Enhancing pre-anesthesia care knowledge and skill: A mixed-method study on multi-method educational intervention for nurse anesthesia undergraduates

Abstract

BACKGROUND:

Given the anesthesia team’s crucial role and the necessity of strong pre-anesthesia knowledge for nurse anesthesia students’ patient safety, innovative teaching methods are vital for enhancing their ability to maintain safety and improve care. This research examines a multi-method educational intervention’s impact on undergraduate nurse anesthesia students’ pre-anesthesia knowledge and skills.

MATERIALS AND METHODS:

A randomized controlled trial with a mixed-methods approach pre-test and post-test design was conducted at AJUMS, Iran. This study involved 48 second and third-year undergraduate anesthesia students, randomly split into control (n = 24) and intervention (n = 24) groups. The intervention group received three 2-hour training sessions using a multifaceted approach. This included initial focus groups for needs assessment and identifying student challenges, followed by simulation (using mannequins and standardized patients in hypothetical clinical scenarios) to teach pre-anesthesia care knowledge and skills. A final focus group summarized key learnings, with content analysis applied to all focus group data. The control group received only standard training during their internship, with no supplementary instruction. Data on students’ knowledge and skills in this domain were collected using a researcher-developed questionnaire and checklist. Subsequently, covariance analysis was performed using SPSS version 26 for statistical analysis. The Chi-square test, independent samples t-test, and analysis of covariance models were used.

RESULTS:

Participants, with a mean age of 22.83 years and approximately 75% female, showed significant improvements. In the post-test, the intervention group’s mean knowledge scores increased from 14.20 to 17.17 (P < 0.001), and their skill scores increased from 77.12 to 93.92 (P < 0.001). The control group also improved, with knowledge scores increasing from 14.21 to 15.79 (P < 0.001) and skill scores increasing from 76.25 to 84.67 (P < 0.001). Crucially, the intervention group’s post-test scores for both knowledge and skills were significantly higher than the control group’s (P < 0.001).

CONCLUSION:

The multi-method educational intervention demonstrates the potential for significantly enhancing pre-anesthesia care knowledge and skills among undergraduate anesthesia students. Consequently, its incorporation into their educational curricula is recommended.

Introduction

Patient safety has become a major area of concern, as studies have highlighted the significant role of human error in adverse events.[1] Anesthesia is crucial for patient safety and comfort during surgery, requiring anesthesia professionals to possess technical and non-technical skills such as communication and decision-making, as deficiencies in these non-technical skills are linked to errors and adverse outcomes.[2,3,4,5] The administration of anesthesia involves essential procedures where omissions can increase complications, making diligent pre-anesthesia care and thorough equipment checks vital.[6,7] Studies indicate that important items are forgotten in 10%–17% of anesthesia preparations, and lack of proper checking contributes to 22%–33% of critical incidents with negative outcomes.[8] Therefore, it is imperative for the anesthesia team to understand equipment functionality, master checking protocols, and acquire pre-anesthesia care knowledge through proper training.[9] Enhancing the scientific and practical level of anesthesia professionals, including undergraduate students through effective educational methods, is seen as a solution.[10] While lecture-based teaching is common, it has weaknesses such as passive learning, hindering reasoning and critical thinking, and creating a dry learning environment.[9,10,11]

The National Medical Commission emphasizes interactive teaching methods for anesthesia postgraduate education to cover cognitive, affective, and psychomotor domains. Multi-method educational intervention can incorporate various educational strategies,[12] such as focus groups and simulation-based training. Simulation-based training offers a safe environment for learners to experience real-life scenarios by using mannequins and standardized patients, proving useful for skills difficult to learn at the bedside.[13] In addition, it is an educational technology that can facilitate learning, improve performance, and develop critical thinking and self-confidence in students.[14]

Focus groups involve small groups guided by a facilitator to generate data through discussion and interaction, allowing for a wider range of ideas and empowering participants.[15,16] There are two important functions of a focus group discussion:

First, participants’ statements are influenced by the group’s attitude; their opinions are reflected through the eyes of other participants. Second, information is not solely extracted by the researcher, but by all group members, including the participants. Therefore, not only are more ideas generated, but group interaction can also empower participants to express their views.[17]

