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Pellemans M, Salmi S, Mérelle S, Janssen W, van der Mei R. Automated Behavioral Coding to Enhance the Effectiveness of Motivational Interviewing in a Chat-Based Suicide Prevention Helpline: Secondary Analysis of a Clinical Trial. J Med Internet Res 2024; 26:e53562. [PMID: 39088244 PMCID: PMC11327631 DOI: 10.2196/53562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 03/01/2024] [Accepted: 06/02/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND With the rise of computer science and artificial intelligence, analyzing large data sets promises enormous potential in gaining insights for developing and improving evidence-based health interventions. One such intervention is the counseling strategy motivational interviewing (MI), which has been found effective in improving a wide range of health-related behaviors. Despite the simplicity of its principles, MI can be a challenging skill to learn and requires expertise to apply effectively. OBJECTIVE This study aims to investigate the performance of artificial intelligence models in classifying MI behavior and explore the feasibility of using these models in online helplines for mental health as an automated support tool for counselors in clinical practice. METHODS We used a coded data set of 253 MI counseling chat sessions from the 113 Suicide Prevention helpline. With 23,982 messages coded with the MI Sequential Code for Observing Process Exchanges codebook, we trained and evaluated 4 machine learning models and 1 deep learning model to classify client- and counselor MI behavior based on language use. RESULTS The deep learning model BERTje outperformed all machine learning models, accurately predicting counselor behavior (accuracy=0.72, area under the curve [AUC]=0.95, Cohen κ=0.69). It differentiated MI congruent and incongruent counselor behavior (AUC=0.92, κ=0.65) and evocative and nonevocative language (AUC=0.92, κ=0.66). For client behavior, the model achieved an accuracy of 0.70 (AUC=0.89, κ=0.55). The model's interpretable predictions discerned client change talk and sustain talk, counselor affirmations, and reflection types, facilitating valuable counselor feedback. CONCLUSIONS The results of this study demonstrate that artificial intelligence techniques can accurately classify MI behavior, indicating their potential as a valuable tool for enhancing MI proficiency in online helplines for mental health. Provided that the data set size is sufficiently large with enough training samples for each behavioral code, these methods can be trained and applied to other domains and languages, offering a scalable and cost-effective way to evaluate MI adherence, accelerate behavioral coding, and provide therapists with personalized, quick, and objective feedback.
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Affiliation(s)
- Mathijs Pellemans
- Department of Mathematics, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- 113 Suicide Prevention, Amsterdam, Netherlands
| | - Salim Salmi
- 113 Suicide Prevention, Amsterdam, Netherlands
- Centrum Wiskunde & Informatica, Amsterdam, Netherlands
| | - Saskia Mérelle
- 113 Suicide Prevention, Amsterdam, Netherlands
- Department of Psychiatry, Amsterdam UMC, Amsterdam, Netherlands
| | - Wilco Janssen
- 113 Suicide Prevention, Amsterdam, Netherlands
- Department of Psychiatry, Amsterdam UMC, Amsterdam, Netherlands
| | - Rob van der Mei
- Department of Mathematics, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Centrum Wiskunde & Informatica, Amsterdam, Netherlands
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Sekizawa Y. Japan's intensive health guidance program has limited effects on cardiovascular risk factors: a regression discontinuity analysis. Public Health 2024; 232:108-113. [PMID: 38772198 DOI: 10.1016/j.puhe.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/03/2024] [Accepted: 04/16/2024] [Indexed: 05/23/2024]
Abstract
OBJECTIVES It is uncertain whether the effects of health counselling programs differ depending on their intensity. This study compared the effectiveness of intensive health guidance (IHG) and less intensive motivation-enhancing guidance (MEG) on cardiovascular risk factors. STUDY DESIGN A regression discontinuity design (RDD) was applied. METHODS In Japan's specific health checkup (SHC) and guidance program, those with a high risk of metabolic syndrome are assigned to IHG or MEG. An RDD was applied using an SHC results database. Four groups were created in which IHG or MEG assignment was solely determined by single cut-off values of the running variables of triglycerides (TGs), high-density lipoprotein cholesterol (HDL-C), fasting blood glucose (FBG), or haemoglobin A1c (HbA1c) measured during SHC. Outcomes were one year's changes in body mass index (BMI), waist circumference (WCF), systolic and diastolic blood pressure, HDL-C, low-density lipoprotein cholesterol, FBG, and HbA1c. RESULTS A total of 541,809 observations among 225,115 people from 2008 to 2017 were analysed. Men assigned to IHG had a significantly but slightly lower BMI and WCF than those assigned to MEG the next year, only when TG or FBG was a running variable. There were no significant differences between IHG and MEG for women's BMI and WCF and other cardiovascular risk factors for both sexes. CONCLUSION Since IHG has limited additional effects on cardiovascular risk factors compared with MEG, abolishing IHG may have little negative impact on the general public's health.
