Observance of patients' rights by physicians and nurses from the COVID-19 patients' perspective.

Observance of patients' rights is a significant indicator in evaluating the quality of healthcare services. The COVID-19 pandemic has become a global crisis and affected the interactions between healthcare providers and patients. This study examined the COVID-19 patients' viewpoint about the observance of their rights by physicians and nurses. This study is a descriptive cross-sectional work of research conducted on the COVID-19 patients in Zanjan Province, Iran, in September 2020. The subjects were selected through convenience sampling, and data was collected using a two-section questionnaire consisting of a demographic characteristics survey and a Likert-type scale for evaluating patients' rights observance. The validity and reliability of the questionnaire were found to be acceptable, and the collected data was analyzed in SPSS v.26 using descriptive statistics, independent t-test, and ANOVA test. The mean score of observance of patients' rights was 69.60±7.36, representing a moderate level. The highest and lowest scores for the observance of patients' rights were related to the dimensions of courteous communication and responsibility, respectively. A significant relationship was found between the observance of patients' rights and their marital status, health insurance, and education level (P<0.05). This study showed that the observance of the COVID-19 patients' rights has not been affected by the social agitation caused by this disease.

Introduction

Patients are one of the most vulnerable groups suffering not only from physical health issues but also from mental and emotional stress. Hence, the foundation of medical and nursing care is based on respect for patients’ self-esteem and identity (1, 2). An efficient healthcare system involves active interactions and satisfactory relationships between medical and healthcare team and patients (3). Courteous communication, respect for patients’ privacy, responsibility, and attention to the cultural values are the primary components of cooperative relationships in healthcare systems (4). In every society, the principle of respect for patients' rights is vital from a medical ethics perspective (5). The patient's rights charter is a framework to defend patients’ rights in emergency situations and to satisfy their needs without discrimination in a respectful environment (6, 7), as well as to promote communication between patients and healthcare providers (4, 8, 9). The first serious step in establishing the concept of patient rights was the Universal Declaration of Human Rights (UDHR) where in its article 2, intrinsic dignity and equal rights are an indispensable part of human rights based on freedom, justice, and peace around the world (10). Thus, patients' rights, including patients' physical, psychological, spiritual, and social needs, are expected to be observed by healthcare providers (11), and oncoming ethical controversies in medical care has challenged fulfilling patients' rights (11 ,12). Advances in medical technology have led to many new ethical challenges requiring legal instructions to protect care recipients' human dignity (13). As in other countries, the patients' rights charter in Iran has been developed while carefully considering religious and cultural issues incorporated in all the articles of the charter (14, 15). According to Parsapoor et al., along with political laws, educating the general public and professionals is required to ensure that patients' rights are properly respected in the healthcare system (15).

When people are exposed to psychological stress, their cognitive, behavioral, and support resources have a fundamental role in controlling their adaptation and emotional reactions, such as fear, anxiety, and panic. Under the psychological stress of an illness, personal and social resources are known as influential factors that can positively or negatively affect treatment results (16, 17). Emphasis on patients' rights in healthcare is especially important for patients with a special disease. These patients are more vulnerable in terms of physical, mental, and social problems (18). According to Al-Rabiaah et al., the perceived stress of a special disease can affect interactions between patients and healthcare providers (e.g. physicians and nurses) (19). Kord et al. reported that Acquired Immune Deficiency Syndrome (AIDS) patients, as individuals with a special disease, expect healthcare providers to observe their rights equally and without discrimination, and treat them as other patients (20).

Near the end of 2019, the outbreak of a new viral disease, called COVID-19, was reported in the city of Wuhan, China (21). Due to its rapid transmission, the COVID-19 pandemic became a global health crisis in all countries within a few months (22). Healthcare workers and their family members have been among the most vulnerable populations in this pandemic and have suffered from psychological tensions due to the fear of getting infected (23). Social anxiety arising from the quick spread of COVID-19 affected the relationships and interactions between healthcare providers and the COVID-19 patients. Therefore, this study aims to assess the observance of patients’ rights by physicians and nurses from the viewpoint of the COVID-19 patients hospitalized in Zanjan Province, Iran.

