
==== Front
J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-235
10.4103/jehp.jehp_948_23
Original Article
Storytelling as an educational strategy for midwifery students: A qualitative study
Ghasab Shirazi Morvarid
Pourghane Parand 1
Mehrabian Fardin 2
Department of Midwifery, Zeynab (P.B.U.H) School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
1 Social Determinants of Health Research Center and Department of Nursing, Zeynab (P.B.U.H) School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
2 Department of Health Education and Promotion, Research Center of Health and Environment, School of Health, Guilan University of Medical Sciences, Rasht, Iran
Address for correspondence: Dr. Parand Pourghane, Department of Nursing, Guilan University of Medical Sciences, Rasht, Iran. E-mail: pourghanep@gmail.com
2024
11 7 2024
13 23502 7 2023
16 11 2023
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
BACKGROUND:

Narratives can provide a framework to teach the concepts of patient-centered care to the students. This article describes the experiences of midwifery students from employing of purposive storytelling as a teaching strategy in the education program.

MATERIAL AND METHODS:

This qualitative study used an in-depth interview method to collect the experiences of midwifery students engaged in a narrative medicine training program. The narrative-based teaching activities focused on three patients to teach four themes (clinical manifestations, treatment options, prevention strategies, and ethics), and related to MMR (maternal mortality rate) concept offered to students from Guilan University of Medical Sciences in 2022–2023. At the end of the course, all students were invited to provide experiences regarding the teaching method. Conventional content analysis was performed simultaneously with data collection. Four-dimension criteria (Lincoln and Guba) were used to evaluate the rigor of the findings.

RESULTS:

Data analysis led to the extraction of three main categories and eight sub-categories: effective learning (extended learning, a safe learning environment, and boosted motivation for midwifery role), challenges on the way of learning (contagious sadness, shattered cohesion, and executive monopoly), and challenges on the way of performance improvement (the necessity of interdisciplinary education and the inevitability of a strong foundation).

CONCLUSIONS:

Narrative-based teaching may improve the learning experience of students, but it is not possible to train all the course content by this method, and it should ideally be a supplement to other educational methods, such as lecturing.

Content analysis
experience
midwifery
narrative-based learning
qualitative study
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pmcIntroduction

Attention to specialization expansions in medical science education is a relatively modern concept that necessitates advanced specialization-based education. In contrast, it dedicates less space to developing the human aspects of the learner.[1] In this regard, narrative medicine is a method of medical education that provides a mental framework for this education. In this method, the stories and experiences of people are evaluated as aspects inseparable from health and illness. This framework can teach the concepts of comprehensive and patient-centered care to the students. Correspondingly, it is regarded as an educational strategy to improve clinical care qualities as well.[2] The philosophy and theoretical principles of narrative medicine have been first investigated by Charon. comprehensively. According to their definition, effective performance in medical education requires some qualifications. These qualifications include the ability to acknowledge, attract, interpret, and act based on patients’ stories and situations by the healthcare provider.[3]

Narrative medicine, in definition, uses the special ability of the stories to improve clinical competence and strengthen moral imagination. Furthermore, it uses this ability to amplify interpersonal understanding in training medical concepts.[4] In addition, this ability impacts some skills, such as listening and interpersonal skills of the caring person. Besides, sympathy and commitment of the caring person are the other influenced skills that are highly crucial to patients.[5] In this regard, educational initiatives have been included in the curriculum to use the narrative medicine advantages.[6]

Midwifery training is the basis of high-quality, safe, and evidence-based care for women and their newborns.[7] About 90% of the reproductive and sexual health services for women and newborns are provided by midwives worldwide. Therefore, it is estimated that 80% of the maternal mortality rate are prevented annually via seasoned midwives by midwifery training with high quality.[89] In this regard, the impact of social and economic factors, especially on maternal mortality issues, makes the attraction of the midwife’s attention more crucial in societies. In these situations, midwifery training does not only create clinical skills and scientific qualifications, and it emphasizes the professional skills to be combined with a deep understanding of the students in the social fields so that the learners can understand these conditions. Consequently, the quality of care services provided by the learners is improved.[10] Studies in Iran show that there is a deep gap between education process and clinical practice.[11]

