What factors affect the quality of life of employed physically disabled people? A qualitative exploration of their experiences

Abstract

BACKGROUND:

According to the literature, the majority of People With Physical Disabilities (PWPDs) have a low Quality of Life (QOL). The goal of this study was to look at the experiences of a group of employed PWPDs in Iran in terms of the factors influencing their QOL.

MATERIALS AND METHODS:

A conventional qualitative content study was carried out in Qazvin City, Iran, from February to August 2020. Twenty-eight semi-structured, in-depth interviews with 20 employed PWPDs (6 men and 14 women), 5 five family members, and 3 of the participants’ employers (n = 3) were conducted. Participants were asked about their experiences with factors that impacted the QOL of employed PWPDs.

RESULTS:

Continuous analysis of data began and continued up to data saturation. The participants’ experiences on influencing variables QOL were merged into four major categories: psychological state, socioeconomic problems, structural obstructions, and physical constraints.

CONCLUSION:

Conducting psychological therapy to reduce stress and using adaptive coping strategies, changing perceptions of the community about PWPDs via the media, and also improving environmental infrastructure may help to increase QOL in PWPDs.

Background

The idea of Quality Of Life (QOL) has evolved as a major term in disability research,[1] referring to a person’s feeling of well-being based on satisfaction with crucial areas of life. Disability is not merely a medical condition; it is also a social issue. People With Disabilities (PWDs) are regularly denied their natural rights, and physical limitations limit their possibilities for school, employment, marriage, and life expectancy. Factors influencing happiness and life satisfaction include physical difficulties and disabilities.[2] Previous studies have found that PWDs had a worse QOL than the general population.[3,4,5] According to the World Health Organization (WHO), the global percentage of PWD hit 15% in 2011 (nearly a billion people).[6] In Iran, the prevalence of disability was 13 per 10,000 people in 2011. The frequency of physical and intellectual disability is higher than that of others.[7] People with a low QOL may experience psychological stress, frustration, feelings of estrangement from society and themselves, emotions of futility, and unhappiness with life.[8] Various variables, such as secondary impairments, activity constraints, participation restrictions, poorly perceived self-efficacy, pain severity, internalized stigma, low self-esteem, depression, and employment status, have been shown in the literature to impact this population’s QOL.[9,10,11,12] Some studies on the QOL of PWDs have been undertaken in Iran, and the findings reveal that a relatively substantial number of Iranians with physical impairments are unemployed.[13,14] According to Pawłowska et al.,[15] work has a substantial impact on the psychological fulfillment and overall health of PWDs aged 18 to 65 years. Their research also found that the QOL of PWDs who were jobless and not seeking employment declined as professional inactive duration increased. Although most previous studies[15] showed disparities in the QOL of various subgroups of PWDs, such as employed or unemployed, the QOL of PWDs has been determined regardless of confounding variables such as job status.[13,14] More knowledge about the elements that impact the QOL of employed People With Physical Disabilities (PWPDs), both favorably and adversely, is needed to build specialized efforts.[16] Therefore, data on the QOL of different societal groups may be utilized to evaluate the effect of interventions and implemented programs on health.[17]

Most studies on QOL of PWDs had been performed quantitatively,[3,8] whereas fewer studies had investigated this phenomenon with a qualitative approach. Qualitative research is an ideal strategy because, rather than being hypothetical, it is an exploratory method that provides a more in-depth knowledge of life satisfaction.[18] QOL is influenced by various factors,[18] and the necessity of investigating this phenomenon is essential in subgroups of PWDs such as employed PWPDs, which have different concerns than other PWDs. Therefore, the purpose of the present study is to identify the influencing factors of QOL among a sample of employed PWPDs with a qualitative approach. These factors may suggest areas of focus for proper planning to meet QOL in employed PWPDs.

Materials and Methods

Study design and setting

A qualitative content analysis approach (conventional method) was used to investigate the experiences of employed PWPDs regarding issues impacting their QOL.[19]

Study participants and sampling

To recruit participants between February and August 2020, the Tavana center for PWDs in Qazvin City, Qazvin Province, Iran, used a maximum variation sampling strategy. The sampling procedure was repeated until the data analysis revealed no new information (data saturation). The selection criteria for this study were as follows: a) being currently employed, b) having been employed at least a year ago, c) having a physical disability, and d) agreeing to participate and share their experiences with issues affecting their QOL.

