The Mediating Role of Meaning in Life in the Relationship Between Character Strengths and Rejection Sensitivity in Individuals with Physical-Motor Disabilities

Disability is an undeniable reality that has always existed as a social phenomenon in human societies. This condition stems from an individual's impairment or disability, limiting or disrupting their ability to perform one or more natural roles defined by age, gender, and other cultural and social factors (Sharma et al., 2021). Physical-motor disability has physical and psychological dimensions that affect an individual's physical and mental health. Individuals facing this type of disability often encounter physical and social limitations that can impact their mental health. They may experience a sense of loss and painful limitations that are physically and emotionally significant. According to the World Health Organization, individuals with disabilities are at a higher risk for psychological and social problems and require special support in this regard (Kim et al., 2025). Individuals with physical-motor disabilities are defined as those who, for any reason, have weakness, impairment, or disability in their motor system or require assistive devices for movement. Estimating the precise prevalence of physical-motor disability is difficult, but statistics show that among the population under 60, this type of disability affects about 10% of the individuals, and its prevalence increases significantly in individuals over 60 (Asadi et al., 2024). According to a 2023 WHO report, over 1.3 billion people worldwide live with a significant disability, equivalent to 16% of the global population. This number is increasing, and many people with disabilities live in low- and middle-income countries. Individuals with disabilities face multiple challenges in all life dimensions and experience extensive limitations in social, economic, environmental, and cultural domains (Gréaux et al., 2023).

Individuals with physical-motor disabilities, in addition to physical problems, also face social and psychological challenges. Experiences of rejection and discriminatory behaviors in society make these individuals more sensitive to social rejection and exclusion. This means they react more quickly and intensely to negative or depriving behaviors from others. Societal stereotypes and negative attitudes towards physical disability, portraying them as incomplete individuals and limiting social interactions, increase this sensitivity and lead to negative reactions in social relationships (Kumar et al., 2024).

Rejection sensitivity can lead to defensive reactions and a state of alertness towards ambiguous social cues. Individuals with high rejection sensitivity automatically show defensive reactions even when faced with uncertain signals from others, interpreting these cues as signs of rejection. These reactions can lead to hostile behaviors and, ultimately, actual experiences of rejection (Shin et al., 2024). Given that rejection sensitivity can affect the quality of life and psychological well-being of individuals with physical-motor disabilities, identifying factors that reduce it is of great importance.

One factor that may prevent rejection sensitivity is character strengths. These strengths are considered a subset of personality traits with moral value that naturally manifest in an individual's thinking, feeling, and behavior, providing higher performance and efficacy. Unlike talents, whose value primarily stems from tangible outcomes, strengths are considered valuable due to their intrinsic and moral nature (Peterson & Seligman, 2004). These strengths are typically classified into six categories: wisdom and knowledge, courage, justice, humanity, temperance, and transcendence (Austin & Dawson, 2014). Some strengths are psychological in nature, enabling individuals to perceive potentially threatening events as less threatening and to control their responses to them. Positive psychologists help individuals and organizations identify their strengths and use them to enhance well-being through various methods  (McGrath, 2015). Research shows that individuals with higher character strengths have a greater ability to confront and adapt to life  problems, experience more meaning in life, see improvement in their physical, emotional, and social functioning, and have increased positive emotions (Brito & Soares, 2023). Also, character strengths lead to increased self-esteem, efficacy, resilience, happiness, life satisfaction, psychological well-being, and reduced symptoms of depression (Niemiec, 2023). Therefore, previous research has shown that individuals with higher character strengths experience higher levels of efficacy and self-esteem, have less self-criticism, and establish more favorable social relationships (Brito & Soares, 2023; Niemiec, 2023). However, most of these studies have been conducted in the general population or other specific groups, and the mediating role of variables such as meaning in life in the relationship between character strengths and rejection sensitivity in individuals with physical-motor disabilities has been less investigated. Therefore, the present study, aiming to examine the mediating role of meaning in life in this relationship, is necessary and can contribute to a better understanding of factors affecting the mental health and well-being of this group.

