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Abstract

Background

Oral health is frequently neglected among institutionalized older adults, despite its association with systemic morbidity and reduced quality of life. Residents of nursing homes and long-term care facilities often depend on nursing staff for daily oral hygiene. Although staff-focused oral-care programs are widely implemented, the extent to which nursing staff awareness directly influences resident oral-health outcomes remains insufficiently clarified.

Aim

To examine the relationship between nursing staff awareness—defined as knowledge, attitudes, perceptions, confidence, or training related to oral health—and oral-health outcomes among institutionalized older adults.

Methods

This systematic review was conducted in accordance with PRISMA 2020 guidelines. Electronic databases (PubMed, CINAHL, Web of Science, and Google Scholar) were searched for studies published between January 2000 and October 2025. Eligible studies included institutionalized older adults and evaluated nursing staff awareness alongside resident-level oral-health outcomes. Methodological quality was appraised using validated design-specific tools. Due to heterogeneity in study designs and outcome measures, findings were synthesized using structured narrative analysis.

Results

Eleven studies met the inclusion criteria. Most employed quasi-experimental or pre–post designs, while only a minority used controlled methodologies. Staff-focused oral-care interventions were consistently associated with improvements in plaque accumulation, gingival status, mucosal condition, and denture hygiene. However, nursing staff awareness was inconsistently measured and frequently inferred rather than directly assessed, limiting causal interpretation.

Conclusion

Structured staff-focused oral-care programs are associated with improved resident oral-health outcomes. Nonetheless, direct empirical evidence linking nursing staff awareness to clinical outcomes remains limited. Robust research designs incorporating validated awareness measures are required to clarify this relationship.

Keywords

nursing staff awareness oral health geriatric residents nursing homes systematic review long-term care

Introduction

Oral health (OH) represents a fundamental yet persistently neglected dimension of health among older adults residing in nursing homes and long-term care (LTC) facilities. Age-related physiological decline, multimorbidity, polypharmacy, frailty, and cognitive impairment collectively reduce the capacity of institutionalized older persons to perform adequate oral self-care. Consequently, residents often depend on nursing staff for routine oral hygiene, early recognition of pathology, and timely referral for dental management (Lipsky et al., 2024; Wong et al., 2019). Poor OH in this population is associated not only with localized complications, including pain, infection, impaired mastication, and nutritional deficiencies, but also with broader systemic consequences such as aspiration pneumonia, cardiovascular disease, and metabolic dysregulation (Müller, 2015; Son et al., 2020). Despite the well-documented clinical significance of OH, epidemiological evidence consistently demonstrates high prevalence rates of untreated caries, gingivitis, periodontal disease, and denture-related pathology within institutional settings (Cocco et al., 2018; Wong et al., 2019). This persistent burden highlights a critical discrepancy between evidence-based standards of care and routine clinical practice.

Within LTC environments, nursing staff constitute the principal workforce responsible for delivering daily oral care. Their responsibilities extend beyond mechanical plaque removal to include maintenance of mucosal integrity, denture hygiene, identification of early oral disease, and coordination of interdisciplinary care (Foiles Sifuentes & Lapane, 2020; Zimmerman et al., 2020). However, the provision of effective oral hygiene is not exclusively a technical procedure. Rather, it is shaped by cognitive, behavioral, and organizational determinants that influence how care priorities are interpreted and enacted. Empirical research has repeatedly shown that many nurses and caregivers receive limited formal education in OH, demonstrate variable levels of knowledge, and frequently report low confidence in performing mouth care (Catteau et al., 2016; Nitschke et al., 2024). Moreover, oral hygiene is often perceived as a secondary task when compared with other clinical responsibilities, particularly in high-workload institutional settings (Weening-Verbree et al., 2021). These patterns suggest that deficits in staff awareness may contribute to suboptimal oral-care practices and sustained OH deterioration among residents.

A critical conceptual distinction must therefore be emphasized between educational interventions and nursing staff awareness. Educational programs represent structured strategies designed to modify staff competencies, whereas awareness reflects the proximal cognitive domain encompassing knowledge, attitudes, perceptions, and perceived priorities related to oral care. Improvements in resident OH observed following staff training cannot be automatically attributed to increased awareness unless awareness is explicitly measured and analytically linked to clinical outcomes. Several intervention studies have reported reductions in plaque accumulation, gingival inflammation, and denture contamination after caregiver education (Frenkel et al., 2001; Kullberg et al., 2010; Seleskog et al., 2018). However, many of these investigations did not directly quantify changes in staff knowledge or attitudes, thereby limiting causal interpretation. Without explicit measurement, it remains unclear whether observed improvements resulted from enhanced awareness, improved procedural skills, increased supervision, or temporary behavioral modification during study periods.

