ABSTRACT
Background and Aims
High‐risk human papillomavirus (HPV) infection is a major cause of cervical and other anogenital cancers, and vaccination is an effective preventive strategy when administered during adolescence. Because parental decision‐making plays a central role in adolescent vaccination uptake, this cross‐sectional study aimed to assess parental awareness, attitudes, and barriers related to HPV infection and HPV vaccination, as well as demographic factors associated with vaccine awareness, among parents of adolescents attending a tertiary pediatric hospital in Babol, Iran.
Methods
In this cross‐sectional survey, 300 parents of children aged 9–18 years who attended inpatient wards or outpatient clinics at Shafizadeh Children's Hospital were consecutively recruited. Data were collected using a structured questionnaire assessing demographic characteristics, awareness of HPV and HPV vaccination, attitudes toward vaccination, and perceived barriers and motivators. Associations between parental awareness of HPV vaccination and demographic variables were analyzed using chi‐square tests, independent‐samples t‐tests, and Mann–Whitney U tests, as appropriate.
Results
Awareness of HPV infection and HPV vaccination was reported by 43.7% and 38.3% of parents, respectively, while only 14.7% correctly identified the recommended age for vaccination. HPV vaccination uptake was very low; only 4 parents (1.3%) had received the vaccine themselves, and 2 (0.7%) had vaccinated their children. Although 52.7% of parents were classified as having a favorable attitude toward HPV vaccination, 96.7% cited high cost and 34.0% limited availability as major barriers. Knowledge of HPV vaccination was significantly higher among parents who were younger, had a university education, resided in urban areas, worked in medical or professional occupations, and had higher household income (p < 0.001).
Conclusion
Parental awareness of HPV vaccination and actual vaccine uptake were low despite generally favorable attitudes. Structural barriers, particularly high cost and limited availability, appear to be major factors linked to poor uptake. Integrating HPV vaccination into national immunization programs, improving insurance coverage, and implementing targeted educational interventions may increase vaccination rates among Iranian adolescents.
Keywords: adolescent, awareness, human papillomavirus (HPV), parents, vaccination
1. Introduction
Human papillomavirus (HPV) infection is a major global contributor to infection‐related malignancies, particularly cervical cancer, and is also associated with non‐malignant conditions such as genital warts and recurrent respiratory papillomatosis [1, 2]. More than 200 HPV genotypes have been molecularly characterized to date. High‐risk HPV types, including 16, 18, 31, 33, 45, 52, and 58, account for nearly 90% of HPV‐related anogenital cancers worldwide. In contrast, the low‐risk variants HPV 6 and HPV 11 are responsible for approximately 90% of genital wart cases. Beyond anogenital malignancies, HPV infection also plays a significant role in the development of a subset of head and neck cancers [3, 4], highlighting its clinical relevance for cancer prevention, screening, and management strategies.
Approximately four out of five sexually active women will acquire an HPV infection during their lifetime, and HPV is responsible for nearly five percent of all cancers worldwide. Among the various genotypes, HPV16 and HPV18 are the most carcinogenic, accounting for about 50% and 20% of cervical cancer cases, respectively [5, 6]. In 2022, an estimated 660,000 women worldwide were diagnosed with cervical cancer, resulting in approximately 350,000 deaths, and this disease ranks as the fourth most common malignancy among women [7, 8]. Moreover, nearly one‐third of men worldwide carry at least one genital HPV strain, and approximately one‐fifth are infected with high‐risk HPV variants [9].
Behavioral factors such as early onset of sexual activity, having multiple sexual partners, and partners' sexual practices are strongly associated with an increased risk of acquiring HPV infection. Higher prevalence of oncogenic HPV types and simultaneous infection with multiple high‐risk genotypes have been linked to sexual behavior patterns, socioeconomic status, high parity, inconsistent use of barrier contraceptives, and prolonged use of oral contraceptives. In addition, several co‐factors influence HPV transmission, viral persistence, and progression toward precancerous and malignant lesions. Beyond persistent infection with high‐risk HPV types, cervical cancer development is further associated with multiple lifetime sexual partners, high parity, long‐term oral contraceptive use, and tobacco smoking [10, 11].