Data collection tool and technique

First, one of the researchers of the present study interviewed (semi-structured type) the participants. After their permission was obtained, the interviews were recorded and then transcribed verbatim. The time of the interviews was mutually agreed upon by the researcher and participants. The interviews were conducted in the Tavana center for PWDs and lasted about 20–35 min. The interview guide is shown in Table 1. The guide was evaluated by two experts in qualitative research. The sampling continued until data saturation. The participant’s demographic characteristics were collected using a questionnaire.

Table 1.

Questions of the interview guide

Interview questions

1. What factors do you think impact the quality of life of employed people with physical disabilities? Please explain.

2. Which social factors may influence the quality of life of employed people with physical disabilities? Please explain.

3. How are the views of yours and other individuals about environmental factors causing the low quality of life in you and other individuals like you? Please explain.

4. Please explain personal factors affecting the quality of life employed people with physical disabilities.

5. Is there anything more concerning the most critical problem or circumstances that may affect your quality of life that you have not mentioned? Please explain

An inductive technique was used for the analysis. We used open code and defined categories during this procedure. The interviews were taped and then transcribed word for word by the researcher. To find the original codes, categories, and sub-categories, the transcriptions were carefully looked over many times. In the last stage, the study subject was broadly characterized using generating categories [Table 2].

Table 2.

Categorization of categories and sub-categories

Categories	Subcategories	Codes
Psychological conditions	1. Negative emotions	Psychological tension-stress-fear (of the future and loneliness)-low self-confidence
	2. Lack of freedom	Lack of mental independence-feeling dependent on others
	3. Coping strategies with disability	Adoptive coping strategies-maladaptive coping strategies
Socio-economic challenges	1. The view of the community towards disabled persons	Sympathetic glances-improper judgments about disability-mistreatment of children with disabilities in some families-restrictions on marriage for the female with physical disabilities
	2. Challenges of communicating with others	Lack of knowledge about the principles of relationship with others- lack of knowledge of parents about the correct way of upbringing and communicating with PWPDs
	3. Job problems	Employment problems for the disabled-problems of the disabled in the workplace-incompatibility of graduation level with the job-low payment
	4. Economic insecurity	The greater cost of equipment needed and travel expenses for the disabled- high costs of treatment, swimming pool, hydrotherapy, and occupational therapy
Structural barriers	1. Improper environmental infrastructure	The inadequate structural condition of the community environment- Inadequate residence environment for people with physical disabilities
	2. Inadequate civil support for the right to equality and the inclusion of people with physical disabilities in society.	Lack of efforts to empower people with physical disabilities by supporting groups
Physical factors	1. Secondary disability complications	Increased risk of infection- the possibility of bed sores in people with spinal cord injuries
	2. Unhealthy lifestyle	Increased risk of dental caries in hand disability-obesity

To reduce research bias and improve validity, two competent external researchers independently assessed the 50% coded transcripts to determine initial classifications. After that, the author and the outside researchers talked about the categories to come to a decision.

Ethical consideration

Participants were given information about the study’s goals and asked to sign a consent form. The study protocol was approved by the Ethics Committee of Iran University of Medical Sciences (with number IR.IUMS.REC.1398.935)

Results

Sociodemographic characteristics of the participants

Twenty employed PWPDs (14 women and 6 men), 5 of their family members, and 3 of the participants’ employers were interviewed. Table 3 shows the demographic information of the study participants. Four key categories were identified: (a) psychological conditions, (b) socioeconomic problems, (c) structural impediments, and (d) physical constraints. Table 2 summarizes the categories and sub-categories. To clarify and document each of the extracted subcategories, a few of the participants’ quotes from the original data text were presented.

Table 3.

Demographic characteristics of study employed people with physical disabilities (n=20)

Variables	n	%	Mean	SD
Age			37.80	8.02
Sex
Female	14	70
Male	6	30
Marital status
Single	11	55
Married	9	45
≤12th grade	6	30
>12th grade	14	70
Work experiences (year)			13.50	9.11
Cause of disability
Congenital	12	60
Non-congenital	8	40

Psychological conditions

Psychological problems were found as contributing variables to the participants’ QOL, with three sub-categories including negative emotions, lack of freedom, and coping strategies with disabilities.