Importantly, nursing staff awareness does not operate in isolation. Oral-care delivery is embedded within complex organizational systems characterized by staffing levels, workload intensity, institutional culture, availability of resources, and managerial priorities. Qualitative and mixed-methods evidence indicates that even knowledgeable caregivers may fail to provide adequate mouth care when constrained by structural barriers, including time pressure, competing clinical demands, and insufficient institutional support (Patterson Norrie et al., 2020; Weening-Verbree et al., 2021). Thus, the awareness–practice relationship is likely mediated by contextual determinants that can either facilitate or suppress the translation of knowledge into consistent care behaviors. Ignoring these systemic influences risks overstating individual-level factors while underestimating the critical role of organizational conditions in shaping care quality.

Although prior reviews have examined caregiver education, dementia-specific oral-care strategies, and implementation frameworks in LTC settings (Albrecht et al., 2016; Manchery et al., 2020; Pombo-Lopes et al., 2025), the specific relationship between nursing staff awareness and resident OH outcomes remains insufficiently synthesized. Existing literature frequently evaluates training effectiveness without disentangling awareness as an independent explanatory construct. This conceptual gap has significant implications for both policy and clinical practice. If awareness is inconsistently associated with measurable outcomes, then educational initiatives alone may be insufficient without concurrent organizational and structural reforms.

Accordingly, this systematic review was designed to examine the relationship between nursing staff awareness defined as knowledge, attitudes, and perceptions related to OH and the OH outcomes of residents in nursing homes and LTC facilities. By critically evaluating how awareness is measured, how it changes following interventions, and how it relates to resident-level clinical indicators, this review seeks to clarify the strength, limitations, and contextual dependencies of the awareness–outcome pathway. Understanding this relationship is essential for developing evidence-based, system-sensitive strategies aimed at reducing OH disparities among institutionalized older populations.

Methods

Design and Protocol Registration

This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement (Page et al., 2021). A review protocol was developed a priori to guide the eligibility criteria, search strategy, study selection, data extraction, and synthesis procedures. The protocol was not registered in PROSPERO. Although prospective registration is recommended to enhance transparency and reduce reporting bias, failure to register does not invalidate a systematic review when methodological procedures are predefined and consistently followed (Page et al., 2021). To mitigate potential bias, all review methods were established prior to study screening, and no post-hoc modifications were introduced.

Review Framework and Research Question

The review question was formulated using the Population–Exposure–Outcome framework, which is particularly suitable for reviews examining non-randomized exposures and practice-related phenomena (Joanna Briggs Institute (JBI), 2020). The population of interest comprised institutionalized older adults aged 60 years or older residing in nursing homes or LTC facilities. The exposure was defined as nursing staff awareness, operationalized as knowledge, attitudes, perceptions, confidence, or training related to OH and oral care. The outcome domain included resident-level OH indicators such as plaque accumulation, gingival or mucosal health, denture hygiene, caries, and standardized oral assessment indices. The resulting review question was defined as follows: “What is the relationship between nursing staff awareness of oral health and oral health outcomes among institutionalized older adults?”

Eligibility Criteria

Studies were considered eligible if they met four core criteria. First, the study population had to include institutionalized older adults aged 60 years or older residing in nursing homes or LTC facilities. Second, nursing staff or caregivers were required to constitute the exposure group. Third, the study needed to assess staff-related constructs associated with awareness, including knowledge, attitudes, perceptions, confidence, or oral-care training. Fourth, at least one resident-level OH outcome had to be reported.

To capture the multidimensional nature of awareness and oral-care delivery, quantitative, qualitative, and mixed-methods designs were considered eligible. Reviews, editorials, conference abstracts, and studies lacking resident-level outcomes were excluded. Studies focusing exclusively on community-dwelling older adults or dental professionals were also excluded. Only full-text articles published in English were considered.

