Medical gaslighting as a threat to beneficence and patient autonomy: a qualitative study

Abstract

Background

Medical gaslighting- a phenomenon where healthcare professionals dismiss or minimize patients’ symptoms- has garnered increasing attention due to its potential to cause significant harm to patients. This study aims to examine the ethical ramifications and implications of medical gaslighting, and explore how patients interpret and experience interactions affected by medical gaslighting.

Methods

We conducted two narrative interviews with fourteen participants. The first interview was conducted 2–3 days after discharge from hospitalization, and the second was carried out a month later. We then interpreted their stories through bioethical lenses.

Results

Data analysis yielded two main themes: (1) Pain dismissal and minimization; (2) Delayed or missed diagnoses- as subjectively perceived by interviewees. Using a principlist approach, we argue that medical gaslighting constitutes an obstacle to respect for patient autonomy and jeopardizes proper actualization of beneficence. Participants frequently described feeling dismissed, especially when presenting with complex or non-visible symptoms.

Conclusions

Medical gaslighting appears to be a common and impactful experience that contributes to psychological distress and reduces trust in the medical system, potentially delaying diagnosis and treatment. Healthcare institutions must prioritize training on implicit bias, communication skills, and patient-centered care to mitigate these harmful interactions. Future research should further explore structural contributors and develop interventions to foster more validating clinical environments. We propose some practical implications for eradicating medical gaslighting based on our findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-025-01324-z.

When the maternal uncle of the first author complained to his primary care physician about back pain, she recommended applying Diclofenac sodium ointment. He followed this advice, but the treatment was ineffective. She then advised him to swim in a pool to alleviate the discomfort. The uncle attempted this as well, yet continued to suffer from persistent pain. Despite this, the physician did not refer him for diagnostic tests or ultrasound imaging. Three months later, he passed away from renal and spinal cancer at the age of 48.

Background

Medical gaslighting (MG) is the mistreatment that patients experience when they are minimized, doubted, questioned, second-guessed, or denied by clinicians [1, 2]. One prominent example is when clinicians dismiss or invalidate a patient’s reported symptoms, disregard a patient’s concerns and attribute the symptoms solely to stress, obesity, poor nutrition, mental health, side effects of medications, or lack of exercise. Such patients may justifiably feel that their health concerns have been dismissed, and that the clinician, who appears unable to hear their claims, denies them the status of a patient and sometimes classifies them as “just plain crazy”[3]. Unlike ordinary diagnostic uncertainty or communication lapses, MG entails a pattern of responses that undermine the patient’s credibility and often lead the patient to question their own bodily experiences, emotions, or judgment. This phenomenon is distinct from honest clinical error because it involves power asymmetry, bias-driven assumptions, and interpretive dominance- where the clinician imposes their explanatory framework while disregarding or belittling the patient’s narrative. Clinicians practicing MG may misuse their structural power and professional authority to impose their own interpretation of the situation.

Despite frequent references to MG in the media, there are few articles about medical gaslighting in academic journals, and examples of inpatients are scarce [4, 5]. This study was therefore designed to investigate this hitherto understudied phenomenon and explore its bioethical aspects. For this purpose, we adopt the principlism model, which is the overarching ethical framework in biomedical ethics, and is guided by the four principles: autonomy; nonmaleficence; beneficence; and justice [6]. We interpret the MG phenomenon as ethical wrongdoing and view MG as undermining the principle of respect for patient autonomy. In addition, MG opposes the practice of beneficence. Our study aims to introduce a bioethical perspective to manifestations of MG under the theoretical auspice of Patient-centered care approach which conceptualizes patients as the experts of their experiences and leverages the information that patients provide to achieve the desired outcome. We base our arguments on empirical evidence for the phenomenon of MG among inpatients hospitalized for lengthy post-operative care.

PCC and the principle of autonomy

Patient-centered care (PCC) secures autonomy and represents the preferred approach to treatment [7]. This approach delivers care that satisfies individual patient preferences, wishes, needs, and values [8–12]. The clinician-patient interaction is a fiduciary relationship in which the clinician is obligated to act in the patient’s interests, with respect for the patient’s autonomy [13, 14]. PCC and patient autonomy are key factors in improving the quality of health service, since promoting patient trust in the clinician is essential to patient compliance (i.e. patient’s adherence to medical recommendations), and self-management of illness [15–19]. However, under certain conditions, these factors may engender conflicts that manifest in structural paternalism and call for further studies to examine the validity of PCC under infringement of patient autonomy [20]. Following the dearth of information concerning the respect for patient autonomy within PCC in hospitals[15, 19, 20], the current study was designed to fill this gap by examining how MG impacts patient autonomy and the related fulfillment of beneficence within PCC.

