The effect of virtual and in-person education on pain management and quality of life of university students with dysmenorrhea

Abstract

BACKGROUND:

Dysmenorrhea affects daily life, mental health, and productivity, raising economic and social concerns. It also significantly affects women’s productivity and quality of life. This study aimed to compare the effectiveness of virtual and in-person education in reducing pain and improving quality of life among university students with primary dysmenorrhea.

MATERIALS AND METHODS:

This quasiexperimental study involved 112 university students with moderate to severe dysmenorrhea (a pain score of 4 or higher over two consecutive menstrual cycles), who were randomly assigned to either In-Person or virtual education groups. An educational intervention was conducted in a 1-hour session (covering topics such as menstrual physiology, nutritional modifications, nonpharmacological treatments, and suitable exercises to alleviate menstrual pain) before their first menstrual cycle. Data were collected using the SF-36 questionnaire, Visual Analog Scale (VAS), and McGill Pain Questionnaire and analyzed with SPSS software.

RESULTS:

Participants, averaging 25.93 years old, experienced dysmenorrhea lasting about 2.49 days per cycle. Before the intervention, there were no notable differences in quality of life. Four weeks postintervention, both groups showed significant improvements in various health-related quality of life) physical functioning (P < 0.001), limitations in physical functioning due to health problems (P < 0.001), bodily pain (P < 0.001), general health (P < 0.001), vitality (P < 0.001), social functioning (P < 0.001), role limitations due to emotional problems (P < 0.001), mental health (P < 0.001), and overall quality of life (P < 0.001) and the pain intensity scores demonstrated a decreasing trend following the intervention (P < 0.001).

CONCLUSION:

Both methods improved quality of life and reduced dysmenorrhea, with a preference for virtual education, particularly during the COVID-19 pandemic, demonstrating meaningful clinical benefits that align with health policy benchmarks for patient-centered outcomes.

Introduction

Dysmenorrhea, affecting about 50% of menstruating women, is characterized by menstrual pain without pelvic pathology.[1] Its prevalence varies globally, from 60% in Canada, 64% in Mexico, 70.2% in India, 78.8% in Turkey, 80% in Australia to 89.1% in Iran.[2,3]

This condition significantly affects quality of life, productivity, and healthcare use, causing daily activity limitations, lower academic performance, poor sleep, and mental health issues such as anxiety and depression.[4] Rising healthcare costs and reduced efficiency highlight its economic and social burden, with studies, such as in India, showing its negative effect on students’ quality of life.[5]

Health-related quality of life is generally accepted as a multidimensional assessment of how disease and treatment affect a patient’s sense of overall function and wellbeing.[6] Researches indicate a strong link between dysmenorrhea severity and lower quality of life, with more severity of symptoms leading to lower quality of life.[7,8] The effect of such disorders varies across cultures and societies.[9] Although primary dysmenorrhea is not life-threatening, it significantly disrupts women’s quality of life and social activities.[10]

Currently, a variety of pharmacological and nonpharmacological methods are employed to treat dysmenorrhea. Nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics such as acetaminophen, cyclooxygenase inhibitors, and oral contraceptives are the main pharmacological treatments for dysmenorrhea; however, a failure rate of 20% to 25% has been reported for these medications.[11] Long-term use of these medications may cause side effects such as depression, headaches, nausea, drowsiness, fatigue, and irritability, leading to dissatisfaction among young women suffering from primary dysmenorrhea and their families.[12]

With technological advancements, the need for nonpharmacological options for managing dysmenorrhea, especially for women experiencing side effects or preferring to avoid medication, has grown. In a study by Jose (2021), it was shown that selected relaxation therapies, namely Laura Mitchell, Jacobson, Benson, relaxation unnamed, yoga, aerobic exercise, and massage, significantly decreased PMS.[13]

Education is a key approach, using methods such as face-to-face teaching, electronic learning, group discussions, lectures, demonstrations, and simulations,[14] each with its own benefits and limitations, prompting ongoing evaluation of these educational strategies.[15]

Virtual education can overcome some of the barriers of traditional education, providing easy and flexible access to learning opportunities. This method, which better aligns with individual learning styles, also facilitates access to education for learners in remote areas, reduces travel costs and time wastage, and improves the exchange of information and skills. Numerous studies have been conducted regarding virtual education and its comparison with traditional methods. In some of these studies, the learning outcomes in both methods were found to be comparable, while in others, one electronic or traditional method outperformed the other.[16]

