Original Article
Evaluation of Health‑Care Providers’
Perception of Spiritual Care and the
Obstacles to Its Implementation
Azam Shirinabadi Farahani1, Maryam Rassouli1, Nayereh Salmani2, Leila Khanali Mojen1,
Moosa Sajjadi3, Mehdi Heidarzadeh4, Zeynab Masoudifar5, Fateme Khademi1
Department of Pediatric and Neonatal Intensive Care Nursing, School of Nursing and Midwifery, 5Oncology Ward, Mofid
Children’s Hospital, Shahid Beheshti University of Medical Sciences, Tehran, 2Department of Meybod Nursing, Shahid
Sadoughi University of Medical Sciences, Yazd, 3Department of Medical‑Surgical Nursing, Social Development and
Health Promotion Research Center, Faculty of Nursing and Midwifery, Gonabad University of Medical Sciences, Gonabad,
4
Department of Critical Care Nursing, Nursing and Midwifery School, Ardabil University of Medical Sciences, Ardabil, Iran
1
Corresponding author: Maryam Rassouli, PhD, RN
School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Tel: 0098‑021‑88655372; Fax: 0098‑021‑88202521
E‑mail: rassouli.m@gmail.com
Received: July 19, 2018, Accepted: October 07, 2018
ABSTRACT
Objective: Cancer patients face many health challenges,
including spiritual issues. Therefore, an awareness of
health‑care providers’ perspective on spiritual care provision
is important. This study aimed to determine health‑care
providers’ perception of spiritual care and to examine the
individual barriers to its implementation in cancer patients.
Methods: The present descriptive study included 136 physicians
and nurses. The Spiritual Care Survey was used as a research
tool. Data were analyzed through descriptive statistics using
IBM SPSS Statistics for Windows, version 20.0. Results: In this
study, 70.6% of the participants considered spiritual care to
be influential in the patients’ quality of life. However, 64.7%
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had received no spiritual care training, while 82.4% indicated a
willingness to attend these courses. Regarding the obstacles
to providing spiritual care, the highest and lowest scores,
respectively, belonged to the lack of time and the person’s
reluctance to talk about spiritual issues. Conclusions: Spiritual
care has not yet found its proper place in the care setting of
Iran, and health‑care team members do not have sufficient
training to provide this kind of care despite their belief in its
positive impact on patients’ quality of life.
Key words: Cancer patients, health‑care providers, palliative
care, spiritual care
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4.0 License, which allows others to remix, tweak, and build upon the
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Website: www.apjon.org
For reprints contact: reprints@medknow.com
DOI:
10.4103/apjon.apjon_69_18
Cite this article as: Farahani AS, Rassouli M, Salmani N, Mojen LK,
Sajjadi M, Heidarzadeh M, et al. Evaluation of Health-Care Providers'
Perception of Spiritual Care and the Obstacles to Its Implementation.
Asia Pac J Oncol Nurs 2019;6:122-9.
© 2019 Ann & Joshua Medical Publishing Co. Ltd | Published by Wolters Kluwer - Medknow
Farahani, et al.: Evaluating Care Providers’ Perception of Spiritual Care
Introduction
Diagnosing a life‑threatening illness such as cancer is
a stressful event that affects all aspects of a person’s life.[1]
Cancer is a major health concern in many parts of the world
and the third main cause of mortality in Iran.[2‑4] Every year,
30,000 deaths occur in Iran due to cancer, and 80,000 new
cases are diagnosed annually.[5] The diagnosis of cancer can
lead to the disruption of relationships, uncertainty about
the future, difficulty in adaptation and coping, increased
loneliness and doubts about spiritual beliefs and values, and
spiritual distress.[6,7] Because of this, many cancer patients
welcome spiritual assessment and spiritual care offered by
health‑care providers.[5]
Holistic care is mandated by the nursing and medical
standards of care.[8] The World Health Organization (WHO)
notes that the spiritual aspect of a patient is inseparable
from the whole person.[9] The provision of spiritual care by
health‑care providers can lead to positive patient outcomes
such as improved coping, well‑being, quality of life, and
hope as well as decreased anxiety regarding death, feelings
of loneliness, depression, and a loss of meaning and
purpose in life.[6,10‑13]
However, the spiritual needs of patients with cancer
are high, as reported by Forouzi et al.[14] Despite the fact
that nurses are familiar with the importance of providing
spiritual care, they are not able to comprehensively meet the
spiritual needs of patients;[15] similarly, 96% of physicians
believe in the important impact of spirituality on health,
but these needs are not met[16] due to specific barriers,
