Investigating ethical considerations in the communication network of married women undergone hysterectomy: Instrumentation of a questionnaire

Investigating ethical considerations in the communication network of married women undergone hysterectomy: Instrumentation of a questionnaire | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Investigating ethical considerations in the communication network of married women undergone hysterectomy: Instrumentation of a questionnaire Elahe Bahador, Laleh Tajadiny, Abolfazl Hossein Nataj, Masumeh Ghazanfarpour, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3964945/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Dec, 2024 Read the published version in BMC Medical Ethics → Version 1 posted 10 You are reading this latest preprint version Abstract Introduction: Considering the importance of complying medical and general ethics and the lack of a study on determining ethical considerations in the communication network of women undergoing hysterectomy surgery, this study aimed to present these aspects in the patients' lives by a standard researcher-made instrument. Method: This mixed method analysis (exploratory sequential mixed methods design was conducted in the whole of 2020 to create the “ethical considerations in communication network of women undergone hysterectomy” questionnaire and investigate its psychometric properties. A researched-made instrument was validated and its psychometric properties were checked among 218 women by confirmatory factor analysis (CFA). Results: Accordingly, the 8 factors extracted included “complying ethical consideration by the physician (a)”, “complying ethical consideration by medical team (b)”, “complying ethical consideration in the hospital (c)”, “complying ethical consideration by the secretory in the clinic (d)”, “complying ethical consideration by the spouse (e)”, and “complying ethical consideration by the family and friends (f)”, “complying ethical consideration by the media and society (g)” and “complying ethical consideration by herself (h)”. The results of Cronbach's alpha test showed that there is moderate to good internal consistency in all dimensions. Cronbach's alpha for the whole questionnaire was calculated as 0.75, which shows that the internal consistency is at a good level. Conclusion: According to the results of this study, the reliability (internal consistency) and construct validity of the ethical considerations in the communication network of women undergoing hysterectomy questionnaire were confirmed. However, in light of the study limitations, caution should be practiced in the interpretation of the results. There is a need for further longitudinal studies in multiple settings using random sampling methods. Figures Figure 1 Introduction Hysterectomy is the second most common operation performed on women after a cesarean section ( 1 ). Over half a million women undergo a hysterectomy procedure for reproductive issues each year ( 2 ). Most of hysterectomies are performed to treat benign conditions such as uterine fibroids, endometriosis, and symptoms such as uncomfortable menstrual bleeding ( 3 ). Some hysterectomies are performed inappropriately and are due to lack of diagnostic evaluation or failure of alternative treatments ( 4 ). The prevalence of Peripartum Hysterectomy among Iranian pregnant women was 2.81 per 1000 deliveries ( 5 ). Having a hysterectomy impacts a woman's life in a significant manner. As such, deciding to undergo a hysterectomy is a difficult process for women, especially from a psychological perspective. Following a hysterectomy, women commonly experience changes in body perception, such as perceiving the body as different, feeling disabled, feeling hollow, believing they are different than other women and feeling that their body is attracting notice. The literature reports that women perceive themselves as different, alienated, impaired and changed after a hysterectomy and that they have difficulty making contact with the environment; furthermore, the more changes in body perception increase, the more depression increases ( 6 ). Not paying attention to the needs of women undergoing this process is not ethical. There are many effects from humankind relations around it. Therefore, a lot of ethical considerations should be undertaken about this common surgery. Ethical considerations in the clinical settings refer to a set of principles and values that "must be taken into account in order to prevent harm to others". The 4 main ethical principles, that is beneficence, nonmaleficence, autonomy, and justice ( 7 ). Today, women's autonomy in decisions related to hysterectomy, its completely private nature and keeping information confidential, considering women's well-being and psychological satisfaction from care, justice in providing care and fair treatment regardless of socioeconomic status and protecting women regardless of their marital status, ethnicity, and religion is one of the things that should be considered ( 8 ). The majority of women experienced a positive attitude towards their decision to elect a hysterectomy based on their perceived sexual functioning and satisfaction; ideas of womanhood to include motherhood and femininity, and their trust in presurgical information from healthcare professionals, or other women ( 2 ). A meta-synthesis to identify and synthesize qualitative research evaluating the real feelings, inner needs and emotional experience of women undergoing hysterectomy found comprehensive consideration before hysterectomy, emotions and experience after hysterectomy, coping strategies such as seeking help from others ( 9 ). The World Health Organization has defined rights for patients, including the right to high-quality care and treatment, the right to fair access to health care and services, the right to access information, the right to confidentiality and privacy, and the right to informed consent including right to free will or independence of vote, the right to health education, the right to protest and complain, and the right to compensation ( 10 ). In addition, there are a lot of ethical consideration about hysterectomy as a choice for permanent sterilization ( 11 ). Medical staff, especially doctors and nurses, are required to protect the women's rights and prevent them harm. These supports include informing and learning, honoring and respecting, supporting, protecting and ensuring continuity of care ( 12 ). Sometimes, clinical judgments based on the benefit and independence are incompatible. When there is no clear benefit and there are clear risks of hysterectomy, the woman, more than anyone else, is in a position to determine what treatment is best for her ( 13 ). Informed consent, as the most obvious manifestation of the moral principle of respect for individual autonomy, is one of the most important elements that must be observed before hysterectomy. The concept of informed consent is recognition of patients' autonomy by health service providers and improvement of relationships with patients. One of the primary purposes of informed consent is to provide information about the treatment process or to improve individuals' health care decisions. Informed consent can have the desired quality only when it reflects moral values ( 7 ). Patients have the right to make a decision about their treatment, and it is necessary to make such a decision by receiving complete information about the benefits and harms, alternative ways and possible costs ( 14 ). Medical staff should follow protocols and guidelines for informing about serious diseases such as uterus cancers. If she does not lose his spirit and can make positive decisions or if she has a fragile spirit and informing her will cause mental discomfort and delay in treatment, the patient's condition should be informed to the family ( 15 ). Since ethics in medical centers are sometimes overshadowed by material issues, it is possible that it is not completely in line with the patient's wishes. In many cases, surgeons and medical centers are in conflict between ethical duties. The principles of medical ethics are beneficence (not doing harmful actions), not doing harm, and the right of the individual ( 7 ). There are very few studies on the intra-individual aspect of ethical considerations in hysterectomy. Although this issue is very important in medical ethics. The aspect of disclosing some diseases or surgeries in the common life, workplace, family and close friends has an important place in the field of medical ethics. Disclosure of this issue after marriage in Iran has created fewer challenges due to the necessity of the wife's consent to surgery. However, there are illegal cases of surgery without the consent of the spouse or non-disclosure of the surgery before marriage ( 16 ). On the other hand, women’s privacy and confidentiality are very important in hysterectomy ( 17 ). Another issue sometimes happens in surgeries is under the table costs imposed on the patient. Determining the doctor's salary is something that must be agreed upon by the parties, and when the doctor and the patient are satisfied with the set amount, the doctor is free to receive it, and basically, under the table does not make sense ( 18 ). Not only moral sensitivity of team of treatment but also support and moral considerations by close family, friends and society directly and indirectly affect on women’s sense towards loss of uterus. This society ranged from close family members, such as the husband, to the broad community cultures about how they see a woman without feminine organs( 19 ). Husband’s support increase self-acceptance after hysterectomy ( 20 ). Some cultures support family (especially husband in fertility organ surgeries) involvement in management decisions. Even in these cultures, verifying patients’ preferences about the roles they wish their families to play is an ethical consideration ( 21 ). Women need visibility in the society as a whole person after their surgery. Even media as a powerful society arm influence on women’s decisions about hysterectomy. Some of them receive their informational support from the Internet, followed by family/friends, books/magazines, and other resources ( 19 ). Considering the importance of complying medical and general ethics and the lack of a study on determining ethical considerations in the communication network of women undergoing hysterectomy surgery, this study aimed to present these aspects in the patients' lives by a standard researcher-made instrument. Method Research population: married women who have been at least 2 months and at most 2 years since their hysterectomy. Research location: Kerman city hospitals This mixed method analysis (exploratory sequential mixed methods design was conducted in the whole of 2020 to create the “ethical considerations in communication network of women undergone