benefit from this. This approach is beneficial because it allows each methodology to counteract the weaknesses of the other (Dawson, 2019). You should consider this option carefully, as it can make your research complicated if not planned correctly.
What should you do to decide on a research methodology? The most logical way to determine your methodology is to decide whether you plan on conducting qualitative or qualitative research. You also have the option to implement a mixed methods approach. Looking back on Dawson's (2019) five "W's" on the previous page , may help you with this process. You should also look for key words that indicate a specific type of research methodology in your hypothesis or proposal. Some words may lean more towards one methodology over another.
Quantitative Research Key Words
Qualitative Research Key Words
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Updated: June 19, 2024
Published: June 15, 2024
When embarking on a research project, selecting the right methodology can be the difference between success and failure. With various methods available, each suited to different types of research, it’s essential you make an informed choice. This blog post will provide tips on how to choose a research methodology that best fits your research goals .
We’ll start with definitions: Research is the systematic process of exploring, investigating, and discovering new information or validating existing knowledge. It involves defining questions, collecting data, analyzing results, and drawing conclusions.
Meanwhile, a research methodology is a structured plan that outlines how your research is to be conducted. A complete methodology should detail the strategies, processes, and techniques you plan to use for your data collection and analysis.
The first step of a research methodology is to identify a focused research topic, which is the question you seek to answer. By setting clear boundaries on the scope of your research, you can concentrate on specific aspects of a problem without being overwhelmed by information. This will produce more accurate findings.
Along with clarifying your research topic, your methodology should also address your research methods. Let’s look at the four main types of research: descriptive, correlational, experimental, and diagnostic.
Descriptive research is an approach designed to describe the characteristics of a population systematically and accurately. This method focuses on answering “what” questions by providing detailed observations about the subject. Descriptive research employs surveys, observational studies , and case studies to gather qualitative or quantitative data.
A real-world example of descriptive research is a survey investigating consumer behavior toward a competitor’s product. By analyzing the survey results, the company can gather detailed insights into how consumers perceive a competitor’s product, which can inform their marketing strategies and product development.
Correlational research examines the statistical relationship between two or more variables to determine whether a relationship exists. Correlational research is particularly useful when ethical or practical constraints prevent experimental manipulation. It is often employed in fields such as psychology, education, and health sciences to provide insights into complex real-world interactions, helping to develop theories and inform further experimental research.
An example of correlational research is the study of the relationship between smoking and lung cancer. Researchers observe and collect data on individuals’ smoking habits and the incidence of lung cancer to determine if there is a correlation between the two variables. This type of research helps identify patterns and relationships, indicating whether increased smoking is associated with higher rates of lung cancer.
Experimental research is a scientific approach where researchers manipulate one or more independent variables to observe their effect on a dependent variable. This method is designed to establish cause-and-effect relationships. Fields like psychology , medicine, and social sciences frequently employ experimental research to test hypotheses and theories under controlled conditions.
A real-world example of experimental research is Pavlov’s Dog experiment. In this experiment, Ivan Pavlov demonstrated classical conditioning by ringing a bell each time he fed his dogs. After repeating this process multiple times, the dogs began to salivate just by hearing the bell, even when no food was presented. This experiment helped to illustrate how certain stimuli can elicit specific responses through associative learning.
Diagnostic research tries to accurately diagnose a problem by identifying its underlying causes. This type of research is crucial for understanding complex situations where a precise diagnosis is necessary for formulating effective solutions. It involves methods such as case studies and data analysis and often integrates both qualitative and quantitative data to provide a comprehensive view of the issue at hand.
An example of diagnostic research is studying the causes of a specific illness outbreak. During an outbreak of a respiratory virus, researchers might conduct diagnostic research to determine the factors contributing to the spread of the virus. This could involve analyzing patient data, testing environmental samples, and evaluating potential sources of infection. The goal is to identify the root causes and contributing factors to develop effective containment and prevention strategies.
Using an established research method is imperative, no matter if you are researching for marketing , technology , healthcare , engineering, or social science. A methodology lends legitimacy to your research by ensuring your data is both consistent and credible. A well-defined methodology also enhances the reliability and validity of the research findings, which is crucial for drawing accurate and meaningful conclusions.
Additionally, methodologies help researchers stay focused and on track, limiting the scope of the study to relevant questions and objectives. This not only improves the quality of the research but also ensures that the study can be replicated and verified by other researchers, further solidifying its scientific value.
Choosing the best research methodology for your project involves several key steps to ensure that your approach aligns with your research goals and questions. Here’s a simplified guide to help you make the best choice.
Clearly define the objectives of your research. What do you aim to discover, prove, or understand? Understanding your goals helps in selecting a methodology that aligns with your research purpose.
Determine whether your research will involve numerical data, textual data, or both. Quantitative methods are best for numerical data, while qualitative methods are suitable for textual or thematic data.
Becoming familiar with the four types of research – descriptive, correlational, experimental, and diagnostic – will enable you to select the most appropriate method for your research. Many times, you will want to use a combination of methods to gather meaningful data.
Consider the resources available to you, including time, budget, and access to data. Some methodologies may require more resources or longer timeframes to implement effectively.
Look at previous research in your field to see which methodologies were successful. This can provide insights and help you choose a proven approach.
By following these steps, you can select a research methodology that best fits your project’s requirements and ensures robust, credible results.
Upon completing your research, the next critical step is to analyze and interpret the data you’ve collected. This involves summarizing the key findings, identifying patterns, and determining how these results address your initial research questions. By thoroughly examining the data, you can draw meaningful conclusions that contribute to the body of knowledge in your field.
It’s essential that you present these findings clearly and concisely, using charts, graphs, and tables to enhance comprehension. Furthermore, discuss the implications of your results, any limitations encountered during the study, and how your findings align with or challenge existing theories.
Your research project should conclude with a strong statement that encapsulates the essence of your research and its broader impact. This final section should leave readers with a clear understanding of the value of your work and inspire continued exploration and discussion in the field.
Now that you know how to perform quality research , it’s time to get started! Applying the right research methodologies can make a significant difference in the accuracy and reliability of your findings. Remember, the key to successful research is not just in collecting data, but in analyzing it thoughtfully and systematically to draw meaningful conclusions. So, dive in, explore, and contribute to the ever-growing body of knowledge with confidence. Happy researching!
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Research methods are the various strategies, techniques, and tools that researchers use to collect and analyze data . These methods help researchers find answers to their questions and gain a better understanding of different topics. Whether conducting experiments, surveys, or interviews, choosing the right research method is crucial for obtaining accurate and reliable results.
In the ever-evolving world of academia and professional inquiry, understanding the various research methods is crucial for anyone looking to delve into a new study or project. Research is a systematic investigation aimed at discovering and interpreting facts , plays a pivotal role in expanding our knowledge across various fields.
Table of Content
Types of research methods, types of research methodology, difference between qualitative and quantitative research.
This article will explore the different types of research methods , how they are used, and their importance in the world of research.
Research is the process of studying a subject in detail to discover new information or understand it better. This can be anything from studying plants or animals, to learning how people think and behave, to finding new ways to cure diseases. People do research by asking questions, collecting information, and then looking at that information to find answers or learn new things.
This table provides a quick reference to understand the key aspects of each research type.
Research Methods | Focus | Methodology | Applications |
---|---|---|---|
Qualitative | Human behavior | Interviews, Observations | Social Sciences |
Quantitative | Data quantification | Statistical Analysis | Natural Sciences |
Descriptive | Phenomenon description | Surveys, Observations | Demographics |
Analytical | Underlying reasons | Data Comparison | Scientific Research |
Applied | Practical solutions | Collaborative Research | Healthcare |
Fundamental | Knowledge expansion | Theoretical Research | Physics, Math |
Exploratory | Undefined problems | Secondary Research | Product Development |
Conclusive | Decision-making | Experiments, Testing | Market Research |
Qualitative research method is a methodological approach primarily used in fields like social sciences, anthropology, and psychology . It’s aimed at understanding human behavior and the motivations behind it. Qualitative research delves into the nature of phenomena through detailed, in-depth exploration.
Definition and Approach: Qualitative research focuses on understanding human behavior and the reasons that govern such behavior. It involves in-depth analysis of non-numerical data like texts, videos, or audio recordings.
Applications: Widely used in social sciences, marketing, and user experience research.
Quantitative research method is a systematic approach used in various scientific fields to quantify data and generalize findings from a sample to a larger population.
Definition and Approach: Quantitative research is centered around quantifying data and generalizing results from a sample to the population of interest. It involves statistical analysis and numerical data .
Applications: Common in natural sciences, economics, and market research.
Descriptive research is a type of research method that is used to describe characteristics of a population or phenomenon being studied . It does not answer questions about how or why things are the way they are. Instead, it focuses on providing a snapshot of current conditions or describing what exists.
Definition and Approach: This Types of Research method aims to accurately describe characteristics of a particular phenomenon or population.
Applications: Used in demographic studies, census, and organizational reporting.
Analytical research is a type of research that s eeks to understand the underlying factors or causes behind phenomena or relationships . It goes beyond descriptive research by attempting to explain why things happen and how they happen.
Definition and Approach: Analytical research method goes beyond description to understand the underlying reasons or causes.
Applications: Useful in scientific research, policy analysis, and business strategy.
Applied research is a type of scientific research method that aims to solve specific practical problems or address practical questions . Unlike fundamental research, which seeks to expand knowledge for knowledge’s sake, applied research is directed towards solving real-world issues .
Definition and Approach: Applied research focuses on finding solutions to practical problems.
Applications: Used in healthcare, engineering, and technology development.
Fundamental research, also known as basic research or pure research, is a type of scientific research method that aims to expand the existing knowledge base. It is driven by curiosity, interest in a particular subject, or the pursuit of knowledge for knowledge’s sake , rather than with a specific practical application in mind.
Definition and Approach: Also known as basic or pure research, it aims to expand knowledge without a direct application in mind.
Applications: Foundational in fields like physics, mathematics, and social sciences.
Exploratory research is a type of research method conducted for a problem that has not been clearly defined. Its primary goal is to gain insights and familiarity with the problem or to gain more information about a topic. Exploratory research is often conducted when a researcher or investigator does not know much about the issue and is looking to gather more information.
Definition and Approach: This type of research is conducted for a problem that has not been clearly defined.
Applications: Often the first step in social science research and product development.
Conclusive research, also known as confirmatory research, is a type of research method that aims to confirm or deny a hypotheses or provide answers to specific research questions. It is used to make conclusive decisions or draw conclusions about the relationships among variables.
Definition and Approach: Conclusive research is designed to provide information that is useful in decision-making.
Applications: Used in market research, clinical trials, and policy evaluations.