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Affiliation(s)
- Y Sekizawa
- Research Institute of Economy, Trade, and Industry, Chiyoda-ku, Kasumigaseki 1-3-1, Tokyo, 100-8901, Japan.
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3
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Gilden AH, Catenacci VA, Taormina JM. Obesity. Ann Intern Med 2024; 177:ITC65-ITC80. [PMID: 38739920 DOI: 10.7326/aitc202405210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024] Open
Abstract
Obesity is a common condition and a major cause of morbidity and mortality. Fortunately, weight loss treatment can reduce obesity-related complications. This review summarizes the evidence-based strategies physicians can employ to identify, prevent, and treat obesity, including best practices to diagnose and counsel patients, to assess and address the burden of weight-related disease including weight stigma, to address secondary causes of weight gain, and to help patients set individualized and realistic weight loss goals and an effective treatment plan. Effective treatments include lifestyle modification and adjunctive therapies such as antiobesity medications and metabolic and bariatric surgery.
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Affiliation(s)
- Adam H Gilden
- Anschutz Health and Wellness Center, and Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado (A.H.G.); Anschutz Health and Wellness Center, and Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado (V.A.C.); Anschutz Health and Wellness Center, and Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado (J.M.T.)
| | - Victoria A Catenacci
- Anschutz Health and Wellness Center, and Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado (A.H.G.); Anschutz Health and Wellness Center, and Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado (V.A.C.); Anschutz Health and Wellness Center, and Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado (J.M.T.)
| | - John Michael Taormina
- Anschutz Health and Wellness Center, and Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado (A.H.G.); Anschutz Health and Wellness Center, and Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado (V.A.C.); Anschutz Health and Wellness Center, and Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado (J.M.T.)
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4
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Chao AM, Moore M, Wadden TA. The past, present, and future of behavioral obesity treatment. Int J Obes (Lond) 2024:10.1038/s41366-024-01525-3. [PMID: 38678143 DOI: 10.1038/s41366-024-01525-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 04/29/2024]
Abstract
Over the last century, hundreds of evaluations have been conducted to examine weight-management interventions related to diet, physical activity, and behavior therapy. These investigations have contributed to a growing body of knowledge that has consistently advanced the field of obesity treatment, while also revealing some persistent challenges. This narrative review summarizes key findings from randomized controlled trials conducted in adults that have combined diet, physical activity, and behavior therapy, an approach variously referred to as behavioral treatment, comprehensive lifestyle modification, or intensive lifestyle intervention. The review shows that current behavioral approaches induce average reductions in baseline body weight of 5 to 10% at 6 to 12 months. Such losses have proven effective in reducing the risk of type 2 diabetes in persons with impaired glucose tolerance and in improving other obesity-related complications. These benefits have also been associated with reductions in healthcare costs. Despite these advances, behavioral treatment is challenged by the need for larger losses to achieve optimal improvements in health, by difficulties associated with maintaining weight loss, and by barriers limiting access to treatment. New anti-obesity medications, when combined with behavioral obesity treatment, hold promise of addressing the first two issues.
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Affiliation(s)
- Ariana M Chao
- Johns Hopkins School of Nursing, Baltimore, MD, USA.
| | - Molly Moore
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas A Wadden
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Shreve MD, Scott A, Davis RL. Reexamining the complex issue of obesity in childhood: A new guideline and patient-focused approach. Nurse Pract 2024; 49:20-28. [PMID: 38386469 DOI: 10.1097/01.npr.0000000000000150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
ABSTRACT Obesity in childhood is a complex, multifaceted condition with various contributors, including genetic, environmental, socioeconomic, and physiologic factors. The latest guidelines recommend annual evaluation beginning at age 2 years. Treatment strategies should be family focused and should target nutrition, physical activity, and behavior.
