Journal of Education and Health Promotion

Abstract BACKGROUND: Patients with heart failure experience severe and chronic physical and psychological
manifestations while the disease progresses. Assessing the degree of distress caused by
manifestations of the disease in patients is the first step in designing and evaluating intervention
programs to improve patients’ symptoms. The aim of this study was to investigate the psychometric
properties of the Persian version of the Symptom Distress Scale in HF patients.
MATERIALS AND METHODS: This study was conducted via methodological research design from
March to November 2019. The translation process and cross‑cultural adaptation were performed
using a process recommended by the World Health Organization. The face and content validity and
internal consistency were used to evaluate the validity and reliability of the instrument. The scale
was evaluated by exploratory and confirmatory factor analysis in 300 patients with heart failure, and
the obtained data were analyzed using SPSS‑22 and AMOS‑22 software.
RESULTS: The content validity of the scale was approved based on the results of the study. One‑factor
scale with 13 items was used in the confirmatory factor analysis, and the results showed that the
instrument had high goodness‑of‑fit indices. Spearman correlation test for convergent validity showed
a correlation between the score obtained by the Scale of Symptoms of Disease and the scores of
The European Heart Failure Self‑care Behavior scale (9 items) (P < 0.0001).
CONCLUSION: The Persian version of the Symptom Distress Scale can be used as a valid instrument
for people with heart failure due to its desirable psychometric properties.

Abstract BACKGROUND: Impulsiveness is a multidimensional and multifaceted construct that plays an 
important role in understanding various psychopathology and problematic behavior. It is necessary 
to study the psychometric properties of instruments in the new culture before its scientific 
application, and it also contributes to external validity. The current study was conducted to 
determine the psychometric properties of the Persian version of Short Form of the Impulsiveness 
Questionnaire UPPS‑P (SUPPS‑P) in a sample of male soldiers serving in the military service.
MATERIALS AND METHODS: The present research design is cross‑sectional in 2019–2020. The Iranian 
version of the SUPPS‑P was prepared across forwarding translation, reconciliation, and back‑translation. 
The research sample included 254 soldiers who were selected via convenience sampling method and 
completed a set of scales, including the SUPPS‑P scales, short‑form self‑compassion scale, McLean 
Screening Instrument for Borderline Personality Disorder(MSI‑BPD), Cognitive Flexibility Inventory (CFI), 
Perth Alexithymia Questionnaire (PAQ), and the Deliberate Self‑harm Inventory (DSHI). The construct 
validity of SUPPS‑P scale was measured using confirmatory factor analysis and convergent and 
divergent validity. For reliability, Cronbach’s alpha and test–retest reliability (with 2 weeks interval) were 
used. Data were analyzed using LISREL software (version 8.8) and SPSS version 22.
RESULTS: The results showed that the SUPPS‑P scale is a reliable and valid scale with acceptable 
internal consistency and acceptable test–retest reliability among soldiers. In terms of convergent 
validity, SUPPS‑P showed a significant positive correlation with measures of MSI‑BPD, PERS, 
and DSHI. SUPPS‑P showed a negative correlation with self‑compassion and cognitive flexibility, 
thus demonstrated a good divergent validity. The results of this study also provide support for the 
five‑factor model of the SUPPS‑P scale.
CONCLUSION: The SUPPS‑P instrument showed acceptable validity and reliability and could be 
useful in assessing impulsivity in Iranian society. The SUPPS‑P scale shows notable promise as a 
measure for use in impulsivity research and clinical settings.

Abstract BACKGROUND: Health‑care workers (HCWs) are highly vulnerable to depression during an
epidemic outbreak. Protecting the mental well‑being of HCWs is a priority while battling with
COVID‑19. However, documentation on COVID‑19‑related depression among HCWs is scarce
due to the limited availability of measuring scales. Hence, this study was purposed to develop
a scale to measure depression relating to COVID-19 and evaluate its psychometric properties
among HCWs.
MATERIALS AND METHODS: A validation study was carried out among 320 HCWs including
physicians of various medical specialties, dental specialists, and nurses in the year 2020. Exploratory
factor analysis using Promax rotation with Kaiser normalization for the determination of factor structure
was employed in data analysis using SPSS version 16 software.
RESULTS: COVID-19 Depression Scale for HCWs (CDS‑HW) demonstrated a two-component
structure identified as “work‑related anxiety” and “psychological distress.” The mean CDS‑HW score
of the study participants was observed to be 23.67 ± 2.82, and the scale demonstrated good internal
consistency reliability (Cronbach’s alpha: 0.741).
CONCLUSION: CDS‑HW is a rapidly administrable, valid, and reliable tool that can be used to
measure COVID-19-related depression among HCWs.

