Perspectives and Challenges in Oral Pharyngeal Cancer Screening Practices of Primary Care Providers—A Preliminary Study

Abstract

Objectives: The purpose of this study was to identify the barriers preventing primary care providers from performing regular oral cancer screening, and to understand the challenges they face in integrating oral cancer screening into their annual examination protocols. Method: Sequential exploratory mixed methods were used. Both qualitative and quantitative data from primary care providers working at Nebraska Medicine were obtained. One-on-one in-depth interviews were performed to identify primary care providers’ perceptions and challenges in performing oral cancer screening. Themes identified in the qualitative phase guided the development of the survey questionnaire. The survey was emailed to all the primary care providers (n = 100) listed on the publicly accessible Nebraska Medicine website. Results: The response rate was 34%. Approximately 60% of the participants reported currently performing oral cancer screening; however, only 3.8% stated they performed comprehensive oral cancer screening consistently. Forty-eight percent of the providers identified time as the biggest challenge. Over 35.3% indicated they screened patients with a history of tobacco or alcohol use. Conclusions: With the limitations of this exploratory study, approximately half of the participants identified lack of time as their primary challenge in performing oral cancer screening and lack of knowledge as their second main obstacle. Very few performed comprehensive oral cancer screening, with visual examination being the most conducted step.

1. Introduction

Oral and oropharyngeal cancer (OPC) is a complex and devastating disease that significantly affects patients’ quality of life. These malignancies are highly invasive and among the most debilitating and disfiguring forms of cancer [1,2,3,4]. For clarity, the term OPC is used throughout this article to refer collectively to cancers of both the oral cavity and oropharyngeal regions [5]. Many OPCs arise as surface malignancies that are often preceded by a clinically detectable premalignant phase, with early signs and symptoms that can be identified during routine examination [6]. Despite the oral cavity being readily accessible for inspection, over 50% of OPC cases are diagnosed at an advanced stage [7]. Early detection is critical for improving outcomes, yet population-based screening is not currently recommended due to insufficient evidence regarding its effectiveness and cost-efficiency [8]. In 2023, OPC accounted for 2.8% of all cancer cases and 1.9% of cancer-related deaths in the U.S. [9]. The primary risk factors for OPC include tobacco use and alcohol consumption, and the U.S. Preventive Services Task Force (USPSTF) recommends counseling high-risk individuals accordingly [10]. Targeted screening of high-risk populations is more cost-effective than screening the general population [11]; however, adherence to follow-up procedures, such as biopsies, remains low, limiting the effectiveness of these efforts [12]. The rising incidence of HPV-16-associated OPC further complicates prevention strategies, as affected individuals often do not exhibit traditional risk factors [13]. In this context, opportunistic screening by primary care providers (PCPs)—who frequently see patients at increased risk—emerges as a practical and potentially impactful approach. Disparities in access to oral healthcare disproportionately affect low-income, uninsured, and racial/ethnic minority, immigrant, or rural populations—groups particularly vulnerable to OPC [14]. These individuals often seek care from physicians, physician assistants, and advanced practice nurses due to limited access to dental services [15]. Opportunistic, annual, non-symptomatic oral pharyngeal cancer screening (OPCS) performed by trained PCPs has the potential to facilitate early detection, thereby reducing morbidity and mortality [13]. Evidence from Cuba demonstrated that opportunistic screening increased Stage I oral cancer diagnoses from 22.8% to 48.2%, with a corresponding decrease in disease-related morbidity and mortality [5]. Despite these benefits, OPCS is not routinely performed by PCPs, contributing to the high rate of advanced-stage OPC diagnoses [16]. Contributing factors include the lack of reliable adjunctive screening tools, insufficient clinical guidelines tailored to PCPs, and limited provider knowledge of OPC [17,18]. Notably, over 77% of patients diagnosed with advanced-stage OPC had seen a physician within 3 to 24 months prior to diagnosis, and 94% had visited a physician in the preceding year [19], highlighting missed opportunities for early detection. Given these gaps, the purpose of the study is to identify barriers that prevent PCPs from performing regular OPCS and to understand the challenges involved in integrating OPCS into routine annual examinations. There are two null hypotheses of the study: (1) there are no barriers that present PCPs from performing regular OCS; and (2) there are no challenges involved in integrating OCS into routine annual examinations.