including nurse and physician perspectives and beliefs and
values regarding spiritual care. Determining health‑care
providers’ perspectives on spiritual care is the first step to
facilitating the provision of such care.[17] It may also be
helpful in the assessment of the patients’ spiritual care needs
and in designing spiritual care education and programs for
health‑care providers.[18]
Previous studies in different countries have identified
obstacles to the provision of spiritual care;[19] it is also
necessary to study these barriers in specific religious
settings,[20,21] such as Iran, where spirituality and religion
are linked together. In addition, it seems necessary to
conduct such researches on nurses working in different
wards as well. In Iran, the spiritual needs of patients may be
neglected for various organizational reasons; these barriers
for nurses include a lack of knowledge and skills,[21] a lack of
executive instructions for spiritual care,[22] a willingness to
perform routine work due to the large number of patients,
lack of time,[23] and their inadequate training in this type
of care.[24] However, according to the author’s experiences
and literature review, studies on individual barriers to
spiritual care from the perspective of the nurses working in
wards where cancer patients receive care have rarely been
conducted in Iran. However, spirituality, as an internal and
individual force,[25] is an essential element in the lives of its
people, which is rooted in the culture and history of this
land.[13] Today, with the formation of palliative care along
with the outlook of the strategic “Iran by 2025” health plan,
which emphasizes the improvement of the mental–spiritual
health of Iranians, religious and spiritual approaches are
necessary as a personal concept to improve the health of
patients and their families. Considering the importance
of improving the quality of life of cancer patients and
their health‑care providers as a palliative care goal and to
develop effective programs to help health‑care givers provide
cancer patients with quality care, the existing challenges
need to be addressed.[26] The first step in facilitating the
provision of spiritual care is to identify the health‑care
providers’ perspectives; as the organizational obstacles
to the implementation of spiritual care in Iran have been
studied, leaving the challenges of individual barriers, the
purpose of the present study was to determine health‑care
providers’ perception of spiritual care and to examine the
individual barriers to its implementation in cancer patients.
Methods
Research samples
The present research is a descriptive study. The research
environment included all governmental hospitals affiliated
with the medical universities nationwide and included
surgical, internal medicine, pediatric, oncology, bone
marrow transplantation, radiotherapy, and palliative care
wards.
The research population included all health‑care providers
to cancer patients including physicians and nurses working
in the abovementioned centers. The nurses and physicians
were chosen using convenience sampling. To this end, Iran
was first divided into the five regions of north, south, east,
west, and center. Considering the research environment, a
quota for each region was determined. The questionnaires
were sent to 15 students pursuing master’s and doctorate
degrees. The participants comprised students of nursing at
a large nursing and midwifery medical center in Iran who
had received the necessary training in the field of spiritual
care. These students distributed the questionnaires among
nurses who were available and had at least 6 months of
experience in the field of oncology nursing. The physicians
taking this survey included all fellowship students and the
residents of oncology, radiotherapy, pediatric, and internal
medicine working at one of the abovementioned hospitals
of the medical universities of the country. The purpose of
this type of sampling was the widespread distribution
of the questionnaires in different parts of the country
Asia‑Pacific Journal of Oncology Nursing • Volume 6 • Issue 2 • April-June 2019
123
Farahani, et al.: Evaluating Care Providers’ Perception of Spiritual Care
among physicians and the nurses working in internal
medicine, pediatric, palliative care, oncology, bone marrow
transplantation, and radiotherapy wards who were more
frequently in contact with cancer patients.
In this descriptive study, 111 nurses and 25 physicians
completed the Spiritual Care Survey in a 4‑month period
(from September to December 2017).
The approximate time required to complete each
questionnaire was 20 min. The nurses and the physicians
completed the questionnaire during their breaks or at home.
They were supposed to complete the questionnaire in <2
work shifts.
