Development, Implementation, and Evaluation of an E-Portfolio System to Enhance Competency-Based Learning and Reflection Among 4th-Year Dental Students

Development, Implementation, and Evaluation of an E-Portfolio System to Enhance Competency-Based Learning and Reflection Among 4th-Year Dental Students | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development, Implementation, and Evaluation of an E-Portfolio System to Enhance Competency-Based Learning and Reflection Among 4th-Year Dental Students Gulrez Amin, Usman Ahmad, Malik Adeel Anwar, Muhammad Hamza Mahmood, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7298133/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background With the growing focus on competency-based education in dental curricula, traditional assessment methods often fail to support longitudinal competency tracking and meaningful student reflection. Electronic portfolios (e-portfolios) have emerged as effective tools to bridge this gap by enabling documentation of clinical experiences, reflective writing, and structured faculty feedback. This study aimed to develop, implement, and evaluate a customized e-portfolio system for fourth-year dental students. Methods A sequential exploratory mixed-methods design was adopted. In the qualitative phase, a modified Delphi method was used to reach expert consensus on core components of the e-portfolio system. In the quantitative phase, a cross-sectional survey was conducted among fourth-year dental students (n = 72) after three months of using the e-portfolio. Thematic analysis was used for qualitative data, while descriptive and inferential statistics (independent t-test, Mann–Whitney U, chi-square) were applied to quantitative data using SPSS version 25. Internal consistency of the survey tool was evaluated using Cronbach’s alpha. Results Seven experts completed all Delphi rounds, resulting in consensus on 8 core components of the e-portfolio, including reflective writing, clinical case uploads, multimedia support, progress dashboards, and structured faculty feedback. Of the 75 students, 72 completed the survey (96% response rate). Overall satisfaction was high: usability (mean = 4.36 ± 0.64), reflective improvement (4.21 ± 0.61), and documentation via multimedia (4.47 ± 0.52) received the highest ratings. A statistically significant gender difference was observed in reflective engagement, with females showing higher agreement (p = 0.043). The survey instrument demonstrated strong reliability (Cronbach’s α = 0.84). Conclusion The study demonstrated that a structured, consensus-driven e-portfolio system can enhance clinical documentation, reflective practice, and student engagement in dental education. While student satisfaction was generally high, the findings highlighted the need for faculty training in feedback provision and strategies to reduce reflection-related workload. E-portfolio dental education competency-based learning reflection clinical documentation mixed-methods student assessment BACKGROUND Over the past few years, dental education has been steadily moving toward a more competency-based framework. The emphasis now is not just on memorizing facts, but on applying clinical skills, thinking critically, and behaving professionally in real-world settings. Traditional tools like end-of-rotation exams, logbooks, or even case-based discussions have been around for ages. They’ve done the job to some extent, but when it comes to things like self-directed learning or reflective thinking, they don’t always cut it [ 1 ]. Similar gaps have been observed in medical education where students do acknowledge the value of autopsy based learning but lacked direct exposure because they relied more on passive substitutes like online videos and printed material [ 2 ]. While still useful, these older methods often miss out on capturing the complete picture of student’s development during training. This has led to a growing push towards more continuous and connected approaches with e-portfolios becoming a key part of that conversation. E-portfolios are basically digital spaces where students can gather all sorts of stuff from their learning journey—like clinical case write-ups, reflections, pictures, videos, and even teacher feedback—all in one place. So, it’s not just about assessment anymore; these platforms actually help students stay more involved and take charge of their own learning [ 3 ]. Since they let learners track their growth, pinpoint weak areas, and get continuous feedback, they offer a richer learning experience than the older paper-based stuff that can feel pretty scattered. Researchers have even linked e-portfolios to stronger professional identity, since they help students build a habit of reflecting and self-checking their work [ 4 , 5 ]. In dental education, where hands-on skills and clinical practice matter a lot, e-portfolios create a link between what’s taught in class and what’s done in clinics. When students upload cases, write reflections, or include photos and videos, it pushes them to really think through what they did and why [ 6 , 7 ]. This deeper thinking is especially useful for final-year students, who are about to move into full-time clinical roles—it helps sharpen their ability to judge and improve their own work. That said, even though digital learning is picking up speed worldwide, e-portfolios haven’t really taken off in countries like Pakistan just yet. A few local studies show potential, but they also point out some big issues—like weak digital systems, teachers not being trained, and students not really knowing how to reflect properly [ 8 , 9 ]. Often, these systems are launched without a solid plan. Students end up unsure how to use them, and teachers aren’t always ready to guide them. One study by Khan et al., for example, showed that while students were generally open to the idea, many didn’t find e-portfolios useful because they hadn’t been properly shown how to use them [ 10 ]. This may point us towards a broader issue as a recent study among dental professionals in Pakistan found that generally low levels of metacognitive awareness indicating many learners struggle with self-evaluation and reflection, skills that the e portfolios are designed to cultivate [ 11 ]. Studies from other countries stress that both teachers and students should be involved in designing these platforms from the start. When users help shape the system, it usually works better and feels more relevant to real learning goals [ 5 , 12 ]. Also, having structured help—like proper training sessions and regular feedback is key if you want the system to be more than just a box-ticking exercise [ 13 , 14 ]. Without that, even the best-designed e-portfolio can end up gathering digital dust. Locally, most studies so far have focused on general attitudes or practical hurdles related to e-portfolios, but very few have evaluated their real impact on things like learning outcomes, reflection habits, or the documentation of student competencies in clinical years [ 15 , 16 ]. In fact, there is hardly any research from Pakistan that involves the creation and use of a tailor-made e-portfolio system within a defined clinical teaching context. This lack of empirical evidence leaves teachers and institutions unsure about how to adopt these