2. Methods

2.1. Design

This study was approved by the Institutional Review Board at the University of Nebraska Medical Center (IRB#558-17-EX dtd September 2017). A sequential exploratory mixed-methods design was employed due to the lack of pre-existing data needed to construct a closed-ended survey capable of addressing the research questions. The study first collected qualitative data to explore PCPs’ perceptions, challenges, and education regarding oral pharyngeal cancer screening (OPCS). The findings from this phase then guided the development of a quantitative survey.

The study sample included PCPs—physicians (internal medicine and family medicine), nurse practitioners, and physician assistants—employed at Nebraska Medicine in 2017, involved in the physical examination of adult patients, and listed on the publicly accessible Nebraska Medicine website as providing primary care services [https://www.nebraskamed.com/primary-care (accessed on 2 October 2017)]. Exclusion criteria included providers from non-primary care specialties (e.g., cardiology, endocrinology), individuals not directly performing physical examinations (e.g., administrators, researchers), those unreachable via listed contact information, and those who declined participation or did not respond after multiple recruitment attempts. Data collection occurred from September 2017 to December 2018.

A sequential exploratory mixed-methods study design was used due to the lack of pre-existing data to build a close-ended survey necessary to answer the research questions. In Phase I, qualitative data were collected first to explore PCPs’ perceptions, challenges and education related to OPCS. The quantitative phase followed in Phase II, in which qualitative study themes were used as a guide in developing the close-ended survey.

2.1.1. Phase 1: Qualitative Study

The proposed semi-structured interview guide was developed by four individuals, including NP (graduate student within the Department of Health Promotion and Behavioral Health), Lea C Pound, MBA, PhD, who was an Assistant Professor within the same department, Lorena Baccaglini, DDS, MS, MPh, who was an Associate Professor within the Department of Epidemiology, and AW, who was an Associate Professor at Creighton University Department of Prosthodontics who acted as the preceptor for this Service Learning Activity. Purposive homogeneous sampling was used to recruit PCPs meeting the inclusion criteria. Recruitment letters were emailed to 30 eligible providers, followed by a second email one week later for non-responders, and a final telephone call for those still non-responsive. Interviews lasted 20–40 min; they were conducted in participants’ offices, audio-recorded, and transcribed after obtaining written consent. A semi-structured interview guide facilitated standardization across interviews (

Table 1. Semi-structured interview guide used for one-on-one healthcare providers.

1.	Can you describe the typical process (in general) for oral cancer screening in your practice?
2.	Based on your experience, what are the barriers (factors hindering/challenging screening patients for oral cancer) you are facing in your practice of oral cancer screening?
3.	Do you feel that you have enough training to identify signs and symptoms of oral cancer?
4.	You mentioned this barrier (each barrier to be discussed separately); in your opinion, how can this barrier be addressed? (elaborate: ASK WHY and HOW the solution would help)
5.	What according to you would be the best educational method to increase knowledge of providers regarding oral cancer screening?
6.	Is there any other way to improve oral cancer screening in your practice given the demographic population you are working with?

).

Recruitment concluded once qualitative saturation was achieved; no new themes emerged after the eighth interview, though two additional interviews were conducted to confirm saturation.

2.1.2. Questionnaire Design

The results of the qualitative study were used as a guide in developing a quantitative 17-item survey questionnaire (

Table 2. Demographic and work characteristics of survey respondents.

Variables	Frequency (n = 34)	%
Gender
Male	15	44.1
Female	19	55.9
Age in Years
30–39	10	29.4
40–49	9	26.5
50–59	7	20.6
60 or above	8	23.5
Area of Practice
Family medicine	19	55.9
Internal medicine	9	26.5
Physician’s assistant	4	11.8
Nurse practitioner	2	5.9
Years of Experience
0–5	6	17.6
6–10	5	14.7
11–20	10	29.4
>20	13	38.2
Practice Type
Both academically & clinically	23	67.6
Only clinically	10	29.4

The total number of individual variables in practice type is less than 34 because of missing responses.

,

Table 3. Challenges identified by PCPs in performing OPCS.

Challenges	Percent of Providers That Agreed with the Challenge n = 34 n (%)
Lack of knowledge to perform OPCS	8 (22.5)
Inadequate time to perform OPCS	17 (50.0)
Not considering OPCS as PCPs’ responsibility	5 (14.7)
None of the above	4 (11.4)
Total	34 (100.0)

PCPs = primary care providers; OPCS = oral pharyngeal cancer screening.