Limited research exists in this area. Research by Ramírez-Durán et al.[18] in Spain demonstrated that a multi-method educational intervention incorporating simulation and focus groups improved breastfeeding knowledge and the identification of solutions for breastfeeding challenges among undergraduate mother and child nursing students. Flynn et al.’s[9] qualitative investigation in Norway, employing focus group discussions and semi-structured interviews, revealed that heightened awareness of non-technical skills contributed to enhanced professionalism and clinical proficiency among nurse anesthetists in mentoring and supervisory roles. Studies have shown that multi-method educational intervention with simulation and focus groups can improve knowledge and problem-solving skills in nursing students, enhance professionalism and clinical proficiency related to non-technical skills in nurse anesthetists,[9] and improve attitudes and quality of teamwork in nurse anesthesia students.[19] Identifying the most effective teaching methods for this purpose is also necessary. Furthermore, there is limited existing research on the impact of combined simulation and focus group educational interventions in this specific context. In medical education, the integrated application of both quantitative and qualitative methods can bridge the gap between quantitative assessments of educational efficacy and a qualitative understanding of learning experiences. Therefore, by combining quantitative and qualitative findings, a comprehensive or convergent report of the findings can be obtained, which would not be possible using a purely quantitative approach. According to the conducted research, studies in the fields of anesthesiology and pre-anesthetic procedures have predominantly been quantitative, and according to my investigations, no mixed-methods study has been conducted in this area. Therefore, the present research endeavor pursued distinct yet interrelated aims. Initially, the primary objective focused on undertaking a thorough needs assessment to inform the subsequent identification and extraction of pertinent initial themes. Subsequently, a secondary objective was to empirically evaluate and compare the differential improvements in both pre-anesthesia care knowledge and skills observed across the two participating undergraduate nurse anesthesia student groups, following a designed multi-method educational intervention in 2025.

Materials and Methods

Study design and setting

This study employed a randomized controlled mixed-methods design using a pre-test/post-test control group. It was conducted at AJUMS, Iran, during the second academic semester of 2025. Data collection and interventions took place in the meeting room and practical skills laboratory of the School of Allied Medical Sciences and the operating rooms of affiliated teaching hospitals in Ahvaz.

Study participants and sampling

The study utilized a multistage convenience sampling method. Forty-eight (48) undergraduate nurse anesthesia students in their 4^th and 6^th semesters, who met the inclusion criteria, signed informed consent and were enrolled in the study. Inclusion criteria were: being a 4^th or 6^th-semester undergraduate anesthesia student, willingness to participate in the research, and full cooperation in the intervention. Exclusion criteria included: absence from more than one intervention session, non-participation in the pre-test or post-test, withdrawal from the study at any time for any reason, concurrent participation in another study or training session focused on pre-anesthesia care, or incomplete completion of study questionnaires. Subsequently, students were randomly assigned to either the intervention group (n = 24) or the control group (n = 24) by using a table of random numbers, resulting in a 1:1 allocation ratio [Figure 1].

Figure 1.

The study flow diagram

Data collection tool and technique

The study employed two researcher-developed instruments to measure pre-induction anesthesia care knowledge and skills in a clinical setting. These instruments were informed by literature and the expertise of anesthesia specialists and faculty at AJUMS. The instruments had three sections. The first section gathered demographic data: age, gender, GPA, and academic semester. The second section was a 22-item multiple-choice questionnaire assessing pre-anesthesia care knowledge, with one correct answer per question (1 point for correct; 0 for incorrect). The questionnaire’s content validity was assessed using a 4-point Likert scale based on the content validity index (CVI) and content validity ratio (CVR), yielding a CVR of 0.83 and a CVI of 0.79. The reliability of the knowledge questionnaire was evaluated using the test-retest method and Cronbach’s alpha. Administered twice to 20 students with a 1-week interval, the Pearson correlation coefficient was 0.87, and Cronbach’s alpha was 0.91. The stability of the knowledge instrument was further assessed using a test-retest method with a 10-day interval involving 10 students, resulting in a Pearson correlation coefficient of 0.889.

