A Thematic Analysis of Dimensions of Spiritual Care

Abstract

Background:

An overview of spiritual care studies can help reveal the dimensions of spiritual care and summarize the findings of available studies. Thus, we designed the present study based on existing studies to explain the dimensions of spiritual care.

Materials and Methods:

In this thematic analysis, we gathered the related articles published in Persian and English in the last 8 years (2013–2021) with the help of the keywords of Care, Support, Spirituality, Religion, Treatment, Hospice, and Palliative, and searching in electronic databases, including PubMed, Scopus, Web Of Sciences, Magiran, Islamic Science Citation (ISC), and Scientific Information Database (SID). We accurately studied 79 articles that met the inclusion criteria, and then the spiritual care components were extracted and coded, and finally, the codes were categorized as themes and sub-theme.

Results:

Thematic analysis of available studies revealed that the dimensions (theme) of spiritual care include: spiritual and religious assessment, developing a structure for providing spiritual care, establishing effective and supportive communication with the patient, training the patient, answering his questions, encouraging, maintaining, and improving social communications, encouraging the patient to live happily, helping the patient to achieve peace and calmness, supporting for spiritual rituals and activities, supporting and training the patient's family, and supporting the dying patient.

Conclusions:

Spiritual care includes various and numerous dimensions. Considering the widespread dimensions of spiritual care, it seems necessary to design and plan appropriate studies to reveal other spiritual care dimensions from the perspective of patients and care providers in different cultures.

Introduction

The World Health Organization defines health as a state of complete physical, mental, social and spiritual well-being and not merely the absence of disease or infirmity.[1,2] These aspects influence one another dynamically and interactively, and individual health depends on providing and paying attention to all aspects of the human identity.[3] Spirituality is a dimension of human beings that shows human's relationship with the unseen world and intuition.[4] This relationship gives humans hope and meaning in life. Spirituality transcends humans beyond time, space, and material interests[5] and gives meaning to human beings for existence and life. Therefore, spirituality is considered the basis of human existence, and in recent years, was considered its impact on human healing.[6]

Currently, spiritual care and its effects on the health has been noticed by scientists, and several definitions are provided for it. For example, spiritual care is defined as an ethical performance standard, communicating with patients and their families,[7] activities and methods for promoting the quality of spiritual life, and spiritual health and spiritual performance.[8] Also, several studies focused on the topic of spiritual care in the rehabilitation of cancer patients,[8] the spiritual health and well-being of hospitalized elderly patients,[9] decreasing the anxiety of patients after coronary artery bypass surgery,[10] and death anxiety in patients with chronic renal failure undergoing hemodialysis in end stages of the disease,[8] as well as the positive attitude of physicians and paramedics about the effect of providing spiritual care to the hospitalized patients.[1,11,12]

Because numerous studies have been done related to spiritual care in Iran and other countries throughout the world and addressing this issue from different perspectives, due to the wide range of topics and the differences between cultures and beliefs about spiritual care, this study was designed and conducted to review the existing studies and explain the dimensions of spiritual care.

Materials and Methods

This study was a thematic analysis of the literature aimed to integrate qualitative findings extracted from available research related to spiritual care. We applied Lachal's tips on how to read and code the data in four steps[13]: 1- Define the research question and the selection criteria: the research question of this study was what are the codes of spiritual care based on the available research? We established codes in research team meetings.[13] We decided to search six electronic databases covering medical studies: three national electronic databases (Magiran, ISC, and SID) and three international electronic databases (PubMed, Scopus, and Web of Sciences). The first step in finding articles is to identify keywords for the electronic search. To ensure both sensitivity and specificity, we decided to use a combined approach of thesaurus terms and free-text terms. Keywords were established during research team meetings and were reported in the article or as supplemental material for more clarity. An example of the final Search strategy used (in the PubMed Web search) is provided in Table 1.

Table 1.