hysterectomy” questionnaire and investigate its psychometric properties. Questionnaire development: The questionnaire was developed and tested using a mixed method approach in 3 phases. In the first phase, an item pool was created. Then, its validity was evaluated using Content Validity Ratio (CVR) and content validity index (CVI). In the third phase, Confirmatory Factor Analysis (CFA) were conducted to assess its construct validity. To set up the initial item pool, 2 approaches were applied, a review of qualitative studies and existing literature, and individual interviews. To investigate the ethical considerations in communication network of women undergone hysterectomy, 10 participants were selected using purposeful sampling method and were interviewed using a semi-structured interview design. We create this tool according to the attitude of diverse women and then, measure its psychometric properties. The initial item pool consisted of 136 items related to different aspects of ethical considerations in communication network of women undergone hysterectomy. The items were scored on a 5-point Likert scale ranging from 0 to 4 (from completely disagree to completely agree). The second phase involved an assessment of content validity using CVR and CVI. To determine the content validity ratio, 10 specialists working in the fields of midwifery, psychology, and reproductive health, nursing, medical education, medical ethic, and Islamic ethic accepted and completed the related forms. The CVR of each item was then calculated using the Lawshe formula. Since there were 10 evaluators in the present study, a minimum acceptable value of 0.62 was set for Lawshe. All items of the questionnaire had acceptable CVR (> 0.80). Moreover, all items had an acceptable CVI (0.70–0.79). In the third phase, construct validity and internal consistency were assessed. ranging from completely disagree to completely agree. The final questionnaire after creation, finalization and approval by experts in the field included 73 questions. Sampling: This descriptive-cross-sectional research was conducted in 2020–2021 with the aim of investigating ethical considerations in the communication network of married women undergoing hysterectomy in selected hospitals in Kerman, after the approval of the code of ethics (ethic code: IR.KMU.REC.1399.067) from Kerman University of Medical Sciences. Then, in order to obtain the statistical population, all the hospitals in Kerman city where hysterectomy is performed will be included in the study. Four hospitals will be selected randomly among them. The entire research sample selected by whole population sampling based on the inclusion criteria. The researchers extracted the telephone numbers of the target women undergone hysterectomy and make a phone call. Those who are interested and qualified to participate in the study, and after obtaining informed consent, received a link of online questionnaire. Finally, 218 women were included in the final analysis. Inclusion criteria: The sample people must be at least two months old since their hysterectomy surgery, their age is less than 65 years old, and a maximum of 2 years have passed since their hysterectomy and they are willing to cooperate and answer questions. Exit criteria: Unwillingness to participate in the study Data calculation and analysis method: The questionnaire was analyzed by confirmatory factor analysis using Amos 24.0 software and using the maximum likelihood (ML) model. Questions with standardized coefficients less than 0.4 were removed. Cronbach's alpha method was used to check the internal consistency of the questions. Ethical considerations: Assuring the participants to keep the information confidential, necessary coordination with the deputy of the research centers and hospitals, full description of the research objectives and working methods to the officials of the centers and all the research units in written and oral form, respecting the research units and assuring them of the confidentiality of the information, delivery of summary of results to respected hospital officials. Results Figure 1 shows the investigated model of the instrument. Goodness of fit indices are reported in Table 1 . Table 1 Goodness of fit indices for the primary research model SRMR RMSEA PCFI CFI \({{\chi }}^{2}\) /df 0.099 0.092 0.61 0.80 2.88 The indices reported in Table 1 are goodness of fit indices, each of which must be in a certain range to say that the model has a good fit. The range of changes of 𝛘2/df index is between 1 and 5. If the CFI index is higher than 0.9, it means that the model has a good fit. Another index that is used for the goodness of fit is PCFI, if its numerical value is greater than 0.6, it indicates the appropriate fit of the model. The next index that is examined is RMSE, and if it is between 0.05 and 0.10, we say that the model has a good fit. If the SRMR index is less than 0.1, the model has a good fit. If we pay attention to the numbers reported in the table above, we can see that only the CFI index is not within the acceptable range. In the Table 2 , the path coefficients between the research variables are shown. For the reported paths, unstandardized and standardized coefficients, standard error, and critical ratio of the structural model are given. Standardized and unstandardized structural path coefficients, if they are significant, it means that the variables and their dimensions are significant and in the expected direction. All coefficients had a value above 0.4 and were significant (p-value < 0.001). Table 2 Regression coefficients of the confirmatory model domain Estimate S.E. C.R. Standardized q1 <--- complying ethical consideration by the physician 1.000 .568 q2 <--- complying ethical consideration by the physician 1.082 .163 6.647 .569 q3 <--- complying ethical consideration by the physician .735 .137 5.369 .431 q5 <--- complying ethical consideration by the physician 1.111 .157 7.060 .620 q6 <--- complying ethical consideration by the physician .872 .134 6.509 .552 q7 <--- complying ethical consideration by the physician .999 .137 7.304 .652 q8 <--- complying ethical consideration by the physician 1.196 .159 7.520 .682 q9 <--- complying ethical consideration by the physician 1.008 .159 6.351 .534 q10 <--- complying ethical consideration by the physician .666 .116 5.764 .471 q11 <--- complying ethical consideration by the physician .572 .110 5.185 .414 q13 <--- complying ethical consideration by the physician .677 .129 5.235 .419 q15 <--- complying ethical consideration by the physician .898 .169 5.319 .426 q16 <--- complying ethical consideration by medical team 1.000 .770 q17 <--- complying ethical consideration by medical team 1.082 .105 10.344 .685 q18 <--- complying ethical consideration by medical team 1.212 .091 13.340 .850 q19 <--- complying ethical consideration by medical team 1.091 .105 10.399 .691 q21 <--- complying ethical consideration by medical team .700 .090 7.768 .529 q22 <--- complying ethical consideration by medical team .854 .061 14.057 .703 q23 <--- complying ethical consideration by medical team .897 .087 10.314 .683 q24 <--- complying ethical consideration by medical team 1.155 .109 10.552 .697 q28 <--- complying ethical consideration by medical team .773 .110 6.998 .484 q31 <--- complying ethical consideration in the hospital 1.000 .595 q32 <--- complying ethical consideration in the hospital .759 .120 6.349 .521 q33 <--- complying ethical consideration in the hospital .773 .109 7.067 .599 q35 <--- complying ethical consideration in the hospital .603 .115 5.244 .414 q37 <--- complying ethical consideration by the secretory in the clinic 1.000 .444 q38 <--- complying ethical consideration by the secretory in the clinic − .993 .233 -4.268 − .409 q39 <--- complying ethical consideration by the secretory in the clinic -1.616 .295 -5.487 − .672 q40 <--- complying ethical consideration by the secretory in the clinic -1.688 .305 -5.526 − .686 q42 <--- complying ethical consideration by the spouse 1.000 .519 q43 <--- complying ethical consideration by the spouse .931 .186 5.016 .407 q44 <--- complying ethical consideration by the spouse .957 .156 6.140 .539 q45 <--- complying ethical consideration by the spouse 1.121 .185 6.069 .530 q46 <--- complying ethical consideration by the spouse .832 .166 5.018 .408 q47 <--- complying ethical consideration by the spouse .931 .152 6.139 .539 q48 <--- complying ethical consideration by the spouse 1.032 .173 5.979 .518 q49 <--- complying ethical consideration by the spouse .860 .163 5.281 .435 q50 <--- complying ethical consideration by the spouse 1.100 .173 6.370 .571 q51 <--- complying ethical consideration by the spouse 1.298 .186 6.978 .664 q52 <--- complying ethical consideration by the spouse 1.573 .203 7.743 .816 q53 <--- complying ethical consideration by the spouse 1.734 .218 7.952 .870 q56 <--- complying ethical consideration by the family and friends 1.000 .706 q57 <--- complying ethical consideration by the family and friends 1.102 .113 9.718 .755 q58 <--- complying ethical consideration by the family and friends .851 .101 8.450 .644 q60 <--- complying ethical consideration by the family and friends .828 .113 7.329 .553 q62 <--- complying ethical consideration by the media and society 1.000 .635 q63 <--- complying ethical consideration by the media and society .769 .118 6.520 .617 q65 <--- complying ethical consideration by the media and society .997 .149 6.694 .647 q68 <--- complying ethical consideration by herself 1.000 .426 q69 <--- complying ethical consideration by herself 1.861 .324 5.745 .732 q70 <--- complying ethical consideration by herself 2.034 .343 5.930 .839 q71 <--- complying ethical consideration by herself 1.900 .350 5.436 .628 q72 <--- complying ethical consideration by herself 1.163 .269 4.323 .405 q73 <--- complying ethical consideration by herself 1.362 .281 4.850 .492 In the Table 3 , the descriptive information of the dimensions of the questionnaire was reported. The results of Cronbach's alpha test showed that there is moderate to good internal consistency in all dimensions. Cronbach's alpha for the whole questionnaire was calculated as 0.75, which shows that the internal consistency is at a good level. Table 3 Descriptive information of questionnaire dimensions and Cronbach's alpha domain Cronbach's alpha Min-max SD mean Number complying ethical consideration by the physician 0.77 29–65 7.66 47.73 12 complying ethical consideration by medical team 0.88 13–45 7.07 32.17 9 complying ethical consideration in the hospital 0.70 5–20 3.13 12.91 4 complying ethical consideration by the secretory in the clinic 0.68 4–18 2.78 12.20 4 complying ethical consideration by the spouse 0.85 20–60 6.93 45.64 12 complying ethical consideration by the family and friends 0.75 4–20 3.00 14.48 4 complying ethical consideration by the media and society 0.71 3–15 2.29 8.37 3 complying ethical