Wu et al.

BMC Oral Health (2024) 24:120 BMC Oral Health

https://doi.org/10.1186/s12903-024-03853-2

RESEARCH Open Access

Patient perception of service quality

to preanesthetic oral examination: a cross-
sectional study using the SERVQUAL model
Ju-Hui Wu1,2, Kun-Tsung Lee1,2, Kuang-I Cheng3,4, Je-Kang Du2,5 and Chen-Yi Lee1,6*

Abstract
Background A phase-III interdisciplinary quality improvement program, the preanesthetic oral examination (PAOE),
was implemented as a new program in an academic medical center to prevent perioperative dental injuries. This
study was aimed at surveying the perceived service quality and satisfaction of patients who had undergone PAOE
based on the SERVQUAL model.
Methods This cross-sectional survey was conducted at the Kaohsiung Medical University Hospital using convenience
sampling. Patients referred for PAOE (PAOE group) and those who had voluntarily availed dental services (control
group) were recruited. A modified SERVQUAL questionnaire was used to assess the perceived service quality and
patient satisfaction with dental services. Cronbach’s alpha for SERVQUAL was 0.861.
Results We enrolled 286 (68.8%) and 130 (31.2%) participants in the PAOE and control groups, respectively. The path
analysis revealed that the PAOE group scored lower in dimensions of reliability (β = -0.074, P = 0.003), responsiveness
(β = -0.148, P = 0.006), and empathy (β = -0.140, P = 0.011). Furthermore, reliability (β = 0.655, P < 0.001) and
responsiveness (β = 0.147, P = 0.008) showed a direct effect on patient satisfaction. Overall, participants were highly
satisfied with the dental services.
Conclusions The PAOE group showed lower satisfaction and perceived quality of dental services compared to
the control group. Although implementing an interdisciplinary program reduces the perceived service quality,
its influence is limited. Employing an interdisciplinary teamwork is a win–win strategy encouraged to improve
patient safety and reduce malpractice claims. Future suggestions should focus on establishing waiting times
that are considered reasonable by patients. Patient-centered education related to the risk of perioperative dental
injuries should be provided, and awareness of oral conditions for patient safety should be improved. Moreover,
interprofessional education in continuous and undergraduate programs is necessary to improve professional quality.
Keywords Interdisciplinary cooperation, Patient safety, Perioperative dental injury, Quality improvement, Service
quality

3
*Correspondence: Department of Anesthesiology, Kaohsiung Medical University Hospital,
Chen-Yi Lee Kaohsiung, Taiwan
4
[email protected]; [email protected] Department of Anesthesiology, Faculty of Medicine, College of Medicine,
1
Department of Oral Hygiene, College of Dental Medicine, Kaohsiung Kaohsiung Medical University, Kaohsiung, Taiwan
5
Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung School of Dentistry, College of Dental Medicine, Kaohsiung Medical
80708, Taiwan University, Kaohsiung, Taiwan
2 6
Department of Dentistry, Kaohsiung Medical University Hospital, Department of Medical Research, Kaohsiung Medical University Hospital,
Kaohsiung, Taiwan Kaohsiung, Taiwan

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Wu et al. BMC Oral Health (2024) 24:120 Page 2 of 8

