key: cord-0769518-ldl2cjzy authors: Abootalebi, Maliheh; Delbari, Ahmad; Abolfathi Momtaz, Yadollah; Kaveh, Mohammad Hossein; Zanjari, Nasibeh title: Facing double jeopardy: Experiences of driving cessation in older adults during COVID-19 pandemic date: 2021-10-22 journal: J Transp Health DOI: 10.1016/j.jth.2021.101285 sha: 5e798cd2684d7bda053046ea522158d16f9409a2 doc_id: 769518 cord_uid: ldl2cjzy INTRODUCTION: The COVID-19 pandemic is a multidimensional phenomenon whose consequences can be detected in various economic, social, cultural, and political areas. Driving cessation in older adults is one of the areas affected by the social consequences of this crisis. This study aimed to explain the concept of facing the double jeopardy of the COVID-19 pandemic and driving cessation in older adults. METHODS: This qualitative study was conducted using a thematic analysis approach. Fifteen older adults aged 60 years and above who lived in a community-based setting of Shiraz, Iran were selected based on purposive sampling. The data were collected using semi-structured interviews. RESULTS: The findings indicated two themes, namely dualization of common challenges and fitness with limitations, and nine sub-themes, which showed the experiences of older adults regarding the main theme of facing the double jeopardy of the COVID-19 pandemic and driving cessation. DISCUSSION: Facing the double jeopardy created unique challenges for older adults, as the combined adverse effects of the two sources simultaneously put them at a greater risk. This double jeopardy endangered the health of older adults in various dimensions. This can be the beginning of a new era in older adults' life and care. In this context, application of telecommunication technology and home-based applications increases the flexibility of older adults as well as their ability to cope with stress to meet their mental, social, and physical health needs. The COVID-19 pandemic is a global health crisis that has caused various challenges for the whole world and has put pressure on healthcare systems (Chen, 2020) . Although people of all ages are at risk of COVID-19, previous studies demonstrated that older adults were more likely to be infected with diseases, experience more severe symptoms, and have a high mortality rate (Takashima et al., 2020) . In another investigation, eight out of ten COVID-19-confirmed deaths in the United States were reported among the people aged over 65 years (Rahman et al., 2020) . According to the Worldometer elaboration of the latest United Nations data, there were 5, 210, 112, 430 deaths, and 4, 453 ,651 recovered cases in Iran until 9 September 2021 (Worldometer, 2021) . Based on the study performed by Hadinejad et al., 25218 out of the 54523 cases infected with COVID-19 were older adults. The mortality rate was more than 13 persons per 100 cases among the hospitalized older adults. Overall, 3512 older people were expired (Hadinejad et al., 2021) . Many countries have taken restraining measures such as social distance and quarantine to prevent the spread of COVID-19. Although strict public health measures can protect older people from being infected with COVID-19, they can create other problems such as social isolation, limited access to standard health services, and poor social care and self-management (Takashima et al., 2020) . As quarantine and social distance continue, these people will be at a greater risk for weakness, sarcopenia, anxiety, depression, and cognitive decline, which challenge their ability to return to everyday life (Chen, 2020) . Various studies have assessed the double risk of COVID-19 in older adults with a variety of conditions. The results of a study conducted in Turkey showed that being old and having several diseases at the same time multiplied the poor results of COVID-19 infection (Turk and McDermott, 2020) . Another study by Chatters et al. disclosed that old age and blackness were associated with an increased risk of serious illness and death from COVID-19 (Chatters et al., 2020) . According to the activity theory, feeling satisfied with life in natural aging requires maintaining an active lifestyle during this period. This theory claims that the individuals who are more involved in the society have the greatest sense of satisfaction (Heinz et al., 2017) . In fact, mobility is considered an essential element to maintain and improve the quality of life of older adults. The ability to drive is one of the most important examples of activity and mobility amongst these individuals (McInerney, 2009) . Driving helps meet the daily needs of older people including access to shops, services, work, and healthcare and active participation in the society (Charles, 2010) . Driving cessation due to various reasons such as illness, age-related functional limitations, and influence of others is one of the challenges amongst older adults, which is associated with adverse consequences such as increased depression, decreased physical function, reduced cognitive function and social participation, loneliness, social isolation, and increased risk of admission for long-term care and mortality (Hirai et al., 2019) . Evidence has revealed that in the older adults who have experienced driving cessation, public transportation may result in dependence on other modes of transportation to keep their independence and social engagement (Lamanna et al., 2020) . On the other hand, the older adults who live in rural regions and depend on their own cars may have restricted or no access