Search strategy in Pubmed

(((Spiritual[Title] OR Spirit*[Title] OR Religious[Title]) AND (Care[Title] OR Care*[Title] OR nursing[Title] OR Nurs*[Title] OR therapeutic[Title] OR therap*[Title] OR therapies[Title] OR therapy[Title] OR treatment[Title] OR health[Title] OR standard[Title] OR protocol[Title] OR charter[Title] OR guideline[Title] OR Statement[Title] OR Bill[Title] OR Right[Title] OR Need[Title] OR Toolkit[Title] OR Treatment method*[Title] OR Hospice Care*[Title] OR Palliative care*[Title])) OR ("Spiritual Therapies"[Title] OR "Spiritual Therapy"[Title] OR "Spiritual Therap*"[Title] OR "spiritual health"[Title] OR "spiritual care*"[Title] OR "spiritual treatment"[Title] OR "Religious care*"[Title] OR "Religious Therap*"[Title] OR "Spiritual care standard*"[Title] OR "Spiritual care protocol"[Title] OR "Spiritual care charter"[Title] OR "Spiritual care guideline"[Title] OR "Spiritual care Statement"[Title] OR "spiritual care Bill"[Title] OR "spiritual care Right*"[Title] OR "spiritual care Need*"[Title] OR "spiritual care Toolkit"[Title] OR "spiritual care method*"[Title])) Filters: Clinical Trial; Journal Article; Review; Free full text; published in the last 5 years; Humans; English; Field: Title

Regarding the inclusion criteria, 1859 full articles electronically available in English and Persian from 2013 to 2021 approaching the topic in the title were selected. Then, we assessed the title, abstracts, and full texts of articles, and we excluded case reports, duplicated articles, and articles not approaching the topic directly from the study. Also, we checked each article reference list looking for new articles we might have overlooked. Finally, we selected 79 articles (40 Iranian articles and 39 articles from other countries) for the meta-synthesis procedure [Diagram 1]. Two members of the research team participated separately in the search and assessment of the articles.

Diagram 1.

PRISMA flow diagram for systematic reviews

2- Quality assessment of included studies: studies were assessed since the articles were published in peer-reviewed journals. Thus, we had no approach to assess the quality of studies.[13] 3- Extracting and presenting the formal data: to understand the context of each study, readers need valid data about each study.[13] The data extraction and presentation enable readers to form their own opinions about the studies included.

4- Data analysis: we used thematic synthesis based on Thomas and Harden's Thematic Synthesis.[14] The first step of this process involved carefully reading and rereading each study. It is active reading, with the intention of appraising, familiarizing, identifying, extracting, recording, organizing, comparing, relating, mapping, stimulating, and verifying. The second step was coding: two researchers coded each part of the data (whole manuscripts), performing a line-by-line coding. In the third step, the codes were grouped and categorized into a hierarchical tree structure. It involves comparing themes across articles to match themes from one article with those from another while ensuring that each key theme captured similar themes from different articles. In the fourth step, we generated analytical themes, which depended on the judgment and insights of the reviewers.[13] To verify the accuracy and robustness of the findings, the research team members (five members) separately tried to formulate overarching themes from initial concepts in primary studies and offered an interpretation. In case of differences, group meetings were held. Also, we expressed statements dependent on the original study participants to verify each theme.[13]

Ethical considerations

This study was approved by the research committee of Qom University of Medical Sciences after obtaining the approval of the Ethics Committee (ethics code: IR.MUQ.REC.1396.63.). The principles of research ethics, honesty, and transparency were considered in all the stages of the study.

Results

After collecting and studying the relevant articles, we extracted 10 main themes about spiritual care as follows: spiritual and religious assessment, developing a structure for providing spiritual care, establishing effective and supportive communication with the patient, training the patient and answering his questions, encouraging maintaining and improving social communications, encouraging the patient to live happily, helping the patient to achieve peace and calmness, supporting for spiritual rituals and activities, supporting and training the patient's family, and supporting the dying patient.

1. Spiritual and religious assessment. The available studies emphasized spiritual assessment of the patient when taking his medical history and asking about the patient's cultural and spiritual needs,[15,16,17,18,19,20,21,22,23] encouraging the patient to express his cultural and spiritual beliefs,[8,10,24,25,26,27,28,29,30] talking about the patient's concerns,[25,31,32,33] talking about the family members' feelings,[16] the patient's spiritual communications,[19] the patient's belief about withdrawing treatment, and the patient's perception of existence, disease, and death.[25] ”Asked about spiritual issues”.[25]/”Questions regarding the meaning of illness”[25]

