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Volume 13, Issue 3 (2025)
Health Educ Health Promot 2025, 13(3): 529-539 |
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Received: 2025/07/2 | Accepted: 2025/08/11 | Published: 2025/08/20
Received: 2025/07/2 | Accepted: 2025/08/11 | Published: 2025/08/20
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Holistic Prenatal Class-Based Learning Model and Its Effect on Pregnant Women's Anxiety. Health Educ Health Promot 2025; 13 (3) :529-539
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URL: http://hehp.modares.ac.ir/article-4-82634-en.html
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Introduction
Pregnancy is a complex physiological process that involves physical, hormonal, psychological, and social changes in a woman [1]. These changes can trigger stress and anxiety, particularly as childbirth approaches [2]. Maternal anxiety has been associated with elevated cortisol levels, immune dysfunction, and disruption of the mother’s physiological balance [3]. This condition may affect fetal health through intrauterine stress mechanisms that influence nervous system development [4]. Therefore, prenatal interventions should comprehensively address the physical, emotional, and spiritual dimensions of the mother [5].
The prevalence of anxiety among pregnant women has been reported to be high in various countries, including Indonesia [6]. A study in Indonesia revealed that approximately 28.7% of pregnant women experience anxiety, with prevalence increasing significantly during the third trimester. The main causes of anxiety include a lack of knowledge about childbirth, negative past experiences, and limited social support [7]. This condition has the potential to increase pregnancy complications, including preterm birth, excessive pain, and unplanned medical interventions [8]. Additionally, maternal anxiety impacts the overall quality of life of mothers, both during pregnancy and after delivery [9].
Most prenatal services remain focused on medical aspects such as pregnancy monitoring and the detection of complications [10]. This approach often neglects the psychological and spiritual dimensions, even though these aspects are critical in preparing mothers for childbirth [11]. As a result, many pregnant women continue to experience high levels of anxiety despite receiving conventional prenatal care [12]. This phenomenon highlights a gap in maternal healthcare systems that have yet to integrate holistic approaches [13].
From a research perspective, most studies on maternal anxiety remain focused on partial interventions such as yoga or relaxation, without integrating the multiple dimensions of maternal health [14]. Moreover, research on the effectiveness of such interventions is more frequently conducted in high-income countries, making it less representative of the social and cultural contexts in developing nations [15]. Prenatal class-based studies that adopt holistic approaches, which simultaneously encompass physical, emotional, and spiritual aspects, remain limited [16]. This indicates a need for research capable of evaluating the effectiveness of holistic models in broader and more diverse contexts [5].
Untreated maternal anxiety can directly affect birth outcomes, including prolonged labor duration [1]. Other studies have shown that anxiety is associated with an increased risk of obstetric complications and medical interventions such as cesarean sections [16]. High anxiety also increases the risk of postpartum depression, which can affect mother-infant bonding. Thus, effective strategies to reduce maternal anxiety are urgently needed in maternal healthcare services.
The novelty of this study lies in the application of bibliometric analysis to map research trends and themes related to holistic prenatal education. Bibliometric analysis enables the mapping of dominant keywords, author collaborations, and the evolution of global research themes. With this approach, studies can identify both emerging and underexplored areas of research. Furthermore, its focus on interventions that integrate physical, emotional, and spiritual aspects into a single learning model makes this study distinct from previous works.
The expected benefits of this study include scientifically enriching the literature on holistic approaches in prenatal education and maternal anxiety, practically providing recommendations for healthcare providers (midwives, doctors, maternity clinics) to design more comprehensive prenatal education modules, in terms of policy, supporting the establishment of prenatal care standards that consider psychosocial and spiritual aspects alongside medical ones, and socially enhancing the emotional well-being of pregnant women, reducing anxiety, and fostering more positive childbirth experiences.
The main objective of this study was to analyze how holistic prenatal education affects anxiety among third-trimester pregnant women and how it relates to birth outcomes. In addition, this study aimed to map global research trends on holistic prenatal education, identify gaps in the literature, and examine the influence of cultural context on its effectiveness.
Instrument and Methods
Research design
A bibliometric analysis was conducted using the Scopus database. Bibliometric analysis is a method used to evaluate and map scientific literature within a specific field of research. This method utilizes statistical and mathematical techniques to measure and analyze academic publications, including articles, books, and other scholarly documents. The primary aim of bibliometric analysis is to identify research trends, collaboration networks among researchers, and the development of prominent topics within a given academic discipline [17, 18].