tools effectively in their own programs. Given this background, the present study was conceptualized to address the specific needs of 4th-year dental students by designing a structured, user-centered e-portfolio system. The main objective was to enhance student engagement in reflective learning and competency tracking through a platform tailored to the local academic environment. The study also aimed to implement this system within a real-time clinical rotation and evaluate its effectiveness through a mixed-methods approach. By doing so, the research hoped to contribute both theoretical insight and practical recommendations for integrating e-portfolios in Pakistani dental education. The objectives were therefore framed to develop a robust digital platform incorporating reflection tools, case uploads, and feedback features; to orient students and faculty for its effective use during clinical postings; and finally, to assess its impact on student satisfaction, reflective engagement, and perceived learning improvement through a structured post-implementation survey METHODS This study followed a sequential exploratory mixed-methods design, allowing for in-depth exploration of expert consensus during the initial qualitative phase, followed by a structured quantitative evaluation based on student feedback. The purpose of this design was to identify essential components for an e-portfolio system through a Delphi process and then assess its effectiveness using a validated student perception survey. The entire study was conducted over a period of eight months, including planning, tool development, implementation, data collection, and analysis. The study took place at University College of Medicine and Dentistry (UCMD), the University of Lahore—a private institution known for its focus on competency-based dental education. This setting worked well for the research because it provided access to a full group of fourth-year BDS students who were already involved in their clinical rotations. That made it a good spot to try out and evaluate how useful a digital platform like an e-portfolio could be for both learning and assessment. The first group of Delphi had ten experts who took take part in the study. These experts had a background in medical or dental education, and experience of more than five years in e-learning and/or curriculum planning. Seven of these experts completed all Delphi rounds. In the quantitative study the participants included all 75 students enrolled in the fourth year of the BDS program. Among these, 72 students completed the survey, resulting in a 96% response rate. The inclusion criteria required students to have actively participated in their clinical rotations and used the e-portfolio system for at least eight weeks. The e-portfolio platform itself was designed and developed by the principal investigator using HTML, CSS, JavaScript, and PHP, with MySQL as the backend database. The system included various features such as clinical case logs, reflective writing modules, multimedia uploads (e.g., images, PDFs), and a dedicated faculty feedback panel. Development of the platform took approximately four weeks. Once the platform was ready, a two-day orientation program was held. The first day focused on a workshop about the purpose and structure of the e-portfolio, while the second day provided hands-on training to students on how to log in, upload cases, and submit reflections. Printed user manuals and short video tutorials were also shared for continued reference. The study began with the Delphi method to reach expert consensus on key features for the proposed e-portfolio. In the first round, experts responded to open-ended questions, and their input was analyzed thematically. This led to a list of 8 important items, which were then rated on a 5-point Likert scale in a second round. Consensus was defined as at least 75% agreement with an interquartile range (IQR) of ≤ 1, following standards in medical education research [ 4 , 17 ]. Final features that received strong support included reflective writing, uploading clinical cases, structured feedback tools, and multimedia support. After the platform was operational, the second phase of study focused on exploring student perspectives via a cross-sectional survey. The survey tool was adapted from previously validated instruments [ 18 ] and refined further with contributions from subject matter experts [ 7 , 14 ]. It consisted of 40 close-ended statements organized under four main themes : platform usability and accessibility, quality of reflective engagement, faculty feedback processes, and perceived impact on learning. Student responses were collected on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). To make sure the questionnaire was clear and meaningful, face validity was checked through pilot testing with a small group of ten students who weren’t part of the main study. Content validity was addressed through a detailed expert review. Additionally, internal consistency was assessed, and Cronbach’s alpha came out to 0.84—which is a good level of reliability in educational research [ 13 , 19 ]. For the data collection process, students were expected to submit at least three clinical cases along with corresponding reflections during their clinical posting. Faculty were instructed to review these weekly and give feedback via the dedicated faculty interface built into the e-portfolio system. Students would receive automated email alerts whenever feedback was uploaded. After four months of use, an online survey link was shared with all 75 students using the university’s official email channel. Participation was fully voluntary, and anonymity of responses was ensured throughout. Data were analyzed using SPSS version 25. Qualitative responses from the Delphi phase were analyzed thematically, while quantitative survey responses were assessed using descriptive statistics, including means, standard deviations, and frequency distributions. Independent t-tests and Mann–Whitney U tests were used to compare scores across gender, and Pearson or Spearman correlation tests were applied where relevant. Responses with missing or inconsistent entries were removed after careful screening. Prior to initiating the study, ethical approval was obtained from the Institutional Review Board (IRB) of the University of Lahore (UOL/IREB/25/07/0070). Written informed consent was secured from all participants after explaining the study objectives, confidentiality, and their right to withdraw at any point without any academic consequences. RESULTS Delphi Phase – Expert Consensus on E-Portfolio Components: Fourteen structured items were rated for relevance and usefulness in the second Delphi round. Most achieved consensus, while two—time management and extracurricular activities—were revised based on feedback and re-evaluated until consensus was reached. All final components are listed in Table 1 . Table 1 Delphi Consensus on E-Portfolio Components No. Component % Agreement IQR Status 1 Personal &Academic writing 91% 0.5 Yes 2 Case log uploads 89% 0.7 Yes 3 Faculty feedback panel 85% 0.6 Yes 4 Multimedia (images/videos) support 92% 0.5 Yes 5 Interprofessional collaboration 88% 0.6 Yes 6 Research participation 79% 1.0 Yes 7 Time management/comment options 62% 1.3 No 8 Record of