2. Developing a structure for providing spiritual care. To provide spiritual care, necessary structures should be created and developed in the health care centers. This structure includes: employing care providers with competency to provide spiritual care (courtesy),[34] harmony with the patient's wishes and needs,[17,35] adherence to religious and spiritual basis[35] and its representation in the appearance and behavior of the care provider,[10] the remembrance of God in the provision of care,[36] reading the Qur'an and revelatory prayers and texts for the patient,[37] trusting God,[36] explaining about available spiritual facilities at the center,[20,35,38] providing spiritual information for patients,[20,35,38] providing right services at the right time (relieving the pain,[19] counseling,[17,35] intervention,[17] supporting the patient[39](, allowing present the patient's family members at the patient's bedside,[36,40,41,42] paying attention to ethical issues (avoiding discrimination,[43] protecting the patient's dignity and respecting him,[19,37,39,44,45] respecting the patient's beliefs,[35,38] maintaining the patient's coverage,[35] respecting the patient's privacy,[46] accepting the patient as a human being,[27,47] respecting the patient's choice,[17,39,48] respect for the patient's freedom,[27] lack of judgment,[49] explaining the process of diagnosis and treatment,[34] and respecting patient boundaries[50](, providing high-quality clinical services (quality management,[50] the physician's skills,[34] the patient's waiting time,[34] the nurse's skills,[34] and the speed of decision-making about the patient[34](, collaborate among the members of treatment team (the referral of patient to other specialists,[26] the referral of patient to supportive care,[51] the quality of teamwork,[34] and providing interdisciplinary spiritual care[52]), accepting spiritual care as part of care[17] (considering the spiritual care as a part of the holistic approach[19,53] and incorporate religion chaplains' work as a key part of health care[48]), predicting and funding the budget to provide spiritual care,[35] providing individualized care (providing services according to the variety of the patient's needs[43,54] and maintaining the patients' integrity[17]), providing appropriate environmental conditions (high-quality food and appropriate temperature,[34] a nourishing environment,[36] the patient's access to a quiet and peaceful environment,[16,34,39,54,55] the proper temperature of the environment,[34] a clean and neat environment,[34,42] and pleasantness of decorations[34]), providing access to the spiritual sacred/chaplain (the presence of a religious advisor in the hospital,[31,33,40,41,45,56] the provision of spiritual counseling,[31,33,40,41,45,56] and the referral of patients with spiritual need[15,32,38,51]), providing spiritual care in a formal way,[48] holding spiritual events and programs in the hospital,[35] providing care with regard to spiritual dimensions,[38,52] and formation of a spiritual care team.[57] No discrimination based on religion, sex, age, or belief in God.[43]/The public relations of the hospital should continuously provide information on how to use the facilities and features developed to carry out spiritual activities.[35]

3. Establishing effective and supportive communication with the patient. Establishing effective and supportive communication with the patient define as providing psychological support,[8,10,21] establishing trust (establishing sense of safety in the patient,[8,10,17,27,43,47,48,54,58,59] give priority to the pat,[17] responsiveness to the patient,[17,53] accepting the patient,[17] and using the full power to improve the patient[24]), paying attention to the patient,[17,34,39] always being available to the patient (establishing a stable relationship,[60] presence with patient,[19,26,53] promptness in responding to the patient,[34] providing compassionate touch,[10,16,39,40,41,53] developing honesty,[8,10] and developing confidentiality),[42] avoiding fanaticism (acceptance of a wide range of spiritual beliefs,[43] remain open to patient's beliefs,[39] and respect different views[48]), avoiding judgment,[17,34,48,61] caring as a critic friend (helping the patient find meaning in illness,[10,17,24,31,47,55] helping the patient find meaning in life,[8,27,31,47,62] reflect back on his life,[55] resolving unsolved problems,[55] sharing one's own life experiences,[55] giving thanks for life,[62] dialogue about patient's beliefs,[63] reviewing the life,[16,19,28,62] and talking about the patient's fears[55]), helping patient to find hope (giving morale to patient,[8,10,36] hope for God's mercy and attention,[56] the possibility of improvement following a miracle,[36] and hope for the future[56,64]), paying attention to the human dimension of the patient,[36,65] turn to patient in a loving attitude (establishing an emotional connection,[28,39,43,48] altruism,[19,47] speaking with the patient,[66] and expressing love[44,47,55,58]), providing laughter and joking,[66] providing intimacy and nearness with the patient,[36,54,67,68] establishing verbal and non-verbal communication,[8,31,40,41,50,69] providing active listening,[16,26,50,69,70] (expressing feelings,[18,37,50] and listening deeply and wholeheartedly[8,10,17,36,50]), spent sufficient time (giving the patient an opportunity to talk[54] and being with the patient[17,34,48]), establishing good communication with the patient (avoidance of angry and blame,[17,27] treating friendly,[17,34] facilitating the communication with the patient,[39] and good humor and morals[36,70]), and providing collaboration (empathy,[10,19,32,36,39,48,49,50,70,71,72] supportive, and protective presence[8,40,41]). Spending sufficient time with the patient.[17]/To be recognized as a person until the end of life.[27]