consideration by herself 0.78 8–30 4.13 23.82 6 total 0.75 112–252 24.46 197.33 55 Discussion This study was designed to develop and conduct a questionnaire for the assessment of “ethical considerations in communication network of women undergone hysterectomy”. The psychometric properties of this tool including reliability (internal consistency) and factorial structure (CFA) were evaluated in a sample of women undergone hysterectomy. Accordingly, the 8 factors extracted included “complying ethical consideration by the physician (a)”, “complying ethical consideration by medical team (b)”, “complying ethical consideration in the hospital (c)”, “complying ethical consideration by the secretory in the clinic (d)”, “complying ethical consideration by the spouse (e)”, and “complying ethical consideration by the family and friends (f)”, “complying ethical consideration by the media and society (g)” and “complying ethical consideration by herself (h)”. It is noteworthy that complying ethical considerations by a woman’s social network about this common surgery has influences on the attitude of women towards hysterectomy and its consequences. These issues point to the ethical issues that may happen around this surgery that affect on the individual thoughts and actions, marital and sexual adjustment and relationships as well as is affected by familial, social and cultural attitude towards hysterectomy ( 9 , 22 – 24 ). After hysterectomy, women not only feel a strong need for support from family members, especially their husbands, they are also seeking support from health care providers and their colleagues. Before the hysterectomy, it is recommended that family members be consulted to ensure the emotional support and care of women after the hysterectomy. It can help the adaptation to hysterectomy ( 22 ). Real experience of women after hysterectomy is related on comprehensive consideration before hysterectomy (a. disease factors; b. fertility factors; c. opinions of others); emotions and experience after hysterectomy (a. postoperative physical condition; b. psychological resilience to the loss of the uterus; c. changes in the couple's relationship); coping strategies (a. self-denial and avoidance; b. change of perception and self‐adjustment; c. seek help from others) ( 9 ). In some low income societies, women faced with embedded social inequality in the form of gender biases, lack of labour security and a maternal-centric health system, demonstrated pragmatic agency in their decision to remove the uterus. When they experienced gynecological ailments, most sought two to three opinions and negotiated financial and logistical concerns. The health system offered few non-invasive services for non-maternal health issues. Moreover, women and health care providers believed there is limited utility of the uterus beyond childbearing. Women's responsibilities as caretakers, workers and producers drove them to seek permanent solutions that would secure their long-term work and health security. Thus, hysterectomy emerged as a normalized treatment for gynecological ailments, particularly for low-income women with limited resources or awareness of potential side effects. In this setting, hysterectomy reflects the power structures and social inequalities in which women negotiated medical treatment and the need to reverse a culture of permanent solutions for low-income women ( 25 ). The majority of women experienced a positive attitude towards their decision to elect a hysterectomy based on their perceived sexual functioning and satisfaction; ideas of womanhood to include motherhood and femininity, and their trust in presurgical information from healthcare professionals, or other women ( 2 ). Educating couples on sexual affairs and rebuilding the self-image is related to offering enough information to the patients ( 26 ). Providing more information and education to them on the possible after-effects of hysterectomy and alternative options will enable them to make more informed choices ( 25 ). Performing non-therapeutic hysterectomy is subject to the clinical judgement of physicians according to their perception of the patient's quality of life ( 27 ). The resources of information women depended on when making a decision to undergo hysterectomy varied and included a second opinion from another physician, social media, opinion from spouse/partner, second opinion from female family members, and opinion from friends ( 28 ). Information on regional rates and on the need for hysterectomy given through the mass media to the general population can change professional practices ( 29 ). For instance, YouTube is currently not an appropriate source for patients to gain information on hysterectomy. Physicians should be aware of the limitations and provide up-to-date and peer-reviewed content on the website ( 30 ). Establishing support groups to share the women’s experiences; and changing community views about hysterectomized women is a beneficial action towards them ( 19 ). Conclusion According to the results of this study, the reliability (internal consistency) and construct validity of the ethical considerations in the communication network of women undergoing hysterectomy questionnaire were confirmed. However, in light of the study limitations, caution should be practiced in the interpretation of the results. There is a need for further longitudinal studies in multiple settings using random sampling methods. Limitations Response bias to provide socially desirable answers might be considered due to the inclusion of self-report questionnaires for data collection. Recommendations Future research can assess the validity of “ethical considerations in the communication network of women undergoing hysterectomy” questionnaire in cross-cultural environments that may have an impact on adoption. Future works are recommended to use a sample size large enough to examine measurement invariance of the questionnaire across aforementioned variables. This tool can be provided deeper insights of ethical considerations in the communication network of women undergoing hysterectomy to health providers. Declarations Ethics approval and consent to participate: The research entitled “Investigating ethical consideration in communication network of married women undergone hysterectomy in Kerman “with Reg. No. 98000607 was approved by ethical committee of Kerman University of Medical Sciences. The Ethic approval Code is IR.KMU.REC.1399.067. From all women orally informed consent was obtained. Consent for publication Not Applicable Funding Declaration: This study was funded by Neuroscience research center, Kerman University of Medical Sciences, Kerman, Iran Availability of data and materials: Data will be available per request. To access data please contact Atefeh Ahmadi ( [email protected] /WhatsApp: 00989133979580) Competing Interest declaration: There is no competing interest to declare for any of the authors. Authors' contributions: E.B. and L.T. collected data, A.H.N. analysed data and wrote the results, M.Gh. wrote the method, A.A. wrote the main manuscript F.Kh. wrote the proposal, M.M. and J.T. approved the first version of the questionnaire Acknowledgment: Thanks a lot, from Neuroscience research center, Kerman University of Medical Sciences to support this research (grant number: 98000607) and all of the women participated in this study. References Stark M, Malvasi A, Mynbaev O, Tinelli A. The Renaissance of the Vaginal Hysterectomy—A Due Act. Int J Environ Res Public Health. 2022;19(18):11381. Webb-Tafoya ME. Exploring Postsurgical Decision Attitudes among Young Women Electing Hysterectomy. Walden University; 2021. Carlin GL, Bodner-Adler B, Husslein H, Ritter M, Umek W. The effectiveness of surgical procedures to prevent post-hysterectomy pelvic organ prolapse: a systematic review of the literature. Int Urogynecol J. 2021;32:775–83. Shaffer T. Women in Mississippi Undergoing Hysterectomies in Absence of Comprehensive Informed Consent Law. Walden University; 2018. Peivandi S, Peivandi S, Habibi A, Atarod Z, Moosazadeh M, Fallah S. Prevalence and factors associated with peripartum hysterectomy among Iranian pregnant women: A retrospective study. Ethiop J Health Sci. 2022;32(2). Erdoğan E, Demir S, Çalışkan BB, Bayrak NG. Effect of psychological care given to the women who underwent hysterectomy before and after the surgery on depressive symptoms, anxiety and the body image levels. J Obstet Gynaecol. 2020;40(7):981–7. Varkey B. Principles of clinical ethics and their application to practice. Med Principles Pract. 2021;30(1):17–28. KIANI M, AHMADI M, AZIMI N, ALAVI MH, A SURVEY ON, OBSERVING PATIENT´ S AUTONOMY IN THE LABOUR SECTIONS OF CHOSEN HOSPITALS OF TEHRAN BY STUDENTS OF MEDICAL SCIENCE DEPARTMENT. 2012. Li N, Shen C, Wang R, Chu Z. The real experience with women's hysterectomy: A meta-synthesis of qualitative research evidence. Nurs Open. 2023;10(2):435–49. Palm W, Nys H, Townend D, Shaw D, Clemens T, Brand H. Patients’ rights: From recognition to implementation. 2020. Burgart AM, Strickland J, Davis D, Baratz AB, Karkazis K, Lantos JD. Ethical controversy about hysterectomy for a minor. Pediatrics. 2017;139(6). Cheraghi R, Valizadeh L, Zamanzadeh V, Hassankhani H, Jafarzadeh A. Clarification of ethical principle of the beneficence in nursing care: an integrative review. BMC Nurs. 2023;22(1):1–9. Fischkoff D, Prager K, Dastidar J, Dugdale L, Neuberg G, Nemeth S, et al. Ethical framework to guide decisions of treatment over objection. J Am Coll Surg. 2021;233(4):508–16. e1. Olejarczyk J, Young M. Patient rights and ethics. 2021. StatPearls [Internet] Treasure Island (FL): StatPearls Publishing. 2021. Jalali R, Jalali A, Jalilian M. Breaking bad news in medical services: a comprehensive systematic review. Heliyon. 2023. Dahlstrand H, Hauksdóttir A, Valdimarsdóttir U, Fürst C-J, Bergmark K, Steineck G. Disclosure of incurable illness to spouses: do they want to know? A Swedish population-based follow-up study. J Clin Oncol. 2008;26(20):3372–9. Tegegne MD, Melaku MS, Shimie AW, Hunegnaw DD, Legese MG, Ejigu TA, et al. Health professionals' knowledge and attitude towards patient confidentiality and associated factors in a resource-limited setting: a cross-sectional study. BMC Med Ethics. 2022;23(1):26. Arab M, Khosravi B, Safari H, Rahmani H, Rajabi Vasokolaei G, Mobinizadeh M, et al. Reasons for informal payments from the perspective of health care providers and recipients: a qualitative study in Iran. Global health Res policy. 2022;7(1):30. Roudi O, Tirgari B, Cheraghi MA, Nayeri ND, Rayyani M. Tender Care: Iranian women’s needs to cope with hysterectomy and oophorectomy-a qualitative content analysis study. Int J Community Based Nurs Midwifery. 