In most cases, the appropriate methods to create effective training conditions for midwifery students, in which they perceive the real condition of their patients, are not employed.[12] This happens because midwifery students encounter some problems by which they are exposed to a wide range of emotions, but employing training methods with inhuman philosophy, paying attention to technology-based approaches, and applying illness-based protocols prevents them to have emotional interaction with the women and their families, and this issue influences providing services by them.[13] Correspondingly, employing educational strategies that emphasize the human aspects and deep emotional involvement can help. Nevertheless, investigating how these strategies can change midwifery students’ experiences of learning, especially, in terms of caring for mothers should be considered.[14]

Applying the narrative medicine method in the midwifery curriculum can increase cognitive learning and improve role acceptance as a midwife in midwifery students and might involve them with the patients’ problems more emotionally.[15] It is difficult to assessing accurately whether narrative medicine programming addresses the unique needs of health professionals in academic medicine.[16] Most of the conducted studies in this vein have focused on the impact of this method on the educational performance of the students and their achieved scores,[2] and a few studies have reported the effect of this method on the behaviors and experiences of midwifery students about using this method. Experience of midwifery students in educational methods has shown that the training methods should lead to capabilities that include the expansion of attitudes, increase in clinical skills, formation of critical thinking, judgment, and clinical decision making in various conditions.[17] This study suggests that the evaluation of the effectiveness of narrative medicine education and training is not only based on quantitative changes; therefore, the main purpose of this study was to explore the midwifery students’ experiences from employing the narrative medicine method in the midwifery training program, in order to provide a reference for the improvement of the quality of narrative medicine education in the future.

Materials and Methods

Study design and setting

This qualitative study used an in-depth interview method to collect the experiences of midwifery students engaged in narrative medicine training program for Maternal Mortality Rate (MMR) concept, followed by content analysis of the transcripts Guilan University of Medical Sciences in 2022-2023.

Study participants and sampling

The participants were third-year undergraduate midwifery students from Guilan University of Medical Sciences. In qualitative studies, participants are those who have first-hand and relevant knowledge about the subject of study.[18] The purposive sampling method was adopted for the interviewees.

Ethical consideration

We explained the objectives of our research, outlined our rationale for recording the interviews, described the confidentiality of the data, outlined the process for deleting the recordings after extracting the data elements, emphasized the right to opt out of the research, and explained the possibility of accessing the final results.

Data collection and technique

Semi-structured interviews were conducted in the class when it was quiet and when students had an opportunity to respond. Qualitative methods offer a depth and a context that elude quantitative analysis.[19]

The issue of maternal mortality rate (MMR) is a section of the maternal and child health book for midwifery students. The narrative-based teaching activities discussed here are part of the midwifery course for MMR concept offered to third-year undergraduates in pursuit of a Bachelor’s degree. The newly re-designed classes (four classes, each of 2 hours duration) used fictional narratives focused on three patients to teach four themes related to MMR, and sessions were carried out suitable with the regarded content in the major curriculum. Therefore, the true narratives of maternal mortality were applied by focusing on three patients to train four subjects relevant to maternal mortality. These four subjects were clinical manifestations, treatment options, prevention strategies, and ethics [Table 1]. Three narrations reported severe bleeding, infections, and preeclampsia–eclampsia as the real causes of maternal mortality in Guilan province (without names and other details). Thus, maternal mortality narrations were provided for the students in the class.

Table 1 Outline of classes and the learning objectives for each class

Class	Theme	Narrative	Examples of students activities	
First	Clinical manifestations	Mother N1: Immediately after cesarean delivery, we encountered hypotension in the recovery room
Mother N2: In the 12th week of pregnancy, after three days of fever, despite antibiotic treatment, she was admitted to the emergency room with nausea and vomiting and abdominal pain at night
Mother N3: Her vision is blurred and she sees blackness in front of her eyes despite her glasses	Use clinical records, examination findings, and interactive research panels to reach a final diagnosis in each case	
Second	Treatment options	Mother N1: echocardiogram was performed
Mother N2: Oral metronidazole and gentamicin were prescribed, but her husband did not allow hospitalization
Mother N3: Full outpatient liver tests were requested, and the mother was not hospitalized	Students argue about the methods that should have been used for treatment: termination of pregnancy, blood transfusions, targeted antibiotic therapy and dialysis, and intensive care.	
Third	Prevention strategies	What could be the steps to prevent the three main causes of maternal death step by step	Check understanding of basic concepts of prevention and timely referral of expectant mothers
Search for evidence to see if these practices exist
Discuss ways to avoid repeating similar cases	
Fourth	Ethics	During a follow-up visit, a biopsy is taken from mother N1 without obtaining her consent
Mother N2’s husband was not explained how dangerous the abdominal pain was for the mother
Mother N3 does not have insurance	In the scenarios, list the key considerations that led to the lack of attention to ethics	