4. Training the patient and answering his questions. It is important to provide the patient with the necessary training and answer his questions on these issues: training about discharge and self-care (how to take care of oneself at home[34] and the discharge process[34]), answering questions about death and life after death,[64] answering questions about why I got sick,[64] talking about nature of the disease and the treatment process[8,32,45,46,53,73] reporting about the current situation to the patient,[39] talking about coping with the existing conditions (coping mechanism with the disease[49] and coping with the sense of loss[24]), encouraging healthy living (inhaling clean air,[59] avoiding the health risks,[63] maintaining the cleanliness and hygiene,[43] avoiding toxic substances such as cigarettes and alcohol,[43] and adhering to a vegetarian diet[43]), increasing the self-awareness (helping the patient to know himself and communicating with himself,[48,59,62,74] listening to the inner voice,[74] discussing the patient's values,[16,49] self-revealing values and spiritual experiences,[59] expressing concerns,[63] encouraging to co-ordinate with values,[33] accepting oneself and reconciling with oneself,[33] explaining his roles in life,[33] directing the patient toward self-actualization,[33] and the recognition of existential capacities),[17,49] talking about the goals of the patient in life,[49] increasing individual skills (problem-solving,[49] positive outlook,[62] reflect on his experiences,[24] decision-making,[24] adjust to the whole situations,[24] and find the strength to continue[24]), and providing information according to the patient's need.[36,49] Explaining the therapeutic process gives the patient information and awareness about the disease to reduce physical and mental stresses.[8]/shelter of intoxication such as smoking, tobacco chewing, and alcoholism.[43]

5. Encouraging maintaining and developing social communications. To prevent the isolation of the patient, the following are recommended: Encouraging to communicate with relatives and friends[18,33,45,55,59,62,70,73,75] (connecting and strengthening the communications and relationships,[18] sharing thoughts and feelings,[31] and receiving support from others[55]), connecting and sharing experiences with other patients,[31] communicating with care providers,[24] cooperation and participation in social affairs,[31] attendance at the workplace,[8] and participating in spiritual activities.[31] Contact with other patients with similar illnesses?.[62]/Relationships with others” such as family, friends, and caregivers.[62]

6. Encouraging the patient to live happily. Following activities are advised to improve the patient's morale and improve his spiritual health: enjoying nature (going to the nature,[55] praising beauty,[44,47] looking at the flowers, green, lowing water,[49,59,75] listening to the sounds of nature such as birds' singing,[49,59,75] raising flowers and plants,[59] and loving animals),[59] being happy and laughing,[10,59,75] going to recreational and spectacular spots,[8,10] enjoying the songs and sounds,[10,47] and doing favorite hobbies and entertainment.[10,76,77] To delve into the beauty of nature.[55]/stoning to birds' singing, water, Qur'an, religious lectures, and sound of nature.[49]