Method

This study is a cross-sectional work of research conducted on the COVID-19 patients admitted to one of the hospitals in September 2020 in Zanjan Province of Iran. The subjects were selected through convenience sampling from the COVID-19 patients. The total number of known patients with COVID-19 admitted and hospitalized in 11 public hospitals during the study was 342. After obtaining permission from the research department and ethics committee of Zanjan University of Medical Sciences and making arrangements with the hospitals' managers, the researchers explained the objectives of the study to the participants and assured them of the confidentiality of their information. To ensure maximum accuracy in data collection, the researchers were present at the patients' bedsides in full compliance with health protocols, including the use of gowns, gloves, masks, and shields, and orally interviewed the patients and completed the questionnaires. The researchers assured the patients that their responses would have no effect on their treatment plans and that they were orally interviewed just to prevent virus spread. Then, as a further precaution, the researchers took photos of the completed questionnaires and then discarded all the paper questionnaires. The participants' informed consent, having been hospitalized for more than one day, and being in stable physical and mental conditions as verified by a physician were the inclusion criteria of this study. The subjects were selected via convenience sampling, and the duration of access to the samples and data collection was between one to three visits to the hospitals.

Data was collected through a two-section questionnaire consisted of a demographic characteristics survey and a Likert-type scale for measuring compliance with the patients' rights charter–the scale was designed and tested in the Ph.D. thesis of Parsapoor in 2014. Demographic characteristics included age, gender, marital status, education level, economic status, health insurance, history of hospitalization, and length of hospital stay. The patients' rights charter questionnaire consisted of 70 questions scored on a Likert scale from 1 (non-observance) to 5 (complete observance) for every item. This questionnaire measured observance of the patients' rights in nine dimensions using the following weight coefficients: (i) courteous communication (weight: 2.5); (ii) justice (weight: 9.2); (iii) privacy (weight: 4.4); (iv) responsibility (weight: 15.8); (v) patient's welfare and comfort (weight: 3.1); (vi) quality of services from a scientific point of view (weight: 25.6); (vii) patients’ interest (weight: 16.3); (viii) access to information (weight: 10.9); and, (ix) respect for patients’ choices (weight: 12.2). Dimension’s weight represented its impact on the respondent’s total score for the observance of patients' rights, and hence the dimensions with the highest and the lowest weights had the most and the least impacts on the total score, respectively.

The total score range of the observance scale is between 20 and 100 based on every dimension's weight. Respondents’ scores were interpreted as follows: low observance (20 to 51), moderate observance (51.01 to 76), and high observance (76.01 to 100). As for courteous communication, based on the dimension’s weight, low, moderate, and high observance were indicated, respectively, by the following scores: 0.5 to 1.27, 1.28 to 1.90, and 1.91 to 2.5. As for justice, based on the dimension’s weight, low, moderate, and high observance were indicated by the following scores, respectively: 1.84 to 4.69, 4.70 to 6.99, and 7 to 9.2. As for privacy, based on the dimension’s weight, low, moderate, and high observance levels were indicated by the following scores, respectively: 0.88 to 2.24, 2.25 to 3.34, and 3.35 to 4.4. As for responsibility, based on the dimension’s weight, low, moderate, and high observance levels were indicated by the following scores, respectively: 3.16 to 8.05, 8.06 to 12, and 12.01 to 15.8. As for the patients’ welfare and comfort, based on the dimension’s weight, low, moderate, and high observance were indicated by the following scores, respectively: 0.62 to 1.58, 1.59 to 2.35, and 2.36 to 3.1. As for the quality of service from a scientific point of view, based on the dimension’s weight, low, moderate, and high observance were indicated by the following scores, respectively: 5.12 to 13.05, 13.06 to 19.45, and 19.46 to 25.6. As for patients’ interests with five questions, based on the dimension’s weight, low, moderate, and high observance levels were indicated by the following scores, respectively: 3.26 to 8.31, 8.32 to 12.38, and 12.39 to 16.3. As for patients’ access to information, based on the dimension’s weight, low, moderate, and high observance levels were indicated by the following scores, respectively: 2.18 to 5.55, 5.56 to 8.28, 8.29 to 10.9. Finally, as for respect for patients’ choices with eight questions, based on the dimension’s weight, low, moderate, and high observance levels were indicated by the following scores respectively: 2.42 to 6.20, 6.21 to 9.22 and, 9.23 to 12.2. The dimensions of the patients' rights charter, the number of questions in each dimension as well as their score ranges and weights are listed in Table 1.