Medical gaslighting as an obstacle to PCC delivery

Despite the acknowledged importance of PCC, recent years have witnessed a phenomenon of MG in clinician-patient encounters. This newly conceptualized phenomenon of MG is of great concern. MG refers to situations in which a person is caused to doubt aspects of their own experience [21]. Most articles about MG refer to gaslighting of clinicians who feel manipulated by the healthcare system [3, 22–27]. The reference to MG in patient experiences debuted in September 2020 in an article about a patient who believed she was gaslit when her symptoms were repeatedly discounted. She was eventually diagnosed with long-COVID [28]. In October 2020, a dismissal of gynecological pain and symptoms was also described as MG[29]. While these earlier sources refer to media coverage introducing the term ‘medical gaslighting’ to the public (a term coined by patients rather than academics), subsequent sources rely on academic studies that exposed cases of MG[30–35]. Refusal to order imaging or lab work, and attributing symptoms solely to poor nutrition, mental health, lack of exercise, obesity, the aging process, or dismissing the results of blood tests, may be indicative of MG[36, 37]. An estimated 15 articles in the literature that examine MG in the context of structural racism, cultural and gender discrimination, and biases as threats to health equity, concluded that women and people of color are the most likely to be targets of MG[1, 3–5, 17, 18, 21–28].

The purpose of the study

Under certain conditions, several factors may engender conflicts that manifest in structural paternalism. Therefore, further studies are needed to examine the validity of PCC in cases where patient autonomy is infringed upon. Given the dearth of information concerning the respect for patient autonomy within PCC in hospitals, the current study was designed to add to the limited evidence base by examining how MG impacts patient autonomy and the related fulfilment of beneficence within PCC. Accordingly, this study aims to explore MG during hospitalization and to offer a bioethical analysis of MG within a PCC framework. For these purposes, we conducted a qualitative research project to uncover inpatients’ experiences of MG.

Methods

Ethics

The ethics committee of the academic institution with which the second author is affiliated granted ethical approval for the study. The study adhered to the Declaration of Helsinki. All interviewees signed informed consent forms for participation and also for the publication of their anonymized quotes. Participants were told that their participation was voluntary and confidential and that they may stop the interview at any point in time. They were also told that the data would be analyzed and may be used for publication. Details of the hospitals and clinicians were omitted to preserve anonymity, and background details for each participant were grouped [38].

Participants

Fourteen patients, six women and eight men, who were hospitalized following a life-threatening event, agreed to participate in this study, and none refused. Participants’ ages ranged from 35 to 81 years. Participants were recruited through a snowball sampling approach. Snowball sampling occurs when study participants refer new participants to the researcher. Accordingly, our snowball sampling was based on patient referrals of acquaintances and not clinician recommendations. The initial participants were four persons that were purposively identified within the second author’s social and professional network and invited to participate. Following their enrollment, they were encouraged to refer other potential participants who met the inclusion criteria. Recruitment continued iteratively until no new themes emerged and data saturation was achieved. No relationships were established prior to study commencement. Inclusion criteria were lengthy hospitalization (at least 3 weeks to a month) due to a life-threatening event and willingness to participate in the study upon discharge from the hospital. Table 1 presents the group demographics and medical conditions [38]. Patients or the public were not involved in the design, conduct, reporting, or dissemination plans of our research.

Table 1.