7. Helping the patient to achieve peace and relaxation. Patient's anxiety can relieve by strengthening the relationship with God (through reading the Qur'an,[22,49,59,78] praying and worshiping,[22,30,33,49,59,74,79,80] thanksgiving and gratitude,[30,47,59,74,80] sadaqah (voluntary charity),[59] promoting the relationship with the nature,[81] expressing attention and affection to others (affection and attention to wife and children,[59] optimism to surrounding people,[49] beneficence,[49] showing affection,[49] infaq (charity)[59,75,79]), overcoming the fears and concerns (doing relieving activities,[31] coping with sadness,[31,82] replacing fear with peace and confidence,[49] and facing new situation with calmness[24]), tawakkul (trusting in God's plan), tawassul (resorting to God) (relying on the endless power of God,[22,55,80,83] trusting in God and resorting to him,[42,49,56,73] and appealing to the imams),[40,42] encouraging forgiveness (forgiving oneself and others,[22,27,29,31,45,47,49,55,59,62,78,84] resolving old disputes and aggressions,[31] strengthening healthy and constructive outlooks,[10,22,47,82] life review,[85] referring to the spiritual advisor,[8,10,65] learning from reviewing the history of spiritual and religious models,[10,59] encouraging companionship with relaxing people,[8,10] repenting and seeking forgiveness from God (making decision to compensate for delinquencies,[56] trying to gain the God's forgiveness[10,22,83]), avoiding peace disturbance by (do good and refrain from evil acts,[59] self-assessment,[59] and critic ones' behavior and conduct[56,59]), encouraging patience (emphasizing the dignity of tolerating suffer and pain,[56,59,80,86] emphasizing the role of disease in the forgiveness of sins,[56] and accepting the divine providence[10,22,59,42]), and encouraging using complementary medicine (teaching of religious medical versions and discussing the psychological effects of prayer and verses of the holy book,[28] using recommended methods in the religion,[28,45,56,64] aromatherapy,[52] guided imagery,[25] relaxation,[25,30,34] meditation,[34,52,56,75,81] music therapy, and spiritual sounds[25,41,52,55,68,87,88]). Discussion about the psychological effects of worshipping.[28]/Help you face your situation with calmness and dignity.[24]

8. Supporting spiritual rituals and activities. The following measures are suggested to support spiritual rituals and activities: providing conditions and supplies for worship and pray (informing the religious times and occasions,[20,36,42] assistance in performing spiritual practices and rituals,[21,33,35,36,42,50,56,64,75] providing time and suitable place for spiritual rituals,[8,35,36,40,41,42,44,54,56,60,72] avoiding the interference of health care with religious practices,[35] the provision of facilities for purification and wudu (ablution),[35,42,69] providing the possibility of matching the patient's bed with qibla,[42] access to religious books and sources,[33,35,39] providing privacy for the patient to do spiritual rituals,[36] and providing freshener[35]), training, strengthening, and supporting patient spiritual beliefs and ideas,[43,48,52,59] providing access to spiritual places and symbols (using the name of God,[74] candlelight,[31] incense,[31] spiritual images,[54] and cross[54] in the patient's room), encouraging to communicate with religious people (sanctities, prayer, sacrifice, penance, and charity),[22,30,74] encouraging to do religious and spiritual activities (reading and hearing spiritual texts such as the Qur'an, salat (namaz), worship, prayer, and rosary,[10,29,31,33,36,39,40,47,55,74,86] participating in shared spiritual ceremonies,[25,31,47,54,55] and suggesting to perform spiritual activities[28,31]), explaining about religious issues,[20,35,59] discussing religious issues,[59] and paying attention to the patient's spiritual needs.[35,77] Keeping their faith in their religion.[43]/Communicating with sanctities, prayer, sacrifice, penance, and charity.[74]

9. Supporting and training the patient's family. This item may include the followings: providing the conditions and a private environment for the communication of the patient and his family,[16,34,77] assuring the family about providing the best patient care for the patient,[16] proper and respectful collaboration with the patient's family (good humor,[36] being friendly with the patient's family,[37] and having a positive attitude toward the presence of the patient's family),[34] respecting the beliefs and opinions of the patient's family,[89] providing the opportunity for family members to talk with each other,[16] supporting the family's decisions,[16,89] advising to help and pay attention to the patient (not leaving the patient alone),[8,16] giving morale to the patient's family,[36] and answering the questions of the patient's relatives.[38] The assured family that patient would be kept comfortable.[16]/specialists should respect families and their religious or spiritual.[89]

10. Supporting the dying patient. Supporting the dying patient is possible by paying attention to the patient's wishes and demands for the end of life,[16] paying attention to the patient's fear and concern about death (clarification about the death,[44,47] talking about the patient's worries and fears,[47] helping reduce the patient's fear,[54] paying attention to the patient's need for survival,[27] and accept death,[47,54,58] supporting spiritual and rituals end of life care,[37,50,54] preparing the patient for the end of life (reviewing the life,[47] completing business, and active preparation for death[62,82]), providing conditions for a comfort death (emphasizing the nature and presence of God,[42] and solace[49]), being and accompanying with the dying patient,[37] and cleaning the deceased.[90,91] Acceptance of death is independent of any religion or belief.[55]/The need for continuity and an afterlife.[30]

Discussion

We conducted this study to explain the dimensions of spiritual care based on available studies. The findings of our study show that the dimensions of spiritual care include: the spiritual and religious assessment, developing a structure for providing spiritual care, establishing effective and supportive communication with the patient, training the patient and answering his questions, encouraging maintaining and improving social communications, encouraging the patient to live happily, helping the patient to achieve peace and calmness, supporting for spiritual rituals and activities, supporting and training the patient family, and supporting the dying patient.

