The Relationship Between Spirituality and Mental Health in HIV-Positive Patients: A Cross-Sectional Study

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The Relationship Between Spirituality and Mental Health in
HIV-Positive Patients: A Cross-Sectional Study
Introduction
Acquired Immunodeficiency Syndrome (AIDS) is a kind
of immune system disease which develops by human
immunodeficiency virus (HIV) (1). AIDS can impair the
body’s ability to fight infections and diseases and ultimately
can lead to death. Despite significant achievements in
combating AIDS, and thus reducing the new infection
and also mortality rates of AIDS-related illnesses, its
negative effects on society and the workplace is significant
(2,3). AIDS is a very profound human tragedy that has
been described as the unannounced deadliest war in the
world (4).
By the end of 2017, about 36.9 million people globally
were living with HIV, while 1.8 million of them were newly
infected ones. Nearly, 940 000 people worldwide died from
HIV-related illnesses in 2017 (5). The prevalence of HIV in
Iran is low among the general population (around 0.08%),
but its prevalence among injecting drug users is reported
to be 13.8%. However, since the beginning of 2001,
successful measures were taken to control the epidemic
among injecting drug users, which resulted in a decline
in its prevalence in this population group. However, the
main cause of the spread of epidemics in Iran is the use of
injectable drugs (6).
AIDS is mainly transmitted through unprotected sexual
intercourse, contaminated blood transfusion, infected
needle, and from mother to child during pregnancy,
childbirth, and breastfeeding (7). AIDS is one of the
chronic disorders that greatly affect physical and mental
health, and so results in mood and anxiety disorders
especially depression and substance dependency. Anxiety
and use of drugs are among the factors that reduce the
adherence of patients to antiretroviral treatments that act
as the key to HIV treatment success (8).
Mental health is a major aspect of public health.
According to the WHO definition, health or well-being
refers to the full physical, psychological and social
health and not just the absence of illness and inability.
Abstract
Objectives: AIDS is among chronic disorders that severely affects the individuals’ physical and mental health. Considering
the importance of spirituality in counteracting the stress arising from chronic diseases and accepting the disease, our study
aimed to determine the relationship between spirituality and mental health in HIV-positive patients who referred to the
Behavioral Disorders Center in Tabriz, Iran.
Materials and Methods: This descriptive analytic cross-sectional research was conducted on 81 HIV-positive patients
referred to behavioral disorders center of Tabriz, Iran in 2017 using the census method. The instruments used in this study
included socio-demographic characteristics questionnaire, Parsian and Dunning’s spirituality questionnaire, and General
Health Questionnaire-28 (GHQ-28) . Data analysis was carried out through independent t test, one-way ANOVA, Pearson
correlation coefficient, and multiple linear regressions.
Results: The mean (SD) of the overall mental health score was 36.0 (16.4) (range: 0-84). Two-thirds of the patients suffered
from mental health disorder; mean (SD) of overall spirituality score in people suffering from positive HIV was 89.0 (15.3)
(range: 29-116). The relationship between the total score of spirituality and overall mental health and its sub-domains was
significant (P < 0.05). Self-awareness was the only mental health predictor.
Conclusions: A considerable percentage of people with HIV suffer from mental health disorders. Regarding the positive
relationship between spirituality and all mental health sub-domains, strengthening spirituality can lead to the promotion
of mental health in these patients.
Keywords: HIV seropositivity, Mental health, Spirituality.
Mina Dianati1
ID
, Azizeh Farshbaf-Khalili2, Mojgan Mirghafourvand3, Parisa Yavarikia4*
ID
Open Access Original Article
Crescent Journal of Medical and Biological Sciences
Received 8 January 2018, Accepted 13 October 2018, Available online 11 November 2018
1Department of Midwifery, Student Research Committee, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz,
Iran. 2Aging Research Institute, Physical Medicine and Rehabilitation Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran.
3Social Determinants of Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. 4Department of Midwifery, Faculty of
Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran.
*Corresponding Author: Parisa Yavarikia, Tel: +989143106239, Fax: +98-41 34796969, Email: p_k_hn@yahoo.com
http://www.cjmb.org
eISSN 2148-9696
Vol. 6, No. 3, July 2019, 403–409

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Mental health moves beyond the absence of mental and
psychological diseases. Person’s feeling of self-control
over life is among the mental health components, in other
words, the flexibility through which mental resistance is
created against mental disorders in the adversities of life
(9).