Here is detailed difference between the qualitative and quantitative research –
Focuses on exploring ideas, understanding concepts, and gathering insights. | Involves the collection and analysis of numerical data to describe, predict, or control variables of interest. | |
To gain a deep understanding of underlying reasons, motivations, and opinions. | To quantify data and generalize results from a sample to a larger population. | |
Non-numerical data such as words, images, or objects. | Numerical data, often in the form of numbers and statistics. | |
Interviews, focus groups, observations, and review of documents or artifacts. | Surveys, experiments, , and numerical measurements. | |
Interpretive, subjective analysis aimed at understanding context and complexity. | Statistical, objective analysis focused on quantifying data and generalizing findings. | |
Descriptive, detailed narrative or thematic analysis. | Statistical results, often presented in charts, tables, or graphs. | |
Generally smaller, focused on depth rather than breadth. | Larger to ensure statistical significance and representativeness. | |
High flexibility in research design, allowing for changes as the study progresses. | Structured and fixed design, with little room for changes once the study begins. | |
Exploratory, open-ended, and subjective. | Conclusive, closed-ended, and objective. | |
Social sciences, humanities, psychology, and market research for understanding behaviors and experiences. | Natural sciences, economics, and large-scale market research for testing hypotheses and making predictions. | |
Provides depth and detail, offers a more human touch and context, good for exploring new areas. | Allows for a broader study, involving a greater number of subjects, and enhances generalizability of results. | |
Can be time-consuming, harder to generalize due to small sample size, and may be subject to researcher bias. | May overlook the richness of context, less effective in understanding complex social phenomena. |
Understanding the different types of research methods is crucial for anyone embarking on a research project. Each type has its unique approach, methodology, and application area, making it essential to choose the right type for your specific research question or problem. This guide serves as a starting point for researchers to explore and select the most suitable research method for their needs, ensuring effective and reliable outcomes.
What are the 4 main types of research methods.
There are four main types of Quantitative research: Descriptive, Correlational, Causal-Comparative/Quasi-Experimental, and Experimental Research . attempts to establish cause- effect relationships among the variables. These types of design are very similar to true experiments, but with some key differences.
The primary purposes of basic research (as opposed to applied research) are documentation, discovery, interpretation, and the research and development (R&D) of methods and systems for the advancement of human knowledge .
The 7 C’s define the principles that are essential for conducting rigorous and credible research. They are Curiosity, Clarity, Conciseness, Correctness, Completeness, Coherence, Credibility.
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Scientific Reports volume 14 , Article number: 20283 ( 2024 ) Cite this article
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Network analysis has become a crucial tool in genetic research, enabling the exploration of associations between genes and diseases. Its utility extends beyond genetics to include the assessment of environmental factors. Unipartite network analysis is commonly used in genomics to visualize initial insights and relationships among variables. Syndromic diseases, such as metabolic syndrome, are characterized by the simultaneous occurrence of various signs, symptoms, and clinicopathological features. Metabolic syndrome encompasses hypertension, diabetes, obesity, and dyslipidemia, and both genetic and environmental factors contribute to its development. Given that relevant data often consist of distinct sets of variables, a more intuitive visualization method is needed. This study applied multipartite network analysis as an effective method to understand the associations among genetic, environmental, and disease components in syndromic diseases. We considered three distinct variable sets: genetic factors, environmental factors, and disease components. The process involved projecting a tripartite network onto a two-mode bipartite network and then simplifying it into a one-mode network. This approach facilitated the visualization of relationships among factors across different sets and within individual sets. To transition from multipartite to unipartite networks, we suggest both sequential and concurrent projection methods. Data from the Korean Association Resource (KARE) project were utilized, including 352,228 SNPs from 8840 individuals, alongside information on environmental factors such as lifestyle, dietary, and socioeconomic factors. The single-SNP analysis step filtered SNPs, supplemented by reference SNPs reported in a genome-wide association study catalog. The resulting network patterns differed significantly by sex: demographic factors and fat intake were crucial for women, while alcohol consumption was central for men. Indirect relationships were identified through projected bipartite networks, revealing that SNPs such as rs4244457, rs2156552, and rs10899345 had lifestyle interactions on metabolic components. Our approach offers several advantages: it simplifies the visualization of complex relationships among different datasets, identifies environmental interactions, and provides insights into SNP clusters sharing common environmental factors and metabolic components. This framework provides a comprehensive approach to elucidate the mechanisms underlying complex diseases like metabolic syndrome.
Metabolic syndrome (MetS) is defined as a cluster of metabolic abnormalities conditions, including abdominal obesity, hypertension, diabetes, and dyslipidemia 1 , 2 . The prevalence of MetS has been reported as 20–25% worldwide 3 , 4 . MetS is known to be associated with an increased risk of type 2 diabetes mellitus, cardiovascular disease, and premature mortality. The individual components of MetS are also known to be important risk factors for cardiovascular diseases 5 , 6 , 7 .
Various attempts have been made to discover the genetic risk factors of MetS. The heritability of MetS has been estimated at over 30% 8 , 9 , 10 . Many genes and variants associated with MetS have been identified through genome-wide association studies (GWAS) 11 , 12 , 13 , 14 . Many studies have also sought to find genetic variants associated with each MetS component by population. For example, variants near insulin receptor substrate 1 were found to be associated with various traits of MetS, such as insulin resistance, HDL cholesterol, and triglycerides in a French population 15 . GCKR has been reported to be associated with fasting glucose and insulin levels in individuals of European ancestry 16 , 17 . UGT1A1 has been reported to impact MetS in both men and women in a Mediterranean population 18 . In the Korean population, CCDC63, LPL, MYL2 , and APOA5 were found to be associated with MetS 14 , 19 . The number of variants associated with MetS continues to increase 1 , 2 .
Meanwhile, studies on pleiotropic single-nucleotide polymorphisms (SNPs) for MetS-related traits have also been conducted. Kraja et al. 20 reported that the same loci were associated with more than one MetS-related trait. Based on pleiotropic associations, their research revealed relationships between SNPs, lipids, inflammation, and obesity 20 . More recently, pleiotropic SNPs and genes related to type 2 diabetes and obesity have been identified by applying genetic analyses incorporating pleiotropy and annotations using GWAS datasets 21 . A study found that IGF2BP2 and TNFRSF13B predisposed individuals to MetS from a pleiotropic standpoint 22 . These results suggest that examining pleiotropy among metabolic traits is essential.
Since MetS is a multifactorial disease, environmental factors influence MetS. Numerous studies have investigated the influence of both genetic and environmental factors on the development of MetS. Specifically, environmental factors including dietary patterns, physical activity levels, and smoking status have been extensively explored 23 , 24 , 25 , 26 , 27 , 28 , 29 . For instance, a sedentary lifestyle and consumption of energy-dense diets have been linked to patterns in the clustering of different MetS traits MetS 30 . Moreover, research indicates that weight loss and increased physical activity are prioritized over pharmacological interventions in managing MetS 31 . Similarly, risk factors related to overnutrition and sedentary behavior have been identified as significant contributors to MetS, alongside a genetic predisposition 27 . Furthermore, a study highlighted the substantial role of various environmental factors, including diet, physical inactivity, stress, education levels, exposure to pollutants, and addictive behaviors, in the development of obesity-related MetS 28 . Recent investigations in Korea have explored the associations between environmental factors—such as sleep duration, sedentary behavior, alcohol consumption, smoking habits, and dietary patterns—and the risk of developing MetS. These studies have reinforced the observation that individuals with unhealthy lifestyle habits are more prone to developing MetS 32 .
Several studies have emphasized the importance of simultaneously considering both environmental and genetic factors 8 , 30 , 31 , 33 , 34 , 35 , 36 , 37 . For instance, a multivariate genetic analysis was conducted on nine endophenotypes associated with MetS, utilizing twin data to identify common genetic and environmental factors 37 . Additionally, Prone-Olazabal et al. 36 provided an updated perspective on the genetics of MetS as a cohesive entity, examining SNPs and gene-diet interactions concerning cardiometabolic markers. In light of the understanding that genetic interactions intersect with an individual’s environment, the distinction between genetic disorders and traits from environmental influences remains challenging 35 .
Network analysis has recently been used for genetic data to investigate disease-gene associations 38 , 39 , 40 . A network is a collection of nodes and edges connecting the nodes. It can be used to visualize biological processes by taking biological entities such as genes, proteins, and diseases as nodes and representing the relationships between the entities by edges 41 , 42 . One-mode unipartite network analysis for each variable set or the whole variable set is widely used for genomic data.
Since it is not easy to investigate complex relationships through statistical models, we consider a more intuitive representation via a smart visualization method. Among several visualization methods, multipartite network analysis has the advantage of enabling researchers to easily grasp the relationships among genes, environments, and diseases. A multipartite network, often referred to as a k-partite graphs, can be seen as a complicated form of a network. The distinctive characteristic of a k-partite network is that the nodes can be divided into k disjoint sets. The edges do not connect nodes in the same set; instead, they only link nodes in different sets 43 .
We applied tripartite network analysis for the case of k = 3, considering that there are three different variable sets relevant to MetS—namely, MetS components, environmental factors, and genetic factors. We considered dichotomous variables for the diagnosis of metabolic syndrome as MetS components, demographic variables, and dietary habits as environmental factors, and selected SNPs from GWAS data as genetic factors. To represent the relationship between two sets of variables, we used projections with weights 38 . A tripartite network was projected onto a two-mode bipartite network, and the projected bipartite network was projected again onto a one-mode network with the least loss of information. Through this procedure, we could visualize not only the relationship among factors in the different sets but also the compressed relationship among factors within the sets.
We used data from the Korean Association Resource (KARE) project ( http://biobank.nih.go.kr ). This project, a part of the Korean Genome Epidemiological Study (KoGES), started in 2007 and is still in progress. The data comprise two community-based cohorts from a rural area (Ansung) and an urban area (Ansan). The cohorts consist of community dwellers and participants recruited from the national health examinee registry. For baseline recruitment, eligible participants were asked to volunteer. Participants completed consent forms and then underwent surveys and examinations to assess their current health status and lifestyle habits. Anthropometric and clinical measurements such as weight, height, waist circumference, and blood pressure were measured. Human biological materials, including blood, urine, and DNA, were collected for analysis. The data include information on genetic variants and environmental factors affecting chronic diseases such as type 2 diabetes, hypertension, obesity, MetS, osteoporosis, cardiovascular disease, and cancer in Koreans 44 . All participants provided their written informed consent to participate in this study. All methods were carried out following relevant guidelines and regulations (Declaration of Helsinki). This study was approved by the Institutional Review Board (IRB) of Eulji University (EU21-003-01).
Among the participants, 10,030 samples from individuals aged between 40 and 69 were genotyped using an Affymetrix Genome-Wide Human SNP Array 5.0. Quality control for the samples and genotypes was performed as previously described by Cho et al. 44 . SNPs with minor allele frequencies (< 0.01), low genotype calling rates (< 95%), and violation of Hardy–Weinberg equilibrium (p-values < 1E − 06) were removed. Participants whose sex/gender did not match or had a low calling rate (< 95%) were excluded. After quality control, 352,228 SNPs in 8840 individuals remained.
To diagnose MetS, the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) criteria are widely used 45 . These include different criteria for the Asian population 1 , 46 . A person who has three or more of the five MetS components is diagnosed with MetS. The five metabolic syndrome components are hypertension (> 130/85 mmHg), abdominal obesity (a waist circumference of ≥ 90 cm in Asian-American men, and ≥ 80 cm in Asian-American women), elevated triglycerides (≥ 150 mg/dL), reduced plasma high-density lipoprotein cholesterol (HDL-C; < 40 mg/dL in men and < 50 mg/dL in women), and impaired glucose tolerance (> 100 mg/dL). We followed these criteria and obtained five dichotomous variables as MetS components.
We also considered 10 variables of demographic characteristics, lifestyle factors, and dietary habits as environmental factors. The demographic variables comprised age, education level, and monthly household income. As lifestyle factors, we analyzed alcohol consumption, smoking, and physical activity (metabolic equivalents of task). The participants were questioned by trained interviewers regarding their socio-demographic status (age, education, household income) and lifestyle (diet, smoking, alcohol consumption, physical activity). Education level was categorized into six groups, and monthly household income was classified into eight groups. In the analysis, low-frequency items were integrated and finally, the education and household income items were reduced to four items and three items, respectively.
