case study peer discussion

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• How to Write Discussions and Conclusions

The discussion section contains the results and outcomes of a study. An effective discussion informs readers what can be learned from your experiment and provides context for the results.

What makes an effective discussion?

When you’re ready to write your discussion, you’ve already introduced the purpose of your study and provided an in-depth description of the methodology. The discussion informs readers about the larger implications of your study based on the results. Highlighting these implications while not overstating the findings can be challenging, especially when you’re submitting to a journal that selects articles based on novelty or potential impact. Regardless of what journal you are submitting to, the discussion section always serves the same purpose: concluding what your study results actually mean.

A successful discussion section puts your findings in context. It should include:

• the results of your research,
• a discussion of related research, and
• a comparison between your results and initial hypothesis.

Tip: Not all journals share the same naming conventions.

You can apply the advice in this article to the conclusion, results or discussion sections of your manuscript.

Our Early Career Researcher community tells us that the conclusion is often considered the most difficult aspect of a manuscript to write. To help, this guide provides questions to ask yourself, a basic structure to model your discussion off of and examples from published manuscripts. 

Questions to ask yourself:

• Was my hypothesis correct?
• If my hypothesis is partially correct or entirely different, what can be learned from the results? 
• How do the conclusions reshape or add onto the existing knowledge in the field? What does previous research say about the topic? 
• Why are the results important or relevant to your audience? Do they add further evidence to a scientific consensus or disprove prior studies? 
• How can future research build on these observations? What are the key experiments that must be done? 
• What is the “take-home” message you want your reader to leave with?

How to structure a discussion

Trying to fit a complete discussion into a single paragraph can add unnecessary stress to the writing process. If possible, you’ll want to give yourself two or three paragraphs to give the reader a comprehensive understanding of your study as a whole. Here’s one way to structure an effective discussion:

Writing Tips

While the above sections can help you brainstorm and structure your discussion, there are many common mistakes that writers revert to when having difficulties with their paper. Writing a discussion can be a delicate balance between summarizing your results, providing proper context for your research and avoiding introducing new information. Remember that your paper should be both confident and honest about the results! 

• Read the journal’s guidelines on the discussion and conclusion sections. If possible, learn about the guidelines before writing the discussion to ensure you’re writing to meet their expectations. 
• Begin with a clear statement of the principal findings. This will reinforce the main take-away for the reader and set up the rest of the discussion. 
• Explain why the outcomes of your study are important to the reader. Discuss the implications of your findings realistically based on previous literature, highlighting both the strengths and limitations of the research. 
• State whether the results prove or disprove your hypothesis. If your hypothesis was disproved, what might be the reasons? 
• Introduce new or expanded ways to think about the research question. Indicate what next steps can be taken to further pursue any unresolved questions. 
• If dealing with a contemporary or ongoing problem, such as climate change, discuss possible consequences if the problem is avoided. 
• Be concise. Adding unnecessary detail can distract from the main findings. 

Don’t

• Rewrite your abstract. Statements with “we investigated” or “we studied” generally do not belong in the discussion. 
• Include new arguments or evidence not previously discussed. Necessary information and evidence should be introduced in the main body of the paper. 
• Apologize. Even if your research contains significant limitations, don’t undermine your authority by including statements that doubt your methodology or execution. 
• Shy away from speaking on limitations or negative results. Including limitations and negative results will give readers a complete understanding of the presented research. Potential limitations include sources of potential bias, threats to internal or external validity, barriers to implementing an intervention and other issues inherent to the study design. 
• Overstate the importance of your findings. Making grand statements about how a study will fully resolve large questions can lead readers to doubt the success of the research. 

Snippets of Effective Discussions:

Consumer-based actions to reduce plastic pollution in rivers: A multi-criteria decision analysis approach

Identifying reliable indicators of fitness in polar bears

• How to Write a Great Title
• How to Write an Abstract
• How to Write Your Methods
• How to Report Statistics
• How to Edit Your Work

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• Research article
• Open access
• Published: 01 December 2022

Integrated clinical case discussions – a fully student-organized peer-teaching program on internal medicine

• Johannes Reifenrath   ORCID: orcid.org/0000-0002-7216-5926 1 ,
• Nick Seiferth 1 ,
• Theresa Wilhelm 1 ,
• Christopher Holzmann-Littig 1 , 2 ,
• Veit Phillip 3 &
• Marjo Wijnen-Meijer 1  

BMC Medical Education volume  22 , Article number:  828 ( 2022 ) Cite this article

1631 Accesses

Metrics details

In response to students´ poor ratings of emergency remote lectures in internal medicine, a team of undergraduate medical students initiated a series of voluntary peer-moderated clinical case discussions. This study aims to describe the student-led effort to develop peer-moderated clinical case discussions focused on training cognitive clinical skill for first and second-year clinical students.

Following the Kern Cycle a didactic concept is conceived by matching cognitive learning theory to the competence levels of the German Medical Training Framework. A 50-item survey is developed based on previous evaluation tools and administered after each tutorial. Educational environment, cognitive congruence, and learning outcomes are assessed using pre-post-self-reports in a single-institution study.

Over the course of two semesters 19 tutors conducted 48 tutorials. There were 794 attendances in total (273 in the first semester and 521 in the second). The response rate was 32%. The didactic concept proved successful in attaining all learning objectives. Students rated the educational environment, cognitive congruence, and tutorials overall as “very good” and significantly better than the corresponding lecture. Students reported a 70%-increase in positive feelings about being tutored by peers after the session.

Peer-assisted learning can improve students´ subjective satisfaction levels and successfully foster clinical reasoning skills. This highlights successful student contributions to the development of curricula.

Peer Review reports

The SARS-CoV2-pandemic´s strain on medical schools has been hard [ 1 , 2 , 3 ] since many stakeholders in medical education are both caregivers and instructors. With limited staff available for teaching [ 4 ] and reduced on-campus presence, many classes were moved to emergency remote teaching courses [ 5 , 6 ]. Emergency remote teaching is the “alternate delivery mode due to crisis circumstances” as opposed to well-planned online teaching [ 7 ].

At Technical University of Munich (TUM) most lectures, seminars, and bedside teachings werecanceled or moved to emergency remote teaching in the spring semester of 2020. Within the student council, the notion quickly gained traction that a peer-assisted learning (PAL) program ought to be established to alleviate pressure on faculty staff while providing students with a safe environment for the acquisition and training of their clinical reasoning skills.

Several universities have promoted PAL programs. It refers to the “development of knowledge and skill through explicit active helping and supporting among status equals” [ 8 ] . Benefits of PAL are i) a similar knowledge base and an understanding of obstacles while studying (cognitive congruence) [ 9 , 10 ], ii) a positive learning environment void of complicated student-instructor relationships due to similar social status (social congruence) [ 9 , 10 ] and iii) relieving pressure on faculty staff [ 11 ]. PAL has been employed in teaching anatomy, physiology, and biochemistry [ 12 ], as well as communication [ 13 ], physical examination [ 14 ], and other procedural skills [ 15 , 16 ]. There students have been shown to assume the roles of lecturers [ 17 ], clinical or practical teachers [ 18 ], mentors [ 19 ], learning facilitators [ 20 , 21 ], role models [ 21 ], and assessors [ 22 ]. In our study, we wish to introduce a curriculum that was fully designed, delivered, and evaluated by undergraduate students based on the Kern Cycle [ 23 ] with minimum intervention by faculty staff. We thus empower students to holistically assume all of the twelve roles of a teacher as proposed by Harden and Crosby in 2000 [ 24 ].

Targeted at students in the clinical phase of their studies, we developed the novel Integrated Clinical Case Discussions (ICCD) that emphasize the training of clinical reasoning skills that are at the heart of the recently released second edition of the competence-based German Medical Training Framework (GMTF) [ 25 ]. In accordance with the GMTF three central learning objectives were identified: i) transfer of clinical knowledge, ii) fostering of diagnostic management skills, and iii) enabling students to discuss findings and procedures in a team. Clinical Case Discussions (CCD) have been shown to enhance clinical and scientific reasoning skills [ 20 , 26 ], self-directed learning [ 26 ], and exchange with colleagues [ 27 ].

This study seeks to explore whether a peer-moderated clinical case discussion can improve students´ subjective satisfaction level with learning opportunities in case of emergency remote teaching.

Setting and participants

For their studies of internal medicine students at TUM attend two series of lectures in two consecutive semesters: In the spring semester of their first clinical year, there is a series of lectures on the cardiovascular and hematologic systems. In the subsequent fall semester, they hear a series of lectures on nephrology, gastroenterology, and endocrinology. Students are routinely requested to evaluate all lectures on a five-point Likert scale. When in the spring semester of 2020 all lectures were moved to an emergency remote teaching format, the mean evaluation of lectures on internal medicine dropped by 1.44 points as opposed to the six years prior (from 1.96 to 3.4, where 1 denoted the greatest and 6 the lowest level of satisfaction).

To provide their peers with an additional opportunity to review the lectures´ content, three students initiated the peer-moderated Integrated Clinical Case Discussions. In the ICCDs we applied a lecture´s content to a patient´s case with special emphasis on diagnostic and management skills in accordance with GMTF level 2 (i.e. clinical reasoning skills).

We prepared ICCDs for 12 topics in the fall semester of 2020 and 12 topics in the spring semester of 2021. For each topic we allocated two 90-min sessions in the week immediately following the general lecture on the topic. We were able to offer one face-to-face and one online tutorial for 11 topics. Due to hygiene regulations, the remaining 13 topics were discussed exclusively online twice a week. The time resources needed for one tutorial included i) 18 h for the tutor to prepare and hold the ICCD, ii) 3.5 h for the organizing students to recruit and mentor tutors as well as to evaluate and advertise the sessions and iii) 1.5 h of supervision by the physician (Fig.  1 ). The remuneration was 250€ per tutor and tutorial and 246.66€ for each organizing student per month (In the first year: authors JR and NS—15 months, TW—5 months. This was later reduced to one organizing student only.). Tutors were trained and supervised by specialist physicians as part of their regular teaching duties (1.5 h per session). Physicians were not reimbursed by the ICCD team. ICCDs were completely voluntary. We advertised ICCDs through weekly email alerts and a note in students´ schedules.

Workflow for the preparation of one ICCD session. Three parties are involved in the preparation and implementation of an ICCD session: an administrative unit consisting of the organizing undergraduate students (*) and the TUM Medical Education Center (†) (bottom row), tutors (middle row) and clinical supervisors (top row). Their respective tasks are indicated at the relative time points for the preparation of one ICCD. The allotted time frame for each task per one ICCD session is included in round brackets. For their first meeting tutors and supervisors are provided with a checklist (‡), i.e. to i) define content-focal points, ii) select an appropriate clinical case iii) define a clinical skill essential for the successful completion of the case, and to iv) provide the tutor with important clinical findings (e.g. laboratory findings, images)

Conception of the didactic concept

ICCDs followed cognitive learning theory. Each session was set as an interactive problem-based learning scenario ( Clinical Case Discussion ), that facilitated learners´ active participation to organize and conceptualize information [ 28 ]. To prompt students to access pre-existing knowledge ICCD sessions started with a voluntary entry-exam of five multiple-choice questions. The prefix Integrated reflects the close alignment of student-led tutorials and the lectures conducted by faculty staff. ICCDs did not seek to introduce new facts but to offer a platform for reviewing and applying the lecture’s contents to a clinical case. Each ICCD comprised two clinical cases in which at least one skill apart from history taking was trained (usually the interpretation of laboratory findings). Tutors and lecturers chose a clinical case from the lecturer´s clinical experience that matched the lecture. Tutors then prepared a powerpoint presentation (Microsoft Corp., Redmond, Washington, USA) to facilitate the case discussion, which was checked by the lecturer for medical content and by the organizing students for the didactic concept. Tutors delivered online sessions through a university zoom account (Zoom Video Communication Inc., 5.7.7, San Jose, California, USA) and—if under the Covid-regulations permissible—face-to-face in the lecturing hall. We instructed tutors to follow a modified version of Linsenmeyer´s approach [ 27 ] (Fig.  2 ). Briefly, tutees´ participation and teamwork were gradually increased by moving from anonymous multiple-choice questions to group discussions in breakout rooms and finally to discussing the ideal diagnostic procedures in the plenary session. An example of one case can be found in the supplementary material S1.

Typical outline of an ICCD session. We modified Linsenmeyer´s approach to stimulating interaction between students (Linsenmeyer, 2021). One ICCD session propagates along the x-axis from left to right. Several layers along the y-axis indicate the roles a tutor assumes at each time point, the teaching techniques they employ (examples provided below), and the level of interaction this is likely to be incentivize between tutees. A: Each session starts with a knowledge probe intended to activate students´ prior knowledge by asking five multiple-choice questions that participants must solve individually and anonymously. As indicated by the green triangle at the bottom of the figure this requires only a minimum level of interaction between students. B: Subsequently, tutors introduce the session´s clinical case and moderate a plenum discussion in which participants collectively take a patient´s history, determine an appropriate diagnostic algorithm, and list differential diagnoses. This gradually raises the level of interaction (upward slope of the triangle). C: In the next stage participants are assigned to break-out groups of two to four students in which they practice interpreting patient-specific clinical findings, lab results or different image modalities. Tutors switch from group to group to help if needed. D: Finally, the breakout groups meet back in the plenum and discuss their findings and differential diagnoses under the tutor´s moderation. We rated this as the most demanding level of interaction as it requires students to present in front of a larger group. At this point, tutors are oscillating between facilitating the discussion as different groups present their findings and providing direct instruction when explaining the meaning behind lab results/images, etc. Under the tutor’s guidance differential diagnoses are eliminated and the final diagnosis emerges. E: Lastly the tutor outlines treatment options. Due to time constraints, this was predominantly done in direct instruction

Recruitment and training of tutors

Tutors were recruited from the student body of those students who had completed the lecture on internal medicine and passed the exam. The recruitment process was based on Engel´s approach [ 17 ] and included a publicly shared application form and a job interview in which a shared decision was made on the topic best suited to the tutor´s interests and experience. A standardized curriculum was designed for tutors and delivered by a joint group of clinicians, the TUM Medical Education Center, and the organizing students who provided the impetus for ICCDs (Fig.  1 ). Mandatory training consisted of an introductory seminar on the ICCD´s didactic concept and a lecture on how to teach clinical reasoning skills and stimulate group interaction. Tutors then prepared their tutorial with their clinical supervisor as described above.

Questionnaire

Tutee evaluations were collected online at the end of each session using EvaSys V8.1 (evasys GmbH, Lueneburg, Germany). The survey comprised 50 self-report questions (supplementary material S2). Items were rated on a five-point Likert scale from 1 (strongly agree) to 5 (strongly disagree). For selected items, we also asked open-ended questions.

The underlying concept of the evaluation tool was modeled on the Student´s Evaluations of Educational Quality Questionnaire (SEEQ), a validated and reproducible evaluation tool proposed by Marsh in 1982 [ 29 ]. Designed for summative assessment of faculty-administered teaching, the SEEQ had to be adapted to our specific needs. We adopted evaluation items “I Learning/Value”, “IV Group Interaction” and all applicable items of “III Organisation” and “V Individual Raport”, yet omitted items VI-IX, since participation was completely voluntary, and examinations were not part of the ICCDs. Following the SEEQ category “I Learning/Value” we compared students´ subjective assessments of gain in knowledge, skill, motivation, and overall grade [ 30 ] after attending only the general lecture with attending both lecture and ICCD. We excluded SEEQ-section “II Enthusiasm” since tutors would have to proactively volunteer to teach in addition to their regular workload. Instead, we wanted to measure tutors´ performance as levels of cognitive congruence and educational environment. The tutor intervention profile by De Grave [ 31 ]and the Student Course Experience Questionnaire by Paul Ginns [ 32 ] reflected the aforementioned categories in more detail than the SEEQ and served as a reference. (Appendix Table 1 ). We also asked tutees to identify roles the tutor had assumed for them as proposed by Bulte et al. [ 21 ]. Learning outcomes were assessed as comparative self-assessment (CSA) for aggregated data [ 33 ]. The questions´ wording was based on the GESIS survey guidelines [ 34 ].

We handed tutors a short survey that asked them to rate the helpfulness of the introductory seminar, their understanding of the overall concept, and their difficulties in preparing the ICCD and enjoyment of the process on a five-point Likert scale.

Statistical analysis

We analyzed data using SPSS Statistics for Windows version 27 (IBM Corp., Armonk, New York, USA) and Microsoft Excel (Microsoft Corp., Redmond, Washington, USA). We included all surveys that had answers to more than 50% of all questions. If a student visited multiple sessions, only their first response to each question was included in the analysis. Learning outcomes and shifts in attitude toward peer teachers were computed as the CSA-gain as proposed by Raupach et al. (2011) [ 33 ]. Briefly, at the end of each session students were asked to retrospectively rate their expertise in the item before and after attending an ICCD session. The average net increase in self-assessment was then displayed as a percentage-wise increase over the average initial self-assessment. Qualitative, descriptive data were measured on a five-point Likert scale and analyzed using mean, mode, and standard deviation. Testing for statistical significance was performed using a two-tailed exact Chi-Square Test for categorical variables. Mann–Whitney-U-test was used for the comparison of metric variables with non-normal distribution between two groups (learning outcome). A p-value of 0.05 was chosen a priori. Effect size was calculated using Cramer´s V for descriptive data and correlations were computed using Spearman Correlation. Cronbach´s alpha was computed to test for internal consistency for the categories “cognitive congruence” and “educational environment”. Answers to open-ended questions were analyzed according to qualitative content analysis by Mayring [ 35 ]. Author JR developed the major categories deductively based on probable answers and supplemented them with subcategories inferred from students´ final responses. Another author, NS, checked categories for traceability. Finally, a category tree with specific anchor examples and defined subcategories emerged. The frequency of items and total number of student comments were recorded.

In the fall semester of 2020, a total of 335 students enrolled in the general lecture, 149 (44.5%) of whom attended at least one ICCD session. In the subsequent spring semester, 334 students enrolled in the general lecture and 237 (71.0%) took part in at least one ICCD session. Some tutees attended multiple sessions throughout the semesters. In sum, we counted 273 student attendances in the first and 521 in the second semester, respectively.

We received evaluations from 32.4% of all participants ( n  = 125). 91 (72.8%) tutees were aged 25 or under and 96 tutees (76.8%) identified as female. This approximately reflected the general student population (female/male: 65/35; mean age: 24 years). Questionnaires without informed consent were excluded from further analysis.

We employed 19 tutors for the implementation of 48 ICCD sessions covering a total of 24 topics. Eleven (57.8%) of those tutors identified as female and 12 (63.1%) had gained previous experience in front-line tertiary teaching.

Acceptance of ICCD

The nature of the ICCD being an add-on to the standard curriculum, we aimed to create additional value to the core curriculum that could not be attained with lectures and seminars alone. Evaluation of the ICCD shall therefore be displayed in direct comparison to the corresponding lecture (Fig.  3 ). ICCDs were generally rated as excellent and significantly better than lectures for all categories: knowledge, skill, attitude, and overall grade. Effect size was greatest for overall grade (V = 0.58; p  < 0.01) and smallest for gain in knowledge (V = 0.37; p  < 0.01) in ICCDs as opposed to the lecture. We observed that gain in knowledge correlated with gain in skills (r = 0.56; p  < 0.01) and overall evaluation of the ICCD session (r = 0.61; p  < 0.01).