Recent evidence indicates that HPV vaccination substantially reduces the risk of infection and progression to cervical cancer. The World Health Organization recommends routine immunization for girls between 9 and 14 years of age [12, 13, 14]. Although the vaccine does not provide protection against all HPV genotypes, regular cervical screening for pre‐invasive lesions remains essential for both vaccinated and unvaccinated women [15]. Since the HPV vaccine is recommended for young adolescents, parental acceptance and awareness are crucial to achieving high vaccine coverage. Thus, parental decision plays a pivotal role in determining adolescent vaccination rates [16, 17].
Parental awareness and acceptance play a pivotal role in adolescent vaccine uptake [18]. Studies conducted in Iran and across the Middle East indicate generally low levels of awareness regarding HPV infection and vaccination. A regional meta‐analysis reported that only about 41% of individuals were aware of HPV vaccination, with an acceptance rate of approximately 46% [19]. For example, one investigation among women of reproductive age reported that knowledge of HPV and its vaccine was rated as insufficient in 86.5% and 79% of participants, respectively [8]. Another study involving healthcare providers found that nearly one‐third demonstrated inadequate understanding of HPV infection. These findings underscore the need to strengthen targeted educational initiatives on HPV vaccination [20]. However, data specifically addressing parental awareness and acceptance of HPV vaccination for adolescents in Iran remain scarce.
In Iran, HPV prevalence is strikingly elevated at 38.68%, leading to an estimated 44,600 cancer cases annually. Despite this burden, the incidence of cervical cancer in Iranian women has been reported as only 1.9 per 100,000 [21, 22]. Vaccination coverage in Iran remains below 10%, constrained by structural barriers such as economic inequality, cultural sensitivities, and inefficiencies in healthcare provision. Most individuals eligible for vaccination remain unvaccinated because distribution is managed by the private sector, and HPV vaccination has not yet been incorporated into the national immunization program. Consequently, HPV immunization is neither widely accessible nor financially feasible for the general population [12, 22, 23]. Despite these challenges, limited information is available on parental awareness of HPV vaccination in Iran. One study reported that 76% of parents had no knowledge of HPV infection, underscoring the urgent need for targeted educational initiatives [18]. Therefore, evaluating parental awareness and acceptance of HPV vaccination, as well as associated demographic and cultural factors, is essential.
To the best of our knowledge, previous studies have not specifically examined awareness and acceptance of HPV vaccination among parents of young adolescents in Iran. This study aims to fill this gap by evaluating the awareness and acceptance of HPV vaccination among parents of 9–18‐year‐old adolescents in northern Iran, and by identifying demographic and cultural factors associated with these attitudes.
2. Methods
2.1. Study Design and Setting
This cross‐sectional study was conducted between 2023 and 2025 at Shafizadeh Children's Hospital in Amirkola, Babol, Iran, a tertiary pediatric referral center. The study population consisted of parents of children aged 9–18 years who were either admitted to the inpatient wards or referred to the hospital's outpatient clinic.
2.2. Sampling Method and Study Population
Participants were recruited using a consecutive convenience sampling method. During the study period, all eligible parents were consecutively approached and invited to participate. Recruitment continued until the predetermined sample size of 300 parents was reached.
The inclusion criteria were parents or legal guardians of children aged 9–18 years whose children were admitted to the inpatient wards or attended the outpatient clinic, and who were willing to participate and provided written informed consent. The exclusion criteria were incomplete questionnaire responses, refusal to participate, and cases in which a specialist identified a medical contraindication to vaccination in the child.
2.3. Data Collection Procedure
Data were collected using a structured questionnaire developed based on relevant literature and previous similar studies. The instrument included sections assessing demographic characteristics such as parental age, education level, occupation, household income, and place of residence, as well as awareness of HPV infection and HPV‑related diseases, awareness of HPV vaccines and optimal vaccination timing, HPV vaccination status of parents and children, and attitudes toward HPV vaccination along with perceived barriers and facilitators. An expert panel reviewed the questionnaire and evaluated the relevance, clarity, comprehensiveness, and appropriateness of each questionnaire item to establish content validity before data collection. Completed questionnaires were examined for completeness and logical consistency, and incomplete or contradictory responses were treated as missing and excluded from the relevant analyses. No multivariable adjustment or regression modeling was performed; therefore, observed relationships should be interpreted as unadjusted associations.