Using effective educational methods to reduce the intensity of menstrual pain forms the internal axis of self-care behaviors. Efforts to gain awareness regarding the causes of menstrual distress and effective methods for alleviating the intensity of menstrual pain, verbal or nonverbal expression of menstrual pain, seeking help from others to reduce menstrual pain, and controlling external factors that influence painful menstruation—such as creating a suitable environment for engaging in social activities during menstruation—constitute the external axis of self-care behaviors. Owing to the absence of a standardized educational approach in the treatment of dysmenorrhea and the varied responses individuals have to different treatment methods, various therapeutic approaches have been developed.[17,18]

In the study by Kabirian et al.,[18] evidence-based educational interventions were shown to play a significant role in promoting self-care behaviors. Additionally, changing adolescents’ behaviors towards self-care can reduce the severity of menstrual pain and contribute to the health improvement of girls suffering from dysmenorrhea. Pilus et al.[19] demonstrated in a study aimed at the impact of face-to-face and online education on the self-efficacy of breastfeeding women that face-to-face education was effective in enhancing self-efficacy. This finding can be interpreted as indicating that face-to-face education fosters greater interaction between the educator and the learner. It also highlights the practical inapplicability of certain types of education for patients, addressing issues and answering other patient queries as well as establishing effective communication and providing personalized education more clearly through this method.

In recent years, the use of various alternative methods has increased in many developing countries, with the utilization of nonpharmacological approaches in Iran varying between 35% and 79%. Owing to the failures of various therapeutic methods, economic challenges, deprivation of conventional treatments, inability to afford pharmacological methods, the low cost of nonpharmacological approaches, and easy access to these methods, educational methods have gained significant popularity among the people.[20]

Given the increasing interest among individuals in using nonpharmacological treatments,[21] along with the high prevalence and severity of dysmenorrhea among adolescents and young women and its significant impact on daily activities, as well as the numerous side effects and substantial economic and social burdens it creates,[22] there is an urgent need to focus on education and the proper use of low-risk and effective methods for preventing and treating dysmenorrhea, such as nonpharmacological approaches. In pursuit of improving the quality of education in the health domain, this research is designed to compare the effects of virtual education and In-Person education on pain reduction and quality of life among female students suffering from primary dysmenorrhea. The goal is to identify the most effective treatment method for managing and alleviating primary dysmenorrhea, thereby taking a significant and impactful step toward enhancing women’s health.

Novelty

Direct head-to-head comparison of virtual vs. in-person education for dysmenorrhea management among university students, using a quasi-experimental study, a standardized 1-hour intervention, and robust HRQoL and pain measures to assess short-term outcomes. Findings suggest virtual education yields at least equivalent QoL and pain improvements, with added pandemic-related accessibility benefits.

Materials and Methods

Study design and setting

This quasi-experimental study conducted in 2023, on university students residing in the dormitories of Jundishapur University of Medical Sciences in Ahvaz, Iran. The project number was RHPRC-0011.

Study participants and sampling

In this study, 112 students who had moderate to severe primary dysmenorrhea were selected.

The sample size was determined based on the results of the study by Pilus et al.,[19] considering a type I error rate of 0.05, effect size (d) of 0.21, and using the following formula while accounting for approximately 10% dropout (56 participants in each group), resulting in a total of 112 participants:

n = (z1 – 2 + z1 – β) 2 (s12 + s22) (x – x)

n = (1/96 + 1/28)² (6/06² + 3/5²) (3/2)² = 51

In the first step, students from the four active dormitories of Ahvaz Jundishapur University of Medical Sciences were selected under coronavirus conditions. To minimize contamination, two dormitories were designated for the Virtual Education group and two dormitories for the In-Person Education group.

Each participant was assigned a code based on the English alphabet, and their contact numbers were collected for easy access if needed. Participants with a pain score of 4 or higher over two consecutive menstrual cycles were included in the intervention phase. Within each dormitory, individuals who met the inclusion criteria were randomly assigned into two groups: Virtual education (56 participants) and In-Person education (56 participants).