Another important factor in rejection sensitivity is meaning in life. The Greek word 'logos' means 'meaning,' and 'logotherapy,' founded by Viktor Frankl, emphasizes finding personal meaning in life. Frankl believed that the search for meaning is the primary human motivation and that life can be meaningful even under the most difficult conditions (Frankl, 1984). According to this perspective, suffering and problems themselves do not destroy a person; rather, the lack of meaning and purpose in life does. In this vein, logotherapy encourages individuals to view life differently, discover positive values, and provide a constructive response to circumstances despite difficulties (Frankl, 2011). Previous studies show that a lack of meaning in life is associated with depression, self-criticism, and reduced quality of life (Baquero-Tomás et al., 2023; Nikdel et al., 2021; Pérez Rodríguez et al., 2024). Individuals with physical-motor disabilities, due to limitations and facing social stigma, are more susceptible to rejection sensitivity. Meaning in life, by focusing on an individual's internal values, goals, and strengths, enhances self-worth and a sense of personal competence. Therefore, the individual becomes less dependent on the approval or acceptance of others, and their sensitivity to rejection decreases. In other words, focusing on the internal aspects of life reduces dependence on others and negative reactions to rejection. Training based on logotherapy can help improve psychological well-being and reduce rejection sensitivity in these individuals by increasing self-esteem, accepting unavoidable conditions, and strengthening personal meaning and purpose (Golshan et al., 2020).

As mentioned, character strengths can directly affect rejection sensitivity in individuals with physical-motor disabilities. However, character strengths may also have an indirect effect on rejection sensitivity by enhancing meaning in life. In other words, meaning in life can act as a mediating variable, shaped by an individual's internal strengths and values. The character strengths scale encompasses four main virtues, each of which can be related to finding meaning in life. Wisdom, courage, humanity, and transcendence. Each virtue includes specific strengths and skills and can be related to finding meaning in life in a specific way. The virtue of wisdom includes strengths such as analytical thinking, informed decision-making, and reasoning ability, enabling individuals to manage their lives with clarity and purpose and find meaning in their decisions and experiences.

The virtue of courage, encompassing bravery, resilience, and perseverance in the face of difficulties, allows individuals to confront problems and find meaning and value in pursuing personal goals. The virtue of humanity, including kindness, empathy, and selflessness, helps individuals have a meaningful and purposeful life experience by creating positive connections and supporting others. The virtue of transcendence, which includes strengths such as hope, purposefulness, and a growth mindset, enables individuals to achieve a positive and meaningful perspective on life even under difficult circumstances (Hassani-Rad, 2021). For example, research shows that character strengths are positively associated with experiencing a meaningful life; in other words, the higher an individual's character strengths, the more they are able to experience their life as more meaningful and purposeful (Casali & Feraco, 2025; Russo-Netzer et al., 2023).

 Put differently, character strengths, as positive internal traits, can lead to reduced rejection sensitivity and enhanced psychological well-being through promoting meaning in life. This mediating role functions by meaning in life increasing feelings of self-worth, enhancing self-esteem, strengthening resilience and coping abilities, and reducing psychological dependence on others' approval, thereby creating the ground for reduced rejection sensitivity. In other words, individuals with higher strengths, by experiencing a more meaningful and purposeful life, are less dependent on others' acceptance and thus feel less sensitive to rejection (Lin & Jiang, 2023). For example, a study showed that using character strengths is associated with increased self-esteem and reduced stress, which can help reduce rejection sensitivity (Azañedo et al., 2021).

Despite previous research examining the role of character strengths and meaning in life on mental health and well-being, a significant gap remains in understanding the factors affecting rejection sensitivity in individuals with physical-motor disabilities. Most existing studies have been conducted in the general population or other specific groups and have not directly examined this relationship in the population with physical-motor disabilities. Furthermore, the mediating role of meaning in life in the relationship between character strengths and rejection sensitivity has been less investigated. This research gap indicates insufficient clarity regarding the mechanisms through which character strengths can reduce rejection sensitivity. Given that rejection sensitivity can have widespread negative consequences on the quality of life, psychological well-being, and social interactions of individuals with physical-motor disabilities, understanding related factors and identifying mediating variables in this relationship has high empirical importance. Also, from a theoretical perspective, examining the role of character strengths and meaning in life in reducing rejection sensitivity can contribute to the development of positive psychology theories and predictive models of mental health in specific populations.

Therefore, the research question of the present study is whether character strengths can reduce rejection sensitivity in individuals with physical-motor disabilities by enhancing meaning in life. Investigating this relationship, in addition to developing positive psychology theories, clarifies the necessity of the present research and can assist in designing psychological and educational interventions to reduce rejection sensitivity and enhance the quality of life for this group.