Protein, carbohydrates, and fat intake, as well as total energy, were used as variables for dietary habits. For dietary assessment, a food-frequency questionnaire (FFQ) involving 103 semi-quantitative items was developed 47 . Information regarding the protocol of the FFQ has been described elsewhere 48 . The frequencies of food consumption were categorized into nine groups, ranging from "rarely" to "more than three times per day." Portion sizes for each food item could be selected from three options: "small", "medium", or "large". The duration of seasonal fruit intake was classified into four categories (3, 6, 9, and 12 months). To assess the overall intake of nutrients such as protein and carbohydrates, the consumption frequency of each food item was multiplied by its nutrient content using the CAN-Pro 2.0 nutrient database developed by the Korean Nutrition Society 49 . Subsequently, the amounts of macronutrients were converted into calories, and the percentages of total calorie intake from each macronutrient were calculated. More details on the KoGES cohort profile can be found in Ref. 50 . The data description is summarized in Table 1 .
A multipartite network or a k-partite network consists of mutually exclusive sets of nodes. Edges can exist only between nodes belonging to different sets. A graph is called k-partite if it can be partitioned into k nonempty, vertex-disjoint, edgeless subgraphs 40 . A k-partite graph can be represented as G = ( \(V,E)\) , where V and E represent vertices and edges satisfying \(V = V_{1} \cup V_{2} \cup \cdots \cup V_{k}\) and \(V_{i} \cap V_{j} = \emptyset\) for \(i \ne j\) and \(E = \{ (u,v):u \in V_{i} ,v \in V_{j} ,i \ne j\}\) , respectively 39 .
There are two types of multipartite networks: closed and open networks. While a closed network has no restriction on its structure, an open network does not allow a circular structure. The adjacent matrix for a k-partite graph is given by
for a closed network, and
for an open network, respectively. Here, \(A_{ij}\) is a rectangular matrix called an incidence matrix. The \(\left( {m,n} \right)\) -th element of \(A_{ij}\) is \(1\) if there is an edge between vertices \(m\) of part \(i\) and \(n\) of part \(j\) , and \(0\) otherwise. Networks can also be classified into directed and undirected networks. As the terms indicate, vertices in a directed network are connected by directed edges, while the nodes of an undirected network are interconnected.
To understand the structure of a multipartite network, various measures can be employed. Degree distribution, where the degree of a node represents the number of edges it connects to other nodes, provides insights into the network’s structure 35 , 51 . Connectivity measures the minimum number of vertices required to separate remaining nodes, indicating strong or weak graph linkage 42 , 52 , 53 . Closeness centrality gauges a node’s proximity to others by calculating the inverse of the average shortest distance to all nodes. Betweenness centrality quantifies a node’s importance by assessing its role in shortest paths 54 . Nodes with high closeness or betweenness centrality act as significant hubs. Additionally, the clustering coefficient indicates the likelihood of neighboring nodes being connected 54 .
When k = 2, the network is a bipartite network. From a bipartite network, a one-mode projection can be created to compress the network and reveal connections within one dataset 55 . This results in two one-mode projections for each dataset: \(P_{1} = A_{12}^{T} A_{12}\) and \(P_{2} = A_{12} A_{12}^{T}\) , where \(A_{12}\) is a bi-adjacency matrix encoding the edges from the first dataset to the second dataset. Similarly, a k-partite network produces k different (k − 1)-mode projections by consolidating information across the remaining set. However, a multi-stage projection onto the \(k - i \, \left( {i > 1} \right)\) mode from a k-partite network is not well established. Assigning weights, which can be simple, hyperbolic, or resource allocation-based, to edges can reduce information loss during the projection process 38 , 56 , 57 .
We propose utilizing k-partite networks to elucidate the complex relationship among genes, environments, and disease components in syndromic diseases. There is potential for k-partite networks to be applied in various fields, but no research has yet used this method to integrate multiple aspects of genetics, environment, and disease. We provide a series of analysis processes and propose concurrent and sequential projections to offer various visualizations of hidden relationships.
We employed a multipartite network to identify the environmental and genetic associations for a syndromic disease. We considered three distinct datasets: genetic factors, environmental factors, and MetS components. As genetic factors, we used SNPs. Ten environmental factors— E0 (age), E1 (education), E2 (income), E3 (alcohol), E4 (smoking), E5 (physical activity), E6 (total energy), E7 (protein intake), E8 (fat intake), E9 (carbohydrate intake)—were considered, as in previous research 29 . Five components of MetS—MetS1 (abdominal obesity), MetS2 (triglycerides), MetS3 (HDL-C), MetS4 (hypertension), and MetS5 (fasting glucose)—were considered as variables in the disease dataset. All analyses were stratified by sex since it is known that there are sex differences in metabolic homeostasis 58 , 59 .
The procedure for the analysis was as follows:
Variable selection: To reduce the number of SNPs in GWAS data, we performed a single SNP analysis using logistic regression. Age and area were considered as covariates. To address the issue of multiple comparisons, we adjusted the p-values using the Bonferroni correction. Since the number of SNPs selected based on this criterion was not sufficient, we used a less stringent threshold of p < 1E − 05. By filtering with this threshold, 42 SNPs for women and 57 SNPs for men were selected.
Addition of reference SNPs: To improve the validity of our study, we also included 131 referenced SNPs that were reported to affect each component of MetS in a GWAS catalog ( https://www.ebi.ac.uk/gwas/home ). We used the five components of MetS as search terms and targeted studies focusing on Asian populations. After reviewing the content of the selected papers, we retrieved a list of relevant SNPs. Using the same threshold of p < 1E − 05, significant SNPs were selected. Excluding overlapping SNPs, 168 SNPs for men and 160 SNPs for women were used in the analysis.
Construction of an adjacency matrix \(A\) , as shown in Eq. ( 1 ): The incidence matrix \(A_{ij}\) was set based on Pearson correlation coefficients. The (m,n) -th elements of \(A_{ij}\) were set to 1 if the correlation coefficient between the m -th variable in dataset i and the n -th variable in dataset j is significant ( \(p<0.001\) ), and 0 otherwise. Through this procedure, 67 nodes for women and 65 nodes for men in the genetic factor set remained. The environmental factor set and MetS component set still had 10 and 5 nodes, respectively.
Building the tripartite network: A tripartite graph was drawn using the adjacency matrix. To represent the strength of the connections between nodes, correlation coefficients were used as the weights of edges. An undirected and closed network was created.
Projection to a bipartite network: We constructed two-mode projections composed of two sets of variables using projection from a tripartite network. They were connected by an edge if they shared a common variable in a third dataset. For example, if an SNP and a MetS component were connected in the two-mode projection, they shared at least one environmental factor. We used the simple weighting method—that is, the strength of the connection between two nodes is proportional to the number of nodes that they shared in the original graph. In total, three two-mode projections were created.
Projection to a unipartite network: Unlike one-level projection, a method for conducting a multi-stage projection onto \(k - i \, \left( {i > 1} \right)\) from a k-partite network has not been well established. There can be various paths from a k-partite to a unipartite network. We proposed two types of projections for obtaining unipartite projections: sequential projection and concurrent projection.
Sequential projection: A \((k-i+1)\) -mode projection is compressed to a to \((k-i)\) -mode projection by aggregating information over the remaining set for \(i=1,\cdots ,k-1\) . That is, for the i -th stage, a \((k-i)\) -mode network is constructed by connecting two nodes within the same dataset if they share at least one node in a different dataset on the \((k-i+1)\) -mode projection. For example, if we have three different datasets, three two-mode bipartite networks are produced in the first stage, and three one-mode unipartite projections are obtained for each two-mode projection in the second stage. The final network varies depending on its route of derivation.
Concurrent projection: A \(k\) -partite network is compressed to a unipartite network at once. To draw a unipartite network of one set, the nodes of the other set are treated as if they belong to the same dataset. For example, if we have three different datasets, only one one-mode projection is obtained for each dataset.
To create a unipartite network via sequential projection, a two-mode projection is compressed in a similar way to (d). In this process, nodes within the same dataset are connected if they share at least one node in another dataset on the two-mode projection, resulting in three one-mode projections per two-mode projection. Concurrent projection compresses a tripartite network directly into a unipartite network without utilizing method (d). Here, nodes from the other set are considered part of the same dataset, yielding three one-mode projections in total.
Construction of one-mode projections from (d). In the network, nodes in the same dataset were connected. For the above procedure (c)–(e), separate networks were established for men and women.
Single SNP association testing was performed using PLINK ( http://pngu.mgh.harvard.edu/~purcell/plink/ ). To draw a multipartite network, the igraph package in R can be used. Since the igraph package does not provide projections of tripartite networks, we modified the algorithm to enable projections using simple weights.
Table 2 demonstrates the descriptive statistics for participants by sex. Although the average age of men and women was similar, there were significant differences in every environmental factor ( \(p<0.001\) ). Each component of MetS showed a higher proportion in women than in men except for MetS5, and a particularly high value for MetS1 was found in women. The overall proportion of individuals with MetS was 32.8%. Therefore, we constructed a separate network for each sex.
Figure 1 shows the tripartite network using the data from men. The nodes that had weak connections with other nodes (p ≥ 0.001) were eliminated in the drawing process. Total of 80 nodes were used to draw the network. The Rs numbers of the SNPs used in the graph are listed in Supplementary Table 1 . In the graph, MetS3 (HDL-C) seemed to have the most connections, followed by MetS2 (triglycerides). E3 (alcohol) was located at the center connecting metabolic components except for MetS1 (abdominal obesity). A group of SNPs, including S64–S67, S70–S73, S76, S78, S105–S107, and S110, showed connections to both MetS2 and MetS3. It is remarkable that MetS1 had no direct connection with most SNPs except for S20 and was mainly related to nutritional factors such as E6 (total energy), E7 (protein intake), E8 (fat intake), and E9 (carbohydrate intake).
Tripartite network of data from men. E0 (age), E1 (education), E2 (income), E3 (alcohol), E4 (smoking), E5 (physical activity), E6 (total energy), E7 (protein intake), E8 (fat intake), E9 (carbohydrate intake); MetS1 (abdominal obesity), MetS2 (triglycerides), MetS3 (HDL-C), MetS4 (hypertension), MetS5 (fasting glucose); S1–S190 (SNPs); Line thickness (degree of association).
The node with the largest degree (i.e., the node that was connected to the most nodes) was MetS3, with a degree of 42. MetS2 had the second-highest degree (34). Among the nodes in the environmental factor set, E3 (alcohol) showed the largest degree (16), and among the nodes in the SNP set, S129 (rs12903590) and S130 (rs4821116) showed the largest degree (7). S129 is mapped to the ALDH1A2 gene and has been reported to be related to HDL-C levels 60 , 61 . S130 has been reported to be located in UBE2L3 and related to hepatitis B virus infections and HDL-C levels 62 , 63 . The nodes with large degrees also showed high centrality. A node with high closeness centrality tends to be in the center of the network, while many other nodes are connected. In contrast, a node with high betweenness centrality builds a bridge that connects a lateral node and a central node rather than being connected to many nodes. MetS3 showed the highest closeness centrality (0.0067) followed by MetS2, (0.0064), E3 (0.0064), S129 (0.0063), and S130 (0.0063). For betweenness centrality, MetS3 (1442.06), MetS2 (1256.88), and MetS4 (hypertension;492.39) showed high values. E3 (373.67) and E9 (370.14) also showed high betweenness centrality. Thus, these nodes played the role of hubs in the network for men.