The inclusion criteria were: Age between 18 and 30 years, Body Mass Index (BMI) ≤30, Regular menstruation every 21-35 days, Duration of bleeding between 3 and 10 days, Moderate to severe dysmenorrhea in the last two cycles assessed by a multidimensional verbal scale, where individuals rated their peak pain during the previous cycle at 4 or higher on the Visual Analog Scale (VAS), Reports of primary dysmenorrhea with characteristics such as the onset of pain hours before or simultaneously with the onset of bleeding, relief from menstrual pain within 72 hours after menstruation begins, and colicky or cramp-like pains in the lower abdomen, lower back, and groin.

The exclusion criteria included: Any significant gynecological illness or abdominal or pelvic surgery in the past six months, severe psychological stress (e.g., parental separation, death of a first-degree relative) in the past six months, Experiencing severe bleeding (using one pad per hour for at least six hours) or recurrent spotting between menstruations in the past six months, A medical history indicating epilepsy, gastrointestinal disorders, cardiovascular and kidney diseases, and other serious illnesses, use of other medications and nonparticipation in the educational program.

The researcher initially posted a notice encouraging students with primary dysmenorrhea to participate. Then, the researcher visited each dorm room, introduced herself, and explained the study’s purpose and procedures. Students willing to cooperate and meeting the inclusion criteria, along with a pain score of 4 or higher as measured by the Visual Analog Scale during two consecutive menstrual cycles, were enrolled in the study.

Data collection tool and technique

After obtaining written informed consent from eligible participants questionnaires were administered.

1. Demographic Questionnaire: This included data on age, education, occupation, age at menarche, age of dysmenorrhea onset, bleeding intervals, and menstrual cycle length, duration of menstruation, onset time of pain, pain duration, BMI, and medications used.

2. The McGill Pain Questionnaire: This questionnaire contains 20 items aimed at assessing individuals’ perception of pain from various dimensions, including “sensory pain perception”, “emotional pain perception”, “evaluative pain perception”, and “diverse types and forms of pain”. It allows patients to express their pain perception in sensory and emotional terms by selecting appropriate words, and it uses a Likert scale from 1 to 10, where 1 indicates no pain and 10 represents very severe pain. For intermediate states, scores are marked between 1 and 10.[23] In the study by Durkin (2009), the content validity of this questionnaire was reported at 80%. Its reliability was calculated using Cronbach’s alpha, yielding coefficients between 83% and 87% for all dimensions.[24]

3. Visual Analog Scale (VAS): This scale consists of a 10-centimeter ruler, where participants mark the intensity of their pain on the first three days of menstruation—representing the highest pain the level of pain experienced on those days.

4. SF-36 Questionnaire: The quality-of-life questionnaire consists of 36 items that evaluate eight different health domains: general health (5 items), physical functioning (10 items), role playing limitations due to physical problems (4 items), role playing limitations due to emotional problems (3 items), bodily pains (2 items), social functioning (2 items), vitality (4 items), and mental health (5 items). The scoring system employs a Likert-type scale. Based on the scores, quality of life is categorized into three levels: poor (score ≤50), moderate (scores 51-75), and good (score ≥76). In the study by Montazeri et al.,[24] the content (79%), face (74%), and construct validity (78%) of this questionnaire were found to be suitable for evaluation purposes.[25]

Randomization

Students who were qualified and gave their consent were randomly allocated to one of two groups: in-person and virtual educational groups. We used block randomization with a block size of 4 and a 1:1 allocation ratio. Every student was given a code for allocation concealment, which was stored in an invisible sealed envelope by the dormitory supervisor until the start of the intervention.

Intervention

In this study, both in-person and virtual educational interventions were conducted once, at a specific time, just before the start of the first menstrual cycle for both groups. It is worth mentioning that the in-person training class was held in a 60-minute session in groups of 9-12 people in the dormitory prayer room, covering topics such as menstrual physiology, nutritional modifications, nonpharmacological treatments, and suitable exercises to alleviate menstrual pain. To maintain social distancing and prevent COVID-19 transmission, small groups of 9 to 12 were formed in dormitory prayer room.

For the virtual group, the content of the educational program was similar to that of the in-person training group and was delivered via what’s App in the form of audio messages, instructional videos, and photographs over two sessions. Throughout the study, the researcher provided her contact number to participants for any questions or issues that might arise, encouraging them to reach out if needed. A theoretical framework was incorporated into the conceptual Figure 1. All participants in both groups proceeded with the study [Figure 2]. In this study, blinding the researcher and participants was not possible.