Evaluation of ICCD vs. lecture. A Kiviat diagram representing students´ mean subjective assessment after attending lectures alone (round dots) and after attending both lectures and ICCD (long dashes) in categories knowledge, skill, attitude, and overall grade each represented on one of the axes of the diagram. Students were asked to rate their gain in each of the categories for both tutorial and the respective lecture on a five-point Likert scale with 1 denoting the greatest and 5 the lowest degree of satisfaction. Questionnaires were administered immediately after each tutorial. Tutorials took place one week after the general lecture. All differences are significant ( p  < .01). Effect size was calculated using Cramer´s V

When asked how comfortable tutees felt about being tutored by peers for an ICCD, tutees indicated a 70% increase in positive feelings after the intervention (CSA gain = 69.57%, n  = 111).

We received 57 answers to the open-ended questions on satisfaction and improvement suggestions (Table 1 ). In these answers, a total of 123 text segments (k) were identified and grouped into four categories. Most test segments praised the general format of the ICCD (k = 45). The second most frequent category included individual feedback on tutors (k = 40). The third category addressed learning value (k = 24) and the last category included improvement suggestions (k = 14).

Evaluation of Tutors

Mean cognitive congruence and educational environment for all sessions were rated as excellent at 1.26 ( n  = 121) and 1.35 ( n  = 107) respectively. Most tutees ascribed the roles “information provider” ( n  = 106, 84.4%) and “facilitator” ( n  = 87, 69.6%) to their tutors. Several tutees also rated their tutors as “role models” ( n  = 68,54.4%) and “assessors” ( n  = 51, 40.8%).

Learning outcome

CSA of learning outcomes revealed an increase in the ability to apply the correct diagnostic algorithm to a given case by 74.65% ( n  = 115). Ability to interpret the findings of diagnostic procedures increased by 70.31% ( n  = 114).

The end-of-course examination on internal medicine in the fall semester of 2020/21 consisted of 70 questions with a mean score of 85%. 30 (43%) questions have been previously discussed only during ICCD sessions, and 40 questions (57%) only during lectures. ICCD questions were answered with a higher score compared to lecture questions (90.3% vs. 82.4%, p  = 0.074). Although not statistically significant, students’ overall performance measured as a grade in the end-of-course examination was improved by material produced during ICCD sessions.

15 of 18 eligible tutors (83.33%) completed the survey. One tutor (author JR) conceived the questionnaire and was thus excluded to prevent potential bias.

Tutors rated the introductory seminar as helpful (mean 1.20) and indicated that the concept of the ICCD had been clearly communicated to them (mean 1.07). They did not report extreme difficulties conceiving a clinical case (mean 1.4) and indicated enjoying the process (mean 1.33).

This study aimed to report on an undergraduate students´ initiative to facilitate the core curriculum on internal medicine by developing and implementing the novel Integrated Clinical Case Discussions to train cognitive clinical skills relevant to the pertaining lecture. This information can help develop further student-led initiatives to address emergency remote teaching or other perceived curricular deficits with the expressed goal of training cognitive clinical skills.

The direct comparison of ICCDs and lectures versus emergency remote lectures alone revealed tutees´ subjective increased proficiency in clinical reasoning (determining diagnostic algorithm and interpreting findings). Similarly, students´ satisfaction levels rose. Tutees expressed positive feelings about being tutored by peers and high cognitive congruence.

We recorded increased participation rates in the second semester of ICCDs. The participation rate was 44.5% in the first and 71.0% in the second semester respectively. These participation rates merit special consideration, as the compulsory curriculum at TUM fulfils the legally required minimum number of classes and is supplemented with a broad range of voluntary courses (There are another 72 elective and extracurricular courses). This results in a competitive curricular environment in which students may be less intent on yet another learning opportunity, though the ICCDs are the only course covering the full spectrum of the lectures on internal medicine. The above-mentioned and increasing participation rates indicate that there is a target group that welcomes the offer of ICCDs, especially in the second semester on the cardiovascular and hematologic systems. We conclude, that a peer-moderated ICCD in response to emergency remote teaching can improve students´ subjective satisfaction level with learning opportunities and is in line with previous research [ 36 ]. Student satisfaction is important to consider, as it is one of the five pillars of Quality Online Education [ 37 ] and is positively correlated with student performance [ 38 ].

Our results support other studies highlighting the effectiveness of peer-teaching [ 39 , 40 ] and CCD [ 41 , 42 ] in teaching cognitive clinical skills. We found that students attending ICCDs in addition to the lecture benefitted from a gain in skill, overall satisfaction, motivation, and knowledge. This aligns with the ICCD´s goal of generating added value to the core curriculum.

Second, we conclude empowering students to organize and execute courses provides an effective way to create custom-tailored and widely accepted teaching formats. The excellent ratings of subjective learning outcomes, educational environment, and cognitive congruence support the notion that student leadership can be useful for curricular development [ 36 , 43 , 44 ].

We described the human and time resources for preparing one ICCD session. With student teachers contributing the most hours to an ICCD we are aware that additional teaching responsibilities might act as an additional stressor on tutors. However, our results suggest that tutors enjoy the process, feel well instructed and mentored in the workflow we proposed. Similarly, previous research has highlighted the benefits of being a peer teacher [ 10 , 45 ]. Furthermore, students who agree to tutor have been shown to have the necessary resources to cope with the additional stress at their command [ 46 ].

It has been repeatedly demonstrated that voluntary courses receive better feedback than compulsory courses [ 47 ]. This study was limited by the ICCD´s voluntary nature, too. Selection bias in the evaluation may be introduced by the self-selection of students who are highly motivated to attend an ICCD session on top of the lecture in comparison to those who attended the general lecture alone. The modest overall response rate of 32% also suggests that certain opinions are likely to be overrepresented while others may be missing. However, with the respondent demographics reflecting the general student population at TUM, we believe our study provides worthwhile data. Response rates of approximately 30% have been reported before in the context of voluntary peer teachings [ 21 ]. A study by Bahous et al. (2018) suggests that the reliability between voluntary questionnaires with a low response rate and compulsory questionnaires with a high response rate is comparable [ 48 ]. To allow for a more comprehensive interpretation of results we also reported the maximum number of possible and de-facto attendances as demonstrated earlier [ 33 ]. The study design does not allow for a follow-up to assess the long-term impact on knowledge, skill, and attitude. Since our findings are based on data from one medical school in Germany they cannot be extrapolated to other medical schools without further consideration. However, the German model of medical education being common in Europe, we have reason to believe that study populations at other medical schools may be similar and our findings of value to their curricular designers [ 49 ].

Empowering students to design their own add-on learning opportunities can improve learning outcomes, teach clinical reasoning skills beyond the scope of the core curriculum and increase satisfaction ratings with learning opportunities. We believe that our concept provides an easy-to-implement and up-scalable format to alleviate pressure on faculty staff and physicians with teaching capabilities for other schools, too.

For future optimization, we propose to advance the beneficial effect of social and cognitive congruence by inviting lecturers to facilitate ICCD sessions in person as we are now planning at TUM for the fall semester of 2022/23. This ultimately leads to a triangularized teaching format in which a student-tutor moderates the discussion, lecturers support discussions with more in depth-knowledge and clinical experience, and tutees engage in an instructive discussion.

Availability of data and materials

The datasets during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Severe Acute Respiratory Syndrome Coronavirus Type 2

Technical University of Munich

Peer-assisted learning

Integrated Clinical Case Discussion

German Medical Training Framework

Clinical Case Discussion

Student´s Evaluations of Educational Quality Questionnaire

Comparative Self Assessment

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Acknowledgements

We would like to thank all our tutors for their outstanding engagement and continuous feedback on improving ICCD as well as all the people who have provided useful productive feedback on earlier manuscripts. We would particularly like to thank the reviewers of this article for their encouragement and highly detailed feedback.

Open Access funding enabled and organized by Projekt DEAL. This work was kindly supported by the Technical University of Munich under a grant for teaching-related projects of excellence at Technical University of Munich (TUM) (“Studienbezogene Exzellenstrategie der TUM”) and partly under a fund jointly handled by student representatives and the TUM Medical Education Center (“Planungsmittelkommission”).

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Johannes Reifenrath, Nick Seiferth, Theresa Wilhelm, Christopher Holzmann-Littig & Marjo Wijnen-Meijer

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JR conceived the didactic concept of the ICCD, developed the questionnaire, and oversaw the data acquisition. NS was chief exchequer, head of human resources, and coordinated cooperation with the lecturers. TW developed administered the online material, zoom-links, and monitored student commentaries for continuous improvement. CHL helped with conceiving the evaluation tool and data analysis. VP matched lecturers to the ICCD sessions, facilitated their communication with the tutors, and majorly revised the manuscript. MWM conducted the didactic lecture and majorly revised the manuscript. All authors have read and approved the manuscript.

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At the time of the study the following statements apply:

Johannes Reifenrath is a fifth-year medical student at Technical University of Munich, School of Medicine, and a student representative to the school´s committee on curricular development.

Nick Luca Seiferth is a fifth-year medical student at Technical University of Munich, School of Medicine, and a student envoy to the school´s faculty council.

Theresa Wilhelm is a sixth-year medical student at Technical University of Munich, School of Medicine, and a student representative to the school´s committee on curricular development.

Christopher Holzmann-Littig, MD, is a resident at Technical 482 University, School of Medicine, Department of Nephrology, and a 483 member of TUM Medical Education Center.483 member of TUM Medical Education Center.

Veit Phillip, MD, Instructor of Medicine, is a senior physician at Technical University, School of Medicine, Department of Gastroenterology and coordinates the lectures on internal medicine.

Marjo Wijnen-Meijer is head of innovation at the TUM Medical Education Center and specializes in curricular development.

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Appendix Table 1. Cognitive Congruence and Educational Environment. The table gives an overview of the items used to compute the cognitive congruence between tutors and tutees using the mean of section “1. Cognitive Congruence”, where 1 denotes the greatest and 5 the lowest level of tutees´ satisfaction. Tutees´ perception of the educational environment was computed by calculating the mean of the items in section “2. Educational Environment”. Cronbach´s alpha for cognitive congruence was 0.76; for educational environment 0.83.

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Reifenrath, J., Seiferth, N., Wilhelm, T. et al. Integrated clinical case discussions – a fully student-organized peer-teaching program on internal medicine. BMC Med Educ 22 , 828 (2022). https://doi.org/10.1186/s12909-022-03889-4

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Promoting Peer-to-Peer Synchronous Online Discussions: Case Study of Intercultural Communication in Telecollaboration

Introduction.

With increases in the number of online and blended learning courses, many instructors and researchers are exploring ways to foster peer-to-peer online discussion through well-designed and purposeful online activities, many of which unfold among peers within synchronous discussion platforms (Helm, 2013, 2016; Kang & Im, 2013; Moore, 1989; Woo & Reeves, 2007). Peer-to-peer interaction plays a critical role in many online learning contexts, particularly in language education in which fostering opportunities for written and oral communication are key objectives shared by teachers and students. Instructors and researchers have therefore focused attention on creating such interactive and collaborative opportunities particularly through a variety of synchronous and asynchronous technologies so that participants have opportunities for virtual learning across cultural, linguistic, and geographic boundaries as they develop the intercultural skills associated with intercultural communication (Belz, 2003; Bohinski & Leventhal, 2015; Guth & Helm, 2010; Slaouti & Motteram, 2006).

This chapter offers a key contribution to this volume in an examination of how to maximize the affordances of synchronous communication in order to promote peer-to-peer synchronous discussions. To that end, the project is localized in the context of language education with in a particular case of a telecollaboration, an online exchange between participants in different geographic, linguistic, and cultural contexts. Peer-to-peer online discussions—those that lead toward opportunities for learners to engage in intercultural communication—hold untapped potential for participants to learn how to initiate, sustain, and engage in complex discussions around topics of joint interest. Unlocking this potential challenges instructors to develop a better understanding of the ways in which classroom-based pedagogical structures can support collaborative learning online among peers. In this effort, the study responds to the call by Levy and Moore (2018) to view task design as “a starting point for learning” by extending opportunities for learners to “interpret tasks and (inter)act in task-based activity to create their own learning opportunities” (p. 2).

To achieve the promotion of high-quality online interactions, instructors need a better understanding of how to purposefully design online discussion tasks and facilitation protocols. The use of protocols can provide structured guidance to engage learners in online interactions and facilitate their learning process (Chen, deNoyelles, Patton, & Zydney, 2017). Facilitation protocols sit at a strategic crossroads for instructors; on the one hand, they communicate the instructor’s view of the interactional purpose and set a particular overarching tone; and on the other hand, participants need enough freedom to co-produce knowledge without putting unnecessary constraints on the emergence of authentic, learner-driven conversations (Darabi, Liang, Survavanshi, & Yurekli, 2013). Well-designed protocols; therefore, balance these goals that provide guidelines without forcing straitjackets so that peer-to-peer interactions can fulfill pedagogical and personal goals (McDonald, Zydney, Dichter, & McDonald, 2012). To address these concerns, researchers have explored ways to structure classroom-based online discussions to better support participants in initiating and sustaining online discussions (Fuchs, Snyder, Tung, & Han, 2017; Liddicoat & Scarino, 2013; O’Dowd, 2016b).

The goal of this chapter is to examine the ways in which teachers in a qualitative case study engage in peer-to-peer online discussions through purposeful task and protocol design that explicitly layer in reflective synchronous conversations. Its particular focus is on distance learning contexts in which participants communicate across distinct and geographically distal locations. Hence, the study explores ways that both multimodal technologies of video sharing as well as real-time videoconferencing can serve as vehicles for engaging learners around explicitly designed facilitation protocols. To this end, the following questions frame this study:

What are the major challenges associated with integrating peer-to-peer, small-group discussions into the context of online learning?

How can facilitation protocols be structured into synchronous, small-group interaction activities as part of the overall structure of online learning?

Key Terms in this Chapter

Computer-Mediated Communication : Online communication that are mediated or affected by different communication technologies.

Teacher Noticing : Teachers’ ability to attend to key instructional incidents and to connect theory and practice with the support of reasoning.

Online Discussion Facilitation : Guided support to effectively engage learners in online discussions.

Intercultural Learning : The knowledge and skills learners need to interact and collaborate with others from different cultures.

Synchronous Online Discussion : Online interactions where learners can view and interact in real time via the platforms of synchronous communication tools (e.g., video conferencing, Skype, Whatsup).

Teacher Reflection : Teachers’ meta-awareness of their thinking or perceptions.

Discussion Protocol : A text-based tool that offers a structured process or guidelines for learners to follow.

Telecollaboration : Virtual exchanges occur among learners across cultures and distances to interact and collaborate on different online communication platforms.

Video-Based/Imbedded/Simulated Reflection : The use of video to generate rich artifacts for reflection.

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Article Contents

Introduction, judgement and decision making in social work, aims and purpose of the model, empirical studies, cognitive continuum theory, peer-aided judgement, a model of peer-aided judgement in social work.

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Theorising Social Work Sense-Making: Developing a Model of Peer-Aided Judgement and Decision Making

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Duncan Helm, Theorising Social Work Sense-Making: Developing a Model of Peer-Aided Judgement and Decision Making, The British Journal of Social Work , Volume 52, Issue 4, June 2022, Pages 2329–2347, https://doi.org/10.1093/bjsw/bcab178

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This article addresses the challenges of sense making in social work practice and presents a descriptive model of peer-aided judgement to facilitate critical debate and knowledge creation. The model is founded in Hammond's Cognitive Continuum Theory and developed in direct application to social work practice. It seeks to expand currently available models of social work judgement and decision making to include processes and outcomes related to informal peer interaction. Building on empirical studies and multiple contemporary literatures, a model of peer-aided judgement is hypothesised, comprising four distinct and interacting elements. By modelling these fundamental aspects of the processes and outcomes of peer-aided judgement, this article provides a tool for illuminating the everyday unseen value of peer interaction in practice and a framework for critical debate of dilemmas and propositions for professional judgement in social work practice. This article concludes by examining some of the implications of the model and its potential use in the further development of theory, methodology and practice.

‘Decision making is a core professional activity at the heart of social work with much of what social workers do involving making decisions with others .’ ( O’Sullivan, 2011 , p. 1, emphasis added). O’Sullivan’s seminal text takes it as axiomatic that very few social work judgements and decisions are made by individuals in complete isolation. The nature of this shared decision making is complex and has been explored to a considerable depth in a range of domains. For example, direct involvement of service users and carers in decision making is a core social work value ( Payne, 1989 ) and subject of considerable research ( Beresford and Carr, 2012 ; Kennan et al. , 2018 ). Case reviews have identified failures of inter-professional assessment as significant contributory factors (e.g. Reder et al. , 1993 ; Munro, 2008 ). Furthermore, involvement of direct line-management in decision making (often through individual supervision) is also an accepted mainstay of support and guidance for professional practice (e.g. Kadushin and Harkness, 2002 ). Social work decision making is therefore seen as an activity inevitably carried out ‘with others’. Whilst the literature on service user involvement, inter-professional practice and supervision is relatively extensive, less attention has been paid so far to the role of informal peer interaction in judgement and decision making; the kind of ongoing contact and informal case talk within social work teams, which is a daily reality in practice.

The author’s own ethnographic study of sense making in a UK local authority child and family social work office provided new insight into the level and significance of peer-interaction as a process of informal shared sense making in social work ( Helm, 2016 , 2017a ). A review of the relevant literature revealed a dearth of research and theory on peer supervision (or consultation) even though ‘Much significant supervision takes place spontaneously among peers, with social workers commonly relying on colleague support, guidance and discussion in relation to their work with specific cases.’ ( O’Sullivan, 2011 , p. 159). This article argues that such interactions between colleagues constitute a form of networked sense making, which plays a fundamental role in professional judgement. Drawing on multiple literatures, this knowledge gap is interrogated and a theoretical model of peer-aided judgement ( Hammond, 1996 ) is proposed to help map and describe this new territory and its significance for further exploration.

Social workers are routinely required to make complex, subjective judgements in conditions of chronic uncertainty ( Helm, 2010 ). Such practice is stressful and subject to the duality of error: Social work errors will include false positives as well as false negatives ( Dalgleish, 2003 ) so no decision is risk-free. Social work may also be described as a ‘wicked’ learning environment (as opposed to a ‘kind’ one) as feedback on judgement and decision making is often delayed, inaccurate or simply unavailable ( Hogarth, 2001 ; Devaney and Spratt, 2009 ). This is a challenging environment for judgement and decision making ( Dalgleish, 2003 ) and attention to the environment, or ecology, of judgement is of fundamental importance .

In an overview of different models applied to the study of social work judgement and decision making, Taylor (2012) recognised that much of the research in this field is atheoretical and that there is a need for theoretical, conceptual models of social work judgement to be developed to guide research, support practice and inform professional education.

The proposed model is a simplified, descriptive model of the essential elements of peer-aided judgement in social work. It draws on psychological theory and a relatively small, but growing, set of data from a range of practice-near studies of judgement and decision making. It provides a framework for the closer examination of the way that intuition and analysis operate as integrated parts of social work reasoning processes. Such models can provide opportunities to gather empirical data and test hypotheses ( Johnsson and Svensson, 2005 ) and the model is presented here with the primary purpose of stimulating debate and extending theory and research in this area.

The original doctoral study ( Helm, 2017a ) which catalysed this contribution to the development of theory has been written up in previous papers and further details on background, methods and findings can be found in those papers ( Helm, 2016 , 2017b ). A brief overview of research design and key findings will be given here and consideration will be given to the limitations of the study and their relevance for the model presented.