2.4. Measurement of Awareness
Parental awareness was assessed using 10 knowledge‐based items about HPV, HPV‐related diseases, and the HPV vaccine. Each correct response was scored as 1, while incorrect or “don't know” responses were scored as 0, yielding a total awareness score ranging from 0 to 10. Parents who correctly answered ≥ 70% of the items (a score of 7 or higher) were uniformly classified as “aware,” while those with lower scores were classified as “unaware.”
Attitude Categorization: Because no previously validated attitude scale specific to HPV vaccination was available in this context, attitude categories were developed based on cumulative response patterns to attitude‐related items after expert review. Parents who expressed consistent support for vaccine safety and benefits were categorized as having a favorable attitude, those with mixed feelings or uncertainty as neutral, and those expressing distrust or resistance as negative/unfavorable.
To ensure participant confidentiality and anonymity, no personal identifiers such as names or national identification numbers were collected. Each questionnaire was assigned a unique numerical code for data management purposes. All data were stored in password‐protected files accessible only to the research team, and analyses were conducted using anonymized datasets.
2.5. Statistical Analysis
Data were analyzed using SPSS software (version 22, IBM, Armonk, NY). The normality of the age variable was confirmed using the Kolmogorov–Smirnov test and was compared using the independent samples t‐test. Associations between categorical variables were examined using chi‐square tests, while continuous variables were compared using independent‐samples t‐tests or Mann–Whitney U tests according to data distribution. A p‐value of < 0.05 was considered statistically significant. Graphs were generated using GraphPad Prism.
2.6. Ethical Considerations
The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Babol University of Medical Sciences (Ethics Approval Code:IR.MUBABOL.REC.1402.102). Participation was voluntary, and written informed consent was obtained from all parents prior to enrollment. All collected data were anonymized and stored securely, accessible only to the research team.
3. Results
3.1. Demographic Characteristics
Among the children of the surveyed parents, 122 (40.7%) were boys and 178 (59.3%) were girls. Regarding parent respondents, 253 (84.3%) were mothers and 47 (15.7%) were fathers. The mean age of participating parents was 31.3 ± 4.6 years (range: 21–46 years). Most participants resided in urban areas (n = 242, 80.7%), while 58 (19.3%) lived in rural areas.
Parental occupations included office employees (n = 69, 23.0%), medical staff (n = 14, 4.7%), and other professions (n = 217, 72.3%). Approximately half of the parents (n = 151, 50.3%) had a university degree, while the remainder had a diploma, sub‐diploma, or were illiterate. Monthly household income ranged from less than 30 million Rials to more than 120 million Iranian Rials, with half of the families earning between 30 and 60 million Iranian Rials (Table 1).
Table 1.
Demographic characteristics of parents of adolescents aged 9–18 years (n = 300).
| Variable | Number | Frequency (%) |
|---|---|---|
| Gender | ||
| Female | 178 | 59.3 |
| Male | 122 | 40.7 |
| Relationship with children | ||
| Mother | 253 | 84.3 |
| Father | 47 | 15.7 |
| Average Age of parents (in years) | 31.3 ± 4.6 | |
| Place of residence | ||
| Urban | 242 | 80.7 |
| Rural | 58 | 19.3 |
| Profession | ||
| Employee | 69 | 23 |
| Medical staff | 14 | 4.7 |
| Others | 217 | 72.3 |
| Education | ||
| Illiterate | 3 | 1 |
| Sub‐diploma | 21 | 7.7 |
| Diploma | 123 | 41 |
| College | 151 | 50.3 |
| Monthly household income | ||
| Less than 30 million Rials | 22 | 7.3 |
| 30 to 60 million Rials | 153 | 51 |
| 60 to 120 million Rials | 111 | 37 |
| More than 120 million Rials | 14 | 4.7 |
3.2. Parental Awareness of HPV and HPV‐Associated Diseases
As it is depicted in Figure 1, 208 participants (69.3%) reported awareness of HPV‐associated diseases, including cervical, penile, and anal cancers, and genital warts. Concern about contracting these diseases was expressed by 85 parents (28.3%).
Figure 1.
Parental awareness toward HPV‐associated diseases.
The most frequently recognized condition was genital warts (117 parents, 39%), followed by cervical cancer (99, 33%), sexually transmitted diseases (80, 26.7%), penile cancer (36, 12%), and anal cancer (30, 10%).