Sample demographics

Age Group	Age Frequency	Disease	Profession and Status	No. of Children
Young (29–36); four participants	29 (n = 1) 33 (n = 1) 35 (n = 1) 36 (n = 1)	Spine cancer; uterine cancer; a neurological disorder; arms and hands crushed.	Software developer (employed); engineer (self-employed); dancer (self-employed); designer (self-employed)	0–2
Middle (43–58); four participants	43 (n = 2) 50 (n = 1) 58 (n = 1)	Breast cancer; an upper limb injury; lung cancer; a neurological disorder.	Teacher (employed); Software engineer (employed); architect (self-employed); photographer (employed)	2–4
Elders (66–81); six participants	66 (n = 1) 72 (n = 1) 74 (n = 1) 75 (n = 2) 81 (n = 1)	Sternum cancer; neurological; uterus cancer; heart failure (2); and allergies.	Consultant (self-employed); insurance agent (employed); psychotherapist (self-employed); Social psychologist (Retired) and a lecturer (employed)	2–4

Interviews

Upon ethical approval, the second author contacted participants using snowball sampling and conducted two face-to-face narrative interviews with each participant: the first interview was conducted 2–3 days post-discharge, and the second one a month later. The interview we conducted was a narrative interview[39]. Interviews took place at the participants’ homes at diverse locations throughout Israel, with no one else present besides the participants and researchers. As is typical of narrative interviews, one general open question was asked: “Please tell me what happened since you arrived at the hospital.” Interviewees were emotional; The interviewer monitored signs of distress and provided information about patient support services when necessary. During the interviews, the interviewer was attentive to any signs of distress, since some participants were still recovering from acute illness. Whenever such signs appeared, the pace and intensity of the interview were adjusted accordingly, and notes were taken regarding non-verbal language. Interviews lasted between an hour to 90 min. Interviews were recorded and then transcribed; Transcripts were sent to four participants, who were asked to review them, and they provided feedback.

Data-analysis

The interviews can be interpreted in the context of a limited self-narrative, during which the interviewees referred to their period of hospitalization. We conducted a three-stage thematic analysis to map the phenomenon of MG within the data [39].

Stage 1 – initial identification of MG-related material

Both authors (female, Ph.D., with over 20 years of experience in qualitative research) independently read all interview transcripts from beginning to end. At this stage, we focused on locating and marking any segment that provided potential evidence of MG within the limited self-narrative context (i.e., descriptions connected to hospitalization). These excerpts were then extracted from the original narratives for further analysis.

Stage 2 – organization and clustering of themes

The extracted material was systematically compared and categorized. The two authors jointly discussed the excerpts, grouped them into recurring patterns, and refined preliminary categories that captured different aspects of MG as they emerged from the interviews. This stage involved moving iteratively between the data and the developing thematic framework, ensuring that the clustering reflected participants’ perspectives while maintaining conceptual coherence. The two authors analyzed the 28 narratives independently to avoid bias and improve the detection of the MG phenomenon. Cohen’s kappa, calculated as an interrater reliability measure, was 0.95.

Stage 3 – synthesis and interpretation

Finally, the phenomenon of MG, as it emerged from the thematic clusters, was reviewed in light of the broader narratives. The authors selected representative quotations that best illustrated the themes and used them to support and exemplify the interpretation. At this point, the thematic map was finalized and presented as the basis for our findings.

Results

We believe that the transcripts of respondents’ interviews are to be viewed not as a static snapshot of their current understanding of the MG experience, but rather as a retrospective interpretation. Accordingly, our analysis exposes the adverse impact of the MG experience on patient satisfaction with care, as well as the personal interactions with clinicians. The collected narratives reflect: (1) Acquired and organized interpretations of MG; and (2) New reflections on MG experiences triggered by the trust relationship between the interviewer and respondent. Although narrative interviews may yield insights that differ between participants, we could identify two distinct categories of MG that emerged through inductive thematic analysis of narrative interviews, following an iterative coding process. We first generated open codes reflecting participants’ descriptions of invalidation and diagnostic neglect, then grouped these codes into conceptually coherent categories: (1) Pain dismissal and minimization, and (2) Delayed or missed diagnoses, as subjectively perceived by interviewees. We hereby provide illustrative quotes that shed light on interviewees’ lived experiences of MG. These quotes were chosen for clarity and thematic relevance.

Pain dismissal and minimization

(Number of interviewees describing this theme- 7, 50%)

A. (f, 39) felt that her pain was dismissed by a clinician who was trying to help but whose communications were condescending and lacking compassion and empathy. She said: " I was in excruciating pain. There was a young doctor in the emergency room who came to me after I had received treatment and said “Listen, I know you’ve had a difficult experience, try to take it to a positive Zen place. I couldn’t even respond.” Ignoring inpatients’ pain and suffering constitutes a unique form of gaslighting[40, 41], as conveyed, for example, by D. (f, 35): “My mother asked the nurse to give me something for the pain and told her, “She’s in terrible pain.” The nurse replied, “So what? So she’s in pain.” I didn’t get painkillers until we insisted. They then took pity on me; and gave me Percocet and another narcotic. I understand that they want to avoid prescribing addictive drugs. I didn’t feel like they were really stingy.”