Negative emotions

According to the participants, when impairment occurs and indicators of physical weakness manifest, the impaired person’s self-reliance comes to an end. They need others and seem to be reliant on others, which worsens with time. Mental strain and stress, lack of confidence, worry about the future, and feelings of isolation have an impact on their minimal capacities. They begin to suffer sorrow and great sadness, as well as unpleasant sensations and melancholy:

Psychological tension

“In the past, I never could cope with my disability. Mental pressure caused me to think, what is the reason for living for me?” (a 34-year-old man)

Stress

“When society cannot supply the needs of PWPDs, he/she gets stressed. He/she feels disappointed and when he cannot express his demands, he/she messes up and gets anxious.” (an employer of the participants)

Fear of the future and loneliness

“Fear of loneliness is hard for me. I always think about the future. I am afraid of the absence of my parents someday.” (a 35-year-old woman)

Reduction of self-confidence

“When I hear my family saying you cannot do one activity, I become sad and my confidence decreases.” (a 34-year-old man)

Lack of freedom

Another problem that PWPDs face is a lack of independence in doing personal affairs. Being dependent on others due to disability prevents mental autonomy and causes PWPDs to underestimate and not accept themselves.

Lack of mental independence

“PWPDs are more dependent on others. They do not think about independence because they do not accept themselves.” (an employer of the participants)

Feeling dependent on others

“Excessive family assistance and a lack of understanding of effective support, without delegating responsibility to the handicapped person, are impediments to her becoming self-sufficient.” (an employer of the participants)

Coping strategies with disability

Physical limitations, whether congenital or happening during life, challenges people’s abilities and often forces them to find new strategies to cope with their condition. According to the participants, the strategies adopted to manage people with a disability may have an impact on their QOL:

Adaptive coping strategies

A number of individuals employed adaptive coping methods such as optimistic thinking, prayer, recognizing one’s talents, seeking social support from friends and family, and acknowledging one’s strengths. “She will feel more at ease when her family and everyone around her understands when they should assist and support her. For example, if two deaf individuals marry and have children, a granny nearby will assist the parents in establishing the children’s language sign. “Those who are disabled or will become disabled in the future and know it as a gift from God or believe that where one door closes, another opens, can cope more easily with their problems and limitations; especially for those who become disabled in the future, religious beliefs can have a great effect on their ability to deal with their disability,” an employer of the participants. “Who have a positive attitude about their lives acquire power over their surroundings, trust in themselves more, and have a greater quality of life,” an employer of the participants. “A disabeld person in my opinion, should be conscious of her skills. She will find her path if this self-awareness is developed and her gifts and abilities are acknowledged.” (a 52-year-old woman).

Maladaptive coping strategies

Along with the variables that contribute to compatibility with a disability, the participants identify certain inhibitors and hurdles, such as blaming themselves, their family, and society, and refusing to accept their condition. Many PWPDs blame their impairment on their family and society.

“For some PWPDs, it is difficult for them to accept their condition. For example, a person with a physical disability who is disabled due to an accident does not believe in his disability. This can lead to aggression, stress, withdrawing into himself or may even lead to depression.”(an employer of the participants)

Sub-categories of socio-economic challenges

The majority of participants stated that socioeconomic hurdles with four subcategories, including the community’s perception of PWPDs, communication difficulties, some work-related issues, and economic instability, may have an impact on the QOL of PWPDs:

Community attitudes and actions toward individuals with disabilities

The incorrect attitude toward PWPDs in their family and society is irritating to them. Although they found that the support of family and friends was one of the most effective factors in improving their QOL, negative reactions irritated them and reduced their QOL. Some attitudes toward PWPDs aim to sympathize with them, but PWPDs finds them annoying and irritating. These incorrect attitudes are represented as sympathetic glances. Other incorrect attitudes included improper judgments about the mistreatment of children with disabilities in some families and restrictions on marriage for females with disabilities:

Sympathetic glance

“When I go out with my crippled wife, I am disturbed by people’s sympathetic glances and communicative approaches.” (a family member of one of the participants)

Misjudges

“Healthy people should stop their improper judgments about the intelligence, talent, and ability of PWPDs.” (a 50-year-old woman)

Mistreatment of children with disabilities in some families

“Many parents force their crippled children to pay their monthly wage to the family (provided by some helping state institutions). In certain homes, there is also mistreatment of children with disabilities.” (a 35-year-old woman),