The relationship between mental health and spirituality
has received attention by psychologists in recent years.
Based on the studies, spirituality has a significant impact
on somatic and psychic health. Spirituality is a personal
concept that includes an individual’s attitudes and his/
her belief in God (10). For many people, spiritual and
religious activities create peace in the patient in the face
of diseases (11,12). Now, the role of spirituality on human
health and disease is of great interest. WHO describes it
in four physical, mental, social and spiritual dimensions
(13,14). In the study by Vance et al, it has been shown
that in the elderly people with HIV, religious and spiritual
resources can be considered as a source to counteract the
regret, depression and anger caused by the complications
of the disease (15). The results of the studies showed that
the use of spiritual interventions in healthcare facilitates
the access to psychological well-being and coping with
the disease in the patients with HIV-positive (16,17). The
results of another study about the impacts of spiritual
beliefs on improving the health of 35 patients with chronic
diseases in Tehran, Iran, showed that spiritual beliefs not
only facilitate the adaptation of patients to the adverse
psychosocial effects of chronic diseases but also decrease
depression symptoms and increase their satisfaction with
their lives (18).
Regarding the negative psychological effects of chronic
diseases, in order to relieve the depression of these
patients and improve their psychic health, heightening life
satisfaction and increasing the power of coping with the
disease are of great importance. The importance of this
research is to link spirituality with the mental health in
patients with AIDS which is regarded as one of the most
common chronic diseases of the present century. Despite
the increasing prevalence of HIV among people in Iran,
there is a lack of adequate training and support for these
infected people. Considering the fact that being affected by
HIV is among the most significant crises in lifetime that is
involved in the occurrence of psychological problems such
as depression, and with regard to the role of spirituality
in dealing with the stress caused by chronic diseases
and admission of the disease, and on the other hand,
since based on searches conducted by the researcher, no
studies have been carried out on the association between
spirituality and mental health of these patients in Iran,
studying the association of spirituality and mental health
is necessary in HIV-positive subjects. Therefore, this study
aimed to evaluate the relationships between spirituality
and mental health in HIV positive subjects who referred
to the behavioral disorder center in Tabriz, Iran.
Materials and Methods
Study Design and Participants
The present study is a descriptive analytic cross-sectional
survey conducted through the census method on all HIV-
positive patients referred to behavioral disorders center of
Tabriz, Iran. East Azerbaijan Province has 19 behavioral
disorders counseling centers. The research center in this
study is the only referral center for behavioral disorders
in Tabriz. Therefore, the sampling was indispensable by
census method and the sample size was based on the
census during the study. The inclusion criteria were as
follows: being HIV-positive, having a medical record at the
behavioral disorders center, having a desire to participate
in the study, and believing in one of the official religions
of the country. Having a history of mental diseases as
reported by the participant was among the exclusion
criteria. The samples included 101 patients with a medical
record in the center. Twenty of them were not willing to
cooperate because of personal reasons, so the study was
conducted on 81 participants.
Sampling
After obtaining the ethical approval from the Ethics
Committee of Tabriz University of Medical Sciences, the
study was conducted in coordination with the officials of
the behavioral disorders center in Tabriz. The subjects were
first evaluated in terms of basic information, inclusion
and exclusion criteria, and once were qualified for the
research, they were provided with information about
the research. Information confidentiality was explained
to the subjects and then, they were invited to participate
and in case of willingness, an informed written consent
was obtained from each participant. Then, the socio-
demographic characteristics questionnaire, Parsian and
Dunning’s spirituality questionnaire (10), and the General
Health Questionnaire-28 (GHQ-28) (19) were completed.
In order to cooperate better, the participants in the study
did not write their names in the questionnaires, and the
coded questionnaires were completed by the participants
and after completion, they were put in a closed box.
Measures
The data collecting tool in this study was a questionnaire
consisting of 3 parts:
1. The socio-demographic characteristics questionnaire:
This questionnaire included questions about gender,
marital status, age, education level, and information
related to the disease.
2. Spirituality inventory developed by Parsian and
Dunning in 2009 assessed the significance of
spirituality in the lives of individuals and measured
their various dimensions. This scale is a self-report
inventory, and the subject must specify a degree
of disagreement or agreement with each of these
phrases on a 4-point Likert scale (ranging between “I
completely disagree = 1” and “I completely agree = 4”).