Figure 1.

Theoretical framework in a conceptual figure

Figure 2.

The CONSORT flow chart of intervention

At the end of the study, the collected data were entered into the SPSS software, version 24.

Ethical consideration

Ethical committee of Ahvaz Jundishapur University of Medical Sciences, approved the study protocol with ethical code: IR.AJUMS.REC.1400.168. All the participants provided informed and written consent. All necessary methods were conducted under the guidelines of the institution and declaration of Helsinki.

Statistical analysis method

SPSS Inc. USA, Chicago, Illinois, version 24 was used to enter all of the data. Demographic characteristics of the samples were reported for quantitative variables as means, standard deviations, minima, maxima, and frequency distributions, while qualitative variables were reported as percentages. The normality of the quantitative variables was assessed using the Shapiro-Wilk test. Paired and independent samples t-tests were employed to examine differences in mean quality-of-life scores when the variables were normally distributed; if normality was violated, nonparametric tests based on repeated measures were used and the level of significance was set as P < 0.05.

Results

In this study, 112 female students residing in the dormitories of Jundishapur University of Medical Sciences in Ahvaz, who experienced moderate to severe primary dysmenorrhea, were examined. The mean age of the participants was 25.93 ± 2.00 years, and all participants were unmarried. The individual characteristics and health status of the participants are presented in Table 1.

Table 1.

Socio-demographic information in the Virtual and In-person education groups

Characteristics		In-person educational group (n=56)		Virtual educational group (n=56)		P-value
		Mean±SD/N (%)
Age (years)		25.89±2.04		25.98±1.92		0.812
Body mass index		24.95±2.13		25.13±1.43		0.600
Education						0.953
Undergraduate		5 (8.9)		5 (8.9)
Master		42 (75)
Medical doctor		6 (10.7)		5 (8.9)
Phd		3 (5.4)		2 (3.6)
Father’s education						0.448
Primary school		2 (3.6)		1 (1.8)
High school		37 (39.5)		32 (57.1)
University		17 (39.5)		23 (41.1)
Mother’s education						0.158
Primary school		17 (30.4)		13 (23.2)
High school		30 (53.6)		39 (69.6)
University		9 (16.19)		4 (7.1)
Doing exercise						0.651
Yes		42 (75)		45 (80.4)
No		14 (25)		11 (19.6)
Yes (once or twice)		17 (44.7)		26 (68.4)

The two groups did not differ significantly in key baseline variables, including educational level, parental education, and exercise habits.

The independent t-test revealed significant differences in quality of life and its dimensions (physical functioning, physical role playing, emotional role playing, vitality, mental health, social functioning, general health) between the two groups after the educational program, in such a way that no statistically significant difference was found in the quality of life and its dimensions before the educational intervention; however, after the educational intervention, a significant relationship was found between the virtual and In-Person groups (P < 0.001) [Table 2].

Table 2.

The mean quality of life in the In-person and Virtual Educational groups before and after the intervention

Characteristics		In-person group n=56		Virtual group n=56		P-value*		P (covariance)		Effect size
		Mean±SD
Physical functioning
Before training		26.25±11.21		21.51±14.58		>0.057		>0.001		0.790
After training		52.85±9.18		75.72±4.97		<0.001
P-value**		<0.001		<0.001
Physical role playing
Before training		14.12±4.01		25.19±7.58		0.357		0.070		0.030
After training		89.28±21.24		95.90±14.14		0.056
P-value		<0.001		<0.001
Emotional role
Before training		13.74±3.57		24.38±7.14		0.342		<0.001		0.105
After training		87.50±2.71		98.27±7.33		<0.001
P-value		<0.001		<0.001
Vitality
Before training		21.96±2.64		23.48±4.56		0.033		<0.001		0.636
After training		64.55±10.50		89.10±7.45		<0.001
P-value		<0.001		<0.001
Mental health
Before training		23.14±2.82		23.35±4.62		0.768		<0.001		0.656
After training		65.89±10.28		90.85±7.80		<0.001
P-value		<0.001		<0.001
Social functioning
Before training		32.81±8.44		35.49±7.45		0.078		<0.001		0.403
After training		60.04±12.48		82.63±14.49		<0.001
P-value		<0.001		<0.001
Pain reduction
Before training		20.13±10.74		20.93±10.99		0.696		<0.001		0.522
After training		57.84±12.37		84.77±13.57		<0.001
P-value		<0.001		<0.001
General health
Before training		40.80±4.24		40.98±5.17		0.842		<0.001		0.498
After training		69.29±8.64		86.17±9.17		<0.001
P-value		<0.001		<0.001
Quality of life (total)
Before training		21.58±4.25		22.56±8.66		0.451		<0.001		0.670
After training		68.40±7.88		88.02±5.80		<0.001
P-value		<0.001		<0.001