3.3. Parental Awareness of HPV and the HPV Vaccine
Based on individual knowledge items, awareness of HPV itself was reported by 131 parents (43.7%). Regarding HPV vaccination, 115 parents (38.3%) reported awareness of the vaccine, 108 (36%) understood its preventive role, and 44 (14.7%) were aware of the recommended age for vaccination (Figure 2).
Figure 2.
Parental awareness toward HPV and HPV vaccine.
3.4. Key Reasons for Not Obtaining the HPV Vaccine for Children
The study examined parental engagement with the HPV vaccine and assessed their perceptions of its accessibility and affordability. Only 4 parents (1.3%) had received the vaccine themselves, and 2 (0.7%) had vaccinated their children. Most parents (n = 290, 96.7%) believed the vaccine cost was unreasonable.
The most commonly reported reasons for not vaccinating children were limited vaccine availability (n = 102, 34%) or the child's young age (n = 93, 31%), other unspecified reasons (n = 84, 28%), and concerns regarding vaccine safety or efficacy (n = 21, 7%) (Figure 3).
Figure 3.
Key reasons for not getting the HPV vaccine for children.
3.5. Motivators for HPV Vaccination
Figure 4 illustrates the factors that motivate parents and children to pursue HPV vaccination. The inclusion of the HPV vaccine in the national immunization program was identified as the primary motivator (n = 214, 71.3%), followed by insurance coverage for vaccination costs (n = 37, 12.3%), reduced vaccine price (n = 19, 6.3%), recommendations from family/friends (n = 7, 2.3%), and other unspecified reasons (n = 23, 7.6%). These findings underscore the critical role of institutional support, including national immunization programs and insurance coverage, in promoting HPV vaccination.
Figure 4.
Motivators for HPV vaccination among parents and adolescents.
3.6. Parental Attitudes Toward HPV Vaccination
As depicted in the Figure 5, The majority of parents (n = 158, 52.7%) were classified as having a favorable attitude toward HPV vaccination, 39 (13%) were classified as having neutral attitudes, and 20 (6.7%) reported negative/unfavorable attitudes.
Figure 5.
Parents atitute toward HPV vaccination.
3.7. Relationship Between Demographics and HPV Vaccine Awareness
Using the predefined overall awareness score (≥ 7 out of 10), parents classified as aware of HPV vaccination were compared with those classified as unaware. Parents aware of the HPV vaccine were younger (mean age 29.7 ± 4.3 years) than those unaware (32.2 ± 4.6 years; p < 0.001). Urban residents had higher awareness (43%) than rural residents (6.9%; p < 0.001).
There was a statistically significant relationship between parental occupation and awareness of the HPV vaccine (p < 0.001). The highest levels of awareness were observed among parents working as medical staff (71.4%), followed by employees (50.7%) and those in other occupations (29%).
Awareness of HPV vaccination was also significantly associated with education level (p < 0.001), with the highest awareness reported among parents with a university education (51.7%) and those holding a diploma (24.4%). None of the parents with less than a diploma or those who were illiterate demonstrated any knowledge of HPV vaccination.
In addition, a statistically significant relationship was found between monthly household income and awareness of the HPV vaccine (p < 0.001). The highest awareness was observed among parents with monthly incomes of 60–120 million Iranian Rials (54.1%), followed by those earning more than 120 million Iranian Rials (50.0%), less than 30 million Iranian Rials (31.8%), and 30–60 million Iranian Rials (22.2%). By contrast, no statistically significant relationship was identified between awareness of HPV vaccination and either the gender of the child or the ratio of parents to children (p > 0.05) (Table 2).
Table 2.