Research tool
The tool, which was based on the Multidimensional
Measure of Religiousness and Spirituality, was derived from
the Religion and Spirituality in the Cancer Care Study. In
order to use this tool in the present research, some minor
changes were applied into it by the research team.[27] The
introduction of this tool includes the definitions of spiritual
care and some examples of it. The participants in the study
were asked to express their views on the various aspects of
spiritual care based on a Likert scale.
Based on the research objectives, three parts of this tool
were completed in the present study.
The first part included demographic data of the
health‑care providers as well as general questions regarding
their general views of spiritual care based on variables
such as age, gender, religion, work experience, ward, the
percentage of patients with advanced cancer, whether they
considered themselves religious or spiritual, the influence
of religious and spiritual beliefs on clinical performance,
the effect of providing spiritual care on patients’ quality of
life, training in spiritual care, and their willingness to take
spiritual care training courses.
The second part of the questionnaire included eight
items to assess health‑care providers’ perspectives on
providing different types of spiritual care using a 6‑point
Likert scale. The lowest and the highest scores were 8 and
48, respectively.
The third part of the questionnaire included 13 items in
a 4‑point Likert scale, to examine the obstacles to providing
spiritual care. The lowest score was 13, and the highest
score was 52.
In order to use this tool, it was translated from English
into Persian and retranslated into English in order
to ensure that the English and Persian versions were
identical.[28] Then, the psychometric evaluation of this
scale was performed. To evaluate the validity of the scale
after its translation and back translation, the content and
face validities were evaluated. After studying the scale,
15 faculty members, experts in the field of spirituality, and
124
professionals in the field of psychology and instrumentation
were asked for their comments and suggestions in terms
of grammatical correctness and appropriate vocabulary
to match the culture of the community. In addition, the
perspectives of five research subjects were used to determine
the level of difficulty of the phrases, the degree of mismatch,
and the existence of any ambiguity. To evaluate the
internal consistency and reliability, Cronbach’s alpha was
calculated. Cronbach’s alpha of the health‑care providers’
perspective and that of the phrases related to the barriers
to care provision was α −0.84 and α +0.79, respectively.
In order to evaluate consistency, the questionnaire was
completed twice within a 2‑week interval by 25 health‑care
providers and the intraclass correlation coefficient (ICC)
was measured using the one‑way random effect model
between two sets of test results (ICC = 0.86, with a 95%
confidence interval).
Statistical analysis
The descriptive statistics were analyzed using IBM SPSS
Statistics for Windows, version 20.0. (IBM Corp., Armonk,
NY, USA) in order to answer the research questions.
Ethical approval
In this study, the researchers obtained informed consent
from the participants while explaining the goals of the
study. For ethical compliance, the researchers assured the
participants about the anonymity of the questionnaires and
the confidentiality of the collected information. The present
study is the result of a research project with the ethics code
of IR.SBMU.PHNM.1395.5.
Results
The majority of the research participants were women,
including 82 (71.3%) nurses and 15 (60%) physicians. Many
were Muslim (106 nurses [95.5%] and 23 physicians [92%]).
Their demographic information is summarized in Table 1.
Overall, 66.2% of the participants (63.1% of the nurses
and 52% of the physicians) regarded themselves as relatively
religious and spiritual and 52.2% (54.1% of the nurses and
44% of the physicians) stated that their spiritual and religious
beliefs affected their clinical performance. Moreover, 70.6%
of all participants believed spiritual care as an impact on
patients’ quality of life. However, 64.7% (74 nurses and 14
physicians) of the participants had received no training on
spiritual care, although 82.4% (83.8% of the nurses and
76% of the physicians) were willing to attend spiritual care
training courses.