2019;7(1):63. Afiyah RK, Hasina SN, Sari RY, Umamah F, Rohmawati R, Wahyuni CU, et al. Husband’s and Health Workers Support Increase Self-acceptance After Hysterectomy. Open Access Macedonian J Med Sci. 2022;10(E):693–7. Alfahmi MZ. Patients’ preference approach to overcome the moral implications of family-centred decisions in Saudi medical settings. BMC Med Ethics. 2022;23(1):128. Goudarzi F, Khadivzadeh T, Ebadi A, Babazadeh R. Women's interdependence after hysterectomy: a qualitative study based on Roy adaptation model. BMC Womens Health. 2022;22(1):40. Mohammadi-Zarghan S, Ahmadi K. Marital adjustment, sexual function, and body image after hysterectomy. Shiraz E-Medical J. 2021;22(9). Alshawish E. Perspective of Women about Her Body after Hysterectomy. Fibroids: IntechOpen; 2020. Desai S. Pragmatic prevention, permanent solution: Women's experiences with hysterectomy in rural India. Soc Sci Med. 2016;151:11–8. Shirinkam F, Jannat-Alipoor Z, Shirinkam Chavari R, Ghaffari F. Sexuality after hysterectomy: a qualitative study on women’s sexual experience after hysterectomy. Int J Women’s Health Reprod Sci. 2018;6(1):27–35. Márquez-González H, Valdez-Martínez E, Bedolla M. Clinical, epidemiologic and ethical aspects of hysterectomy in young females with intellectual disability: A multi-centre study of public hospitals in Mexico City. Front Public Health. 2021;9:746399. Al Baalharith M, AlSary S, Bamanie E, Al Mowallad S, Makki JS, Basudan SK et al. Attitudes Toward Hysterectomy in Saudi Arabian Women Undergoing Evaluation for Uterovaginal Prolapse: A Cross-Sectional Study. Cureus. 2023;15(12). Domenighetti G, Luraschi P, Gutzwiller F, Pedrinis E, Casabianca A, Spinelli A, et al. Effect of information campaign by the mass media on hysterectomy rates. Lancet. 1988;332(8626–8627):1470–3. Lee K-N, Son G-H, Park S-H, Kim Y, Park ST. YouTube as a source of information and education on hysterectomy. J Korean Med Sci. 2020;35(25). Additional Declarations No competing interests reported. Supplementary Files TableS1.docx Cite Share Download PDF Status: Published Journal Publication published 21 Dec, 2024 Read the published version in BMC Medical Ethics → Version 1 posted Editorial decision: Revision requested 22 Oct, 2024 Reviews received at journal 07 Oct, 2024 Reviewers agreed at journal 27 Aug, 2024 Reviews received at journal 25 Jun, 2024 Reviewers agreed at journal 15 Jun, 2024 Reviewers invited by journal 22 May, 2024 Editor invited by journal 28 Feb, 2024 Submission checks completed at journal 28 Feb, 2024 Editor assigned by journal 28 Feb, 2024 First submitted to journal 17 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3964945","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":275430740,"identity":"0a4a2f31-b2c8-4386-b078-112f838a7eb3","order_by":0,"name":"Elahe Bahador","email":"","orcid":"","institution":"Kerman University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Elahe","middleName":"","lastName":"Bahador","suffix":""},{"id":275430741,"identity":"89378295-a06e-41c8-975b-e6325710bee0","order_by":1,"name":"Laleh Tajadiny","email":"","orcid":"","institution":"Kerman University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Laleh","middleName":"","lastName":"Tajadiny","suffix":""},{"id":275430742,"identity":"d01bdaaf-b60a-4d4c-9b5b-3d18fd7ea8de","order_by":2,"name":"Abolfazl Hossein Nataj","email":"","orcid":"","institution":"Mazandaran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Abolfazl","middleName":"Hossein","lastName":"Nataj","suffix":""},{"id":275430743,"identity":"65530e72-c547-4f3f-a2e2-f0e4100107d1","order_by":3,"name":"Masumeh Ghazanfarpour","email":"","orcid":"","institution":"Kerman University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Masumeh","middleName":"","lastName":"Ghazanfarpour","suffix":""},{"id":275430744,"identity":"87664d40-5251-4ad3-becd-b21dbab0c890","order_by":4,"name":"Atefeh Ahmadi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAklEQVRIie3PPUvEMBjA8YRCpitdvW9hJ0c/iItF0OnZO9QjRyFd1DmD9r7C3dK55YHcUnA9UPDKgZsQF+kg4lMRB6GtboL5Q14I+RHCmMv1BxM0LGMlLVFmbUyr58lBEgjG9SdRXNcd4cNkqr7IsfB81Z2NkP2HtJI2uT8KshO18/Nz2hBp46KfGBHNtXkEXTdZeFOsQSOX/KK+GyCTg91EIMhNJPeeCgOSiMdVPzk0wXP6+oaw6Ih/bWAxRugVnnKFsNxEaurLBJbj5DScX14hrOomDbUpYUWkGvwLYiPbF4R8fdZsbTKD/BarbRv3k+/hx1z++D41+81ll8vl+ie9A/X0boifmwfXAAAAAElFTkSuQmCC","orcid":"","institution":"Kerman University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Atefeh","middleName":"","lastName":"Ahmadi","suffix":""},{"id":275430745,"identity":"c5c2d7ff-4a7b-4b13-9b8a-3d5b0e13dc9d","order_by":5,"name":"Fahimeh Khorasani","email":"","orcid":"","institution":"Kerman University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Fahimeh","middleName":"","lastName":"Khorasani","suffix":""},{"id":275430746,"identity":"9c32c5ee-e967-456d-8aad-c3fee5bc6157","order_by":6,"name":"Mina Mobasher","email":"","orcid":"","institution":"Kerman University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mina","middleName":"","lastName":"Mobasher","suffix":""},{"id":275430747,"identity":"9f5e78c6-ead4-44ef-87dc-bcd4f849927d","order_by":7,"name":"Jaleh Tajadini","email":"","orcid":"","institution":"Kerman University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Jaleh","middleName":"","lastName":"Tajadini","suffix":""}],"badges":[],"createdAt":"2024-02-17 20:02:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3964945/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3964945/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12910-024-01152-7","type":"published","date":"2024-12-21T15:57:17+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":52029094,"identity":"a48e4551-712b-4cad-8244-8962aff4ed7e","added_by":"auto","created_at":"2024-03-05 16:16:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":345127,"visible":true,"origin":"","legend":"\u003cp\u003eResearch measurement model and its parameters using standardized coefficients\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3964945/v1/ac862f0eef98b332e62733f9.png"},{"id":72202042,"identity":"374a9cb0-b883-4f6c-a4bf-728f2e66ff40","added_by":"auto","created_at":"2024-12-23 16:13:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":926893,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3964945/v1/a36e3e66-aa36-4337-a46e-e575c624ff50.pdf"},{"id":52029093,"identity":"8aec3e7d-996b-44ba-8b0e-fd30c8f462b4","added_by":"auto","created_at":"2024-03-05 16:16:39","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":26993,"visible":true,"origin":"","legend":"","description":"","filename":"TableS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3964945/v1/fc5045c432a538f101b4e442.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Investigating ethical considerations in the communication network of married women undergone hysterectomy: Instrumentation of a questionnaire","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHysterectomy is the second most common operation performed on women after a cesarean section (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Over half a million women undergo a hysterectomy procedure for reproductive issues each year (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Most of hysterectomies are performed to treat benign conditions such as uterine fibroids, endometriosis, and symptoms such as uncomfortable menstrual bleeding (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Some hysterectomies are performed inappropriately and are due to lack of diagnostic evaluation or failure of alternative treatments (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The prevalence of Peripartum Hysterectomy among Iranian pregnant women was 2.81 per 1000 deliveries (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHaving a hysterectomy impacts a woman's life in a significant manner. As such, deciding to undergo a hysterectomy is a difficult process for women, especially from a psychological perspective. Following a hysterectomy, women commonly experience changes in body perception, such as perceiving the body as different, feeling disabled, feeling hollow, believing they are different than other women and feeling that their body is attracting notice. The literature reports that women perceive themselves as different, alienated, impaired and changed after a hysterectomy and that they have difficulty making contact with the environment; furthermore, the more changes in body perception increase, the more depression increases (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Not paying attention to the needs of women undergoing this process is not ethical. There are many effects from humankind relations around it. Therefore, a lot of ethical considerations should be undertaken about this common surgery.\u003c/p\u003e \u003cp\u003e Ethical considerations in the clinical settings refer to a set of principles and values that \"must be taken into account in order to prevent harm to others\". The 4 main ethical principles, that is beneficence, nonmaleficence, autonomy, and justice (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Today, women's autonomy in decisions related to hysterectomy, its completely private nature and keeping information confidential, considering women's well-being and psychological satisfaction from care, justice in providing care and fair treatment regardless of socioeconomic status and protecting women regardless of their marital status, ethnicity, and religion is one of the things that should be considered (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe majority of women experienced a positive attitude towards their decision to elect a hysterectomy based on their perceived sexual functioning and satisfaction; ideas of womanhood to include motherhood and femininity, and their trust in presurgical information from healthcare professionals, or other women (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). A meta-synthesis to identify and synthesize qualitative research evaluating the real feelings, inner needs and emotional experience of women undergoing hysterectomy found comprehensive consideration before hysterectomy, emotions and experience after hysterectomy, coping strategies such as seeking help from others (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe World Health Organization has defined rights for patients, including the right to high-quality care and treatment, the right to fair access to health care and services, the right to access information, the right to confidentiality and privacy, and the right to informed consent including right to free will or independence of vote, the right to health education, the right to protest and complain, and the right to compensation (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In addition, there are a lot of ethical consideration about hysterectomy as a choice for permanent sterilization (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMedical staff, especially doctors and nurses, are required to protect the women's rights and prevent them harm. These supports include informing and