Abstract BACKGROUND: Demanding careers like medicine requires a lot of motivation and the Academic
Motivation Scale (AMS) developed by Vallerand et al. (1992) is an instrument to measure motivation.
This study evaluated the validity and reliability of AMS among medical students in the Middle East.
MATERIALS AND METHODS: This was a methodological research utilizing a convenient sampling
technique. AMS scale comprising 28 items subdivided into seven subscales was administered to 900
students (281 students returned the filled AMS). Data were analyzed using the descriptive statistics,
one‑way ANOVA, and t‑tests. Exploratory factor analysis and Cronbach’s alpha were used to evaluate
the validity and reliability of the scale, respectively.
RESULTS: There was a statistically significant difference between both genders in overall
scores (P = 0.015*), two subscales, namely “Identified Regulation” (P =0.017*) and “Stimulating
Experience” (P = 0.015*), with females showing higher value. Second‑year students (n = 91) had
significantly higher score (10.9 ± 4.1) for “Amotivation” (P =.001*) and first‑year students (n = 48)
had significantly higher score (16.2 ± 3.0) for “Achievement” subscale (P =.014*). P < 0.05
was considered statistically significant with 95% confidence interval. No statistically significant
difference was observed between the groups based on nationality or age. Bartlett’s test of
sphericity was significant (Chi‑square: 2988.010; df = 278; P < 0.001). Kaiser–Meyer–Olkin
was 0.890. Principal component analysis with varimax rotation extracted seven factors
corresponding to the original items of AMS questionnaire. All subscales correlated positively
except “amotivation.” Structural equation modeling revealed the relation between observed
and unobserved variables.
DISCUSSION: This study demonstrated that AMS is valid and reliable for application among Middle
East medical students, without needing any modification. AMS has widespread application in medical
education as it impacts learning outcomes.
CONCLUSION: This study demonstrated that AMS is valid and reliable for application among the
Middle East students without needing any modification.

Abstract BACKGROUND: Metacognition is the awareness and the capability to regulate one’s own thinking
process. Metacognition is critical in medical education for clinical reasoning and management. Hence,
the objective of this study is to evaluate the construct validity and reliability of the Metacognitive
Awareness Inventory (MAI) among first‑year medical and dental students, from a private medical
university in India, using confirmatory analysis and internal consistency method.
MATERIALS AND METHODS: This was a cross‑sectional study using convenient sampling.
Fifty‑two‑item MAI was administered to 933 first‑year medical and dental students from a private
medical university in India. Exploratory factor analysis (EFA), principal component analysis,
Cronbach’s α, and confirmatory factor analysis with global fit indices were performed. Structural
equation modeling (SEM) was performed to evaluate the relationship between the structural path
and factors using AMOS version 22.
RESULTS: During EFA, 12 items with <0.40 factor loadings were trimmed sequentially. The remaining
items with respective factors had a good internal consistency of ≥ 0.9. Comparative fit index (0.78),
goodness‑of‑fit index (0.8), adjusted goodness of fit index (0.77), Tucker–Lewis index (0.7),
standardized root mean square residual (0.06), and root mean square error of approximation (0.09)
values showed that six‑factor model fits to satisfactory. Pearson’s correlation coefficient was found
to be high between factors (>0.80). SEM for each item (observed) and factor (unobserved) illustrated
the hypothesized model.
CONCLUSION: The resultant 40‑item model based on MAI designed by Schraw is a valid and
reliable tool for assessing the metacognitive awareness of Indian students. Employing a valid and
reliable tool in assessing the metacognitive awareness will help the academicians in incorporating
appropriate curricular interventions.