Search Strategy and Information Sources

A comprehensive literature search was conducted in October 2025 across four major databases: PubMed, CINAHL, Web of Science, and Google Scholar. The search period was restricted to January 2000 through October 2025. This timeframe was selected to reflect contemporary developments in geriatric nursing models and structured oral-care interventions within LTC environments. The search strategy combined controlled vocabulary (e.g., MeSH terms) and keywords relating to nursing staff, caregivers, knowledge, awareness, attitudes, OH, nursing homes, and LTC. To enhance retrieval completeness, the reference lists of included studies and relevant reviews were manually screened. Key journals in geriatric dentistry and nursing were additionally hand-searched to reduce database indexing bias (Gusenbauer & Haddaway, 2020).

Google Scholar Screening Approach

Google Scholar was included to capture potentially relevant studies not indexed in traditional biomedical databases. Given its high recall and low precision characteristics, screening was conducted using relevance ranking. Consistent with methodological recommendations, the first 200 records were screened to reduce the likelihood of missing eligible studies (Gusenbauer & Haddaway, 2020). Screening continued until saturation was achieved, defined as the absence of new eligible studies across consecutive records.

Study Selection

All retrieved citations were imported into Rayyan systematic review software (Ouzzani et al., 2016), where duplicate records were identified and removed. Two reviewers independently screened titles and abstracts against the predefined eligibility criteria. Full-text articles were subsequently evaluated for inclusion. Disagreements were resolved through consensus, with arbitration by a third reviewer when necessary. The selection process was documented using a PRISMA flow diagram.

Data Extraction

Data extraction was performed using a standardized form to ensure consistency and reproducibility. Extracted variables included study characteristics (author, year, country, design, setting), sample size, measures of staff awareness, resident OH outcomes, intervention components, and principal findings. One reviewer conducted the extraction, and a second reviewer independently verified the accuracy of all entries.

Quality Appraisal

Methodological quality and risk of bias were assessed using validated design-specific tools. The JBI critical appraisal checklists were applied to quasi-experimental and cohort studies (Barker et al., 2024, 2025), while the Cochrane Risk of Bias 2 (RoB 2) tool was used for randomized trials (Sterne et al., 2019). Quality assessments informed interpretation of findings rather than serving as exclusion criteria.

Data Synthesis

Due to substantial heterogeneity in study designs, exposure measurements, and OH outcomes, quantitative meta-analysis was not appropriate. A structured narrative synthesis was therefore conducted following JBI methodological guidance (Lisy & Porritt, 2016). Studies were grouped according to design and outcome domain. Greater interpretive emphasis was placed on controlled and longitudinal studies, while findings from quasi-experimental designs were interpreted cautiously in light of potential confounding.

Results

Eleven studies met the inclusion criteria, the majority of which were conducted in nursing homes or LTC facilities in Europe and South America. Study designs were predominantly quasi-experimental or pre–post intervention studies, with only two controlled trials and one cluster randomized controlled trial (Frenkel et al., 2001; Seleskog et al., 2018) as in Figure 1.

Figure 1.

PRISMA flow chart demonstrating the study selection process in this review (Haddaway et al., 2022).

Study Selection

The database search across PubMed, CINAHL, Web of Science, and Google Scholar yielded studies published between January 2000 and October 2025. Following duplicate removal and multi-stage screening, 11 studies met the predefined eligibility criteria. The study selection process is summarized in Figure 1.

Study Characteristics

The included studies were conducted primarily in Europe and South America and demonstrated substantial methodological diversity. Most investigations employed quasi-experimental or pre–post intervention designs (Isaksson et al., 2000; Lago et al., 2017; Portella et al., 2015; Samson et al., 2009), while only two controlled trials and one cluster randomized controlled trial were identified (Frenkel et al., 2001; Nicol et al., 2005; Seleskog et al., 2018). Sample sizes varied considerably, ranging from small institutional cohorts (Kullberg et al., 2010) to large multi-site studies (Frenkel et al., 2001). Detailed study characteristics and quality appraisal outcomes are presented in Table 1.

Table 1.

Study Characteristics and Quality Appraisal of Non-Randomized Experimental Studies.