learning, honoring and respecting, supporting, protecting and ensuring continuity of care (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Sometimes, clinical judgments based on the benefit and independence are incompatible. When there is no clear benefit and there are clear risks of hysterectomy, the woman, more than anyone else, is in a position to determine what treatment is best for her (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Informed consent, as the most obvious manifestation of the moral principle of respect for individual autonomy, is one of the most important elements that must be observed before hysterectomy. The concept of informed consent is recognition of patients' autonomy by health service providers and improvement of relationships with patients. One of the primary purposes of informed consent is to provide information about the treatment process or to improve individuals' health care decisions. Informed consent can have the desired quality only when it reflects moral values (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePatients have the right to make a decision about their treatment, and it is necessary to make such a decision by receiving complete information about the benefits and harms, alternative ways and possible costs (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Medical staff should follow protocols and guidelines for informing about serious diseases such as uterus cancers. If she does not lose his spirit and can make positive decisions or if she has a fragile spirit and informing her will cause mental discomfort and delay in treatment, the patient's condition should be informed to the family (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSince ethics in medical centers are sometimes overshadowed by material issues, it is possible that it is not completely in line with the patient's wishes. In many cases, surgeons and medical centers are in conflict between ethical duties. The principles of medical ethics are beneficence (not doing harmful actions), not doing harm, and the right of the individual (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere are very few studies on the intra-individual aspect of ethical considerations in hysterectomy. Although this issue is very important in medical ethics. The aspect of disclosing some diseases or surgeries in the common life, workplace, family and close friends has an important place in the field of medical ethics. Disclosure of this issue after marriage in Iran has created fewer challenges due to the necessity of the wife's consent to surgery. However, there are illegal cases of surgery without the consent of the spouse or non-disclosure of the surgery before marriage (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). On the other hand, women\u0026rsquo;s privacy and confidentiality are very important in hysterectomy (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Another issue sometimes happens in surgeries is under the table costs imposed on the patient. Determining the doctor's salary is something that must be agreed upon by the parties, and when the doctor and the patient are satisfied with the set amount, the doctor is free to receive it, and basically, under the table does not make sense (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNot only moral sensitivity of team of treatment but also support and moral considerations by close family, friends and society directly and indirectly affect on women\u0026rsquo;s sense towards loss of uterus. This society ranged from close family members, such as the husband, to the broad community cultures about how they see a woman without feminine organs(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Husband\u0026rsquo;s support increase self-acceptance after hysterectomy (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Some cultures support family (especially husband in fertility organ surgeries) involvement in management decisions. Even in these cultures, verifying patients\u0026rsquo; preferences about the roles they wish their families to play is an ethical consideration (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Women need visibility in the society as a whole person after their surgery. Even media as a powerful society arm influence on women\u0026rsquo;s decisions about hysterectomy. Some of them receive their informational support from the Internet, followed by family/friends, books/magazines, and other resources (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsidering the importance of complying medical and general ethics and the lack of a study on determining ethical considerations in the communication network of women undergoing hysterectomy surgery, this study aimed to present these aspects in the patients' lives by a standard researcher-made instrument.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eResearch population: married women who have been at least 2 months and at most 2 years since their hysterectomy.\u003c/p\u003e \u003cp\u003eResearch location: Kerman city hospitals\u003c/p\u003e \u003cp\u003eThis mixed method analysis (exploratory sequential mixed methods design was conducted in the whole of 2020 to create the \u0026ldquo;ethical considerations in communication network of women undergone hysterectomy\u0026rdquo; questionnaire and investigate its psychometric properties.\u003c/p\u003e \u003cp\u003eQuestionnaire development: The questionnaire was developed and tested using a mixed method approach in 3 phases. In the first phase, an item pool was created. Then, its validity was evaluated using Content Validity Ratio (CVR) and content validity index (CVI). In the third phase, Confirmatory Factor Analysis (CFA) were conducted to assess its construct validity.\u003c/p\u003e \u003cp\u003eTo set up the initial item pool, 2 approaches were applied, a review of qualitative studies and existing literature, and individual interviews. To investigate the ethical considerations in communication network of women undergone hysterectomy, 10 participants were selected using purposeful sampling method and were interviewed using a semi-structured interview design. We create this tool according to the attitude of diverse women and then, measure its psychometric properties.\u003c/p\u003e \u003cp\u003eThe initial item pool consisted of 136 items related to different aspects of ethical considerations in communication network of women undergone hysterectomy. The items were scored on a 5-point Likert scale ranging from 0 to 4 (from completely disagree to completely agree).\u003c/p\u003e \u003cp\u003eThe second phase involved an assessment of content validity using CVR and CVI. To determine the content validity ratio, 10 specialists working in the fields of midwifery, psychology, and reproductive health, nursing, medical education, medical ethic, and Islamic ethic accepted and completed the related forms. The CVR of each item was then calculated using the Lawshe formula. Since there were 10 evaluators in the present study, a minimum acceptable value of 0.62 was set for Lawshe. All items of the questionnaire had acceptable CVR (\u0026gt;\u0026thinsp;0.80). Moreover, all items had an acceptable CVI (0.70\u0026ndash;0.79). In the third phase, construct validity and internal consistency were assessed. ranging from completely disagree to completely agree. The final questionnaire after creation, finalization and approval by experts in the field included 73 questions.\u003c/p\u003e \u003cp\u003eSampling:\u003c/p\u003e \u003cp\u003e This descriptive-cross-sectional research was conducted in 2020\u0026ndash;2021 with the aim of investigating ethical considerations in the communication network of married women undergoing hysterectomy in selected hospitals in Kerman, after the approval of the code of ethics (ethic code: IR.KMU.REC.1399.067) from Kerman University of Medical Sciences. Then, in order to obtain the statistical population, all the hospitals in Kerman city where hysterectomy is performed will be included in the study. Four hospitals will be selected randomly among them. The entire research sample selected by whole population sampling based on the inclusion criteria. The researchers extracted the telephone numbers of the target women undergone hysterectomy and make a phone call. Those who are interested and qualified to participate in the study, and after obtaining informed consent, received a link of online questionnaire. Finally, 218 women were included in the final analysis.\u003c/p\u003e \u003cp\u003eInclusion criteria: The sample people must be at least two months old since their hysterectomy surgery, their age is less than 65 years old, and a maximum of 2 years have passed since their hysterectomy and they are willing to cooperate and answer questions.\u003c/p\u003e \u003cp\u003eExit criteria: Unwillingness to participate in the study\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData calculation and analysis method:\u003c/h2\u003e \u003cp\u003eThe questionnaire was analyzed by confirmatory factor analysis using Amos 24.0 software and using the maximum likelihood (ML) model. Questions with standardized coefficients less than 0.4 were removed. Cronbach's alpha method was used to check the internal consistency of the questions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations:\u003c/h2\u003e \u003cp\u003eAssuring the participants to keep the information confidential, necessary coordination with the deputy of the research centers and hospitals, full description of the research objectives and working methods to the officials of the centers and all the research units in written and oral form, respecting the research units and assuring them of the confidentiality of the information, delivery of summary of results to respected hospital officials.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the investigated model of the instrument. Goodness of fit indices are reported in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGoodness of fit indices for the primary research model\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSRMR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRMSEA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePCFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({{\\chi }}^{2}\\)\u003c/span\u003e\u003c/span\u003e/df\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0.099\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.092\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe indices reported in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e are goodness of fit indices, each of which must be in a certain range to say that the model has a good fit. The range of changes of \u0026#120536;2/df index is between 1 and 5. If the CFI index is higher than 0.9, it means that the model has a good fit. Another index that is used for the goodness of fit is PCFI, if its numerical value is greater than 0.6, it indicates the appropriate fit of the model. The next index that is examined is RMSE, and if it is between 0.05 and 0.10, we say that the model has a good fit. If the SRMR index is less than 0.1, the model has a good fit. If we pay attention to the numbers reported in the table above, we can see that only the CFI index is not within the acceptable range.