to public transportation. Thus, such restricted transportation choices may motivate the people who live in rural zones to hold their licenses longer compared to those living in urban regions (Hansen et al., 2020) . Today, older adults use public transportation far less than before the pandemic due to fear from being infected (Park and Cho, 2021) . On the other hand, due to driving cessation, transportation limitations, and decreased social interactions, they face more problems in meeting their basic needs (Mobasseri et al., 2020) . In other words, simultaneous driving cessation with the COVID-19 pandemic has doubled the risk of this condition in older adults, because the combined adverse effects of these two sources outweigh the negative effects of each one and make them more challenging (Francis et al., 2020) . The ability to drive is an important factor for older people to maintain their independence and social relationships. Thus, when an older adult's driver's license is revoked, it can have serious impacts on one's quality of life (Marshall, 2008) . A review of the existing studies showed that so far, no research has been conducted on the experiences of older adults who stopped driving during the COVID-19 pandemic. Hence, there is a paucity of evidence for deep and comprehensive understanding of this dual risk in older adults living in Iran. Since the outcomes of this situation can cause irreparable damages to the older adult population, the experiences of these individuals have to be evaluated using a qualitative approach. Qualitative research can help researchers discover the feelings, values, and perceptions that underlie and affect behaviors, recognize client needs, and create hypotheses for advanced testing as well as for quantitative survey development. In comparison to quantitative studies, qualitative research gives breadth, depth, and context to questions. Moreover, qualitative research can offer investigators to get to the participants' thoughts and feelings, which can empower the understanding of the meanings that individuals attribute to their experiences (Mohajan, 2018) . Understanding the perspectives of older adults in this particular situation with the help of qualitative studies will enable policymakers and healthcare providers design appropriate preventive interventions, assess confrontation with this dual risk, promote the empowerment of older adults, and ultimately increase their adaptability to an acceptable level. Therefore, the present study aims to explain the concept of facing the double jeopardy of the COVID-19 pandemic and driving cessation in older adults. This qualitative study was conducted using thematic analysis approach in older adults of a community-based setting in Shiraz, Iran. Purposive sampling with maximum variation was used to select the participants, and sampling was continued until data saturation. The study participants included 15 older adults aged 60 years and above who had appropriate cognitive health status based on the results of an Abbreviated Mental Test Score (AMTS) and had stopped driving permanently during the past month. AMTS measures orientation, concentration/attention, and short-and long-term memory and is used to screen cognitive disorders in older adults. The total score of this test is computed by summing up the scores of 10 questions and can range from 0 to 10, with lower scores representing the higher severity of cognitive impairment. In the research carried out by Foroughan et al. the reliability of the test questions was approved by Cronbach's alpha = 0.88-0.91 in Iranian older adults. Additionally, the cut-off point of 6 was calculated for 99% sensitivity and 85% specificity (Foroughan et al., 2017) . The data were collected using semi-structured interviews. Interviews were performed within 10 months from April to December 2020 during the COVID-19 pandemic. At the beginning of the interview, the investigators introduced themselves and stated the objectives. First, the researchers asked for the demographic information to communicate with the participants and gain their trust. The following questions were asked in a general way at first and in a more specific way afterwards. For example, the participants were asked "how has your life changed since you stopped driving during the COVID-19 pandemic" or "what helped you cope with not driving in the COVID-19 period." The interviews were continued with probing questions such as "can you explain more" and "when you say …., what do you mean." The time and place of the interviews were determined according to the participants' conditions; eight interviews were conducted via video call in WhatsApp. Each interview lasted for 20-70 min. The interviews and data analysis were conducted over one year and continued until saturation. It is worth mentioning that the interviews were conducted in Persian and were translated into English. Then, they were translated from English to Persian to make sure that the original texts were preserved. The data were analyzed using the approach proposed by Braun and Clarke (2006) . First, the interviews were transcribed and read several times. Second, two members of the research team independently open-coded the data and initial codes were generated. Next, the team members searched for the potential themes during consultation sessions. The fourth stage was to review the themes, which was done by reading and re-reading the interview transcripts. The next step was to define and name each theme, which included explaining