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The questionnaire has 29 phrases and consists of 4 sub-
scales of self-awareness (10 phrases), the importance
of spiritual beliefs (4 phrases), spiritual practices (6
phrases), and spiritual needs (9 phrases). Higher
scores indicate higher spirituality (20). Spirituality
questionnaire has undergone a psychometric test in
Iran, and Cronbach’s alpha coefficients of the whole
tool, self-awareness subscale, the importance of
moral beliefs, spiritual practices, and spiritual needs
were 0.90, 0.84, 0.90, 0.77 and 0.82, respectively (20).
3. General Health Questionnaire (GHQ-28): This
questionnaire is used in clinical trials to track people
with mental disorders. This questionnaire consists
of 28 items and can be used by all people. The
questionnaire has four sub-factors and each sub-scale
consists of 7 questions (19). The subject specifies his/
her response rate to each of those phrases on a 4-point
Likert scale (ranging between never = 0 and more
than usual = 3). The first sub-scale (GHQ-A) involves
somatic symptoms, including items concerning
individuals’ feelings about their health and their
tiredness. The second sub-scale (GHQ-B) includes
items concerning anxiety and insomnia, and the third
sub-scale (GHQ-C) shows social dysfunction and the
fourth sub-scale (GHQ-D) shows the level of severe
depression of individuals. People with a total score of
over 24 have mental health problems and the lower
the score, the higher the mental health. The range of
scores for the entire questionnaire is 0-84 and 0-21 for
each of the sub-scales. In addition, the cut-off point is
considered to be 24 for the entire questionnaire and
5 for each of the sub-scales (19). In Iran, the validity
of the GHQ-28 has been measured by Janbozorgi et al
on 223 students, and the Cronbach’s alpha coefficient
is calculated as 0.49 (21).
In this study, the validity of the tool was tested through
face and content validity for personal-social information
and the disease-related information. Likewise, the
questionnaires were given to 10 academic staff of Tabriz
University of Medical Sciences in relevant fields for
further study. After using their corrective comments, the
necessary modifications were made in the final forms.
In addition, by conducting pretrial and retrial on 10
participants in a two-week interval, the reliability was
obtained in two dimensions of repeatability (ICC = Intra-
class correlation coefficient) and internal consistency
(Cronbach α coefficient). The ICC (95% confidence
interval) and Cronbach α for spirituality were obtained
as 0.98 (0.96-0.99) and 0.83, respectively, and for mental
health, they were 0.97 (0.94-0.98) and 0.80, respectively.
Data Analysis
The questionnaires were completed and then the data
were analyzed using SPSS version 21.0. Descriptive and
analytical statistics were used for analyzing the findings.
We examined the normal distribution of quantitative
data using Kolmogorov-Smirnov test, indicating that all
data were normal. In order to describe spirituality and
mental health, descriptive statistics including frequency
distribution and percentage were used. In addition, central
and dispersion indicators such as mean and standard
deviation were used.
Bivariate statistical tests such as Pearson correlation
coefficient, independent t-test, and one-way ANOVA were
used to analyze the relationship between spirituality and
socio-demographic characteristics with mental health.
We estimated the effect of each independent variable
(spirituality and socio-demographic characteristics) on
the dependent variable (mental health). The independent
variables with P value <0.1 in the bivariate analysis were
entered into the multivariate linear regression model
through the backward strategy in order to control
confounders. Before multivariate analysis, the regression
assumptions such as normality of residuals, co-linearity,
outliers, and independence of residuals were examined.
Results
The results of socio-demographic characteristics
questionnaire showed that around half of the participants
(46.8%) were in the age group 31-40 years, and over
half of the subjects (69.1%) were male. About half of
them (46.9%) were married. More than one-third of the
participants (35%) had finished secondary school, and
about half of them (42.9%) were housekeepers, and more
than two-thirds (65.8%) of them reported insufficient
income. Less than half of the participants (40%) reported
being exposed to HIV due to needle injuries. Over half of
the participants (58.9%) reported using condoms in their
sexual relations. And about half (52.5%) had a history
of imprisonment. Based on the results of bivariate tests,
only the relationship between the variable of monthly
income adequacy and mental health score was significant
(Table 1).
