The impact of attachment styles and self-compassion on medication adherence in breast cancer patients: A cross-sectional study

Abstract

Medication adherence is crucial for positive health outcomes in breast cancer patients. Psychological factors, such as attachment styles, may is associated with adherence behaviors. This study examined whether self-compassion mediates the relationship between attachment styles and medication adherence in female breast cancer patients. A descriptive, cross-sectional study was conducted with 197 women recruited via convenience sampling who completed self-report measures of medication adherence, attachment styles, and self-compassion. Results indicated that self-compassion mediated the relationship between both attachment anxiety (indirect effect = 0.41; CI = 0.24 to 0.58) and attachment avoidance (indirect effect = 0.32; CI = 0.12 to 0.54) with medication adherence. However, self-compassion played a stronger mediating role in the relationship with attachment anxiety. These findings suggest that enhancing self-compassion may support medication adherence among breast cancer patients with insecure attachment styles.

Introduction

Breast cancer continues to be the second most common cancer worldwide and the second most common cause of cancer-related mortality for women (Sedeta et al., 2023), posing a complicated physical and psychological burden (Fortin et al., 2021; Tang et al., 2024). The worldwide occurrence of female breast cancer is projected to be approximately 2.3 million new cases, continuing the upward trend seen in recent years (Kim et al., 2025). The latest age-standardized incidence rate (ASIR) for breast cancer in Iran is 35.8 per 100,000 women, with projections suggesting this could rise to over 70 per 100,000 by 2030 (Dolatkhah et al., 2023).

Treatment adherence (also known as adherence to medication) refers to the extent to which a person’s behavior follows medical advice and, in particular, taking prescribed medication in the manner prescribed (Chakrabarti, 2014; Mir, 2023). For oral endocrine treatments like tamoxifen and aromatase inhibitors to be effective, adherence is especially crucial (Bright et al., 2023; Koni et al., 2023). Non-adherence is still common, though; studies show that 41% of early breast cancer patients show nonadherence at least once, and 17% of patients are nonpersistent (Rinder et al., 2024). Moreover, despite the growing medical framework for treating breast cancer, a large percentage of patients experience difficulty with adherence to their prescribed treatment, which research supports psychological well-being (Lin et al., 2017). Adherence problems are more frequently caused by psychological predispositions related to coping, illness attitudes, and distress than by practical problems or side effects (Lerman and Schwartz, 1993; Pezzolato et al., 2023).

Among these psychological influences, how individuals relate to significant others throughout life has profound implications for their interactions with medical professionals and medication adherence (Brown and Newton-John, 2022; Dimatteo, 2004). Research indicates that there is a strong correlation between medication adherence and the quality of patient-provider interactions (Ciechanowski et al., 2001; Omar et al., 2022; Sherbourne et al., 1992). Internal working models of attachment, which are shaped by early caregiver experiences, impact these interactions by dictating trust and emotional control (Brandão et al., 2020; White et al., 2020). Bowlby (1982) first put forward attachment theory, which explains how early relations with caregivers influence people’s expectations of relationships and patterns of regulating emotions (Gross, 2013; Obegi and Berant, 2010). These attachments, considered avoidant, anxious, or secure, are essential for stress management, social support seeking, and healthcare-related actions (Karbowa-Płowens, 2023; Pietromonaco and Beck, 2019). Better medication adherence may result from secure attachment, which is typically linked to less overall distress, adaptive coping, and increased trust in medical professionals (Holwerda et al., 2013; Klest and Philippon, 2016; I. N. Nasika et al., 2023). Conversely, insecure-dismissing attachment style is linked to poorer medication adherence (Hooper et al., 2016). Whereas attachment anxiety might lead to high engagement but lower completion due to overwhelming distress, attachment avoidance is characterized by emotional suppression and resistance to support, both hindering adherence (Adams et al., 2018).