extracurricular activities 68% 1.2 Revised 9–14 Remaining 8 items ≥ 75% ≤ 1 Yes Quantitative Phase – Student Survey Results: Of these respondents, 58.3% were female (n = 42) and 41.7% were male (n = 30). The average age of the participants was 22.6 years. All had used the e-portfolio for a minimum of 8 weeks during their clinical rotations. The tool used to assess the students; s perception had 40 items divided into four domains: usability, reflective engagement, faculty feedback and learning impact. Results showed that most students were satisfied with the system across these areas. The highest rated item pertained to multimedia documentation (Mean = 4.47 ± 0.52), while usability also scored high (Mean 4.36 ± 0.64). These values suggest the platform is not only accessible but also student friendly. The other domains averages showed that faculty feedback and reflective engagement were positively rated. The faculty feedback domain scored slightly lower on some items compared to others which these students attributed to variables response times form instructors. (Table 2 ) Table 2 Domain-Wise Summary Statistics Domain Mean SD Min Max Usability 3.90 0.78 1.00 5.00 Reflection 4.07 0.50 2.50 5.00 Feedback 4.10 0.54 2.00 5.00 Learning Impact 4.00 0.51 2.14 5.00 Gender based differences: A comparison of male and female students showed that on average female students gave higher ratings in nearly all domains. However the difference was significant only in reflection domain. Although other domains also had higher means for females, but the difference was not statistically significant. (Table 3 ) Table 3 Gender Comparison of Domain Scores Domain Mean (Male) Mean (Female) p-value Usability 3.85 4.02 0.078 (a) Reflection 4.00 4.25 0.042 (b) Feedback 3.85 4.24 0.056 (a) Learning Impact 3.90 4.10 0.061 (a) (a) T test, (b): Mann–Whitney U To confirm the reliability of the student instrument Cronbach’s alpha was calculated. The alpha score was 0.84 indicating strong internal consistency which supports this tool’s use for evaluating e-portfolio systems in similar academic settings. DISCUSSION The Delphi process was quite effective in helping shape a contextually appropriate portfolio system, developed with strong agreement and consensus among local experts. Students feedback showed overall satisfaction with the platform, particularly in terms of its reflective component and ease of usability. Interestingly, female students were more engaged in reflective writing compared to males. Although the feedback feature received generally positive ratings overall, responses indicated that student experience was somewhat mixed. Still, the platform demonstrated good reliability and performed well within the given educational context. These findings are consistent with prior research. Gallagher et al. also found web-based portfolios to be effective among oral health students [ 1 ]. Similarly, Shaheen et al noted that traditional assessment methods often lack the ability to track progress over time. Sometimes this e-portfolio system can be addressed through structured feedback and continuous documentation [ 20 ]. Among all assessed components, reflection emerged as one of the most positively rated mean score (4.07), pointing toward a meaningful engagement. The gender- difference in reflective depth was statistically significant (p = 0.042), with female students showing a deeper involvement. This aligns with prior work by Gadbury-Amyot et al. and Woldt MS et al who emphasized the role of structured reflection in shaping clinical judgment and professional identity [ 6 , 21 ]. One reason for the high level of engagement could be features such as built-in prompts for reflection, case-based modules, and opportunities for instructor feedback on their portfolios. Heathman et al. , also observed that using structured rubrics can increase the reliability of reflective assessment which was incorporated in this platform design [ 13 ]. The difference in reflection quality between genders, suggested that future interventions could include templates or that is more supportive especially for the males students Activities like peer-led group discussions or small reflection circles could help give equitable opportunities for all students, irrespective of gender to participate In the initial phase, the Delphi method was used to develop the tool with contributions from key stakeholders. In total, 16 features were finalized like reflective writing, uploading clinical cases, feedback from faculty, multimedia support, and tracking competencies using these tools. Some features, like “direct messaging with supervisors,” sparked a lot of debate and were changed after feedback., This shows how open and evolving the Delphi process can be. This approach aligns with Greviana et al., who stressed about involving both students and faculty to enhance their utility and acceptance when creating learning tools [ 5 ]. Mathur et al also noted that collaboratively codesigned systems are more likely to overcome problems like institutional resistance or lack of participation [ 21 ]. Based on these results, this kind of model might work well and be more effective for other educational innovations too, especially where digital learning and interdisciplinary teamwork are important. The observed gender difference in reflective writing is also supported by earlier studies. For example, Nafari et al. found that female students tend to go deeper in their reflections in health-related disciplines [ 23 ]. This raises important questions about how to make reflective activities inclusive. Mentorship tailored for different and diverse needs or more flexible formats might help especially for male students. Cultural and social factors in Pakistan’s dental education system might influence how students engage with reflective learning, necessitating further exploration. Although the feedback system got decent ratings overall, it scored a bit lower than other areas (4.10). Some students reported delays or inconsistent feedback, which may explain this trend. Javed et al also noted that some faculty members struggled to provide timely and constructive feedback in digital settings due to various other commitments and workload [ 24 ]. Heathman et al. emphasized that digital effective feedback works best when faculty are trained well in online tools and formative assessment techniques [ 13 ]. To address these challenges, institutions might consider training for faculty development programs that cover online mentoring, feedback timelines, and student reflections. Establishing clear policies for feedback timing and quality standards could further enhance the e-portfolio’s value. However, some students noted that reflective writing felt like an additional task, particularly during busy clinical rotations. Though these concerns were not reported in writing, they reflect a common problem between clinical duties and time for reflection. Simon and Al-Ghailani reported similar observations, noting that students view reflection as burdensome unless it is integrated naturally into their routines. Shorter prompts, dedicated time slots, or reflection breaks during clinical training could help students engage without feeling overwhelmed [ 25 ]. As with any research, limitations exist in this study. This study was