Like D, Y (m, 81) was also terribly disappointed to find out that the treating clinician was indifferent to his severe abdominal pain. In this case, the indifference led to failure to identify blockages in the Ureter as the source of his suffering, leading to a lengthy hospitalization, a heart attack, and open-heart surgery; Y recalls: “I was in excruciating pain. I got to the emergency room. I was in so much pain and the young doctor did not appreciate the intensity of my pain at all. He sent me back to the community for tests: “Go get an ultrasound of the abdomen, liver, kidneys through your health insurance fund”. I was hospitalized upon receiving the results and underwent 2 weeks of attempts to open the blockages that they had previously failed to diagnose.”

Another interviewee L. (f, 75), who complained of leg weakness and allergies, was disappointed to receive the following dismissive response from clinicians: “When I met the doctor, I complained of severe pain in my legs and couldn’t walk. He didn’t pay attention, didn’t even examine my leg”; “My pain got worse and worse. Every 30 yards I had to stop and sit down. I had to insist on an injection to relieve the pain because the doctor refused to give it to me”; This interviewee also recalls another case where three physicians discounted and disregarded her suffering: “At another time, with another doctor, a cyst causing me excruciating pain was discovered behind my knee. I had trouble walking and getting up. I haven’t walked safely yet. By the time I was able to get to the doctor, he said disdainfully, uh…it’ll take a few months and it’ll pass, using belittling nonverbal communication with his hands and discounting my immense suffering.”

Delayed or missed diagnoses, as subjectively perceived by interviewees

(Number of interviewees describing this theme- 9, 67%)

In one illustrative situation, the clinician disregarded the respondent’s complaints and gaslit him by attributing the symptoms to side effects of steroids. This delayed the diagnosis of a tumor on the spinal cord. M. (m, 43) recalls as follows: “One day I was lying in bed and my right foot felt as if it was freezing. Initially, I ignored it, but after a week, I went to the doctor. During this period, I had been taking a lot of steroids for a health problem and the doctor dismissed the phenomenon as a side effect of the steroids. I was tired of doctors I went home. The feeling continued up my leg until only half my body could feel immersion in cold water in a swimming pool on vacation in Eilat, while the other half felt nothing. The numbness increased to the point that I burned the numb leg in the shower. When we came home after the vacation, I went to a neurologist who did tests and referred me to a hospital, where they did a CT and then an MRI. The scan results revealed a tumor on the spinal cord, which proved that I wasn’t just complaining.”

Another interviewee reported a dreadful incident of post-operation bleeding that led to pain in his arms and neck and full paralysis by the morning. G. (m, 43) recalls as follows: “At 12:30 at night, I complained of excruciating pain in my hand. The only treating doctor on duty responded to my complaints of a lack of feeling in my hands and a pain in the neck (not in the limbs), by saying it is because of the surgery. I believe that overlooking a new symptom was a mistake stemming from a lack of listening and disdain. It can’t be from a lack of intelligence because they admitted him to medical school, so his MCAT score must be very high. I wanted to scream that he was wrong. You didn’t realize that someone following Lumbar surgery (T6-T7) was standing in front of you, so maybe you didn’t fail the anatomy test, but you belittled my complaints and failed to read the “signs.” It’s unforgivable, in the morning, I was already paralyzed.”

We proceed now to discuss the ethical implications of the MG phenomenon.

Discussion

Our study joins the recently accumulating studies documenting MG [1, 3–5, 17, 18, 21–28] and provides empirical evidence for MG experiences among inpatients. The contribution of our study is threefold: First, it offers a conceptualization of MG from a bioethical perspective, as we discuss hereafter, and it debates the actualization of PCC under the infringement of patient autonomy. Secondly, it offers an extension of a theoretical contribution by exposing the hitherto unstudied phenomenon of MG in hospitals. Thirdly, we suggest several practical recommendations that may facilitate the prevention of MG due to the doubt about the ability of some clinicians to respect patient autonomy and to exercise beneficence while delivering PCC.