Table 1

Observance level of patients’ rights in various dimensions of patients’ rights

Dimensions of patients' rights	Mean	Standard deviation	Highest score	Lowest score	Number of questions	Weight	Score range	Categorization of scores
Courteous communication	2.10	0.32	2.5	0.85	11	2.5	0.5 – 2.5	Low: 0.5 – 1.27
								Moderate: 1.28 – 1.90
								High: 1.91 – 2.5
Justice	6.76	1.52	9.2	3.07	4	9.2	1.84 – 9.2	Low: 1.84 – 4.69
								Moderate: 4.70 – 6.99
								High: 7 – 9.2
Privacy	3.01	0.71	4.4	1.32	5	4.4	0.88 – 4.4	Low: 0.88 – 2.24
								Moderate: 2.25 – 3.34
								High: 3.35 – 4.4
Responsibility	9.95	2.81	15.8	4.74	3	15.8	3.16 – 15.8	Low: 3.16 – 8.05
								Moderate: 8.06 - 12
								High: 12.01 – 15.8
Patients’ welfare and comfort	1.91	0.3	2.92	1.15	15	3.1	0.62 – 3.1	Low: 0.62 – 1.58
								Moderate: 1.59 – 2.35
								High: 2.36 – 3.1
Quality of service	18.67	3.98	24.75	10.24	7	25.6	5.12 – 25.6	Low: 5.12 – 13.05
								Moderate: 13.06 – 19.45
								High: 19.46 – 25.6
Patients’ interests	11.09	3.2	16.3	4.08	5	16.3	3.26 – 16.3	Low: 3.26 – 8.31
								Moderate: 8.32 – 12.38
								High: 12.39 – 16.3
Access to information	9.07	0.96	10.68	6.10	12	10.9	2.18 – 10.9	Low: 2.18 – 5.55
								Moderate: 5.56 – 8.28
								High: 8.29 – 10.9
Respect for patients’ choices	6.99	1	10.03	4.15	8	12.2	2.42 – 12.2	Low: 2.42 – 6.20
								Moderate: 6.21 – 9.22
								High: 9.23 – 12.2
Total observance score	69.60	7.36	87.88	46.60	70	100	20-100	Low: 20 – 51
								Moderate: 51.01 - 76
								High: 76.01 - 100

The reliability, internal consistency, and validity of this questionnaire were tested in Parsapoor’s Ph.D. thesis, and the results were within acceptable limits. Parsapoor used the intra-class correlation (ICC) and Cronbach’s alpha indexes to assess the questionnaire's reliability and internal consistency. Total ICC was 0.87 and the Cronbach's alpha was 0.91, showing that the reliability and internal consistency of this questionnaire were satisfactory. Parsapoor evaluated the questionnaire's validity by measuring the relevance and clarity of its items. The questionnaire's total relevance and clarity were found to be, respectively, 97.2 and 90.2, indicating that the tool was suitable for evaluating the observance of patients' rights. The relevance and clarity of the items were assessed by experts in the field of patients’ rights, cooperative patients who had been informed of the study’s objectives, and an experienced methodologist (24). The collected data was analyzed in SPSS v.26 using descriptive statistics, independent t-test, and ANOVA test.

Results

All COVID-19 patients admitted to one of the hospitals of Zanjan Province were selected for data collection. Among these patients, 54 patients had been taken to Intensive Care Units (ICUs) and were unable to respond to the researchers’ questions due to their unstable conditions. Thirteen patients were unwilling to participate and were, therefore, excluded. Eventually, 275 questionnaires were completed and analyzed. Analysis of the demographic characteristics showed that the participants' mean age was 58.25±10.2 years. Most of the participants were female (70.9%), married (82.2%), and had primary school education (64%). In terms of economic status, 52.7%, 37.4 %, and 9.9% described their status as middle, low, and high, respectively. Moreover, 82.9% had health insurance and 71.3% had a history of hospitalization. Additionally, the participants' average length of hospital stay at the time of this study was 4.65±1.86 days.

The mean score for the observance of patients' rights by physicians and nurses from the COVID-19 patients’ perspective was found to be 69.60 with a standard deviation of 7.36, indicating moderate observance. Moreover, the dimension of courteous communication had the highest score (2.10 ± 0.32), while the dimension of responsibility had the lowest score (9.95 ± 2.81); courteous communication and responsibility were the most and the least observed dimensions of the patients' rights charter, respectively. The mean scores, standard deviations, the highest and the lowest scores, and score ranges are shown in Table 1.