Background patients who had undergone a phase-III quality improve-

Perioperative dental damage is a common anesthesia- ment program, i.e., PAOE, based on the SERVQUAL
related adverse event responsible for many malpractice model. We hypothesized that implementing the new
claims against anesthesiologists [1–5]. The incidence program would change the perceptions of service quality
of dental trauma after anesthesia varies with the study and satisfaction in dental patients, whether or not they
design. Prospective studies (2.23–38.6%) tend to report receive anesthesia. Exploring the SERVQUAL dimen-
significantly higher rates of dental injury compared to sions immediately after dental services could more accu-
retrospective studies (0.02–0.7%) [3, 6, 7], owing to pos- rately elucidate the elements that contribute to patient
sible selection bias and underreported injuries in ret- satisfaction in the interdisciplinary program.
rospective studies [7]. Laryngoscopes are commonly
used in perioperative intubations to lift the epiglot- Methods
tis for proper visualization of the larynx. The use of the Interdisciplinary quality improvement program
maxillary teeth as a fulcrum, and of excessive pressure, At the Kaohsiung Medical University (KMU) Hospital,
may lead to dental injuries when the laryngoscope is the Quality Improvement Program was conducted from
employed [7]. After surgery, patients with poor dental February 1, 2010, to July 31, 2011. Phase I of the program
conditions may accidentally injure their teeth before they was conducted from August 1, 2011, to July 31, 2012,
fully recover from anesthesia. while phase II was initiated on August 1, 2012. Kuo et al.
For risk avoidance, associated staff education and in 2016 reported the detailed contents of the two-phase
department policy changes to optimize the management program [3]. In November 2018, phase III was imple-
of dental trauma have become increasingly crucial to mented as a new program applied to all patients who
address the entire preoperative evaluation process, which required general anesthesia. PAOE was conducted in the
is essential for improving medical quality and patient family dentistry department to improve safety and ser-
safety [3, 8, 9]. Prevention of dental damage starts with vice quality for all eligible patients.
the identification of risk factors. All patients with vulner- As the standard procedure, the surgeon referred the
able teeth should be evaluated by a dentist for remedial patient to a dentist for an oral examination before induc-
or restorative dental work to prevent damage preopera- ing general anesthesia for an elective surgical opera-
tively. Securing a loose tooth or mouth guard is a cautious tion. A visiting staff member explained the need for an
measure to prevent aspiration and aid tooth retrieval in oral examination, then a detailed examination was per-
the case of dislodgment [9]. Although a consensus on the formed by an intern, the results were double-checked by
preoperative protocol for cooperation between anesthe- a resident, and finally triple-checked by the visiting staff
tists and dentists is required, different institutions have member. If tooth mobility was detected, the dentist man-
adopted different strategies to prevent dental injuries and aged the pathologically mobile teeth with wire fixation
promote patient safety. or extraction to minimize the dental injury associated
At an academic medical center in Taiwan, the first with anesthesia preoperatively. The goals of preoperative
interdisciplinary quality improvement program for dental evaluation were to assess the patient’s oral status,
reducing dental injury rates was executed in 2011. It provide oral hygiene instructions, and reduce the risk of
has been proven to be efficient [3]. After implementing dental damage. After oral examination, recording of the
a two-phase quality improvement program, the inci- degree of tooth mobility was uploaded to the Hospital
dence of dental injury reduced significantly from 0.108 to Information System for healthcare providers to check
0.051% and remained at a low level of 0.009% [3]. There- and alert critical information.
fore, preanesthetic oral examination (PAOE) has been According to a statistical report from the KMU Hospi-
extended as a new program in the hospital. Although tal’s Patient Safety Bulletin, the average incidence rate of
these improvements in reducing dental injury rates have dental injury between November 2016 and October 2018
benefited the hospital system, patient experiences have was 0.0255%. After the PAOE in November 2018, the
not been adequately studied. Patient satisfaction and average incidence rate of tooth damage between Novem-
service quality related to preoperative assessment clinics ber 2018 and July 2020 was 0.0144%.
is generally high [10–12]. Communication of informa-
tion is the most positive component related to satisfac- Study design
tion, while waiting time is the most negative one [11, 12]. This was a cross-sectional study using convenience sam-
The SERVQUAL model has revealed a similar finding pling. The survey was conducted from August 2020 to
[10]. However, these preoperative assessments have not April 2021. We enrolled patients referred from other
included oral examinations. departments for PAOE (PAOE group) and those who
The aim of the present study was to detect relationships attended the family dentistry department for dental ser-
between perceived service quality and the satisfaction of vices (control group). A trained researcher explained the
Wu et al. BMC Oral Health (2024) 24:120 Page 3 of 8