\u003c/p\u003e \u003cp\u003eIn the Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the path coefficients between the research variables are shown. For the reported paths, unstandardized and standardized coefficients, standard error, and critical ratio of the structural model are given. Standardized and unstandardized structural path coefficients, if they are significant, it means that the variables and their dimensions are significant and in the expected direction. All coefficients had a value above 0.4 and were significant (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRegression coefficients of the confirmatory model\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003edomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEstimate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eS.E.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC.R.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStandardized\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.568\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.647\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.569\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.735\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.369\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.431\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.060\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.620\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.872\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.509\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.552\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.304\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.652\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.520\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.682\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.534\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.666\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.764\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.471\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.572\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.414\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.677\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.235\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.419\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.898\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.319\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.426\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by medical team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.770\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by medical team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10.344\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.685\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by medical team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.091\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13.340\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.850\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by medical team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.091\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10.399\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.691\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by medical team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.700\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.090\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.768\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.529\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by medical team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.854\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.061\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.703\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by medical team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.897\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10.314\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.683\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by medical team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10.552\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.697\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by medical team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.773\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.998\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.484\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration in the hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.595\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration in the hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.759\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.349\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.521\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration in the hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.773\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.599\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration in the hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.603\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.414\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the secretory in the clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.444\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the secretory in the clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.993\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.233\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-4.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.409\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the secretory in the clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.616\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-5.487\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.672\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the secretory in the clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.688\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.305\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-5.526\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.686\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.519\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.931\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.407\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.957\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.539\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.069\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.530\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.832\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.408\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.931\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.539\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.979\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.518\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.860\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.281\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.435\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.370\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.571\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.978\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.664\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.573\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.743\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.816\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.734\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.952\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.870\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the family and friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.706\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the family and friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9.718\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.755\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the family and friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.851\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8.450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.644\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the family and friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.828\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.553\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the media and society\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.635\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the media and society\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.769\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.520\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.617\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by the media and society\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.997\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.694\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.647\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by herself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.426\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by herself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.861\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.745\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.732\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by herself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.034\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.343\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.930\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.839\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by herself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.436\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.628\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by herself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.269\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.323\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.405\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eq73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplying ethical consideration by herself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.362\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.281\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.850\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.492\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the descriptive information of the dimensions of the questionnaire was reported. The results of Cronbach's alpha test showed that there is moderate to good internal consistency in all dimensions. Cronbach's alpha for the whole questionnaire was calculated as 0.75, which shows that the internal consistency is at a good level.