,

Table 4. Factors that influence providers’ decision to perform oral cancer screening.

Factors	Number of Providers That Agreed with Each Variable as an Important Factor in Deciding to Perform OPCS n = 34 n (%)
Patient complains of a problem	9 (26.5)
Age of the patient	1 (2.9)
Smoking/alcohol history	12 (35.3)
I do it on every patient	6 (17.6)
I do not screen for OPCS	6 (17.6)
Total	34 (100.0)

OPCS = oral pharyngeal cancer screening.

,

Table 5. Association between the education received on OPCS and current OPCS practice of PCPs.

Variable		Providers Received Training on OPCS		Total n (%)	p-Value Significance (2-Sided)
		Yes	No	Total	0.665
Providers Performing OPCS	Yes	11 (78.5%)	8 (66.7%)	19 (73.1%)
	No	3 (21.4%)	4 (33.3%)	7 (26.9%)
	Total	14 (73.0%)	12 (27.0%)	26 (100.0%)

PCPs = primary care providers; OPCS = oral pharyngeal cancer screening.

and

Table 6. Primary care providers’ OPCS behavior related to the education they received on OPCS during their medical training.

Current OPCS Behavior	PCPs That Received Education on OPCS
Screening Practices	Yes (n = 14)	No (n = 12)	Total (n = 26)	p-Value
How often do you perform comprehensive OPCS?
100% of the patients	7.1	0.0	3.8	0.438
75% of the patients	7.1	0.0	3.8
50% of the patients	14.3	8.3	11.5
<25% of the patients	57.1	50.0	53.8
Do not perform	14.3	41.7	26.9
How often do you discuss risk factors of OPC with patients?
100% of the patients	14.3	0.0	7.7	0.260
75% of the patients	14.3	0.0	7.7
50% of the patients	14.3	8.3	11.5
<25% of the patients	50.0	66.7	57.7
Do not discuss	7.1	25.0	15.4
How often do you perform visual inspection of the oral cavity?
100% of the patients	28.6	16.7	23.1	0.856
75% of the patients	42.9	41.7	42.3
50% of the patients	21.4	16.7	19.2
<25% of the patients	7.1	25.0	15.4
Do not perform	0.0	0.0	0.0
How often do you palpate soft tissues in the oral cavity for lumps and bumps?
100% of the patients	0.0	0.0	0.0	0.944
75% of the patients	14.3	8.3	11.5
50% of the patients	7.1	8.3	7.7
<25% of the patients	57.1	66.7	61.5
Do not perform	21.4	16.7	19.2
How often do you perform visual inspection of the oro-pharynx?
100% of the patients	14.3	16.7	15.4	0.650
75% of the patients	35.7	33.3	34.6
50% of the patients	35.7	25.0	30.8
<25% of the patients	7.1	25.0	15.4
Do not perform	7.1	0.0	3.8
How often do you perform neck palpation?
100% of the patients	35.7	16.7	26.9	0.064
75% of the patients	42.9	58.3	50.0
50% of the patients	21.4	0.0	11.5
<25% of the patients	0.0	25.0	11.5
Do not perform	0.0	0.0	0.0
How often do you perform an extra-oral visual exam of the oral cavity?
100% of the patients	14.3	0.0	7.7	0.188
75% of the patients	21.4	25.0	23.1
50% of the patients	14.3	0.0	7.7
<25% of the patients	21.4	58.3	38.5
Do not perform	28.6	16.7	23.1

OPCS = oral pharyngeal cancer screening; OPC = oropharyngeal cancer.

). The questionnaire was content-validated with expert input, similar to Phase I, but not subjected to formal psychometric validation (e.g., construct validity, reliability testing), and this will limit the robustness of inferences. One-on-one interview participants mentioned multiple challenges regarding why they may not perform OPCS. All the challenges were incorporated into the survey to determine the variables that most of the participants identified as a challenge. Questions regarding PCP education on OPCS and current OPCS practice were added to determine if an association between these two variables exists. Additionally, questions on performing OPCS were included to estimate the percentage of providers performing comprehensive OPCS. Demographic questions were also included.