The mean (standard deviation) of the overall score of
spirituality in HIV-positive subjects was 89.04 (15.33)
(range: 29-116). Among the dimensions related to
spirituality, the highest mean scores were related to sub-
domains of spiritual needs (79.70) and the importance of
spiritual beliefs (79.0), and the lowest mean scores were
related to sub-domains of self-awareness (74.57) and
spiritual practices (74.62) (Table 2).
The mean (SD) of the overall mental health score in
HIV-positive subjects was 36.0 (16.4) (range: 0-84) and
66.7% of them had mental health disorders. Among the
mental health dimensions, the highest mean score in the
sub-domain of social dysfunction was 11.8 (4.2), and
the lowest score in the severe depression dimension was
6.8 (6.58). Moreover, the mean scores in the dimension
of anxiety and insomnia and somatic symptoms were
8.6 (5.6) and 9.5 (5.3), respectively. Pearson’s correlation
coefficient showed a significant correlation between the
total score of spirituality and mental health (P<0.001).

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Moreover, there were significant correlations between
the total score of spirituality and all mental health sub-
domains (P < 0.05) (Table 3). According to the results of
a multivariate linear regression test, self-awareness was
alone the predictive variable of mental health in women,
which, in general, accounted for 44% of the variances
observed in the overall mental health score (Table 4).
Discussion
According to the findings, the mean of total score of
spirituality in HIV positive subjects was above average.
Among the dimensions concerning spirituality in HIV-
positive subjects, the highest score belonged to the
dimension of spiritual needs. The mean of overall mental
health score in HIV positive subjects was higher than the
cut-off point, and two-thirds of them had mental health
disorders. Meanwhile, the relationship between the overall
score of spirituality and overall mental health and all sub-
domains of it was significant. Self-awareness was the only
predictor of mental health.
In recent years, there has been extended research on
how religion and spirituality affect various aspects of
physical and mental health. Some studies have indicated
that spirituality has a significant relationship with the
overall health of people, so religion and spirituality are
the main resources for adapting to the stressful events
of life. In fact, spirituality on the one hand affects mood
and mental well-being and on the other hand improves
their physical conditions (22) and increases the ability of
the patient to cope with a disease and speeds up the rate
of recovery (23). Disabling and chronic diseases make
the individual face challenges regarding the sense of
meaning and purpose in life (24). The studies performed
by Johnson (25), Litwinczuk and Groh (26), and McNulty
et al (27) implied the relationship between spirituality and
physical and mental health, and also adaptation to the
disease which is consistent with the results of this study.
Patients with chronic diseases, including AIDS,
constantly live with uncertainty and hesitation, and this
can affect their lives in physical, social, spiritual, mental,
and economic dimensions (28). This uncertainty is
accompanied by increased mood disorders, decreased
quality of life, and reduced adaptability of affected ones.
Peterson et al pointed out in their study that the role of
hope and spirituality in patients with AIDS is vital (29).
The findings of the survey by Cotton et al in 2006 showed
that AIDS patients rely on their religious beliefs to adapt
to the disease, and those with more spiritual and religious
beliefs are more self-confident, more optimistic, and more
satisfied with their lives, and their alcohol consumption
is low (17) which are in accordance with the results of the
current study. The traditional definition of spirituality
emphasizes religion and religious beliefs, while in recent
years, spirituality has been defined more broadly and
integrates all aspects of human life (17).