Relationship between parental demographic characteristics and awareness of HPV vaccination.
| Demographic variable | Awareness of vaccine application Yes/No (%) | p value | |
|---|---|---|---|
| Yes | No | ||
| Children's gender | |||
| Female | 67(37.6) | 111(62.4) | 0.475 |
| Male | 41 (33.6) | 81 (66.4) | |
| Relationship with children | |||
| Father | 14 (29.8) | 33 (70.2) | 0.334 |
| Mather | 94 (37.2) | 159 (62.8) | |
| Average age of parents | 29.7 ± 4.3 | 32.2 ± 4.6 | < 0.001 |
| Place of residence | |||
| Urban | 104 (43) | 138 (57) | < 0.001 |
| Rural | 4 (6.9) | 54 (93.1) | |
| Occupation | |||
| Employee | 35 (50.7) | 34 (49.3) | < 0.001 |
| Medical staff | 10 (71.4) | 4 (28.6) | |
| Others | 63 (29) | 154 (71) | |
| Education | |||
| Illiterate | 0 | 3 (100) | |
| Sub‐diploma | 0 | 23 (100) | < 0.001 |
| Diploma | 30 (24.4) | 93 (75.6) | |
| College | 78 (51.7) | 73 (48.3) | |
| Monthly household income | |||
| Less than 30 million Rials | 7 (37.8) | 15 (68.2) | < 0.001 |
| 30 to 60 million Rials | 34 (22.2) | 119 (77.8) | |
| 60 to 120 million Rials | 60 (54.1) | 51 (45.9 | |
| More than 120 million Rials | 7 (50) | 7 (50)7 (50) | |
4. Discussion
In this cross‐sectional study, despite moderate awareness of HPV‐associated diseases (69.3%), fewer than half of parents were aware of HPV infection itself (43.7%) or the HPV vaccine (38.3%), and only 14.7% correctly identified the recommended age for vaccination. Actual vaccine uptake was extremely low, with vaccination reported in only 0.7% of children and 1.3% of parents. Although more than half of parents (52.7%) expressed a positive attitude toward HPV vaccination, most perceived significant barriers, particularly high cost (96.7%), limited availability (34%), and the belief that their child was too young (31%). Awareness of HPV vaccination was significantly higher among younger, urban, educated parents and medical staff, suggesting socioeconomic disparities in access to information.
Vaccination is the most effective intervention for preventing diseases associated with HPV [24]. To date, limited research has examined parental awareness and acceptance of the HPV vaccine, particularly in relation to young adolescents in Iran. The findings of the present study indicate that only a small proportion of parents were aware of the need to vaccinate their children against HPV. This level of awareness, particularly regarding vaccine timing and preventive benefits, is substantially lower than that reported in many other settings; for example, a European review found that, on average, approximately 64% of parents had heard of HPV [3], and studies from the United States and China have documented greater parental willingness to vaccinate their children [25, 26]. Such comparisons must be interpreted cautiously. Countries like the United States differ fundamentally from Iran in terms of health system organization, media exposure, routine physician counseling, insurance coverage, and inclusion of HPV vaccination in national immunization schedules [27]. In many high‐income countries, HPV vaccination is integrated into mandatory childhood or school‐based immunization programs, whereas in Iran it remains optional, self‐funded, and largely inaccessible due to cost [28, 29]. These cultural, economic, and policy differences critically shape parental awareness and vaccine uptake and limit the direct comparability of international figures.
Within Iran, our awareness figures are consistent with past findings that parental knowledge is generally low. Ghojazadeh et al. [18] reported that 76% of Iranian parents had no prior information about HPV. The small minority of parents who had actually vaccinated their children (0.7%) is consistent with the generally low HPV vaccine uptake reported in Iran [22]. A previous survey among Iranian students similarly noted poor awareness [23].
Most parents in our sample had favorable attitudes toward HPV vaccination (52.7%), which aligns with some other reports that parents tend to support vaccination in principle. However, this theoretical acceptance did not translate into action. The primary barriers were logistical, as almost all parents cited the cost of the vaccine as prohibitive, and many also reported issues related to its availability. These findings are consistent with regional and global reviews indicating that, in the Middle East and North Africa region, limited understanding of the vaccine and its benefits, along with high cost, are among the most frequently cited reasons for low HPV vaccine uptake [12]. Household income was also significantly associated with awareness, corroborating findings by Davlin et al. [30], who reported lower HPV awareness among individuals from low‐income backgrounds. In addition, Alizadeh et al. [31] identified several other barriers to HPV vaccination in Iran, including informational gaps, psychological concerns, and socio‑cultural factors. Religious concerns are another major contributor to parental reluctance toward HPV vaccination [23]. In our study, institutional factors like inclusion in a national program were strong motivators; 71% of parents indicated they would vaccinate if the vaccine were part of the routine schedule. This suggests that policy measures (such as government funding or insurance coverage) may contribute to improved vaccine uptake. Indeed, the strategy proposed in a recent Iranian policy analysis emphasizes integrating HPV vaccination into the national immunization program and leveraging public‐private partnerships to improve access [22, 31].