Conceptualization of MG from a bioethical perspective

Analysis of interviewees’ narratives reveals that, similarly to other testimonies obtained in previous studies [1–4], patients were disappointed to find out that the medical staff dismissed their concerns, medical complaints, and pain. Physicians and nurses alike were perceived by participants as inattentive and insensitive, as they repeatedly tended to ignore patients’ suffering and predicament. Based on these findings and using a consequentialist perspective, we argue that MG should be seen as wronging because it is a serious obstacle to fulfilling the prima facie obligation for benevolence to the reasonable clinician, and at the same time MG represents the infringement of the patient’s prima facie right to compassionate and dedicated healthcare. Consequentialism in bioethics emphasizes that the moral weight of an action depends on its outcomes rather than on intentions, rules, or professional duties alone. Applying this to MG highlights why a consequentialist approach is particularly suitable. We wish to highlight the following three aspects of our bioethical analysis of MG:

1. Focus on patient harm and well-being

The ethical concern in MG does not lie solely in whether a physician violated a duty (deontological view) or failed to respect patient autonomy (principlist view). Instead, the gravest issue is the consequences: delayed diagnosis, worsening illness, psychological distress, erosion of trust, and, in severe cases, preventable disability or death.

• 2. Capturing the systemic ripple effects

Consequentialism allows us to account not only for the immediate harm to the individual but also for broader systemic effects- such as reduced trust in the healthcare system, avoidance of care, and poorer population health outcomes.

From this lens, MG is unethical primarily because of its downstream consequences for both individuals and society.

• 3. Guiding ethical practice by anticipating outcomes

A consequentialist perspective guides practitioners and institutions to minimize harmful consequences and maximize beneficial ones. For example, training clinicians to listen carefully and validate patient concerns is not just a matter of professional virtue; it is ethically imperative because it improves outcomes like diagnostic accuracy, treatment adherence, and patient satisfaction.

Medical gaslighting jeopardizes the respect for patient autonomy

Unfortunately, the phenomenon of MG jeopardizes the respect for patient autonomy as it leads patients to question their authentic emotions and physical self. We posit to view the principle of respect for autonomy, through a wide lens that encompasses respectful attentiveness to the suffering and pain of patients and trust patients’ medical complaints. In MG, patients who are already vulnerable may be inclined to question their experience, and sometimes tend to doubt themselves thinking that they cannot trust their own basic awareness of their body, which is utterly destabilizing by clinicians, further weakening patients due to an unwarranted authority of a clinician. MG may jeopardize the ability of patients to make autonomous, evidence-based and reasoned medical decisions. Respect for autonomy calls upon clinicians to disclose adequate medical details and to ensure that patients behave in a voluntary mode. Failing to provide diagnostic diligence can cause clinicians’ moral residue if later patients are diagnosed with a serious illness that could have been revealed at an earlier phase of its trajectory. This moral residue may have an adverse impact on clinicians’ wellbeing and professional integrity [39].

The principle of beneficence and medical gaslighting

The principle of beneficence is represented in a large variety of actions that are guided by a moral obligation to facilitate the benefit for other individuals [15]. Experiences of MG reported by our interviewees, as well as by participants of other studies, demonstrated the dismissal of patient concerns by clinicians, as patients were told that symptoms are psychosomatic or attributed to anxiety, downplaying their claims of pain and suffering [29, 33, 40]. – [41] The dismissal of medical complaints is therefore a wrong pro tanto which we consider morally indefensible. This dismissal of complaints and suffering stands in sharp contrast to patients’ positive right to adequate and responsible healthcare; hence, beneficence is threatened and poorly translated into practice. Furthermore, Beauchamp & Childress [15] distinguish between obligatory beneficence versus ideal beneficence, and we claim that of these, MG contradicts the obligatory beneficence that the reasonable clinician assumes.

Although MG has some roots in women’s health discourse, our sample included more men, possibly because of the inclusion criteria (long hospitalization, post-life-threatening events). We found that both men and women reported similar experiences of pain dismissal. Accordingly, our findings with both females and males lend support to ignoring pain complaints as a specific manifestation of MG; specifically, this dismissal violates the beneficence rule of “Remove conditions that will cause harm to others”. Since pain is sometimes a symptom of severe illnesses, ignoring pain complaints also violate the rule of “Rescue persons in danger.” When patients report pain, this symptom may signal a potentially severe underlying illness (e.g., cardiac ischemia, infection, malignancy). If a clinician dismisses or trivializes these complaints- as happens in cases of medical gaslighting- the opportunity to identify and treat a life-threatening condition may be lost. In such situations, ignoring the pain complaint is not simply a failure of attentiveness or communication, but an ethical violation of the duty to “rescue persons in danger”: the clinician fails to take action that could prevent serious harm or even death.