According to Table 1, in addition to courteous communication, the dimensions of justice, quality of service from a scientific point of view, and access to information were reported to be highly observed. The participants evaluated the dimensions of privacy, patients’ welfare and comfort, patients’ interests, and respect for patients’ choices as moderately observed. Only the dimension of responsibility was reported to be poorly observed.

Moreover, the researchers examined the relationship between the subjects’ demographic variables, namely age, gender, marital status, education level, economic status, health insurance, history of hospitalization, and length of hospital stay, as well as their total mean scores for the observance of patients' rights. Table 2 shows the frequency and percentage of the demographic variables, and the mean and standard deviation of the patients’ total scores for the observance of patients’ rights along with the results of the statistical tests used to investigate the relationship between the participants’ demographic variables and their scores.

Table 2

Mean score and standard deviation of the patients' rights observance in terms of demographic characteristics variables

Variable		Frequency (Percentage)	Mean and Standard Deviationfor Observance ofPatients' Rights	Statistical Test	P-value
Gender	Man	91 (33.1%)	69.90±7.73	Independent T-Test	0.62
	Woman	184 (66.9%)	69.45±7.17
Marital Status	Single	8 (2.9%)	69.90±8.73	ANOVA	0.001
	Married	226 (82.2%)	70.71±5.89
	Divorced	17 (6.2%)	60.94±10.26
	Widowed	24 (8.7%)	65.16±11.01
Education Level	Illiterate	87 (20.7%)	70.66±6.55	ANOVA	0.005
	Primary School	176 (64%)	70.92±6.07
	High school/ Diploma	28 (10.2%)	68.40±8.21
	College	14 (5.1%)	60.26±8.77
Economic Status	Good	27 (9.8%)	71.19±5.99	ANOVA	0.063
	Moderate	146 (53.1%)	70.81±4.79
	Bad	102(37.1%)	69.38±5.97
Health Insurance	Yes	228 (82.9%)	70.85±6.23	Independent T-Test	0.005
	No	47 (17.1%)	63.55±9.25
History of Hospitalization	Yes	196 (71.3%)	69.69±6.75	Independent T-Test	0.73
	No	79 (28.7%)	69.39±8.72

Table 2 shows that the total score for the observance of patients' rights does not correlate with gender, economic status, or history of hospitalization. However, with regard to the impact of patients’ marital status on how they estimate the observance of their rights, the Analysis of Variance (ANOVA) test results showed a statistically significant relationship between the two (P-value<0.05). The results of the post hoc test of Least Significant Difference (LSD), after equality of variances, had been ensured via Levene’s test, determined that the mean score of the married patients was significantly higher than those of the divorced and widowed patients. Moreover, the mean observance score of the single patients was significantly higher than that of the divorced patients (P-value<0.05).

The results showed a statistically significant relationship between the participants' total mean scores for the observance of patients’ rights and their education level (P-value<0.05). The post hoc test results for identifying differences between the groups showed that only the mean observance score of the patients with a college degree was significantly lower than that of patients with other education levels (P-value<0.05). The LSD post hoc test’s results for identifying possible differences between the participants’ observance of patients’ rights scores based on their marital status and education level are shown in Table 3. The results also showed a statistical difference between the total mean scores of the patients' rights observance and their health insurance. The independent t-test’s results showed that the patients with health insurance evaluated the observance of patients’ rights more highly than the patients without health insurance, and the difference was statistically significant (P-value<0.05).

Table 3

The LSD post hoc test’s results for the mean differences between the participants based on marital status and education level

Variable	Groups		Mean Difference	P-Value
Marital Status	Single	Married	-0.80	0.74
		Divorced	8.96	0.00
		Widowed	4.74	0.09
	Married	Single	0.8	0.74
		Divorced	9.76	0.00
		Widowed	5.54	0.00
	Divorced	Single	-8.96	0.00
		Married	-9.76	0.00
		Widowed	-4.22	0.54
	Widowed	Single	-4.74	0.09
		Married	-5.54	0.00
		Divorced	4.22	0.54
Education Level	Illiterate	Primary	-0.26	0.80
		High School/ Diploma	2.26	0.14
		College	10.40	0.00
	Primary	Illiterate	0.26	0.54
		High School/ Diploma	2.52	0.06
		College	10.66	0.00
	High School/ Diploma	Illiterate	-2.26	0.14
		Primary	-2.52	0.06
		College	8.13	0.00
	College	Illiterate	-10.40	0.00
		Primary	-10.66	0.00
		High School/ Diploma	-8.13	0.00

To examine the relationship between the variables of age and length of hospital stay, the Pearson's correlation test was used. The results showed no significant relationship between the patients' mean scores for the observance of patients’ rights and their age or length of hospital stay (Table 4).