Method

The present research was an applied study with a descriptive-correlational method using structural equation modeling. The statistical population of this study consisted of individuals with physical-motor disabilities residing in Mashhad in 2023, whose disability was confirmed by experts from the Welfare Organization. The population included individuals with various types of physical-motor disabilities, including amputation, skeletal abnormalities, and spinal cord injuries, with severity levels ranging from mild to severe. Due to conditions created by the COVID-19 pandemic, sampling was conducted using a convenience method via the internet. The research population included all individuals with physical-motor disabilities residing in Mashhad in 2023 whose disability was confirmed by Welfare Organization experts (approximately 5000 people). To determine the sample size, Cochran's formula was used with a sampling error of 5%, estimating the required sample size to be approximately 350 individuals. In this study, initially 350 eligible individuals were invited, and after applying the criteria and removing incomplete data, information from 330 individuals was usable for final analysis. For research employing modeling and path analysis approaches, samples of 300 or more are necessary (Guadagnoli & Velicer, 1988). In this study, initially 350 eligible individuals with physical-motor disabilities were invited using inclusion and exclusion criteria. After applying the criteria and removing incomplete data, information from 330 individuals was usable for final analysis.

Inclusion criteria for the study consisted of having a physical-motor disability according to medical records, a minimum education level of primary school, and providing informed consent and willingness to participate. Exclusion criteria included taking psychiatric medication or having a diagnosed psychiatric disorder by a psychiatrist. After obtaining participants' consent and explaining the research objectives, online questionnaires were provided to them. They were asked to carefully read the questions and select answers based on their own characteristics. Data were collected individually, and participants were assured that all information would remain confidential. Furthermore, participants could withdraw from participation at any stage if they no longer wished to continue responding.

Data analysis was conducted in two parts: descriptive statistics (using indices such as mean, standard deviation, and correlation matrix) and inferential statistics (via structural equation modeling). Data processing was performed using SPSS and AMOS software, version 23.

Measures

Values in Action Inventory of Strengths (VIA-IS): This instrument was designed by Peterson and Seligman (2004) to measure positive personality strengths within the framework of six main virtues. The original version of this scale consists of 24 items assessing strengths within the categories of wisdom and knowledge, courage, humanity, justice, temperance, and transcendence. Participants respond to each item on a five-point scale from 1 (strongly disagree) to 5 (strongly agree), with the potential score range varying from 24 to 120. A higher score indicates greater character strengths. Previous research has shown that this scale has appropriate validity and reliability. Peterson and Seligman (2004) reported an internal consistency coefficient above 0.7 in a study in Germany, and the scale's Cronbach's alpha coefficient was 0.7. Park et al. (2004) tested the German version of the questionnaire on 1674 adults and obtained an average alpha coefficient of 0.77 and a test-retest reliability of 0.73 over a one-month interval. In Iran, Namdari (2010) standardized and validated this questionnaire. Factor analysis extracted four factors: humanity, wisdom, responsibility, and care, which together explained 78.36% of the test variance; however, it was noted that the original subscales of the six virtues were still usable in analyses. In that study, test-retest coefficients ranged from 0.62 to 0.86, and Cronbach's alpha ranged from 0.86 to 0.96. In the study by Namdari et al. (2009), the total scale's Cronbach's alpha was 0.98, and for the subscales of wisdom, courage, humanity, justice, temperance, and transcendence, it was 0.95, 0.95, 0.94, 0.95, 0.95, and 0.94, respectively.

Rejection Sensitivity Questionnaire (RSQ): This questionnaire was designed by Downey and Feldman (1996) to assess rejection sensitivity in individuals. The scale consists of 18 two-part questions (a and b) scored on a six-point Likert scale. In part (a) of each question, the individual's anxiety in the related situation is measured (1= not at all concerned to 6= very concerned). In part (b), the perceived likelihood of receiving a positive response from the other person is assessed (1= very unlikely to 6= very likely). For example, one question is: "You ask your friend to do you a big favor." In part (a), the individual is asked, "How concerned would you be that your friend would do it?" and in part (b), "What is the likelihood that your friend would gladly do it?" The method for calculating the final rejection sensitivity score is as follows: First, the scores from part (b) ("expectation of acceptance") are subtracted from 7. The result is then multiplied by the score from part (a) ("anxiety level"). The average of the resulting scores for the 18 situations represents the final rejection sensitivity score. The minimum score for this questionnaire is 1 and the maximum is 36; a higher score indicates greater individual sensitivity to rejection. This questionnaire is psychometrically valid. In the original sample of 321 girls and 263 boys, Cronbach's alpha = 0.88 and acceptable test-retest reliability were reported. Factor analysis of principal components accepted a single general factor explaining 27% of the variance, with all items having factor loadings above 0.3. Subsequent studies have also shown that the RSQ possesses desirable psychometric properties; for example, Berenson et al. (2018) reported a Cronbach's alpha of 0.89 and test-retest reliability of 0.99. In Iran, studies by Karamlou et al. (2016) and Tajaldini et al. (2018)reported Cronbach's alpha coefficients between 0.81 and 0.83 and confirmed the content validity of the scale.