2.1.3. Phase 2: Quantitative Study

Survey distribution and data collection were managed using REDCap (Research Electronic Data Capture). All 100 PCPs identified on the Nebraska Medicine website received the survey with a cover letter (78 physicians, 12 physician assistants, 10 nurse practitioners). Three follow-up emails were sent at five-day intervals to maximize response rates [20].

2.2. Analysis

Qualitative data: Verbatim transcripts were generated using Trint (https://trint.com) and manually checked by a single investigator for accuracy. Coding was performed based on three pre-determined categories from the interview guide: (1) challenges in performing OPCS, (2) OPCS education during medical training, and (3) current OPCS practices. Coded data were analyzed to identify themes and trends aligned with the study objectives.

Quantitative data: Analysis was conducted using IBM SPSS (Version 22.0, IBM Corporation, Chicago, IL, USA). Fisher’s exact test assessed associations between binary variables, including OPCS education and current practice. Chi-square tests examined relationships between polytomous variables, such as OPCS education and performance of critical OPCS steps (e.g., visual examination of the oral cavity, extra-oral examination, oropharyngeal inspection, soft tissue palpation, and neck palpation). Descriptive statistics summarized participant characteristics, work styles, primary challenges in performing OPCS, and perceived risk factors for oral and pharyngeal cancer.

3. Results

3.1. Qualitative Results

A total of 10 PCPs participated in one-on-one interviews. Saturation occurred after the eighth interview, but two additional participants were recruited to ensure no new themes emerged. Of the participants, 80% were female and 20% male; 50% were physicians, 30% physician assistants, and 20% nurse practitioners.

Theme 1: Education on OPCS during PCPs’ medical training: Some providers reported receiving general training in oral examinations to detect abnormalities, but not specific education on OPCS. Several noted that while they routinely check patients’ mouths, they had not considered screening specifically for oral and pharyngeal cancer (OPC). Some participants could not recall details of their training. Two participants (Participant 1 and Participant 10) reported receiving formal OPCS training during medical education.

Theme 2: Barriers to implementing OPCS in PCP practice: Participants identified multiple challenges to performing OPCS, including limited time, lack of necessary equipment, and the perception that OPCS is primarily the dentist’s responsibility. Lack of time was cited as the most significant barrier. Notably, participants who had received OPCS education during training consistently performed screenings and reported minimal challenges, describing OPCS as a procedure that requires only a few minutes. In contrast, participants not performing OPCS cited time constraints as the main impediment.

Theme 3: Current OPCS practice: Most PCPs indicated that OPCS is not part of their standard protocol and they rely on dentists for screening. Some reported discussing oral cancer with patients who use tobacco or alcohol. When describing OPCS procedures, providers generally mentioned only visual examination. Only two participants performed comprehensive OPCS, including soft tissue and lymph node palpation.

3.2. Questionnaire Design

The survey included questions on demographics (age, gender) and work characteristics (years of experience, practice type). The four main challenges identified in qualitative interviews—inadequate time, lack of equipment, lack of knowledge, and perception that OPCS is not a PCP responsibility—were included to identify primary barriers. Education and current screening practices were also included to evaluate potential associations. Questions assessing OPCS behaviors were adapted from prior studies [21].

3.3. Quantitative Study

Participants’ characteristics: Thirty-four PCPs completed the survey (34% response rate). Participant characteristics are summarized in Table 2.

Challenges in performing OPCS: Table 3 shows that 50% of participants cited lack of time as the primary barrier, followed by lack of knowledge (22.5%). Few participants reported other challenges, and none considered lack of equipment to be a barrier.

Factors that influence providers’ decision to perform OPCS: As shown in Table 4, most participants reported screening patients with a history of tobacco or alcohol use (35.3%). Screening every patient regardless of risk factors was reported by 17.6%, while age was considered the least important factor (2.9%).

Association between the education received on OPCS and current OPCS practice: Fisher’s exact test (Table 5) examined the association between OPCS education during medical training and current OPCS practice. Participants who did not recall their training were combined with those who reported no education. Results indicated no significant association (p = 0.665).

Current OPCS practice: Table 6 shows that while 60% of PCPs reported performing OPCS, only 3.8% conducted comprehensive OPCS at every patient visit. About 26.9% never performed comprehensive OPCS. Visual examination of the oral cavity was performed most frequently, whereas other steps, including palpation of oral tissues, were rarely performed; over 60% of participants palpated oral tissues in fewer than 25% of patients. Analysis of the association between education and performance of specific OPCS steps revealed no significant findings, except for neck palpation, which approached significance (p = 0.064).