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Cartes-Velásquez R, Varnet-Pérez T, Martínez-Delgado CM, Villanueva-Vilchis MDC, Ramírez-Trujillo MDLÁ, Faustino-Silva DD. Motivational interviewing for preventing oral morbidities in adults: Systematic review and meta-analysis. Community Dent Oral Epidemiol 2024; 52:84-92. [PMID: 37668224 DOI: 10.1111/cdoe.12904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 07/11/2023] [Accepted: 07/31/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE This systematic review with meta-analysis was performed to assess whether motivational interviewing (MI) effectively prevents oral morbidities in adults. METHODS Studies considered were randomized controlled trials, cluster-randomized controlled trials and community-based randomized trials assessing interventions based on MI or indicating that a counselling technique based on the principles developed by Miller and Rollnick was used. Controls were any type of oral health education or negative controls. Participants were 18-60 years old. The main outcome was any oral morbidity. From 602 studies identified in MEDLINE, Scopus, Web of Science and LILACS databases, seven studies were included in the synthesis. RESULTS Studies included only evaluated periodontal outcomes, no studies were found for other oral morbidities. Patients' mean age was 43.7 years, and the follow-up time after MI or MI-based intervention varied between 1 month and 1 year. The total study population was 272 people with moderate-to-severe periodontitis; other groups analysed were pregnant women (n = 112) and patients with mental disorders and alcohol problems (n = 60). Meta-analysis for the plaque index (four studies, n = 267), bleeding on probing (two studies, n = 177) and gingival index (two studies, n = 166) were carried out. The summary effects for the random-effects model were estimated respectively as -3.59 percentage points (CI: [-11.44; 4.25] for plaque index, -6.41 percentage points (CI: [-12.18, -0.65]) for bleeding on probing and -0.70 (CI: [-1.87; 0.48]) for gingival index, marginally favouring the MI group. The reduced number of studies, the non-disclosure of some aspects of the data and the heterogeneity among them undermine the precision of the estimates. CONCLUSION The current evidence available is limited to periodontal outcomes, and it is not possible to determine whether MI effectively prevents oral morbidities in adults.
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Wee CC, Cornell JE. Conversations About Obesity and Weight: Good News We Can Use. Ann Intern Med 2023; 176:1546-1547. [PMID: 37931270 DOI: 10.7326/m23-2568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
Affiliation(s)
| | - John E Cornell
- Associate Editor for Statistics, Annals of Internal Medicine
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Snowball JE, Flight WG, Heath L, Koutoukidis DA. A paradigm shift in cystic fibrosis nutritional care: Clinicians' views on the management of patients with overweight and obesity. J Cyst Fibros 2023; 22:836-842. [PMID: 36966039 DOI: 10.1016/j.jcf.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/13/2023] [Accepted: 03/15/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Overweight and obesity among people with cystic fibrosis (pwCF) has become more prevalent since the widespread adoption of CF transmembrane conductance regulator (CFTR) modulator therapies and presents a new challenge for nutritional care. We aimed to explore how clinicians working in CF care approach the management of adults with overweight and obesity. METHODS We conducted semi-structured interviews with n = 20 clinicians (n = 6 physiotherapists, n = 6 doctors and n = 8 dietitians) working in 15 adult CF centres in the United Kingdom. The interviews explored their perspectives and current practices caring for people with CF and overweight/obesity. Data were analysed using reflexive thematic analysis. RESULTS Four main themes were identified: 1) challenges of raising the topic of overweight and obesity in the CF clinic (e.g., clinician-patient rapport and concerns around weight stigma); 2) the changing landscape of assessment due to CF-specific causes of weight gain: (e.g., impact of CFTR modulators and CF legacy diet) 3) presence of clinical equipoise for weight management due to the lack of CF-specific evidence on the consequences of obesity and intentional weight loss (e.g., unclear consequences on respiratory outcomes and risk of weight related co-morbidities) and 4) opportunities for a safe, effective, and acceptable weight management treatment for people with CF (e.g., working collaboratively with current multidisciplinary CF care). CONCLUSIONS Approaching weight management in the CF setting is complex. Trials are needed to assess the equipoise of weight management interventions in this group and CF-specific issues should be considered when developing such interventions.
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Affiliation(s)
- Joanna E Snowball
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, United Kingdom; Oxford Adult Cystic Fibrosis Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU, United Kingdom; NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom.
| | - William G Flight
- Oxford Adult Cystic Fibrosis Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU, United Kingdom
| | - Laura Heath
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, United Kingdom
| | - Dimitrios A Koutoukidis
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, United Kingdom; NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
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Pigsborg K, Kalea AZ, De Dominicis S, Magkos F. Behavioral and Psychological Factors Affecting Weight Loss Success. Curr Obes Rep 2023; 12:223-230. [PMID: 37335395 DOI: 10.1007/s13679-023-00511-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE OF REVIEW There is a large variability between individuals in the weight loss response to any given diet treatment, which fuels interest into personalized or precision nutrition. Although most efforts are directed toward identifying biological or metabolic factors, several behavioral and psychological factors can also be responsible for some of this interindividual variability. RECENT FINDINGS There are many factors that can influence the response to dietary weight loss interventions, including factors related to eating behavior (emotional eating, disinhibition, restraint, perceived stress), behaviors and societal norms related to age and sex, psychological and personal factors (motivation, self-efficacy, locus of control, self-concept), and major life events. The success of a weight loss intervention can be influenced by many psychological and behavioral constructs and not merely by physiological factors such as biology and genetics. These factors are difficult to capture accurately and are often overlooked. Future weight loss studies should consider assessing such factors to better understand the underlying reasons for the large interindividual variability to weight loss therapy.