the themes and paying attention to the absence of overlap. The final stage involved the selection of vivid and compelling examples, final analysis of the selected extracts, relating the analysis to the research aim, and producing a report of the analysis (Braun and Clarke, 2006) . MAXQDA software, version 2018 was used for data analysis. To achieve trustworthiness, the authors used the criteria proposed by Lincoln and Guba (1985) including prolonged engagement with the study subject, confirmation of data analysis by two independent investigators, confirmation of the analysis by several participants, and detailed writing of the findings and the study process. To improve the trustworthiness of the research, a qualified specialist evaluated the extracted themes and subthemes. This study was approved by the Research Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Ethics approval code: IR.USWR.REC.1398.067). Oral and written informed consent for taking part in the study was obtained from the study participants. Asking the older adults for permission to record the interviews, ensuring the confidentiality of the recorded information, observing the fidelity of the interview transcripts, the right to withdraw from the study, and keeping the principle of anonymity were the other aspects of research ethics. The study participants included 15 older adults who had ceased driving during the past year. Ten participants were male and aged 67-82 years and five participants were female and aged 63-81 years. In addition, 12 participants were married and 3 were widowed. Additionally, 10 older adults lived with their spouses and children, two lived with their spouses, two lived with their children, and one lived alone. Their levels of education varied from the ability to read and write to bachelor's degree. Moreover, 10 participants were retired, 2 were homemakers, and 3 were self-employed. The participants had stopped driving for different reasons including physical and functional impairment, fear from harming themselves and others, feedback from family, friends, and others in the community, and traffic problems. A total of 350 initial codes were extracted from the detailed and in-depth descriptions of the participants. The codes were summarized after several revisions and were classified according to similarity and appropriateness. Facing the double jeopardy included two main categories, namely dualization of common challenges and fitness with limitations, which showed the older adults' experiences of driving cessation during the COVID-19 pandemic. This theme indicated double challenges in the older adults who had stopped driving during the COVID-19 pandemic. The feeling of double pressure from two sources caused the older adults to experience problems with more negative effects than one source alone. This theme consisted of the following five sub-themes: Co-occurrence of home quarantine following the COVID-19 pandemic and driving cessation intensified a kind of mandatory, preventive social isolation among the older adults. In other words, older adults had to endure staying at home and some kind of social isolation to prevent COVID-19 infection. "When I stopped driving, I stayed home, but when the COVID-19 disease started, things got much worse and I had to stay home more often" (P8: male, 75 y/o). "When I drove, I used to travel with my family, we had fun, but now I do not drive. Besides, because of the COVID-19 disease, we don't go anywhere, because it is dangerous, especially if the car is not yours" (P9: male, 67 y/o). Psychological consequences of driving cessation affected older adults in different areas, namely independence, personal identity, depression, mental health, and life satisfaction. Its coincidence with the COVID-19 pandemic, during which individuals were exposed to bad news, mourned for their loved ones, were afraid of possible exposures to the virus, had reduced social interactions, and attended religious ceremonies as well as gatherings with friends to a less extent, predisposed older adults to mental illnesses such as anxiety and depression, eventually doubling their stress levels. "After giving up driving, I was depressed for a long time until COVID-19 disease came and the news about it made me even more anxious" (P7: female, 69 y/o). "Since I quit driving, the enthusiasm of my life has diminished, and now I am constantly struggling with unreasonable fatigue and worry about my children. Hearing the statistics of the sick and the dead makes me sad" (P12: male, 72 y/o). To break the human chain and the spread of COVID-19 disease, the country's health officials have emphasized the necessity to reduce traffic and attending crowded places. It has forced many seniors to stay home and not to be able to walk even in a park near their houses. On the other hand, driving cessation during this period and fear from the COVID-19 infection in public places have caused people to lead a sedentary lifestyle. "Since I stopped driving, I have been less out of the house and I walk less. This COVID-19 pandemic has even made things worse" (P3: female, 74 y/o). "Fear from COVID-19 infection has made me less likely to go to the park and exercise. On the other hand, because I do not drive, I cannot go to farther distances and exercise and walk comfortably" (P6: female, 63 y/o). The co-occurrence of the COVID-19 pandemic and home quarantine with driving cessation resulted in the limitation of meaningful social interactions with relatives and friends. "My children are