Health‑care providers’ perspectives on spiritual care
are summarized in Table 2. The highest mean scores
belonged to “asking patients about their spiritual or religious
beliefs” (3.85 ± 1.25) and “asking questions that persuade
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Farahani, et al.: Evaluating Care Providers’ Perception of Spiritual Care
Table 1: The distribution of some demographic characteristics
of participants
Variable
Frequency (%)
Nurses
Physicians
Total
Female
82 (73.9)
15 (60)
97 (71.3)
Male
29 (26.1)
10 (40)
39 (28.7)
Yes
99 (89.2)
14 (56)
113 (83.1)
No
12 (10.8)
11 (44)
23 (16.9)
≤5
68 (61.3)
15 (60)
83 (61)
6-10
23 (20.7)
4 (16)
27 (19.9)
≥11
20 (18)
6 (24)
26 (19.1)
Internal medicine
84 (75.7)
20 (80)
104 (76.5)
Pediatrics
25 (22.5)
4 (16)
29 (21.3)
Palliative care
1 (0.9)
0 (0)
1 (0.7)
Radiotherapy
1 (0.9)
1 (4)
2 (1.5)
Gender
Presence of oncology ward
Work experience (year)
Employment ward
Percentage of patients with advanced
cancer
0
8 (7.2)
3 (12)
11 (8.1)
≤10
16 (14.4)
5 (20)
21 (15.4)
11-40
38 (34.2)
4 (16)
42 (30.9)
41-70
35 (31.5)
12 (48)
47 (34.6)
>70
14 (12.6)
1 (4)
15 (11)
106 (95.5)
23 (92)
129 (94.9)
55 (4.5)
2 (8)
7 (5.1)
Religion
Islam
Christianity
Table 2: The health‑care providers’ perspective on spiritual
care according to “Spiritual Care Survey”
Items
Mean±SD
Asking patients about their religious or spiritual background to
be aware of whether or not it is important to them
3.85±1.25
Encouraging patients in their spiritual activities or beliefs that
are helpful to them
3.48±1.11
Asking questions that invite patients to talk about spiritual
matters if they want to
3.71±1.38
For patients who are religious or spiritual, asking if there
are ways their faith affects how they make decisions about
treatment
3.16±1.32
For patients who may want to talk about spiritual
matters, asking if they would like to speak with a chaplain
(spiritual care provider)
2.94±1.06
If patients have religious or spiritual supports that are
important, asking if they would like those spiritual supporters
to be included in their care in some way
3.19±1.47
If a patient asks for prayer, the doctor or nurse praying with the
patient
3.26±1.42
A religious/spiritual doctor or nurse offering prayer for a patient
3.67±1.71
SD: Standard deviation
them to talk about spiritual issues” (3.71 ± 1.38) and the
lowest mean scores belonged to “asking patients about
their willingness to speak with a clergyman” (2.94 ± 1.06).
Assessment of the barriers to providing spiritual care
revealed the highest mean scores for “the lack of sufficient
time” (3.18 ± 0.97) and “being concerned about the patient’s
discomfort” (3.17 ± 0.74), while the lowest mean scores
were for “personal reluctance to talk about spiritual issues
with the patient” (2 ± 0.95) and “concern about disturbing
the family’s comfort” (2.22 ± 0.89) [Table 3].
Discussion
Although providing spiritual care as a part of cancer
care and palliative care instruction has benefits such as
increased patient satisfaction; improved quality of life;
and reduced costs of providing care, especially in the late
stages of life,[21,27] studies show that this kind of care has
been neglected[23] and that not only patients but also their
care providers receive this kind of care less often than they
desire. This gap between the willingness of care providers
to provide spiritual care and the lack of provision of these
services necessitates action.
As one of the requirements for providing spiritual care
is an awareness of the care providers’ perspectives on
providing this care and the barriers to its implementation,
the present study was conducted to address these issues.