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive information of questionnaire dimensions and Cronbach's alpha\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003edomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCronbach's alpha\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMin-max\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003emean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecomplying ethical consideration by the physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u0026ndash;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e47.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecomplying ethical consideration by medical team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e32.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecomplying ethical consideration in the hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecomplying ethical consideration by the secretory in the clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecomplying ethical consideration by the spouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e45.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecomplying ethical consideration by the family and friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecomplying ethical consideration by the media and society\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecomplying ethical consideration by herself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112\u0026ndash;252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e197.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study was designed to develop and conduct a questionnaire for the assessment of \u0026ldquo;ethical considerations in communication network of women undergone hysterectomy\u0026rdquo;. The psychometric properties of this tool including reliability (internal consistency) and factorial structure (CFA) were evaluated in a sample of women undergone hysterectomy.\u003c/p\u003e \u003cp\u003eAccordingly, the 8 factors extracted included \u0026ldquo;complying ethical consideration by the physician (a)\u0026rdquo;, \u0026ldquo;complying ethical consideration by medical team (b)\u0026rdquo;, \u0026ldquo;complying ethical consideration in the hospital (c)\u0026rdquo;, \u0026ldquo;complying ethical consideration by the secretory in the clinic (d)\u0026rdquo;, \u0026ldquo;complying ethical consideration by the spouse (e)\u0026rdquo;, and \u0026ldquo;complying ethical consideration by the family and friends (f)\u0026rdquo;, \u0026ldquo;complying ethical consideration by the media and society (g)\u0026rdquo; and \u0026ldquo;complying ethical consideration by herself (h)\u0026rdquo;.\u003c/p\u003e \u003cp\u003eIt is noteworthy that complying ethical considerations by a woman\u0026rsquo;s social network about this common surgery has influences on the attitude of women towards hysterectomy and its consequences. These issues point to the ethical issues that may happen around this surgery that affect on the individual thoughts and actions, marital and sexual adjustment and relationships as well as is affected by familial, social and cultural attitude towards hysterectomy (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAfter hysterectomy, women not only feel a strong need for support from family members, especially their husbands, they are also seeking support from health care providers and their colleagues. Before the hysterectomy, it is recommended that family members be consulted to ensure the emotional support and care of women after the hysterectomy. It can help the adaptation to hysterectomy (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Real experience of women after hysterectomy is related on comprehensive consideration before hysterectomy (a. disease factors; b. fertility factors; c. opinions of others); emotions and experience after hysterectomy (a. postoperative physical condition; b. psychological resilience to the loss of the uterus; c. changes in the couple's relationship); coping strategies (a. self-denial and avoidance; b. change of perception and self‐adjustment; c. seek help from others) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn some low income societies, women faced with embedded social inequality in the form of gender biases, lack of labour security and a maternal-centric health system, demonstrated pragmatic agency in their decision to remove the uterus. When they experienced gynecological ailments, most sought two to three opinions and negotiated financial and logistical concerns. The health system offered few non-invasive services for non-maternal health issues. Moreover, women and health care providers believed there is limited utility of the uterus beyond childbearing. Women's responsibilities as caretakers, workers and producers drove them to seek permanent solutions that would secure their long-term work and health security. Thus, hysterectomy emerged as a normalized treatment for gynecological ailments, particularly for low-income women with limited resources or awareness of potential side effects. In this setting, hysterectomy reflects the power structures and social inequalities in which women negotiated medical treatment and the need to reverse a culture of permanent solutions for low-income women (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe majority of women experienced a positive attitude towards their decision to elect a hysterectomy based on their perceived sexual functioning and satisfaction; ideas of womanhood to include motherhood and femininity, and their trust in presurgical information from healthcare professionals, or other women (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Educating couples on sexual affairs and rebuilding the self-image is related to offering enough information to the patients (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Providing more information and education to them on the possible after-effects of hysterectomy and alternative options will enable them to make more informed choices (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Performing non-therapeutic hysterectomy is subject to the clinical judgement of physicians according to their perception of the patient's quality of life (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe resources of information women depended on when making a decision to undergo hysterectomy varied and included a second opinion from another physician, social media, opinion from spouse/partner, second opinion from female family members, and opinion from friends (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Information on regional rates and on the need for hysterectomy given through the mass media to the general population can change professional practices (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). For instance, YouTube is currently not an appropriate source for patients to gain information on hysterectomy. Physicians should be aware of the limitations and provide up-to-date and peer-reviewed content on the website (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Establishing support groups to share the women\u0026rsquo;s experiences; and changing community views about hysterectomized women is a beneficial action towards them (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAccording to the results of this study, the reliability (internal consistency) and construct validity of the ethical considerations in the communication network of women undergoing hysterectomy questionnaire were confirmed. However, in light of the study limitations, caution should be practiced in the interpretation of the results. There is a need for further longitudinal studies in multiple settings using random sampling methods.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLimitations\u003c/strong\u003e \u003cp\u003eResponse bias to provide socially desirable answers might be considered due to the inclusion of self-report questionnaires for data collection.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eRecommendations\u003c/strong\u003e \u003cp\u003eFuture research can assess the validity of \u0026ldquo;ethical considerations in the communication network of women undergoing hysterectomy\u0026rdquo; questionnaire in cross-cultural environments that may have an impact on adoption. Future works are recommended to use a sample size large enough to examine measurement invariance of the questionnaire across aforementioned variables. This tool can be provided deeper insights of ethical considerations in the communication network of women undergoing hysterectomy to health providers.\u003c/p\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe research entitled \u0026ldquo;Investigating ethical consideration in communication network of married women undergone hysterectomy in Kerman \u0026ldquo;with Reg. No. 98000607 was approved by ethical committee of Kerman University of Medical Sciences. The Ethic approval Code is IR.KMU.REC.1399.067. From all women orally \u0026nbsp;informed consent was obtained.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding Declaration:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by Neuroscience research center, Kerman University of Medical Sciences, Kerman, Iran\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData will be available per request. To access data please contact Atefeh Ahmadi ([email protected]/WhatsApp: 00989133979580)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting Interest declaration:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere is no competing interest to declare for any of the authors.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors' contributions:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eE.B. and L.T. collected data, A.H.N. analysed data and wrote the results, M.Gh. wrote the method, A.A. wrote the main manuscript F.Kh. wrote the proposal, M.M. and J.T. approved the first version of the questionnaire\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgment:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThanks a lot, from Neuroscience research center, Kerman University of Medical Sciences to support this research (grant number: 98000607) and all of the women participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStark M, Malvasi A, Mynbaev O, Tinelli A. The Renaissance of the Vaginal Hysterectomy\u0026mdash;A Due Act. Int J Environ Res Public Health. 2022;19(18):11381.