Journal of Education and Health Promotion

Abstract BACKGROUND: Chemotherapy is a complex, multi‑disciplinary, and error‑prone process. Information
technology is being increasingly used in different health care settings with complex work procedures
such as cancer care to enhance the quality and safety of care. In this study, we aimed to develop
a computerized physician order entry (CPOE) for chemotherapy prescribing in patients with gastric
cancer and to evaluate the impact of CPOE on medication errors and order problems.
MATERIALS AND METHODS: A multi‑disciplinary team consisting of a chemotherapy council group
and system design and implementation team was formed for chemotherapy process evaluation,
requirement analysis, developing computer‑based protocols, and implementation of CPOE. A before
and after study was conducted to evaluate the impact of CPOE on the chemotherapy process and
medication errors and problem orders. To evaluate the level of end‑user satisfaction, an ISO Norm
9241/110 usability questionnaire was chosen for the evaluation.
RESULTS: Before the implementation of the CPOE system, 37 medication errors (46.25%) and
53 problem orders (66.25%) were recorded for 80 paper‑based chemotherapy prescriptions. After
implementation of the CPOE system, 7 (8.7%) medication errors and 6 (7.5%) problem orders were
recorded for 80 CPOE prescriptions. The implementation of CPOE reduced the medication error by
37.55% and the problematic order by 58.75%. The results for usability evaluation indicate that the
CPOE was within the first class of the ISONORM level rating; this shows that a CPOE is with very
high satisfaction and a very high functionality rate.
CONCLUSION: Developing a CPOE system significantly improved safety and quality of the
chemotherapy process in cancer care settings by reducing the medication error, deleting unnecessary
steps, improving communication and coordination between providers, and use of updated
evidence‑based medicine in direct chemotherapy orders. However, the CPOE system does not
prevent all medication errors and may cause new errors. These errors can be human‑related factors
or associated with the design and implementation of the systems.

Abstract BACKGROUND: Breast cancer (BC) is the most common cause of cancer‑related deaths in women
globally. Currently, many machine learning (ML)‑based predictive models have been established to
assist clinicians in decision making for the prediction of BC. However, preventing risk factor formation
even with having healthy lifestyle behaviors or preventing disease at early stages can significantly
lead to optimal population‑wide BC health. Thus, we aimed to develop a prediction model by using a
genetic algorithm (GA) incorporating several ML algorithms for the prediction and early warning of BC.
MATERIAL AND METHODS: The data of 3168 healthy individuals and 1742 patient case records
in the BC Registry Database in Ayatollah Taleghani hospital, Abadan, Iran were analyzed. First, a
modified hybrid GA was used to perform feature selection and optimization of selected features.
Then, with the use of selected features, several ML algorithms were trained to predict BC. Afterward,
the performance of each model was measured in terms of accuracy, precision, sensitivity, specificity,
and receiver operating characteristic (ROC) curve metrics. Finally, a clinical decision support system
based on the best model was developed.
RESULTS: After performing feature selection, age, consumption of dairy products, BC family history,
breast biopsy, chest X‑ray, hormone therapy, alcohol consumption, being overweight, having children,
and education statuses were selected as the most important features for prediction of BC. The
experimental results showed that the decision tree yielded a superior performance than other ML
models, with values of 99.3%, 99.5%, 98.26% for accuracy, specificity, and sensitivity, respectively.
CONCLUSION: The developed predictive system can accurately identify persons who are at elevated
risk for BC and can be used as an essential clinical screening tool for the early prevention of BC and
serve as an important tool for developing preventive health strategies.

Abstract BACKGROUND: COVID‑19 pandemic has spread all over the world. However, information regarding
clinical characteristics and prognostic factors is scarce. The aim of this study was to explore the
impact of preexistent chronic comorbid conditions and multimorbidity on risk of mortality in patients
with COVID‑19.
MATERIALS AND METHODS: We designed a retrospective, cross‑sectional, observational,
single‑center study. Data were analyzed from all consecutive patients diagnosed with COVID‑19 who
admitted in a pandemic hospital affiliated with Tabriz University of Medical Sciences, Tabriz, Iran,
from February 20, 2020, to September 25, 2020. The independent effects of preexistent conditions
were evaluated using multivariate logistic regression model.
RESULTS: A total of 2597 hospitalized patients with COVID‑19 were included. At least one preexistent
condition was observed in 36.5% of study population. Multivariate logistic regression analysis showed
that older age, male sex, diabetes, cardiovascular disease, hypertension, cancer, chronic kidney
diseases, liver diseases, and chronic obstructive pulmonary disease were associated with increased
risk of mortality. In addition, the number of comorbidities was significantly associated with increased
odds of mortality compared to no‑comorbidity.
CONCLUSION: The results of this study suggest that patients with comorbidities have an increased
risk of in‑hospital mortality following COVID‑19 infection.