The results of a study by Pirasteh Motlag and Nikmanesh
Table 1. Sociodemographic and Disease Characteristics and their Relationship
with the Total Score of Mental Health in HIV-positive Subjects (n = 81)
Sociodemographic
Characteristics No. (%) Mental Health
Mean (SD) P Value
Age 0.229a
17-30 10 (12.7) 39.71 (13.06)
31-40 37 (46.8) 34.18 (15.30)
41-50 21 (26.6) 33.22 (20.40)
More than 50 11 (13.9) 25.36 (9.66)
Gender 0.082b
Female 25 (30.9) 37.92 (15.41)
Male 56 (69.1) 31.17 (16.14)
Marital status 0.743 a
Single 21 (25.9) 34.14 (15.41)
Married 38 (46.9) 32.33 (17.22)
Divorced 10 (12.3) 35.11 (18.35)
Widow 12 (14.8) 33.06 (13.40)
Cause of infection 0.299 a
Blood transition 3 (3.8) 29 (13.52)
Having contact with needle 32 (40) 31.65 (14.12)
Sexual relationship 25 (31.3) 133.88 (17.02)
Don’t know 14 (17.5) 37.24 (19.63)
Other 6 (7.6) 31.66 (12.70)
Injection 0.727 b
Yes 37 (46.3) 33.93 (14.90)
No 43 (53.8) 32.65 (17.45)
Education level 0.631 c
Illiterate 9 (11.3) 35.68 (15.64)
Primary 20 (25) 32.73 (17.70)
Secondary 28 (35) 36.17 (15.44)
High school 6 (7.5) 23.77 (11.74)
Diploma 11 (13.8) 32 (20.71)
University 6 (7.5) 29.39 (9.87)
Occupation 0.207 a
Worker 13 (16.9) 34.06 (22.35)
Employee 2 (2.6) 26.35 (9.40)
House keeper 33 (42.9) 37.36 (15.38)
Private sector 29 (37.7) 61 (8.41)
Income 0.003c
Insufficient 52 (65.8) 39.81 (16.19)
Sufficient and somehow
sufficient 27 (34.2) 28.25 (14.74)
Use of condom 0.743 b
Yes 43 (58.9) 33.38 (16.66)
No 30 (41.1) 38.82 (16.37)
History of imprisonment 0.411**
Yes 42 (52.5) 40.16 (15.52)
No 38 (47.5) 32.20 (15.94)
Having the disease 0.009 b
Active 50 (73.5) 39.74 (15.36)
Inactive 18 (26.5) 28.40 (15.12)
a Chi square test; b Fisher exact test; c Linear by linear chi-square.

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in 2011 suggested a significant positive connection
between spirituality and quality of life. They concluded that
spirituality affects the quality of life of patients with AIDS
(20) which is consistent with our findings. Tsevat pointed
out in his study that spiritualism plays an important role
in improving the quality of life of patients with AIDS.
According to the findings of their study, patients with
AIDS turn to spiritualism after they are aware of their
disease to better cope with it (30), which is consistent
with our findings. In the study by Allahbakhshian et al,
the relationship between spiritual health and the quality
of life of multiple sclerosis patients was investigated.
The relationships between spiritual health in religious
dimension and the quality of life in mental dimension, as
well as between spiritual health in existential dimension
and the quality of life in both physical and mental domains
were significant (31).
Based on the existing arguments about the function of
religion, it seems that spiritualism and religious beliefs
have a positive relationship with health. Concerning the
impact of religion on health and explaining the mechanism
of this relationship, some authors mention that there is
an important link between religion and health. Social
support is one of the strongest predictors of psychological
well-being. Therefore, it seems logical that participating
in religious activities along with a crowd of the same
beliefs would be a source of satisfaction, being with other
people in a supporting and contributing religious context
Table 2. The Scores of Spirituality and its Sub-domains in HIV-Positive Individuals (n = 81)
Spirituality Mean SD Score Based on Percent Obtained Scores Obtainable Scores
Total score of spirituality 89.04 15.33 76.76 46.2-115.0 29-116
Self-awareness 29.83 6.40 74.57 12.0-40.0 10-40
Importance of spiritual beliefs 12.72 3.15 79.0 4.0-16.0 4-16
Spiritual practices 17.91 3.29 74.62 10.0-24.0 6-24
Spiritual needs 28.70 5.42 79.70 11.6-36.0 9-36
Higher scores show higher spirituality.
Table 3. The Scores of Mental Health and its Sub-domains and its Relationship with the Overall Score of Spirituality in the Studied HIV-positive Individuals (n =
81)
Variable Mean SD Obtained
Scores
Obtainable
scores
Frequency
of Disorder
Relation With Spirituality
r (P Value*)
Overall score of mental health 36.0 16.4 4.3-70.0 0-84 54 (66.7) -0.55 (<0.001)
Somatic symptoms 9.5 5.3 0-20 0-21 54 (66.7) -0.40 (<0.001)
Anxiety/ insomnia 8.6 5.6 0-21 0-21 52 (64.2) -0.32 (<0.001)
Social dysfunction 11.8 4.2 1.2-20.0 0-21 70 (88.6) -0.67 (<0.001.)