Restrictions on marriage for females with disabilities

There’s a common belief that says females with physical disabilities are not able to marry because one of the conditions for a girl to marry is being physically healthy. Often, it is thought that PWDs will have children with different disabilities. “I have gotten married. I went out with my fiancé. Many people showed bad reactions and said: oooh! What’s it with this gentleman who has married this female with a physical disability? They surely won’t have healthy children.” (a 53-year-old woman)

Challenges of communicating with others

Having personal relationships is important for everyone and is necessary for the growth and development of society. Having a stable and satisfactory relationship with family, friends, parents, and others is one of the preferences of people, especially PWDs. Each family’s reaction to disability is unique. It may be difficult for a family to accept a child suffering from some disorders. Some may be afraid and need more information about what will happen in the future:

Lack of knowledge by parents about the correct way of upbringing and communicating with PWPDs

“The first step is informing parents so that if they are having disabled children, they have the skills and awareness to grow with them and know what problems their children will have and how they can remove barriers for their children.” (a 40-year-old woman)

Lack of knowledge about the principles of communication with others

“Disability may cause some problems for the person’s positive self-esteem, and PWPDs may have problems in social interactions and when communicating with others. They may feel humiliated. Learning effective communication skills with others is necessary for PWPDs.” (a 33-year-old man)

Job problems

Working is one of the most important activities in life. The most important effect of having a job is preparing social and financial partnerships so that self-fulfillment and self-esteem increase. According to the participants’ opinion, PWPDs face many barriers to finding a suitable job; for example, incompatibility between the job and education level, an inappropriate physical work environment, and not receiving a fair wage. Also, PWPDs are mostly hurt by this attitude, which says they are not qualified to learn skills and work:

Employment problems for the PWPDs

“Working conditions are not available for PWPDs everywhere. For example, they say you must be healthy and have the full ability to work. Even if you are interested in a job and could do it and are able to do it, they say “No, you cannot.” (a family member of one of the participants)

Problems of PWPDs in the workplace

“I’m having much more difficulty finding suitable employment.” I, for example, braces. As a result, I am unable to work in venues with stairwells.” (a 38-year-old man)

Incompatibility of graduation level with job-low payment

“As an educated person, I anticipate my wage to be based on my competency and graduation level, but this is not the case.” (a 38-year-old woman)

Economic insecurity

Financial problems, which also face normal people in society with difficulty in supplying daily expenses, put double pressure on PWPDs and their families to supply their essential and vital needs. Due to their special conditions, PWPDs cannot ignore some of their essential apparatus and equipment, so they have to bear high costs:

Greater cost of equipment needed and travel expenses for PWPDs

“According to the labor office laws, the minimum salary that is assigned to PWPDs is as much as that of a healthy person. But PWPDs need additional funds to purchase braces, crutches, hearing aids, and rehabilitation devices. They also have some difficulty using public transportation (such as buses). Therefore, their costs increase.” (an employer of the participants)

High cost of treatment, swimming pool, hydrotherapy, and occupational therapy

“I pay a lot of money for therapy. PWPDs who use the swimming pool, hydrotherapy, or physical treatment do not receive a discount.” (a 45-year-old man).

Sub-categories of structural barriers

According to the research participants, structural hurdles with two sub-categories, including improper environmental infrastructure and inadequate civil support for the right to equality and participation of PWPDs in the community, might impact the QOL of them:

Improper environmental infrastructure

The participants said that improper environmental infrastructure may influence the QOL of PWPDs:

The community’s structural condition is inadequate

“Urban environmental structures should be designed in such a way that a handicapped person may live as comfortably as a healthy one.” (a 31-year-old woman), “My husband has a lot of trouble traveling to hospitals or retail malls because of the stairs.” (a participant’s family member).

Inadequate residence environment

“My mother’s residence is not physically accessible to me. I can’t not just go to the toilet or the bathroom.” (a 50-year-old woman).

Inadequate civil support for the right to equality and the inclusion of PWPDs in society

Supporting PWPDs as a vulnerable group in society has special importance. According to the participants, the developed rules and supporting actions for PWPDs do not have the essential executive power to support all of them and their lives. Also, they are not wide enough so members of society, institutions, and organizations would consider the execution of these rules as their legal duty. Thus, PWPDs are less supported by the law. It is necessary to develop the capability of this group and provide a platform for them to flourish in society by removing the obstacles and presenting expert measures:

Lack of efforts to empower the PWPDs

“Supporting organizations do not work on the empowerment and rehabilitation of PWPDs. If the attitude changes, it can have good results for PWPDs and society as a whole. The PWPDs can have a productive role instead of receiving a negligible allowance predicted for them and hearing” we are supporting this PWDs, although such assistance has no effect on their empowerment.” (an employer of the participants)

Sub-categories of physical factors

According to the participants, secondary consequences of handicaps (such as an increased risk of infection owing to inappropriate use of braces or prostheses) and an unhealthy lifestyle were the two biggest influencers on these people’s QOL.