conducted at a single institution, so findings may not apply everywhere. Secondly, the follow-up period spanned over three months, limiting insight into long-term effects. Additionally, feedback was collected solely from students, integrating faculty perspectives could have been beneficial. Finally, some students likely faced technical issues, such as unreliable internet or device problems, which may have impacted platform usage. In future studies involving multiple institutions and extended follow-up periods are suggested. It would also be good to compare different e-portfolio systems across different educational environments. Exploring how integrated digital platforms are combining formative and summative assessments affecting learning outcomes would be particularly beneficial. Long-term studies tracking e-portfolios’ impact on clinical performance and professional development would be the next step. CONCLUSION The e-portfolio aided students in enhancing their reflective abilities and maintaining better organization during clinical rotations. Majority of students found the platform easy to use and advantageous. However, the study faced certain limitations, including brief duration, restriction to a single institution, and absence of faculty input. Allocating more time for student reflection and improving technology access could further boost results. For greater impact, future research should incorporate faculty viewpoints and be conducted on a larger scale to ensure broader applicability of the findings. Declarations Human Ethics and Consent to Participate This study was reviewed and approved by the Institutional Review Board (IRB) of The University of Lahore (IRB Approval Number: UOL/IREB/25/07/0070). All research methods and data collection were performed in accordance with the relevant guidelines and regulations of IRB approval. Author’s contribution Conception and design of the study: GA, UA, LB Acquisition of data: GA, MAA, MHM, KM Analysis and interpretation of data: GA, MAA, MHM, KM Writing the manuscript, drafting the article: GA, UA, MAA Revising content: MHM, KM, LB Final approval of the version: GA, UA, MAA, MHM, KM, LB All authors reviewed and contributed to the manuscript, verified the manuscript and gave consent for its publication. Conflict of interest: The authors declare no conflict of interest. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7298133","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":502209905,"identity":"8eea3e8c-268a-4ccc-9ee4-a2d3e76b90a2","order_by":0,"name":"Gulrez Amin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIiWNgGAWjYFAC5gYozcD4ACHCBqR5cGlhhGthNkCIEKUFqEyCKC3yEYltHz78YZDXbec9Vs1Ts43B4HhjA8OHssMM5jwHsGoxvJHYPHMGD4PhtsN8abd5jt1mMDhzsIFxxrnDDJa9Ddi1zEhsZuaRYGDcdpjH7DZvA1DLjcQGZt62wwwG57E7DKzljwGDPUhLMVzLXzxa5CWAWhgSGBJBWpjhWhhBWs5id5gBz8Nmxp4DEslALcaSc47d5pEE+uVgz7l0Hsse7N6Xb08+zPDjj43ttvNnDD+8qbktx3e8+eCDH2XWcuY8CdhtgZgkARcARwZIkMcAu1cY5LG7F2waTplRMApGwSgYYQAAocteanfovtIAAAAASUVORK5CYII=","orcid":"","institution":"University College of Medicine and Dentistry, The University of Lahore","correspondingAuthor":true,"prefix":"","firstName":"Gulrez","middleName":"","lastName":"Amin","suffix":""},{"id":502209906,"identity":"64f94ada-88b3-4bc3-b661-ac9d2764ab03","order_by":1,"name":"Usman Ahmad","email":"","orcid":"","institution":"Punjab Institute of Neurosciences Lahore General Hospital Lahore","correspondingAuthor":false,"prefix":"","firstName":"Usman","middleName":"","lastName":"Ahmad","suffix":""},{"id":502209907,"identity":"4ff34389-4616-47a9-8497-a8d1e79af8a4","order_by":2,"name":"Malik Adeel Anwar","email":"","orcid":"","institution":"University College of Medicine and Dentistry, The University of Lahore","correspondingAuthor":false,"prefix":"","firstName":"Malik","middleName":"Adeel","lastName":"Anwar","suffix":""},{"id":502209908,"identity":"e832e0e5-7ab1-492b-98c7-94f0733cef1e","order_by":3,"name":"Muhammad Hamza Mahmood","email":"","orcid":"","institution":"University College of Medicine and Dentistry, The University of Lahore","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Hamza","lastName":"Mahmood","suffix":""},{"id":502209910,"identity":"376d9f74-9396-4bda-8874-76464313cd9d","order_by":4,"name":"Khadijah Mukhtar","email":"","orcid":"","institution":"University College of Medicine and Dentistry, The University of Lahore","correspondingAuthor":false,"prefix":"","firstName":"Khadijah","middleName":"","lastName":"Mukhtar","suffix":""},{"id":502209911,"identity":"779c4148-0f2f-4bd9-be14-ed361bb6f2b3","order_by":5,"name":"Lubna Baig","email":"","orcid":"","institution":"University College of Medicine and Dentistry, The University of Lahore","correspondingAuthor":false,"prefix":"","firstName":"Lubna","middleName":"","lastName":"Baig","suffix":""}],"badges":[],"createdAt":"2025-08-05 08:23:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7298133/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7298133/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89853813,"identity":"b5e99a3d-f351-4ac9-bc49-6b929fcddff4","added_by":"auto","created_at":"2025-08-25 18:20:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":603871,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7298133/v1/4e0c39a8-00b4-4d9a-a331-21188448f496.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development, Implementation, and Evaluation of an E-Portfolio System to Enhance Competency-Based Learning and Reflection Among 4th-Year Dental Students","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eOver the past few years, dental education has been steadily moving toward a more competency-based framework. The emphasis now is not just on memorizing facts, but on applying clinical skills, thinking critically, and behaving professionally in real-world settings. Traditional tools like end-of-rotation exams, logbooks, or even case-based discussions have been around for ages. They\u0026rsquo;ve done the job to some extent, but when it comes to things like self-directed learning or reflective thinking, they don\u0026rsquo;t always cut it [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Similar gaps have been observed in medical education where students do acknowledge the value of autopsy based learning but lacked direct exposure because they relied more on passive substitutes like online videos and printed material [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While still useful, these older methods often miss out on capturing the complete picture of student\u0026rsquo;s development during training. This has led to a growing push towards more continuous and connected approaches with e-portfolios becoming a key part of that conversation.