*Independent test, **paired t test

Results from the independent t-test showed no statistically significant differences in the mean pain scores and their dimensions between the virtual and In-Person training groups before the intervention; however, significant differences were observed in the mean overall pain scores and their dimensions after the intervention in both groups (P < 0.001) [Table 3].

Table 3.

The mean of pain before and after intervention in the virtual and In-Person training groups

Characteristics		In-person group n=56		Virtual group n=56		P-value*		P (covariance)		Effect size
		Mean±SD
Pain score (total)
Before training		3.65±0.09		3.65±0.09		0.99*		<0.001		0.95
After training		2.08±0.13		1.18±0.11		<0.001*
P-value**		<0.001		<0.001
Sensory pain perception
Before training		3.98±0.10		3.98±0.12		0.451*		<0.001		0.88
After training		2.11±0.14		1.22±0.17		<0.001*
P-value**		<0.001		<0.001
Emotional pain perception
Before training		2.70±0.10		2.72±0.14		0.184*		<0.001		0.84
After training		1.90±0.25		1.04±0.08		<0.001*
P-value**		<0.001		<0.001
Pain evaluation perception
Before training		4.05±0.22		4.01±0.13		0.313*		<0.001		0.46
After training		3.12±1.01		1.53±0.65		<0.001*
P-value**		<0.001				<0.001
Diverse and various pains
Before training		3.83±0.23		3.92±0.13		0.017*		<0.001		0.77
After training		1.98±0.26		1.14±0.16		<0.001*
P-value**		<0.001		<0.001

*Independent test, **Paired t test

Discussion

One of the causes of psychological stress in girls is dysmenorrhea-related disorders, which can be seen as a problem leading to significant socio-economic and psychological losses. The results obtained from this study indicate that before the educational intervention, there was no statistically significant difference in quality of life and its dimensions; however, after the educational intervention, a significant relationship was found between the two groups, with better quality of life reported in the virtual training group. PMS impact on women’s quality of life, including social, occupational, and psychological aspects.[26]

Furthermore, a study by Kannan et al.,[27] in 2015, found that although there was no significant difference in the overall quality of life score and its dimensions—including physical functioning, physical health, emotional health, social functioning, and pain—before the educational intervention, two months after the educational program, the average scores in the intervention group were significantly higher than in the control group. This indicates that educational interventions have a positive effect on the quality of life and its dimensions in women, which is consistent with the findings of the present study.

Mohamadi et al.[28] compared two methods—motivational interviewing and peer-led education—on puberty health among female high school students. They found that puberty health education increases students’ self-efficacy; that accurate information should be conveyed by peers and through motivational interviewing; and that motivational interviewing is more effective.

In the study by Kücükkelepce et al.[29] in 2021, face-to-face education based on the health belief model increased awareness, altered the structures of the health belief model, and enhanced the adoption of preventive behaviors against premenstrual syndrome (PMS). This indicates the effectiveness of the educational content in promoting preventive behaviors among girls. Additionally, research has shown that dysmenorrhea affects all dimensions of women’s quality of life, and increasing awareness can improve their quality of life.[6]

In other words, considering that menstruation is a biological, psychological, and social process, girls need to understand how this event occurs. Therefore, emotional and social support, along with the necessary health education, are crucial principles for enhancing their quality of life.[30] In the study by Parsa et al.,[31] which examined the impact of education on the quality of life of menopausal women, the educational intervention did not affect the psychological dimension of their quality of life. In this study, 36 women participated and were randomly assigned to test and control groups. The test group received face-to-face education, while the control group received educational content in the form of a video, and they were monitored two months later. The differences in obtained results and their inconsistency with the findings of the present study can be attributed to the nature of the participants’ issues and the content of the educational intervention.