Secondary disability complications

PWPDs are exposed to secondary complications of disability, such as health complications and difficulties, which are related to their primary health condition. They need precautionary health care. These difficulties include pressure ulcers, urinary tract infections, and pain, which can make the person weak or incapacitated in doing daily tasks, but they can be noticed and many of them can be prevented by on-time intervention:

Increased infection risk

“If inner foot braces are not correctly adjusted, they might cause harm to the body and there is a risk of infection.” (a 38-year-old woman)

Bed sores are a possibility

“Bedsore occurs in people with spinal cord injuries as a result of prolonged sitting in a wheelchair.” (a 33-year-old man)

Unhealthy lifestyle

A lifestyle is a combination of behavioral patterns and individual habits throughout life, including nutrition, physical activity, stress, smoking, and sleep quality. Due to their conditions, PWPDs are exposed to inactivity, which also causes disorders in healthy organs. As a result, they suffer from problems such as obesity. Because of complex and fundamental physical problems, PWPDs take care of their mouths and teeth as well as they should, or it is hard for them to do so, leaving them vulnerable to oral diseases and tooth decay:

Increased risk of dental caries

“The incapacity of persons with impairments to practice personal hygiene is a significant issue for them. My spouse’s bathing and cleaning his teeth are difficult for him, and I should assist him.” (a participant’s family member)

Obesity

“Prolonged sitting increases my body mass index. I do not lead a healthy life.” (a 45-year-old man)

Discussion

Psychological condition category

The current findings of this study suggest that psychological condition was one of the contributing variables to the participants’ QOL. This conclusion is consistent with several studies demonstrating that PWDs have greater psychological issues than non-disabled people.[20,21] Several variables, according to the research, may predict psychological disorders among physically challenged people.[8,22] Participants in the current study reported that negative emotions, such as psychological tensions, anger, despair, stress, feelings of helplessness, hopelessness, and dread were prominent in PWDs. They anticipated that a lack of freedom, as well as the tactics adopted to cope with a handicap, contributed to this undesirable psychological state. Personal dignity is linked to independence. Thus, being independent does not imply completing all things alone, but it does include being autonomous when making decisions. PWDs must fight for their right to live distinct lives.[23] Desalegn et al. showed that people with locomotor disabilities who employed spirituality coping more frequently had lower distress levels,[24] which is consistent with our findings. PWDs, families, policymakers, and society should be aware of the rights of PWDs to live meaningful lives. In psychosocial rehabilitation, healthcare workers should also be taught how to teach PWPDs about the effects of bad behaviors and the benefits of learning new ways to live with their disability.

Socioeconomic challenges category

Socioeconomic problems were identified as another element impacting the participants’ QOL in our study. They indicated that the community’s attitude toward PWDs was hostile. This conclusion was similar to earlier studies.[25,26] According to Zheng et al.,[26] prejudice and unfavorable attitudes toward PWDs are frequent. One of the possible challenges to establishing social equality is the public’s disrespect toward PWDs. A lot of our participants struggled to communicate with others. Bertschi et al.[27] established that people with locomotor disabilities have difficulties interacting with their families and others. Although all participants were employed, they faced various job challenges, such as job incompatibility with their competence and graduation level, and a lack of equipment required by some PWDs, such as proper desks and chairs in the workplace. Employees with mobility disabilities, however, showed lower work satisfaction than healthy people. According to Schur (2017), there is a shortage of assistive technology or employer accommodations, which may explain the disparity between employed PWDs and employees without impairments.[28] Additional initiatives to enhance employer understanding may aid in the gradual removal of obstacles in the workplace for PWDs.[29] Economic insecurity was a regular occurrence among the participants. They stated that the majority of their earnings were spent on using rehabilitation services and on drugs to help them overcome their limits. These two elements were cited as the primary causes of their economic difficulties. Similarly, Pinilla-Roncancio et al.[30] demonstrated that poverty and deprivation were correlated. According to the literature, PWDs are subjected to deplorable living situations. Because of their constraints, they have a more difficult situation in getting jobs. However, their poverty raises their chance of impairment.[31] Identifying what variables cause poverty at all levels among this group is critical for developing supportive economic policies, economic empowerment, and poverty reduction measures for handicapped individuals. Some rules should be put in place to help PWDs who need personal help and technology.