study purpose to eligible patients, and informed consent Statistical analysis

was obtained before delivering the questionnaire. The Questionnaires with incomplete or neglected reverse
study protocol was approved by the Human Experiment items were excluded from the statistical analysis. To
and Ethics Committee of the Chung-Ho Memorial Hos- further differentiate the perspectives on dental services
pital, KMU (KMUHIRB-E(II)-20,200,166). between PAOE and control groups, the descriptions of
each item were classified as “agree,” “non-committal or
Instruments disagree,” and “no response.” “Agree” was rated 5–7 on the
The survey comprised three parts: demographic infor- Likert scale; “non-committal or disagree” was rated 1–4;
mation (including sex, age, educational level, residence, “no response” was considered as a missing value. The
and job), questions regarding the participants’ perspec- chi-square test was used to compare sociodemographic
tives on dental services, and the perceived service quality variables and perspectives on dental services between the
items adapted from the SERVQUAL survey developed by two groups. The independent t-test was used to compare
Parasuraman et al. [13]. Additionally, the clinical char- the scores in the five SERVQUAL dimensions. Statistical
acteristics of patients in the PAOE group (including the analyses were performed using Statistical Package for the
referral department, surgical history, tooth mobility, and Social Sciences (SPSS, version 20).
tooth fixation) were collected from their medical records. In order to examine the hypothesized relationships
among the patient types, sociodemographic variables,
Measuring perspectives on dental services five dimensions of SERVQUAL, and patient satisfaction,
Previous studies adopted “loyalty” as a construct, which a path analysis model was developed and tested using
included patient satisfaction, intention to recommend, AMOS 26. Rigorous evaluation criteria were adopted to
and intention to return [14–16]. Considering the insig- ensure an adequate model fit. A χ2 test was chosen as
nificance of the “intention to return” in the PAOE group, the statistical test for the model fit (α = 0.05). As this test
questions regarding perspectives on dental service were is sensitive to minor deviations in the model fit in large
modified to include only overall satisfaction with hospital samples, comparative fit index (CFI), Tucker-Lewis index
dental services and intention to recommend the service (TLI), standardized root mean squared residual (SRMR),
to others. Additionally, a question specific to patients and root mean square error of approximation (RMSEA)
receiving anesthesia regarding their attitude towards the were used to evaluate the model fit. The following cutoff
necessity of PAOE was added. All answers were mea- values were used to establish an adequate fit: CFI ≥ 0.95,
sured on a seven-point Likert scale from 1 (strongly dis- TLI ≥ 0.95, SRMR < 0.08, and RMSEA < 0.06 [21].
agree) to 7 (strongly agree).
Results
Measuring perceived service quality Sample characteristics
SERVQUAL was designed to measure consumer quality We included 416 valid questionnaires: 286 (68.8%) for
perceptions of services using 22 items across five dimen- the PAOE group and 130 (31.2%) for the control group.
sions, including tangibles (physical facilities, equipment, Respondents included 260 (62.5%) women and 156
and appearance of personnel; four items), reliability (37.5%) men. The most prevalent age group was 40–49
(dependability with respect to timeliness and accuracy; years (27.4%), followed by 50–59 years (24.5%) and 20–29
five items), responsiveness (willingness to help customers years (21.4%). Most (61.5%) respondents had completed
and prompt service; four items), assurance (courtesy and college or higher education, were residents of the Kaoh-
inspiring trust and confidence; four items), and empa- siung City (84.1%), and were employed (79.7%; Table 1).
thy (individualized consideration of a patient’s welfare; The comparisons between the groups revealed that
five items). In its original format, SERVQUAL measures the control group was significantly younger in age, had
the service–quality gap between patient expectations higher education levels, and had a lower percentage of
and perceptions. We measured only patient perceptions. employment (Table 1).
We measured the service quality on a seven-point scale
from 1 (strongly disagree) to 7 (strongly agree), with Clinical characteristics of patients in the PAOE group
nine reverse-scored items. The score for each dimension Table 2 showed the clinical characteristics of patients in
was the mean value of the corresponding item scores. the PAOE group. The most frequent referral department
SERVQUAL has been widely used in many studies in Tai- was otolaryngology (29.7%), followed by gynecology and
wan [15, 17–20]. In the present study, Cronbach’s alpha obstetrics (15.0%). Most (71.0%) participants were under-
of the SERVQUAL scale was 0.861, indicating good inter- going surgery for the first time at the KMU hospital. The
nal consistency reliability. oral examination revealed tooth mobility in 38 (13.3%)
participants and tooth fixation in 24 (8.4%) participants.
Wu et al. BMC Oral Health (2024) 24:120 Page 4 of 8