The third instrument was a 54-item researcher-developed checklist assessing pre-anesthesia care skills, evaluated by blinded educational mentors (Master’s students) in the clinical setting. The checklist had three subscales: communication, equipment handling, and pre-anesthesia drug selection, with a 3-point Likert scale for scoring, yielding a maximum possible score of 108. Content and face validity were established through a review by five anesthesia specialists and four faculty members from the Nurse Anesthesia Department at Ahvaz University of Medical Sciences, whose feedback led to revisions. The CVI was 0.83, and the CVR was 0.86. The reliability of the checklist was determined using Cronbach’s alpha coefficient, which was 0.7 in a pilot administration to 10 nurse anesthesia students meeting inclusion criteria but not participating in the main study. Inter-rater reliability, assessed by two independent raters, resulted in a correlation coefficient of 0.81. The minimum achievable score for both knowledge and skill tests was 0, and the maximum was 130.

After receiving ethics approval from AJUMS, eligible students (n = 48) were invited to an orientation session detailing the study’s purpose, implementation, training sessions, duration, and benefits, emphasizing voluntary participation and confidentiality, and provided written consent forms. In the second phase, students completed a demographic form and a 22-question baseline knowledge questionnaire (25-minute time limit). Additionally, four mentors (Master’s students) evaluated students’ communication, equipment, and pre-anesthesia drug selection skills in the clinical setting by using a checklist. The educational mentors had previously participated in a session led by the research team to familiarize themselves with the checklist completion process and clarify any ambiguities. Mentor inclusion criteria included a bachelor’s degree in nurse anesthesia, thorough pre-anesthesia care knowledge, unbiased assessment ability, and commitment to the evaluation. Following the pre-test, students were randomly assigned to intervention and control groups using a random number table.

In the third phase, a needs assessment was conducted with the intervention group students through focus group discussions. Students were divided into two groups of 12, each participating in a 2-hour session facilitated by the researcher. They discussed pre-anesthesia care, including equipment preparation, anesthesia drug preparation, and patient preparation. A summary at the end identified student challenges in these areas. Subsequently, content analyses were performed on the transcribed focus group data to identify required topics for the students. This involved: 1) data collection (recording and transcription), 2) creating meaning units (identifying specific concepts in sentences or phrases), 3) condensing meaning units (creating shorter expressions), 4) interpreting underlying meaning, 5) creating subthemes (grouping similar condensed units), and 6) creating themes (combining subthemes into broader ideas, with the main theme encompassing all data). Based on these themes, scenarios were designed for the simulation training in the next phase. For content analysis, the software MAXQDA was used [Table 1].

Table 1.

Thematic structure of anesthesia students’ experiences in pre-anesthesia care

Main theme		Subtheme		Student quote
Insufficient understanding of pre-anesthesia care in specific conditions		- Lack of awareness of assessment priorities for emergency pregnant patients		“When an emergency pregnant woman was brought in, I only took her blood pressure, but I didn’t know what was important after that!”
		- Lack of knowledge regarding anesthesia considerations in emergency pregnancy
		- Feeling unprepared to manage emergency cases in pregnancy
Insufficient understanding of pre-anesthesia care in different patients		- Lack of awareness of care differences in various patients		“For a neonate, I didn’t know how to adjust the drug dose at all!”
		- Lack of mastery over anesthesia drug dose calculations in neonates
		- Need for specialized training in pediatric anesthesia pharmacology
Need to strengthen practical and communication skills in a real environment		- Inability to make quick decisions in emergency situations		“In the ward, when it gets noisy, I don’t know what I should do first!”
		- Deficiencies in identifying patient needs in the early stages of care
Need to strengthen practical and communication skills in a real environment		- Weakness in establishing effective verbal communication with anxious patients		“When the patient was scared, I just stayed silent. I didn’t know what to say!”
		- Lack of familiarity with patient relaxation and reassurance techniques
		- Need for training in therapeutic communication skills
Lack of precise knowledge of anesthesia drugs		- Mistake in identifying drugs with similar names		“Sometimes I confuse drugs that have similar names.”
		- Need for more accurate review and learning of drug names and uses

In the fourth phase, the intervention group participated in a 4-hour simulation-based training session in the practical skills lab. It began with a 1-hour lecture on operating room equipment preparation based on the needs assessment. Students received an explanation of the session’s content and the simulation process. A standardized patient (a trained volunteer student) and a mannequin were used to simulate a clinical environment. Students practiced skills under the researcher’s guidance and received immediate feedback. The researcher developed scenarios based on three pre-anesthesia protocol domains: preparation of anesthesia equipment (suction, monitor, intubation, technique-specific equipment), preparation of medications (anesthetic and emergency), and patient preparation (history, airway evaluation, non-invasive monitoring, IV access). Two Anesthesia Department faculty members reviewed and provided feedback on these scenarios before implementation.