Managing the emotional toll of illness is greatly influenced by an individual’s capacity to respond to their suffering with compassion rather than harsh self-judgment, which goes beyond interpersonal patterns. A critical psychological resource for nurturing resilience for people living with health hardships is self-compassion, which is founded on mindfulness and self-kindness (Austin et al., 2023). Self-compassion consists of treating oneself with kindness and understanding in painful situations while decreasing self-judgment and emotional suffering (Marsh et al., 2017; K. Neff, 2003; Neff, 2022). It activates the soothing system (Gilbert, 2014), down-regulating the threat response and reducing negative emotions (Inwood and Ferrari, 2018). Developmental research links self-compassion to early attachment (Neff, 2023); Secure attachment styles are positively correlated with higher self-compassion (I.-N. Nasika, C. Wiart et al., 2023; Rezagholiyan et al., 2025), and self-compassion mediates the link between insecure attachment styles and emotional distress (Joeng et al., 2017). It reduces anxiety and depression in breast cancer survivors by reducing worry and rumination, potentially benefiting prevention and treatment (Brown et al., 2019). Evidence suggests that self-compassion could buffer against the detrimental effects of insecure attachment (Kim and Jo, 2022; Oh and Chang, 2024), promoting adaptive emotional regulation and engagement with health-promoting behaviors (F. Sirois et al., 2015). Self-compassion-focused interventions have effectively reduced cancer patients’ distress and enhanced their adherence to treatment (Grégoire et al., 2024; Sirois and Hirsch, 2018). As a result, there is growing evidence that self-compassion is a predictor of adherence (Gonzalez et al., 2015; Khalili et al., 2021; Laabidi et al., 2024). In the case of breast cancer, self-compassion may act as a mediational mechanism in which attachment style may affect adherence by allowing patients to cope with distress and adhere to treatment plans.

Although research on attachment and self-compassion is becoming increasingly prominent, there are a limited number of studies that have examined the interaction of both attachment and self-compassion on adherence in breast cancer patients. In order to fill this gap in the literature, the current study will investigate whether self-compassion acts as a mediator between medication adherence and attachment styles in female breast cancer patients. Specifically, we hypothesize that (1) insecure attachment styles (anxious and avoidant) will be negatively associated with medication adherence, (2) self-compassion will be positively associated with adherence, and (3) self-compassion will mediate the relationship between insecure attachment and adherence. By clarifying these relationships, this study seeks to contribute to developing psychological interventions that enhance adherence and improve health outcomes in breast cancer patients.

Method

Participants

The final sample consisted of 197 female patients diagnosed with breast cancer. The inclusion criteria were: (a) diagnosis of stage I to III breast cancer, (b) currently undergoing pharmacological treatment, (c) ability to provide informed consent, and (d) willingness to complete self-report questionnaires. Based on an a priori power analysis using MedPower (Kenny, 2017) with an alpha level of 0.05 and a power of 0.80, a minimum sample of 190 participants was required to detect small-to-medium mediation effects. Participants were recruited through a convenience sampling approach, which is commonly employed in clinical and disaster-related research when the target population cannot be fully identified or accessed. While this method limits the generalizability of the findings, it represents a practical and often the only feasible strategy under such conditions (Stratton, 2021).

Procedure

This descriptive, cross-sectional research study was conducted in healthcare facilities in Tehran and Mashhad, Iran, from January 20 to May 20, 2025. Eligible participants were approached during their medical appointments and provided with detailed information about the study. Informed consent was obtained through both verbal and written means. To ensure data quality, a screening process was implemented to verify that participants met the inclusion criteria and were capable of completing the questionnaires. Additionally, the questionnaires were reviewed for completeness and accuracy upon submission. Data were collected via self-administered questionnaires, which participants filled out in a private and tranquil environment within the hospital. The study adhered to the ethical standards of the 1964 Declaration of Helsinki and received ethical approval (IR.SBMU.MSP.REC.1403.189) from the Research Vice-Chancellor of Shahid Beheshti University of Medical Sciences.

Measures

Medication adherence was measured using the translated and validated Persian version (see Dehghan et al. (2015)) eight-item Morisky Medication Adherence Scale (MMAS-8). This scale has demonstrated strong reliability, with a reported Cronbach’s alpha of 0.83 in patients with hypertension, and it has shown a significant correlation with blood pressure control. Although the MMAS-8 was originally developed for hypertensive patients, its application has been widely extended to oncology settings. Specifically, previous research has demonstrated its validity and reliability for assessing adherence in breast cancer patients undergoing long-term oral hormonal therapy (e.g., Aromatase Inhibitors), as the daily self-administration nature of these regimens’ mirrors that of chronic conditions like hypertension (Brier et al., 2015). A commonly used cut-off score of 6 provides a sensitivity of 93% and specificity of 53% for distinguishing between low and higher levels of adherence. The MMAS-8 has also exhibited excellent concurrent and predictive validity, making it a valuable screening tool across various outpatient populations—scores on the MMAS-8 range from 0 to 8, with higher scores showing worse adherence. Cronbach’s alpha in our study was 0.79.