The original study was a non-participant ethnography of sense making in a social work office. Ethical approval was given by the General University Ethics Panel and ethical concerns identified were managed through existing arrangements for researcher and participant supervision. It was carried out in one local authority child and family social work team over twelve weeks with the researcher observing the duty social worker's movements and interactions with people and artefacts in the course of their work. The study was inductive, and Miles and Huberman's (1994 ) analysis framework was used to identify themes and patterns emerging from the data gathered through observation, contemporaneous notes and reflective recordings.

The study found that social workers were agentic in connecting with their colleagues to discuss many different dimensions of their work with children and their families. They actively managed proximity and choice of which topics to discuss with different peers ( Helm, 2016 , 2017a ). Emotions play a significant role in sense making and findings made links between practitioners feeling secure and being able to exercise curiosity and critical rigour in their thinking ( Helm, 2016 ). Practitioners were found to be discriminating users of peer-support and this kind of informal collegial or peer interaction was identified as a distinct form of support for judgement, bridging the gap between entirely individual sense making and more structured and formal shared decision-making forums ( Helm, 2017a ).

There has been little evaluation of naturalistic social work decision making ( Hackett and Taylor, 2014 ) but a range of near-practice studies have now begun to provide valuable insight (e.g. Gillingham and Humphreys, 2010 ; Ferguson, 2011 ; Helm, 2016 ; Saltiel, 2016 ; Cook, 2017 ; Whittaker, 2018 ) and can be used to construct theoretical models of judgement and decision making in practice. By drawing on thick descriptions of actual practice ( Geertz, 1973 ) it may be possible to counter the tendency to offer top-down solutions based on normative models of rationality ( Helm, 2017a ). The findings from my own doctoral study have accordingly been synthesised with the broader research findings to inform a hypothesised model of peer-aided judgement. The model focuses on social relational aspects of social work sense making instead of adopting more controlled research designs and tuning out such important variables as if a form of contextual white noise.

The theoretical framework underpinning the proposed model was developed originally by psychologist Kenneth Hammond. Hammond's Cognitive Continuum Theory (CCT) ( Hammond, 1996 ) provides a framework for the study of individual's engagement with information from the task environment to make clinical judgements ( Hammond, 1955 ). I will summarise the main tenets of the theory before exploring its relevance to the further development of models of social work judgement and decision making.

Theories about modes of cognition tend to focus on the dual processes of intuition and analysis (e.g. Epstein, 1994 ; Sloman, 1996 ). Dual process theorists argue that there are two separate cognitive systems: System 1 being rapid, automatic and requiring little cognitive effort whilst System 2 is slow, deliberate and cognitively demanding ( Kahneman, 2011 ). System 1 is often likened to the autopilot dealing with routine and ordinary judgement tasks with System 2 only taking over when the demands of the judgement task are sufficiently high as to be warranted. In the field of judgement and decision making, System 1 equates to intuition and System 2 to analysis ( Kahneman, 2003 ).

Most contemporary research on judgement and decision making has focused on the strengths of analytic cognition and the limitations of intuition (e.g. Gilovich et al. , 2002 ) and this has been echoed in social work (see e.g. Brandon et al. , 2008 ; Wonnacott and Watts, 2014 ). Despite the popularity of dual process models, there is little empirical data on the ways that these two systems interact ( Dhami and Thomson, 2012 ) and this is a significant gap for social work as a profession where the gut instinct of intuition and the defensible logic of analysis are both required in combination.

CCT is based on a number of fundamental propositions ( Hammond, 1996 , 2000 , 2001 ):

cognition moves on an intuitive-analytical continuum (our thinking is not fixedly either intuitive or analytical);

forms of cognition lie on the continuum between intuition and analysis; this ‘quasirationality’ includes elements of both intuition and analysis; and

the properties of different cognitive tasks will induce different forms of cognition: intuition, quasi-rationality and analysis.

Our cognitive strategies ‘… most of the time are neither fully intuitive nor fully analytical’ ( Hammond, 2007 , p. 237). The term ‘quasirationality’ describes cognition between the poles of intuition and analysis. Quasirationality comprises different combinations of intuition and analysis to best fit with the properties of the judgement task and our level of expertise ( Hammond, 2007 ). Judgement tasks that present large amounts of complexly related data to an unfamiliar judge with little time or access to feedback will induce intuitive cognition. Tasks that present less information in a more structured way, with more time and opportunities for feedback, will induce analytical cognition ( Hammond et al. , 1987 ; Hammond, 1996 ).

A social worker is unlikely to employ a highly analytical mode of cognition as the nature of practice precludes the higher levels of manipulation required to create the required task environment (such as controlled testing or blinding) ( Standing, 2010 ). Systems to aid judgement may include assessment frameworks, policies and processes (such as core group meetings) and these provide a supporting structure for clinical judgement through application of research findings and theory or checks and balances on individual judgements. However, these systems are not used in a vacuum. Social workers will share some high-level judgements with line managers but the majority are made intuitively or through informal interaction and discussion with colleagues. As such, social workers are highly reliant on peer-aided judgement to move from strongly intuitive modes of cognition towards to the more conscious, explicable and defensible forms of analytical cognition.

Peer-aided judgement in health settings has been conceptualised as ‘extending professional knowledge with experienced colleagues and seeking expert advice where required.’ ( Standing, 2010 , p. 114). The great majority of judgements made by social workers are not made in collaboration with managers or consultants but in discussion with colleagues. Through informal discussion and non-deliberate sharing of information, judgements are regularly but perhaps unthinkingly co-created with peers. Sense making is a dialogical and social process ( Cook and Gregory, 2020 ) and, in social work, peers play a fundamental but poorly understood role in this process.

CCT provides a powerful mechanism for understanding the direct relationship between the structure of the judgement task (the task environment) and the form of cognition that it will induce. Social work practice is distinct in the levels of uncertainty faced in making judgements, the social/moral dimension of many judgement tasks and the tradition of working in teams. Social work is inherently social in its concerns and in its practices. We make judgements and decisions within complex networks and our peers play a fundamental role in how these responsibilities are carried out.

The following diagram identifies core elements of peer-aided judgement ( Fig. 1 ) and their role in relation to processes and outcomes. Each hypothesised element is addressed in turn so that propositions on peer-aided judgement can be made explicit and therefore subject to critical debate and further inquiry.

This component of the model acts as a mediator for all other elements and it is therefore addressed first. There are multiple barriers and facilitators to peer-aided judgement. The key variables in this part of the model include the temporal, spatial and psycho-social.

Peer-aided judgement is more accessible when people have worked together long enough to understand each other’s judgement policies and have a shared history of sense making ( Hammond, 1996 ). Earlier studies suggest that these shared experiences may serve to develop trust and make it more likely that these peers will seek each other out in future judgement tasks ( Kram and Isabella, 1985 ).

Judgement processes are played out over different timescales. Whilst intuitive judgements may be more or less immediate, more analytical judgements require more time. Found that proximity with peers over time in shared office allowed social workers to share uncertainties, hypotheses and reflections. For example, one social worker was observed speaking to their nearest colleague as a way of sharing their developing hypotheses, e.g. ‘maybe I’m reading something into it…’ as well as reviewing earlier judgements, e.g. ‘reflecting back…perhaps I could have…’ which was possible because of their shared history and understanding of these case examples (p. 391). However, whilst time spent together may help social workers to access peer-aided judgement it may not necessarily lead to more better judgements and this domain of evaluative function also requires consideration within any model of these processes.

The richness of direct face-to-face communication may be facilitated by working spaces and team cultures where case discussion and sharing is encouraged between peers. Research comparing difference in practice between teams in large open-plan ‘hot-desk’ offices and teams in smaller, ‘own-desk’ offices ( Ferguson, 2020 ) has identified benefits from these smaller more connected teams in relation to more supportive, reflective working practices. Jeyasingham (2015 ); Saltiel (2016) ; and Helm (2016 ) suggest that social workers actively engage with office layout to create more or less private spaces for peer interaction. Peer-aided judgement is now increasingly accessed through mobile technology and this rapid and generally uncritical move of social work sense making into the cyber-spatial dimension requires further attention in its own right.

Policy and management practices that emphasise positivism and risk elimination over social constructionism and engagement with risk are less likely to create an environment where thinking and feeling are as highly prized or rewarded as action (Cooper et al. , 2003 ). Qualities such as open-mindedness and professional commitment have been correlated with capacity for engagement with uncertainty and complexity ( Ruch, 2007b ) but they are not fixed properties of the individual, and opportunities for peer support in judgement are likely to be influenced by a wide range of psycho-social factors. Other ethnographic studies have found that social workers gained catharsis from talking to colleagues after difficult home visits. This ‘interpersonal emotional processing’ was seen as built on trust:

‘I think with informality you’ve got to trust the person haven’t you?’ ( Cook, 2016 , p. 197).

Diversity within the social work workforce requires a model of peer-aided judgement to include social and cultural dimensions. Consideration must therefore be given to dimensions such as gender, age or ethnicity within the workforce may influence access to peer-aided judgement.

Having considered some of those factors that influence ‘access’ to peer-aided judgement, I now consider core elements of the process directly: Security, Acquisition, Generation and Evaluation (SAGE).

Emotions are central to social work sense making, including the impact of anxieties not being effectively contained ( Bion, 1962 ; Ruch, 2005 ; Morrison, 2006 ). Social workers act as a focus for the projection of society's anxieties and blame ( Taylor et al. , 2007 ) and this emotional context is both a challenge and an integral part of the judgement task. The supportive role of teams has been under-acknowledged ( Ruch, 2007a ) but practice cultures of collaboration, communication and case discussion can support critical reflexivity ( Helm, 2016 ; Ruch, 2007a ). Peer-aided judgement occurs in spaces where emotions may be acknowledged and explored as a fundamental part of the sense-making process. Through these informal interactions, social workers gain opportunities for emotional listening ( Ruch, 2007a ), observing peers making judgements and critical reflection on their own sense making ( Helm, 2016 ).

Knowledge can be acquired both explicitly and tacitly. The majority of professional endeavour is focused on the former and the gaining of formal or product knowledge with its attendant claims to objectivity and rigour ( Sheppard and Ryan, 2003 ). Implicit learning (Polyani, 1967) is where expertise is developed through an individual's interactions with the practice world. Teams have traditionally been seen a source of explicit learning (e.g. through the sharing of books or conference notes) but they are also a source of implicit learning on how knowledge is developed, applied and reviewed in practice. Acquiring this knowledge of ‘how’ things are done is learned though ‘doing’ (Polyani, 1967) and the SAGE model allows interaction between peers to be scrutinised as a process through which knowledge may be acquired, articulated and made explicit.

Intuition has been linked to creativity ( Fook et al. , 1997 ; Dane and Pratt, 2007 ) where solutions are frequently required for problems that are novel, and unique therefore not amenable to logical, linear thinking based on existing knowledge. A review of the literature ( Pétervári et al. , 2016 ) has shown intuition to be associated with both generation and evaluation of phases of ideas in problem solving although the links are not fully understood ( Dane and Pratt, 2007 ).

Informal peer interaction has been shown in some research to support professional curiosity ( Helm, 2016 ). Curiosity is about ‘stepping outside of one’s comfort zone’ and is perhaps more likely when practitioners believe that the discomfort associated with uncertainty can be managed effectively (Revel and Burton, 2018 , p. 1512). In the face of bureaucratic managerialist organisational contexts, the non-judgemental non-accountable nature of peer-aided judgement may help practitioners to make their intuitive insights and explorations of uncertainty more explicit and subject to further testing and refining.

The development of expertise in judgement and decision making requires feedback which is diagnostic, accurate and timely ( Klein, 1997 ). Peers represent an easily (often immediately) accessible source of evaluative feedback on judgements but the quality of such feedback is largely unknown and potentially questionable, given the lack of attention paid to peer-aided judgement in training and organisational policy. Achieving accuracy in social work assessments is an important and valid goal but we are reminded that, in social work, ‘decisions are a negotiated process related to moral reasoning, identities, relationship and culpability.’ ( Keddell, 2011 , p. 1266) and external measures of accuracy are not always readily available ( Hammond, 1996 ). Informal peer discussion is understood to contribute to addressing practice problems such as deflection strategies and rising thresholds ( Platt and Turney, 2014 ; Saltiel, 2016 ). Attention to the evaluative function of peer interaction may provide valuable insight into the way that social workers seek to achieve logical and defensible judgements in conditions of uncertainty.

Over time, cognition will oscillate between analysis and intuition ( Hammond, 1996 ). Rationality is rarely seen to be wholly intuitive or analytical and this article has explored the role of peer-aided judgement as a form of quasirationality. By mapping out the main elements of peer-aided judgement, it is possible to consider how the interactions between these elements facilitate movement on the cognitive continuum.

Practitioners have been observed to move ‘with some fluidity between intuitive and analytical modes of cognition’ ( Whittaker, 2018 , p. 1975). These movements are determined by properties of the judgement task, such as amount and format of information, and/or the decision maker’s familiarity with the task, opportunity for feedback, and extent of time pressure ( Hammond, 1996 , 2000 ; Dhami and Mumpower, 2018 ). A fast-moving and poorly structured task environment (such as a home visit) is expected to induce a more intuitive form or rationality. Where more time is available for thinking and information is presented in more linear forms, a more analytical form of cognition is induced.

It is easier to restructure the task environment than it is to purposefully alter one’s approach to rationality ( Hammond, 1996 ). For example, a social worker cannot deliberately ‘be analytical’ within the complex fast-moving judgement task of a home visit. However, they can become more analytical when writing up the visit back at the office. Informal interaction with peers effectively restructures the task environment for judgement. For example, talking to a colleague about what happened in a home visit shifts a poorly structured set of complex data towards a coherent narrative structure with a focus on fewer selected indicators. This move in the task structure will provoke a similar move on the cognitive continuum from intuition towards analysis. Expressing emotions to a peer when ‘stuck’ with an assessment broadens the focus to include the affective dimension, with a change in task environment associated with more intuitive modes of cognition.

Restructuring the judgement task is a key element of supervision (e.g. examining decisions to check for biases or question weak hypotheses) but this is limited in frequency and scope. However, informal discussions with colleagues do offer frequent opportunities to reflect on judgements through iterative discussions. There is limited writing on ad-hoc peer supervision ( Kadushin and Harkness, 2002 ; Golia and McGovern, 2015 ) and, whilst peer-aided judgement is not a substitute for management guidance and supervision, it is a form of daily practice which is under-researched and under-theorised ( Taylor, 2017 ). Further studies may usefully focus on the role of informal case-talk as a mechanism for restructuring task environments to support movement on the cognitive continuum, and the potential for meaningful exploration of ethical tensions and positionality in practice.

The study that highlighted the potential of peer-aided judgement and initiated work on the model was a small-scale UK-based ethnography and is therefore limited in capacity for generalising and transferring knowledge. Intersectionality in peer relationships is not addressed explicitly or in depth in many of the studies that inform this article, and this limitation needs to be acknowledged in both the potential application of the model and in an agenda for further research.

The literature review that was included in the original thesis provides access to relevant data from similar research as well as the underpinning theory. By grounding this work in established theory and then developing a hypothesised model, the aim is to facilitate critical debate and offer an initial framework upon which to develop further theory and research. Whilst the domains of the model are rooted in existing research findings, further work is required to extend the knowledge base and the potential utility of the model.

The model cannot be used to evaluate the quality of judgement and decision making. Indeed, the elements of peer-aided judgement that have been observed in social work practice and incorporated into this model may be negative influences on competence. For example, peers may be sources of knowledge that is problematic or incorrect, and networked judgements may accelerate rather than guard against common errors of reasoning. This model is not a prescription for practice but a framework for developing a fuller understanding of the components which may ultimately contribute to improved practice.

Peer relationships are commonly viewed as being informal, non-assigned and relatively equal. However, power flows from personal and structural sources ( Fook and Gardner, 2007 ) across a broad range of dimensions such as age, gender, ethnicity, professional identity and knowledge. As power is invested at a societal level, so structural perpetuation of such inequalities must necessarily be included in individual constructions of peer status. Dominelli (2002) reminds us ‘identity is a fluid and constantly changing terrain’ (p. 39) so the impact of such influences needs to be viewed within a wider social and cultural perspective over time.

There is a ‘distinct dearth of research on the operation and outcomes of quasirationality’ ( Dhami and Mumpower, 2018 , p. 14). The proposed model allows some important aspects of social work judgement and decision making to be held up for greater scrutiny. In particular, it provides a lens on the inter-subjective nature of judgement and the influence that peers have on the process and outcomes of these judgements.

The category of ‘Security’ in the model recognises affect as central to sense making in social work. In this way, emotions may be viewed as a crucial element of human judgement, rather than a hindrance to ‘good’ rationality ( Demasio, 2006 ). Uncertainty and anxiety are simultaneously fundamental and problematic in critically reflexive social work practice ( Cooper et al. , 2003 ; Ruch, 2007a ). ‘… for reflective practice to be possible, the appropriate physical, mental and emotional space—containers—need to be provided’ ( Ruch, 2007b , p. 664). Collegial practice within teams is an interpersonal space where containment can be offered. However, such opportunities are increasingly threatened by the individualisation of practice ( Braye and Preston-Shoot, 2000 ) and agile working ( Jeyasingham, 2015 ). Conceptualising peer support as a key element of social work judgement may support closer consideration of the contribution that team practices can make to working with anxiety and uncertainty.

Reflective practice as a concept tends to be based on practitioners’ retrospective accounts their work, not direct observation of the work itself ( Sheppard et al. , 2000 ; Johnsson and Svensson, 2005 ) and this ex post facto analysis risks developing explanations that are based on knowledge of an outcome not known at the time of judgement itself. It is therefore beneficial to develop models for the study of judgement and decision making that do not rely on retrospective self-reporting but can offer structure to naturalistic research and theory development.

Failure in a particular cognitive mode is thought to provoke movement on the cognitive continuum ( Hammond, 1996 ; Dhami and Thomson, 2012 ) yet we find that social workers can experience ‘assessment paralysis’ ( Reder and Duncan, 1999 ) when their analytical cognition is overwhelmed and ‘confirmation bias’ when their intuitive judgement proves insufficient to the task ( Munro, 1999 ). In pursuit of creative thinking and analytical rigour, the model provides a tool to consider the processes that facilitate movement on the cognitive continuum and the conditions that mediate access to these processes.

Peer interaction alters the task environment and this, in turn, induces oscillation on the cognitive continuum. For example, social workers naturally tell their colleagues what happened on a home visit when they return to the office. The role of discourse and narrative is well established across professions ( Riessman and Quinney, 2005 ) and problematised in social work (e.g. Riemann, 2005 ; Doherty, 2017 ; Hood, 2018). The role of case-talk in inducing movement on the cognitive continuum is potentially highly significant and study of such processes is facilitated by this model.

Teams of professionals working effectively together represent collective memory ( Förkby and Höjer, 2011 ) and emergent expertise gained through social work practice. Whilst this knowledge may be tacit and therefore not easily accessible to conscious defensible logic, it represents an opportunity to test the competency of judgement coherence (logic, consistency) as well as correspondence (empirical accuracy) ( Hammond, 1996 ) This has implications for the construction and ongoing development of teams as well as professional education for judgement and decision making ( Custers, 2019 ).

Evaluations of the Reclaiming Social Work approach have shown that specifically defined roles in social work teams can have a positive impact on judgement and decision making ( Cross et al. , 2010 ; Forrester et al. , 2013 ) and the peer-aided judgement model may help to explore team composition and the potential benefits of team supports for effective thinking. Latent conditions for error ( Reason, 2000 ) are those which lie buried in the heart of organisations and structures ( De Bortoli and Dolan, 2015 ). Whilst the model facilitates a close examination of conditions within these organisational structures, the impact of latent conditions must also feature in that analysis. This is particularly relevant when considering power dimensions within peer networks, the domain of Security in this model and the factors moderating access to peer-aided judgement.