Table 1 Patient characteristics (n = 416) Table 3 Comparing the perspectives on dental service by
Variables N (%) χ2 P patient type
Total Patient type Perspectives N (%) χ2 P
PAOE Control Total Patient type
(n = 286) (n = 130) PAOE Control
Sex (n = 286) (n = 130)
Male 156(37.5) 108(37.8) 82(63.1) 0.027 0.870 Satisfaction
Female 260(62.5) 178(62.2) 48(36.9) “Agree” 365 237 (82.9) 127 (97.7) 18.463 < 0.001***
Age group (87.5)
(years) “Non-committal” 32 29 (10.1) 3 (2.3)
20–29 89(21.4) 50(17.5) 39(30.0) 12.553 0.014* or “disagree” (7.7)
30–39 78(18.8) 51(17.8) 27(20.8) No response 20 20 (7.0) 0 (0.0)
(4.8)
40–49 114(27.4) 87(30.4) 27(20.8)
Recommendation
50–59 102(24.5) 77(26.9) 25(19.2)
“Agree” 353 230 (80.4) 123 (94.6) 15.353 < 0.001***
60–64 33(7.9) 21(7.3) 12(9.2)
(84.9)
Education level
“Non-committal” 46 39 (13.6) 7 (5.4)
College or 256(61.5) 159(56.0) 97(74.6) 13.945 < 0.001***
or “disagree” (11.1)
higher
No response 17 17 (5.9) 0 (0.0)
Senior/vo- 129(31.0) 100(35.2) 29(22.3)
(4.1)
cational high
Necessity
school
“Agree” -- 240(83.9) -- -- --
Junior high 29(7.0) 25(8.8) 4(3.1)
school or lower “Non-committal” -- 28(9.8) --
or “disagree”
Resident in
Kaohsiung No response -- 18(6.3) --
Yes 350(84.1) 245(85.7) 105(80.8) 1.604 0.205 PAOE, preanesthetic oral examination; ***: P < 0.001

No 66(15.9) 41(14.3) 25(19.2)

Job Perspectives on dental services
Employed 318(79.7) 235(85.1) 83(67.5) 23.484 < 0.001*** Overall, the participants were satisfied with the ser-
Unemployed 55(13.8) 33(12.0) 22(17.9) vice in the family dentistry department (mean score:
Student 26(6.5) 8(2.9) 18(14.6) 6.24 ± 1.093) in both PAOE (mean score: 6.17 ± 1.208) and
PAOE, preanesthetic oral examination; *: P < 0.05; ***: P < 0.001 control (mean score: 6.39 ± 0.792) groups. Participants
were willing to recommend the service (mean score:
Table 2 Clinical characteristics of participants in the 6.16 ± 1.266) in both PAOE (mean score: 6.05 ± 1.400) and
preanesthetic oral examination group (n = 286) control (mean score: 6.37 ± 0.899) groups. Table 3 shows
Variables Valid responses % the results of transforming the scores of these items and
(n) combining them with the missing-value analysis. Com-
Referral department pared to the control group, significantly more patients in
Otolaryngology 85 29.7 the PAOE group answered “non-committal or disagree”
Orthopedics 29 10.1 or did not answer the question. Regarding the necessity
Gynecology and obstetrics 43 15.0 of performing an oral examination before anesthesia,
Ophthalmology 18 6.3 240 (83.9%) participants answered “agree” (mean score:
Plastic surgery 28 9.8 6.15 ± 1.294); 28 (9.8%) participants answered “non-com-
Others 83 29.0 mittal or disagree”; 18 (6.3%) participants did not answer.
Surgery history at the KMU hospital
First time 203 71.0
Perceived service quality
Not the first time 73 25.5
Regarding the five dimensions of perceived service qual-
Canceled a surgery 10 3.5
ity, tangibles, reliability, responsiveness, assurance, and
Tooth mobility
empathy scored a total of 25.28, 31.93, 23.40, 25.37, and
N 248 86.7
30.75, respectively, and a mean of 6.32, 6.39, 5.85, 6.34,
Y 38 13.3
and 6.15, respectively. Table 4 shows the comparisons
Tooth fixation
between PAOE and control groups. The PAOE group
N 262 91.6
scored significantly lower in reliability, responsiveness,
Y 24 8.4
KMU, Kaohsiung Medical University
assurance, and empathy than the control group. In rela-
tion to sociodemographic characteristics, the younger
age groups scored significantly higher in responsiveness
Wu et al. BMC Oral Health (2024) 24:120 Page 5 of 8