Attachment Style was measured using the translated and validated Persian version (see Asgarizadeh et al. (2000)) The Revised Adult Attachment Scale (RAAS) was developed by Collins and Reid in 1990 and revised in 1996. This scale includes 18 items, rated on a five-point Likert scale, and is divided into three subscales: Dependence, Closeness, and Anxiety. Based on participants’ responses, participants will classify individuals as either secure, anxious, or avoidant. Specifically, items 1, 6, 8, 12, 13, and 17 measure secure attachment; items 2, 5, 7, 14, 16, and 18 measure avoidant attachment; and items 3, 4, 9, 10, 11, and 15 measure anxious-ambivalent attachment. Items marked with an asterisk are reverse-scored. The subscale scores emerged from summing the six items related to each attachment style. In our study, Cronbach’s alpha was as follows: 0.83 for the anxiety subscale, 0.76 for the avoidance subscale, and 0.81 for the total score.

Self-compassion was measured using the translated and validated Persian version (see Khanjani et al. (2016)) 12-item Self-Compassion Scale–Short Form (Raes et al., 2011). This scale includes items such as “I try to be understanding and patient toward those aspects of my personality I do not like,” which are rated on a 5-point Likert scale ranging from 1 (almost never) to 5 (almost always). The short form of the scale has shown a nearly perfect correlation with the original 26-item Self-Compassion Scale developed by K. D. Neff (2003) and has demonstrated good internal consistency in diverse populations, including Dutch and American undergraduates and middle-aged adults. The SCS-SF has also shown strong criterion-related validity by predicting reductions in depressive symptoms over 5 months (Raes et al., 2011). After reverse-scoring relevant items, a total mean score was calculated, with higher scores showing higher levels of self-compassion. Cronbach’s alpha in our study was 0.80.

Statistical analyses

This study conducted preliminary data screening to examine missing values and data quality. All 197 responses were initially retained, as no participant had more than 10% missing data on any scale. However, preliminary data screening using boxplots and the interquartile range (IQR) method identified one univariate outlier for the attachment avoidance variable. Consequently, this specific case was excluded from all analyses involving attachment avoidance. Missing item-level data was minimal and appeared random, so it was imputed using person-mean substitution, which involves replacing missing responses with the individual’s mean score for the corresponding scale. This method, commonly used for handling item-level missing data in self-report questionnaires (Baraldi and Enders, 2010), was deemed appropriate due to the low level of missingness. Before testing the primary hypothesis, descriptive statistics and bivariate Pearson correlations were calculated to explore the relationships among attachment anxiety, attachment avoidance, self-compassion, and medication adherence.

To test the central hypothesis—whether self-compassion mediates the relationship between attachment insecurity and medication adherence—simple mediation models were constructed using the PROCESS macro for SPSS (Hayes, 2022). Two separate mediation analyses were performed: one with attachment anxiety as the independent variable and the other with attachment avoidance, with self-compassion as the mediator and medication adherence as the outcome variable in both models. A regression-based approach with 10,000 bias-corrected bootstrap samples was used to estimate the confidence intervals for the indirect effects. Mediation was considered statistically significant if the 95% bootstrap confidence interval for the indirect effect did not include zero (Preacher and Hayes, 2008). This methodology provided a robust estimation of the mediation pathways, even under conditions of potential non-normality and moderate sample size.

Results

The present study was conducted on 197 cancer patients. A total of 197 patients were female. Table 1 presents their demographic characteristics.

Table 1.

Demographic characteristics of sample (n = 197 breast cancer patient).

Characteristics	n (%), M (SD)
Age (y)	48.28 (9.09)
Missing	5
Marriage status
Single	32 (16.2%)
Married	165 (83.8%)
Cancer stage
Stage I	39 (19.8%)
Stage II	73 (37.1%)
Stage III	68 (34.5%)
Missing	17 (8.6%)

The mean age of the patients was 48.28 years (9.09), with the majority being married (83.8%). Regarding the disease severity, Stage II was the most prevalent (37.1%), followed by Stage III (34.5%) and Stage I (19.8%). Table 2 presents the descriptive statistics, including means, standard deviations, skewness, and kurtosis, for the study variables.

Table 2.

Descriptive statistics for study measures (n = 196 ^a ).

Measure	Mean	Standard deviation	Skewness	Kurtosis
1 Attachment anxiety	2.69	0.93	0.06	−0.56
2 Attachment avoidance	2.66	0.53	−0.10	−0.26
3 Self-compassion	3.16	0.49	−0.19	−0.10
4 Medication adherence	0.27	0.20	0.74	−0.04

^aExcludes one univariate outlier for attachment avoidance identified using the interquartile range (IQR).