Citation	Country	Study Design	Setting	Sample Size	Participant Characteristics (Age and Gender Distribution)	Overall Quality (%)
Portella et al. (2015)	Brazil	Quasi-experiment with baseline evaluation and 1-year follow-up	Nursing Home (NH)	80 at baseline; 55 at follow-up	71.7% female; 4.2% aged 60–69; 36.6% aged 70–79; 43.4% aged 80–89; 15.8% aged 90+	56
Kullberg et al. (2010)	Sweden	Longitudinal evaluation pre- and post-education (3 weeks)	NH	43 at baseline; 41 at follow-up	Age 69–99 years; 12 men, 31 women	67
Frenkel et al. (2001)	United Kingdom	Cluster randomized controlled trial (RCT)	22 NHs	412 (IG = 178; CG = 200)	Mean age: IG 84.9 years, CG 84.0 years; IG 81.1% female; CG 75.8% female	89
Seleskog et al. (2018)	Sweden	Controlled clinical trial	Two NHs	IG = 15; CG = 22	Median age: IG 91 years, CG 88 years; IG 10 women, 3 men; CG 11 women, 7 men	89
Isaksson et al. (2000)	Sweden	Quasi-experimental pre–post design	Six LTC facilities	170 baseline and follow-up	Mean age: 84.6 years; 70% female	56
Nicol et al. (2005)	Scotland, UK	Controlled interventional study	Three NHs and two LTCs	78 (39 per group)	Group I: median age 84 (F), 82 (M); Group II: median age 86 (F), 80 (M)	78
Johansson et al. (2020)	Sweden	Longitudinal feasibility intervention	Three wards in one NH	48 (CG = 16; IG1 = 13; IG2 = 17)	Mean age: 88.7 years (73–98); 84.8% women	44
Samson et al. (2009)	Norway	Quasi-experimental repeated cross-sectional	One NH	88 baseline; 88 follow-up	Baseline: 74 women, 14 men; Follow-up: 69 women, 19 men	50
Lago et al. (2017)	Brazil	Longitudinal quasi-experimental study	One LTC	40 residents	Mean age: 82.3 years (60–97); 52.5% women	67
Zenthoefer et al. (2016)	Germany	Controlled trial	14 NHs	219 (IG = 144; CG = 75)	Mean age: 83.1 years; 68.5% female	67

Methodological Quality

Quality appraisal revealed moderate variability in methodological rigor. The controlled and randomized studies demonstrated comparatively stronger internal validity (Frenkel et al., 2001; Nicol et al., 2005; Seleskog et al., 2018), whereas quasi-experimental designs exhibited limitations associated with confounding, absence of randomization, and limited control of co-interventions (Isaksson et al., 2000; Samson et al., 2009). Common methodological concerns included selection bias, performance bias, and insufficient adjustment for institutional factors (Portella et al., 2015; Zenthoefer et al., 2016).

Measurement of Nursing Staff Awareness

Only a subset of studies explicitly measured nursing staff awareness. Awareness-related constructs included knowledge, attitudes, confidence, and perceived competence in delivering oral care (Johansson et al., 2020; Kullberg et al., 2010; Nicol et al., 2005). Studies that directly assessed awareness consistently reported improvements following educational interventions. For example, Kullberg et al. (2010) demonstrated statistically significant improvements in staff knowledge and confidence after a structured OH education program. Similarly, Nicol et al. (2005) reported enhanced caregiver knowledge and parallel improvements in resident oral hygiene indicators.

However, measurement instruments varied substantially across studies, and validated awareness assessment tools were rarely employed (Johansson et al., 2020; Nicol et al., 2005). Several intervention studies did not directly measure awareness but inferred its improvement based on resident OH outcomes (Frenkel et al., 2001; Samson et al., 2009; Seleskog et al., 2018). This methodological pattern limits the ability to determine whether observed clinical improvements were mediated by increased staff awareness or by alternative mechanisms, including procedural modifications or enhanced supervision.

Resident OH Outcomes

All included studies reported at least one resident-level OH indicator. Frequently assessed outcomes included plaque accumulation, gingival condition, mucosal health, and denture hygiene (Frenkel et al., 2001; Lago et al., 2017; Portella et al., 2015; Seleskog et al., 2018). Despite heterogeneity in assessment instruments and follow-up durations, most studies reported improvements in OH indicators following staff-focused interventions.

Controlled trials provided the most robust evidence. Frenkel et al. (2001) reported statistically significant reductions in plaque and denture debris among residents following caregiver education. Similarly, Seleskog et al. (2018) demonstrated improvements in mucosal-plaque scores under a dental-hygienist-supported oral-care model. In contrast, quasi-experimental studies consistently reported improvements in plaque, gingivitis, and denture hygiene (Isaksson et al., 2000; Lago et al., 2017; Portella et al., 2015), although the absence of control groups restricts causal inference.