The thickness of the edges denotes the strength of the connection between the nodes. Not only S129 and S130, but also S127 (rs17411126) and S138 (rs6805251) showed strong connection with E3 in Fig. 1 . S127 is mapped to the LPL gene and is known to be related to the cholesterol ratio in the Korean population 64 . S138 is mapped to the GSK3B gene and has been reported to be associated with HDL-C 65 . Table 3 shows the top five edges based on the absolute value of the correlation coefficients and their p-values. All relationships for which the absolute value of correlations was greater than 0.10 are presented in Supplementary Table 2 . The information obtained from the graph is confirmed.
Similarly, Fig. 2 represents the tripartite network for women. In this network, after eliminating the nodes with weak correlations (p ≥ 0.001), 82 nodes were used to form the network. The same process as with the data from men was conducted to filter the significant nodes. Instead of E3 (alcohol), which played an important role in the network for men, socioeconomic variables such as E0 (age), E1 (education), E2 (income), and E8 (fat intake) were located at the center, connecting various MetS components in the network for women. Moreover, these showed strong connections. As in the network for men, E3 was linked to MetS3, and there were several SNPs (S104-S107) linking MetS2 and MetS3, playing the role of bridges. S120 (rs10899345) connected MetS4 to the environmental variables of E0, E1, E2, and E8, while S162 (rs2156552) linked these environment variables to E5 (physical activity). S120 has been identified in the B3GNT6 gene, and the reported trait is waist circumference 66 . S162 is in LOC105372112 and is known to be associated with HDL-C and LDL-C in various populations 67 , 68 .
Tripartite network of data from women. E0 (age), E1 (education), E2 (income), E3 (alcohol), E4 (smoking), E5 (physical activity), E6 (total energy), E7 (protein intake), E8 (fat intake), E9 (carbohydrate intake); MetS1 (abdominal obesity), MetS2 (triglycerides), MetS3 (HDL-C), MetS4 (hypertension), MetS5 (fasting glucose); S1–S190 (SNPs); Line thickness (degree of association).
MetS3 had the largest degree (41). Among the environmental nodes, E2 showed the largest degree (8). Among the SNPs, the degrees of S162 and S120 were high (6 and 4, respectively). MetS3, E2, E0, E1, E8 were the five nodes with the highest closeness centrality (MetS3:0.0069, E2:0.0063, E0:0.0062, E1:0.0062, E8:0.0061) while MetS3, MetS2, MetS4, E3, E2 were the five nodes with the highest betweenness centrality (MetS3:2404.22, MetS2:863.22, MetS4:738.17, E3:532.00, E2:484.00). No SNP seemed to be important in terms of centrality. MetS4 and MetS1 showed the highest correlations with E0 (age). It is remarkable that they had high negative correlation coefficients with E1 (education) (Table 3 ).
To elucidate the relationship between the nodes in two different sets, we projected the tripartite network into a two-mode bipartite network. Three two-mode projections were created for each sex. Among them, bipartite networks with the metabolic component set and SNP set for each sex are shown in Fig. 3 . The projected bipartite network implies an indirect relationship between the nodes. For instance, in the network for men, MetS4 and S62 (rs4244457) are connected because they share E0, E1, E2, and E5 in the tripartite network. To reduce the loss of information, we applied simple weighting for the projection. The thickness of the edges was proportional to the number of environmental factors shared by the two nodes. We can interpret this as indicating a large indirect association between MetS4 and S62 through environmental factors, although there was no significant direct association, as shown in the tripartite network. S162 (rs2156552) and MetS4 also showed slightly stronger indirect relationships than other nodes. In the network for women, S120 (rs10899345) and S162 (rs2156552) showed strong connections with every component of metabolic syndrome. These SNPs showed high degrees in the tripartite network, but their direct correlations with metabolic syndrome components were low. However, the projected bipartite network indicated that they had strong indirect relationships with metabolic components, reflecting environmental factors. The bipartite networks of MetS components and environmental factors, as well as environmental factors and the SNP set, can be interpreted similarly (Supplementary Figs. 1 , 2 ).
Projected bipartite network of MetS components and the SNP set. MetS1 (abdominal obesity), MetS2 (triglycerides), MetS3 (HDL-C), MetS4 (hypertension), MetS5 (fasting glucose); S1–S190 (SNPs) ; Line thickness (degree of association). ( a ) Data from men ( b ) Data from women.
Figure 4 demonstrates the projected unipartite graph of data from men and women using concurrent projection. By the definition of a closed tripartite network, nodes in the same set were disconnected in the original tripartite network. However, through the projection, indirect relationships between the nodes in the same set could be discovered in the unipartite network. For men, MetS2 and MetS3 were strongly related through SNPs and environmental factors, and MetS1 was not related to other MetS components. In the data from women, the relationships involving MetS2 and MetS3 were weaker, but all the components were connected. For the environmental network, E0, E3, and E5 for men and E0, E1, E2, and E8 for women were strongly related through SNPs and MetS components. The unipartite network for SNPs showed several SNP clusters, each of which shared the same environments and MetS components.
Projected unipartite networks using concurrent projection. E0 (age), E1 (education), E2 (income), E3 (alcohol), E4 (smoking), E5 (physical activity), E6 (total energy), E7 (protein intake), E8 (fat intake), E9 (carbohydrate intake); MetS1 (abdominal obesity), MetS2 (triglycerides), MetS3 (HDL-C), MetS4 (hypertension), MetS5 (fasting glucose); S1–S190 (SNPs) ; Line thickness (degree of association). ( a ) Data from men. ( b ) Data from women.
To obtain unipartite networks using sequential projection, we re-compressed the projected bipartite network. For each dataset, two different unipartite networks were produced. The resulting structure of the unipartite network and the relationship between the nodes differed according to the order of the aggregating dataset. For instance, although (b) and (d) in Fig. 5 both denote relationships between environmental factors, the graphs are completely different. This is because (b) was obtained by aggregating information over MetS component information from the environment-MetS components bipartite network (a), whereas (d) was obtained by aggregating information using the SNPs from the environment-SNP bipartite network (c). In the data from men, E3 and E4 were strongly connected by metabolic components, but nothing was connected to E4 via SNPs. The remaining unipartite networks obtained by sequential projection can be seen in Supplementary Figs. 3 – 7 .
Projected unipartite networks using sequential projection for the data from men. ( a ) Projected bipartite network of the metabolic component set and the environmental set. ( b ) Projected unipartite network of environmental factors using sequential projection to ( a ). ( c ) Projected bipartite network of the environmental set and the SNP set. ( d ) Projected unipartite network of the environmental set using sequential projection to ( c ). E0 (age), E1 (education), E2 (income), E3 (alcohol), E4 (smoking), E5 (physical activity), E6 (total energy), E7 (protein intake), E8 (fat intake), E9 (carbohydrate intake); MetS1 (abdominal obesity), MetS2 (triglycerides), MetS3 (HDL-C), MetS4 (hypertension), MetS5 (fasting glucose); S1–S190 (SNPs) ; Line thickness (degree of association).
To visualize the structure of numerous relationships among different variable sets—corresponding to genes, environments, and diseases—at once, a multipartite network was used. From a methodological perspective, the following novel points are proposed.
Utilizing multipartite networks to explore genetic and environmental influences on syndromic diseases: To understand genetic and environmental influences on syndromic diseases, we constructed independent variable sets and utilized multipartite networks to visualize the relationships between each set of variables at a glance.
Identifying indirect relationships via projected bipartite networks: Using a projected bipartite network enabled the identification of indirect relationships between nodes that could not be discovered in a usual network. Connections in the lower mode network graphs derived through projection do not indicate direct associations, but rather indirect associations reflecting the factors in a hidden set. For example, if an SNP and a metabolic component are connected in a projected bipartite network, this does not imply a direct association between them, but rather that they share a hidden environmental factor.
Proposing two different multi-stage projection methods: To elucidate the relationship between nodes in the same set, we suggested two different projection methods. Using the concurrent method allows us to represent associations between variables explained by variables from different groups. For instance, in a graph of diseases obtained from the projection into a one-mode unipartite network, diseases with significant indirect influences from both environment and genetics are strongly connected. In our data, the concurrent projection method was preferred due to its ease of interpretation. However, if the variable sets are nested, such as SNPs, genes, and pathways, sequential projection would be more meaningful. It is recommended to choose a projection method considering the relationship between sets.
Applicability to small samples: Many studies did not conduct sex-stratified analyses due to sample size limitations or analytical complexities 69 , 70 . Moreover, the effects of individual variables can be weak in complex diseases. Multipartite networks serve as exploratory tools, capable of revealing not only strictly significant variables but also potential underlying associations. Therefore, they can offer advantages in small-scale studies.
Applicability to pleiotropy: We set each component of MetS as a node. However, if a node is defined as a disease, a pleiotropic effect can also be seen through a tripartite network graph.
From the perspective of MetS analysis results, the study’s novel findings can be summarized as follows:
Sex-based variations in network patterns on metabolic syndrome: Utilizing Korean GWAS data, we identified distinct patterns between men and women. A notable contrast is the central and hub role of alcohol in the network for men, whereas its significance was lower within the female network. While the impact of alcohol consumption on health issues such as hypertension and dyslipidemia has been acknowledged 71 , 72 , 73 , the use of multipartite networks helped confirm its influence on MetS components, particularly in men. Furthermore, within the male network structure, HDL-C, triglyceride, and hypertension from the MetS component set; rs12903590 and rs4821116 from the SNP set; and carbohydrate intake and alcohol from the environmental set served as central and bridging nodes. In contrast, key nodes in the female data comprised age, education, income, and fat intake from the environmental set, which were strongly linked with MetS components, displaying a distinct pattern compared to men. Previous studies have underscored sex/gender differences in the risk and genetic effects of MetS 58 , 59 , 74 . Additionally, the effects of socioeconomic variables and dietary habits on MetS have been reported 75 , 76 , 77 . Certain SNPs, such as rs12903590 and rs4821116, have been associated with HDL-C cholesterol levels in the Asian population 78 , 79 . However, network graphs offer a clear depiction of their associations with pertinent SNPs.
Environmental interactions on MetS and genes: The projected bipartite network enabled the identification of indirect relationships between MetS components influenced by environmental factors and SNPs can be identified. The analysis indicated that in men, rs4244457 is associated with hypertension through age, education, and physical activity, while rs2156552 appears to be prominently linked to hypertension through age, income level, and physical activity. In women, rs10899345 and rs2156552 are associated with all MetS components through age, education level, income, and fat intake. These findings could not be obtained through simple correlation analysis, underscoring the need for further analyses such as gene-environmental interaction analysis or mediation analysis. While there have been various prior studies on this topic 80 , 81 , 82 , the specific SNPs with lifestyle interactions on MetS addressed are, to the best of the authors’ knowledge, not covered in those studies.
Among the identified SNPs in this study, rs1290359, which showed a direct relationship with metabolic components, maps to the ALDH1A2 gene. ALDH1A2 is involved in converting retinol into retinoic acid (RA), a critical regulator of lung and cardiovascular development during human embryogenesis. Additionally, this gene is implicated in T-cell acute lymphoblastic leukemia and is considered a candidate tumor suppressor in prostate cancer 83 , 84 . ALDH1A2 may also promote a progressive phenotype in glioblastoma 85 . Furthermore, rs4821116 is located in the UBE2L3 gene, which has been associated with various autoimmune diseases, including rheumatoid arthritis, celiac disease, Crohn’s disease, and systemic lupus erythematosus, through its role in ubiquitination of the NF-κB precursor 86 , 87 , 88 . The SNP identified via indirect relationships, rs2156552, maps to the ACAA2 gene. ACAA2 is a rate-limiting enzyme in mitochondria responsible for catalyzing the final step of the mitochondrial beta-oxidation pathway 89 . Dysfunction of this enzyme may contribute to several metabolic disorders and diseases. The ACAA2 expression has been proposed as a potential molecular marker for small-cell neuroendocrine cancers 89 . The ACAA2 locus also has been linked to blood lipid abnormalities, particularly in HDL and LDL cholesterol levels 68 . Considering this information, future studies could explore potential associations with diseases related to these genes.