The fifth phase involved a 2-hour concluding focus group discussion for the intervention group to synthesize their experiences from the initial discussions and the simulation training. Following this phase, all participants in the intervention and control groups completed a post-test identical to the pre-test. The verbal data from the intervention group’s focus group sessions were recorded and transcribed for qualitative analysis to explore students’ opinions, experiences, feelings, and beliefs regarding the interventions. This analysis aimed to identify the advantages and limitations of the educational approach and inform recommendations for optimization, ultimately contributing to enhanced clinical education quality and patient safety.

The control group students received traditional and routine pre-anesthesia care education during their internship using conventional methods without any additional training.

Rigor of the study

To evaluate the accuracy and robustness of the study, Lincoln and Guba’s criteria[20] were used. To ensure credibility of the data, the following strategies were employed: accurate recording and transcription of interviews, review and confirmation of interpretations by participants, and evaluation of initial categorizations by a senior anesthesia expert and two anesthesia faculty members. To ensure dependability, the coding of the interviews was re-done by a co-author experienced in qualitative data coding. Furthermore, all research details were documented to allow for external auditability.

Ethical consideration

The present study was approved by the Ethics Committee of AJUMS (IR.AJUMS.REC.1404.104) and was conducted in accordance with the principles of the Declaration of Helsinki (2013). Prior to enrollment, potential participants were fully informed about the study’s objectives, methodology, conditions of participation, their right to withdraw without penalty at any stage, the purpose of audio recording, and the strict confidentiality of their data. Written informed consent was subsequently secured from all students who agreed to participate.

Statistical analysis method

Quantitative data were analyzed using SPSS version 26 software. The normality of quantitative variables was assessed using the Shapiro-Wilk test. To examine the association between qualitative variables, the Chi-square test (or Fisher’s exact test) was used, and to compare quantitative variables between the two independent groups (intervention and control), the independent samples t-test was used. Analysis of covariance models were used to determine the effectiveness of the intervention, considering the type of outcome and the presence of confounding variables. The significance level for all statistical tests was set at P value < 0.05.

Results

The findings of this research indicated that the majority of participants were women (75.0%, 36 individuals), and the highest frequency pertained to 6^th-semester students (56.3%, 27 individuals). In addition, 43.8% (21 individuals) were studying in the 4^th semester. The mean age of the control group was 22.17 ± 2.04 years. The mean age of the intervention group was 23.50 ± 4.99 years. In both the intervention and control groups, women constituted the majority (intervention group: 70.8%, 17 individuals; control group: 79.2%, 19 individuals), and no significant difference was observed between the two groups in terms of gender [Table 2]. Regarding GPA, the control group had a mean GPA of 16.61 ± 1.31. The mean GPA of the intervention group was 16.66 ± 1.77, and no significant difference was observed in the mean GPA between the control and intervention groups (P = 0.903) [Table 3, Figure 2].

Table 2.

Frequency and percentage of participants in the control and intervention groups based on gender

Variable	Category	Control (number (%))	Intervention (number (%))	Total (number (%))	P
Gender	Female	19 (79.2%)	17 (70.8%)	36 (75.0%)	0.505
	Male	5 (20.8%)	7 (29.2%)	12 (25.0%)
Academic semester	4	11 (45.8%)	10 (41.7%)	21 (43.8%)	0.771
	6	13 (54.2%)	14 (58.3%)	27 (56.3%)

Table 3.

Comparison of mean age and mean GPA of participants in the control and intervention groups

Variable		Control (mean (SD))		Intervention (mean (SD))		P
Age		22.17 (2.04)		23.50 (4.99)		0.231
GPA		16.61 (1.31)		16.66 (1.77)		0.903

Figure 2.

Intervention effect

The mean knowledge score in the control group before the intervention was 14.21. After the intervention, it reached 15.79. In the intervention group, the mean knowledge score before the intervention was 14.20, which increased to 17.17 after the intervention [Table 4].

Table 4.

Mean scores of knowledge level regarding pre-anesthesia care in the control and intervention groups

Group		Before intervention (n=24)		After intervention (n=24)
		Standard deviation		Mean
Control		1.91		14.21
Intervention		2.22		14.2

The mean skill level score in the control group before the intervention was 76.25. After the intervention, it reached 84.67. In the intervention group, the mean skill level score before the intervention was 77.12, which increased to 93.92 after the intervention [Table 5].