Participants reported a mean score of 2.69 (SD = 0.93) for attachment anxiety and 2.66 (SD = 0.53) for attachment avoidance, while the mean for self-compassion was 3.16 (SD = 0.49). The mean score for medication adherence was 0.27 (SD = 0.20). Additionally, the skewness and kurtosis values generally fell within acceptable ranges, indicating that the data distribution was approximately normal for most measures. Table 3 presents the Pearson correlation coefficients among the study variables.

Table 3.

Pearson’s correlations for study measures (n = 196).

Measure	1	2	3	4
1 Attachment anxiety	-	0.47**	−0.53**	0.26**
2 Attachment avoidance	​	-	−0.24**	0.21**
3 Self-compassion	​	​	-	−0.46**
4 Medication adherence	​	​	​	-

Note. Significance levels: *p < .05; **p < .01.

Correlational analyses revealed that both dimensions of insecure attachment were negatively associated with self-compassion. Specifically, attachment anxiety demonstrated a strong inverse relationship with self-compassion (r = −0.53), while attachment avoidance showed a significant, though weaker, negative correlation (r = −0.24). Regarding health behaviors, both attachment anxiety (r = 0.26) and attachment avoidance (r = 0.21) were positively correlated with the medication adherence score, indicating that higher attachment insecurity is linked to poorer adherence. In contrast, self-compassion displayed a significant negative association with the medication adherence score (r = −0.46), suggesting that higher levels of self-compassion are related to better adherence outcomes. According to Cohen (1988), the correlation between attachment anxiety and self-compassion reached a “large” effect size, while the associations involving attachment avoidance and other variables were in the “small to medium” range. Descriptive statistics and correlation coefficients are reported in Tables 2 and 3

As illustrated in Figure 1, the mediation model was fitted using the PROCESS macro version 4.2 (Hayes, 2022) for IBM SPSS Statistics 27 (IBM Corp, 2020). There was a significant indirect effect of attachment anxiety on medication adherence through self-compassion, b̂ = 0.05, 95% BCa CI [0.03, 0.07]. This effect was medium, β = 0.24. The overall model explained 20% of the variance in medication adherence. A separate analysis was conducted to examine the influence of demographic covariates (age, marital status, and cancer stage) on the mediation model. It should be noted that due to missing values in demographic variables, the sample size for this analysis was reduced to 175 (compared to 197 in the unadjusted model). Even after controlling for these factors, the indirect effect of attachment anxiety on medication adherence through self-compassion remained significant, b̂ = 0.05, 95% BCa CI [0.02, 0.07]. Among the covariates, age was a significant negative predictor of self-compassion (b = −0.009), indicating that older participants reported lower levels of self-compassion. Additionally, cancer stage significantly predicted medication adherence (b = −0.04); given that lower scores denote better adherence, this suggests that patients in more advanced stages adhered better to their medication. Marital status had no significant effect on either variable (p > .05). Comparing this to the unadjusted model, the standardized effect size remained largely stable (β = 0.21 vs β = 0.24), demonstrating the robustness of the mediation effect regardless of demographic factors.

Figure 1.

Standardized parameter estimates of the mediation analyses for attachment anxiety and medication adherence. *p < 0.05; **p < 0.01; and ***p < 0.000.

Similarly, as illustrated in Figure 2, there was a significant indirect effect of attachment avoidance on medication adherence through self-compassion, b̂ = 0.04, 95% BCa CI [0.02, 0.07]. This effect was small, β = 0.10. The overall model explained 22% of the variance in medication adherence. These results confirm that self-compassion fully mediates the link between both forms of insecure attachment and medication adherence among breast cancer patients. A separate analysis was conducted to examine the influence of demographic covariates (age, marital status, and cancer stage) on the mediation model (N = 174). Even after controlling for these factors, the indirect effect of attachment avoidance on medication adherence through self-compassion remained significant, b̂ = 0.04, 95% BCa CI [0.01, 0.07]. Regarding the covariates, cancer stage significantly predicted medication adherence (b = −0.04); suggesting that patients in more advanced stages adhered better to their medication. However, unlike the attachment anxiety model, neither marital status nor age showed any significant association with self-compassion or medication adherence in this analysis (p > .05). Comparing this to the unadjusted model, the standardized effect size remained largely stable (β = 0.10 in both models), further confirming the robustness of the mediation effect.