Although the data were obtained according to systematic and standardized epidemiological data quality control procedures, this study still has several limitations. First, bias is possible since the variables related to lifestyle and diet were obtained from self-reported survey forms. Second, we used SNP chip data, which could be impacted by bias according to the direct genotyping approach without imputation analysis.
A few noteworthy methodological points are as follows. First, in selecting the threshold of p < 1E − 05, we aimed to balance between the rigorous control of false positives, as done with the Bonferroni correction, and the need to include a sufficient number of SNPs to catch meaningful signals for exploratory analysis. This threshold enables more SNPs in our graph while still maintaining a reasonable level of statistical significance. Various studies have used the same threshold in the analysis of GWAS data 81 , 90 , 91 , 92 , 93 , 94 . Second, linkage disequilibrium (LD) pruning was not performed in the variable selection stage. Unlike regression-based methods, LD pruning is not required in the variable selection stage, because representing SNPs in LD does not influence the results of network-based methods. Instead, we investigated the selected SNPs in a post hoc analysis. A list of the SNP pairs with high LD (r 2 ≥ 0.9) is presented in Supplementary Table 2 .
For the indirect relationships identified in this study, validation through mediation analysis or Mendelian randomization could be considered. These avenues could be pursued in future research endeavors.
The Korea Association Resource (KARE) project data will be publicly distributed by the Distribution Desk of the Korea Biobank Network. Researchers who wish to receive epidemiological and genomic information data should apply through the ‘Human Resources Distribution Desk ( http://biobank.nih.go.kr ).’ After completing the application form and submitting the research plan and IRB approval (or waiver), it goes through deliberation by the Distribution Review Committee, which meets once a month. The researchers will directly receive the distributed resources after approval. For any inquiries, contact [email protected].
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This study was conducted with bioresources from the National Biobank of Korea, the Korea Disease Control and Prevention Agency, Republic of Korea (NBK-2021-059).
This research was supported by a National Research Foundation of Korea (NRF) Grant funded by the Korean government (MSIT) (NRF-2021R1A2C1007788).
These authors contributed equally: Ji-Eun Shin and Nari Shin.
Department of Biomedical Informatics, Konyang University, Daejeon, Republic of Korea
Ji-Eun Shin
Department of Statistics, Korea University, Seoul, Republic of Korea
Department of Statistics, Seoul National University, Seoul, Republic of Korea
Taesung Park
Department of Preventive Medicine, Eulji University, Daejeon, Republic of Korea
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Conceptualization: MP. Data curation: JS. Formal analysis: JS, NS. Funding acquisition: MP. Methodology: MP. Writing—original draft: MP, NS. Writing—review & editing: TP, MP.
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Shin, JE., Shin, N., Park, T. et al. Multipartite network analysis to identify environmental and genetic associations of metabolic syndrome in the Korean population. Sci Rep 14 , 20283 (2024). https://doi.org/10.1038/s41598-024-71217-5
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Meditation has a history that goes back thousands of years, and many meditative techniques began in Eastern traditions. The term “meditation” refers to a variety of practices that focus on mind and body integration and are used to calm the mind and enhance overall well-being. Some types of meditation involve maintaining mental focus on a particular sensation, such as breathing, a sound, a visual image, or a mantra, which is a repeated word or phrase. Other forms of meditation include the practice of mindfulness, which involves maintaining attention or awareness on the present moment without making judgments.
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Meditation and mindfulness practices usually are considered to have few risks. However, few studies have examined these practices for potentially harmful effects, so it isn’t possible to make definite statements about safety.
A 2020 review examined 83 studies (a total of 6,703 participants) and found that 55 of those studies reported negative experiences related to meditation practices. The researchers concluded that about 8 percent of participants had a negative effect from practicing meditation, which is similar to the percentage reported for psychological therapies. The most commonly reported negative effects were anxiety and depression. In an analysis limited to 3 studies (521 participants) of mindfulness-based stress reduction programs, investigators found that the mindfulness practices were not more harmful than receiving no treatment.
According to the National Health Interview Survey, an annual nationally representative survey, the percentage of U.S. adults who practiced meditation more than doubled between 2002 and 2022, from 7.5 to 17.3 percent. Of seven complementary health approaches for which data were collected in the 2022 survey, meditation was the most popular, beating out yoga (used by 15.8 percent of adults), chiropractic care (11.0 percent), massage therapy (10.9 percent), guided imagery/progressive muscle relaxation (6.4 percent), acupuncture (2.2 percent), and naturopathy (1.3 percent).
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In a 2012 U.S. survey, 1.9 percent of 34,525 adults reported that they had practiced mindfulness meditation in the past 12 months. Among those responders who practiced mindfulness meditation exclusively, 73 percent reported that they meditated for their general wellness and to prevent diseases, and most of them (approximately 92 percent) reported that they meditated to relax or reduce stress. In more than half of the responses, a desire for better sleep was a reason for practicing mindfulness meditation.
Meditation and mindfulness practices may have a variety of health benefits and may help people improve the quality of their lives. Recent studies have investigated if meditation or mindfulness helps people manage anxiety, stress, depression, pain, or symptoms related to withdrawal from nicotine, alcohol, or opioids.
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Mindfulness meditation practices may help reduce insomnia and improve sleep quality.
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Mindfulness-based approaches may improve the mental health of people with cancer.
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Studies have reported different results of evaluation methods of clinical competency tests. Therefore, this study aimed to design, implement, and evaluate a blended (in-person and virtual) Competency Examination for final-year Nursing Students.
This interventional study was conducted in two semesters of 2020–2021 using an educational action research method in the nursing and midwifery faculty. Thirteen faculty members and 84 final-year nursing students were included in the study using a census method. Eight programs and related activities were designed and conducted during the examination process. Students completed the Spielberger Anxiety Inventory before the examination, and both faculty members and students completed the Acceptance and Satisfaction questionnaire.
The results of the analysis of focused group discussions and reflections indicated that the virtual CCE was not capable of adequately assessing clinical skills. Therefore, it was decided that the CCE for final-year nursing students would be conducted using a blended method. The activities required for performing the examination were designed and implemented based on action plans. Anxiety and satisfaction were also evaluated as outcomes of the study. There was no statistically significant difference in overt, covert, and overall anxiety scores between the in-person and virtual sections of the examination ( p > 0.05). The mean (SD) acceptance and satisfaction scores for students in virtual, in-person, and blended sections were 25.49 (4.73), 27.60 (4.70), and 25.57 (4.97), respectively, out of 30 points, in which there was a significant increase in the in-person section compared to the other sections. ( p = 0.008). The mean acceptance and satisfaction scores for faculty members were 30.31 (4.47) in the virtual, 29.86 (3.94) in the in-person, and 30.00 (4.16) out of 33 in the blended, and there was no significant difference between the three sections ( p = 0.864).
Evaluating nursing students’ clinical competency using a blended method was implemented and solved the problem of students’ graduation. Therefore, it is suggested that the blended method be used instead of traditional in-person or entirely virtual exams in epidemics or based on conditions, facilities, and human resources. Also, the use of patient simulation, virtual reality, and the development of necessary virtual and in-person training infrastructure for students is recommended for future research. Furthermore, considering that the acceptance of traditional in-person exams among students is higher, it is necessary to develop virtual teaching strategies.
Peer Review reports
The primary mission of the nursing profession is to educate competent, capable, and qualified nurses with the necessary knowledge and skills to provide quality nursing care to preserve and improve the community’s health [ 1 ]. Clinical education is one of the most essential and fundamental components of nursing education, in which students gain clinical experience by interacting with actual patients and addressing real problems. Therefore, assessing clinical skills is very challenging. The main goal of educational evaluation is to improve, ensure, and enhance the quality of the academic program. In this regard, evaluating learners’ performance is one of the critical and sensitive aspects of the teaching and learning process. It is considered one of the fundamental elements of the educational program [ 2 ]. The study area is educational evaluation.
Various methods are used to evaluate nursing students. The Objective Structured Clinical Examination (OSCE) is a valid and reliable method for assessing clinical competence [ 1 , 2 ]. In the last twenty years, the use of OSCE has increased significantly in evaluating medical and paramedical students to overcome the limitations of traditional practical evaluation systems [ 3 , 4 ]. The advantages of this method include providing rapid feedback, uniformity for all examinees, and providing conditions close to reality. However, the time-consuming nature and the need for a lot of personnel and equipment are some disadvantages of OSCE [ 5 , 6 ]. Additionally, some studies have shown that this method is anxiety-provoking for some students and, due to time constraints, being observed by the evaluator and other factors can cause dissatisfaction among students [ 7 , 8 ].
However, some studies have also reported that this method is not only not associated with high levels of stress among students [ 9 ] but also has higher satisfaction than traditional evaluation methods [ 4 ]. In addition, during the COVID-19 pandemic, problems such as overcrowding and student quarantine during the exam have arisen. Therefore, reducing time and costs, eliminating or reducing the tiring quarantine time, optimizing the exam, utilizing all facilities for simulating the clinical environment, using innovative methods for conducting the exam, reducing stress, increasing satisfaction, and ultimately preventing the transmission of COVID-19 are significant problems that need to be further investigated.
Studies show that using virtual space as an alternative solution is strongly felt [ 10 , 11 , 12 ]. In the fall of 2009, following the outbreak of H1N1, educational classes in the United States were held virtually [ 13 ]. Also, in 2005, during Hurricane Katrina, 27 universities in the Gulf of Texas used emergency virtual education and evaluation [ 14 ].
One of the challenges faced by healthcare providers in Iran, like most countries in the world, especially during the COVID-19 outbreak, was the shortage of nursing staff [ 15 , 16 ]. Also, in evaluating and conducting CCE for final-year students and subsequent job seekers in the Clinical Skills Center, problems such as student overcrowding and the need for quarantine during the implementation of OSCE existed. This problem has been reported not only for us but also in other countries [ 17 ]. The intelligent use of technology can solve many of these problems. Therefore, almost all educational institutions have quickly started changing their policies’ paradigms to introduce online teaching and evaluation methods [ 18 , 19 ].
During the COVID-19 pandemic, for the first time, this exam was held virtually in our school. However, feedback from professors and students and the experiences of researchers have shown that the virtual exam can only partially evaluate clinical and practical skills in some stations, such as basic skills, resuscitation, and pediatrics [ 20 ].
Additionally, using OSCE in skills assessment facilitates the evaluation of psychological-motor knowledge and attitudes and helps identify strengths and weaknesses [ 21 ]. Clinical competency is a combination of theoretical knowledge and clinical skills. Therefore, using an effective blended method focusing on the quality and safety of healthcare that measures students’ clinical skills and theoretical expertise more accurately in both in-person and virtual environments is essential. The participation of students, professors, managers, education and training staff, and the Clinical Skills Center was necessary to achieve this important and inevitable goal. Therefore, the Clinical Competency Examination (CCE) for nursing students in our nursing and midwifery school was held in the form of an educational action research process to design, implement, and evaluate a blended method. Implementing this process during the COVID-19 pandemic, when it was impossible to hold an utterly in-person exam, helped improve the quality of the exam and address its limitations and weaknesses while providing the necessary evaluation for students.