4. Discussion

Thirty-four participants completed the survey (34% response rate). A majority (82.4%) of the participants were physicians. Around half (50.0%) of the participants identified lack of time as their primary challenge in performing OPCS. Participants identified a lack of knowledge as their second main obstacle (22.5%). Furthermore, no provider considered the lack of equipment as a challenge. These results are similar to a study conducted to assess the knowledge level and practices related to screening and preventing oral cancer among PCPs who worked in Federally Qualified Health Centers in Michigan, where it was concluded that the most prominent barrier for OPCS was the lack of adequate training (64%), followed by shortage of specialists to whom they could refer a patient (48%) and lack of time (15%) [22]. Results from this survey indicated that there is a significant association between PCPs’ knowledge level and practice of oral cancer screening as well as a willingness to participate in oral cancer screening/prevention programs. These findings underscore the importance of providing up-to-date education regarding oral cancer screening to PCPs [23].

Lack of time is the most important barrier, and PCPs should be educated that it does not take very long to screen for OPC if you do it regularly. The more one does it, the easier it gets to understand what is normal and perform OPCS quicker. It is possible to train health workers to perform the OPCS test as accurately as doctors, although experience appears to be a crucial component of health workers’ accuracy [23]. Lack of time can be overcome by educating the entire office staff, not just the physicians or main service providers. This could be facilitated through courses offered at conventions and study clubs or as in-office sessions [24].

When they were asked about each step in OPCS, no provider answered that they palpate soft tissues for lumps and bumps all the time. Only 26.9% perform neck palpation in every patient. These two discovery procedures are essential aspects of the detection of OPC, and the study results indicate that only a few providers are performing them. Inadequate skills and knowledge to perform OPCS might be a reason for not completing comprehensive OPCS. This result is comparable to the study conducted in Massachusetts, where PCPs demonstrated poor knowledge in identifying symptoms associated with OPC and self-reported that they are not adequately trained to perform OPCS [23,25]. It is indicated that continuing education courses had a positive influence on dentists’ inclusion of neck palpation as part of the examination significantly [26]. A systematic review summarizing the available scientific evidence about the educational competence of medical practitioners in dealing with OC/OPC concluded that there is a need for improved OC/OPC training at all levels of medical education to increase competence worldwide [27].

A high proportion of participants (35.5%) mentioned that they perform OPCS when patients have a history of smoking and alcohol use and consider them to be significant risk factors for OPC. However, very few participants (2.9%) mentioned that they consider the age of the patient while screening for OPC. There is evidence that risk-based screening of high-risk individuals could provide substantial gains in the efficiency of OPCS programs [28]. Tobacco and alcohol consumption are the main risk factors in the etiology of OPC. However, the etiology is multifactorial and genetic factors, diet, occupational exposure, and lifestyle can also be implicated in the development of these cancers [29]. Over the past three decades, despite decreasing smoking rates, there has been a period of stagnation followed by an increase in the incidence of OPC. This site-specific increase has been noted particularly among middle-aged white men compared with traditional patients with OPC, namely, older men with a significant smoking and drinking history [30]. This is probably because HPV plays a pathogenic role in a subset of head and neck cancers, mostly cancers of the oropharynx, which have distinct epidemiological, clinical, and molecular characteristics compared with head and neck cancers not caused by HPV [31]. Therefore, it can be stated that opportunistic screening in asymptomatic patients is beneficial, as opposed to solely relying on targeted screening of OPC.

Results showed that providers who received education on OPCS during their medical training and those who did not receive any education are equally likely to perform the screening. This finding does not support the importance of education for providers on OPCS. However, we cannot rule out the importance of education because the participants were not tested for their actual knowledge of OPCS. Those who are educated might have a better understanding of OPCS but may not be performing screening for various other reasons. These results are consistent with a previous study, where traditional education methods did not improve providers’ knowledge or did not influence their screening behavior [32].

In the survey, 60% of participants answered that they perform OPCS. However, only 3.8% of participants mentioned performing comprehensive OPCS every time they saw a patient. A study to evaluate self-perceived competency in screening for OPCs found that only 7% of the PCPs reported examining 100% of their patients for OPCs [33]. This is very similar to our findings. A greater percentage of the PCP group felt their knowledge about OPCs was not up to date and inaccurately identified common signs and sites of early OPCs [33].