afraid to come to our house, because their mother has diabetes and they are afraid of transmitting the disease to her. On the other hand, because I do not drive, I do not go to their house alone and I see them less often" (P11: male, 82 y/o). "Since I stopped driving, I have been less likely to be with my friends and coworkers due to the difficulty of getting around. Since COVID-19 disease started, we haven't seen each other for a long time" (P2: female, 74 y/o). Older people travel in the city by car or on foot instead of using public transportation due to fear from being infected and to maintain social distance. Quitting driving makes this situation more complicated. This subcategory indicated that older adults, especially those with chronic illnesses, were less likely to use public transportation due to the COVID-19 pandemic despite quitting driving. "Since COVID-19 disease started, my wife and I have been trying to make less use of the bus or subway because of our age" (P8: male, 75 y/o). On the other hand, some older adults temporarily restricted the use of public transportation to prevent the spread of COVID-19 infection and were not able to use the vehicles of other family members. In addition, it was not easy for them to pay for closed services. Therefore, they had to struggle with more problems to meet their basic needs. "I always went to the market by bus and bought fresh fruit, but now that I do not take the bus and I do not drive. I have to buy low-quality fruit from our local shop at a higher price" (P10: male, 70 y/o). This theme revealed the participants' adaptation with the situation. It included interventions by the individuals and their families to minimize the synergy of the risks of the COVID-19 pandemic and driving cessation, leading to an easier adaptation with the situation. This theme consisted of the following four sub-themes: The limitations of driving cessation and the COVID-19 pandemic forced older adults to accept a new home-based lifestyle in order to avoid the negative consequences. Generally, each person has skills to adapt one's life to a new lifestyle. "I try to exercise at home, so that I will not become lazy" (P1: male, 67 y/o). "To help me stay home, my daughter helps me shop online" (P6: female, 63 y/o). Fear of loneliness and death, fatigue, changes in sleeping patterns, stress, and frustrating thoughts were some experiences in this period. However, establishment of proper relationships between older adults and their children can create a calm and lively environment. To better and more effectively communicate with their parents, children should consider these issues and choose the appropriate solution accordingly. This will, in turn, allow older people to spend more time with their children. "I have fun with my grandchildren. They are so sweet-speaking that I like to spend most of my time with them. This gives me patience and hope that I can cope with my losses and my emptiness, so that I can adapt with my problems" (P5: female, 80 y/o). Older adults' friendship with the cyberspace provides the conditions for them to cope more easily with loneliness, isolation, and limited social relationships due to the double jeopardy of COVID-19 pandemic and driving cessation. In fact, the cyberspace provides a platform that increases the interaction amongst people while being at home, helps older adults feel less lonely, and fills their time. "In WhatsApp, I have a group of coworkers and friends who have been very helpful for me, especially during this time, and we are in touch. We take photos and send videos. This makes me feel less alone" (P12: male, 72 y/o). "During this time, I have learned to make video calls with my children and relieve depression" (P15: male, 68 y/o). The development of online stores with the expansion of the cyberspace business infrastructure has been a step towards increasing public welfare and easy access to shopping. "My daughter showed me some shirts on the Instagram. We picked one up together and ordered it online. It was very comfortable; we sat at home and walked around the market" (P2: female, 74 y/o). Families are an essential source of support that can reduce stress and anxiety in older adults by providing social support including emotional and practical support as well as by sharing information and news. "During these COVID-19 days, when I do not drive and I have to stay at home, my son does the shopping" (P2: female, 74 y/o). "My daughter keeps calling us and does not let us feel alone" (P8: male, 75 y/o). This study explained the concept of facing the double jeopardy of the COVID-19 pandemic and driving cessation in Iranian older adults. The study results showed that in the face of this double jeopardy, older adults faced additional pressures such as mandatory social isolation, exacerbation of emotional pain, warning of a sedentary lifestyle, narrowing the circle of meaningful communication, and gaps in transportation needs. To overcome and adapt with these limitations, they used such strategies as the acceptance of a new home-based lifestyle, strengthening intergenerational relationships, friendship with the cyberspace, and building a supportive family network. Different groups of older persons, especially those in need of external support such as informal or paid caregivers or nursing homes, as well as those living in the community (including those residing in assisted living facilities and other senior housings outside nursing home facilities) are more sensitive to the COVID-19 pandemic and