Meaning in Life Questionnaire (MLQ): This questionnaire was designed by Steger et al. (2006) to measure the degree of meaning in life. It consists of 10 items scored on a seven-point Likert scale (from "strongly disagree" to "strongly agree"). The instrument has two subscales: Presence of Meaning and Search for Meaning. Items 1, 4, 5, 6, and 9 assess the presence of meaning, and the remaining items assess the search for meaning. Only item number 9 is reverse-scored. Numerous studies have confirmed the psychometric properties of this questionnaire. Steger et al. (2006) reported satisfactory internal consistency coefficients for both subscales (Cronbach's alpha 0.81 for presence of meaning and 0.84 for search for meaning), and appropriate reliability coefficients were obtained in a one-month retest (0.70 for presence of meaning and 0.73 for search for meaning). In Iran, the psychometric properties of this tool have also been examined and confirmed. Mesrabadi et al. (2013) standardized the questionnaire in Iran and, in confirmatory factor analysis, showed that all factor loadings for both subscales were above 0.5 and significant, with discriminant validity reported as 0.89 using discriminant function analysis. Also, Eshtehad (2009) in their research reported Cronbach's alpha for the presence of meaning subscale as 0.78 and for the search for meaning subscale as 0.75. These results indicate the desirable reliability and validity of the questionnaire for use in the Iranian population.

Results

The present study sample consisted of 330 individuals, of whom 221 were male (67%) and 109 were female (33%). Regarding marital status, 230 were single (69.7%) and 100 were married (30.3%). In terms of education, 74 had primary education (22.4%), 81 had middle school education (24.5%), 92 had high school and diploma (27.9%), 71 had associate's or bachelor's degrees (21.5%), and 12 had master's degrees or higher (3.6%). Regarding employment status, 25 were full-time employed (7.6%), 108 were part-time employed (32.7%), and 197 were unemployed (59.7%). Furthermore, regarding the type of physical disability, 16 had amputation (4.8%), 105 had skeletal abnormalities (31.8%), and 209 had spinal cord injuries (63.3%). The mean and standard deviation of the age of individuals with physical-motor disabilities participating in the study were 32.09 and 8.46, respectively. Table 1 presents the descriptive indices of the variables character strengths, meaning in life, and rejection sensitivity in individuals with physical-motor disabilities.

Table 1.

Mean and Standard Deviation of Research Variables

Before presenting the results of Pearson correlation analysis, the assumptions of parametric tests were examined. In this regard, the status of missing data, normality of variables, independence of errors, and absence of multicollinearity were first evaluated. Then, after confirming sample size adequacy and appropriate data fit for analysis, Pearson correlation test and structural equation modeling were performed.

In the first step, the mean substitution method was used to handle missing data. To assess the normality of variables, skewness and kurtosis indices were calculated; the range of skewness coefficients was between -1.30 and 0.40, and kurtosis coefficients ranged between -0.51 and 0.77. Given that all skewness and kurtosis values fell within the range of +2 to -2, it can be concluded that the distribution of research variables had acceptable normality. Another important assumption of path analysis is the absence of multicollinearity among independent variables. Pearson correlation results (Table 2) showed that the correlation between predictor variables was less than 0.90, and therefore this assumption was met.

Table 2.

Correlation Matrix of Research Variables

Additionally, univariate outliers were examined using box plots, and the results indicated no outliers in the dataset. To examine the independence of errors, the Durbin-Watson statistic was calculated (DW = 1.85), indicating the assumption of error independence was met. Also, to ensure the absence of multicollinearity, tolerance and Variance Inflation Factor (VIF) indices were examined. Results showed that tolerance values were less than 1 and VIF values were less than 10, confirming this assumption as well. Subsequently, the KMO sample adequacy measure was 0.94, and Bartlett's test of sphericity was significant (df=105, P<0.01), indicating the suitability of the data for structural equation modeling. Accordingly, the findings related to the measurement models of the research variables are presented.