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWebb-Tafoya ME. Exploring Postsurgical Decision Attitudes among Young Women Electing Hysterectomy. Walden University; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarlin GL, Bodner-Adler B, Husslein H, Ritter M, Umek W. The effectiveness of surgical procedures to prevent post-hysterectomy pelvic organ prolapse: a systematic review of the literature. Int Urogynecol J. 2021;32:775\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaffer T. Women in Mississippi Undergoing Hysterectomies in Absence of Comprehensive Informed Consent Law. Walden University; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeivandi S, Peivandi S, Habibi A, Atarod Z, Moosazadeh M, Fallah S. Prevalence and factors associated with peripartum hysterectomy among Iranian pregnant women: A retrospective study. Ethiop J Health Sci. 2022;32(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErdoğan E, Demir S, \u0026Ccedil;alışkan BB, Bayrak NG. Effect of psychological care given to the women who underwent hysterectomy before and after the surgery on depressive symptoms, anxiety and the body image levels. J Obstet Gynaecol. 2020;40(7):981\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVarkey B. Principles of clinical ethics and their application to practice. Med Principles Pract. 2021;30(1):17\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKIANI M, AHMADI M, AZIMI N, ALAVI MH, A SURVEY ON, OBSERVING PATIENT\u0026acute; S AUTONOMY IN THE LABOUR SECTIONS OF CHOSEN HOSPITALS OF TEHRAN BY STUDENTS OF MEDICAL SCIENCE DEPARTMENT. 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi N, Shen C, Wang R, Chu Z. The real experience with women's hysterectomy: A meta-synthesis of qualitative research evidence. Nurs Open. 2023;10(2):435\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalm W, Nys H, Townend D, Shaw D, Clemens T, Brand H. Patients\u0026rsquo; rights: From recognition to implementation. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurgart AM, Strickland J, Davis D, Baratz AB, Karkazis K, Lantos JD. Ethical controversy about hysterectomy for a minor. Pediatrics. 2017;139(6).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheraghi R, Valizadeh L, Zamanzadeh V, Hassankhani H, Jafarzadeh A. Clarification of ethical principle of the beneficence in nursing care: an integrative review. BMC Nurs. 2023;22(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFischkoff D, Prager K, Dastidar J, Dugdale L, Neuberg G, Nemeth S, et al. Ethical framework to guide decisions of treatment over objection. J Am Coll Surg. 2021;233(4):508\u0026ndash;16. e1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlejarczyk J, Young M. Patient rights and ethics. 2021. StatPearls [Internet] Treasure Island (FL): StatPearls Publishing. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJalali R, Jalali A, Jalilian M. Breaking bad news in medical services: a comprehensive systematic review. Heliyon. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDahlstrand H, Hauksd\u0026oacute;ttir A, Valdimarsd\u0026oacute;ttir U, F\u0026uuml;rst C-J, Bergmark K, Steineck G. Disclosure of incurable illness to spouses: do they want to know? A Swedish population-based follow-up study. J Clin Oncol. 2008;26(20):3372\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTegegne MD, Melaku MS, Shimie AW, Hunegnaw DD, Legese MG, Ejigu TA, et al. Health professionals' knowledge and attitude towards patient confidentiality and associated factors in a resource-limited setting: a cross-sectional study. BMC Med Ethics. 2022;23(1):26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArab M, Khosravi B, Safari H, Rahmani H, Rajabi Vasokolaei G, Mobinizadeh M, et al. Reasons for informal payments from the perspective of health care providers and recipients: a qualitative study in Iran. Global health Res policy. 2022;7(1):30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoudi O, Tirgari B, Cheraghi MA, Nayeri ND, Rayyani M. Tender Care: Iranian women\u0026rsquo;s needs to cope with hysterectomy and oophorectomy-a qualitative content analysis study. Int J Community Based Nurs Midwifery. 2019;7(1):63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAfiyah RK, Hasina SN, Sari RY, Umamah F, Rohmawati R, Wahyuni CU, et al. Husband\u0026rsquo;s and Health Workers Support Increase Self-acceptance After Hysterectomy. Open Access Macedonian J Med Sci. 2022;10(E):693\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlfahmi MZ. Patients\u0026rsquo; preference approach to overcome the moral implications of family-centred decisions in Saudi medical settings. BMC Med Ethics. 2022;23(1):128.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoudarzi F, Khadivzadeh T, Ebadi A, Babazadeh R. Women's interdependence after hysterectomy: a qualitative study based on Roy adaptation model. BMC Womens Health. 2022;22(1):40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohammadi-Zarghan S, Ahmadi K. Marital adjustment, sexual function, and body image after hysterectomy. Shiraz E-Medical J. 2021;22(9).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlshawish E. Perspective of Women about Her Body after Hysterectomy. Fibroids: IntechOpen; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDesai S. Pragmatic prevention, permanent solution: Women's experiences with hysterectomy in rural India. Soc Sci Med. 2016;151:11\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShirinkam F, Jannat-Alipoor Z, Shirinkam Chavari R, Ghaffari F. Sexuality after hysterectomy: a qualitative study on women\u0026rsquo;s sexual experience after hysterectomy. Int J Women\u0026rsquo;s Health Reprod Sci. 2018;6(1):27\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026aacute;rquez-Gonz\u0026aacute;lez H, Valdez-Mart\u0026iacute;nez E, Bedolla M. Clinical, epidemiologic and ethical aspects of hysterectomy in young females with intellectual disability: A multi-centre study of public hospitals in Mexico City. Front Public Health. 2021;9:746399.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl Baalharith M, AlSary S, Bamanie E, Al Mowallad S, Makki JS, Basudan SK et al. Attitudes Toward Hysterectomy in Saudi Arabian Women Undergoing Evaluation for Uterovaginal Prolapse: A Cross-Sectional Study. Cureus. 2023;15(12).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDomenighetti G, Luraschi P, Gutzwiller F, Pedrinis E, Casabianca A, Spinelli A, et al. Effect of information campaign by the mass media on hysterectomy rates. Lancet. 1988;332(8626\u0026ndash;8627):1470\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee K-N, Son G-H, Park S-H, Kim Y, Park ST. YouTube as a source of information and education on hysterectomy. J Korean Med Sci. 2020;35(25).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3964945/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3964945/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction: Considering the importance of complying medical and general ethics and the lack of a study on determining ethical considerations in the communication network of women undergoing hysterectomy surgery, this study aimed to present these aspects in the patients' lives by a standard researcher-made instrument.\u003c/p\u003e \u003cp\u003e Method: This mixed method analysis (exploratory sequential mixed methods design was conducted in the whole of 2020 to create the \u0026ldquo;ethical considerations in communication network of women undergone hysterectomy\u0026rdquo; questionnaire and investigate its psychometric properties. A researched-made instrument was validated and its psychometric properties were checked among 218 women by confirmatory factor analysis (CFA).\u003c/p\u003e \u003cp\u003e Results: Accordingly, the 8 factors extracted included \u0026ldquo;complying ethical consideration by the physician (a)\u0026rdquo;, \u0026ldquo;complying ethical consideration by medical team (b)\u0026rdquo;, \u0026ldquo;complying ethical consideration in the hospital (c)\u0026rdquo;, \u0026ldquo;complying ethical consideration by the secretory in the clinic (d)\u0026rdquo;, \u0026ldquo;complying ethical consideration by the spouse (e)\u0026rdquo;, and \u0026ldquo;complying ethical consideration by the family and friends (f)\u0026rdquo;, \u0026ldquo;complying ethical consideration by the media and society (g)\u0026rdquo; and \u0026ldquo;complying ethical consideration by herself (h)\u0026rdquo;. The results of Cronbach's alpha test showed that there is moderate to good internal consistency in all dimensions. Cronbach's alpha for the whole questionnaire was calculated as 0.75, which shows that the internal consistency is at a good level.\u003c/p\u003e \u003cp\u003e Conclusion: According to the results of this study, the reliability (internal consistency) and construct validity of the ethical considerations in the communication network of women undergoing hysterectomy questionnaire were confirmed. However, in light of the study limitations, caution should be practiced in the interpretation of the results. There is a need for further longitudinal studies in multiple settings using random sampling methods.\u003c/p\u003e","manuscriptTitle":"Investigating ethical considerations in the communication network of married women undergone hysterectomy: Instrumentation of a questionnaire","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-05 16:16:35","doi":"10.21203/rs.3.rs-3964945/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-22T07:41:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-07T15:45:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2024-08-27T07:21:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-25T16:11:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"216374088553943407312760402039992269945","date":"2024-06-15T13:57:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-22T11:44:45+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-02-28T07:48:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-28T07:46:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-28T07:46:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Ethics","date":"2024-02-17T19:53:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0190af76-f698-4231-9929-5c41e8fc21ac","owner":[],"postedDate":"March 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T16:06:47+00:00","versionOfRecord":{"articleIdentity":"rs-3964945","link":"https://doi.org/10.1186/s12910-024-01152-7","journal":{"identity":"bmc-medical-ethics","isVorOnly":false,"title":"BMC Medical Ethics"},"publishedOn":"2024-12-21 15:57:17","publishedOnDateReadable":"December 21st, 2024"},"versionCreatedAt":"2024-03-05 16:16:35","video":"","vorDoi":"10.1186/s12910-024-01152-7","vorDoiUrl":"https://doi.org/10.1186/s12910-024-01152-7","workflowStages":[]},"version":"v1","identity":"rs-3964945","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3964945","identity":"rs-3964945","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}