its consequences (Cohen and Tavares, 2020) . The COVID-19 pandemic and the associated social distance have brought about considerable changes in interaction with the family and friends as well as in other relationships among the older adults who no longer drive. One of the unintended consequences of social distancing, especially for close social groups such as family and friends, is the increase in forced social isolation followed by feeling of loneliness, which have been found to be associated with deteriorating mental health and well-being as well as with a 25-30% increase in the risk of mortality amongst older adults (Chatters et al., 2020) . The results of the study by Kotwal et al. indicated that older adults mentioned social isolation during the pandemic in nearly half of the interviews (Kotwal et al., 2021) . Hansen et al. also disclosed that the older people who no longer drove had more difficulty in socializing (Hansen et al., 2020) . This social isolation was partly due to the inability to drive to meet family and friends and partly to the lack of transportation to engage in social activities. Generally, the older adults who cease driving with restricted resources are at an even greater risk of social isolation, which is exacerbated due to the COVID-19 pandemic. Identifying social isolation or social support deficiencies may be a gateway for identification of vital unmet needs amongst older adults. In general, pandemics are quite stressful for everyone and can accelerate the onset or recurrence of mental disorders such as depression, anxiety, sleep disorders, and other problems in some people, especially vulnerable older adults (Hwang et al., 2020) . These people experience more insecurity due to conflicting and suspicious information about disease transmission, inadequate control measures, and lack of effective treatment mechanisms (Bhattacharjee and Acharya, 2020) . The mental disorders caused by this pandemic are exacerbated in the older adults who no longer drive. A study by Stinchcombe et al. indicated that driving cessation was associated with a higher rate of depression and mental distress (Stinchcombe et al., 2019) . Moreover, Shrira et al. reported a significant relationship between loneliness due to social isolation following the COVID-19 pandemic and the levels of anxiety, depression, and traumatic distress in older adults (Shrira et al., 2020) . Overall, older adults experience an increased risk of mental disorders due to driving cessation resulting from such conditions as the COVID-19 pandemic. Physical activity is essential for older people to maintain a level of independence and prevent functional decline. Driving cessation restricts the mobility and freedom of older adults and puts them at risk of a sedentary lifestyle. Although quarantine is a measure to protect the older population from COVID-19 pandemic, staying home can lead to negative consequences such as reduced physical activity and inactivity. The results of a study by Goethals et al. indicated that older people refrained from group sport activities due to the fear of infection (Goethals et al., 2020) . Another study by Amagasa et al. demonstrated that older drivers were more physically active compared to those who did not drive, indicating greater access to outdoor activities or expansion of the social network (Amagasa et al., 2018) . Overall, not driving during the COVID-19 pandemic can accelerate the progression of a sedentary lifestyle and functional decline. Long-term social distance during a pandemic and reduced contact with loved ones can limit meaningful relationships in older people. The results of the research by Chee showed that older people living in aged care homes were separated from their families and loved ones during the pandemic and could not spend time with them (Chee, 2020) . Furthermore, the results of the study by Mezuk et al. revealed a 50% reduction in the size of the friendship network after driving cessation due to traffic difficulties (Mezuk and Rebok, 2008) . Driving cessation was also associated with a decrease in the extent of social networks, which was exacerbated by the COVID-19 pandemic. In general, older adults need public transportation for commuting after driving cessation. Nonetheless, the widespread prevalence of COVID-19 infection has forced older adults to use public transportation less due to the fear of being infected. De Vos explained in his study that because of the COVID-19 pandemic, people reduced their trips and preferred to use their private cars rather than public transportation. Driving cessation also challenged this situation and put people at a greater risk of social isolation (De Vos, 2020) . The low frequency of public transportation may increment waiting times and widen the gaps in transportation needs among the older adults who do not have the choice to utilize their cars for trips. Thus, it is imperative to preserve the mobility of the older adults who do not own a car by guaranteeing satisfactory levels of sustainable transportation even during particular situations such as the COVID-19 pandemic. Home quarantine, restrictions imposed by COVID-19 pandemic, and lack of personal means of transportation have led older adults to accept a new lifestyle. A study by Cancello et al. found that more than a third of people could reorganize their lives during forced home quarantine (Cancello et al., 2020) . In contrast, the results of a study by Takashima et al. showed that despite social distancing, no considerable changes