Figure 1.

Structural Model of Character Strengths and Rejection Sensitivity Mediated by Meaning in Life in Participants

According to the results in Table 3 and Figure 1, after ensuring the existence of correlations between components, the unstandardized and standardized regression coefficients of the model paths for character strengths and rejection sensitivity mediated by meaning in life in individuals with physical-motor disabilities were examined. The direct effect of character strengths on rejection sensitivity was significant and negative (β = -0.43, p < 0.001). The direct effect of character strengths on meaning in life was significant and positive (β = 0.67, p < 0.001). The direct effect of meaning in life on rejection sensitivity was also significant and negative (β = -0.36, p < 0.001).

Table 3.

Unstandardized and Standardized Regression Coefficients of the Model Paths for Character Strengths and Rejection Sensitivity Mediated by Meaning in Life in Participants

According to Table 4, results indicate that the fit of the conceptual research model with the data is favorable. All fit indices, including GFI, AGFI, CFI, NFI, IFI, and RMSEA, are within the range of accepted criteria (Hu & Bentler, 1999). This finding suggests that the proposed model is capable of explaining the relationships between the research variables, and we can proceed to examine the mediating role of "Meaning in Life" in the relationship between character strengths and rejection sensitivity.

Table 4.

Model Fit Indices

To examine the mediating role of meaning in life in the relationship between character strengths and rejection sensitivity in individuals with physical-motor disabilities, the Bootstrap test was used.

Table 5. Results of the Bootstrap Test for Examining Indirect Paths

According to the results in Table 5, the indirect effect coefficient of character strengths on rejection sensitivity through the mediating role of meaning in life (β = -0.25, p < 0.001) was significant. In accordance with the Bootstrap results, the indirect path of the model was confirmed. Consequently, the mediating role of meaning in life in the relationship between character strengths and rejection sensitivity in individuals with physical-motor disabilities is confirmed.

Discussion

The present study aimed to examine the mediating role of meaning in life in the relationship between character strengths and rejection sensitivity in individuals with physical-motor disabilities. The results of data analysis showed that character strengths have a significant, direct, and negative effect on rejection sensitivity; meaning that as the level of character strengths increases, the degree of rejection sensitivity in these individuals decreases. This finding is consistent with previous research which has shown that positive personality traits can play a protective role against negative psychological and social outcomes (Austin & Dawson, 2014; Peterson & Seligman, 2004; Sharma et al., 2021 ).

Character strengths, as a set of positive and value-based traits, include components such as courage, hope, kindness, self-control, and honesty, which enable individuals to show more adaptive responses when facing difficult conditions and threatening situations. Individuals with physical-motor disabilities, due to experiencing physical limitations and frequent encounters with negative societal attitudes and discriminatory behaviors, are exposed to higher levels of rejection sensitivity. However, possessing character strengths can, by strengthening a sense of worth, increasing self-esteem, and enhancing interpersonal skills, reduce the fear of rejection and help improve the quality of social relationships for such individuals (Kim et al., 2025 Niemiec, 2023).

Furthermore, the study findings showed that character strengths have a significant, direct, and positive effect on meaning in life. This result aligns with the findings of Casali and Feraco (2025) and Russo-Netzer et al. (2023), which indicate that individuals with higher levels of character strengths experience their lives as more meaningful, purposeful, and valuable. Character strengths, particularly components like hope, gratitude, courage, and humanity, help individuals find personal meaning and purpose for their lives even under restrictive and challenging conditions, and interpret their sufferings within a meaningful framework. In explaining this finding, it can be said that character strengths, by providing positive cognitive and emotional frameworks, enable individuals to perceive negative events as less threatening and feel a greater sense of control and competence over their lives. Based on the positive psychology perspective, these strengths act as stable internal resources that help individuals experience meaning not only in favorable conditions but also in the face of difficulties (Niemiec, 2023).

Another important finding of the present study showed that meaning in life has a significant, direct, and negative effect on rejection sensitivity. This result is consistent with both domestic and international research indicating that a lack of meaning is associated with increased social anxiety, self-criticism, and psychological vulnerability, while experiencing a meaningful life is linked to reduced sensitivity to negative evaluations by others and an increased sense of psychological security (Baquero-Tomás et al., 2023; Frankl, 1984 ; Nikdel et al., 2021).