Table 4 Comparing the perceived service quality by patient interval = 0.000, 0.065; CFI = 0.996 and TLI = 0.989. The
type model revealed that the PAOE group scored lower in
Variables Patient type (M ± SD) t P reliability (β = -0.074, P = 0.003), responsiveness (β =
PAOE Control
-0.148, P = 0.006), and empathy (β = -0.140, P = 0.011)
(n = 286) (n = 130)
compared to the control group. Furthermore, reliabil-
Tangibles (4–28) 25.07 ± 3.44 25.74 ± 2.85 -1.920 0.056
ity (β = 0.655, P < 0.001) and responsiveness (β = 0.147,
Reliability (5–35) 31.47 ± 4.42 32.92 ± 3.15 -3.783 < 0.001***
P = 0.008) directly affected the patient satisfaction.
Responsiveness 22.45 ± 7.00 25.48 ± 4.48 -5.240 < 0.001***
(4–28) Regarding the influences of sociodemographic variables,
Assurance (4–28) 25.05 ± 4.31 26.05 ± 2.57 -2.918 0.004** the older age group scored lower in responsiveness (β =
Empathy (5–35) 29.81 ± 7.56 32.82 ± 4.61 -4.946 < 0.001*** -0.122, P = 0.038), whereas the group with a higher edu-
PAOE, preanesthetic oral examination; **: P < 0.01; ***: P < 0.001 cation level scored higher in responsiveness (β = 0.155,
P = 0.011). The PAOE group was lower in education level.
and empathy; those with college or a higher education Hence, age, education level, and employment showed
level scored significantly higher in responsiveness and significant interrelationships between each other. Finally,
empathy; and student status was significantly more asso- the five dimensions of perceived service quality exhibited
ciated with responsiveness and empathy (see Appendix). significant interrelationships.
Sex and residence were of no significance in relation to
the five perceived service quality dimensions. Discussion
In the present study, a detailed oral examination was
Path-analysis model performed by a dental team, including the assessment
Figure 1 illustrates a proposed path model based on the of tooth mobility. The tooth mobility and fixation rates
literature review and the results of univariate analyses in were 13.3% and 8.4%, respectively. The posterior teeth
this study. Participants who studied mostly at the medi- with grade-I mobility were not fixed because of the
cal university near the hospital with student status were unaffected pathology relative to the anterior teeth with
excluded from the data analysis. Figure 2 illustrates the grade-I mobility; therefore, they had a lower fixation rate.
path-analysis model. The model fit to the data was sat- Moreover, POAE group in the phase III program showed
isfactory with the following values: χ2 = 19.765; df = 15; a higher mobility rate than the pre-operative patients in
P = 0.181; SRMR = 0.038; RMSEA = 0.031, 90% confidence phases I and II (7.53% and 9.74%, respectively) [3]. The

Fig. 1 Theoretical framework of the study. A proposed path model predicting patient satisfaction
PAOE, preanesthetic oral examination
Wu et al. BMC Oral Health (2024) 24:120 Page 6 of 8

Fig. 2 Path-analysis model relating service quality, patient type, and sociodemographic variables to patient satisfaction
Standardized path coefficients are presented
Non-significant paths are represented by dashed lines
The significant paths with P < 0.01 are in bold
Significance: *P < 0.05; **P < 0.01; ***P < 0.001
PAOE, preanesthetic oral examination

difference between Phase III and Phase I or Phase II is general dental patients. Therefore, they tended to possess
that a qualified dental team surveyed the oral condition lower health literacy [22]. The reliability scale indicates
of the participant before surgery. Therefore, this result the service quality dimension representing timeliness and
might be explained by the thorough examination con- accuracy. A lower score indicates that the interdisciplin-
ducted by the qualified dental team. ary quality improvement program increased the length
In the present study, patients in the PAOE group scored of hospital stay of patients in the PAOE group, possibly
significantly lower in most dimensions of SERVQUAL leading to reduced patient satisfaction. Moreover, the
compared to the control group. Moreover, they reported responsiveness scale indicates the dimensions related to
significantly lower satisfaction compared to the con- information and communication. PAOE is a new pro-
trol group. In the path-analysis model, the five dimen- gram; therefore, most patients may have insufficient
sions of SERVQUAL were interrelated. The patient knowledge about its importance, as demonstrated by
type directly affected the reliability, responsiveness, and the lower agreement of the necessity to perform an oral
empathy scores; age directly affected the responsiveness examination before anesthesia in the present study, this
score; educational level directly affected the responsive- is consistent with previous studies on preoperative clinics
ness score and empathy scores; and the reliability and [10–12]. In clinical practice, the need for a preanesthetic
responsiveness scores were significant indicators affect- oral examination was explained by a visiting staff mem-
ing patient satisfaction (Fig. 2). The interrelationships ber before the oral examination. However, at times, the
between PAOE, age, education level, and employment patients did not even understand the anesthesia process.
indicated that patients who required general anesthesia Insufficient health literacy and the use of dialect preva-
were older and with a relatively lower education than the lent in Southern Taiwan increased the gap between the
Wu et al. BMC Oral Health (2024) 24:120 Page 7 of 8