Abstract BACKGROUND: Patient relationship management (PRM), in addition to saving costs, increases
patient loyalty and creates a satisfactory environment for the patient and the service provider. This
study aimed to design a model of PRM in general hospitals using the combination of the analytic
hierarchy process and interpretive structural modeling (ISM).
METHODS: This was an applied and cross‑sectional study conducted in 2020 at three stages. At
the first stage, using a systematic review, factors affecting PRM were identified. In the second stage,
these factors were prioritized based on the pair‑wise comparisons. In the third stage, the interaction
levels of the factors were modeled for the general hospitals using ISM through the use of the MICMAC
technique and Excel 2007 software.
RESULTS: The results showed that “integrated information system,” “registration of the patient’s
essential information,” and “right data at the correct time” were the first to third priority in implementing
PRM in the general hospitals. In the final model of ISM, three levels of effective factors were extracted,
and 10, 4, and 6 factors were identified in the first, second, and third levels, respectively.
CONCLUSION: Establishing the PRM strategy in the hospital, in addition to executive and managerial
requirements, depends on the existence of an electronic customer relationship management system,
and the choice of new technology, as well as the integration of information systems and technology
culture, should be given special attention by managers.

Abstract BACKGROUND: Informal settlements are considered as one of the social problems in societies. As
the residents do not have adequate access to basic services, including health services, their health
is at risk. This study was conducted to evaluate the access to health services and determine the
health needs of informal settlements in Bam city.
MATERIALS AND METHODS: This cross‑sectional study was carried out in the spring of 2020 in
Bam. The sample size was 400 residents of informal settlements in Bam, and the multi‑stage random
cluster sampling was used. A researcher‑made questionnaire was used to collect the required
data. The validity of the questionnaire was confirmed using the content validity, and its reliability
was 85% by Cronbach’s alpha. The data were analyzed using the SPSS version 23 software and
descriptive statistics (frequency, mean, standard deviation, and percentage) as well as analytical
statistics (Mann–Whitney and Kruskal–Wallis tests).
RESULTS: More than 50% of the individuals had good access to general practitioners and health
centers. However, over 50% had poor access to dental, para‑clinical, specialist, and hospital services.
Furthermore, 49.3% of the people assessed their health status as poor in the previous year. A total
of 46 items in the areas of communicable and non‑communicable diseases, women’s health, mental
and social health and addiction, environmental health, etc., were identified as the most important
health needs of the informal settlement residents.
CONCLUSION: Informal settlements are facing various health problems including environmental
health, mental and social health, and addiction, meeting which requires collaboration of all
stakeholders as well as provision of a comprehensive program and appropriate service packages.

Abstract CONTEXT: The success of the health system research and technology management in the 21st century
can play an important role in advancing the country toward becoming a scientific power.
AIMS: The study aimed to increase knowledge and identify factors affecting the health system
research and technology, as well as to provide solutions for improving the status of health science
and technology.
MATERIALS AND METHODS: This was an applied and descriptive study conducted in 2018 using
cross‑impact analysis. The factors affecting the Iranian Health System Research and Technology
Management and their influences on each other were identified using an expert panel. The key‑driven
factors were determined using the MICMAC software.
RESULTS: The input, stake, target, resultant, excluded, and regulating factors were identified. The
degree of fill rate the matrix was 58.9%. Financial annex of the health scientific map (S = 206),
roadmap (S = 206), governmental laws and regulations (S = 198), and sufficient governmental budget
allocation (S = 194) earned the highest potential influence scores by 2025. Furthermore, scientific
authority (S = 216), international communication (187), university relationship with industries (S = 187),
and competitive infrastructure (S = 178) obtained the highest potential dependence scores by 2025.
CONCLUSIONS: The success of the Iranian Health System Research and Technology Management
by 2025 requires the development of the financial annex of the comprehensive scientific health map,
the development of the road map, and the allocation of sufficient governmental budget for health
research. Policy‑making in health system research and technology management requires more
attention to these factors and the dynamics of relationships among factors in the model.

Abstract BACKGROUND: Today, the scope of dental activities is a broad range from the needs assessment
for epidemiological studies to the implementation of comprehensive programs for the prevention of
oral diseases at various levels of the society. This study aimed to identify and prioritize the need
researches in the field of oral and dental health in a dental hospital in Tehran, Iran.
METHODS: This applied research was a mixed methods study carried out in Tehran, Iran, in
2018. The data gathering tool included a data collection form used for reviewing the documents,
a semi‑structured interview, and an open questionnaire. MAXQDA 10.0, Expert Choice 11.0, and
Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) software were used for
analyzing the collected data.
RESULTS: After analyzing the results of the qualitative phase, 171 research topics in 6 areas
were obtained, including 44 topics in “dental clinical care and treatment,” 37 topics in “health and
prevention,” 19 topics in “education and health promotion,” 37 topics in “management of dental care
delivery,” 16 topics in “policy and its requirements,” and 18 topics in “dentistry materials, equipment
and technologies.”
CONCLUSION: According to the results, it can be recommended that the research resources should
be allocated based on the priorities identified by the present study so that the studied hospital has
the highest dynamic performance in achieving its goals and objectives.