Structural impediments category

The third element impacting the participants’ QOL was structural impediments. They are regularly advised that poor environmental infrastructure and a lack of civil assistance may have a negative impact on their QOL. According to the literature, inaccessible constructed environments (e.g. a lack of attention to travel pathways, facilities, and so on) are problematic for PWDs.[32] Although PWDs tend to participate in their communities, confronting barriers in the built environment might lessen their experience of loss of control and independence.[33] Greater knowledge of Iranian physically impaired people’s experiences with impediments to involvement in the environment may reveal a wide range of essential environmental infrastructure in Iran. Laws related to civil rights highlight the equal rights of PWDs to access services and society’s involvement with people who do not have these limitations. However, research participants stated that the involvement and equality rights of PWDs were frequently overlooked. According to their findings, separate anti-discrimination laws for the handicapped community must be enacted and enforced. In accordance with this, Flynn demonstrated that advocacy mechanisms should be governed by human rights standards for individuals with disabilities.[31]

Physical factors category

Physical factors were found to be the fourth contributing factor to our participants’ QOL. They said that they faced more barriers to adopting a healthy lifestyle, particularly in terms of physical exercise and personal hygiene. Rimmer and Rowland found that impaired kids do not get enough daily physical exercise and are much less active and fat than their counterparts without impairments. They highlighted the need to develop measures to promote physical activity and fitness in young people with impaired mobility.[34] According to the literature, different personal and environmental variables might influence people’s physical activity with a handicap, and important variable determinants of physical activity should be addressed through lifestyle interventions.[35] According to Washburn et al.,[36] PWDs do not have adequate nutritional status. PWDs have poorer oral health than non-disabled people, according to Manley.[37] They have limited access to healthcare services owing to a variety of barriers.[38] It is proposed that specific measuring instruments be developed that can capture all the consequences of personal hygiene on the QOL of PWDs. Our data revealed that the individuals had secondary impairment issues. According to the research, PWDs may be at a higher risk of a variety of secondary health disorders such as pain, spasticity, urinary tract infections, exhaustion, depression, and sleep difficulties. These circumstances may have an influence on their QOL,[39] which may have a detrimental impact on the social involvement of PWDs.[40] Healthcare practitioners, PWDs, and their carers should be informed about the ways of preventing and treating secondary health issues among PWPDs. It is important for every country to have non-governmental organizations (NGOs) or government institutions that help PWDs through volunteer work.

Although this was the first study on the experiences of a sample of Iranian-employed PWPDs, it had a limitation. The findings were derived from a qualitative study approach, which meant that they could not be applied to different subsets of challenged populations. However, the current study may provide some recommendations to healthcare practitioners and governments for enhancing the QOL of PWPDs.

Conclusions

The present research shows that a variety of factors may influence the QOL of employed PWPDs. Establishing activities such as giving mental health education and healthy lifestyle training (e.g. eating a healthy diet, exercising, and so on) to PWPDs or training the community to have a positive perspective on skills of PWPDs may assist them in adapting to their disabilities. Employees who are physically challenged face greater socioeconomic obstacles than healthy people. PWPDs may be more prone to secondary health problems such as pain, stiffness, urinary tract infections, tiredness, depression, and sleep problems. The bulk of their earnings were spent on rehabilitation services and drugs. Increased insurance coverage is required to offer important services and treatments for this population. Although employed PWPDs are more likely to participate in their communities, structural context may limit this desire. Health professionals can train city managers about the importance and principles of building PWDs friendly environment to adapt the environment to the needs of PWPDs.

Ethics approval and consent to participate

The study was approved by the Ethics Committee of Iran University of Medical Sciences, Tehran, Iran (Ethical Approval Code: IR.IUMS.REC.1398.935). All participants were informed about the study objectives and completed a consent form. They were assured that their voices were kept secured and coded according to each participant’s identification number.

Financial support and sponsorship

This study was supported by the Iran University of Medical Sciences, Tehran, Iran.

Conflicts of interest

There are no conflicts of interest.