dentists and patients, indicating that patient-centered is a win–win strategy encouraged to improve patient
education is necessary in the future. safety and reduce malpractice claims.
Strategies and policies focused on preventing periop-
Abbreviations
erative dental injuries vary among institutions and coun- PAOE Preanesthetic oral examination
tries. At some institutions, anesthesiologists evaluate the SERVQUAL Service quality
risks of dental trauma based on the dental history or a M Mean
SD Standard deviation
self-report questionnaire related to the patient’s dental CFI Comparative fit index
status. Patients at high risk are transferred to dentists TLI Tucker-Lewis index
for a mouthguard [23–25]. Some Japanese institutions SRMR Standardized root mean squared residual
RMSEA Root mean square error of approximation
have included oral function management in an interdis-
ciplinary system for perioperative management [26]. In
Japan, treatment fees for perioperative oral management Supplementary Information
by dentists were included in the dental fee schedule of The online version contains supplementary material available at https://doi.
org/10.1186/s12903-024-03853-2.
the National Health Insurance to prevent postoperative
complications in 2012. Preoperative/perioperative oral Supplementary Material 1
management by dentists were proved to be effective in
preventing the occurrence of postoperative aspiration Acknowledgements
pneumonia and reducing mortality and total medical The authors would like to thank all the participants.
costs [27–29]. Although anesthesiologists consistently
Author contributions
work in the oral cavity of patients, they may not have JHW and CYL conceived and designed the study. JHW conducted the survey,
studied the comprehensive education of teeth, surround- collected the data, and wrote a draft. CYL performed data analyses and revised
ing tissues, and intraoral prostheses [9]. Therefore, the the manuscript. JHW, KTL, KIC, and JKD aided in interpreting the results and
drafted the manuscript. All authors read and approved the final manuscript.
interdisciplinary cooperation involving anesthesiologists
and dental team seems to be a better strategy to simul- Funding
taneously reduce malpractice claims and improve patient This work was supported by the Kaohsiung Medical University (grant
no.: KMUH-110-0M71), Kaohsiung Medical University Hospital (grant no.:
safety and postoperative outcomes. NSYSUKMU 109-P017), and National Science and Technology Council, Taiwan,
In the present study, although patients in the PAOE ROC (grant no.: MOST 111-2410-H-037-033-MY2).
group were reported to have lower perceived service
Data availability
quality and patient satisfaction compared to the control The datasets generated and/or analyzed during the current study are not
group, the reported scores remained high. This indi- publicly available because of the regulation of KMUHIRB, but are available
cates that the decline in service quality owing to the new from the corresponding author upon reasonable request.
program was limited. Future suggestions should focus
on establishing adequate waiting times that are consid- Declarations
ered reasonable by patients. Patient-centered educa- Ethics approval and consent to participate
tion related to the risk of perioperative dental injuries All methods were carried out in accordance with relevant guidelines and
should be provided, and awareness of the oral condition regulations. Informed consent was obtained from all the participants.
The study protocol was approved by the Human Experiment
for patient safety should be improved. Moreover, inter- and Ethics Committee of the Chung-Ho Memorial Hospital, KMU
professional education in continuing and undergraduate (KMUHIRB-E(II)-20200166).
programs is necessary to improve professional quality.
Consent for publication
This study has several limitations. First, owing to con- Not applicable.
venience sampling, a potential sample bias may exist.
Second, only perceived service quality and satisfaction Competing interests
The authors declare no competing interests.
were evaluated, and the gaps between expectations and
perceptions were not assessed. Future studies by address- Received: 28 August 2023 / Accepted: 3 January 2024
ing these limitations are warranted.

Conclusions
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