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Article History

Received: 9 February 2026

Accepted: 17 May 2026

First Online: 20 May 2026

Declarations

:

: The original 2010 Iran Multiple Indicator Demographic and Health Survey (IrMIDHS) protocol was reviewed and approved by the Ethics Committee of Tehran University of Medical Sciences (Tehran, Iran), the information office of the Ministry of Health and Medical Education (MoHME), the review board of the Statistical Center of Iran (SCI), the Policy Council, and the Board of Deputies of the MoHME, as detailed in the official study protocol (Rashidian et al., 2014; available at: ). Verbal informed consent was obtained from all eligible participants at the household level after explaining the study purpose, its voluntary nature, confidentiality, and the right to refuse or withdraw participation at any time. The original IrMIDHS survey and the present secondary analysis were conducted in accordance with the ethical principles of the Declaration of Helsinki. The present study is a secondary analysis of fully anonymized and de-identified data from that national survey, with no new data collection, no contact with participants, and no access to personally identifiable information. Under the national regulations and guidelines for biomedical research ethics administered by the Ministry of Health and Medical Education (MoHME) of Iran — specifically through the National Committee for Ethics in Biomedical Research — secondary analyses of fully anonymized and de-identified national health survey data do not require additional ethics committee approval or renewed informed consent. This is consistent with standard practices in Iran for secondary use of such datasets, where no additional human participant involvement occurs. No new ethics approval was sought or obtained for this analysis, and no reference/approval number applies.

: Not applicable.

: The authors declare no competing interests.