The innovation of this research lies in evaluating the clinical competency of final-year nursing students using a blended method that focuses on clinical and practical aspects. In the searches conducted, only a few studies have been done on virtual exams and simulations, and a similar study using a blended method was not found.
The research investigates the scientific and clinical abilities of nursing students through the clinical competency exam. This exam, traditionally administered in person, is a crucial milestone for final-year nursing students, marking their readiness for graduation. However, the unforeseen circumstances of the COVID-19 pandemic and the resulting restrictions rendered in-person exams impractical in 2020. This necessitated a swift and significant transition to an online format, a decision that has profound implications for the future of nursing education. While the adoption of online assessment was a necessary step to ensure student graduation and address the nursing workforce shortage during the pandemic, it was not without its challenges. The accurate assessment of clinical skills, such as dressing and CPR, proved to be a significant hurdle. This underscored the urgent need for a change in the exam format, prompting a deeper exploration of innovative solutions.
To address these problems, the research was conducted collaboratively with stakeholders, considering the context and necessity for change in exam administration. Employing an Action Research (AR) approach, a blend of online and in-person exam modalities was adopted. Necessary changes were implemented through a cyclic process involving problem identification, program design, implementation, reflection, and continuous evaluation.
The research began by posing the following questions:
What are the problems of conducting the CCE for final-year nursing students during COVID-19?
How can these problems be addressed?
What are the solutions and suggestions from the involved stakeholders?
How can the CCE be designed, implemented, and evaluated?
What is the impact of exam type on student anxiety and satisfaction?
These questions guided the research in exploring the complexities of administering the CCE amidst the COVID-19 pandemic and in devising practical solutions to ensure the validity and reliability of the assessment while meeting stakeholders’ needs.
Research setting, expert panel members, job analysis, and role delineation.
This action research was conducted at the Nursing and Midwifery School of Lorestan University of Medical Sciences, with a history of approximately 40 years. The school accommodates 500 undergraduate and graduate nursing students across six specialized fields, with 84 students enrolled in their final year of undergraduate studies. Additionally, the school employs 26 full-time faculty members in nursing education departments.
An expert panel was assembled, consisting of faculty members specializing in various areas, including medical-surgical nursing, psychiatric nursing, community health nursing, pediatric nursing, and intensive care nursing. The panel also included educational department managers and the examination department supervisor. Through focused group discussions, the panel identified and examined issues regarding the exam format, and members proposed various solutions. Subsequently, after analyzing the proposed solutions and drawing upon the panel members’ experiences, specific roles for each member were delineated.
Given the nature of the research, purposive sampling was employed, ensuring that all individuals involved in the design, implementation, and evaluation of the exam participated in this study.
The participants in this study included final-year nursing students, faculty members, clinical skills center experts, the dean of the school, the educational deputy, group managers, and the exam department head. However, in the outcome evaluation phase, 13 faculty members participated in-person and virtually (26 times), and 84 final-year nursing students enrolled in the study using a census method in two semesters of 2020–2021 completed the questionnaires, including 37 females and 47 males. In addition, three male and ten female faculty members participated in this study; of this number, 2 were instructors, and 11 were assistant professors.
In order to enhance the validity and credibility of the study and thoroughly examine the results, this study utilized a triangulation method consisting of demographic information, focus group discussions, the Spielberger Anxiety Scale questionnaire, and an Acceptance and Satisfaction Questionnaire.
A questionnaire was used to gather demographic information from both students and faculty members. For students, this included age, gender, and place of residence, while for faculty members, it included age, gender, field of study, and employment status.
Multiple focused group discussions were conducted with the participation of professors, administrators, experts, and students. These discussions were held through various platforms such as WhatsApp Skype, and in-person meetings while adhering to health protocols. The researcher guided the talks toward the research objectives and raised fundamental questions, such as describing the strengths and weaknesses of the previous exam, determining how to conduct the CCE considering the COVID-19 situation, deciding on virtual and in-person stations, specifying the evaluation checklists for stations, and explaining the weighting and scoring of each station.
This study used the Spielberger Anxiety Questionnaire to measure students’ overt and covert anxiety levels. This questionnaire is an internationally standardized tool known as the STAI questionnaire that measures both overt (state) and covert (trait) anxiety [ 22 ]. The state anxiety scale (Form Y-1 of STAI) comprises twenty statements that assess the individual’s feelings at the moment of responding. The trait anxiety scale (Form Y-2 of STAI) also includes twenty statements that measure individuals’ general and typical feelings. The scores of each of the two scales ranged from 20 to 80 in the current study. The reliability coefficient of the test for the apparent and hidden anxiety scales, based on Cronbach’s alpha, was confirmed to be 0.9084 and 0.9025, respectively [ 23 , 24 ]. Furthermore, in the present study, Cronbach’s alpha value for the total anxiety questionnaire, overt anxiety, and covert anxiety scales were 0.935, 0.921, and 0.760, respectively.
The Acceptability and Satisfaction Questionnaire for Clinical Competency Test was developed by Farajpour et al. (2012). The student questionnaire consists of ten questions, and the professor questionnaire consists of eleven questions, using a four-point Likert scale. Experts have confirmed the validity of these questionnaires, and their Cronbach’s alpha coefficients have been determined to be 0.85 and 0.87 for the professor and student questionnaires, respectively [ 6 ]. In the current study, ten medical education experts also confirmed the validity of the questionnaires. Regarding internal reliability, Cronbach’s alpha coefficients for the student satisfaction questionnaire for both virtual and in-person sections were 0.76 and 0.87, respectively. The professor satisfaction questionnaires were 0.84 and 0.87, respectively. An online platform was used to collect data for the virtual exam.
Qualitative data analysis was conducted using the method proposed by Graneheim and Lundman. Additionally, the criteria established by Lincoln and Guba (1985) were employed to confirm the rigor and validity of the data, including credibility, transferability, dependability, and confirmability [ 26 ].
In this research, data synthesis was performed by combining the collected data with various tools and methods. The findings of this study were reviewed and confirmed by participants, supervisors, mentors, and experts in qualitative research, reflecting their opinions on the alignment of findings with their experiences and perspectives on clinical competence examinations. Therefore, the member check method was used to validate credibility.
Moreover, efforts were made in this study to provide a comprehensive description of the research steps, create a suitable context for implementation, assess the views of others, and ensure the transferability of the results.
Furthermore, researchers’ interest in identifying and describing problems, reflecting, designing, implementing, and evaluating clinical competence examinations, along with the engagement of stakeholders in these examinations, was ensured by the researchers’ long-term engagement of over 25 years with the environment and stakeholders, seeking their opinions and considering their ideas and views. These factors contributed to ensuring confirmability.
In this research, by reflecting the results to the participants and making revisions by the researchers, problem clarification and solution presentation, design, implementation, and evaluation of operational programs with stakeholder participation and continuous presence were attempted to prevent biases, assumptions, and research hypotheses, and to confirm dependability.
Data analysis was performed using SPSS version 21, and descriptive statistical tests (absolute and relative frequency, mean, and standard deviation) and inferential tests (paired t-test, independent t-test, and analysis of variance) were used. The significance level was set at 0.05. Parametric tests were used based on the normality of the data according to the Kolmogorov-Smirnov statistical test.
Given that conducting the CCE for final-year nursing students required the active participation of managers, faculty members, staff, and students, and to answer the research question “How can the CCE for final-year nursing students be conducted?” and achieve the research objective of “designing, implementing, and evaluating the clinical competency exam,” the action research method was employed.
The present study was conducted based on the Dickens & Watkins model. There are four primary stages (Fig. 1 ) in the cyclical action research process: reflect, plan, act, observe, and then reflect to continue through the cycle [ 27 ].
The cyclical process of action research [ 27 ]
Identification of the problem.
According to the educational regulations, final semester nursing students must complete the clinical competency exam. However, due to the COVID-19 pandemic and the critical situation in most provinces, inter-city travel restrictions, and insufficient dormitory space, conducting the CCE in-person was not feasible.
This exam was conducted virtually at our institution. However, based on the reflections from experts, researchers have found that virtual exams can only partially assess clinical and practical skills in certain stations, such as basic skills, resuscitation, and pediatrics. Furthermore, utilizing Objective Structured Clinical Examination (OSCE) in skills assessment facilitates the evaluation of psychomotor skills, knowledge, and attitudes, aiding in identifying strengths and weaknesses.
P3, “Due to the COVID-19 pandemic and the critical situation in most provinces, inter-city travel restrictions, and insufficient dormitory space, conducting the CCE in-person is not feasible.”
Based on the reflections gathered from the participants, the exam was designed using a blended approach (combining in-person and virtual components) as per the schedule outlined in Fig. 2 . All planned activities for the blended CCE for final-year nursing students were executed over two semesters.
P5, “Taking the exam virtually might seem easier for us and the students, but in my opinion, it’s not realistic. For instance, performing wound dressing or airway management is very practical, and it’s not possible to assess students with a virtual scenario. We need to see them in person.”
P6"I believe it’s better to conduct those activities that are highly practical in person, but for those involving communication skills like report writing, professional ethics, etc., we can opt for virtual assessment.”
Design and implementation of the blended CCE
Cce implementation steps.
The CCE was conducted based on the flowchart in Fig. 3 and the following steps:
Steps for conducting the CCE for final-year nursing students using a blended method
The panelists were guided to design the blended exam in focused group sessions and virtual panels based on the ADDIE (Analysis, Design, Development, Implementation, Evaluation) model [ 28 ]. Initially, needs assessment and opinion polling were conducted, followed by the operational planning of the exam, including the design of the blueprint table (Table 1 ), determination of station types (in-person or virtual), designing question stems in the form of scenarios, creating checklists and station procedure guides by expert panel groups based on participant analysis, and the development of exam implementation guidelines with participant input [ 27 ]. The design, execution, and evaluation were as follows:
In-person and virtual meetings with professors were held to determine the exam schedule, deadlines for submitting checklists, decision-making regarding the virtual or in-person nature of stations based on the type of skill (practical, communication), and presenting problems and solutions. Based on the decisions, primary skill stations, as well as cardiac and pediatric resuscitation stations, were held in person. In contrast, virtual stations for health, nursing ethics, nursing reports, nursing diagnosis, physical examinations, and psychiatric nursing were held.
News about the exam was communicated to students through the college website and text messages. Then, an online orientation session was held on Skype with students regarding the need assessment of pre-exam educational workshops, virtual and in-person exam standards, how to use exam software, how to conduct virtual exams, explaining the necessary infrastructure for participating in the exam by students, completing anxiety and satisfaction questionnaires, rules and regulations, how to deal with rejected individuals, and exam testing and Q&A. Additionally, a pre-exam in-person orientation session was held.
To inform students about the entire educational process, the resources and educational content recommended by the professors, including PDF files, photos and videos, instructions, and links, were shared through a virtual group on the social media messenger, and scientific information was also, questions were asked and answered through this platform.
Correspondence and necessary coordination were made with the university clinical skills center to conduct in-person workshops and exams.
Following the Test-centered approach, the Angoff Modified method [ 29 , 30 ] was used to determine the scoring criteria for each station by panelists tasked with assigning scores.
Additionally, in establishing standards for this blended CCE for fourth-year nursing students, for whom graduation was a prerequisite, the panelists, as experienced clinical educators familiar with the performance and future roles of these students and the assessment method of the blended exam, were involved [ 29 , 30 ](Table 1 ).
Software infrastructure.