Medical gaslighting in hospitalized inpatients

Inpatients shared being dismissed by hospital medical staff and frustrated when their pain was not believed, or was perceived by clinicians as entirely psychological, or hysterical and were treated from their perspective as just drug seeking rather than having their physical symptoms investigated [40, 41]. Furthermore, when these inpatients did not receive the needed help, they felt this contributed to a sense of abandonment and disappointment with clinicians.

According to the PCC approach, clinicians are required to help patients achieve their goals and cultivate their abilities as autonomous agents. This implies a moral duty on clinicians to facilitate patients’ ability to exercise autonomy. Respect for the patient’s autonomy represents a moral demand, and not merely a patient’s right [15]. MG contrasts this ethical expectation and leads the gaslighting clinician to ignore the fundamental human right of the patients to behave as independent agents and make decisions regarding their health. Moreover, MG often leads to what patients may consider a failure to diagnose diseases and syndromes, which may sometimes constitute medical negligence, potentially violating the principle of beneficence. Participants who experienced MG, as well as respondents in studies we cited, felt that they were treated almost as if they were incompetent and lacked self-awareness. Such treatment is morally indefensible. Perhaps one of the reasons for MG is that hospital clinicians are evaluated by the hospital management using quantitative measures of harm and benefit, rather than by assessing the way they adhere to common morality.

Study limitations

This study has several limitations. First, the sample was relatively small and recruited through snowball sampling, which may have introduced selection bias and limits the transferability of findings beyond the specific group of inpatients interviewed. Second, the data relied on participants’ retrospective and self-reported accounts of their hospitalizations. While narrative interviews offer rich insight into lived experiences, they may also be shaped by memory recall, emotional states, or personal interpretation, which limits the ability to establish causal connections between clinician behaviors and patient outcomes.

Practical implications and policy recommendations

Patients who feel heard, understood, and cared-for will not feel gaslighted; and with proper dialogue, it is more likely that clinicians will order the required tests in a timely fashion [36]. We therefore recommend health managements to raise awareness of MG, identify unconscious attitudes, and cultivate sensitivity to nuances in situations that may be indicative of MG. Clinicians are called upon to (a) foster an environment with attitudes enabling patients to feel comfortable expressing their experiences without fear of disbelief. (b) integrate constructive listening, empathy, and accountability of clinicians to validate the experiences of patients. (c) rebuild trust, eradicating the toxic dynamics of MG. This can be achieved by implementing measures to improve patient-clinician communication, such as validating patient concerns (e.g., ‘I hear your concern and we will investigate it further’), and establishing escalation protocols when symptoms persist. MG is indeed a deeply concerning phenomenon that jeopardizes the fulfillment of the principle of beneficence and adversely affects patient autonomy and patient agency.

Conclusions

The contribution of the study is the conceptualization of MG as a violation of the principle of respect for patient autonomy as well as the failure to fulfill the principle of beneficence. See Fig. 1 for a graphical illustration of MG implications. In the pursuit of optimal patient care, clinicians must be aware of MG as a disturbing reality that may lurk in the shadows of the profession, leaving patients questioning their own experiences [1]. Clinicians are expected to not only have the right technical skills, medical knowledge, and expertise, but also be empathetic and compassionate to patient complaints, experiences, and suffering [42].

Fig. 1.

The vicious cycle of medical gaslighting

Abbreviations

MG

Medical gaslighting

Authors’ contributions

Y.B.C. and G.G. conceptualized the study, conducted the formal analysis, and drafted the initial manuscript.G.G. contributed to methodology design, data curation, and conducted the personal interviews.Y.B.C. supervised the project, and reviewed and revised the manuscript critically for important intellectual content.Both authors read and approved the final version of the manuscript.

Funding

There was no funding for this study.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study adhered to the Declaration of Helsinki. Ethics approval was obtained from the IRB ethics committee of Achva Academic College. Consent to participate was obtained from participants by written informed consent forms.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.