\u003c/p\u003e\u003cp\u003eE-portfolios are basically digital spaces where students can gather all sorts of stuff from their learning journey\u0026mdash;like clinical case write-ups, reflections, pictures, videos, and even teacher feedback\u0026mdash;all in one place. So, it\u0026rsquo;s not just about assessment anymore; these platforms actually help students stay more involved and take charge of their own learning [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Since they let learners track their growth, pinpoint weak areas, and get continuous feedback, they offer a richer learning experience than the older paper-based stuff that can feel pretty scattered. Researchers have even linked e-portfolios to stronger professional identity, since they help students build a habit of reflecting and self-checking their work [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn dental education, where hands-on skills and clinical practice matter a lot, e-portfolios create a link between what\u0026rsquo;s taught in class and what\u0026rsquo;s done in clinics. When students upload cases, write reflections, or include photos and videos, it pushes them to really think through what they did and why [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This deeper thinking is especially useful for final-year students, who are about to move into full-time clinical roles\u0026mdash;it helps sharpen their ability to judge and improve their own work.\u003c/p\u003e\u003cp\u003eThat said, even though digital learning is picking up speed worldwide, e-portfolios haven\u0026rsquo;t really taken off in countries like Pakistan just yet. A few local studies show potential, but they also point out some big issues\u0026mdash;like weak digital systems, teachers not being trained, and students not really knowing how to reflect properly [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Often, these systems are launched without a solid plan. Students end up unsure how to use them, and teachers aren\u0026rsquo;t always ready to guide them. One study by Khan et al., for example, showed that while students were generally open to the idea, many didn\u0026rsquo;t find e-portfolios useful because they hadn\u0026rsquo;t been properly shown how to use them [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This may point us towards a broader issue as a recent study among dental professionals in Pakistan found that generally low levels of metacognitive awareness indicating many learners struggle with self-evaluation and reflection, skills that the e portfolios are designed to cultivate [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStudies from other countries stress that both teachers and students should be involved in designing these platforms from the start. When users help shape the system, it usually works better and feels more relevant to real learning goals [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Also, having structured help\u0026mdash;like proper training sessions and regular feedback is key if you want the system to be more than just a box-ticking exercise [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Without that, even the best-designed e-portfolio can end up gathering digital dust.\u003c/p\u003e\u003cp\u003eLocally, most studies so far have focused on general attitudes or practical hurdles related to e-portfolios, but very few have evaluated their real impact on things like learning outcomes, reflection habits, or the documentation of student competencies in clinical years [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In fact, there is hardly any research from Pakistan that involves the creation and use of a tailor-made e-portfolio system within a defined clinical teaching context. This lack of empirical evidence leaves teachers and institutions unsure about how to adopt these tools effectively in their own programs.\u003c/p\u003e\u003cp\u003eGiven this background, the present study was conceptualized to address the specific needs of 4th-year dental students by designing a structured, user-centered e-portfolio system. The main objective was to enhance student engagement in reflective learning and competency tracking through a platform tailored to the local academic environment. The study also aimed to implement this system within a real-time clinical rotation and evaluate its effectiveness through a mixed-methods approach. By doing so, the research hoped to contribute both theoretical insight and practical recommendations for integrating e-portfolios in Pakistani dental education. The objectives were therefore framed to develop a robust digital platform incorporating reflection tools, case uploads, and feedback features; to orient students and faculty for its effective use during clinical postings; and finally, to assess its impact on student satisfaction, reflective engagement, and perceived learning improvement through a structured post-implementation survey\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e This study followed a sequential exploratory mixed-methods design, allowing for in-depth exploration of expert consensus during the initial qualitative phase, followed by a structured quantitative evaluation based on student feedback. The purpose of this design was to identify essential components for an e-portfolio system through a Delphi process and then assess its effectiveness using a validated student perception survey. The entire study was conducted over a period of eight months, including planning, tool development, implementation, data collection, and analysis.\u003c/p\u003e\u003cp\u003eThe study took place at University College of Medicine and Dentistry (UCMD), the University of Lahore\u0026mdash;a private institution known for its focus on competency-based dental education. This setting worked well for the research because it provided access to a full group of fourth-year BDS students who were already involved in their clinical rotations. That made it a good spot to try out and evaluate how useful a digital platform like an e-portfolio could be for both learning and assessment.\u003c/p\u003e\u003cp\u003eThe first group of Delphi had ten experts who took take part in the study. These experts had a background in medical or dental education, and experience of more than five years in e-learning and/or curriculum planning. Seven of these experts completed all Delphi rounds. In the quantitative study the participants included all 75 students enrolled in the fourth year of the BDS program. Among these, 72 students completed the survey, resulting in a 96% response rate. The inclusion criteria required students to have actively participated in their clinical rotations and used the e-portfolio system for at least eight weeks.\u003c/p\u003e\u003cp\u003eThe e-portfolio platform itself was designed and developed by the principal investigator using HTML, CSS, JavaScript, and PHP, with MySQL as the backend database. The system included various features such as clinical case logs, reflective writing modules, multimedia uploads (e.g., images, PDFs), and a dedicated faculty feedback panel. Development of the platform took approximately four weeks. Once the platform was ready, a two-day orientation program was held. The first day focused on a workshop about the purpose and structure of the e-portfolio, while the second day provided hands-on training to students on how to log in, upload cases, and submit reflections. Printed user manuals and short video tutorials were also shared for continued reference.\u003c/p\u003e\u003cp\u003eThe study began with the Delphi method to reach expert consensus on key features for the proposed e-portfolio. In the first round, experts responded to open-ended questions, and their input was analyzed thematically. This led to a list of 8 important items, which were then rated on a 5-point Likert scale in a second round. Consensus was defined as at least 75% agreement with an interquartile range (IQR) of \u0026le;\u0026thinsp;1, following standards in medical education research [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Final features that received strong support included reflective writing, uploading clinical cases, structured feedback tools, and multimedia support.