Furthermore, bibliometric analysis provides valuable insights into international research collaborations. It can be employed to identify underdeveloped research areas and potential opportunities for collaboration among researchers across different countries [19]. This is crucial for strengthening research networks and improving the overall quality of scientific output. More broadly, bibliometric analysis can also be used to evaluate the impact of research on policy development and practical implementation in the field.
The inclusion criteria comprised studies relevant to holistic prenatal education and pregnancy-related anxiety, published in English. Studies focusing exclusively on pharmacological interventions or those outside the context of the third trimester were excluded.
One of the primary applications of bibliometric analysis is to understand the development of a particular research area. Data were collected using the following keywords: “Holistic Prenatal Learning Model,” “Third Trimester Pregnant Women’s Anxiety,” “Childbirth Results,” and “Prenatal Classroom Approach.” The search strategy employed was (TITLE-ABS-KEY (“holistic prenatal learning”) OR TITLE-ABS-KEY (“third trimester pregnant”) OR TITLE-ABS-KEY (anxiety) OR TITLE-ABS-KEY (“childbirth results”) OR TITLE-ABS-KEY (“prenatal classroom approach”)) AND TITLE-ABS-KEY (“holistic approach”) AND PUBYEAR. This search returned a total of 521 documents.
VOSviewer was employed to identify research trends, network mapping, and citation analysis. In addition, Biblioshiny was used to compile citation statistics.
Findings
Publication patterns
Bibliometric statistics on research on the holistic prenSatal learning model and its impact on maternal anxiety and childbirth outcomes were assessed (Figure 1).
![src=./files/hehp/images/HTML_Publish/82634/1.png]()
Figure 1. Bibliometric statistics on research related to the holistic prenatal learning model and its impact on maternal anxiety and childbirth outcomes (2014-2024)
The number of publications has increased annually, with a noticeable peak in the last three years. Key journals that have frequently published articles on holistic prenatal learning include the Journal of Midwifery & WoAmen’s Health and BMC Pregnancy and Childbirth (Figure 2).
![src=./files/hehp/images/HTML_Publish/82634/2.png]()
Figure 2. Visualization of leading journals publishing on the holistic prenatal learning model (2014-2024)
Based on the visualization of the research data, several key journals emerged as major sources for publications related to holistic prenatal education. Among them, the International Journal of Environmental Research and Public Health and the Journal of Clinical Medicine were identified as the most prolific, each contributing 9 articles. This indicates a strong alignment of holistic maternal health research within the domains of environmental and clinical health sciences.
PLOS ONE and Frontiers in Psychology also contributed significantly, with 6 and 5 documents, respectively, emphasizing the psychological and public health dimensions of this research topic. In addition, the Journal of Holistic Nursing and the Journal of Multidisciplinary Healthcare each published 5 and 4 articles, respectively, reflecting considerable academic attention to multidisciplinary and integrative approaches in maternal healthcare.
Collectively, these journals demonstrate a wide-ranging interest in holistic and psychological approaches to maternal health management, underscoring both the multidisciplinary perspectives and clinical relevance in the realm of public health practice.
Co-Authorship Analysis
Co-authorship analysis showed that the most productive research collaborations originated from countries, such as the United States, United Kingdom, and Australia. Krajewski and Schwartz emerged as leading contributors in this field (Figure 3).
![src=./files/hehp/images/HTML_Publish/82634/3.png]()
FigureS 3. Visualization of a three-field plot displaying Citation References (CR), Authors (AU), and Descriptive Keywords/Terms (DE)
Keywords co-occurrence
The most frequently occurring keywords associated with holistic prenatal classes and pregnancy-related anxiety were “holistic learning,” “prenatal anxiety,” “childbirth,” and “pregnancy outcomes.” These findings Aindicate an increasing research focus on integrative educational approaches during pregnancy (Figure 4).
![src=./files/hehp/images/HTML_Publish/82634/4.png]()
Figure 4. Visualization of keyword trend topics from 2014 to 2024
Other notable contributors included the University of California and Radboud University Medical Center, with 17 and 16 articles, respectively. Research institutions in Shanghai, Tokyo, and London also played important roles, demonstrating the global nature of acadeAmic collaboration in this field (Figure 5).