Managerial oversight plays an important role in terms of emotional, epistemological and procedural containment ( Ruch, 2007b ) and peer-aided judgement is not a replacement for such functions. However, the shortcomings of managerial supervision are well recognised (e.g. Wilkins et al. , 2017 ) and the power imbalance between managers and social workers can result in social workers deferring to managers in decision making when greater rigour and scrutiny is called for. Authority should not be unquestioningly equated with expertise ( Weick and Sutcliffe, 2015 ) and further study of peer-aided judgement, alongside line-managed decision-making processes, may help to strengthen judgement and decision making for both social workers and managers.

This article has proposed a hypothesised model of peer-aided judgement. By grounding the model in CCT there is an explicit acknowledgement of quasirationality as the predominant form of cognition in most judgement tasks ( Hammond, 1996 ). A better understanding of the processes and outcomes of quasirationality has the potential to inform developments in many areas of social work practice.

The model provides a lens for the closer scrutiny of peer interaction as a key element of professional judgement and this article has identified implications in relation to the effective use of intuition ( Munro, 1999 , 2008 ), debiasing ( Saltiel, 2016 ; Cook, 2017 ), and feedback loops on decision making ( Kirkman and Melrose, 2014 ). Studies of social work judgement and decision making will benefit from the further development of models to explore the functions of peer-interactions.

The implications of the model have been highlighted in relation to those factors that mediate access to peer-aided judgement. Recognising the limitations of the empirical evidence to date on this matter, the proposed model has focused primarily on informal interaction within teams and there is a need for further exploration of how social work judgements, and their outcomes, can meaningfully incorporate and take account of the needs and perspectives of service users and minority communities.

Conflict of interest statement . None declared.

Core elements of peer-aided judgement.

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Education & training

What happens during a peer discussion?

Danielle Stacey // 06, Jan 2019

Danielle Stacey, a Lead Pharmacist in Antimicrobials, recently discussed her practice with some expert UKCPA peers. She found it insightful and valuable.

I was apprehensive at the thought of completing a peer discussion. But I had spent a lot of time working on my Faculty portfolio and assessing my own perceived stage of practice, and I was keen to get some impartial feedback on my performance.

I chose to complete the first of my discussions at the UKCPA Conference. I was keen to discuss my work with someone outside of my own workplace so that I could get an alternative perspective. 

My first step was to decide which case to discuss. During my day to day practice I encounter many interesting cases and make effective interventions. In order to select the best example of my practice, I looked at the case based discussion assessment formand considered the competencies I was expected to demonstrate through my case discussion. 

After careful thought, I decided to discuss a service improvement project I had implemented as I felt this was one of the best examples of my practice and it demonstrated competencies across the first two clusters of the Advanced Pharmacy Framework.

I was initially nervous going into the discussion, but I needn’t have been. My assessors were very welcoming and instantly made me feel at ease. They invited me to talk through my case and asked me questions which encouraged me to expand on my discussion. My assessors asked me why I did what I did, what other options I considered and why they were discounted. This challenged me to reflect on my practice and question my approach. This led me to talk about what I had learnt and what I would do differently next time.

The feedback described the strengths that I had demonstrated and suggested some opportunities to develop my practice further

At the end of the discussion, the assessors provided me with written and verbal feedback.  The feedback described the strengths that I had demonstrated and suggested some opportunities to develop my practice further.  We also discussed how the case mapped to the Advanced Pharmacy Framework. The assessors helped me to realise that I could map some competencies at a higher stage than I had identified myself.

The discussion provided far more insight than I had expected. I wanted to hear how others perceived my practice, but I unexpectedly found that it enabled me to reflect on my practice in a way which I would not have done otherwise. The assessors asked me questions that I would not have asked of myself and this challenged my thinking. 

The experience made me realise that we should all be completing peer discussions regularly to support our professional development. It is something that I will continue to do and will encourage my peers to do the same.

What does a peer discussion involve?

The aim of a peer discussion (often called a case based discussion, because it focusses on a specific case, project or scenario) is that it is a supportive discussion between you and a peer. It is not an exam – you cannot pass or fail. You will be able to share your experience and receive advice on how to develop yourself.

The discussion should take between 15 and 25 minutes. You can choose what you would like to discuss. This could be clinical or patient facing, or it might be non-clinical – perhaps a service improvement initiative or a scenario involving leadership or management.

What are the benefits to me?

A peer discussion will allow you to demonstrate your strengths and achievements and identify areas where you could develop further, in a relaxed and supportive environment. The topic or case you wish to discuss is entirely up to you. The key points of the discussion can be captured by your peer on a form which you can then submit as evidence for your GPhC CPD. You can also use the form for your RPS Foundation or Faculty portfolio.

Would you like an opportunity to discuss a recent patient case or scenario with an experienced pharmacy colleague in a supportive environment? We offer free peer discussion opportunities for UKCPA members at our learning events . Please contact us if you are interested.

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Danielle Stacey

Danielle is Deputy Chief Pharmacist (Medicines Optimisation) at the Dudley Group NHS Foundation Trust. In 2018 she completed the NHS England Chief Pharmaceutical Officer Clinical Fellowship, and has a special interest in antimicrobial therapy.

Follow @DL_Stacey_

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• Published: 28 June 2021

The role of peers on student ethical decision making: evidence in support of the social intuitionist model

• David Ohreen   ORCID: orcid.org/0000-0001-7396-3033 1  

International Journal of Ethics Education volume  6 ,  pages 289–309 ( 2021 ) Cite this article

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The history of ethics often presupposes rationalist thinking on moral issues. An alternative to rationalism has been proposed by the social intuitionist model. This model suggests the bulk of our moral decisions are ‘gut reactions’ or intuitions. Unlike the rationalists, which support reasons and deliberation to draw moral conclusions, intuitionists argue such reasoning is used to support preconceived ethical decisions. This paper provides the first investigation to determine if intuitionism has any validity within business ethics. Using data from the Defining Issues Test and individual journal entries, results indicate discussion-based pedagogy improved the moral reasoning of participants but had very little influence over their beliefs. In short, the social intuitionist model is supported by this study. Most importantly, ethics education that focuses on peer-to-peer discussion can change how students’ reason about moral problems and should be heavily incorporated into classrooms.

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The effectiveness of codes of ethics is also suspect when it comes to preventing student cheating. Research has investigated a number of factors that influence student cheating including university codes of conduct, the acceptance and understanding of such codes, being reported by a peer, severity of penalty, and the behaviour of colleagues. Results show peers to be the strongest influencer on student cheating behaviour, in part, because it provides normative support for such actions (McCabe et al. 1996 ; McCabe and Trevino 2002 ).

Thanks to Binod Sundararajan, Valerie Trifts, Scott Comber, and David Boutland for helping collecting the data.

Students were not trained on how to discuss ethical cases with others but merely relied on the open-ended questions provided to stimulate conversation. Although, I use dialogue and discussion interchangeably, it should be noted there are differences between the two concepts. The primary goal of discussion is to listen to group member’s opinions about to listen to group member’s opinions about creating understanding. No single person is pressing a particular point or arguing for a position; dialogue is about exploring ideas to create a learning environment for all members (Graybill and Easton Brown 2015 ). In this sense, dialogue can be more ‘free flowing’; new ideas can be raised without taking defensive positions or feeling like a groups member has lost the debate (Senge 2006 ).

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Ohreen, D. The role of peers on student ethical decision making: evidence in support of the social intuitionist model. International Journal of Ethics Education 6 , 289–309 (2021). https://doi.org/10.1007/s40889-021-00125-3

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Case Study Quasi-Qualitative Analysis of Peer Group Supervision of a Child Trauma Recovery Program in Occupied Palestine

Ian g. barron.

1 School of Education and Social Work, University of Dundee, Nethergate Dundee, UK

Ghassan Abdallah

2 Center for Applied Research in Education, Ramallah, Israel

Unni Heltne

3 Centre for Crisis Psychology, Bergen, Norway

This case study explores the impact of peer group supervision (PGS) for counselors delivering Teaching Recovery Techniques (TRT), a group psycho-social program for traumatized adolescents. Interviews were conducted with seven school counselors, from villages near East Jerusalem in occupied Palestine; a skilled supervisor; and an international trainer. A quasi-qualitative analysis was conducted to quantify responses and themes along with a measure of inter-rater reliability. Participants reported that even in a context of military violence, PGS provided a reflective process inclusive of formative, normative and restorative functions. Locally available PGS was viewed as essential within a geographically fragmented context. Counselors’ reported PGS led to a trusting environment in contrast to military practices and gender norms. War stressors and lack of Training of Trainers led to low counselor confidence in training others in TRT. PGS and Trainer of Trainers were recommended as core aspects of program delivery and to support training of colleagues.

Peer group supervision (PGS) has been used with a range of professions, including occupational therapy, nursing, social work and psychology and professional levels, such as managers, supervisors and practitioners (Spence et al. 2001 ). Despite PGS being widely used in practice, research has remained limited (Mastoras and Andrews 2011 ). Evaluative studies tend to focus on students studying for professional practice (Bjorke 2013 ), post-qualifying professionals (Remley et al. 1987 ) and private practitioners (Lewis et al. 1988 ). Most studies report a range of positive effects (Lakeman and Glasgow 2009 ).

PGS has been defined as “the regular meeting of a group of supervisees (a) with a designated supervisor or supervisors, (b) to monitor the quality of their work, and (c) to further their understanding of themselves as clinicians, of the clients with whom they work, and of service delivery in general. These supervisees are aided in achieving these goals by their supervisor(s) and by their feedback from and interactions with each other” (Bernard and Goodyear 2009 , p.244). Within occupied Palestine, the compartmentalized nature of the West Bank with restrictions on movement, and the need to apply for travel permits (Barron et al. 2013 ), has limited access to any skilled supervision.

The aims of PGS include the development of professional knowledge/skills, values, identity and the development of a network to reduce counselor isolation and burn out (Certo 2012 ). Counselors report a wide range of benefits including: sharing experience; reflection and problem-solving; new perspectives; skills practice; emotional support; and the development of cooperation and communication. Benefits also accrue to organizations, with the growth of cultures of appreciation, enhanced knowledge/skill and flexibility (McMahon and Patton 2000 ). Corey ( 2011 ) suggests PGS is a cost-effective way for organizations to support staff. Counselors have identified a number of factors for successful delivery, including: the centrality of a reflective process (Corey 2011 ); supervisee sense of safety (Fleming et al. 2010 ); confidentiality and trust; clarity of time and place; mutual support; the positive resolution of conflict and shared learning (Rutter 2006 ). Page and Wosket ( 2001 ) suggest the size and structure of groups are important to facilitate self-disclosure and feedback. Closed groups of three to six participants are recommended.

A range of supervision models for PGS have been suggested. Baruch ( 2009 ) identified seven; however, most therapeutic paradigms have developed a model of supervision based on the theory and methods of therapy, such as solution focused, cognitive-behavioral, psychodynamic, developmental group process and counselor/client role centered supervision (Lassiter et al. 2008 ). The congruity of therapeutic and supervision model helps the transfer of experiential learning to practice (Bradley and Ladany 2001 ). The current study therefore, utilized the same CBT model for program delivery and PGS. PGS compared to program delivery, however, is a context of greater intimacy and trust, where counselors can be challenged to disclose their thoughts and feelings more so than adolescents in a group (Bradley and Ladany 2001 ).

Hawkins and Shohet ( 2006 ) describe the three functions of supervision as formative, normative and restorative. The formative function involves educating counselors about the client group, their context and the nature of program delivery. In Palestine, this includes the needs of adolescents and families living under occupation; the impact of trauma on adolescents and counselors; and the challenges of delivering a program within a context of military violence. Program factors include understanding theoretical foundations; implementing protocols; program adaptation and evaluation (Joubert et al. 2013 ). The normative function of supervision aims to support counselors to adhere to professional, program and evaluation protocols with some supervision groups being accredited for continuing professional learning (Thomasgard and Collins 2003 ). Ethical practice is often enshrined in codes of professional behavior including respect, genuineness, trust, choice, empathic engagement and self-responsibility (Corey et al. 2014 ). Many professions require evidence of supervision attended over a stipulated number of hours. Codes of practice, however, are not without their problems. The prescribing of professional behavior can lead to overly bureaucratic practice, which can undermine counselor/client relationship (Fenton 2014 ). PGS, however, can provide a context to help counselors reflect and resolve such incongruities.

The restorative function of PGS involves creating an emotional and physically safe environment to facilitate reflection (Shulman 2010 ). Counselors can be helped to notice signs of stress, trauma or burn out within themselves. Anxiety, helplessness, depersonalisation, de-realisation, somatic symptoms and flashbacks are all signs of concern (Cohen and Collens 2013 ). Counselors can be supported to identify strategies and if necessary, support services. Delivering trauma-specific programs can trigger personal issues that need to be addressed, not in supervision, but in therapy (Trippany et al. 2004 ). Counselor self-care is also part of the restorative function. Time with friends and family, hobbies, and setting boundaries on work/life balance are all important (Skovholt and Trotter-Mathison 2014 ).

PGS, however, is not without its problems. Counselman and Weber ( 2004 ) identified supervisee shame and guilt as barriers to self-disclosure. These occur as a consequence of the lack of challenge for the counselor to take risks in sharing thoughts and feelings. Poor relational contracting can also undermine the effectiveness of PGS. Lack of leadership, irregular attendance, frequent lateness, and inappropriate turn-taking can all be undermining. Proctor ( 2004 ) highlighted that coercive communication can occur among peers. As a consequence, individual supervision, in addition to PGS, may be advisable (Akhurst and Kelly 2006 ).

The Current Study

No study to date has explored the effect of PGS for counselors delivering a trauma recovery program in a situation of violent military occupation. The current case study sought to address this omission by introducing and evaluating PGS for school counselors delivering a CBT group-based trauma recovery program (Teaching Recovery Techniques: TRT) to adolescents in occupied Palestine. Counselors were experiencing isolation and low levels of confidence in a compartmentalized geographical context. In addition to the three functions of PGS, it was hoped supervision might encourage counselors to have the confidence to train other West Bank counselors in TRT, an explicit aim of TRT training. Hitherto they had been reluctant to do so. As outcome evaluations delivered too soon can undermine promising initiatives (Barron and Topping 2011 ), an exploratory qualitative case study approach was utilized. Semi-structured interviews were held with stakeholders in the project (counselors, skilled supervisor and international trainer) to assess counselor experience of PGS.

Study Design

The case study had two goals: 1) to explore counselor, supervisor and trainer perception of PGS in supporting TRT delivery to adolescents in the violent military context of occupied Palestine, and 2) to seek counselor perception of whether PGS increased the likelihood of them delivering TRT training to other counselors. As noted previously, the latter is an assumption within TRT training. As PGS was a new initiative, a qualitative approach using semi-structured interviews was taken to assessing participant experience, perception of impact and identification of future supervision needs. The study sought to compare and contrast the multiplicity of perspectives from participants and explore the singularity and uniqueness of participant experience. Research ethics approval was through a UK University Research Ethics Committee (UREC). This required active informed consent from the Palestinian Authority Ministry of Education, counselors, skilled supervisor and the Children and War Foundation TRT trainer. The latter is a non-governmental organization (NGO) established to develop empirically-based trauma recovery programs for children in disaster and war contexts.

Participants

The recruitment strategy involved purposive selection of (i) school counselors ( n  = 10), from a corpus sample of 18, who had experienced PGS to facilitate TRT delivery (Smith et al. 2008 ); (ii) the skilled supervisor, a Palestinian educational psychologist who held an overview of counselor practice and (iii) the Children and War Foundation trainer, who held a view of training across countries. Ten school counselors from five schools in five different villages along the separation wall near East Jerusalem were invited to participate. Counselors were selected because of the high levels of military violence experienced in these school areas (Barron et al. 2016 ). Counselors experienced PGS with others counselors in the same areas (other participants). Counselors were from two professions, social work ( n  = 5) and psychology ( n  = 5), with five males and five females. Counselor skill levels were reported, by the skilled supervisor, as based on theoretical knowledge from 1 year’s University training rather than skilled practice. Counselors were initially approached by the field researcher via telephone and invited to participate in the study. The trainer and supervisor were approached by email by the principal researcher.

Researchers

In qualitative research it is important to make explicit the position and potential bias of researchers (Orne and Bell 2015 ). Two researchers were involved in the design and delivery of the study and a research assistant was subsequently involved in inter-rater reliability analysis. This provided another independent view of the data. The two researchers included a reader in trauma studies at a UK University and a director of a NGO dedicated to peace building in occupied Palestine. The researchers are experienced and accredited educational psychologists, one in the UK, the other in Palestine. The research assistant was a theology of religion graduate working with a refugee NGO in Scotland and who had previously worked in the West Bank for 18 months. The two researchers are experienced in training and delivering supervised professional practice. PGS training was delivered by the researchers. The Palestinian researcher, was the skilled supervisor in the study. Issues of bias are addressed in the discussion.

Posttraumatic stress is a pervasive problem in Palestine (Barron et al. 2013 ). TRT, developed by the Children and War Foundation, doubles as a training program for delivering TRT to adolescents and as a Trainer of Trainers. TRT has a developing evidence base for reducing posttraumatic stress in 11-18 years olds in disaster situations and contexts of war (Barron et al. 2013 , 2016 ; Ehntholt et al. 2005 ). The program, delivered to adolescents in groups of ten, is based on cognitive-behavioral theory, and is delivered over five sessions. The initial session enables adolescents to understand that the trauma reaction is normal in extreme circumstances and teaches adolescents how to feel emotionally safe. Subsequent sessions teach adolescents a range of coping skills to stop intrusive images, sounds or smells; reduce hyper-arousal through stabilization and relaxation techniques; and desensitize phobic avoidance behavior through use of relaxation with anxiety and anger hierarchies. A three-day training for the eighteen counselors included information on: normalizing the trauma reaction, working through case studies and experiencing the same activities as adolescents to learn coping skills for flashbacks, hyperarousal and avoidance.

Supervision

To support high standards of program delivery and encourage counselors to train other counselors in TRT, skills’ training was provided in PGS (Proctor 2004 ). Counselors were expected to meet monthly with other counselors in the same area for an hour in pairs/small groups during the 6 month project to: prepare and reflect on program delivery; cope emotionally; follow program protocols; make program adaptations within theoretical guidelines; and assess their continuing professional development needs. Supervision sessions held in local schools negated the need for counselors to apply for travel permits, frequently denied by Israeli Authorities (OCHA 2013 ). The model of supervision involved peers taking turns at leading sessions. Two PGS sessions, however, were led by a skilled supervisor and occurred during the second and fourth months of the project. These session lasted 90 min each and followed the same process as other PGS sessions. A higher level of advice was provided by the skilled supervisor. A one-day PGS training was delivered by the two researchers. Training emphasized the importance of attendance, timings, closed membership, record keeping, clarity of leadership, rules, turn-taking, respect, self-disclosure, reciprocal support and permission to challenge. PGS training was based on TRT group process and involved creating an active, positive group environment; normalizing and labelling reactions; the promotion of self-efficacy and coping skills; and modeling and role play of TRT activities with feedback. The tasks of supervision were educative (what do I need to know about trauma and the TRT program), restorative (reflecting on feelings) and normative (holding to program protocols and adaptations within theoretical guidelines).