\u003c/p\u003e\u003cp\u003eAfter the platform was operational, the second phase of study focused on exploring student perspectives via a cross-sectional survey. The survey tool was adapted from previously validated instruments [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and refined further with contributions from subject matter experts [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. It consisted of 40 close-ended statements organized under four main themes : platform usability and accessibility, quality of reflective engagement, faculty feedback processes, and perceived impact on learning. Student responses were collected on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree).\u003c/p\u003e\u003cp\u003eTo make sure the questionnaire was clear and meaningful, face validity was checked through pilot testing with a small group of ten students who weren\u0026rsquo;t part of the main study. Content validity was addressed through a detailed expert review. Additionally, internal consistency was assessed, and Cronbach\u0026rsquo;s alpha came out to 0.84\u0026mdash;which is a good level of reliability in educational research [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFor the data collection process, students were expected to submit at least three clinical cases along with corresponding reflections during their clinical posting. Faculty were instructed to review these weekly and give feedback via the dedicated faculty interface built into the e-portfolio system. Students would receive automated email alerts whenever feedback was uploaded. After four months of use, an online survey link was shared with all 75 students using the university\u0026rsquo;s official email channel. Participation was fully voluntary, and anonymity of responses was ensured throughout.\u003c/p\u003e\u003cp\u003eData were analyzed using SPSS version 25. Qualitative responses from the Delphi phase were analyzed thematically, while quantitative survey responses were assessed using descriptive statistics, including means, standard deviations, and frequency distributions. Independent t-tests and Mann\u0026ndash;Whitney U tests were used to compare scores across gender, and Pearson or Spearman correlation tests were applied where relevant. Responses with missing or inconsistent entries were removed after careful screening.\u003c/p\u003e\u003cp\u003e Prior to initiating the study, ethical approval was obtained from the Institutional Review Board (IRB) of the University of Lahore (UOL/IREB/25/07/0070). Written informed consent was secured from all participants after explaining the study objectives, confidentiality, and their right to withdraw at any point without any academic consequences.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eDelphi Phase \u0026ndash; Expert Consensus on E-Portfolio Components:\u003c/h2\u003e\u003cp\u003eFourteen structured items were rated for relevance and usefulness in the second Delphi round. Most achieved consensus, while two\u0026mdash;time management and extracurricular activities\u0026mdash;were revised based on feedback and re-evaluated until consensus was reached. All final components are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDelphi Consensus on E-Portfolio Components\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComponent\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e% Agreement\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIQR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStatus\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePersonal \u0026amp;Academic writing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCase log uploads\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e89%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFaculty feedback panel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMultimedia (images/videos) support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e92%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInterprofessional collaboration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e88%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eResearch participation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e79%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTime management/comment options\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRecord of extracurricular activities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eRevised\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u0026ndash;14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRemaining 8 items\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;75%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eQuantitative Phase – Student Survey Results:\u003c/h3\u003e\n\u003cp\u003eOf these respondents, 58.3% were female (n\u0026thinsp;=\u0026thinsp;42) and 41.7% were male (n\u0026thinsp;=\u0026thinsp;30). The average age of the participants was 22.6 years. All had used the e-portfolio for a minimum of 8 weeks during their clinical rotations. The tool used to assess the students; s perception had 40 items divided into four domains: usability, reflective engagement, faculty feedback and learning impact. Results showed that most students were satisfied with the system across these areas. The highest rated item pertained to multimedia documentation (Mean\u0026thinsp;=\u0026thinsp;4.47\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.52), while usability also scored high (Mean 4.36\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.64). These values suggest the platform is not only accessible but also student friendly. The other domains averages showed that faculty feedback and reflective engagement were positively rated. The faculty feedback domain scored slightly lower on some items compared to others which these students attributed to variables response times form instructors. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDomain-Wise Summary Statistics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMin\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMax\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUsability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReflection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFeedback\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLearning Impact\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eGender based differences:\u003c/h3\u003e\n\u003cp\u003eA comparison of male and female students showed that on average female students gave higher ratings in nearly all domains. However the difference was significant only in reflection domain. Although other domains also had higher means for females, but the difference was not statistically significant. (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eGender Comparison of Domain Scores\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (Male)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean (Female)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUsability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.078\u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReflection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.042\u003c/b\u003e\u003csup\u003e(b)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFeedback\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.056\u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLearning Impact\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.061\u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e(a) T test, (b): Mann\u0026ndash;Whitney U\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo confirm the reliability of the student instrument Cronbach\u0026rsquo;s alpha was calculated. The alpha score was 0.84 indicating strong internal consistency which supports this tool\u0026rsquo;s use for evaluating e-portfolio systems in similar academic settings.