![src=./files/hehp/images/HTML_Publish/82634/5.png]()
Figure 5. Institutions with the highest research output
These network analyses reveal that research on holistic maternal care is being conducted within a robust framework of international collaboration, with the United States, the United Kingdom, and India serving as leading contributors. The transnational nature of this collaboration highlights the universal importance of prenatal mental health and the increasing global recognition of holistic care models (Figure 6).
![src=./files/hehp/images/HTML_Publish/82634/Screenshot_2025-12-16_101128.png]()
Figure 6. Corresponding author countries in the development of holistic prenatal education models
Citation Analysis
This section identifies the most highly cited articles and evaluates their contributions to the field. The article by Padula et al. was the most frequently cited, with 606 citations. This study explored the impact of holistic education on the emotional well-being of pregnant women and has served as a foundational reference for subsequent research (Figure 7).
![src=./files/hehp/images/HTML_Publish/82634/7.png]()
Figure 7. Visualization of citation trends for research articles on holistic prenatal education (2014-2024)
Thematic Mapping
Thematic maps generated from the analyzed literature reveal that emerging themes in holistic prenatal education research not only cover psychological dimensions but also address physiological aspects, such as the reduction of labor complications. These findings underscore the dual focus of holistic care models—enhancing emotional resilience while also improving tangible health outcomes. Future research should continue exploring the intersection of psychological, physiological, and environmental factors in maternal health through the lens of holistic education.
![src=./files/hehp/images/HTML_Publish/82634/8.png]()
Figure 8. Tree map visualization of keyword trends related to the holistic model (2014-2024)
Mental Health and Psychology also appear as important keywords, underscoring growing attention to the psychological dimensions of pregnancy and their influence on maternal quality of life (Figure 9).
![src=./files/hehp/images/HTML_Publish/82634/9.png]()
Figure 9. Network visualization of holistic model development
The thematic evolution map from 2014-2022 to 2023-2024 revealed several notable shifts in research focus:
Themes from 2014-2022: Early research was primarily centered on topics, such as Parkinson’s disease, risk factors, and post-traumatic stress, indicating an emphasis on chronic medical conditions and health risk identification. The holistic approach and anxiety disorders were also prominent, reflecting increased interest in holistic strategies for managing anxiety-related conditions (Figure 10).
![src=./files/hehp/images/HTML_Publish/82634/10.png]()
Figure 10. Thematic evolution of research topics in holistic models (2014-2024)
Discussion
This study aimed to analyze how holistic prenatal education affects anxiety among third-trimester pregnant women and how it relates to birth outcomes. The research in this area spans a ten-year period from 2014 to 2024, indicating increasing scholarly attention over the past decade. A total of 521 documents were published during the specified timeframe, demonstrating substantial academic interest in holistic prenatal learning and its association with maternal anxiety and birth outcomes. With an annual growth rate of 18.26%, this reflects a rapid increase in research, highlighting growing awareness of the importance of holistic approaches in maternal health, particularly in mitigating anxiety and improving delivery outcomes. Additionally, a total of 2,577 authors contributed to this body of research, indicating broad collaboration and considerable scholarly engagement across different regions of the world.
Approximately 20.35% of published articles involved international collaboration, underscoring the global nature of scholarly engagement in this field [20, 21]. The average number of authors per document was 5.08, suggesting a tendency towards large-scale or multidisciplinary research teams [22, 23]. A total of 1,649 keywords were used across the dataset, reflecting the thematic diversity of studies related to holistic prenatal education, anxiety, and childbirth outcomes [24]. The high number of references, totaling 25,824, indicates that this field is supported by an extensive and in-depth literature base, which reinforces the reliability and credibility of the findings [24, 25]. The cited documents had an average age of 3.27 years, showing that the literature is relatively recent and aligned with current research trends, contributing to its relevance and academic influence [26, 27]. Each document received an average of 10.58 citations, demonstrating the scholarly impact and influence of the research in this domain.