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Affiliation(s)
- Kristina Pigsborg
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Rolighedsvej 26, 1958, Frederiksberg, Denmark.
| | - Anastasia Z Kalea
- Division of Medicine, University College London, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Stefano De Dominicis
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Rolighedsvej 26, 1958, Frederiksberg, Denmark
| | - Faidon Magkos
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Rolighedsvej 26, 1958, Frederiksberg, Denmark.
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Huang X, Xu N, Wang Y, Sun Y, Guo A. The effects of motivational interviewing on hypertension management: A systematic review and meta-analysis. PATIENT EDUCATION AND COUNSELING 2023; 112:107760. [PMID: 37075650 DOI: 10.1016/j.pec.2023.107760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/17/2023] [Accepted: 04/14/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE This systematic review aimed to examine the effects of motivational interviewing-based interventions on hypertension management. METHODS Six databases were searched from inception to 25 July, 2022 for randomized controlled trials involving adults diagnosed with hypertension and including motivational interviewing in the treatment interventions. RESULTS In total, 11 studies with 2121 participants were included. Compared with no or minimal additional intervention, motivational interviewing-based intervention showed greater reduction in systolic blood pressure (MD: -6.56, 95 % CI: -10.51, -2.62, P = 0.001) and diastolic blood pressure (MD: -3.75, 95 % CI: -4.92, -2.58, P < 0.001). Compared with the lower intensity intervention, motivational interviewing-based intervention produced statistically significant effect on reducing systolic blood pressure (MD: -2.72, 95 % CI: -5.34, -0.10, P = 0.040); while there was no significant effect on reducing diastolic blood pressure (MD: -0.47, 95 % CI: -2.21, 1.28, P = 0.600). Four out of six studies demonstrated medication adherence significantly improved following motivational interviewing-based intervention. Two studies included self-efficacy and quality of life, and inconsistent findings were observed. CONCLUSION Motivational interviewing could be effective in improving blood pressure control among patients with hypertension. Future studies with more rigorous study designs should be conducted to confirm the effects of motivational interviewing on medication adherence and psychological well-being. PRACTICE IMPLICATIONS Motivational interviewing could be applied as a promising intervention strategy among patients with hypertension.
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Affiliation(s)
- Xinghe Huang
- School of Nursing, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100144, China
| | - Nuo Xu
- School of Nursing, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100144, China
| | - Yuyu Wang
- School of Nursing, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100144, China
| | - Yixin Sun
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Aimin Guo
- School of Nursing, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100144, China.
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Dragomir AI, Voisard B, Gosselin Boucher V, Szczepanik G, Bacon SL, Lavoie KL. Effectiveness of Motivational Interviewing in Managing Overweight and Obesity. Ann Intern Med 2022; 175:W104-W105. [PMID: 36122402 DOI: 10.7326/l22-0237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Anda I Dragomir
- Centre Intégré Universitaire de santé et services sociaux du Nord-de-l'Ile-de-Montréal and Concordia University, Montreal, Quebec, Canada
| | - Brigitte Voisard
- Centre Intégré Universitaire de santé et services sociaux du Nord-de-l'Ile-de-Montréal and Université du Québec à Montréal, Montreal, Quebec, Canada
| | - Vincent Gosselin Boucher
- Centre Intégré Universitaire de santé et services sociaux du Nord-de-l'Ile-de-Montréal and University of British Columbia, Montreal, Quebec, and Vancouver, British Columbia, Canada
| | - Geneviève Szczepanik
- Centre Intégré Universitaire de santé et services sociaux du Nord-de-l'Ile-de-Montréal, Montreal, Quebec, Canada
| | - Simon L Bacon
- Centre Intégré Universitaire de santé et services sociaux du Nord-de-l'Ile-de-Montréal and Concordia University, Montreal, Quebec, Canada
| | - Kim L Lavoie
- Centre Intégré Universitaire de santé et services sociaux du Nord-de-l'Ile-de-Montréal and Université du Québec à Montréal, Montreal, Quebec, Canada
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Smith J. Effectiveness of Motivational Interviewing in Managing Overweight and Obesity. Ann Intern Med 2022; 175:W104. [PMID: 36122403 DOI: 10.7326/l22-0236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jonathan Smith
- Mel and Enid Zuckerman College of Public Health at The University of Arizona, Tucson, Arizona
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Wittleder S, Jay M. Increasing Motivation for Lifestyle Change Is Not Enough to Treat Obesity. Ann Intern Med 2022; 175:901-902. [PMID: 35344377 DOI: 10.7326/m22-0715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Melanie Jay
- NYU Grossman School of Medicine, New York, New York
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Navaee M, Hassanzei Y, Navidian A. The effect of motivational interviewing on self-efficacy and decision-making about type of delivery in primigravid women: A randomized clinical trial. Nurs Midwifery Stud 2022. [DOI: 10.4103/nms.nms_16_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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