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe Delphi process was quite effective in helping shape a contextually appropriate portfolio system, developed with strong agreement and consensus among local experts. Students feedback showed overall satisfaction with the platform, particularly in terms of its reflective component and ease of usability. Interestingly, female students were more engaged in reflective writing compared to males. Although the feedback feature received generally positive ratings overall, responses indicated that student experience was somewhat mixed. Still, the platform demonstrated good reliability and performed well within the given educational context.\u003c/p\u003e\u003cp\u003eThese findings are consistent with prior research. Gallagher et al. also found web-based portfolios to be effective among oral health students [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Similarly, \u003cb\u003eShaheen et al\u003c/b\u003e noted that traditional assessment methods often lack the ability to track progress over time. Sometimes this e-portfolio system can be addressed through structured feedback and continuous documentation [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAmong all assessed components, reflection emerged as one of the most positively rated mean score (4.07), pointing toward a meaningful engagement. The gender- difference in reflective depth was statistically significant (p\u0026thinsp;=\u0026thinsp;0.042), with female students showing a deeper involvement. This aligns with prior work by \u003cb\u003eGadbury-Amyot et al.\u003c/b\u003e and \u003cb\u003eWoldt MS et al\u003c/b\u003e who emphasized the role of structured reflection in shaping clinical judgment and professional identity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. One reason for the high level of engagement could be features such as built-in prompts for reflection, case-based modules, and opportunities for instructor feedback on their portfolios. \u003cb\u003eHeathman et al.\u003c/b\u003e, also observed that using structured rubrics can increase the reliability of reflective assessment which was incorporated in this platform design [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe difference in reflection quality between genders, suggested that future interventions could include templates or that is more supportive especially for the males students Activities like peer-led group discussions or small reflection circles could help give equitable opportunities for all students, irrespective of gender to participate\u003c/p\u003e\u003cp\u003eIn the initial phase, the Delphi method was used to develop the tool with contributions from key stakeholders. In total, 16 features were finalized like reflective writing, uploading clinical cases, feedback from faculty, multimedia support, and tracking competencies using these tools. Some features, like \u0026ldquo;direct messaging with supervisors,\u0026rdquo; sparked a lot of debate and were changed after feedback., This shows how open and evolving the Delphi process can be.\u003c/p\u003e\u003cp\u003eThis approach aligns with Greviana et al., who stressed about involving both students and faculty to enhance their utility and acceptance when creating learning tools [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Mathur et al also noted that collaboratively codesigned systems are more likely to overcome problems like institutional resistance or lack of participation [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Based on these results, this kind of model might work well and be more effective for other educational innovations too, especially where digital learning and interdisciplinary teamwork are important.\u003c/p\u003e\u003cp\u003eThe observed gender difference in reflective writing is also supported by earlier studies. For example, Nafari et al. found that female students tend to go deeper in their reflections in health-related disciplines [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This raises important questions about how to make reflective activities inclusive. Mentorship tailored for different and diverse needs or more flexible formats might help especially for male students. Cultural and social factors in Pakistan\u0026rsquo;s dental education system might influence how students engage with reflective learning, necessitating further exploration.\u003c/p\u003e\u003cp\u003eAlthough the feedback system got decent ratings overall, it scored a bit lower than other areas (4.10). Some students reported delays or inconsistent feedback, which may explain this trend. Javed et al also noted that some faculty members struggled to provide timely and constructive feedback in digital settings due to various other commitments and workload [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Heathman et al. emphasized that digital effective feedback works best when faculty are trained well in online tools and formative assessment techniques [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo address these challenges, institutions might consider training for faculty development programs that cover online mentoring, feedback timelines, and student reflections. Establishing clear policies for feedback timing and quality standards could further enhance the e-portfolio\u0026rsquo;s value.\u003c/p\u003e\u003cp\u003eHowever, some students noted that reflective writing felt like an additional task, particularly during busy clinical rotations. Though these concerns were not reported in writing, they reflect a common problem between clinical duties and time for reflection. Simon and Al-Ghailani reported similar observations, noting that students view reflection as burdensome unless it is integrated naturally into their routines. Shorter prompts, dedicated time slots, or reflection breaks during clinical training could help students engage without feeling overwhelmed [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAs with any research, limitations exist in this study. This study was conducted at a single institution, so findings may not apply everywhere. Secondly, the follow-up period spanned over three months, limiting insight into long-term effects. Additionally, feedback was collected solely from students, integrating faculty perspectives could have been beneficial. Finally, some students likely faced technical issues, such as unreliable internet or device problems, which may have impacted platform usage.