Parents with university degrees were far more likely to know about HPV vaccination than less‐educated parents (51.7% vs 0%). This finding parallels global and regional patterns where education is an important correlate of vaccine knowledge [32, 33, 34]. In line with Degarege et al. [35], parents residing in urban areas were significantly more aware than those in rural settings, highlighting disparities in access to health information. Previous work has suggested that rural populations may face additional barriers to participation in vaccination programs [36]. Furthermore, parents employed in medical or professional occupations demonstrated higher awareness, consistent with reports by Rivera et al. [37]. The association between parental age and awareness also underscores the need for age‐tailored educational interventions, although findings across studies remain mixed [38].
5. Limitations and Strengths
Our results must be interpreted in light of certain limitations. First, the cross‐sectional design precludes causal inferences, and the observed relationships should be interpreted strictly as associations rather than causal effects. Second, the sample was derived from a single‐center, hospital‐based population in a specific region, which may limit the generalizability of the findings. Parents who accompany children to a tertiary hospital might differ from the general population in health awareness or socioeconomic status (sampling bias). Third, our measures relied on self‐reported knowledge and attitudes, which can be affected by social desirability bias. (It is possible that some parents overreported positive attitudes because of perceived expectations.) Fourth, although the questionnaire was reviewed by an expert panel for content validity, no formal psychometric validation, such as construct validity or internal consistency reliability testing, was performed, which remains a limitation of this study. Our categorization of “favorable/neutral/unfavorable” attitude could be refined and formally validated in future studies. Finally, while we collected data on many demographic factors, unmeasured confounders (e.g. prior exposure to health campaigns) might influence the observed associations.
Despite these limitations, this study has strengths. It is among the first to quantitatively assess HPV vaccine awareness and acceptance in Iranian parents of adolescents. The sample size (n = 300) is reasonably large for a single‐center study, and we obtained detailed socio‐demographic data that allowed analysis of key correlates. Our findings highlight a clear research gap and can inform targeted interventions.
6. Future Directions
Future studies should employ multicenter and population‐based designs to improve representativeness and reduce selection bias. Longitudinal studies are needed to assess causal relationships and track changes in awareness and uptake following policy or educational interventions. Qualitative research could further elucidate cultural beliefs, religious concerns, and parental decision‐making processes. Importantly, intervention studies should evaluate the impact of integrating HPV vaccination into the national immunization program, expanding insurance coverage, and implementing targeted educational campaigns.
7. Conclusion
Low awareness of HPV vaccination, combined with high cost and limited availability, was associated with very low vaccine uptake among adolescents in this study. Although parental attitudes toward HPV vaccination are generally favorable, structural and policy barriers remain important challenges to improving vaccine uptake. Addressing these barriers through national immunization policies, insurance coverage, and targeted education is essential for reducing the burden of HPV‐related diseases and improving public health outcomes.
Author Contributions
Sahar Sadr Moharerpour: conceptualization, methodology, data curation, investigation, supervision, funding acquisition, visualization, project administration, resources, writing – original draft, writing – review and editing. Arefeh Babazadeh: visualization. Hasan Mahmoodi: visualization, Resources. Atefeh Ahmadi: conceptualization, data curation, investigation, visualization. Soheil Ebrahimpoor: visualization. Hematollah Gholinia: methodology, software. All authors have read and approved the final version of the manuscript corresponding author had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.
Ethics Statement
All procedures performed in studies involving human participants were following ethical standards and informed consent was obtained. This project was approved by the Ethics Committee of Babol University of Medical Sciences (ethics code: IR. MUBABOL. REC.1402.102).
Conflicts of Interest
The authors declare that there is no conflicts of interest. All authors mentioned have approved the manuscript. Moreover, the authors have no relevant financial or non‐financial interests to disclose.
1. Transparency Statement
Transparency Statement: The lead author affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
Acknowledgments
This article was derived from a research project approved by Babol University of Medical Sciences for earning an M.Sc. thesis. The authors would like to gratefully thank to the participants in this study. This study was financially supported by a grant from Babol University of Medical Sciences (Project code: 724134805).
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.