Table 4

Pearson’s correlation coefficients between mean scores for observance of patients’ rights and their age and length of hospital stay

Variable	Correlation Coefficient	P-value
Age	0.038	0.53
Length of hospital stay	0.034	0.57

Discussion

This study’s results show that the observance level of patients' rights from the COVID-19 patients’ viewpoint is moderate, whereas many other studies reported different results. The results of the study by Sheikhbardsiri et al. consistent with the present study’s results, showed that the observance level of patients' rights in emergency wards from the patients’ viewpoint is moderate (43.10 ±15.05) (24). Similarly, Zandiyeh et al. reported that the observance level of patients' rights is average (50.2) (25). However, Ghaljeh et al. reported the mean and standard deviation of the observance level of patients' rights as perceived by patients to be 6.28±1.02, or low (26). Dehghan et al. showed that the mean and standard deviation of the observance level of patients' rights is 2.91±0.74, in the range of 0 to 4 from the patients' viewpoint (11). Likewise, a study conducted in Oman showed that healthcare providers’ adherence to patients' rights in practice is low, while their awareness of the importance of respecting patients' rights was high. That study also suggested that devising measures to improve healthcare providers’ observance of patients’ rights is critically necessary (27). Another study conducted in Pakistan reported that only 41% of the patients who participated in the research were satisfied with the observance of their rights, and most of them were dissatisfied (28). According to a study conducted in Iran, although nurses' knowledge about patients' rights was inadequate, their performance in observing patients' rights was moderate (6). A comparison between the present study’s findings and those of previous researches shows that observance of patients' rights varies in different conditions, but most research results indicate a moderate observance level. The present study shows that the observance of patients' rights in the critical social conditions of the COVID-19 pandemic is moderate to high.

Furthermore, the results of the present study show that observance of most dimensions of the patients' rights charter is moderate or high. Courteous communication (the highest), justice, quality of service from a scientific point of view, and access to information were found to be the highly observed dimensions. The dimensions of privacy, patients’ welfare and comfort, patients’ interests, and respect for patients’ choices were moderately observed. The least observed dimension from the patients’ perspective was responsibility. Overall, the observance level of the patients' rights charter was moderate to high.

Parsapoor et al. reported a low observance level in access to information dimension, and they highlighted the necessity of closer attention to the management of information communication between healthcare providers and patients (29). The present study’s results about the highly observed dimension of patients' rights charter are consistent with those of Sookhak et al. where the highest score for the observance of patients' rights was related to "the right to be treated with respect" (43.4%), indicating nurses' good performance in this area (6). Sookhak et al. also reported that nurses' performance was unsatisfactory in respecting patients’ rights to have access to information, to choose, to receive appropriate care and treatment, and to complain. As with the present study, they reported the observance level of patients’ right to privacy to be moderate (6). On the contrary, Sabzevari et al. found the highest observance level of patients' rights to be in domains of respecting patients' privacy and maintaining patients’ confidentiality (9).

A comparison between the present study and similar studies shows that respect and courteous communication with patients are still the most highly-observed aspects of the patients' rights charter. Even in the current critical conditions, physicians and nurses believe that patients should be treated with respect. One of the obvious differences between the findings of the present study and those of other studies concerns the dimension of access to information. The results of the present study regarding access to information are not consistent with those of Parsapoor et al., Sookhak et al., and Sabzevari et al. This discrepancy can be attributed to the social conditions caused by the COVID-19 pandemic where the COVID-19 patients are regarded as patients with special conditions compared to other patients. Furthermore, due to the pandemic, hospitalization of non-COVID-19 patients has greatly reduced due to fear of infection. Accordingly, physicians and nurses have enough time to provide information to COVID-19 patients.

As with the present study, the study of Farzianpour et al. showed that patients' viewpoint on observance level of "access to medical records and information" as part of the patient's rights charter was found to be moderate to high (8). Farzianpour et al. also reported that the observance level of "the right to replace physicians and refuse treatment" was found to be average. This aspect of the patients’ rights is comparable with the dimension of "respect for patients’ choices" in the present study which was evaluated to be moderately observed (8).