Awareness–Outcome Relationship

Direct empirical linkage between nursing staff awareness and resident OH outcomes was limited. Only a minority of studies concurrently measured both domains (Kullberg et al., 2010; Nicol et al., 2005). Although studies assessing awareness frequently observed parallel improvements in resident OH indicators, none conducted formal mediation or correlational analyses to quantify this relationship. Across the evidence base, improvements in resident OH were commonly attributed to staff education or training (Frenkel et al., 2001; Samson et al., 2009; Seleskog et al., 2018). However, the absence of standardized awareness measurement and analytic modeling weakens the ability to isolate awareness as an independent explanatory construct.

Influence of Study Design

The predominance of quasi-experimental and uncontrolled designs introduces vulnerability to confounding and temporal bias (Isaksson et al., 2000; Samson et al., 2009). Co-interventions, including the introduction of new oral-care tools, standardized protocols, or enhanced clinical monitoring, were frequently described but rarely controlled analytically (Lago et al., 2017; Portella et al., 2015). Consequently, while improvements in OH indicators were consistently observed, attribution of these effects to nursing staff awareness alone remains uncertain.

Discussion

This systematic review examined the relationship between nursing staff awareness and OH outcomes among institutionalized older adults. Overall, the findings indicate that staff-focused oral-care interventions are consistently associated with improvements in plaque control, gingival condition, mucosal integrity, and denture hygiene. However, the evidence supporting a direct, quantifiable relationship between nursing staff awareness and resident-level OH outcomes remains limited and methodologically constrained.

The strongest evidence emerged from controlled and randomized studies, which demonstrated statistically significant improvements in resident OH indicators following caregiver-focused interventions (Frenkel et al., 2001; Nicol et al., 2005; Qtait, 2025; Seleskog et al., 2018). These studies provide comparatively robust protection against confounding and suggest that structured oral-care programs can positively influence clinical outcomes. Nevertheless, even within these higher-quality designs, awareness was rarely operationalized as an independent analytical construct. Instead, improvements were primarily attributed to educational or programmatic interventions, thereby limiting inference regarding the specific mediating role of staff awareness.

A central observation across the literature is the frequent conflation of education, training, and awareness. Many studies implicitly assumed that educational exposure directly increased staff awareness, yet few directly measured changes in knowledge, attitudes, or perceptions using validated instruments (Catteau et al., 2016; Johansson et al., 2020). This distinction is conceptually critical. Educational programs represent strategies designed to modify caregiver competencies, whereas awareness constitutes the proximal cognitive mechanism that may influence care delivery behaviors. Without explicit measurement, it is not possible to determine whether improvements in resident OH resulted from enhanced awareness, improved technical skills, increased procedural standardization, or heightened staff attention during intervention periods (Kullberg et al., 2010; Nicol et al., 2005).

Only a limited number of studies concurrently assessed staff awareness and resident outcomes (Kullberg et al., 2010; Nicol et al., 2005). Although these investigations reported parallel improvements across both domains, none conducted formal mediation or correlational analyses capable of quantifying the awareness–outcome pathway. Consequently, the empirical basis for interpreting awareness as an independent causal determinant remains weak. This methodological pattern is consistent with broader challenges in behavioral and implementation research, where proximal cognitive variables are frequently assumed rather than measured (Zimmerman et al., 2020).

Importantly, oral-care delivery within nursing homes and LTC facilities occurs within complex organizational systems. Structural determinants—including staffing levels, workload intensity, institutional culture, access to oral-care supplies, and managerial priorities—substantially influence care practices (Patterson Norrie et al., 2020; Weening-Verbree et al., 2021). Several included studies introduced system-level modifications alongside staff education, such as standardized oral-care protocols or new hygiene technologies (Lago et al., 2017; Portella et al., 2015). These co-interventions likely contributed to observed clinical improvements, yet their independent effects were rarely disentangled analytically. As a result, improvements attributed to awareness may partially reflect broader organizational or procedural changes rather than purely cognitive shifts among staff.

The predominance of quasi-experimental and uncontrolled designs further complicates interpretation (Isaksson et al., 2000; Samson et al., 2009). Such designs are inherently vulnerable to temporal bias, performance bias, and confounding by concurrent institutional initiatives. While improvements in plaque and gingival indices were consistently reported, causality cannot be confidently assigned to awareness-related mechanisms alone. This limitation underscores the importance of cautious interpretation, particularly when translating findings into clinical or policy recommendations.