The educational resources were lectures, PowerPoint slides, images, and practical notes that were made available via the Navid system (virtual education of national medicine in Iran) before each class. The students were divided into three small groups of 5-7 for training. Each patient was assigned to one of three groups of students, who followed up the same patient in practical classes throughout the course. During the class, students were given problems and tasks. In the first session, the students detected the problem based on clinical manifestations and wrote a midwifery diagnostic report. In the second session, the students investigated and recommended treatment options. In the third session, the strategies to prevent maternal death were examined in terms of the case. Accordingly, the students were requested to write the factors that caused and prevented maternal mortality in the regarded case. In the last session, the ethics, such as the position and value of women in society, the safe furtherance of maternal via human rights, and traditional beliefs were discussed. Furthermore, the effective obstacles to women’s health during pregnancy and childbirth and the role of midwifery ethics in decreasing maternal mortality were other discussed subjects. The teacher in each class discussed all three cases with the entire cohort after each of the group activities.

At the end of session 4, the students were interviewed individually and sometimes in a group via a semi-structural interview. The interviews were conducted by the authors of this study, each interview began with an explanation of the purpose of the study and an invitation for the respondent to fill in the interviewee’s consent form, followed by a semi-structured in-depth interviewing. Students expressed their experiences with the narrative medicine method. The interviews continued until the information was saturated (the following data be the same and similar). The interview guide included some open-ended questions included: 1- “Please explain your experience with the educational method of narrative medicine” and 2-“Please explain your experience with the educational method dimensions of narrative medicine”. If needed, exploratory questions were employed to understand the ambiguities, explain more experiences of the students, and increase the depth of the interview.

Before data analysis, the interview recordings were transcribed into text. Data collection and data analysis were conducted concurrently. In this study, the four criteria of Goba and Lincoln were used to evaluate the validity of the findings. These criteria included Credibility, Transferability, Dependability, and Confirmability.[20] To do so, the interview text was presented to several experienced colleagues along with the codes and emerged categories. Therefore, the data were analyzed, and their correctness was discussed. There was permanent involvement with the subject and the project data for credibility. The interviews, extracted codes, and sub-categories were shared with some of the qualitative research experts, and their views were applied. The research stages and decisions made during it were recorded and reported to provide others the opportunity to follow the study if needed. Therefore, data reliability and confirmation were possible. Besides, the data transferability was investigated by two people outside the research by confirming the obtained information. These two people had conditions similar to those of the study participants.[21]

This study has been conducted in strict compliance with the ethical principles of the Declaration of Helsinki (1964), including the informed consent request for the participants. Students in the study were voluntary, as well as the signing of participation request. The exclusion criteria of the study were the lack of participants’ tendency to continue participation, absence, or lack of participation in one of the class sessions.

Results

The participants in the current study were 38 sixth-semester undergraduate students of midwifery at Guilan University of Medical Sciences. Face-to-face interviews lasted approximately 20-50 minutes. Three main categories and eight sub-categories were extracted from the conducted interviews according to the participants’ statements. The main category of “effective learning” included these sub-categories: extended learning, a safe learning environment, and boosted motivation for midwifery role. The main category of “challenges on the way of learning” included the following sub-categories: contagious sadness, shattered cohesion, and executive monopoly. The main category of “on the way of performance improvement” included these sub-categories: the necessity of interdisciplinary education and the inevitability of a strong foundation [Table 2].