The pre- and post-virtual exam questions, scenarios, and questionnaires were uploaded using online software.
The exam was conducted on a trial basis in multiple sessions with the participation of several faculty members, and any issues were addressed. Students were authenticated to enter the exam environment via email and personal information verification. The questions for each station were designed and entered into the software by the respective station instructors and the examination coordinator, who facilitated the exam. The questions were formatted as clinical scenarios, images, descriptive questions, and multiple-choice questions, emphasizing the clinical and practical aspects. This software had various features for administering different types of exams and various question formats, including multiple-choice, descriptive, scenario-based, image-based, video-based, matching, Excel output, and graphical and descriptive statistical analyses. It also had automatic questionnaire completion, notification emails, score addition to questionnaires, prevention of multiple answer submissions, and the ability to upload files up to 4 gigabytes. Student authentication was based on national identification numbers and student IDs, serving as user IDs and passwords. Students could enter the exam environment using their email and multi-level personal information verification. If the information did not match, individuals could not access the exam environment.
A student list was prepared, and checklists for the in-person exam and anxiety and satisfaction questionnaires were reproduced.
Educational needs of faculty members and academic staff include conducting clinical competency exams using the OSCE method; simulating and evaluating OSCE exams; designing standardized questions, checklists, and scenarios; innovative approaches in clinical evaluations; designing physical spaces and setting up stations; and assessing ethics and professional commitment in clinical competency exams.
According to the students’ needs assessment results, in-person workshops on cardiopulmonary resuscitation and airway management and online workshops were held on health, pediatrics, cardiopulmonary resuscitation, ethics, nursing diagnosis, and report writing through Skype messenger. In addition, vaccination notes, psychiatric nursing, and educational files on clinical examinations and basic skills were recorded by instructors and made available to students via virtual groups.
The CCE was held in two parts, in-person and virtual.
The OSCE method was used for this section of the exam. The basic skills station exam included dressing and injections, and the CPR and pediatrics stations were conducted in person. The students were divided into two groups of 21 each semester, and the exam was held in two shifts. While adhering to quarantine protocols, the students performed the procedures for seven minutes at each station, and instructors evaluated them using a checklist. An additional minute was allotted for transitioning to the next station.
The professional ethics, nursing diagnosis, nursing report, health, psychiatric nursing, and physical examination stations were conducted virtually after the in-person exam. This exam was made available to students via a primary and a secondary link in a virtual space at the scheduled time. Students were first verified, and after the specified time elapsed, the ability to respond to inactive questions and submitted answers was sent. During the exam, full support was provided by the examination center.
The examination coordinator conducted the entire virtual exam process. The exam results were announced 48 h after the exam. A passing grade was considered to be a score higher than 60% in all stations. Students who failed in various stations were given the opportunity for remediation based on faculty feedback, either through additional study or participation in educational workshops. Subsequent exams were held one week apart from the initial exam. It was stipulated that students who failed in more than half of the stations would be evaluated in the following semester. If they failed in more than three sessions at a station, a decision would be made by the faculty’s educational council. However, no students met these situations.
The evaluation of the exam was conducted by examiners using a checklist, and the results were announced as pass or fail.
In this study, both process and outcome evaluations were conducted:
All programs and activities implemented during the test design and administration process were evaluated in the process evaluation. This evaluation was based on operational program control and reflections received from participants through group discussion sessions and virtual groups.
Sample reflections received from faculty members, managers, experts, and students through group discussions and social messaging platforms after the changes:
P7: “The implementation of the blended virtual exam, in the conditions of the COVID-19 crisis where the possibility of holding in-person exams was not fully available, in my opinion, was able to improve the quality of exam administration and address the limitations and weaknesses of the exam entirely virtually.”
P5: “In my opinion, this blended method was able to better evaluate students in terms of clinical readiness for entering clinical practice.”
The study outcomes were student anxiety, student acceptance and satisfaction, and faculty acceptance and satisfaction. Before the start of the in-person and virtual exams, the Spielberger Anxiety Questionnaire was provided to students. Additionally, immediately after the exam, students and instructors completed the acceptance and satisfaction questionnaire for the relevant section. After the exam, students and instructors completed the acceptance and satisfaction questionnaire again for the entire exam process, including feasibility, satisfaction with its implementation, and educational impact.
The exam was planned using a blended method (part in-person, part virtual) according to the Fig. 2 schedule, and all planned programs for the blended CCE for final-year nursing students were implemented in two semesters.
In this study, 84 final-year nursing students participated, including 37 females (44.05%) and 47 males (55.95%). Among them, 28 (33.3%) were dormitory residents, and 56 (66.7%) were non-dormitory residents.
In this study, both process and outcome evaluations were conducted.
All programs and activities implemented during the test design and administration process were evaluated in the process evaluation (Table 2 ). This evaluation was based on operational program control and reflections received from participants through group discussion sessions and virtual groups on social media.
Anxiety and satisfaction were examined and evaluated as study outcomes, and the results are presented below.
The paired t-test results in Table 3 showed no statistically significant difference in overt anxiety ( p = 0.56), covert anxiety ( p = 0.13), and total anxiety scores ( p = 0.167) between the in-person and virtual sections before the blended Clinical Competency Examination.
However, the mean (SD) of overt anxiety in persons in males and females was 49.27 (11.16) and 43.63 (13.60), respectively, and this difference was statistically significant ( p = 0.03). Also, the mean (SD) of overt virtual anxiety in males and females was 45.70 (11.88) and 51.00 (9.51), respectively, and this difference was statistically significant ( p = 0.03). However, there was no significant difference between males and females regarding covert anxiety in the person ( p = 0.94) and virtual ( p = 0.60) sections. In addition, the highest percentage of overt anxiety was apparent in the virtual section among women (15.40%) and the in-person section among men (21.28%) and was prevalent at a moderate to high level.
According to Table 4 , One-way analysis of variance showed a significant difference between the virtual, in-person, and blended sections in terms of acceptance and satisfaction scores.
The results of the One-way analysis of variance showed that the mean (SD) acceptance and satisfaction scores of nursing students of the CCE in virtual, in-person, and blended sections were 25.49 (4.73), 27.60 (4.70), and 25.57 (4.97) out of 30, respectively. There was a significant difference between the three sections ( p = 0.008).
In addition, 3 (7.23%) male and 10 (76.3%) female faculty members participated in this study; of this number, 2 (15.38%) were instructors, and 11 (84.62%) were assistant professors. Moreover, they were between 29 and 50 years old, with a mean (SD) of 41.37 (6.27). Furthermore, they had 4 to 20 years of work experience with a mean and standard deviation of 13.22(4.43).
The results of the analysis of variance showed that the mean (SD) acceptance and satisfaction scores of faculty members of the CCE in virtual, in-person, and blended sections were 30.31 (4.47), 29.86 (3.94), and 30.00 (4.16) out of 33, respectively. There was no significant difference between the three sections ( p = 0.864).
This action research study showed that the blended CCE for nursing students is feasible and, depending on the conditions and objectives, evaluation stations can be designed and implemented virtually or in person.
The blended exam, combining in-person and virtual elements, managed to address some of the weaknesses of entirely virtual exams conducted in previous terms due to the COVID-19 pandemic. Given the pandemic conditions, the possibility of performing all in-person stations was not feasible due to the risk of students and evaluators contracting the virus, as well as the need for prolonged quarantine. Additionally, to meet the staffing needs of hospitals, nursing students needed to graduate. By implementing the blended exam idea and conducting in-person evaluations at clinical stations, the assessment of nursing students’ clinical competence was brought closer to reality compared to the entirely virtual method.
Furthermore, the need for human resources, station setup costs, and time spent was less than the entirely in-person method. Therefore, in pandemics or conditions where sufficient financial resources and human resources are not available, the blended approach can be utilized.
Additionally, the evaluation results showed that students’ total and overt anxiety in both virtual and in-person sections of the blended CCE did not differ significantly. However, the overt anxiety of female students in the virtual section and male students in the in-person section was considerably higher. Nevertheless, students’ covert anxiety related to personal characteristics did not differ in virtual and in-person exam sections. However, students’ acceptance and satisfaction in the in-person section were higher than in the virtual and blended sections, with a significant difference. The acceptance and satisfaction of faculty members from the CCE in in-person, virtual, and blended sections were the same and relatively high.
A blended CCE nursing competency exam was not found in the literature review. However, recent studies, especially during the COVID-19 pandemic, have designed and implemented this exam using virtual OSCE. Previously, the CCE was held in-person or through traditional OSCE methods.
During the COVID-19 pandemic, nursing schools worldwide faced difficulties administering clinical competency exams for students. The virtual simulation was used to evaluate clinical competency and develop nursing students’ clinical skills in the United States, including standard videos, home videos, and clinical scenarios. Additionally, an online virtual simulation program was designed to assess the clinical competency of senior nursing students in Hong Kong as a potential alternative to traditional clinical training [ 31 ].
A traditional in-person OSCE was also redesigned and developed through a virtual conferencing platform for nursing students at the University of Texas Medical Branch in Galveston. Survey findings showed that most professors and students considered virtual OSCE a highly effective tool for evaluating communication skills, obtaining a medical history, making differential diagnoses, and managing patients. However, professors noted that evaluating examination techniques in a virtual environment is challenging [ 32 ].
However, Biranvand reported that less than half of the nursing students believed the in-person OSCE was stressful [ 33 ]. At the same time, the results of another study showed that 96.2% of nursing students perceived the exam as anxiety-provoking [ 1 ]. Students believe that the stress of this exam is primarily related to exam time, complexity, and the execution of techniques, as well as confusion about exam methods [ 7 ]. In contrast to previous research results, in a study conducted in Egypt, 75% of students reported that the OSCE method has less stress than other examination methods [ 9 ]. However, there has yet to be a consensus across studies on the causes and extent of anxiety-provoking in the OSCE exam. In a study, the researchers found that in addition to the factors mentioned above, the evaluator’s presence could also be a cause of stress [ 34 ]. Another survey study showed that students perceived the OSCE method as more stressful than the traditional method, mainly due to the large number of stations, exam items, and time constraints [ 7 ]. Another study in Egypt, which designed two stages of the OSCE exam for 75 nursing students, found that 65.6% of students reported that the second stage exam was stressful due to the problem-solving station. In contrast, only 38.9% of participants considered the first-stage exam stressful [ 35 ]. Given that various studies have reported anxiety as one of the disadvantages of the OSCE exam, in this study, one of the outcomes evaluated was the anxiety of final-year nursing students. There was no significant difference in total anxiety and overt anxiety between students in the in-person and virtual sections of the blended Clinical Competency Examination. The overt anxiety was higher in male students in the in-person part and female students in the virtual section, which may be due to their personality traits, but further research is needed to confirm this. Moreover, since students’ total and overt anxiety in the in-person and virtual sections of the exam are the same in resource and workforce shortages or pandemics, the blended CCE is suggested as a suitable alternative to the traditional OSCE test. However, for generalization of the results, it is recommended that future studies consider three intervention groups, where all OSCE stations are conducted virtually in the first group, in-person in the second group, and a blend of in-person and virtual in the third group. Furthermore, the results of the study by Rafati et al. showed that the use of the OSCE clinical competency exam using the OSCE method is acceptable, valid, and reliable for assessing nursing skills, as 50% of the students were delighted, and 34.6% were relatively satisfied with the OSCE clinical competency exam. Additionally, 57.7% of the students believed the exam revealed learning weaknesses [ 1 ]. Another survey study showed that despite higher anxiety about the OSCE exam, students thought that this exam provides equal opportunities for everyone, is less complicated than the traditional method, and encourages the active participation of students [ 7 ]. In another study on maternal and infant care, 95% of the students believed the traditional exam only evaluates memory or practical skills. In contrast, the OSCE exam assesses knowledge, understanding, cognitive and analytical skills, communication, and emotional skills. They believed that explicit evaluation goals, appropriate implementation guidelines, appropriate scheduling, wearing uniforms, equipping the workroom, evaluating many skills, and providing fast feedback are among the advantages of this exam [ 36 ]. Moreover, in a survey study, most students were satisfied with the clinical environment offered by the OSCE CCE using the OSCE method, which is close to reality and involves a hypothetical patient in necessary situations that increase work safety. On the other hand, factors such as the scheduling of stations and time constraints have led to dissatisfaction among students [ 37 ].