Figure 2.

Standardized parameter estimates of the mediation analyses for attachment avoidance and medication adherence. *p < 0.05; **p < 0.01; and ***p < 0.000.

The findings indicated that self-compassion fully mediated the relationship between both attachment anxiety and attachment avoidance with medication adherence. These indirect effects remained statistically significant and robust even after controlling for demographic covariates, including age, marital status, and cancer stage.

Discussion

Overview of findings

The present study advances our understanding of the relationships among medication adherence, self-compassion, and attachment styles in female breast cancer patients. The amount of variance explained (R²) was .20 for the first model, which examined attachment anxiety as the predictor, and .22 for the second model, which focused on attachment avoidance—both with self-compassion as the mediating variable—indicating a meaningful contribution of these psychological factors to adherence outcomes. These results align with previous research suggesting that psychological variables play a significant role in adherence behaviors (Arlt et al., 2017; Celano et al., 2020; Chong et al., 2024).

Attachment insecurity and medication adherence

Both attachment anxiety and avoidance were negatively associated with self-compassion and adherence, supporting the theoretical perspective that insecure attachment can impair adaptive coping mechanisms (Daum et al., 2023; Mikulincer and Shaver, 2010; I.-N. Nasika, C. Wiart et al., 2023). Specifically, anxiously attached individuals, despite potentially engaging more frequently with healthcare providers, may experience emotional dysregulation that undermines consistent adherence. For instance, taking medication in public may heighten fears of rejection or abandonment, resulting in irregular adherence patterns (Blake Helms et al., 2017). This result is consistent with earlier research showing that attachment insecurity is associated with worse health outcomes because it leads to maladaptive coping mechanisms and more psychological distress (Keyvanloo et al., 2025; McWilliams and Bailey, 2010). Avoidantly attached individuals, on the other hand, tend to suppress negative emotions and downplay health threats (Shaver and Mikulincer, 2007), which may manifest as resistance to seeking or following medical advice (Chambers et al., 2025). This finding reinforces previous literature suggesting that Insecure attachment, including avoidant attachment style, is associated with lower engagement in self-care behaviors and reduced adherence to treatment recommendations (Maunder and Hunter, 2001).

The mediating role of self-compassion

The mediation analysis confirmed that self-compassion significantly bridges the relationship between attachment styles and adherence. In line with previous research that found self-compassion protects against stress and promotes health-promoting behaviors (F. M. Sirois et al., 2015; Terry and Leary, 2011), higher levels of self-compassion were associated with treatment adherence, indicating that self-kindness, mindfulness, and a non-judgmental view of personal suffering can facilitate adherence behaviors (Neff, 2011). From a clinical perspective, the aforementioned findings indicate that self-compassion enhance interventions could improve adherence rates among individuals with an insecure attachment system. Mindfulness-based self-compassion programs, which encourage self-kindness and attachment-related programs, would suggest that people may learn to have a more positive relationship with themselves and, therefore, will probably adhere to treatment plans more readily (Wasson et al., 2020).

Robustness across demographic and clinical covariates

A noteworthy strength of this study lies in the robustness of the findings across demographic and clinical profiles. Our separate analyses involving covariates demonstrated that the mediating role of self-compassion remains significant even after controlling for age, marital status, and cancer stage. Interestingly, patients in more advanced stages of cancer exhibited better medication adherence, consistent with the Health Belief Model, which suggests that greater perceived illness severity may prioritize adherence to manage the heightened health threat (DiMatteo et al., 2007). Conversely, marital status did not significantly predict adherence or self-compassion, indicating that the attachment–adherence pathway operates independently of partnership status. Furthermore, in the attachment anxiety model, older age was associated with lower self-compassion, highlighting a potential vulnerability that warrants targeted intervention during long-term survivorship.

Implications for clinical practice and policy

The findings of this study offer actionable insights for mental health practitioners, including psychotherapists and social workers operating within oncology settings. Given that self-compassion was identified as a full mediator, it serves as a crucial clinical target for improving medication adherence. First, practitioners should consider incorporating attachment style assessments into the initial intake process. Identifying patients with high attachment anxiety or avoidance can help screen for those at greater risk of non-adherence and psychological distress.