According to Dehghan et al., the essential aspect of the patient's rights was receiving optimal healthcare services from both nurses' and patients' viewpoints (11). They also concluded that the most observed aspect of the patients’ rights was patients’ privacy and confidentiality and the least observed aspects were compensation for medical errors, handling patient's complaints, and respecting patients’ rights to complain (11). Similarly, the present study’s participants reported the dimension of responsibility to be poorly observed. The dimension of responsibility in the present study assessed the handling of patients’ complaints by physicians and nurses.

The present study’s results showed a statistically significant correlation between the total score of the observance level of patients' rights charter and the following variables: marital status, education level, and health insurance support. The married patients, compared to the divorced and widowed patients, reported a higher observance level of patients’ rights. Moreover, single patients, compared to divorced patients, reported a higher observance level of patients’ rights. In addition, patients with a college degree, compared to the patients with other education levels, evaluated the patients' rights observance level to be lower, which was statistically significant. The results also showed that the patients with health insurance, compared to the patients without health insurance, reported a higher observance level of patients’ rights. Regarding the history of hospitalization, Mack reported that patients with a history of hospitalization were more satisfied with the received healthcare services, while the present study’s results did not show a significant relationship between these two variables (30). According to Farzianpour et al., younger patients, compared to middle-aged and older patients, were less satisfied with their healthcare services (8). In this study, most COVID-19 patients admitted to the hospitals were in a certain age range, and the age did not appear to affect the mean of the reported observance level of these patients' rights. As with the present study, Sabzevari et al. did not find a significant relationship between patients’ demographic characteristics, including age, gender, education level, and career, and their perception of observance of patients’ rights (9).

Vakili et al., Mokhtari and Khorami Markani, and Rafiei et al., in their studies, did not found a statistically significant correlation between patients’ marital status and their perception of observance of patients’ rights (31,32,33). As with the present study, the results of Babamahmoudi et al. showed that the observance level of patients' rights from viewpoint of patients with an academic degree was statistically lower (34). Although more research is required on why subjects with higher education levels evaluate observance of patients’ rights less favorably than others, greater knowledge and awareness of such individuals could be a reason.

The present study’s results can be extended to other provinces of Iran because not many cultural differences in the aspects considered in this study can be observed among other provinces. However, further research in other provinces is suggested for more accurate results. Major cultural differences among Iran and the other countries prevent the generalization of this study’s results to other countries. Furthermore, patients' psychological conditions, and satisfaction with hospital equipment could affect their assessment of observance of patients' rights, factors disregarded in the present study. Therefore, for a more accurate evaluation, all the factors affecting patients' perception of the observance of their rights, including the interactions of medical and non-medical staff with patients and their families as well as patients’ satisfaction with medical equipment and hospital facilities should be addressed. Future studies are recommended to cover more provinces with larger sample sizes, all dimensions affecting observance of patients’ rights, and dimensions of patients' rights charter with reported low observance level from the patients’ perspective. The outcomes of such studies should be considered by the healthcare system’s managers and policy-makers for planning improvement as well as future research and development.

Conclusion

Based on the present study’s findings, the observance level of patients' rights from the COVID-19 patients’ viewpoint was found to be moderate. Compared to similar previous studies, more dimensions of the patients’ rights charter were found to be well observed during the pandemic. Courteous communication was the most highly-observed patient right from the participants' viewpoint, indicating that the COVID-19 patients were treated with respect during their hospitalization by physicians and nurses. These findings refute the hypothesis that physicians and nurses, major human resources in healthcare systems, are disregarding patients' rights during the pandemic crisis due to their fear and anxiety as well as panic of getting infected and the possibility of transmitting coronavirus to their family. This study’s findings show that, from the COVID-19 patients’ viewpoint, the observance level of patients’ rights as prescribed by the patients’ rights charter has not diminished as a result of the uneasy atmosphere in the society following the outbreak of COVID-19.

Ethical Considerations

Permission to conduct the present study was obtained from the Research Department and Ethics Committee of Zanjan University of Medical Sciences (IR.ZUMS.REC.1399.164). All the study participants were informed about the objectives of the study, the confidentiality of the information, and the voluntary nature of their participation.