Based on the three-field plot visualization, the top three most frequently cited references were Braun & Clarke, regarding thematic analysis in psychology; Finlay & Khan [28], concerning the Dermatology Life Quality Index (DLQI); and Zigmond & Snaith [29], related to the Hospital Anxiety and Depression Scale (HADS). These references provided a strong theoretical foundation for studies focusing on quality of life and mental health outcomes [30]. Research by Padula et al. reports that exposure to air pollution and heavy metals during pregnancy, when combined with maternal psychosocial stress, can worsen fetal and child health. This combined exposure increases the risk of developmental delays, low birth weight, and neurocognitive problems [31]. The most frequently appearing keywords included depression, anxiety, quality of life, and mental health. These topics indicate the central research themes in exploring the interrelationship between psychological health and physical health conditions. The plot illustrates a strong link between theoretical frameworks on mental health, the pivotal role of prolific authors, and the growing depth of research on depression, anxiety, and quality of life within palliative and chronic pain care settings [32].
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Pregnancy is a complex physiological process that involves physical, hormonal, psychological, and social changes in a woman [1]. These changes can trigger stress and anxiety, particularly as childbirth approaches [2]. Maternal anxiety has been associated with elevated cortisol levels, immune dysfunction, and disruption of the mother’s physiological balance [3]. This condition may affect fetal health through intrauterine stress mechanisms that influence nervous system development [4]. Therefore, prenatal interventions should comprehensively address the physical, emotional, and spiritual dimensions of the mother [5].
The prevalence of anxiety among pregnant women has been reported to be high in various countries, including Indonesia [6]. A study in Indonesia revealed that approximately 28.7% of pregnant women experience anxiety, with prevalence increasing significantly during the third trimester. The main causes of anxiety include a lack of knowledge about childbirth, negative past experiences, and limited social support [7]. This condition has the potential to increase pregnancy complications, including preterm birth, excessive pain, and unplanned medical interventions [8]. Additionally, maternal anxiety impacts the overall quality of life of mothers, both during pregnancy and after delivery [9].
Most prenatal services remain focused on medical aspects such as pregnancy monitoring and the detection of complications [10]. This approach often neglects the psychological and spiritual dimensions, even though these aspects are critical in preparing mothers for childbirth [11]. As a result, many pregnant women continue to experience high levels of anxiety despite receiving conventional prenatal care [12]. This phenomenon highlights a gap in maternal healthcare systems that have yet to integrate holistic approaches [13].
From a research perspective, most studies on maternal anxiety remain focused on partial interventions such as yoga or relaxation, without integrating the multiple dimensions of maternal health [14]. Moreover, research on the effectiveness of such interventions is more frequently conducted in high-income countries, making it less representative of the social and cultural contexts in developing nations [15]. Prenatal class-based studies that adopt holistic approaches, which simultaneously encompass physical, emotional, and spiritual aspects, remain limited [16]. This indicates a need for research capable of evaluating the effectiveness of holistic models in broader and more diverse contexts [5].
Untreated maternal anxiety can directly affect birth outcomes, including prolonged labor duration [1]. Other studies have shown that anxiety is associated with an increased risk of obstetric complications and medical interventions such as cesarean sections [16]. High anxiety also increases the risk of postpartum depression, which can affect mother-infant bonding. Thus, effective strategies to reduce maternal anxiety are urgently needed in maternal healthcare services.
The novelty of this study lies in the application of bibliometric analysis to map research trends and themes related to holistic prenatal education. Bibliometric analysis enables the mapping of dominant keywords, author collaborations, and the evolution of global research themes. With this approach, studies can identify both emerging and underexplored areas of research. Furthermore, its focus on interventions that integrate physical, emotional, and spiritual aspects into a single learning model makes this study distinct from previous works.
The expected benefits of this study include scientifically enriching the literature on holistic approaches in prenatal education and maternal anxiety, practically providing recommendations for healthcare providers (midwives, doctors, maternity clinics) to design more comprehensive prenatal education modules, in terms of policy, supporting the establishment of prenatal care standards that consider psychosocial and spiritual aspects alongside medical ones, and socially enhancing the emotional well-being of pregnant women, reducing anxiety, and fostering more positive childbirth experiences.
The main objective of this study was to analyze how holistic prenatal education affects anxiety among third-trimester pregnant women and how it relates to birth outcomes. In addition, this study aimed to map global research trends on holistic prenatal education, identify gaps in the literature, and examine the influence of cultural context on its effectiveness.