Abstract CONTEXT: Iranian National Health Scientific Map is a national plan the implementation of which
remarkably influences the progress of the country, though it is facing challenges in its implementation
phase.
AIMS: The present study has been conducted with the main aim of identifying the challenges facing
the comprehensive scientific health map of Iran.
SETTING AND DESIGN: This is an applied and qualitative study.
SUBJECTS AND METHODS: The study was done in 2017 with the content analysis approach
among experts of research and technology management. Some 18 people were selected and were
deeply interviewed, meanwhile observing the credibility of research.
STATISTICAL ANALYSIS USED: Data analysis was performed based on content analysis and
using ATLAS.ti software.
RESULTS: Data analysis resulted in the identification of 427 codes, 84 subthemes, and 12 themes.
Twelve themes were specified including policy‑making, management, university autonomy,
quantitative development, consideration of science production chain, designing and monitoring of
science map, finance, qualitative assessment, human resources, research ethics, as well as allocating
attention to the infrastructure and communication.
CONCLUSION: The scientific map of health challenges are indicative of the need for modification
of the scientific map and adhering to solutions in line with the removal of the identified challenges.
Today, paying attention to the solutions capable of meeting such challenges is a must.

Abstract BACKGROUND: Innovation is a competitive advantage, with its preservation and continuity dependent
on the organizational innovation capability. This study was conducted with the aim of determining the
innovation capability dimensions and components in medical sciences universities of Iran.
METHODS: The present study is a qualitative study with content analysis approach, undertaken
in 2016–2017. The data processing included 10 deep interviews with the experts of the health
innovation domain in top management of the three types of the medicine sciences universities of
Iran with >5 years of experience. Targeted data sampling was performed using snowball method and
continued until the saturation of the data. Data analysis was performed using conventional content
analysis method using Maxqda 12 software.
RESULTS: Data analysis resulted in the extraction of 28 categories and 8 main themes including
communications and interactions, innovation climate, university setting, policy factors (policy‑making,
rules and regulations), organizational culture, organizational resources, management and leadership,
and organizational learning in two university internal and external dimensions.
CONCLUSION: To accelerate innovation in medical sciences universities, recognizing the potential
of innovation capability is essential.

Abstract Background: The expansion of outpatient services and the desire to provide more outpatient
care than inpatient care create some problems such as the overcrowding in the outpatient
clinics. Given the importance of overcrowding in the outpatient clinics, this qualitative study
aimed to determine the factors influencing the overcrowding in the specialty and subspecialty
clinic of a teaching hospital. Materials and Methods: This was a qualitative study conducted in
the specialty and subspecialty clinic of a hospital using content analysis method in the period
of January to March 2014. The study population was all managers and heads of the outpatient
wards. The studied sample consisted of 22 managers of the clinic wards who were selected
using the purposive sampling method. The required data was collected using semi‑structured
interviews. The collected data was analyzed using conventional content analysis and the
MAXQDA 10.0 software. Results: Three themes were identified as the main factors affecting
the overcrowding including the internal positive factors, internal negative factors, and external
factors. Conclusions: Despite the efforts made to eliminate overcrowding, and reduce waiting
times and increase access to the services for patients, the problem of overcrowding still has
remained unresolved. In addition, the use of some strategies such as clarifying the working
processes of the clinic for staff and patients and the relationships between the clinic and
other wards especially emergency department, as well as using a simple triage system on the
patients’ arrival at the clinic are recommended.

Abstract Background: The application of the nursing research findings is one of the most important
indicators of development in the nursing profession, which leads to providing efficient and
effective patient care and improving the quality of nursing care. According the result of some
studies, transferring the evidence‑based findings to the nurses’ practice and education in
the world has been slow and sometimes unsuccessful. This study aimed to investigate the
most important barriers to the application of research findings from the nurses’ perspective.
Materials and Methods: This cross‑sectional study conducted on a sample of 210 nurses
in a teaching hospital in Tehran in 2013. The data were collected using a researcher‑made
questionnaire consisted of two parts, including items about nurses’ demographic characteristics
and 30 items to identify the most important barriers to the application of research findings from
the studied nurses’ perspective. Results: “The lack of sufficient time for reading the studies,”
“the lack of sufficient time to implement the new ideas,” “the lack of adequate facilities to
implement the ideas,” “nurses’ little interest in conducting studies,” and “the lack of authority
to change the methods and patterns of care” with, respectively, 85%, 84.6%, 83.8%, 83.4%,
and 80.5% agreement with the existence of barriers were the most barriers to application of
research findings from the studied nurses’ perspective. Conclusion: The lack of time was the
most important barrier to the use of research findings from the perspective of studied nurses.
Therefore, some effective strategies should be used by hospital managers and health policy
makers to overcome this barrier. Some of these strategies can be employing new personnel
and hiring skilled and efficient human resources in order to decrease the workload of nurses,
organizing the nurses’ work shifts, providing right balance between patients and nurses in the
wards, etc.