Interviews followed a semi-structured format. The field researcher conducted the interviews with counselors a month following the end of the project. Pre-supervision interviews were not held because of budgetary constraints. The principal researcher conducted the interviews with the skilled supervisor and trainer. Interviews lasted 45 min on average and were held at the end of the school day. All interviews were conducted by telephone and digitally recorded. Questions, based on issues and gaps identified in the literature, included: aims of supervision; spontaneously reported gains; changes in understanding; protocol adherence; impact on ethical practice; effect on stress; challenges; the negative aspects of supervision; the nature of future TRT delivery; the likelihood of TRT training to other counselors; and recommendations for future supervision. Counselors were requested to rate gains from 0 to 10, where 0 was no gain and 10 was a substantial gain.

All data was transcribed in Arabic and translated into English by a Palestinian interpreter. A quasi-qualitative approach was taken to analyzing the data (Braun and Clarke 2006 ). This six-step approach involved familiarization with the whole data set; initial identification of codes of meaning from statements; reviewing and adapting codes and related statements and the initial identification of themes; counting the number of statements under each code; revisiting statements, codes and themes for accuracy; and drafting the report that afforded another review of codes, statements within codes and themes. The approach was iterative, where researcher and research assistant sought to discover meanings from participants own words. Codes and themes were identified for similarity, difference and doubt within and between counselors, supervisor and trainer. An aim was to make data accessible for contestability by providing codes and themes in participants’ own words, as well as providing small and large quotes to exemplify themes. In the discussion section, the analysis of data is compared with pre-existing categories about supervision from the research. Inter-rater reliability involved the principal investigator and research assistant independently analyzing participant statements, codes and themes. This inter-rater reliability is reported as Cohen’s Kappa k . for collated themes.

Extent of Participation

Two social workers (males) and one psychologist (female) did not attend for interview. Reasons were increased settler violence, excessive work demands, school closure and non-payment of salary. Counselors attended 5.4 peer PGS sessions (4 to 7 range) on average, during a 6 month period. Sessions occurred before, during and after program delivery. The average length of session was 46 min, ranging from 40 to 60 min. All counselors’ experienced face to face supervision and three, in addition, experienced phone supervision. As one counselor commented “PGS was possible with counselors close by.” Five counselors experienced PGS led by the skilled supervisor. Sessions lasted 80 min and were held in Ministry of Education offices. Two counselors attended two sessions; five counselors attended one session. Table ​ Table1 1 shows the comparative benefits of PGS identified by participants. Patterns of commonality and distinctive contributions by counselors, supervisor and trainer are evident in the codes and themes. Across all questions inter-rater reliability was high and at a satisfactory level for qualitative studies ( k  = .94). The research assistant identified ‘receiving and giving feedback’ as part of ‘skill gain’ benefit and framed the ‘knowledge and skill’ barrier theme as competency issues. There was some uncertainty whether some comments were knowledge or skill gains) e.g. making appropriate responses).

PGS themes: perceived benefits

C counsellor, S supervisor, T trainer

a Additional supervisor themes – evaluative practice; culture of appreciation; communication across geographical areas; relationships between organisations; and PGS challenged cultural norms

PGS Aims and Functions

Counselors reported five PGS aims: “clarifying program content and procedures” ( n  = 4 statements); “checking doing the right thing” ( n  = 4); problem-solving ( n  = 3); “sharing work done” ( n  = 2); and “time for reflection” ( n  = 1). The supervisor identified similar aims: “follow up on how things were going; finding out what counselors are facing and the need to overcome these” ( n  = 2). This included “questions about implementation and not enough time with students in school” which resulted in “lessons delivered after school.” The supervisor, however, took a longer term view of progress than counselors, “I think the noticeable difference may be by the second semester” ( n  = 2). The trainer, as with the counselors and supervisor, held the aim of PGS as formative, “local supervisors was a great advantage, because supervision could clarify things.” The trainer also recognized the inter-relationship between formative and restorative functions, “Counselors were sharing the same information from training and getting a sense of being in it together … some participants had an emotional reaction at training and approached me.” In response they received “more clarification and feedback on techniques to address stress … and participants were encouraged to form a group … the importance of local coordination for this was emphasized.” For counselors new to delivering TRT and PGS, frequency of comments suggests aims were mostly formative (learning from each other and a skilled supervisor) and normative (am I doing it well enough) and to a lesser extent, restorative (a sense of being in it together).

PGS Provided Opportunity to Share and Practice

Counselors valued “practicing with colleagues” ( n  = 5); “the opportunity to learn from others ( n  = 3); “meeting colleagues to exchange ideas” ( n  = 3); “share what done” ( n  = 2); “time for reflection” ( n  = 2) and “asking about small things.” The supervisor, however, identified the need for PGS as ongoing, “Many questions were raised and discussed and the number of inquiries showed they still need more opportunity for this”.

Gains in Understanding/Skills

All counselors reported that PGS led to increases in understanding (8.42 average; six to eight range) and “improved communication skills” with adolescents ( n  = 10). The supervisor rated the group “around 8, at least they now reflect, listen to each other, listen to somebody else.” Counselors reported gains in understanding as: “knowing the right ways to respond to group needs and questions” ( n  = 10); being “better informed” ( n  = 7); and clearer about what was expected. Growth in skills included: “active listening” ( n  = 5), “respecting and engaging all” ( n  = 4); “giving students more time to talk and understand” ( n  = 2); “better at making the group feel relaxed” ( n  = 2); and “more aware students feeling the group was under control” ( n  = 1). One counselor reported TRT was “easier to do as a result.” Knowledge and skill gains reflected a balance of formative and normative functions.

The trainer (T) and supervisor (S) reiterated the value of PGS for clarifying practice. “Local peer supervision was a great advantage because supervision could clarify what to do (T)” and “participants gained reassurance … sharing and hearing each other’s experiences and experiencing that they were in it together” ( n  = 3). The supervisor also reported counselors “felt the seriousness of the work. Not like what others are doing, they experienced serious follow-up.”

Gains in Ethical Practice

Counselors reported gains in ethical practice at 7.75 on average (seven to eight range). The supervisor rated the group 7. Counselors emphasized their learning of how important it is to “listen to children ( n  = 5).” The trainer reported training placed emphasis on “respectful caring and not doing things not professionally skilled to do, recognizing their own limits.” The supervisors comments were different again and referred to the counselors’ process of engagement, consistency and predictability and keeping the group process safe for all as, “Counselors were very committed to this (ethical practice): talking about informing parents; respecting parents and students; invitations in good time; not changing meeting time; making sure no student interrupting others, using insulting words, and not contradicting each other.” It appears, counselors experienced gains in ethical practice that bridged both formative and normative functions.

Improved Protocol Adherence

The normative function of protocol adherence was “emphasized in training” (T). Counselors rated protocol adherence following PGS as 7.29, ranging from six to eight. Counselors rated adapting protocols within theoretical guidelines similarly at 7.12, ranging from seven to eight. The supervisor, rating 5, was less confident of counselor capacity, expressing, “Not so much, a new hope that they will.” It is, therefore, uncertain the extent to which this normative function of PGS was achieved. A more objective measure of program fidelity before and after PGS would be helpful to assess such a skill change.

Increased Confidence and Reduced Stress

In terms of PGS providing a restorative function, counselors reported an increase in confidence and a reduction in stress. All counselors rated increases in confidence (average 7.28; six to eight range), for example, “It made it easier, I felt more confident about delivering the program.” The supervisor rated counselors, who attended skilled supervision, similarly at 7.5 on average but noted “they were not all at the same level of confidence. Some counselors were at least a 9, because of their different experiences, social cultural background, and different levels of commitment … PGS helped raise counselor self-esteem and confidence. I think they felt they are doing something important.” Counselors and supervisor perceived gains in counselor self-confidence was a consequence of PGS; however, there was a range of experience and this may have been related to significance of purpose, as well as gains in understanding and skills.

All counselors reported a significant reduction in stress, with an average rating of 7.1 with a narrow range from six to eight, reporting “I wasn’t so anxious with the students” and “I was more relaxed about delivering TRT.” The supervisor reported counselors “returned for a second session, they were not embarrassed, not feeling weak and it was in their faces, hand gestures and ways of talking.” He rated counselors as making higher gains in reduced stress (an eight) than counselors themselves. Reduced stress and increased confidence may or may not be related, but either way, PGS provided a restorative function that led to emotional gains for counselors.

Additional Supervisor Themes

A further five themes were identified from the skilled supervisor. PGS was reported as encouraging: (i) evaluative practice ( n  = 4), as “Unfortunately evaluation is not something done much in my community, particularly in this field. We have managed to break through the mentality that it is not enough to be trained and implement, but also what is needed is evaluation”; (ii) a culture of appreciation ( n  = 1), given “Another thing is the high appreciation of the people involved in this training: trainer, researchers, supervisor and the Department of Counselling and the Minister of Education;” (iii) communication across geographical areas ( n  = 1), as it was noted that “Counselors contacted colleagues after the work was done in other areas. They are talking more across areas”; (iv) relationships between organizations ( n  = 6), as “PGS helped us discover the commitment … among counselors and the criteria for this, coming on time although it was after school day; asking lots of questions; not wasting time and keeping in touch. I think it helped a lot in building of trust between organizations” and (v) PGS challenged cultural norms ( n  = 3). For instance, “for a female to be out in the community, and to be ready to give her phone number is not an easy thing. To get a man’s phone number is easy. You need to realize how conservative the counselors are.” Finally, more in relation to TRT than supervision, the supervisor commented, “What I liked was none of them expressed that this program is against his/her social cultural background or even religious background,” possibly indicating how culturally congruent TRT was. Table ​ Table2 2 summarizes and compares the issues, themes and codes related to barriers of implementation for TRT and PGS reported by counselors, supervisor and trainer. Three core issues, six themes and twenty codes were identified. There was, however, less commonality of barrier codes and themes across counselors, supervisor and trainer than was evident in the benefits of PGS.

Perceived barriers

C counselor, S supervisor, T trainer

Barriers to Program Delivery - Competency

Counselors reported: “new things raised doubt” ( n  = 1); “limited time” ( n  = 1); “being shy” ( n  = 1); “feeling unable to deliver” ( n  = 1); “By knowing about other work, I sometimes get confused” ( n  = 1); and “I keep watching and just write every small word” ( n  = 1). One counselor noted, “Practice felt superficial.” The supervisor reported “Counselors were so thirsty and hungry for responses to their needs. There were issues in understanding and acquiring how to implement TRT methodology.” Several counselors were scared to implement because they were “not confident until they knew it perfectly.” “We don’t want to be a curse instead of a blessing … she was afraid because of the high complexity of problems for students and because she was not very skillful, that she might do something wrong or deepen the trauma. Highly cautious is what I observed.” The supervisor reported PGS was “not so much about theory but in response to their questions and enquiries. Most of the time they pretend to understand the theory, however, the main challenges are the implementation, how to deliver. What they are used to is sitting with the student and filing in a form. In contrast counselors had to learn to work face to face, this was new for them. This was an unexpected challenge for them, the need to give extra effort and adaptation.” Counselors asked for more “practice amongst themselves.” The supervisor commented, “The focus of PGS was on being fully prepared, aware of the students’ situation, aware of the issues in your area and do what you can do to increase your confidence and self-esteem. If they are very religious, they pray before they go into the session.”

Barriers to Program Delivery - Situational Context

Some parents were reported as barriers to TRT, as they were “suspicious of why the program was being run”; others were “hesitant about involvement, as they did not want children to be late after school because of settler violations. For example, one female student, 12 years old, was stopped by a female Israeli soldier and delayed her from going home after she beat her up. This girl was in the media.” And finally the supervisor reported “all the counselors were victims of unpaid salaries, payments and strikes.” This apparently led to “fewer opportunities to practice skills.” Barriers to program delivery, therefore, included parental uncertainty, sessions after school increasing risks for adolescents; and school closures leading to less opportunities to practice.

Barriers to Training Others

Counselors rated 5.6 on average (4–6 range), for likely to train others. Comments included: “I need more follow up” ( n  = 3) and “I want to hear and know more” ( n  = 2). A range of barriers were identified by the supervisor, as it was noted that “some are trained in other programs and don’t want to leave other sources of knowledge. Other counselors heard about the training and questioned why they were not included. Some counselors were not able to convey TRT knowledge and skills to them. Culturally, the offer of training was misconstrued at a personal level, it was seen as showing off.” Positively, the supervisor concluded, “some believe in team work and have professional awareness. Seriousness and strict follow-up by Department of Counseling makes me feel more optimistic.”

According to the trainer, the challenge of counselors training other counselors has been a “major issue.” Counselors were seen as “over estimating … feeling they have to be very skilled to train others,” whereas “these are people experienced with children, dealing with children all the time, when they start to train adults they feel they have to be brilliant.” In addition, the trainer reflected on the “negative impact of the separation wall and checkpoints involved in travelling around the West Bank. As a consequence this causes very real practical problems in delivering training in different locations.” In summary, barriers to delivering training included: counselors perceived lack of knowledge and skill, need for more support; other counselors not wanting trained for various reasons, and travel restrictions.

Recommendation for Training of Trainers

The trainer and counselors emphasized the need for “encouragement and feedback … to support each other in peer groups (S)… and more role-play and practice” (C), to be able to train others. Ongoing supervision was considered important, as it challenged counselors to “move beyond their comfort zone (T).” The supervisor was specific in recommending ‘training of trainers’ sessions to bring together counselors, “four from Nablus, East Jerusalem/Ramallah, Jenin and Hebron to present this training as a rehearsal to empower them to work on what they face in the field.”

In summary, as counselors made most statements, this appropriately gave weight within the analysis to counselor experience. Counselor themes showed an inter-relatedness of the functions of supervision, however, formative and normative functions were spoken of most. The restorative function was needed immediately after training and subsequently led to reduced stress and increased confidence in program delivery. This is perhaps not surprising given counselors were new to the program and had a short period of time before delivering TRT. The supervisor tended to rate gains for counselors only slightly lower than counselors rated themselves. While there was high commonality of themes between counselor and supervisor, the supervisor reported on a range of unique themes, indicating a wider perspective. Trainer themes, covered the inter-dependence of the three functions in PGS, in order for skills to transfer from training to program delivery and concerns for barriers that could get in the way. PGS was seen as a way of addressing some of these barriers.

This case study, of the unique development of PGS to TRT for counselors in villages in Palestine, contrasted counselor, supervisor and trainer perspectives. Reports by all three participant groups indicate that even in a context of military violence, PGS provides a reflective process inclusive of formative, normative and restorative functions. Although many of the benefits of PGS reported by counselors and supervisor can be found in supervision literature (increasing clarity of practice, sharing learnings, growth in confidence, program protocol adherence, reduced stress, and improved listening and group communication skills; Hawkins and Shohet 2006 ), comments indicated counselors and supervisor held unique perspectives on PGS within a context of occupation. For example, despite years of delivering service, this was counselors’ first experience of supervision. Not surprisingly, counselors reported anxiety in the early stages, however, it is apparent from counselor and supervisor reports that counselors became increasingly comfortable with PGS. A particular benefit to counselors in Palestine was having supervision available locally. This appears to have avoided many of the problems of travel, such as the need for permits and the risk of checkpoints suddenly closing, resulting in the cancelation of meetings. Likewise, as salaries are regularly unpaid (Barron and Abdallah 2014 ), local supervision avoided the added pressure of travel costs. Within a geographically fragmented context, then, PGS with counselors from nearby schools appears to have reduced counselor isolation, fulfilling a restorative function.

Counselors’ reported an increased capacity to listen to each other and respect each other’s work. Specifically to Palestine, PGS provided a formative context for counselors to discuss and practice the skills of group work in moving from the narrow practice of form filling to one of interactive group activities. Of particular relevance, PGS facilitated counselors’ self-disclosure within a context of distrust. This is an important restorative and normative issue, as the use of informants in the region has embedded suspicion into community and professional relationships (Barron and Abdallah 2014 ). PGS then, appears to have created emotionally safe spaces in a context of adversity for counselors to share their work-based thoughts and feelings. Likewise, PGS was reported as enabling self-disclosure for women. This is challenging of cultural gender norms, as women living in a male dominated Palestinian culture are not expected to share personal information in a mixed sex public sphere. Indeed, in some parts of Palestinian society, it would viewed as a stigma for unmarried woman to have contact with a man beyond the family (Hasso 2005 ).

The supervisor raised a number of unique perspectives on PGS. Counselors, for example, were reported as using prayer in their preparation of PGS and program delivery. In contrast to the West, spiritual practices of this kind, and their impact on effectiveness, are rarely discussed. The field of spiritual counseling, however, would be an exception (Stebnicki 2006 ). The supervisor also highlighted, that despite the demoralizing context of war, PGS provided a process that facilitated counselor motivation through increased sense of purpose and support. Professional and cultural isolation reduced because of counselor contact with national and international organizations; that is, PGS provided a context for enwalled counselors to have productive communication with professionals beyond Palestine. Finally, the trainer perceived PGS as a useful follow-up to address emotive issues that had arisen in training, incorporating both formative and restorative functions. It would appear that contributions from different perspectives identified a wide range of benefits that PGS can bring to a context of violent military occupation.

Similarly to the benefits of PGS, many barriers reported by counselors are identified in current literature. This included experiencing uneasiness as a result of reflecting on the limitations of past practice, discomfort during the process of learning new knowledge and skills, and counselor cautiousness in being sufficiently skilled to deliver a program for the first time (Proctor 2004 ). Some of the reported barriers of PGS were, however, unique to the context of military occupation. These barriers were numerous including unpaid salaries resulting in school strikes and closures; no funds for other formative or restorative activities; military incursions stopping or interrupting sessions; and spontaneous unpredictable road blocks requiring plans for meetings to be changed. Despite these barriers, PGS appears to have been sufficiently valued by counselors to sustain participation.

In contrast, there was a significant difference between trainer, counselors and supervisor regarding counselor capacity to train other counselors. The trainer reported counselors overestimated their need for further input, given their extensive experience of working with traumatized adolescents. Despite PGS, however, only 50% of counselors felt ready to train others. Counselors and supervisor identified a range of factors in Palestine underpinning this lack of self-efficacy: the lack of sufficient training in psychology and social work; the geographical, social and political isolation and division felt as professionals and as individuals; the cumulative violence, trauma and daily humiliations experienced by themselves, relatives and the adolescents and families; the unpredictability of daily life; and the nature and extent of complex trauma in adolescents. In summary, counselors and supervisor reported that the daily events of military occupation left counselors’ feeling professionally and personally demoralized to such an extent that there was little confidence in going beyond program delivery to train peers. The lack of receptiveness of some non-trained counselors was reported as low because of similar issues.

Limitations

Case studies are criticized for the singularity of their focus and the limited generalizability to other situations. On the other hand, they provide a richness of information about participant experience and their meanings in particular contexts (Orne and Bell 2015 ). In this study, unique accounts were recorded from counselors, supervisor and trainer. Given there were seven counselors, this may not have been sufficient for saturation of issues to emerge, again limiting generalization of findings. Orne and Bell ( 2015 ) suggest sample sizes of 12–14 are needed for no new significant issues to emerge. It is unknown if non-participants held significantly different views. The case study was conducted in rural villages; the experience may be different for school counselors in cities, where there may be more resources. With researchers conducting supervision training, this may have led to reluctance on the part of counselors to share their negative PGS experiences. As one of the researchers was the supervisor, counselor response may have included appreciation for supervision received, and less critical of skilled PGS. Further, as the supervisor was interviewed as a participant, he may have been more positive about his experiences. To address this concern, much of the supervisor’s discourse has been reported to enable reader analysis of contribution. Interviews were conducted post-supervision only. Pre-supervision interviews would have enabled an evaluation of change in counselor perspective before and after PGS. Although there were rating scales and frequency counts of codes, the study did not seek to quantify the nature of counselor change. Quasi-qualitative analysis can be criticized for being overly compartmentalized and frequency counts may not necessarily convey a sense of greater importance of meaning.