Instrument and Methods
Research design
A bibliometric analysis was conducted using the Scopus database. Bibliometric analysis is a method used to evaluate and map scientific literature within a specific field of research. This method utilizes statistical and mathematical techniques to measure and analyze academic publications, including articles, books, and other scholarly documents. The primary aim of bibliometric analysis is to identify research trends, collaboration networks among researchers, and the development of prominent topics within a given academic discipline [17, 18].
Furthermore, bibliometric analysis provides valuable insights into international research collaborations. It can be employed to identify underdeveloped research areas and potential opportunities for collaboration among researchers across different countries [19]. This is crucial for strengthening research networks and improving the overall quality of scientific output. More broadly, bibliometric analysis can also be used to evaluate the impact of research on policy development and practical implementation in the field.
The inclusion criteria comprised studies relevant to holistic prenatal education and pregnancy-related anxiety, published in English. Studies focusing exclusively on pharmacological interventions or those outside the context of the third trimester were excluded.
One of the primary applications of bibliometric analysis is to understand the development of a particular research area. Data were collected using the following keywords: “Holistic Prenatal Learning Model,” “Third Trimester Pregnant Women’s Anxiety,” “Childbirth Results,” and “Prenatal Classroom Approach.” The search strategy employed was (TITLE-ABS-KEY (“holistic prenatal learning”) OR TITLE-ABS-KEY (“third trimester pregnant”) OR TITLE-ABS-KEY (anxiety) OR TITLE-ABS-KEY (“childbirth results”) OR TITLE-ABS-KEY (“prenatal classroom approach”)) AND TITLE-ABS-KEY (“holistic approach”) AND PUBYEAR. This search returned a total of 521 documents.
VOSviewer was employed to identify research trends, network mapping, and citation analysis. In addition, Biblioshiny was used to compile citation statistics.
Findings
Publication patterns
Bibliometric statistics on research on the holistic prenSatal learning model and its impact on maternal anxiety and childbirth outcomes were assessed (Figure 1).
Figure 1. Bibliometric statistics on research related to the holistic prenatal learning model and its impact on maternal anxiety and childbirth outcomes (2014-2024)
The number of publications has increased annually, with a noticeable peak in the last three years. Key journals that have frequently published articles on holistic prenatal learning include the Journal of Midwifery & WoAmen’s Health and BMC Pregnancy and Childbirth (Figure 2).
Figure 2. Visualization of leading journals publishing on the holistic prenatal learning model (2014-2024)
Based on the visualization of the research data, several key journals emerged as major sources for publications related to holistic prenatal education. Among them, the International Journal of Environmental Research and Public Health and the Journal of Clinical Medicine were identified as the most prolific, each contributing 9 articles. This indicates a strong alignment of holistic maternal health research within the domains of environmental and clinical health sciences.
PLOS ONE and Frontiers in Psychology also contributed significantly, with 6 and 5 documents, respectively, emphasizing the psychological and public health dimensions of this research topic. In addition, the Journal of Holistic Nursing and the Journal of Multidisciplinary Healthcare each published 5 and 4 articles, respectively, reflecting considerable academic attention to multidisciplinary and integrative approaches in maternal healthcare.
Collectively, these journals demonstrate a wide-ranging interest in holistic and psychological approaches to maternal health management, underscoring both the multidisciplinary perspectives and clinical relevance in the realm of public health practice.
Co-Authorship Analysis
Co-authorship analysis showed that the most productive research collaborations originated from countries, such as the United States, United Kingdom, and Australia. Krajewski and Schwartz emerged as leading contributors in this field (Figure 3).
FigureS 3. Visualization of a three-field plot displaying Citation References (CR), Authors (AU), and Descriptive Keywords/Terms (DE)
Keywords co-occurrence
The most frequently occurring keywords associated with holistic prenatal classes and pregnancy-related anxiety were “holistic learning,” “prenatal anxiety,” “childbirth,” and “pregnancy outcomes.” These findings Aindicate an increasing research focus on integrative educational approaches during pregnancy (Figure 4).
Figure 4. Visualization of keyword trend topics from 2014 to 2024
Other notable contributors included the University of California and Radboud University Medical Center, with 17 and 16 articles, respectively. Research institutions in Shanghai, Tokyo, and London also played important roles, demonstrating the global nature of acadeAmic collaboration in this field (Figure 5).