Table 2 Main categories, sub categories and codes extracted from the Experience of Narrative Medicine

Code	Subcategories	Main categories	
• Improving the ability to connect the topic with previous topics	Extended Learning	Effective Learning	
• More learning with high student participation	 	 	
• Better learning by putting yourself in the patient’s shoes	 	 	
• Reducing student anxiety	Safe Learning	 	
• Getting out of the formal mode	Environment	 	
• Easier discharge of emotions	 	 	
• Increase performance motivation	Boosted Motivation of the Midwifery Role	 	
• Increasing motivation with greater awareness of the important role of midwives	 	 	
• Feeling heartbroken after hearing the story	Contagious Sadness	Challenges on the Way of Learning	
• Feeling sad in class	 	 	
• Time-consuming class sessions	Shattered Cohesion	 	
• Deviation from the topic	 	 	
• Impossibility of applying in all courses due to the long class process	Executive monopoly	 	
• Impossibility of applying in all courses due to the necessity of a limited number of students	 	 	
• Accompanying the lesson with other basic sciences	The Necessity of Interdisciplinary Education	On the way of Performance Improvement	
• Accompanying teaching with care principles	 	 	
• Strengthening the student’s basic sciences	The Necessity of a Strong Foundation	 	
• Paying more attention to the relationship between theory and clinical practice	 	 	

Effective learning

Extended learning

Most of the participants stated that they consider participating in the class a factor in more learning to establish the teaching subject with previous experiences. Therefore, they can remember better, learn more, and put themselves in the mother role. Participant 12 claimed as follows: learning in this class was much high and effective. In this class, I learned the new contents well in addition to remembering the materials I had learned. Participant 11 reported: “This method of learning has a highly attractive point, and it is putting oneself in the role of mother. This kind of learning, in fact, is kind of sympathizing with mother that leads to learning improvement”.

Safe learning environment

Some of the students considered the created environment in the class a safe environment for learning. They reported that the storytelling method in the class reduces their anxiety, separates the class from formal mode, and discharges their emotion. Participant 8 stated: “It was an attractive class, and our anxiety was significantly reduced by feeling comfort in the class”. Participant 1 highlighted: “Unlike many other classes, this class was out of the dry and boring mode, and the content was extremely pleasant and more understandable for us”. Participant 6 stresses: “We were immersed in the story by participating in the class, and learning occurred with discharging emotion”.

Boosted motivation of the midwifery role

Some of the participants claimed that by participating in the class, motivation, learning, and performance are increased with more awareness about the important role of a midwife. Participant 16 reported: “The participation of students in the class was high and such participation increases the motivation for learning and performance”. Participant 10 stated: “Participation in this class made me aware of the crucial role of a midwife in decreasing maternal mortality and in the medical team. Moreover, this participation increased our motivation in line with more effort in this field of study”.

Challenges on the way of learning

Contagious sadness

Some of the students stated that depression feeling by hearing the story and feeling sadness in class are the challenges of this method. Participant 8 emphasized: “Although, I understood the content in the class well, but, I felt a great sadness by getting immersed in the story”. Participant 2 reported: “As I was listening to the story and getting immersed in it, I felt very uncomfortable”.

Shattered cohesion

Some of the participants reported the possibility of deviation from the main subject as the challenges in this direction; thus, it led to shattered cohesion. Participant 15 highlighted: “This method of teaching wasted much time, during the story, I would deviate from the main topic of the lesson.” Participant 1 asserted: “In my opinion, the existence of an order is necessary for presenting content to enhance the quality of teaching. Sometimes, cluttering about different issues causes confusion and distraction for the student”.

Executive monopoly

Some of the students reported that teaching by storytelling and the long procedure of the class makes it difficult to apply the storytelling method for all courses. In addition, the absence of the possibility to perform in classes with a large number of students was the other reason to refuse to employ this method. Participant 7 insisted: “Considering the teaching procedure in the form of storytelling, this method is not appropriate for some courses, such as basic sciences”. Participant 16 reported: “This method is an interesting method to remember subjects; however, wasting time limits this kind of teaching”.

On the way of performance improvement

The necessity of interdisciplinary education

Students talked about the requirement of joining the lesson content teaching to other basic science and caring principles to improve the efficiency of this method. Participant 38 stated: “If the course content is close to the basic science, our learning will be highly enhanced”. Participant 9 claimed: “Mentioning the details of subjects to rescue the patient, emphasizing medicine and care principles can increase the efficiency of this method despite mentioning the general content”.