were observed in people's daily lives (Takashima et al., 2020) . Generally, life changing events such as driving cessation may influence lifestyle behaviors. The COVID-19 pandemic has also changed the lifestyle drastically. This situation may motivate people to accept a new home-based lifestyle including online shopping and exercising at home. Acceptance of this new home-based lifestyle seems to be an important alternative to adapt with this dual risk. Regardless of the possibility of transmitting the infection, strengthening intergenerational integrity can help older adults cope with stress (Ayalon et al., 2020) . In the research conducted by Williams et al. several participants argued that because of the COVID-19 pandemic, they could gain positive points from social distancing and quarantine. In fact, they could spend more time with their grandchildren (Williams et al., 2020) . The grandparent-grandchild attachment is a basic intergenerational relationship that can be useful for both generations. Intergenerational integrity can help reduce social isolation and loneliness among the older adults who have stopped driving during the COVID-19 pandemic and decrease ageism in young adults (McDarby et al., 2021) . One possible solution to deal with this dual risk and communicate with others is to use video chats (e.g., Skype) or online social media (e.g., Facebook). These solutions may temporarily replace physical contact (for example, with friends, acquaintances, children, or grandchildren), compensate for the inability to go to children's homes, and reduce the feeling of social isolation or loneliness (Hajek and König, 2021) . However, many older persons may not be familiar with these new technologies, and this style of interaction may not be able to meet their emotional needs effectively. Yet, older adults can overcome technological barriers with the help of their families and friends (Hwang et al., 2020) . Chen et al. stated that technologies such as telephone, Internet, and email played an important role in individuals' daily lives including information sharing, social networking, and shopping (Chen et al., 2021) . Nevertheless, the results of a study by Ahmad et al. showed that social media played a crucial role in spreading anxiety about the outbreak of COVID-19 pandemic in Iraqi Kurdistan (Ahmad and Murad, 2020) . Families and caregivers need to ensure access to food and medicine and meet the needs of older adults, especially when they have to stay home due to social distance or lack of transportation means (Hwang et al., 2020) . Kotwal et al. disclosed that telephone calls were the most common means of familial interaction with older adults, which provided emotional support (Kotwal et al., 2021) . Moreover, Choi et al. found that family support for transporting the older people who no longer drove helped prevent social isolation (Choi et al., 2012) . Building a supportive family network is a coping strategy, which is related to a higher quality of life and well-being amongst older adults. Evidence has indicated that receiving support from the family network can optimize self-perception and feeling of commitment to others, create happiness, and boost life satisfaction in older adults (Tomini et al., 2016) . Based on the results of the current qualitative study, larger scale quantitative or longitudinal studies, specifically using moderation analysis, are recommended to further investigate the social and psychological effects of this phenomenon. Moreover, since this research was performed on older adults without cognitive impairment, future investigations are suggested to be conducted on older adults with dementia and other cognitive disorders. Despite the researchers' efforts to enroll participants with maximum diversity, one of the study limitations was the lack of access to older adults with a variety of cultural and social backgrounds. Furthermore, this study was performed qualitatively on the older persons without cognitive impairment. Thus, the results cannot be generalized to other older adults in the community (including nursing homes, etc.). The COVID-19 pandemic has caused a double risk amongst older people who no longer drive, thereby creating challenges in this population. Although this double jeopardy endangers the health of older adults in various dimensions, it can be the beginning of a new era in their life and care. In this context, the application of telecommunication technology as well as home-and community-based applications increases the flexibility of older adults as well as their ability to cope with stress and meet their mental, social, and physical health needs. Family members, friends, local charities, voluntary organizations, media, and healthcare providers can also work together through an organized and comprehensive approach to support these individuals during social isolation so as to minimize the adverse effects of this risky situation. Furthermore, the government and public health authorities should look for ways to expand access to health services such as telemedicine and telephone counseling and strengthen self-care amongst older adults. This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors. None declared. 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They would also like to appreciate Ms. A. Keivanshekouh at the Research Consultation Center (RCC) of Shiraz University of Medical Sciences for improving the use of English in the manuscript. Thanks also go to all the seniors who participated in this study.