Table 5.

Mean scores of skill level regarding pre-anesthesia care in the control and intervention groups

Group		Before intervention (n=24)		After intervention (n=24)
		Standard deviation		Mean
Control		8.06		76.25
Intervention		9.54		77.12

To thoroughly explore anesthesia students’ experiences in pre-anesthesia care, focus group sessions were conducted at AJUMS. After transcription and repeated review, the qualitative data yielded 400 semantic units. During the analysis process, these semantic units were organized and summarized based on conceptual similarities. This stage was carried out with the aim of achieving a comprehensive understanding of the students’ perspectives. Ultimately, this process resulted in the formation of four main themes and a number of abstract subthemes, which are detailed in Table 1.

The four main themes that emerged from the data analysis are as follows: insufficient understanding of pre-anesthesia care in specific conditions, insufficient understanding of pre-anesthesia care in different patients, the need to strengthen practical and communication skills in a real environment, and a lack of precise knowledge of anesthetic drugs. These themes explain the various dimensions of students’ experiences and challenges in the field of pre-anesthesia care. Furthermore, the subthemes related to each of these main themes reveal more detailed aspects of these experiences and needs.

Discussion

This study investigated the impact of a multi-method educational intervention on the pre-anesthesia care knowledge and skills of Bachelor of Science in Anesthesia nursing students at AJUMS. As anticipated due to stratified random assignment by academic semester, the mean pre-test scores of the intervention and control groups showed no statistically significant difference. Furthermore, the control group showed no significant improvement in mean knowledge and skill scores between the pre-test and post-test, likely due to their internship education relying on traditional teaching methods. The traditional teaching approach often relegates students to the role of passive recipients of information, with minimal peer interaction and negligible influence on the curriculum. This can result in instructors being less attuned to students’ specific needs and academic struggles, potentially leading to unaddressed learning requirements and unresolved issues. Furthermore, this method can erode students’ self-assurance and impair their future patient communication skills. Because pre-anesthesia care is a highly sensitive and crucial area demanding complete mastery, the traditional teaching method falls short. Its neglect of active learning, effective patient communication, and student needs assessment risks producing graduates unprepared for professional practice. These individuals may lack the self-confidence, essential knowledge, necessary patient care skills, and crucial communication abilities, consequently leading to diminished patient care quality and compromised safety. As the results of the study by Zhao et al.[10] showed, the use of the traditional teaching method leads to lower quality learning because the students’ role is merely to listen to the content presented by the professor and complete the assignments they assign, and they themselves have no role in the educational process.

The comparison of the pre-test and post-test scores of the intervention group showed a significant difference. The intervention group showed a marked increase in their knowledge and skills vital for anesthesia care, specifically in communication, equipment preparation, and drug selection. This improvement demonstrates the power of the multi-method educational intervention method to significantly boost student proficiency in these key areas. This success can be attributed to the dynamic and active focused group discussions inherent in multi-method educational intervention, where students actively participated and interacted with both the instructor and their peers, freely voiced their opinions and learning needs, and collaboratively identified learning topics through the exchange of information. This led to increased student self-confidence, improved communication with each other, and acceptance of their role and responsibility in learning. Consistent with our findings, Mestre et al.[21] highlighted in their study that professor-led guidance and mentoring within small groups allows students to analyze their own weaknesses and strengths, thereby directing their learning and enhancing its quality. Similarly, Gibson et al.[22] concluded that collaborative and interactive teaching methods improve knowledge and clinical skills, boost self-confidence, and consequently lower student anxiety and stress, further supporting the benefits observed in our intervention group. The division of students into small groups during focused discussions and simulations facilitated more attentive listening and analysis of their opinions and needs by the professor, allowing for personalized feedback. This smaller setting also empowered students to better focus on recognizing their strengths and weaknesses and expressing their difficulties. Aligning with the findings of other studies, our research indicates that this teaching method enhances both knowledge and patient care skills. Our results further confirm that this approach increases pre-anesthesia care knowledge and skills in Bachelor of Anesthesia students, suggesting its potential to develop professionals capable of providing superior and more expert care during the crucial pre-induction phase. This method also reduces stress and increases students’ motivation for learning. This is because, instead of just being listeners, they actively participated in the learning process and considered themselves responsible for their own learning. They freely asked their questions and discussed skills throughout the training. In addition, group members helped each other to better understand the material, and due to friendly participation among them, their stress was well-managed.