From Frankl's logotherapy perspective, meaning plays a central role in maintaining human mental health. When individuals perceive their lives as meaningful and purposeful, they become less dependent on external validation. Consequently, their reactions to rejection or ambiguous social cues become less emotional and defensive. In individuals with physical-motor disabilities, meaning in life can reduce the intensity of negative reactions to social rejection by focusing on internal values, personal goals, and a sense of usefulness, thereby aiding psychological adaptation.

The results revealed that meaning in life plays a significant and partial mediating role in the relationship between character strengths and rejection sensitivity. In other words, character strengths, in addition to their direct effect on reducing rejection sensitivity, also indirectly contribute to reducing rejection sensitivity by enhancing meaning in life. This finding aligns with previous research that emphasizes the mediating role of meaning-making variables in the relationship between positive personality traits and psychological outcomes (Asadi & Oskouyi-Shomali, 2024; Golshan et al., 2010).

Conclusion

Findings indicate that character strengths, by reinforcing meaning in life, increase feelings of self-worth, self-esteem, and psychological resilience. As a result, the individual's dependence on the acceptance and approval of others decreases, and sensitivity to rejection lessens. However, since the direct effect of character strengths on rejection sensitivity remained significant, it can be concluded that meaning in life is only one of the explanatory mechanisms in this relationship, and other factors may also play a role.

In summary, the findings of the present study demonstrate that rejection sensitivity in individuals with physical-motor disabilities is not merely a consequence of facing physical limitations or negative social attitudes. Instead, it can be explained within the framework of internal psychological resources and meaning-making processes. Unlike many previous studies that examined the variables of character strengths, meaning in life, or rejection sensitivity separately, the present study, by integrating these constructs into an analytical model, shows how character strengths can modulate individuals' emotional reactions to social rejection, both directly and through the enhancement of meaning in life. This explanatory model creates a conceptual link between positive psychology and meaning-centered approaches, showing that positive internal resources can play an active role in the psychological adaptation of individuals with physical-motor disabilities. Thus, the results of the present study not only confirm previous findings but also, by providing an integrated explanation, contribute to a deeper understanding of the psychological mechanisms related to rejection sensitivity in this group.

Limitation and Future Studies

The present study has limitations that should be considered when interpreting the results. Limitations include the online administration of questionnaires, the use of convenience sampling, and the lack of control for influential factors and variables such as age, gender, socioeconomic status, and education level, which could affect character strengths, meaning in life, and rejection sensitivity. Therefore, future research is recommended to be conducted with larger populations and control for these influential variables to increase the generalizability of the results.

Practical suggestions from the research include utilizing the findings in counseling, rehabilitation, and psychological education programs aimed at promoting character strengths and increasing meaning in life for individuals with disabilities. Psychologists and counselors can reduce negative attitudes and psychological injuries related to rejection sensitivity by teaching positive personality skills and strengths. Educational programs by support organizations and rehabilitation centers can contribute to enhancing the mental and social health of these individuals by emphasizing the importance of meaning in life and character strengths.

Acknowledgments

We hereby express our gratitude to all individuals who assisted in the advancement of this research. It should be noted that this article is derived from the master's thesis of the first author.

Funding

The authors have not received any financial support from governmental, public, commercial, or non-profit organizations.

Authors’ Contribution

Azam Zarbi: Study design, data collection, data analysis and interpretation, drafting the initial manuscript.

Yasser Rezapour Mirsaleh: Conceptualization and study design, supervision of the research process, critical revision of intellectual content.

Mohammad Hadi Safi: Critical revision of intellectual content, provision of methodological guidance.

Zahra Sadat Loghmani: Critical revision.

Conflict of Interest

No conflict of interest is observed in the present study, and its results have been presented completely clearly and without any bias.

Ethical Consideration

This study complied with the ethical standards of the Declaration of Helsinki. Participants were fully informed about the study objectives and procedures, signed written informed consent, and were assured of confidentiality and anonymity throughout the research process. The authors acknowledge the use of an AI-based language model (ChatGPT, OpenAI) for professional English translation, native-level editing, and text summarization of the original Persian draft.

Patient Consent

Before inclusion, all participants signed informed consent forms.

Data Availability Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.