Another result obtained was the comparison of pain intensity and its dimensions between the two groups. The results showed that before the educational intervention, the average pain intensity was high in both the In-Person and virtual groups, but after the intervention, pain intensity decreased, and a significant relationship was found between the two groups postintervention. According to studies conducted in various countries, severe pain has been reported in the range of 3.6% to 42%.[32] Differences in reported pain intensity may relate to cultural differences in pain perception and tolerance.

Most studies indicate that many women are affected by this issue, which a primary factor is causing disruptions in the quality of life and activities of young women. The highest prevalence of Dysmenorrhea was 68.8% in Mashhad and Sabzevar city[33] and was 83.6% in Tehran city.[34] These results indicate that educating girls in this area increases their awareness and leads to effective outcomes.

Armour et al.[35] demonstrated in their study that increasing awareness among girls regarding dysmenorrhea leads to an improvement in their quality of life. Education helps to inhibit the transmission of pain signals to the brain, resulting in reduced pain perception. Teaching relaxation techniques, introducing self-generated thoughts and cognitive restructuring, planning enjoyable activities, and providing time management training facilitate adequate participation and balance between work, leisure, rest, and social activities. According to the gate control theory of pain, this approach effectively decreases pain intensity.

Since dysmenorrhea encompasses a wide range of symptoms, the most effective strategy for preventing and managing these symptoms involves implementing educational interventions and offering various recommendations in both physical and psychological dimensions. These aspects were carefully incorporated into this research.[36]

These results indicate that, although both educational methods led to improvements in quality of life and reduced dysmenorrhea, virtual education was more favorably received during the COVID-19 pandemic. This preference may be attributed to the flexibility, accessibility, and reduced risk of infection associated with virtual platforms. Such advantages position virtual education as a more practical and patient-centered approach, particularly in situations where face-to-face interaction is limited, and align well with current health policy goals focused on individualized care and accessibility.

Strengths and limitations

This study found notable improvements in quality of life and pain reduction in both educational approaches, with a clear preference for virtual education during the pandemic—suggesting its potential for shaping future educational and health policies.

However, limitations include the inability to control for participants’ psychological states during data collection, lack of long-term follow-up due to time constraints, and the limited generalizability as the sample included only female university students. Moreover, blinding of participants and researchers was not possible, which may have introduced bias.

Conclusion

The results of this study indicated that although educational interventions delivered through both in-person and virtual methods increased awareness among girls and reduced the physical and psychological symptoms as well as pain intensity in participants, virtual education has been more effective in improving quality of life and reducing dysmenorrhea, especially during the COVID-19 pandemic. Therefore, depending on individual circumstances, one of the two aforementioned educational methods can be used.

Implications for practice

Virtual and In-Person Education enhanced quality of life and reduced dysmenorrhea, with a preference for virtual education, especially during the COVID-19 pandemic. Then, depending on the circumstances, either educational methods can be used.

Declaration of consent to participate

All the participants provided informed and written consent. All necessary methods were conducted under the guidelines of the institution and declaration of Helsinki.

AI policy statement

The authors acknowledge using an artificial intelligence tool, including Qwen (Tongyi Lab, Perplexity), to assist with language improvement. All scientific decisions, interpretations, and conclusions were made solely by the human author.

Abbreviations

QoL: Quality of Life; SF-36 instrument: Short form 36 QoL instrument; VAS: Visual Analog Scale; MPQ: McGill Pain Questionnaire; SPSS: Statistical Package for the Social Sciences; QoL: total Overall Quality of Life.

Ethical approval

Ethical committee of Ahvaz Jundishapur University of Medical Sciences, approved the study protocol with ethical code: IR.AJUMS.REC.1400.168.

Author’s contributions

NMA was involved in data acquisition, wrote the main manuscript. SA involved in designing of study, MHH involved in analyzing data. ZA was involved in designing the study, interpreting the data and writing the manuscript. All authors reviewed and approved the manuscript.

Data availability statement

All data that are generated during this study are included in this article. The data that support the findings of this study are available on request from the corresponding author, upon reasonable request.

Conflicts of interest

The authors declare no competing interests.

Funding Statement

This study was funded by Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.