From a theoretical perspective, the findings align with contemporary models of healthcare behavior, which conceptualize awareness as a necessary but insufficient condition for practice change. Knowledge and attitudes may influence caregiver intentions; however, translation into sustained clinical behavior requires enabling organizational conditions (Weening-Verbree et al., 2021). Thus, interventions exclusively targeting awareness may produce limited effects when systemic barriers remain unaddressed.

The geographic and temporal distribution of included studies also warrants consideration. Most investigations were conducted in European settings, with several published more than a decade ago (Frenkel et al., 2001; Nicol et al., 2005). LTC systems have since undergone substantial transformation in staffing models, regulatory frameworks, and infection-control standards. Accordingly, generalizability to contemporary LTC environments—particularly in low-resource or conflict-affected regions—should be approached cautiously (Pombo-Lopes et al., 2025).

Overall, the evidence supports the effectiveness of structured, staff-focused oral-care programs, yet does not provide strong empirical confirmation that nursing staff awareness alone functions as an independent determinant of resident OH outcomes. Rather, awareness appears embedded within broader educational, behavioral, and organizational processes. Future research should therefore adopt designs capable of explicitly measuring awareness, quantifying its mediating role, and incorporating multilevel analyses that account for institutional context (Zimmerman et al., 2020).

Strengths and Weaknesses

This review followed a structured systematic approach using a comprehensive multi-database search strategy. Methodological rigor was enhanced through the application of validated quality appraisal tools. Inclusion of diverse study designs enabled examination of oral-care practices across real-world LTC settings.

Several limitations must be acknowledged. The protocol was not registered, and substantial heterogeneity in study designs and outcome measures precluded quantitative synthesis. Most included studies employed quasi-experimental designs, limiting causal inference. Nursing staff awareness was inconsistently measured and frequently inferred rather than directly assessed.

Implications for Nursing Practice

OH should be systematically integrated into routine nursing assessment, documentation, and individualized care planning in LTC settings. Nurses must apply standardized OH assessment tools and ensure consistent monitoring of plaque control, mucosal integrity, and denture hygiene. Nurse managers should institutionalize evidence-based oral-care protocols, implement auditing mechanisms, and guarantee adequate access to supplies. Competency-based training that combines knowledge, supervised practice, and performance feedback is essential to strengthen clinical proficiency. Interdisciplinary collaboration with dental professionals should be formalized. Structural support, including appropriate staffing and workload management, is necessary to sustain effective oral-care delivery.

Conclusion

Staff-focused oral-care interventions are associated with improved OH outcomes among institutionalized older adults. Direct empirical evidence supporting nursing staff awareness, as an independent causal determinant remains limited. Organizational and contextual factors likely play a significant mediating role.

Supplemental Material

sj-docx-1-son-10.1177_23779608261434362 - Supplemental material for The Relationship Between the Awareness of Nursing Staff in Geriatric Institutions and the Dental Health of Residents: A Systematic Review

Supplemental material, sj-docx-1-son-10.1177_23779608261434362 for The Relationship Between the Awareness of Nursing Staff in Geriatric Institutions and the Dental Health of Residents: A Systematic Review by Samer H. Sharkiya, PhD, Irit Ohana, PhD, Mohammad Sabbah, PhD, Olga Lipovetski, PhD and Khaled Awawdi, PhD in SAGE Open Nursing

Footnotes

Acknowledgments

We would like to express our sincere gratitude to all individuals who have contributed to this research.

ORCID iD

Samer H. Sharkiya

Ethics Approval

This study was a systematic review that analyzed data derived exclusively from previously published research. Therefore, it did not involve direct interaction with human participants or the collection of identifiable personal data. In accordance with international research ethics standards and institutional policies, formal ethical approval and informed consent were not required. All included studies were assumed to have received approval from their respective institutional review boards or ethics committees prior to publication.

Author Contributions

All authors contributed equally to the conception, design, data collection, analysis, and writing of this manuscript. All authors read and approved the final version of the paper.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All data supporting the findings of this systematic review are derived from previously published, peer-reviewed studies that are publicly available in scientific databases, including PubMed, Scopus, CINAHL, Web of Science, and Google Scholar. No new primary data were generated or collected for this study. Detailed reference information for all included studies is provided within the manuscript. Data extraction tables and supplementary materials can be made available from the corresponding author upon reasonable request.

Supplemental Material

Supplemental material for this article is available online.

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