The case study found that, despite the small number of supervision sessions and the ongoing stressors of military occupation, PGS provided a reflective process inclusive of formative, normative and restorative functions. Benefits did not simply fit into one function or another. Rather the interaction of all three functions seems to have been significant. Benefits and barriers of PGS mirrored both issues within PGS literature, and unique issues within a context of violent military occupation. Locally available PGS was reported as essential within a geographically fragmented context. Counselor self-disclosure within PGS led to a trusting environment in contrast to military practices and gender norms. The use of prayer in preparation of supervision was an unexpected finding that needs more research. Finally, indications are there are too many situational war stressors undermining counselor confidence for PGS to enable counselors’ to train their peers in TRT.

Recommendations for Practice and Policy

PGS should continue to be available locally for counselors delivering TRT in the West Bank. This should be augmented by skilled supervisor sessions. Opportunities for individual as well as group supervision should be explored. Responding to counselor and supervisor requests, a trainer of trainers should be developed to enable counselors to train colleagues across the West Bank. PGS should be expanded to be trialed for counselors in city schools. Finally, PGS cannot compensate for addressing the political and military barriers identified by counselors. Peaceful political solutions need to be sought.

PGS training and supervised practice needs to be embedded within Palestinian Authority Ministry of Education policy. Schools need guidelines on recognizing the value of PGS including releasing counselors for supervision. Guidelines should also facilitate ongoing evaluation of PGS and their practice. This would enable a longitudinal perspective on impact. Funding, for example, from international NGOs, needs explored to sustain this.

Recommendations for Research

Interviews could be held before and after PGS as a next step in evaluating effectiveness. Beyond case studies, quasi-experimental and experimental methodologies are needed to quantify the outcomes of PGS for counselors and subsequently for adolescents who experience TRT. Larger sample populations need to be in city and rural locations. Finally, the impact of prayer on PGS effectiveness needs explored.

Compliance with Ethical Standards

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.

Conflict of Interest

Dr Ian Barron and Dr Abdallah have received research grants from the Children and War Foundation. Dr Unni Heltne is an international trainer for the Children and War Foundation.

This study was funded by the Children and War Foundation (grant number 510.811183).

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Case Study: Should you listen to a peer reviewer?

Getting a Fair Shake?   Gail is an Associate Professor who has published extensively and rightly considers herself one of the leading experts in her field. She knows the drill for developing and submitting a proposal for funding. Her most recent proposal is based on considerable prior research that she and colleagues have conducted, and it employs methodology that she knows will produce valid findings.   Gail is anxious about her proposal being reviewed and funded. Prior to submitting, she ran it by a network of capable colleagues with whom she works collaboratively to develop and critique ideas. They all share the same dedication to medical research with important long-term implications for public health, as well as short-term implications for federal policies and funding.   When Gail finally receives the funder’s evaluation, she is happy to see that she received a high score on her proposal. However, the score is below the cut-off point at which it can be funded. Gail turns to see what objections and concerns the reviewers had with her proposal. She plans to revise and resubmit for the next funding cycle.   Gail is flabbergasted to read what the reviewers said. In their feedback, they find that her methods are “flawed”. And they suggest changes to the study design that Gail is certain would significantly compromise the quality of the science as well as its impact on the development of her field. They clearly did not understand her approach, which is highly novel.   Gail is considering re-submitting the proposal employing the reviewers’ suggested methodology, then actually doing the study as she proposed it in the first place, explaining that “pilot testing” indicated that her methodology would work best.   However, Gail worries that this is deceptive. And who knows if the same reviewers would be evaluating her resubmission? Perhaps she is better off proposing her original “flawed” methodology—with a direct response to reviewers—in hopes that she will receive new reviewers or that her reviewers will be unusually open minded. Gail has two months before the revised proposal is due. She feels caught between a rock and a hard place.   What should Gail do?

Email Updates

• Open access
• Published: 26 November 2023

A landscape on disorders following different COVID-19 vaccination: a systematic review of Iranian case reports

• Mona Sadat Larijani 1 ,
• Delaram Doroud 2 ,
• Mohammad Banifazl 3 ,
• Afsaneh Karami 4 ,
• Anahita Bavand 1 ,
• Fatemeh Ashrafian 1 &
• Amitis Ramezani 1  

European Journal of Medical Research volume  28 , Article number:  542 ( 2023 ) Cite this article

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There have been massive studies to develop an effective vaccine against SARS-CoV-2 which fortunately led to manage the recent pandemic, COVID-19. According to the quite rapidly developed vaccines in a fast window time, large investigations to assess the probable vaccine-related adverse events are crucially required. COVID-19 vaccines are available of different platforms and the primary clinical trials results presented acceptable safety profile of the approved vaccines. Nevertheless, the long-term assessment of the adverse events or rare conditions need to be investigated. The present systematic review, aimed at classification of probable vaccine-related unsolicited adverse events in Iranian population through the data collection of the published case report studies.

The related published case reports were explored via PubMed, Web of Science and Google scholar according to the available published data up to 14 th Dec, 2022 using PRISMA guideline. Out of 437 explored studies, the relevant data were fully investigated which totally led to 40 studies, including 64 case reports with a new onset of a problem post-vaccination. The cases were then classified according to the various items, such as the type of adverse event and COVID-19 vaccines.

The reported COVID-19 vaccines in the studied cases included BBIBP-CorV, ChAdOx1-S, Sputnik V and COVAXIN. The results showed that the adverse events presented in 8 different categories, including cutaneous involvements in 43.7% ( n  = 28), neurologic problems ( n  = 16), blood/vessel involvement ( n  = 6), cardiovascular involvement ( n  = 5), ocular disorders ( n  = 4), liver disorder/failure ( n  = 2), graft rejection ( n  = 2) and one metabolic disorder. Notably, almost 60% of the cases had no comorbidities. Moreover, the obtained data revealed nearly half of the incidences occurred after the first dose of injection and the median duration of improvement after the symptom was 10 days (range: 2–120). In addition, 73% of all the cases were either significantly improved or fully recovered. Liver failure following ChAdOx1-S vaccination was the most serious vaccine adverse event which led to death in two individuals with no related medical history.

Although the advantages of COVID-19 vaccination is undoubtedly significant, individuals including with a history of serious disease, comorbidities and immunodeficiency conditions should be vaccinated with the utmost caution. This study provides a comprehensive overview and clinical implications of possible vaccine-related adverse events which should be considered in further vaccination strategies. Nevertheless, there might be a bias regarding potential under-reporting and missing data of the case reports included in the present study. Although the reported data are not proven to be the direct vaccination outcomes and could be a possible immune response over stimulation, the people the population with a medium/high risk should be monitored after getting vaccinated against COVID-19 of any platforms. This could be achieved by a carefull attention to the subjects ‘ medical history and also through consulting with healthcare providers before vaccination.

COVID-19 as the most recent global pandemic, typically presents as lower respiratory tract infection which may lead to severe symptoms [ 1 , 2 ]. To date, vaccines have been one of the most effective ways to control the infectious diseases [ 3 , 4 ]. Fortunately, vaccination against COVID-19 was explored at the right time and led to fast outcomes through different platforms and hopefully pandemic control [ 5 , 6 ]. Nevertheless, booster shots are still recommended as the immunity wanes over the time and new variants are capable to escape from immune system [ 7 , 8 ].

From another point of view, the quick procedure of vaccine development could possibly have lately unsolicited events beside the immunity protection. Many studies have shown SARS-CoV-2 manifestations through which the virus affects the host in various presentations even in a late episode [ 9 , 10 ]. As the number of vaccinated individuals grows up, the knowledge of possible and probable vaccine effect develops through case reports and safety studies [ 11 , 12 ].

Although the exact mechanism through which the vaccine components can manipulate human body is not clear yet, the cumulative and comparative data would bring sufficient data especially by the follow-up programs.

Early studies on COVID-19 vaccines-related adverse events (AEs) mainly reported local reaction at the site of the injection and some temporary systemic side effects which normally lasted few days, among which fever, headache and fatigue were the most common ones. Moreover, further investigation indicated that the AEs are mostly mild, hence individual daily activities are not normally interfered with [ 13 , 14 ]. A cross-sectional study in Nepal, presented higher rate of vaccine adverse events after the first dose of both vaccines, while a follow-up study from Iran demonstrated that the vast majority of the vaccine-related AEs were set after receiving the booster shots [ 15 , 16 ]. It should be also noticed that, COVID-19 vaccination has been the most recently administrated vaccine worldwide and the massive studies and reports on the related side effects are naturally highlighted. However, comparison of advantages and disadvantages of COVID-19 vaccines has shown that it is still recommended. It has been assumed that there will be more in cardiovascular diseases due to spike proteins encoded in vaccines [ 17 , 18 ]. Furthermore, there is a possible threat of unknown organ hurt caused by the immunization which is still hidden. Thus, any type of study in this era regarding vaccine safety seems highly practical for future vaccine programs. Along with the different type of the conducted studies on COVID-19 vaccination, case report studies have been massively published. Owing to the fact that this kind of study provides a detailed report of many aspects, including symptoms, diagnosis and follow-up of individuals, they could possibly bring a new insight to the COVID-19 vaccines-related side effects. Furthermore, these reports usually describe a novel or unusual incidences in a faster window time than cross-sectional research or follow-up studies. According to several case reports post-vaccination against COVID-19, the present study aimed to classify the new onset of disorders in Iranian individuals with no previous related medical history. The present data provides a better overview of documented COVID-19 vaccine-related disorders along with the cases’ characteristics and the treatment/follow-up after administration of primary and/or booster doses. Furthermore, the screened disorders post vaccination are classified based on the organ involvement to facilitate the recognition of adverse events prevalence, time of the incidence and the final outcome.

Search strategy

The present study was conducted according to preferred reporting items for systematic reviews and meta - analyses (PRISMA) in all relevant items [ 19 ].

Three databases, PubMed, Web of Science and Google scholar, were explored. The initial search started in December, 2022 and all the available data up to December 14, 2022 were collected. The relevant data were targeted with terms of: “COVID-19 vaccine”, “SARS-CoV-2”, “case reports”, “adverse events” and “Iran”. In order not to miss any published relevant data we explored each searching item solely and also in combination forms.

Data collection

To exclude the irrelevant data, titles and abstracts were initially screened. To maximize the validity, the preprints or unpublished data were not included. At the next step, the full texts of the articles were evaluated regarding the eligibility of inclusion in the study. The full text screening and data extraction was done by the end of the February, 2023. To collect the relevant studies two main principles were considered in inclusion criteria. First, the reported adverse events only were considered post-vaccination against COVID-19, not the infection itself. Thus, data including the case reports after COVID-19 disease were also removed. Moreover, only the new onsets were considered which means the cases who had a history of the exactly same disorder were not included (Fig.  1 ).

The review flowchart based on PRISMA

The following data were extracted according to a valid datasheet, including: age, gender, vaccine type, date of injection, date of disorder appearance, duration of the symptoms, type of the developed disorder, medical history of the case, hospitalization, response to the treatment, follow-up and outcomes. All the mentioned items were exactly collected from the case report studies and were re-checked thoroughly and was completed by March 2023.

Data analysis

Statistical analyses were performed using SPSS software (version 22). Descriptive analyses are presented by numbers, percentages, frequencies and mean (SD) or median (min‐max) were applied to report the quantitative variables.

The initial search yielded 437 studies. After duplication removal, 250 papers were investigated regarding the titles and abstracts from which 128 articles were excluded according to the eligibility of the criteria including the case reports which had the same medical history or those with insufficient data. Eventually 40 manuscripts met the criteria of the systematic review.

A total of 64 cases including 31 females and 33 males with a mean age of 47.67 ± 17.69 and a range of 18 to 91 were investigated from whom 60% had no remarkable medical history. The previous history of COVID-19 was rare among the cases and all the COVID-19 PCR tests were negative at the time of manifestation (Tables 1 , 2 , 3 and 4 ).

The reported COVID-19 vaccines in the studied cases included BBIBP–CorV (Sinopharm).

( n  = 35), ChAdOx1 nCoV-19 (AstraZeneca) ( n  = 22), Sputnik V ( n  = 6) and COVAXIN ( n  = 1).

The median of duration between the vaccination and any appeared event was 7 days (range: 1–60). Of 64 cases, 52 ones experienced a type of manifestation post-first dose, 10 post-second dose and only 2 after the booster shot.

COVID-19 vaccine triggered different manifestations from which cutaneous disorders (Table 1 ) were spotted as the most frequent one accounting for 43.7% ( n  = 28) followed by neurologic problems (Table 2 ) in 25% of the cases ( n  = 16). Other unsolicited events included blood/vessel involvement ( n  = 6), cardiovascular involvement ( n  = 5), ocular disorders ( n  = 4), liver disorder/failure ( n  = 2), graft rejection ( n  = 2) and one metabolic disorder (Tables 3 and 4 ). The median duration of improvement after the symptom onset was 10 (range: 2–120) days.

Cutaneous involvement presented in various forms, such as alopecia, lichen planus, rash, dermatitis and stromal keratitis. Notably, the dermal manifestation occurred equally on both men and women among whom only one person had a history of COVID-19. The other interesting finding is that rare diseases were also screened such as Steven–Johnson syndrome, Morphea and Toxic Epidermal Necrolysis (TEN). BBIBP–CorV, ChAdOx1-S and Sputnik V vaccines led to 21, 6 and 1 cutaneous disorders, respectively. Finally, almost 90% of the skin manifestations were fully or significantly improved after the applied treatment (Fig.  2 , Table 1 ).

COVID-19 vaccines and their potential association with disorders in case reports. Each complication is shown with a different color to simplify comparison between the vaccines. The final reported status for each disorder is also presented

In addition to type of disorders, we also evaluated the recovery time as well. To achieve that, the provided data were categorized to 6 outcomes as resolved, significant improvement, partial improvement, under treatment, not-treated and expired. Based on the outcome statement of the studied cases, of 64 incidences, 13 were resolved, 33 were significantly improved and 10 were partially improved. 4 cases were under treatment, one remained untreated and 2 cases expired. Three studies did not mention the outcome. Therefore, 73% of all the cases were either significantly improved or fully recovered from the incidence.

According to the available statements, 20 cases were hospitalized and 22 ones were recommended to be followed-up in the schedule varying from 14 days to 6 months.

Neurological problems were mostly induced by ChAdOx1-S ( n  = 8) followed by BBIBP–CorV ( n  = 5) and Sputnik V ( n  = 3). Guillain–Barre syndrome and Bell’s palsy were the most common ones. Totally, 62.5% of these problems met significant improvement or were resolved (Fig.  2 , Table 2 ).

The most serious vaccine outcomes might be acute liver failure which was captured in two ChAdOx1-S recipients and led to expiration. Both cases were young (34 and 35 years) with no similar medical history (Table 4 ). Both incidence occurred post-first injection one after 2 and the other after 8 days [ 52 , 53 ].

Massive vaccination campaigns have been launched since December 2020, applying mRNA vaccines and also the viral vector-based vaccine as well as inactivated viral-based and recombinant protein vaccines. By the end of January 2023, more than 5 billion individuals were fully vaccinated [ 42 ]. Thus, there is an increasing rate of reports over the adverse events associated with the administrated vaccines in the real world. General symptoms which have been normally screened include weakness, fever/chills, body pain, headache and local injection-site reactions. These symptoms are usually transient and do not normally need to be treated with specific medical care.

Herein, we discussed 64 cases of 40 studies who experienced unsolicited events after vaccinating against COVID-19. The applied vaccines included viral-vector and inactivated virus-based vaccines. We tried to select the case reports with new onset of the symptoms in whom the pre-existing comorbidity was not as same as the triggered adverse events. Various disorders were captured induced by different vaccines suggesting that the type of a specific regimen is not the only factor in outcomes. Moreover, there is not enough clues to support the triggered manifestations and their association with the applied vaccine. However, the healthy individuals who did not have any remarkable medical history and experienced serious events suggest that this potency of COVID-19 vaccine must be considered.

The common reported adverse events of ChAdOx1-S vaccine were pain at the injection site, fever, lethargy, muscle pain and headache which were mostly screened after the first dose of the vaccine [ 60 ]. The investigation by Pasteur Institute of Iran on ChAdOx1-S vaccine showed that a higher incidence of symptoms including fatigue, chills and myalgia were seen among homologous ChAdOx1-S recipients rather than those of a heterologous ChAdOx1-S/PastoCovac Plus group [ 61 ]. Moreover, irritability, nausea, myalgia, and chills some hours after vaccination with AZD1222 were reported in Nepal [ 62 ]. In addition to common adverse events, severe disorders were captured as postural drop in blood pressure, abdominal cramps, syncope and urticarial [ 63 ]. In this review, we found that ChAdOx1-S mostly led to neurological incidences, including encephalopathy [ 20 ], acute vestibular neuritis [ 34 ] and Guillain–Barre syndrome [ 38 ]. Although the safe administration of vaccines is a crucial factor, many unusual events following ChAdOx1-S vaccine have been reported. The Concern about neurological abnormalities regarding COVID-19 vaccines firstly rose in 2020 when some cases of Guillain–Barré syndrome and transverse myelitis were screened post-Oxford/ChAdOx1-S vaccine [ 64 , 65 ]. In a recent comprehensive study on COVID-19 vaccines-related AEs, the most common observed neurological disorder was also Guillain–Barre syndrome. However, no association between the vaccines and the syndrome has been confirmed yet [ 66 ].

On the other hand, ChAdOx1-S has been the only cause of liver disorder in forms of Fulminant hepatitis [ 53 ] and acute liver failure which led to death in both cases in the present studied cases [ 52 ]. The previous studies on liver injury after COVID-19 vaccination of different platforms showed that mRNA-based vaccines and the vector-based ones both contributed to the captured disorders among which Pfizer‐BioNTech vaccine led to a liver failure [ 67 ]. Liver injury following COVID-19 vaccination is also investigated in a systematic review on individuals who got to Moderna (mRNA–1273), Pfizer–BioNTech BNT162b2 mRNA or ChAdOx1 nCoV-19 vaccine. Nevertheless, in those cases, pre-existing comorbidities was common as 69.6%, such as liver disease. The mortality rate due to live disorders was reported 4.3% [ 68 ].

The other adenovirus-based vaccine, Sputnik V, was also previously reported with fever/chills, general discomfort, headache arthralgia, myalgia, asthenia, tenderness as the common side effects [ 69 , 70 ]. Similar to ChAdOx1-S, this vaccine mostly led to neurologic manifestations as Bell’s Palsy and Facial Paresis [ 31 , 35 ]. Previous review study found Pfizer and Moderna vaccines as the most common reported causes of Bell’s palsy; however, COVAXIN and Sputnik V also led to it as well [ 71 ].

According to conducted studies in China, inactivated viral-based vaccines led to adverse events including injection site pain, lethargy and muscle pain 15.6% after the first and 14.6% after the second dose among the healthcare workers. The most common is pain at the injection site, followed by fatigue, muscle pain, and headache [ 72 , 73 ]. Furthermore, two serious events as multiple sclerosis and emesis were also recorded with hospitalization requirement [ 74 , 75 ].