In this study, the majority of participants evaluated
themselves as relatively religious and spiritual and
acknowledged that their spiritual perspectives influenced
their clinical practice. When one sees his/her profession
as a spiritual one, the ability to provide spiritual care also
improves accordingly.[29] In one study, 89.4% of nurses
considered nursing to be part of their spiritual lives.[30]
Individual spirituality seeks to provide one with meaning
and purpose in life through relationships and interactions
with the environment and others. Therefore, spirituality
will manifest itself in the workplace through relationships
with others and with the environment.[31]
In the present study, care providers believed that spiritual
care has positive effects and influences patients’ quality of
life, a finding that aligns with those of previous studies in
Iran.[32‑34] In this research too, care providers believed that
spiritual care has positive effects and influences patients’
quality of life. Religion and spirituality can affect one’s
ability to adapt to life tensions[35] and spiritual care improves
the quality of life.[36]
A lack of spiritual care training was reported by most of
the participants of the current study, although more than
75% indicated a willingness to attend training courses on
spiritual care. In a study of care providers in 15 Middle
Eastern countries regarding the need for palliative care,
68% of the participants expressed an interest in receiving
palliative care training. As the mortality rate due to cancer
in these countries is 66.4%, it seems natural that training
to provide palliative care is a necessity for care providers.[37]
Although spirituality and religion are merged in people’s
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Farahani, et al.: Evaluating Care Providers’ Perception of Spiritual Care
Table 3: Care providers’ perception of barriers to providing
spiritual care
Barriers
Mean±SD
Not enough time
3.18±0.97
I am worried that patients will feel uncomfortable
3.17±0.74
I do not believe cancer patients want spiritual care from
nurses/physicians
3.06±0.82
Lack of private space to discuss these matters with my patients
3.04±0.87
I worry that the power inequity between patient and
nurse/physician makes spiritual care inappropriate
2.83±1.06
Religion/spirituality is not important to me personally
2.78±1.16
I have not received adequate training
2.67±0.96
I think it is inappropriate to engage these issues with patients
who belong to a different religious/spiritual group than I do
2.6±0.85
I feel uncomfortable engaging these issues with patients
whose religious/spiritual beliefs may differ from my own
2.5±1.04
I believe that spiritual care is better done by others in the
health‑care team
2.4±0.94
I do not believe it is my professional role to engage patient
spirituality
2.32±1.14
I am worried that it will upset the patient’s family dynamic
2.22±0.89
I am personally uncomfortable discussing spiritual issues
2±0.95
SD: Standard deviation
lives to a great extent in Iran,[26,38] they are neglected in
practice, and there is no trace of spiritual care training
courses in the medical education curriculum.[39] Meanwhile,
education can be considered from two perspectives: first, it
helps to promote the care providers’ self‑awareness of their
spiritual life[40] and second, because of the direct correlation
between spiritual training and the ability to provide spiritual
care, spiritual training courses may lead to the improvement
of this kind of care.[30]
As shown in Table 2, the findings of this study show that
care providers’ perspective regarding the field of spiritual
care is diverse and mostly expressed in the form of actions
such as asking patients about their spiritual or religious beliefs
and if welcomed by patients and asking those questions that
would persuade them to talk about spiritual issues. The
review of texts suggests that spiritual care is provided in
various forms, such as praying for patients, reading religious
books,[41,42] inviting religious advisers,[43,44] participating in
the religious rituals of patients,[44] encouraging the patient
to pray,[43,45] and speaking about the spiritual concerns
of patients.[43,45,46] Diversity in the provision of spiritual
care stems from individual perspectives on spiritual care
and the care providers’ self‑consciousness regarding their
spiritual beliefs.[46] The participants in the study preferred
to provide spiritual care mostly by speaking with the
patient about his/her religious beliefs and encouraging
discussions on spiritual issues, a finding similar to that in
the qualitative study by Rassouli et al. They concluded that
in the interaction between the nurse and the patient, the
topic of communication is a factor that has positive effects
on the spiritual aspects of both the patient and the nurse,
126
and that nurses who have effective relationships with their
patient have a better opportunity to provide spiritual care.[13]
Furthermore, Bailey et al. reported that more than half of
the nurses stated that establishing a personal relationship
with their patients is important in providing spiritual care
and almost all of them believed that nurses could provide
spiritual care by listening to patients and encouraging them
to express their fears and anxieties.[47]
In the present study, the analysis of health‑care providers’
perceptions about different types of spiritual care revealed
that patients are not usually asked about their willingness
to interact with a clergyman. In the qualitative study by
Zamanzadeh et al., one perceived challenge described by
nurses was the absence of clergyman in the hospital for the
spiritual support of both patients and nurses.[48] Providing
spiritual care to hospitalized patients is offered by clerics
in some countries, which requires certification,[49] although
their role is not defined in the health structure.
As shown in Table 3, evaluation of the barriers to
providing spiritual care revealed that the study participants
felt that a lack of time and a fear of patient discomfort were
the major obstacles to effective spiritual care.