Severe depression 6.8 6.6 0-21 0-21 37 (45.7) -0.26 (0.020)
* Pearson correlation.
The cut-off point is in the overall mental health score is 24 and it is 5 for each of the subscales, and those with higher cut-points have a mental health problem.
Table 4. Predictors of Mental Health in the Subjects Studied
Variable β (CI 95%) PAdjusted R
Self-awareness -1.64 (-2.12 to – 1.16) ˂0.001 0.44
can be considered as an important factor in improving
the health of individuals, and considering the impact of
social support on mental stress and the immune system,
this does not seem unlikely. The feeling of a sense of social
support based on religion, unlike other forms of social
support, can increase so much that many may regard it
as the source of the supreme support, that is, relationship
with God (32).
The findings indicated that two-thirds of patients
had mental disorders. Moreover, among mental health
dimensions, the highest mean score (the most common
disorder) was related to the sub-domain of social
impairment and the lowest score was related to the sub-
domain of severe depression. The mean of all mental
health subscales was higher than the cut-off point, and in
fact, there was a disorder in all of them. In this regard, the
results of studies show that mental health among patients
with AIDS is generally reported at a lower level, and they
do not have a very positive attitude towards their physical
and mental status in the future (15, 28, 32, 33). Jani et
al concluded that the amounts of perceived stress, self-
efficacy and mental health disorders, physical symptoms,
depression, anxiety and social dysfunction are higher in
patients with AIDS than in patients with other chronic
diseases (33) which is consistent with our findings.
The results of this study indicated a significant
correlation between the total score of spirituality and
overall mental health and all sub-domains of it. The
findings of the present study are consistent with those of
Pirasteh Motlag and Nikmanesh that showed a positive
significant connection between the spiritual beliefs in life
and overall dimensions of quality of life (20). The results
of a study by Viese and Moradi showed that the quality of

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408
life of female patients with AIDS varies in terms of their
religious beliefs, in a way that more religious women have
a higher quality of life than women with lower religious
credence (34). These findings are consistent with the
findings of the study by Prado et al, suggesting that Black
American mothers with AIDS having high religious
behaviors had fewer psychological disorders than those
with low religious behavior (35). It is also consistent
with the studies of Morse et al who found that the use of
religion reduces mental illness and leads to more effective
coping strategies in women with AIDS (36).
According to the findings, paying attention to spirituality
and meeting the spiritual needs of these people, as well
as raising the self-awareness of people and providing the
necessary training in this regard would help to promote
mental well-being in all its dimensions that in turn leads
to improvement in the quality of life of HIV-positive
patients. Therefore, special attention should be paid to the
care of these individuals by the responsible organizations.
The major limitation is the cross-sectional design of the
study, in which the relationship between mental health and
spirituality and some socio-demographic characteristics
does not necessarily indicate a causal relation. The lack of
cooperation of all patients referred and the small number
of patients participated in the study are among the other
disadvantages. Finally, considering that this study was
performed only in one province of the country, it cannot
be generalized to other patients in different regions with
different cultures. It is suggested that this research be
carried out with more samples in other provinces of Iran
so as to strongly confirm the validity and truth of the
findings. It is also suggested that the level of spirituality
and mental health of patients with AIDS be analyzed
through qualitative and phenomenological method and by
conducting personal interviews with the participants, and
the living experiences of patients be used in their living
environment so that hidden angles of this phenomenon
be revealed and more knowledge be gained in this field.
Conclusions
Based on the results, two-thirds of HIV positive patients
have mental disorders and the correlation between
spirituality and mental health and, also, all of its sub-
domains are significant. Moreover, the highest score in
spirituality was related to the dimension of spiritual needs.
Considering the importance of spirituality in coping with
the tensions associated with chronic diseases, including
HIV and the acceptance of the disease, and according to
the results of this study indicating the relationship between
spirituality and mental health, providing backgrounds for
the improvement of spirituality in HIV positive people for
improving mental health in these people is essential.
Conflict of Interests
Authors have no conflict of interests.
Ethical Issues
The Ethics Committee of Tabriz University of Medical
Sciences approved the study (IR.TBZMED.REC.1396.69),.
Acknowledgments
This study was taken from the master’s thesis. Hereby, the
authors are grateful to the Deputy of Research of Tabriz
University of Medical Sciences for the financial support
for the research and all the patients who participated and
cooperated in this work.
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