Other existing review studies have not presented a classification of the spiritual care dimensions, and each of them has focused on the dimension of spiritual care. For example, Isaac et al.[63] focused on combining spiritual care in primary care and health education models in this context and Azizi et al.[72] explained spiritual care at different levels of prevention. Memaryan et al.[17] in a review study reported that the dimensions of spiritual care were spiritual needs assessment, spiritual care candidates, the main components of spiritual care, spiritual care providers, the settings of spiritual care, and the resources and facilities for spiritual care.

The results of our study emphasize the necessity of spiritual evaluation in taking a medical history. In this regard, the results of another study revealed that assessing the spiritual needs of patients, spiritual screening of patients, and taking their spiritual history are important parts of spiritual care and can facilitate the next steps in the patient care process.[17]

For the results of our study providing spiritual care requires developing proper structures. In this regard, Memaryan et al.[17] emphasized the need for the presence of spiritual care providers capable of coordinating with the patient's demands, needs, and able to provide counseling, as well as respect for the patient's choice, acceptance of spiritual care as a part of the health care services, and considering various existential dimensions of the patient.

Our review study revealed that effective and supportive communication is one of the essential components of spiritual care. Other review studies emphasized putting the patient as a priority, accountability toward the patient, paying attention to the patient,[17] not judging the patient[20,67] helping the patient understand the concept of illness,[17] understanding the concept and purpose of life,[62] talking about the patient's beliefs,[63] helping the patient in reviewing life,[62] expressing feelings and responding to the patient's words, listening to the patient deeply and wholeheartedly, spending sufficient time with the patient, avoiding blaming,[17] and empathy with the patient.[72]

For the results of our study, as part of spiritual care, the patient's questions in various contexts need to be answered, on the other studies, help the patient for acquiring self-awareness and self-reconciliation,[68] recognizing the existential capacities,[63] and creating a positive attitude[62] are among the essential training for the patient. The results of our study emphasize that the patients not only should be encouraged to maintain their social communications but also need to develop them. In this regard, Loetz et al.[62] reported the encouragement of the patient to communicate with relatives and friends. Encouraging the patient to live happily is another dimension of spiritual care. The available review studies have not addressed this dimension of spiritual care. Another dimension of spiritual care is helping the patient to achieve peace and calmness. Also, Loetz et al.[62] suggest that forgiving oneself and others is one of the ways that the patients can use to achieve peace and relaxation, and he mentions music therapy and spiritual music as other methods of providing spiritual care.

Our review revealed that health care providers should support spiritual rituals and activities as one of the dimensions of spiritual care in line with the findings of Hefti et al.[52] study. They emphasized maintaining and reinforcing the spiritual beliefs of the patient. Spiritual care not only means caring and paying attention to the patient but also involves supporting and training the patient's family. None of the available review studies had pointed to this dimension of spiritual care.

Supporting the dying patient is another dimension of spiritual care in our review study. Performing spiritual ceremonies before death,[33] helping the patient to participate in the pre-death preparation,[62] and companionship with the dying patient[37] are some of the dimensions of spiritual care associated with death, which have been referred to by other review studies.

One of the limitations of this study was to review and gather merely Persian and English articles since some articles on spiritual care may have been published in other languages that the researchers did not study due to lack of mastery over other languages. Also, some studies may have been carried out but not published while we searched the related articles; therefore, we do not cite those studies in our study.

Conclusion

The current study shows that spiritual care includes various and numerous dimensions. Considering the widespread dimensions of spiritual care, it seems necessary to design and plan appropriate studies to reveal other spiritual care dimensions from the perspective of patients and care providers in different cultures.

Financial support and sponsorship

Qom University of Medical Sciences

Conflicts of interest

Nothing to declare.