In the present review, BBIBP–CorV vaccine resulted in corneal graft rejection in to cases a week after the first dose of injection [ 59 ]. In a study by Shah AP et al., four cases with a history of keratoplasty developed rejection after being vaccinated with mRNA-1273 [ 76 ]. This incidence has also been reported after adenovirus vector (AZD1222) and mRNA (BNT162) vaccines [ 77 ]. A systematic review also showed that Cornea rejection was the most reported organ rejection after vaccination against COVID-19, followed by kidney and liver rejections [ 78 ].

Dermal abnormalities have been the most frequent reported incidences after BBIBP–CorV vaccine among which new-onset lichen planus (LP) was observed in 6 cases [ 29 ]. Nevertheless, rare conditions were also screened, such as Toxic Epidermal Necrolysis [ 27 ], Morphea [ 25 ] and Pemphigus vulgaris [ 28 ]. Notably, of 28 skin disorders in the reported cases in this review, 20 cases got BBIBP–CorV vaccine. The other study from Iran evaluated the cutaneous reactions post-COVID‐19 vaccination which presented that most of the individuals showed symptoms after injection of ChAdOx1-S, BBIBP–CorV, Sputnik V, and COVAXIN vaccines [ 79 ].

Herpes zoster has been reported in case series and has also been documented in the Center of Disease Control following COVID-19 vaccines (VAERS). There are more than 1000 cases with mRNA vaccine-triggered herpes zoster in VAERS, mostly aged over 60 [ 80 ]. We also found a reported case of Herpes Zoster in a 60-year-old healthy woman 6 days after the first dose of BBIBP–CorV vaccine [ 25 ]. It has been suggested that molecular mimicry between the human components and vaccine‐induced proteins could lead to pathological autoantibodies generation and hence, autoimmunity accordingly [ 81 ].

As previously discussed, a quarter of the investigated cases experienced neurological involvements mostly as Guillain–Barré syndrome [ 38 ] and Bell's palsy caused [ 35 ] which were triggered by adenovirus-based vaccines and also BBIBP–CorV. Although the most incidences were captured post-first dose, a 60-year-old man presented Guillain–Barré syndrome 20 days after the BBIBP–CorV booster shot [ 82 ]. The correlation between Bell's palsy and vaccinations has been introduced previously, such as influenza H1N1 monovalent vaccine and intranasal inactivated influenza vaccine [ 83 , 84 ]. Similar to other unknown mechanisms of vaccine induced problems, precise pattern of neurologic disorders is still under question. Some hypothetical thoughts though propose that autoimmune phenomenon as a result of host molecules mimicry with the vaccine antigen could activate auto‐reactive T cells [ 85 ].

Blood/vessels involvement were also reported in 6 cases as vasculitis, thrombotic thrombocytopenia, Cerebral venous sinus thrombosis, acquired thrombotic and lymphocytic vasculopathy caused by BBIBP–CorV and ChAdOx1-S [ 20 , 44 , 45 , 46 , 86 ]. Notably, all the cases presented the manifestation after the first dose of vaccination. A review study showed that thrombotic complications occurred 5–25 day post-first dose of ChAdOx1-S vaccinated individuals in which the thrombosis site was mostly in cerebral veins [ 87 ]. Although the exact mechanism of the events is not well-understood, the pre-existing antibodies such as heparin-PF4 antibody in the cases might give rise to the manifestations [ 88 ]. In addition, vasculitis precipitation has been also detected after other vaccines against hepatitis B virus (HBV), influenza virus and human papillomavirus (HPV) [ 89 ].

Although the discussed disorders have been screened post-vaccination, it is suggested that host immune responses are strongly the potential cause of the events. It is to say that, anti-spike immune responses might be linked to post-vaccine syndromes as all the vaccines against COVID-19 encode the whole or a part of spike protein. In addition to spike protein, anti-idiotypic antibodies can bind to the ACE-2 receptor as well [ 90 ]. Furthermore, the generated autoantibody stemming from molecular mimicry and independent immune-dysregulation may both contribute to a symptom onset [ 91 ]. However, it must be taken to attention that these mechanisms are still theoretical and have not been established as causal factors yet. Further studies are crucial to provide enough evidence.

In the present review, a comprehensive overview of COVID-19 vaccine-related case reports has been conducted. The classification of the vaccine-related AEs could make the recognition much easier and would contribute to further vaccine administration as well. Nevertheless, this study is only based on case reports which normally include inherent data quality and causality limitations and provides conclusive evidence of a causal relationship between the administered vaccines and the adverse events. Eventually, a comprehensive causality assessment in future studies to establish a more robust link between vaccinations and adverse events is of a high value owing to the fact that assessment the causality based on case reports would not be sufficient to draw general conclusions about vaccine safety. Eventually, case reports are often subject to selective reporting, which might have influenced the findings.

The present review showed that various unsolicited adverse events have been captured as case reports in Iran. Interestingly, all the vaccine platforms could result in similar unsolicited events. Although, clinical trials provide safety data, the long-term evaluation of newly launched vaccines are essential to keep the public trust balanced.

COVID-19 has been the most recent mass vaccination program due to the broad range of infection world-wide. Thus, it is not far from view to face some rare disorders or late onset of a disease. Considering the advantage of the vaccination against SARS-CoV-2 which eventually led to the chaos management globally, the number of unsolicited AEs are not significant. However, the collective data from different populations would result in a better perspective for further vaccination program. The high risk individuals including those with a history of serious disease or comorbidities and those with immunodeficiency conditions should be vaccinated with the utmost caution. Future research to establish causality, the importance of continuous vaccine safety monitoring and the potential benefit–risk assessment for different populations are strongly recommended.

Availability of data and materials

Not applicable. A preprint has been previously published [ 92 ].

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Sadat Larijani MD, D.; Banifazl, M.; Karami, A.; Bavand, A.; Ashrafian, F.; Ramezani, A. A landscape on disorders following different COVID-19 vaccination: a systematic review of Iranian case reports. 2023.

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Mona Sadat Larijani, Anahita Bavand, Fatemeh Ashrafian & Amitis Ramezani

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MSL contributed to the conceptualization, wrote the original draft and provided methodology and data collocation; DD, MB, AK, AB and FA contributed to the data curation, re-check process and classification; AR supervised the data and revised the manuscript.

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Sadat Larijani, M., Doroud, D., Banifazl, M. et al. A landscape on disorders following different COVID-19 vaccination: a systematic review of Iranian case reports. Eur J Med Res 28 , 542 (2023). https://doi.org/10.1186/s40001-023-01531-7

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Relationship between PIWIL1 gene polymorphisms and epithelial ovarian cancer susceptibility among southern Chinese woman: a three-center case–control study

• Shanshan Liu 1   na1 ,
• Yaping Yan 1   na1 ,
• Zhizhong Cui 2 ,
• Haipeng Feng 3 ,
• Fengmei Zhong 3 ,
• Ziguang Liu 3 ,
• Xiang Ou 5 &
• Wenjuan Li 4  

BMC Cancer volume  23 , Article number:  1149 ( 2023 ) Cite this article

30 Accesses

Metrics details

To investigate the potential correlation between piwi-like RNA-mediated gene silencing 1 ( PIWIL1 ) polymorphisms and susceptibility to epithelial ovarian cancer (EOC).

A case–control study was conducted to evaluate the susceptibility of EOC using multinomial logistic regression analysis. The study analyzed the relationship between five functional single nucleotide polymorphisms (SNPs) in the PIWIL1 gene and EOC risk. Genotyping of 288 cases and 361 healthy samples from South China was identified using a TaqMan assay. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to estimate the relationship between the five selected SNPs and EOC susceptibility.

Among the five SNPs analyzed, the rs10848087 G > A and rs7957349 G > C variants significantly increased the susceptibility of EOC, rs10773771 C > T was associated with a decreased risk of EOC, while the rs35997018 and rs1106042 variants were not in Hardy–Weinberg equilibrium ( p  < 0.05). The rs10848087 G > A was significantly associated with increased risk of EOC in individuals with metastasis, FIGO stage I and III, low and high pathological grade, tumor numbers ≤ 3 and > 3, tumor size > 3 cm and ≤ 3 cm, pregnant more than 3 times, pre-menopausal status, and strong positive expression of ER (estrogen receptor), PR (progesterone receptor), PAX8 (paired-box 8), wild-type p53 (tumor protein 53), WT1 (Wilm’s tumor gene), P16 (cyclin-dependent kinase inhibitor 2A). In addition, rs10848087 G > A enhanced the EOC risk of cases with negative/mild positive expression of wild p53 and Ki67, and with or without mutant p53 expression. The rs7957349 G > C variant was linked to an increased risk of EOC in subgroups with certain characteristics, including age equal or less than 53 years, metastasis, clinical stage I, low pathological grade, tumor number, tumor size, pregnant times, post-menopause, pre-menopause, and strong positive expression of wild p53 and Ki67 (Antigen identified by monoclonal antibody Ki-67), as well as without mutant p53 expression. The rs10773771 CT/TT alleles were identified to have a protective effect on EOC in women aged 53 years or older, as well as in cases with metastasis, advanced clinical stage, high pathological grade, multiple tumors, tumor size equal to or less than 3 cm, history of pregnancy, post-menopausal status, and strong positive expression of ER, PR, wild-type p53, PAX8, WT1, P16, and Ki67. Furthermore, rs10773771 CT/TT also showed a protective effect in patients with negative or mildly positive expression of PR, PAX8, wild-type p53, WT1, and P16, as well as positive expression of mutant p53. Compared to the reference haplotype GCG, individuals harboring haplotypes GTG were found to have a significantly decreased susceptibility to EOC. PIWIL1 was significantly expressed in the thyroid, pituitary, and adrenal glands with rs7957349 CC alleles.

Conclusions

PIWIL1 rs10848087 and rs7957349 were associated with increased risk of EOC, while rs10773771 may have a protective effect against EOC. These genetic variants may serve as potential biomarkers for EOC susceptibility in the South China population.

Peer Review reports

Introduction

Ovarian cancer is the second most common cause of gynecologic cancer death in women worldwide [ 1 ]. There are three major types of ovarian cancer-epithelial, germ cell, and sex cord-stromal tumors. Epithelial ovarian cancer (EOC) is a highly heterogeneous phenotype with five major histotypes for invasive disease-high-grade serous, low-grade serous, endometrioid, clear cell, and mucinous histotype [ 2 ]. It accounts for approximately 3.4% and 4.7% of new cancer cases and deaths among women worldwide [ 3 ]. Unfortunately, due to the lack of specific clinical manifestations and mature screening techniques in the early stage, most EOC cases are already diagnosed in the late stage (advanced III-IV), and cancer has already spread and metastasized in the abdominal cavity [ 4 ]. As a result, approximately 70% of cases have reached the late stage without early warning symptoms [ 5 ]. The 5-year survival rate for this disease is around 45% [ 6 ], which is relatively low due to poor pathological features resulting in limited clinical efficacy [ 7 ].

Early diagnosis is an optimal strategy for enhancing the dismal survival rates associated with ovarian cancer. If the disease is detected at early stages (IA and IB), characterized by small or localized tumors, approximately 93% of patients can achieve a five-year survival rate after diagnosis [ 8 , 9 ]. Diagnostic testing for symptomatic individuals includes physical examination and radiological imaging techniques such as transvaginal ultrasound (TVUS). However, there are currently no available screening strategies for asymptomatic women to detect ovarian cancer in its early stages. The most promising screening tools presently include the cancer antigen 125 (CA125) blood test and TVUS [ 10 , 11 ]. Additionally, human epididymis protein 4 (HE4) has been investigated as a potential biomarker for ovarian cancer screening; however, further studies are warranted [ 10 ]. The medical and surgical treatment strategies for epithelial ovarian cancer in women are continuously evolving. In recent years, significant progress has been achieved, supported by groundbreaking clinical trials. Although the treatment of primary epithelial ovarian cancer still involves a combination of surgery and systemic therapy, there is now a standardization of more intricate surgical procedures and novel therapeutic approaches [ 12 , 13 ]. Cytotoxic chemotherapy and maximal surgical efforts remain the mainstream approach; however, targeted therapies are increasingly being utilized as well, while new data have raised questions regarding the role of surgery in women with recurrent disease [ 14 , 15 ]. Poly-ADP-ribose polymerase inhibitors have demonstrated improved progression-free survival rates in both first-line and recurrent patients, leading to their increasing utilization [ 16 ]. The recent classification based on genetic alterations further emphasizes the recommendation for germline genetic testing in all women diagnosed with epithelial ovarian cancer [ 17 , 18 , 19 , 20 ], while new drug approvals driven by biomarker analysis suggest potential benefits from somatic molecular testing as well.

PIWIL1 , piwi-like RNA-mediated gene silencing 1, a member of the PIWI subfamily of Argonaute proteins, is involved in stem cell self-renewal, RNA silencing, and translational regulation in various organisms. PIWIL1 may, as an oncogene, be overexpressed in multiple types of tumors, such as gastric cancer [ 21 ], lung cancer [ 22 ], hepatocellular carcinoma [ 4 ], pancreatic adenocarcinoma [ 23 ], and endometrial cancer [ 24 ]. PIWIL1 Knocking out the PIWIL1 gene (PIWIL1-KO) has significantly reduced gastric cancer cell proliferation, migration, metastasis, and tumorigenesis [ 21 , 25 ]. In pancreatic ductal adenocarcinomas, Feng Li et al. [ 26 ] discovered that human PIWIL1 functions as an oncoprotein, activating the anaphase-promoting complex/cyclosome E3 complex in the absence of piRNAs, this complex targets a critical cell adhesion-related protein to enhance PDAC metastasis. Cheng et al. [ 27 ] observed that the RASSF1C-PIWI-piRNA pathway promotes lung cancer cell growth and progression and suggests that PIWIL1 protein is abnormally expressed in various types of cancer, making it a potential biomarker and therapeutic target. Wen et al . [ 28 ] reveal that Piwil serves as a crucial regulator gene in germ cell division during gonadal development and is closely associated with germ cell differentiation. A total of 219, 256, and 234 piRNAs were detected in normal ovary, endometrioid, and serous ovarian cancer samples, respectively. The functional analysis of the predicted targets of differentially expressed piRNAs revealed their potential to modulate key processes and pathways involved in ovarian oncogenesis [ 29 ]. However, it is important to note that these findings are just the tip of the iceberg, as the relationships between the piRNA pathway and ovarian cancer progression have not yet been extensively studied.

Additionally, allele-specific DNA methylation differences at regulatory sites of genes involved in piRNA regulation have been linked to impaired spermatogenesis [ 30 ]. While a single-nucleotide polymorphisms study (SNPs) has shown that the GG genotype and G allele of rs28416520 within the PIWIL1 gene promoter CpG 67 region are associated with an increased risk of gastric cancer [ 31 ], the impact of SNPs of PIWIL1 gene on EOC risk has not been studied.

The predominant histological subtypes of ovarian cancer encompass high-grade serous carcinoma, low-grade serous carcinoma, endometrioid carcinoma, clear cell carcinoma, and mucinous carcinoma. Nuclear antigens comprise cell cycle-associated proteins (such as P16 and Ki-67), tumor suppressor gene products (such as p53 and WT1), and steroid hormone receptors (such as ER and PR). Notably, the expression patterns of WT1, ER, PR, mutant P53, and wild-type P53 can effectively discriminate between different types of ovarian cancer [ 32 , 33 ]. PAX8 can be used to distinguish primary ovarian cancer from metastatic cancer [ 34 , 35 ]. Additionally, PAX8 can serve as a useful tool in distinguishing primary ovarian cancer from metastatic cancer [ 34 , 35 ]. In the context of ovarian cancer prognosis analysis, increased expression of p16 and Ki67 has been associated with more aggressive tumor growth patterns and poorer clinical outcomes [ 36 ]. These aforementioned markers have been employed in our stratification analysis.

Given the evidence that the PIWIL1 gene promoted tumorigenesis, we conducted a three-center case–control study to explore the association between genetic variations in the PIWIL1 gene and the risk of EOC in southern Chinese women.

Materials and methods

Patients and healthy controls.

A total of 288 EOC patients and 361 healthy controls, ranging from 20 to 88 years old, were recruited from Guangzhou Women and Children's Medical Center, Shunde Hospital of Southern Medical University, and The First Affiliated Hospital of Jinan University between 2016 and 2022. The diagnosis was confirmed by two pathologists independently, and tumors were classified according to the WHO Classification of Tumors of the female genital tract [ 37 ]. All participants in this study provided written informed consent, and the Ethics Committee of Guangzhou Women and Children's Medical Center (117A01) and Shunde Hospital of Southern Medical University (KYLS20220903) approved the research. The experiments were conducted by the Declaration of Helsinki. The demographic characteristics of all participants are presented in Table S 1 . The PIWIL1 gene SNPs rs10848087 G > A, rs7957349 G > C, and rs10773771 C > T were stratified based on various factors including age, metastasis, clinical stage, pathological grade, tumor number, tumor size, pregnancy history, menopausal status, and expression levels of ER, PR, PAX8, wild-type p53, mutant p53, WT1, P16, and Ki67 (refer to Table 2 for details).

SNP selection and genotyping

Five SNPs (rs10848087 G > A, rs35997018 T > C, rs10773771 C > T, rs7957349 G > C, and rs1106042 G > A) were selected from the NCBI dbSNP database ( http://www.ncbi.nlm.nih.gov/projects/SNP ) based on previously described criteria [ 38 ]. The potential functions of these SNPs were evaluated using the SNPinfo online server ( http://snpinfo.niehs.nih.gov/snpfunc.htm ). Genomic DNA from patient samples was extracted using the TIANamp DNA Kit (Tiangen, Beijing, China) from paraffin-embedded tissue. In contrast, genomic DNA from controls was extracted from peripheral blood specimens using the TIANamp Blood DNA Kit (Tiangen, Beijing, China). DNA purity and concentration were measured using a UV absorption spectrophotometer (Nano Drop Technologies Inc.). Genotyping analysis was conducted using TaqMan PCR master mix and ABI Prism 7900HT genetic detection system through real-time PCR [ 39 ]. A random selection of 5% samples was used as positive and negative controls to ensure the accuracy of genotyping results.

Statistical analyses

We conducted a χ 2 test to evaluate the heterogeneity of genotypes and ages between patients and controls. We assessed the association between SNP and ovarian cancer risk using a generalized linear regression model and calculated crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs). A χ 2 chi-square test was performed to evaluate deviation from Hardy–Weinberg equilibrium (HWE) among the control group [ 40 ]. All statistical tests were conducted using SAS software (Version 9.4; SAS Institute, Cary, NC, U.S.A.), with a two-sided P -value of < 0.05 considered significant.

Association of PIWIL1 genes SNPs and EOC risk

In this study, five PIWIL1 gene SNPs (rs10848087 G > A, rs35997018 T > C, rs10773771 C > T, rs7957349 G > C, and rs1106042 G > A) were genotyped in 288 EOC samples and 361 age-matched healthy controls. The study found that three SNPs (rs10848087 G > A, rs10773771 C > T, and rs7957349 G > C) were in Hardy–Weinberg equilibrium ( p  > 0.05). However, the rs35997018 and rs1106042 variants were not ( p  < 0.05). Single-locus analysis was conducted to examine the relationship between rs10848087 G > A, rs10773771 C > T, rs7957349 G > C and EOC risk. The results revealed that rs10848087 AA (adjusted OR = 5.654, 95% CI = 1.562–20.464, p  = 0.0083) and rs7957349 CC (adjusted OR = 2.984, 95% CI = 1.491–5.972, p  = 0.002) variants significantly increased the susceptibility of EOC. On the other hand, rs10773771 CC (adjusted OR = 0.573, 95% CI = 0.404–0.812, p  = 0.0018) was associated with a decreased risk of EOC (Table 1 ). Location of PIWIL1 gene polymorphisms that may influence cancer risk (Fig.  1 ).