Furthermore, another study showed that virtual simulations effectively improve students’ skills in tracheostomy suctioning, triage concepts, evaluation, life-saving interventions, clinical reasoning skills, clinical judgment skills, intravenous catheterization skills, role-based nursing care, individual readiness, critical thinking, reducing anxiety levels, and increasing confidence in the laboratory, clinical nursing education, interactive communication, and health evaluation skills. In addition to knowledge and skills, new findings indicate that virtual simulations can increase confidence, change attitudes and behaviors, and be an innovative, flexible, and hopeful approach for new nurses and nursing students [ 38 ].
Various studies have evaluated the satisfaction of students and faculty members with the OSCE Clinical Competency Examination. In this study, one of the evaluated outcomes was the acceptability and satisfaction of students and faculty members with implementing the CCE in blended, virtual, and in-person sections, which was relatively high and consistent with other studies. One crucial factor that influenced the satisfaction of this study was the provision of virtual justification sessions for students and coordination sessions with faculty members. Social messaging groups were formed through virtual and in-person communication, instructions were explained, expectations and tasks were clarified, and questions were answered. Students and faculty members could access the required information with minimal presence in medical education centers and time and cost constraints. Moreover, with the blended evaluation, the researcher’s communication with participants was more accessible. The written guidelines and uploaded educational content of the workshops enabled students to save the desired topics and review them later if needed. Students had easy access to scientific and up-to-date information, and the application of social messengers and Skype allowed for sending photos and videos, conducting workshops, and questions and answering questions. However, the clinical workshops and examinations were held in-person to ensure accuracy. The virtual part of the examination was conducted through online software, and questions focused on each station’s clinical and practical aspects. Students answered various questions, including multiple-choice, descriptive, scenario, picture, and puzzle questions, within a specified time. The blended examination evaluated clinical competency and did not delay these individuals’ entry into the job market. Moreover, during the severe human resource shortage faced by the healthcare system, the examination allowed several nurses to enter the country’s healthcare system. The blended examination can substitute in-person examination in pandemic and non-pandemic situations, saving facilities, equipment, and human resources. The results of this study can also serve as a model to guide other nursing departments that require appropriate planning and arrangements for Conducting Clinical Competency Examinations in blended formats. This examination can also be developed to evaluate students’ clinical performance.
One of the practical limitations of the study was the possibility that participants might need to complete the questionnaires accurately or be concerned about losing marks. Therefore, in a virtual session before the in-person exam, the objectives and importance of the study were explained. Participants were assured that it would not affect their evaluation and that they should not worry about losing marks. Additionally, active participation from all nursing students, faculty members, and staff was necessary for implementing this plan, achieved through prior coordination, virtual meetings, virtual group formation, and continuous reflection of results, creating the motivation for continued collaboration and participation.
Among other limitations of this study included the use of the Spielberger Anxiety Questionnaire to measure students’ anxiety. It is suggested that future studies use a dedicated anxiety questionnaire designed explicitly for pre-exam anxiety measurement. Another limitation of the current research was its implementation in nursing and midwifery faculty. Therefore, it is recommended that similar studies be conducted in nursing and midwifery faculties of other universities, as well as in related fields, and over multiple consecutive semesters. Additionally, for more precise effectiveness assessment, intervention studies in three separate virtual, in-person, and hybrid groups using electronic checklists are proposed. Furthermore, it is recommended that students be evaluated in terms of other dimensions and variables such as awareness, clinical skill acquisition, self-confidence, and self-efficacy.
Conducting in-person Clinical Competency Examination (CCE) during critical situations, such as the COVID-19 pandemic, is challenging. Instead of virtual exams, blended evaluation is a feasible approach to overcome the shortages of virtual ones and closely mimic in-person scenarios. Using a blended method in pandemics or resource shortages, it is possible to design, implement, and evaluate stations that evaluate basic and advanced clinical skills in in-person section, as well as stations that focus on communication, reporting, nursing diagnosis, professional ethics, mental health, and community health based on scenarios in a virtual section, and replace traditional OSCE exams. Furthermore, the use of patient simulators, virtual reality, virtual practice, and the development of virtual and in-person training infrastructure to improve the quality of clinical education and evaluation and obtain the necessary clinical competencies for students is recommended. Also, since few studies have been conducted using the blended method, it is suggested that future research be conducted in three intervention groups, over longer semesters, based on clinical evaluation models and influential on other outcomes such as awareness and clinical skill acquisition self-efficacy, confidence, obtained grades, and estimation of material and human resources costs. This approach reduced the need for physical space for in-person exams, ensuring participant quarantine and health safety with higher quality. Additionally, a more accurate assessment of nursing students’ practical abilities was achieved compared to a solely virtual exam.
The datasets generated and analyzed during the current study are available on request from the corresponding author.
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We want to thank the Research and Technology deputy of Smart University of Medical Sciences, Tehran, Iran, the faculty members, staff, and officials of the School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran, and all individuals who participated in this study.
All steps of the study, including study design and data collection, analysis, interpretation, and manuscript drafting, were supported by the Deputy of Research of Smart University of Medical Sciences.
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Tahereh Toulabi
Cardiovascular Research Center, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran
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RM. Participating in study design, accrual of study participants, review of the manuscript, and critical revisions for important intellectual content. TT : The investigator; participated in study design, data collection, accrual of study participants, and writing and reviewing the manuscript. AM: Participating in study design, data analysis, accrual of study participants, and reviewing the manuscript. All authors read and approved the final version of the manuscript.
Correspondence to Tahereh Toulabi .
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This action research was conducted following the participatory method. All methods were performed according to the relevant guidelines and regulations in the Declaration of Helsinki (ethics approval and consent to participate). The study’s aims and procedures were explained to all participants, and necessary assurance was given to them for the anonymity and confidentiality of their information. The results were continuously provided as feedback to the participants. Informed consent (explaining the goals and methods of the study) was obtained from participants. The Smart University of Medical Sciences Ethics Committee approved the study protocol (IR.VUMS.REC.1400.011).
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Mojtahedzadeh, R., Toulabi, T. & Mohammadi, A. The design, implementation, and evaluation of a blended (in-person and virtual) Clinical Competency Examination for final-year nursing students. BMC Med Educ 24 , 936 (2024). https://doi.org/10.1186/s12909-024-05935-9
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DOI : https://doi.org/10.1186/s12909-024-05935-9
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An urgent report from the WHO Regional Office for Europe reveals that condom use among sexually active adolescents has declined significantly since 2014, with rates of unprotected sex worryingly high. This is putting young people at significant risk of sexually transmitted infections (STIs) and unplanned pregnancies. The new data were published as part of the multi-part Health Behaviour in School-aged Children (HBSC) study, which surveyed over 242 000 15-year-olds across 42 countries and regions in 2014–2022.
Overall, the report highlights that a substantial proportion of sexually active 15-year-olds are engaging in unprotected sexual intercourse, which WHO warns can have far-reaching consequences for young people, including unintended pregnancies, unsafe abortions and an increased risk of contracting STIs. The high prevalence of unprotected sex indicates significant gaps in age-appropriate comprehensive sexuality education, including sexual health education, and access to contraceptive methods.
Compared to 2014 levels, the new data show a significant decline in the number of adolescents reporting condom use during last sexual intercourse. From the data, it is clear that the decrease in condom use is pervasive, spanning multiple countries and regions, with some experiencing more dramatic reductions than others.
The report underscores the urgent need for targeted interventions to address these concerning trends and promote safer sexual practices among young people within the wider context of equipping them with the foundation they need for optimal health and well-being.
“While the report’s findings are dismaying, they are not surprising,” noted Dr Hans Henri P. Kluge, WHO Regional Director for Europe. “Age-appropriate comprehensive sexuality education remains neglected in many countries, and where it is available, it has increasingly come under attack in recent years on the false premise that it encourages sexual behaviour, when the truth is that equipping young persons with the right knowledge at the right time leads to optimal health outcomes linked to responsible behaviour and choices. We are reaping the bitter fruit of these reactionary efforts, with worse to come, unless governments, health authorities, the education sector and other essential stakeholders truly recognize the root causes of the current situation and take steps to rectify it. We need immediate and sustained action, underpinned by data and evidence, to halt this cascade of negative outcomes, including the likelihood of higher STI rates, increased health-care costs, and – not least – disrupted education and career paths for young persons who do not receive the timely information and support they need.”
The findings underscore the importance of providing comprehensive sexual health education and resources for young people. “As teenagers, having access to accurate information about sexual health is vital,” said Éabha, a 16-year-old from Ireland. “We need education that covers everything from consent to contraception, so we can make informed decisions and protect ourselves.”
“Comprehensive sexuality education is key to closing these gaps and empowering all young people to make informed decisions about sex at a particularly vulnerable moment in their lives, as they transition from adolescence to adulthood,” said Dr András Költő of the University of Galway, the lead author of the report. “But education must go beyond just providing information. Young people need safe spaces to discuss issues like consent, intimate relationships, gender identity and sexual orientation, and we – governments, health and education authorities, and civil society organizations – should help them develop crucial life skills including transparent, non-judgmental communication and decision-making.”
While the findings are sobering, they also offer a roadmap for the way ahead.
The report calls for sustainable investments in age-appropriate comprehensive sexuality education, youth-friendly sexual and reproductive health services, and enabling policies and environments that support adolescent health and rights.
“The findings of this report should serve as a catalyst for action. Adolescents deserve the knowledge and resources to make informed decisions about their sexual health. We have the evidence, the tools and the strategies to improve adolescent sexual health outcomes. What we need, though, is the political will and the resources to make it happen,” said Dr Margreet de Looze of Utrecht University, one of the report’s co-authors.
The WHO Regional Office for Europe calls upon policy-makers, educators and health-care providers to prioritize adolescent sexual health by:
“Ultimately, what we are seeking to achieve for young persons is a solid foundation for life and love,” said Dr Kluge. “Sexual and reproductive health and rights, informed by the right knowledge at the right time along with the right health and well-being services, is critical. By empowering adolescents to make informed decisions about their sexual health, we ultimately safeguard and improve their overall well-being. This is what all parents and families should want for their children, everywhere.”
Communications officer
Bhanu Bhatnagar
Press & Media Relations Officer WHO Regional Office for Europe
Joseph Hancock
Communications Officer for the HBSC study
WHO/Europe Press Office
A focus on adolescent sexual health in Europe, central Asia and Canada: Health Behaviour in School-aged Children international report from the 2021/2022 survey
Health Behaviour in School-aged Children (HBSC) study
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Copenhagen, 29 August 2024New report reveals high rates of unprotected sex among adolescents across Europe, with significant implications for health and safety An urgent report from the WHO Regional Office for Europe reveals that condom use among sexually active adolescents has declined significantly since 2014, with rates of unprotected sex worryingly high. This is putting young people at ...