\u003c/p\u003e\u003cp\u003eIn future studies involving multiple institutions and extended follow-up periods are suggested. It would also be good to compare different e-portfolio systems across different educational environments. Exploring how integrated digital platforms are combining formative and summative assessments affecting learning outcomes would be particularly beneficial. Long-term studies tracking e-portfolios\u0026rsquo; impact on clinical performance and professional development would be the next step.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe e-portfolio aided students in enhancing their reflective abilities and maintaining better organization during clinical rotations. Majority of students found the platform easy to use and advantageous. However, the study faced certain limitations, including brief duration, restriction to a single institution, and absence of faculty input. Allocating more time for student reflection and improving technology access could further boost results. For greater impact, future research should incorporate faculty viewpoints and be conducted on a larger scale to ensure broader applicability of the findings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Institutional Review Board (IRB) of The University of Lahore (IRB Approval Number: UOL/IREB/25/07/0070). All research methods and data collection were performed in accordance with the relevant guidelines and regulations of IRB approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and design of the study: \u0026nbsp;GA, UA, LB\u003c/p\u003e\n\u003cp\u003eAcquisition of data: GA, MAA, MHM, KM\u003c/p\u003e\n\u003cp\u003eAnalysis and interpretation of data: GA, MAA, MHM, KM\u003c/p\u003e\n\u003cp\u003eWriting the manuscript, drafting the article: GA, UA, MAA\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRevising content: MHM, KM, LB\u003c/p\u003e\n\u003cp\u003eFinal approval of the version: GA, UA, MAA, MHM, KM, LB\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and contributed to the manuscript, verified the manuscript and gave consent for its publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u0026nbsp;\u003c/strong\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding declaration:\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number:\u003c/strong\u003e Not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGallagher D, Radif MS, Zheng M, Iyer P. 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Educ Med J. 2023;15(3):17\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.21315/eimj2023.15.3.2\u003c/span\u003e\u003cspan address=\"10.21315/eimj2023.15.3.2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"E-portfolio, dental education, competency-based learning, reflection, clinical documentation, mixed-methods, student assessment","lastPublishedDoi":"10.21203/rs.3.rs-7298133/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7298133/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eWith the growing focus on competency-based education in dental curricula, traditional assessment methods often fail to support longitudinal competency tracking and meaningful student reflection. Electronic portfolios (e-portfolios) have emerged as effective tools to bridge this gap by enabling documentation of clinical experiences, reflective writing, and structured faculty feedback. This study aimed to develop, implement, and evaluate a customized e-portfolio system for fourth-year dental students.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA sequential exploratory mixed-methods design was adopted. In the qualitative phase, a modified Delphi method was used to reach expert consensus on core components of the e-portfolio system. In the quantitative phase, a cross-sectional survey was conducted among fourth-year dental students (n\u0026thinsp;=\u0026thinsp;72) after three months of using the e-portfolio. Thematic analysis was used for qualitative data, while descriptive and inferential statistics (independent t-test, Mann\u0026ndash;Whitney U, chi-square) were applied to quantitative data using SPSS version 25. Internal consistency of the survey tool was evaluated using Cronbach\u0026rsquo;s alpha.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eSeven experts completed all Delphi rounds, resulting in consensus on 8 core components of the e-portfolio, including reflective writing, clinical case uploads, multimedia support, progress dashboards, and structured faculty feedback. Of the 75 students, 72 completed the survey (96% response rate). Overall satisfaction was high: usability (mean\u0026thinsp;=\u0026thinsp;4.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64), reflective improvement (4.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.61), and documentation via multimedia (4.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52) received the highest ratings. A statistically significant gender difference was observed in reflective engagement, with females showing higher agreement (p\u0026thinsp;=\u0026thinsp;0.043). The survey instrument demonstrated strong reliability (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.84).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe study demonstrated that a structured, consensus-driven e-portfolio system can enhance clinical documentation, reflective practice, and student engagement in dental education. While student satisfaction was generally high, the findings highlighted the need for faculty training in feedback provision and strategies to reduce reflection-related workload.\u003c/p\u003e","manuscriptTitle":"Development, Implementation, and Evaluation of an E-Portfolio System to Enhance Competency-Based Learning and Reflection Among 4th-Year Dental Students","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-25 18:12:33","doi":"10.21203/rs.3.rs-7298133/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-13T07:29:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-06T06:09:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-18T14:59:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"258496869502842187980604212866122188793","date":"2025-09-18T14:49:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109210936489751963469132703321197688837","date":"2025-09-16T00:47:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-18T10:42:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"154095318941681338189687106736145514088","date":"2025-08-18T04:34:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33515670898436953260844978334833852657","date":"2025-08-18T04:34:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-16T04:07:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-14T09:46:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-13T12:42:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-08-13T12:39:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"833167b8-52bd-43ac-9dd8-8b84f0e9313f","owner":[],"postedDate":"August 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T13:53:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-25 18:12:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7298133","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7298133","identity":"rs-7298133","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}