Second, for patients exhibiting insecure attachment patterns, interventions specifically designed to cultivate self-compassion—such as Mindful Self-Compassion (MSC) (Neff and Germer, 2013) or Compassion-Focused Therapy (CFT) (Gilbert, 2014)—are highly recommended. Psychotherapists can utilize these modalities to help patients develop “inner safety” and self-soothing techniques. By learning to treat themselves with kindness rather than self-judgment, patients can regulate the emotional distress associated with their illness without relying on maladaptive attachment strategies (Mikulincer and Shaver, 2016), thereby facilitating better adherence to treatment protocols. Finally, clinical social workers and nurse navigators can use these findings to tailor their support. For instance, when working with older patients or those in early stages of cancer (who showed lower self-compassion or adherence in our covariates analysis), practitioners might prioritize psycho-education that emphasizes self-care as a form of self-kindness, rather than merely focusing on medical compliance.

At the policy level, hospital administrators and policymakers should consider integrating routine psychological screening—particularly for attachment insecurity and self-compassion deficits—into standard oncology care protocols. Allocating resources toward training oncology staff in brief self-compassion interventions and establishing referral pathways to mental health specialists could meaningfully improve adherence rates and, ultimately, treatment outcomes at a systemic level.

Limitations and future directions

Even though these results offer valuable insights into the interplay between attachment styles, self-compassion, and medication adherence, they must be interpreted taking into account the limitations of the research design. First, we utilized a cross-sectional design. Although this approach is common in mediation studies, it restricts our ability to draw causal inferences. Longitudinal studies are needed to understand the temporal dynamics between attachment insecurity and health behaviors. Second, the reliance on convenience sampling limits the representativeness of our sample. Consequently, the findings may not be fully generalizable to the larger population of breast cancer patients with diverse backgrounds. Third, all data, including medication adherence, were collected based on self-report measures. Thus, the data may be susceptible to “recall bias” and “social desirability bias,” where patients might over-report their adherence. Future research would benefit from incorporating objective methods, such as pharmacy refill records or pill counts. Finally, while we controlled for certain demographic and clinical variables (e.g., age and cancer stage), the study did not account for other potential confounding factors that have a direct impact on adherence. Specifically, we did not control for medication side effects—often cited as a primary reason for non-adherence—nor did we assess social support, concomitant mental disorders (e.g., clinical depression or anxiety), socioeconomic factors (income level and education), or the specific type of drug treatment. Finally, given the vulnerability observed in older patients regarding self-compassion, future studies should explore age-specific interventions to bolster self-kindness and improve long-term treatment outcomes.

Conclusion

This study identified self-compassion as a central variable in the relationship between attachment insecurity and medication adherence among breast cancer patients. Indeed, insofar as self-compassion serves as a full mediator in the relationship between attachment anxiety and avoidance and medication adherence, interventions aimed at promoting treatment adherence should prioritize the development of self-compassion. The period following a breast cancer diagnosis is a critical time for establishing consistent self-care routines and psychological resilience; it is therefore important to better understand the different relationships between these variables to better support patients during this challenging journey. Importantly, these findings carry broader implications beyond the current clinical context: in any future health crisis that demands sustained medication adherence—such as pandemics or chronic disease outbreaks—addressing patients’ psychological needs, particularly attachment security and self-compassion, should be recognized as an integral component of effective treatment strategies. Policymakers and healthcare administrators are encouraged to incorporate psychological support frameworks into standard care pathways to enhance patient outcomes on a population level.

ORCID iDs

Aida Zouerami https://orcid.org/0009-0006-9272-1922

Amir Sam Kianimoghadam https://orcid.org/0000-0001-8686-523X

Ethical considerations

This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Shahid Beheshti University of Medical Sciences (Ethics Code: IR.SBMU.MSP.REC.1403.189) on June 6, 2024. All participants provided written and verbal informed consent prior to participation. The consent process included information about the study’s purpose, procedures, and the voluntary nature of participation. Participant confidentiality and anonymity were strictly maintained throughout the study. No identifiable personal data are included in this manuscript. The authors confirm that all research procedures complied with relevant ethical standards and institutional guidelines.

Consent to participate

All participants received detailed information about the study and provided both written and verbal informed consent prior to participation. The consent process was conducted in accordance with the ethical standards of the 1964 Declaration of Helsinki and was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (Code: IR.SBMU.MSP.REC.1403.189) on June 6, 2024. This research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki.

Consent for publication

All authors have given their consent for the publication of this manuscript. Additionally, where applicable, participants have provided consent for the publication of any data or images included in the manuscript.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request. Due to ethical restrictions related to participant confidentiality, the data are not publicly available.*