Furthermore, clinical simulation allowed students to apply and practice their knowledge and skills in a standardized, near-clinical environment. Ramírez-Durán et al.[18] corroborate this in their study, stating that clinical simulation can reinforce knowledge and provide an opportunity for students to implement what they have learned. Ostad Hasanloo et al.[23] mentioned in their study that simulation bridges the knowledge-practice gap and reduces patient risk by offering students the chance to repeatedly practice and experience situations similar to real clinical scenarios in a stress-free environment before encountering them in practice. In addition, designing multiple scenarios enhances their clinical judgment and reasoning. In the present study, various scenarios were also designed and implemented to simulate different clinical situations regarding pre-anesthesia care, familiarizing students with optimal decisions and actions in these circumstances.

Moreover, combining the two educational methods of simulation and focused group discussion allows us to leverage the advantages of both and achieve better learning outcomes. The findings of Lockey et al.[24] also support the results of the present study, indicating an increase in learning quality following the implementation of diverse teaching methods and a shift from a teacher-centered to a learner-centered approach. Karimi et al.[25] reported in their study that combining multiple teaching methods is an innovative approach to learning, and it is better to shift from traditional methods toward multi-method educational intervention to deepen understanding. In the present research, the combination of the two educational methods made the sessions more engaging and reduced the monotony and repetitiveness of the classroom for students.

Despite differences in study setting, research population, procedure of interest, and duration compared to the cited works, the present study adopted a designed multi-method educational intervention approach, aligning with the significant and increasing integration of modern and diverse teaching methods. Due to accurate needs assessment, significant interaction and participation in focused discussion sessions, as well as practical application of learned material in simulated clinical situations and group activities, this method can lead to improved student learning, increased student attention to educational content, enhanced motivation and self-confidence, and the promotion of knowledge and skills in performing pre-anesthesia care. This can create a significant change in the education, care, and treatment system because it may lead to better performance of the anesthesia team in the future and improved quality of patient care, which will consequently result in patient satisfaction.

Strengths and limitations

One of the key strengths of this study is its use of diverse and modern educational methods. It employed a mixed-methods approach, which has been rarely used in previous research. For quantitative data assessment, valid, reliable, and standardized instruments were utilized. Additionally, the incorporation of qualitative methods added depth and credibility to the quantitative findings and helped confirm them. However, this study also had some limitations. It was conducted in a single university, and the sample size was relatively small. Moreover, there was no long-term follow-up to assess skill retention.

Suggestions

While the current study demonstrates promising short-term improvements, it is crucial to consider the broader applicability and sustained impact of such educational interventions. To this end, future research should prioritize larger-scale, multicenter trials to enhance the generalizability of these findings across diverse educational and clinical settings. Additionally, conducting longitudinal follow-up studies is essential to evaluate the long-term retention of pre-anesthesia care knowledge and skills among undergraduate nurse anesthesia students, providing a more comprehensive understanding of the intervention’s lasting effectiveness.

Conclusion

The findings of this study demonstrate that a multi-method educational intervention approach enhances pre-anesthesia knowledge and practical skills among undergraduate anesthesia students. Aligned with key health policy benchmarks, this method proves effective in strengthening clinical preparedness, efficient due to its low cost and minimal resource requirements, and accessible for broad implementation across educational settings. By promoting active learning and student engagement, it contributes to equitable learning opportunities and ultimately supports the delivery of safer, higher-quality patient care. Adoption of this approach across medical education systems can serve as a strategic policy initiative to build a more competent and practice-ready healthcare workforce.

Abbreviations

AJUMS: Ahvaz Jundishapur University of Medical Sciences; GPA: Grade Point Average; CVI: Content Validity Index; CVR: Content Validity Ratio.

Author’s contributions

KA: Concepts, design, manuscript preparation, manuscript editing, manuscript review. MT: Design, definition of intellectual content, literature search, data acquisition, data analysis, manuscript preparation, manuscript review. NS: Data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review.

Conflicts of interest

There are no Conflicts of interest.

Availability of data and materials

Data and the materials are available at the request of the readers. Request for data should be addressed to the corresponding author.

Funding Statement

This study was financially supported by the Ahvaz Jundishapur University of Medical Sciences.