Figure 5. Institutions with the highest research output
These network analyses reveal that research on holistic maternal care is being conducted within a robust framework of international collaboration, with the United States, the United Kingdom, and India serving as leading contributors. The transnational nature of this collaboration highlights the universal importance of prenatal mental health and the increasing global recognition of holistic care models (Figure 6).
Figure 6. Corresponding author countries in the development of holistic prenatal education models
Citation Analysis
This section identifies the most highly cited articles and evaluates their contributions to the field. The article by Padula et al. was the most frequently cited, with 606 citations. This study explored the impact of holistic education on the emotional well-being of pregnant women and has served as a foundational reference for subsequent research (Figure 7).
Figure 7. Visualization of citation trends for research articles on holistic prenatal education (2014-2024)
Thematic Mapping
Thematic maps generated from the analyzed literature reveal that emerging themes in holistic prenatal education research not only cover psychological dimensions but also address physiological aspects, such as the reduction of labor complications. These findings underscore the dual focus of holistic care models—enhancing emotional resilience while also improving tangible health outcomes. Future research should continue exploring the intersection of psychological, physiological, and environmental factors in maternal health through the lens of holistic education.
Figure 8. Tree map visualization of keyword trends related to the holistic model (2014-2024)
Mental Health and Psychology also appear as important keywords, underscoring growing attention to the psychological dimensions of pregnancy and their influence on maternal quality of life (Figure 9).
Figure 9. Network visualization of holistic model development
The thematic evolution map from 2014-2022 to 2023-2024 revealed several notable shifts in research focus:
Themes from 2014-2022: Early research was primarily centered on topics, such as Parkinson’s disease, risk factors, and post-traumatic stress, indicating an emphasis on chronic medical conditions and health risk identification. The holistic approach and anxiety disorders were also prominent, reflecting increased interest in holistic strategies for managing anxiety-related conditions (Figure 10).
Figure 10. Thematic evolution of research topics in holistic models (2014-2024)
Discussion
This study aimed to analyze how holistic prenatal education affects anxiety among third-trimester pregnant women and how it relates to birth outcomes. The research in this area spans a ten-year period from 2014 to 2024, indicating increasing scholarly attention over the past decade. A total of 521 documents were published during the specified timeframe, demonstrating substantial academic interest in holistic prenatal learning and its association with maternal anxiety and birth outcomes. With an annual growth rate of 18.26%, this reflects a rapid increase in research, highlighting growing awareness of the importance of holistic approaches in maternal health, particularly in mitigating anxiety and improving delivery outcomes. Additionally, a total of 2,577 authors contributed to this body of research, indicating broad collaboration and considerable scholarly engagement across different regions of the world.
Approximately 20.35% of published articles involved international collaboration, underscoring the global nature of scholarly engagement in this field [20, 21]. The average number of authors per document was 5.08, suggesting a tendency towards large-scale or multidisciplinary research teams [22, 23]. A total of 1,649 keywords were used across the dataset, reflecting the thematic diversity of studies related to holistic prenatal education, anxiety, and childbirth outcomes [24]. The high number of references, totaling 25,824, indicates that this field is supported by an extensive and in-depth literature base, which reinforces the reliability and credibility of the findings [24, 25]. The cited documents had an average age of 3.27 years, showing that the literature is relatively recent and aligned with current research trends, contributing to its relevance and academic influence [26, 27]. Each document received an average of 10.58 citations, demonstrating the scholarly impact and influence of the research in this domain.
Based on the three-field plot visualization, the top three most frequently cited references were Braun & Clarke, regarding thematic analysis in psychology; Finlay & Khan [28], concerning the Dermatology Life Quality Index (DLQI); and Zigmond & Snaith [29], related to the Hospital Anxiety and Depression Scale (HADS). These references provided a strong theoretical foundation for studies focusing on quality of life and mental health outcomes [30]. Research by Padula et al. reports that exposure to air pollution and heavy metals during pregnancy, when combined with maternal psychosocial stress, can worsen fetal and child health. This combined exposure increases the risk of developmental delays, low birth weight, and neurocognitive problems [31]. The most frequently appearing keywords included depression, anxiety, quality of life, and mental health. These topics indicate the central research themes in exploring the interrelationship between psychological health and physical health conditions. The plot illustrates a strong link between theoretical frameworks on mental health, the pivotal role of prolific authors, and the growing depth of research on depression, anxiety, and quality of life within palliative and chronic pain care settings [32].
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