Abstract Background: Considering globalization of health care and quality improvement trend to
respond to competition and customer orientation, attention to organizational structure
and its relationship with market orientation is essential. Therefore, this study reviews the
relationship between organizational structure and market orientation in selected hospitals
of Isfahan (Iran). Materials and Methods: This study was a descriptive survey. The study
population comprised nurse managers from selected hospitals (n = 80). Data collection tools
were two questionnaires (market orientation questionnaire and organizational structure) that
the validity and reliability were confirmed (r = 0.83 for market orientation questionnaire and
r = 0.87 for organizational structure). SPSS (Ver. 16) software was used for the analyses.
Results: The mean score of organizational structure was 65.4 (11.2) and total mean of
market orientation was 51.14 (17.6). All aspects of the organizational structure (Organization
Centralization, Formalization in Organization, and Organization Complication) and market
orientation (responding to competition, accountability, customer satisfaction, intelligent
organization)—except by responding to clients with Formalization in Organization—as well as
all aspects of the Systemic attitude (the system of internal coordination and communication
systems_ and market orientation (responding to competition, accountability, customer
satisfaction, intelligent organization), there was a meaningful relationship (P < 0.05).
Conclusion: Market orientation and its dimensions have a significant relationship with
organizational structure and can lead managers’ view to the analysis and recognizing elements
of success and achievement to goals. With increasing competition in markets, globalization
of health services, and presence in international markets and more attention to patients’
satisfaction, hospitals need to understand and use of market orientation in order to promote
quality and services in the health care system.

Abstract Background: Hemodialysis patients have lower quality of life and one of the ways to improve
their quality of life is providing self‑care education to them using some models including self‑care
model. This study aimed to determine and evaluate the effects of using self‑care model on
health and quality of life outcomes in hemodialysis patients. Materials and Methods: This was
a quasi‑experimental study conducted in 2012 on the patients who were referred to a military
hospital in Tehran, Iran to be treated with hemodialysis. All 32 patients referred to this hospital in
2012 were selected and studied. Required data were collected using the Short Form‑36 (SF‑36)
standard questionnaire and a researcher‑made questionnaire. The educational intervention was
implemented using self‑care model. Collected data were analyzed using SPSS for Windows
version 18.0 and some statistical tests including paired samples t‑test, Wilcoxon and McNemar
tests. Results: The results showed that the mean and standard deviation (SD) of patients’
parameters including weight and blood pressure improved significantly after the educational
intervention compared to before the intervention (P < 0.001). Also, all dimensions of the quality
of life of hemodialysis patients, including physical function, role physical, bodily pain, general
health, vitality, social function, mental health, and role emotional improved compared to those
before the intervention (P < 0.001). Conclusion: Implementing the self‑care model increased
the quality of life of hemodialysis patients. Therefore, the use of this model in hemodialysis
patients is recommended.

Abstract Background: Military hospitals are responsible for preserving, restoring and improving the health of
not only armed forces, but also other people. According to the military organizations strategy, which
is being a leader and pioneer in all areas, providing quality health services is one of the main goals of
the military health care organizations. This study was aimed to evaluate the service quality of selected
military hospitals in Iran based on the Joint Commission International(JCI) standards and comparing
these hospitals with each other and ranking them using the analytic hierarchy process (AHP)
technique in 2013. Materials and Methods: This was a cross‑sectional and descriptive study
conducted on five military hospitals, selected using the purposive sampling method, in 2013.
Required data collected using checklists of accreditation standards and nominal group technique.
AHP technique was used for prioritizing. Furthermore, Expert Choice 11.0 was used to analyze the
collected data. Results: Among JCI standards, the standards of access to care and continuity of
care (weight = 0.122), quality improvement and patient safety (weight = 0.121) and leadership
and management (weight = 0.117) had the greatest importance, respectively. Furthermore, in
the overall ranking, BGT (weight = 0.369), IHM (0.238), SAU (0.202), IHK (weight = 0.125) and
SAB(weight = 0.066) ranked first to fifth, respectively. Conclusion: AHP is an appropriate technique
for measuring the overall performance of hospitals and their quality of services. It is a holistic
approach that takes all hospital processes into consideration. The results of the present study can
be used to improve hospitals performance through identifying areas, which are in need of focus
for quality improvement and selecting strategies to improve service quality.