The necessity of a strong foundation

Some of the participants expressed that a strong learning foundation is made to improve the student’s learning. This happens if the student’s basic science is strengthened, and the teaching content can provide a relationship between theory and clinical practice. Participant 4 stated: “In this class, which was conducted using the storytelling method, it was noticeable that more effective learning was associated with the completion and strengthening of the student’s basic sciences”. Participant 17 reported: “Creating a relationship between the course content and theory and clinical practice can provide an essential role in more learning for the student”.

Discussion

The results of this study could be important for the development of narrative-based medical education framework according to the midwifery students’ experiences. Narrations are strong tools for training students.[22] On the other hand, focusing on the narrations in the clinical environment might help healthcare providers fill the gap between pathological knowledge and experimental knowledge in the patients’ stories. Therefore, using narrative medicine is more regarded to respond to the growing requests for patient-centered services in modern medical and treatment environments.[23] The students’ experiences in this study have been placed in three main categories including effective learning, challenges on the way of learning, and on the way of performance improvement.

In this study, effective learning meant improving the learning experience among students. Similar study reported similar results.[24] Moreover, the student’s experience of learning has been beyond pure knowledge. Confirming our findings, in study of Nouri et al. (2022), students stated that traditional clinical education did not satisfy their educational needs.[25]

This result was in congruence with similar research that revealed narrations can be a method to facilitate learning instead of transferring pure knowledge.[2627] The reason was to use extended learning, a safe environment, and motivated learning in this study. Extended learning can have numerous reasons in the current research. In study of Nematzad et al. (2023), the results showed a significant difference between the two groups in terms of the mean perceived susceptibility scores before the intervention of education.[28]

In this field, a study indicated that stories are stored in memory by various methods. Comprehensive or visual memory, which is more applied in narratives, is more effective in transferring pure knowledge than separate facts. This case is used more in the process of oral storytelling.[21] Furthermore, narrations are precious tools for strengthening reflective learning. Presenters of this educational method can use a reflection to investigate their position as doctors or therapists.[29] Employing the trained content improved after the narrative medicine period, and the students could remember the contents better.[30]

On the other hand, enhancing the ability to create a relationship between the subject and the previous subjects in the current research caused the students to experience more extended learning and effective learning. A story can picture a holistic and alive experience of a subject that is trained and create a new and significant relationship between the existing area of knowledge (Moon). A similar study revealed that the narrations help organize the knowledge in a structure or scheme to which new information can be added.[31] More participation of the students in the teaching process can be effective in extended learning and consequently effective learning. A study in this field reported an increasing perception of subjects in the narrative medicine method.[32] This happened due to creating capacity for participation and creating relationships better and more with the subject and the people around during education. In addition, individual learning skills and group learning skills were formed among the students after education with this method.[2] Actually, improvement of learning the course concepts via increasing communication and participation during learning was the teaching method advantages of narrative medicine in a similar study.[33]

On the contrary, when the person’s feelings are involved in the learning process, more extended learning will happen.[34] This result was emphasized in the present research that the students put themselves in the role of a considered case by involving feelings. Correspondingly, they experienced a safe environment for learning. Besides, they stated low anxiety in education. Similar studies indicated that storytelling is a crucial method for training and helping prepare students in line with creating certainty and a safe learning environment in the clinical place. Therefore, significant anxiety is reduced among the students when they attend clinics.[35] The reason for anxiety reduction among the students using this educational method might be placing them in an educational environment that is free of formality. This experience was mentioned by the students in this study. In this vein, a similar study claimed that narrations provide flexibility capability for training medical concepts.[36] However, arousal of emotions alone cannot lead to effective learning. Creating boosted motivation in students was another experience that caused effective learning. They reported a positive experience of their future role as midwives by participating in the class sessions. This result might have been achieved due to a deeper understanding of the future job and professional identity. A study, in this case, confirmed that participating in the sessions of narrative medicine helped students better understand and process the stresses that they experience in the workplace.[37] Also, it is probable that narratives could serve a unique role in fostering cultural sensitivity and expanding the moral imagination in students[38] that can facilitate awareness of professional identity.[39]

Moreover, experiencing boosted motivation in the midwife’s role can be due to empathy improvement among the students. A study reported that this method helps students strengthen listening and observation skills. Besides, it leads to increasing an individual’s capability to think about career prospects via arousing emotions and creating empathy abilities.[40] Therefore, the narrative medicine method can be used as an innovative tool to create a professional feeling perception in the future career of the students.[4142] A deep understanding of career and medical personnel performance is a subject that should be educated in the initial stages of medical education. This perception can result in acknowledging an individual’s career type that is similar to the experience mentioned by the students in the present research.