An important determinant of a delay in OPC diagnosis is tumor location on the less-visible surfaces of the oral cavity and oropharynx. This means that health campaigns should not only be for public education but also professional training; otherwise, several patients with an early lesion will certainly be misdiagnosed [18]. Analysis of data from general dentists who attended standardized continuing education courses throughout the ten public health districts of the USA indicated that continuing education courses had a positive influence on participants’ oral cancer attitudes, knowledge, and behavior that potentially could make a difference in prevention, early detection, and ultimately OPC control [26]. Dentists in British Columbia and Nova Scotia observed that they could benefit from undergraduate and continuing education courses to increase their knowledge of health history assessment, examination for OPC, and risk reduction strategies, such as counseling about tobacco cessation [34].

4.1. Limitations

This study has several limitations. The central limitation for this study is the use of a non-validated questionnaire that was developed based on qualitative findings and expert input; however, formal validation of the instrument was not conducted. As such, the reliability and construct validity of the questionnaire items remain unverified, which may impact the accuracy and interpretability of the responses. The findings should be interpreted as exploratory and not generalizable beyond the study population at Nebraska Medicine.

The sample size is also relatively small, with only 10 participants in the qualitative phase and 34% response rate in the quantitative survey. A small sample limits the ability to generalize findings to all primary care providers (PCPs) at Nebraska Medicine or to PCPs in other healthcare settings. Small sample sizes may also reduce statistical power, making it more difficult to detect meaningful associations between variables, such as the impact of education on current OPCS practices. Additionally, variability in provider characteristics or practice patterns may not be fully captured, potentially overlooking important perspectives or behaviors.

Questionnaire-based studies frequently encounter low response rates, and in this study, the survey response rate was 34%. While comparable to similar research in the field, this further constrains the representativeness of the sample and increases the likelihood of response bias. Respondents may differ systematically from non-respondents, for example by being more interested in oral cancer screening or more engaged in preventive care. Indeed, 60% of respondents reported already performing OPCS, suggesting potential selection bias in favor of providers who are more proactive or confident in performing screening. This may overestimate the prevalence of OPCS in the broader PCP population and underestimate barriers faced by less-engaged providers.

Taken together, these limitations suggest that while the study provides valuable exploratory insights into PCP knowledge, attitudes, and practices regarding OPCS, caution should be exercised when applying the findings to the wider PCP population. Future research with larger, more diverse samples and higher response rates would be needed to confirm these results and improve generalizability.

Additionally, the study was conducted at an academic medical center, where 67% of the participants work both clinically and academically. This may not reflect the attitudes and practices of providers in non-academic or purely clinical settings. Academic affiliations may influence providers to adhere more closely to health promotion guidelines due to institutional culture, role-modeling expectations, or exposure to ongoing research, potentially limiting the external validity of the findings.

Finally, the study relied on self-reported data regarding providers’ knowledge, barriers, and practices. Objective measures, such as direct observation or chart reviews, were not employed, which introduces the possibility of social desirability bias and overreporting of desirable behaviors.

4.2. Future Direction

Formal validation of the questionnaire used or use of a validated instrument is highly recommended in future studies. In addition, the use of a larger sample size and broader sampling should be recruited, including participants from academic, non-academic, public health, and private organizations. The results could have greater external validity. In addition, the questionnaire should include inquiries on OPC and OPCS to test the knowledge of PCPs, and the results can be compared with their educational background to determine if providers who received education on OPCS are more knowledgeable than those who did not receive such education.

5. Conclusions

Within the limitations of this exploratory study, approximately half of the participants identified lack of time as their primary challenge in performing OPCS and lack of knowledge as their second main obstacle. Very few participants provide comprehensive OPCS and visual examination of the oral cavity is the only step performed frequently. A high proportion of participants mentioned that they perform OPCS only when patients have a history of smoking and alcohol use and consider them as significant risk factors for OPC. Providers who received education on OPCS during their medical training and those who did not receive any education are equally likely to perform the screening. Therefore, planning educational programs to emphasize the importance of performing comprehensive OPCS, and to address skill gaps, is necessary to develop competence in this area.