SNPs location of PIWIL1 gene. The picture shows the SNP sites used in this paper. The polymorphism of the ovarian cancer risk gene are shown in red, and the site that has a protective effect on EOC are shown in blue. Green was not found to be significant

Stratification analysis of rs10848087, rs7957349 and rs10773771 with EOC susceptibility

Genotype rs10848087 AA had a harmful effect on cases with metastasis (adjusted OR = 8.919, 95% CI = 2.141–37.165, p  = 0.0027), clinical stage 1 (adjusted OR = 7.301, 95% CI = 1.348–39.537, p  = 0.0211), clinical stage 3 (adjusted OR = 6.490,95% CI = 1.403–30.022, p  = 0.0167), low pathological grade (adjusted OR = 5.908, 95% CI = 1.143–30.546, p  = 0.0341), high pathological grade (adjusted OR = 6.718, 95% CI = 1.770–25.493, p  = 0.0051), single tumor (adjusted OR = 5.443, 95% CI = 1.016–29.161, p  = 0.0479), multiple tumors (adjusted OR = 4.602, 95% CI = 1.008–21.012, p  = 0.0488), tumor size > 3 cm (adjusted OR = 6.503, 95% CI = 1.381–30.615, p  = 0.0178), tumor size ≤ 3 cm (adjusted OR = 5.523, 95% CI = 1.392–21.912, p  = 0.0151), pregnant times ≤ 3 (adjusted OR = 7.386, 95% CI = 0.650–29.486, p  = 0.0046), pregnant times > 3 (adjusted OR = 4.725, 95% CI = 1.096–20.367, p  = 0.0373), pre-menopause (adjusted OR = 6.172, 95% CI = 1.437–26.516, p  = 0.0144), strong positive ER expression (adjusted OR = 6.232, 95% CI = 1.202–32.300, p  = 0.0293), strong positive PR expression (adjusted OR = 6.584, 95% CI = 1.048–41.362, p  = 0.0444), strong positive PAX8 expression (adjusted OR = 5.885, 95% CI = 1.164–30.005, p  = 0.0330), negative/mild positive wild p53 expression (adjusted OR = 6.172, 95% CI = 1.773–37.671, p  = 0.0071), strong positive wild p53 expression (adjusted OR = 4.717, 95% CI = 1.210–18.395, p  = 0.0255), mutant p53 expression (adjusted OR = 5.723, 95% CI = 1.326–24.700, p  = 0.0194) no mutant p53 expression (adjusted OR = 5.969, 95% CI = 1.496–23.817, p  = 0.0114), strong positive WT1 expression (adjusted OR = 10.408, 95% CI = 2.511–43.135, p  = 0.0012), strong positive P16 expression (adjusted OR = 12.751, 95% CI = 3.190–50.966, p  < 0.001), strong positive Ki67 expression (adjusted OR = 10.378, 95% CI = 1.947–55.310, p  = 0.0061).

The rs7957349 CC was also identified to increase the EOC risk in woman with age ≤ 53 years (adjusted OR = 3.399, 95% CI = 1.387–8.326, p  = 0.0074), metastasis (adjusted OR = 3.622, 95% CI = 1.542–8.511, p  = 0.0031), no metastasis (adjusted OR = 2.752, 95% CI = 1.250–6.058, p  = 0.0119), clinical stage 1 (adjusted OR = 5.870, 95% CI = 2.428–14.191, p  < 0.0001), low pathological grade (adjusted OR = 3.033, 95% CI = 1.200–7.664, p  = 0.0190), single tumor (adjusted OR = 4.063, 95% CI = 1.719–9.634, p  = 0.0014), multiple tumors (adjusted OR = 2.490, 95% CI = 1.028–6.029, p  = 0.0432), tumor size > 3 cm (adjusted OR = 3.019, 95% CI = 1.137–8.018, p  = 0.0266), tumor size ≤ 3 cm (adjusted OR = 3.024, 95% CI = 1.421–6.434, p  = 0.0041), pregnant times ≤ 3 (adjusted OR = 3.768, 95% CI = 1.697–8.368, p  = 0.0011), pregnant times > 3 (adjusted OR = 2.359, 95% CI = 1.039–5.354, p  = 0.0402), post-menopause (adjusted OR = 3.020, 95% CI = 1.394–6.544, p  = 0.0051), pre-menopause (adjusted OR = 3.163, 95% CI = 1.106–9.048, p  = 0.0317), strong positive wild p53 expression (adjusted OR = 3.460, 95% CI = 1.693–7.072, p  = 0.0007), no mutant p53 expression (adjusted OR = 4.254, 95% CI = 20.19–8.963, p  = 0.0001), strong positive Ki67 expression (adjusted OR = 3.126, 95% CI = 1.286–7.602, p  = 0.0119).

The rs10773771 CT/TT could protect the woman from the risk of EOC on age > 53 years (adjusted OR = 0.390, 95% CI = 0.221–0.688, p  = 0.0012), metastasis (adjusted OR = 0.529, 95% CI = 0.322–0.870, p  = 0.0121), no metastasis (adjusted OR = 0.624, 95% CI = 0.411–0.947, p  = 0.0267), clinical stage 3 (adjusted OR = 0.433, 95% CI = 0.264–0.709, p  < 0.001), high pathological grade (adjusted OR = 0.563, 95% CI = 0.378–0.839, p  = 0.0048), multiple tumors (adjusted OR = 0.520, 95% CI = 0.332–0.815, p  = 0.0043), tumor size ≤ 3 cm (adjusted OR = 0.503, 95% CI = 0.337–0.751, p  = 0.0008), pregnant times ≤ 3 (adjusted OR = 0.609, 95% CI = 0.383–0.969, p  = 0.0363), pregnant times > 3 (adjusted OR = 0.532, 95% CI = 0.348–0.813, p  = 0.0036), post-menopause (adjusted OR = 0.485, 95% CI = 0.323–0.728, p  < 0.001), strong positive ER expression (adjusted OR = 0.355, 95% CI = 0.202–0.625, p  < 0.001), negative/mild positive PR expression (adjusted OR = 0.466, 95% CI = 0.222–0.981, p  = 0.0443), strong positive PR expression (adjusted OR = 0.428, 95% CI = 0.211–0.868, p  = 0.0187), negative/mild positive PAX8 expression (adjusted OR = 0.245, 95% CI = 0.103–0.583, p  = 0.0015), strong positive PAX8 expression (adjusted OR = 0.427, 95% CI = 0.244–0.748, p  = 0.0029), negative/mild wild p53 expression (adjusted OR = 0.502, 95% CI = 0.291–0.868, p  = 0.0136), strong positive wild p53 expression (adjusted OR = 0.603, 95% CI = 0.407–0.893, p  = 0.0116), mutant p53 expression (adjusted OR = 0.450, 95% CI = 0.287–0.706, p  = 0.0005), negative/mild positive WT1 expression (adjusted OR = 0.240, 95% CI = 0.105–0.549, p  < 0.001), strong positive WT1 expression (adjusted OR = 0.491, 95% CI = 0.293–0.825, p  = 0.0072), negative/mild positive P16 expression (adjusted OR = 0.294, 95% CI = 0.135–0.641, p  = 0.0021), strong positive P16 expression (adjusted OR = 0.530, 95% CI = 0.305–0.922, p  = 0.0247), strong positive Ki67 expression (adjusted OR = 0.445, 95% CI = 0.269–0.736, p  = 0.0016) (Table 2 ).

Haplotype analysis of PIWIL1 gene SNPs correlated with EOC susceptibility

Our study investigated the association between haplotypes of the PIWIL1 gene SNPs and the risk of EOC. The haplotype containing the wild-type alleles (GCG) was considered the reference group. The haplotype GTG (adjusted OR = 0.688, 95% CI = 0.509–0.926, p  = 0.014) was significantly associated with a decreased risk of EOC (Table 3 ).

Expression Quantitative Trait Loci (eQTL) analyses

To determine the functional relevance of PIWIL1 rs10848087, rs7957349, and rs10773771, we analyzed released data from GTEx. It revealed that the rs10848087 G > A and rs10773771 C > T were not significantly associated with PIWIL1 expression. However, the rs7957349 CC genotype had high expression in the thyroid, pituitary, and adrenal glands (Fig.  2 ).

The effect of PIWIL1 gene polymorphisms on PIWIL1 expression. PIWIL1 expression with different genotypes in various organs and tissues was analyzed based on the public database GTEx portal. The expression of PIWIL1 with different rs7957349 genotypes was shown in the Thyroid ( A ), Pituitary ( B ), and Adrenal ( C )

SNP-SNP interaction analysis

The MDR analysis revealed that the best statistically significant interaction model predicting a potential EOC risk was that of order three among polymorphisms rs10848087, rs7957349, and rs10773771, P  = 0.2403 (Table 4 ). The interaction map shows the following interaction order: PIWIL1 gene polymorphisms rs7957349 × rs10773771 > rs10773771 × rs10848087 > rs7957349 × rs10848087 with low values of positive entropy or synergism (-0.36%, -0.99%, -1.43%, respectively, shown in green and blue); low entropy values mean redundancy or even independence (Fig.  3 ).

Interaction map for EOC risk. The interaction model describes the percentage of the entropy (information gain) that is explained by each factor or 2-way interaction. Negative entropy (plotted in yellow-green or green) indicates independence or additivity (redundancy)

Our study provides epidemiological evidence supporting the role of piRNA processing gene PIWIL1 polymorphisms in determining the risk of EOC in southern Chinese women. Through a case–control study, we discovered the potential association between PIWIL1 gene polymorphisms and the risk of EOC in a population of southern Chinese women. Among the five selected polymorphisms, rs10848087 and rs7957349 were associated with increased EOC risk, while rs10773771 was associated with decreased risk. Our research is to report the association between PIWIL1 gene polymorphisms and EOC.

Recent reports suggest that population-based polygenic risk scores are strongly associate with breast cancer and EOC risks for BRCA 1/2 carriers and predict significant differences in absolute risk for women at polygenic risk score distribution extremes [ 41 ] . G enetic variation in transmembrane transport genes may be linked to an increased risk of EOC across different histologic subtypes. The disruption of cellular transport, including trace elements, hormones, and small molecules, may play a role in the development of EOC [ 42 ]. Common SNPS can appear in both gene-coding regions and non-coding regions. Although the probability of occurrence in the coding region is relatively small, they will affect the function of genes and lead to changes in biological traits, which is of great significance in the study of genetic diseases [ 43 ]. SNPs alter the binding site of the transcription factors, thereby, affecting the efficiency of transcription and translation of the gene [ 44 ]. Additionally, the widespread expression of Piwi-interacting RNA (piRNA) pathway genes in human EOC suggests their involvement in tumorigenesis [ 45 ]. The PIWIL1 gene belongs to the PIWI family of miRNA processing cleaving enzymes, is associated with tumor growth, and is a crucial member of the Argonaute protein family. PIWIL1 can bind with a new class of low scores of non-coding RNA piRNAs, which regulate tumor proliferation, metastasis, invasion, and prognosis [ 46 ]. PIWIL1 is a component of ribonucleoprotein complexes and belongs to the evolutionarily conserved PIWI protein family which plays a crucial role in RNA silencing [ 47 ]. Studies have reported that increased expression of the PIWIL1 gene is associated with various cancers such as endometrial cancer, cervical squamous cell carcinoma, colon cancer, and hepatocellular carcinoma [ 48 , 49 ]. Recent studies have evaluated the association between PIWIL1 polymorphisms and the risk of other types of cancers, but no significant associations were observed [ 50 , 51 ]. Liu et al. found that PIWIL1 rs10773771 CT/CC variant genotypes were associated with a decreased risk of HCC compared to the wild-type TT. The rs10773771 C allele also enhanced the binding of hsa-miR-1264 to the 3'-UTR of PIWIL1 . These results suggest that rs10773771 may be linked to HCC by affecting miRNA binding to PIWIL1 [ 47 ]. The SNP rs10773771 is located in the 3'-UTR of PIWIL1 [ 52 ] and can alter the mRNA secondary structure of PIWIL1 . Moreover, rs10773771 can affect the binding of three miRNAs (hsa-miR-1264, hsa-miR-340, hsa-miR-590-3p) to the 3'-UTR of PIWIL1 . In a previous study, Liu et al. used reporter gene assays to show that rs10773771 can modify the binding ability of hsa-miR-1264 to the 3'-UTR of PIWIL1 [ 47 ]. In Seo's study, the SNP rs10848087 located in the 5'-UTR of PIWIL1 was identified as a high-quality SNV associated with Alzheimer's disease susceptibility genes and significant associations with hippocampal volume (Hv) in vivo AD pathologies [ 53 ]. On the other hand, research on the upstream transcript variant PIWIL1 rs7957349 has not been observed recently.

The main strength of our study is its focus on women from South China, which allowed us to gather enough statistical data to identify even minor differences in risk. In this study, we found that the AA genotype of the PIWIL1 rs10848087 was associated with an increased risk of EOC in pre-menopausal women, as well as in patients with stages I and III tumors and metastasis. Specifically, a reduction of both ER and PR has been detected in metastatic tissue [ 54 ]. EOC distant metastases account for approximately 16% of cases, with the most common sites being the pleura (33%), liver (26%), and lung (3%) [ 55 ]. The role of hormonal receptor status, specifically ER [ 56 ] and PR [ 57 ] as prognostic parameters in EOC patients has been extensively investigated. However, the reported results are controversial [ 58 ]. Our findings suggested that the AA genotype of PIWIL1 rs10848087 was associated with a higher risk of EOC in women with strong positive expression of ER and PR. Nuclear transcriptional regulator p53 plays a crucial role in various cellular processes. By binding to DNA, p53 regulates the expression of numerous target genes to maintain homeostasis and genome integrity. In case of DNA damage, p53 can activate DNA repair proteins, halt cell growth at the G1/S transition for DNA repair, and initiate apoptosis if the DNA damage is irreparable [ 59 ]. Given its vital function in tumor suppression, it is not surprising that p53 is frequently mutated in cancer, with TP53 mutations present in over 50% of all types of human cancers. Missense mutations in TP53 are particularly common in ovarian cancer (OC), and early-stage cancers have a significantly higher rate of null mutations compared to late-stage disease [ 60 ]. In this study, it was found that the CC genotype of the PIWIL1 rs7957349 variant increased the risk of EOC in women who had strong positive wild p53 expression and no mutant p53 expression. Ki67, encoded by the MKI67 gene, functions as a biological surfactant that disperses mitotic chromosomes. It is commonly used as a proliferation marker in basic research and cancer prognosis [ 61 ]. Ki67 is considered a prognostic marker that helps determine the growth fraction of a tumor. Overexpression of Ki67 is associated with malignancy, tumor aggression, poor prognosis, and metastasis [ 62 ]. Ki67 is a frequently used tool for evaluating preoperative endocrine in breast cancer [ 63 ]. Sehouli's 2019 publication demonstrated that Ki67 is a prognostic factor and a biomarker for predicting therapy outcomes and complete resection in low-grade serous ovarian cancer [ 64 ]. However, few studies have evaluated the Ki67 proliferation rate in EOC and the differentiation between histotypes is a frequent problem [ 65 ]. Our study revealed that the CC variant of PIWIL1 rs7957349 was significantly expressed in the Thyroid, Pituitary, and Adrenal glands. Additionally, we observed that this variant might augment the susceptibility of EOC in women with strong positive expression of the Ki67 protein. It may be inferred that the CC variant of the PIWIL1 rs7957349 gene has an impact on the glands in women, leading to changes in hormone secretion and an increase in the production of Ki67. This variant can be a diagnostic tool for predicting prognosis and assessing survival rates. This study aims to analyze the correlation between Ki67 expression and PIWIL1 rs7957349 in EOC.

However, limitations of our research include the lack of functional or molecular biology studies to establish the biological significance of the observed associations the small sample size in women, and the presence of rs28416520 was not assessed in the study. The study found that genetic variation in PIWIL1 genes may increase the risk of EOC, particularly in southern Chinese women. However, there is a weakness in the study due to a small sample size of women, and the contribution of genetic and biological differences to EOC among different ethnic groups is still unclear. Nonetheless, given the observed ovarian cancer health disparities globally and in the U.S., further dedicated studies on this topic are necessary [ 66 ]. The underlying mechanisms of the identified associations between rs10848087, rs7957349, rs10773771, and EOC also require further investigation.

Our research has shown that genetic variation in PIWIL1 is linked to the risk of EOC. Specifically, we have identified an association between three specific genetic markers (rs10848087, rs7957349, and rs10773771) and EOC in southern Chinese women. These markers can potentially serve as biomarkers for EOC susceptibility and aid in determining appropriate chemotherapeutic options. However, further research is needed to understand the underlying mechanisms involved fully.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Acknowledgements

Thanks to Dr. Shanrong Shu, Department of Gynecology and Obstetrics, The First Affiliated Hospital of Jinan University, kindly supplied EOC tissue samples.

This work was supported by grants from the Scientific Research Start Plan of Shunde Hospital, Southern Medical University (CRSP2020004).

Hunan Provincial Natural Sciences Foundation of China (2021JJ30751) by Xiang Ou. Scientific Research Project of the Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China (YNKY202304) by Xiang Ou.

Author information

Shanshan Liu and Yaping Yan contributed equally to this work.

Authors and Affiliations

Department of Hematology and Oncology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, 510623, China

Shanshan Liu & Yaping Yan

Department of Traditional Chinese Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, Guangdong Province, China

Zhizhong Cui

Department of Pathology, Shunde Hospital, Southern Medical University, Foshan, 528000, Guangdong, China

Haipeng Feng, Fengmei Zhong & Ziguang Liu

Medical Research Center, Shunde Hospital, Southern Medical University, Foshan, 528000, Guangdong, China

Yan Li & Wenjuan Li

The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, Changsha, China

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Contributions

Shanshan Liu wrote the manuscript. Yaping Yan performed the data analysis, Zhizhong Cui, Haipeng Feng, Fengmei Zhong, Ziguang Liu, and Yan Li collected samples; Xiang Ou and Wenjuan Li performed the financial support for the project leading to this publication.

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Correspondence to Xiang Ou or Wenjuan Li .

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Ethics approval and consent to participate.

The Ethics Committee of Guangzhou Women and Children's Medical Center (117A01) and Shunde Hospital of Southern Medical University (KYLS20220903) approved the research. All participants signed an informed consent approved by the Institutional Review Board and agreed to participate in the study.

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Supplementary Information

Additional file 1:.

Table S1. Clinical characteristics of EOC patients and healthy control subjects.

Additional file 2: Table S2.

DNA quality data.

Additional file 3: Table R2.

Stratification analysis of PIWIL1 polymorphisms with EOC susceptibility.

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Liu, S., Yan, Y., Cui, Z. et al. Relationship between PIWIL1 gene polymorphisms and epithelial ovarian cancer susceptibility among southern Chinese woman: a three-center case–control study. BMC Cancer 23 , 1149 (2023). https://doi.org/10.1186/s12885-023-11651-2

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Published : 27 November 2023

DOI : https://doi.org/10.1186/s12885-023-11651-2

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