The student’s experience of learning via this method has caused some challenges as well. Contagious sadness, shattered cohesion, and executive monopoly have been some of the reasons for this experience. In this line, a study highlighted that narrations can teach medical errors to students without harming the patient.[34] Nevertheless, the emotional involvement of students and the creation of sadness among them have been reported as the challenges of this method. This issue can be compatible with this study by putting the person in the role of mother. Furthermore, using narrative knowledge can facilitate empathy and think about the emotional aspects of the subject.[23] This subject causes narrative medicine to be applied to understand patients’ pain and create effective communication between students or therapists and the patients.[43] The reason is that this method requires encountering and analyzing a narration that results in self-reflection, sharing feelings, and exploring a person’s feelings in relation to others.[2] This case might impact the sad feeling of the students for patients, considering the nature of the trained subject in this study. Experiencing shattered cohesion of the content and executive monopoly of this method were the other challenges mentioned by the students. Besides, long class sessions and consequently boredom with this method can be other mentioned challenges. Similarly, another study showed that the stressful and intensive nature of medical science program changes the traditional methods of medical education and creates some feelings. These feelings include disappointment and negative emotions toward attitudes and perceptions after small changes.[23] Furthermore, a lot of content and boredom with the presented sessions have been reported by the students who were trained by the narrative method.[37] Thus, integrating educational methods in medical science can reduce these challenges. The students expressed their experiences with promoting the educational method in this study. This method is an effective one for the student’s participation, especially, in subjects about caring for known patients.[44] There should be a strong foundation for this educational method by strengthening the training foundation and creating an effective relationship between basic science and clinical practice. This case has been regarded for the students with the necessity of training care principles, and it has been considered an experience on the way of performance improvement.

Limitation and recommendation

Like all studies, our current research is subject to important limitations. For example, while the individualized, idiographic approach adopted in this study provides a richness of data, it also limits the generalizability of the research. However, this limitation was addressed through theoretical sampling and through inviting researchers not directly involved in the study to review the findings. Similarly, the study was limited to student’s perception and experience of teaching methods in the collage of East Guilan. The application of the narrative medicine method was defined in classes in terms of long-term effects. It was detected that presenting services of which the training was done via this method was performed better by the students. This achievement can be due to a better perception of the position and requirements of the patients.[19] However, more studies should be conducted to investigate the long-term effects of using this method in medical science education.

Finally, the current study relied exclusively upon interview data. Future studies might objectively measure both actual levels of self-efficacy and evaluations of work performance.

Conclusion

The final purpose of clinical midwifery is transferring clinical knowledge to the students; nevertheless, knowing in action is not enough. Storytelling is a useful tool to facilitate the process of perceiving situations and midwifery clinical events.[14] The educational program of narrative medicine generally impacts the students’ knowledge and performance, positively.[19] Few studies have been conducted about the students’ experiences of education with this method. This article detects the theoretical structure based on the student’s experiences of using stories in midwifery higher education and presents illustrative examples of the midwifery students’ experiences in this way. Narrative-based learning may improve the learning experience of students, but it is not possible to train all the course content by this method and continuity and balance should be prepared between the details of the patient’s medical case and educational general concepts. More studies are required to determine whether the skills of interpretation and trained thought are performed by the students in the narrative medicine class after getting graduated. The researchers of this study also believe that narrative-based learning in midwifery education should not be the only method for presenting content. Besides, it should ideally be a supplement to other educational methods, such as lecturing.

Ethical approval

Ethical approval of the research was obtained from the Ethics Committee of Guilan University of Medical Sciences, Rasht, Iran (Code: IR.GUMS.REC.1400.260).

Financial support and sponsorship

The present article received financial support from Research Deputy and Determinants of Health Research Center, at Guilan University of Medical Sciences Rasht, Iran.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

The researchers express their gratitude to the dear students who helped the researchers conduct this study. Also, the researchers thank the support and funding of the Research Deputy and Determinants of Health Research Center at Guilan University of Medical Sciences Rasht, Iran.
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