However, in a study conducted by Bar‑Sela et al. of
770 physicians and nurses from 14 countries in the Middle
East, a lack of adequate training was the most important
predictor of the lack of spiritual care, while it was one of the
least important factors in the current study.[28] The reason for
this difference may be explained by the blending of religious
and spiritual issues with the everyday lives of Iranians, the
traces of which are evident in the politics, custom, law, and
universities of the country. Therefore, care providers do not
feel the need of receiving such specific training.
The barrier of inadequate time has been identified and
confirmed in numerous studies.[50‑53] The lack of sufficient
time results in the spiritual needs of patients remaining
unidentified[54] and insufficient time to provide spiritual
care for patients.[55] In Iran, the shortage of nurses is one
of the factors affecting the quality of care. The number of
nurses is not appropriate to the number of patients, leading
to nursing work overload and a lack of time to provide
the different types of care required by patients. In such
situations, nurses provide essential care,[56] such as physical
care, prior to providing other types of care.[57]
A concern about patient discomfort was identified as
the second barrier. Similar to this finding, other reported
concerns which were identified as deterrents to the provision
of spiritual care were lack of feeling of comfort in patients
while providing spiritual care,[27] the fact that the spiritual
needs of patients are considered private, and the way in which
care team members enter this zone and deal with the spiritual
needs of patients can lead to spiritual distress in patients.[58]
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Farahani, et al.: Evaluating Care Providers’ Perception of Spiritual Care
The unwillingness of health‑care providers to discuss
patients’ spiritual issues and worry about bothering the
patient’s family dynamic by providing spiritual care to the
patient were the barriers with the lowest scores.
Individuals’ willingness to provide spiritual care is
influenced by their self‑knowledge; in other words, nurses
with spiritual self‑knowledge who pay attention to their own
spiritual aspects deliver better care to others.[59] Therefore,
the fact that the majority of the care providers completing
this survey evaluated themselves as religious and spiritual
people possessing some degree of spiritual self‑scrutiny
indicates a tendency to provide spiritual care; therefore, they
do not consider these obstacles to be significant.
The concern about bothering the patient’s family
dynamic by providing spiritual care was another obstacle
considered insignificant by the study participants. Nemati
et al. reported spiritual distress due to losing hope in God’s
mercy and the feeling of being neglected by God to be a
spiritual challenge faced by the family care providers of
cancer patients. However, the other side of the coin is
the feeling of spiritual coherence from providing care to
cancer patients. Therefore, considering the general belief
of health‑care providers regarding the positive effects
of spirituality, the concern about bothering the patient’s
family dynamic by providing spiritual care may be rarely
considered an obstacle.[60]
Limitations
The limitations of this study included the lack of
palliative care departments, which specifically provide
spiritual care in these wards; women’s predominance as
research samples; and the Muslim population with data
collection from one site, which limit the generalizability
of the findings.
Conclusion
The results of the present study indicate that health‑care
providers regard themselves as spiritual and that spiritual
care would improve the patients’ quality of life. The lack of
time and high workloads, however, are barriers to providing
this care.
Moreover, health‑care providers felt the need to receive
specialized training in providing spiritual care, which rarely
happens. Because spiritual care is effective in improving
patients’ quality of life, and as spiritual care provision is
considered to be the responsibility of health‑care providers,
organizational and managerial support are essential in
this regard. Providing adequate workforce, revising the
strategies of governing care settings regarding the allocation
of health‑care providers’ services, and designing and
implementing theoretical and practical training courses
in the form of in‑service training programs can help to
overcome the existing problems and may be effective in
promoting the provision of spiritual care.
Proposal for further research
The perspectives of spiritual care providers who follow
other religions should also be examined and compared with
the results of the present study. As cancer care includes
teamwork, spiritual care provided by team members other
than physicians and nurses might also have an impact
on patient outcomes and meeting of patients’ spiritual
needs. Further study is also necessary to evaluate the
perspective regarding palliative care in team members other
than physicians and nurses who have direct contact with
cancer patients. This knowledge might help to promote
administrative support for spiritual care in the oncology
setting.
Financial support and sponsorship
The authors would like to appreciate the deputy of
research of Shahid Beheshti University of Medical Science
for their support.
Conflicts of interest
There are no conflicts of interest.
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