Abstract BACKGROUND: Disordered eating attitude may lead to full‑blown eating disorders. Recent
longitudinal studies show that disordered eating attitudes either remain stable or even increase from
childhood to adulthood. The current study was done to determine the psychometric properties of the
Eating Attitudes Test‑8 (EAT‑8) and introduce the suitable measure for researchers and therapist in
the field of clinical psychology and psychiatrist.
MATERIALS AND METHODS: The Persian version of the EAT‑8 was produced through forward
translation, reconciliation, and back translation. A sample of 302 students were selected through
convenience sampling method and completed a set of questionnaires, including the EAT‑8,
Eating Attitudes Test‑16 (EAT‑16), Eating Beliefs Questionnaire‑18 (EBQ‑18), self‑esteem scale,
and self‑compassion scale short‑form. The construct validity of the EAT‑8 was assessed using
confirmatory factor analysis and divergent and convergent validity. Internal consistency and test–retest
reliability (2 weeks’ interval) were conducted to evaluate the reliability. Data analysis was conducted
using SPSS (version 22) software and LISREL (version 8.8).
RESULTS: EAT‑8 was found to be valid and reliable measures, with good internal consistency and
good test–retest reliability among students. In terms of convergent validity, EAT‑8 showed a significant
positive correlation with self‑report measures of EAT‑16 and EBQ‑18. EAT‑8 showed a negative
correlation with self‑compassion and self‑esteem, thus demonstrated a good divergent validity. The
results of this study also provide support for the one‑factor model of the EAT‑8.
CONCLUSION: The EAT‑8 showed good validity and reliability and could be useful in assessing
disordered eating in Iranian population. The EAT‑8 shows notable promise as a measure for use in
disordered eating research and clinical settings.

Abstract CONTEXT: Empathy is considered to be backbone of the patient–physician relationship. The
consultation and relational empathy (CARE) measure is widely used internationally to measure
empathy. However, no validated tool is available to gather patient feedback on dentists’ empathy
in India.
OBJECTIVE: The objective of this study was to explore the reliability and validity of a CARE measure
and to assess the factors influencing CARE score and to determine if there was an association
between their CARE score and satisfaction of the patient.
SETTING AND DESIGN: A cross‑sectional study was done in dental colleges.
SUBJECTS AND METHODS: A questionnaire study was carried out among 100 patients from 6
dental colleges in Bangalore using validated CARE measure.
STATISTICAL ANALYSIS: Internal consistency of items was evaluated by the Cronbach’s alpha,
and construct validity was assessed by confirmatory factor analysis. Satisfaction was assessed by
a question response on 5‑point Likert scale. Descriptive and inferential statistics were performed
with significance set at 5%.
RESULTS: The mean CARE score was 43.80 ± 5.36. Internal reliability was high (Cronbach’s
alpha: 0.859) and was reduced by the removal of any of 10 items. High corrected item‑total correlations
ranged from 0.752 to 0.847. Factor analysis showed a single solution with high item loadings (>0.80).
Self‑perception of overall health (odds ratio [OR] = 3.78), relationship with family (OR = 4.61) and
friends (OR = 3.78), and previous dental experience (OR = 16.00) were more likely, whereas
dentist‑provided treatment (OR = 0.20), number (OR = 0.07) and dental treatment taken (OR = 0.13),
presence of anxiety (OR = 0.03), and fear (OR = 0.05) were less likely to have CARE score. The
satisfaction of the patient regressed significantly with the relationship with family members (ß = 0.77)
and CARE score (ß = 0.21).
CONCLUSION: This study confirms the educational opportunity and implementation of CARE in
dental students. CARE scores among patients varied depending on personal factors and dental
treatment‑related factors. The satisfaction of the patient was influenced by the relationship with
family members and CARE scores.

Abstract Introduction: Diabetes is one of the most common chronic diseases in the world. Incidence and
prevalence of diabetes are increasing in developing countries as well as in Iran. Retinopathy is
the most common chronic disorder in diabetic patients. Materials and Methods: In this study,
we used the information of diabetic patients’ reports that refer to endocrine and metabolism
research center of Isfahan University of Medical Sciences to determine diabetic retinopathy
risk factors. We used factor analysis to extract retinopathy’s factors. Factor analysis is using
to analyze multivariate data, in which a large number of dependent variables summarize into
the fewer independent factors. Factor analysis is applied, in both diabetic and nondiabetic
patients, separately. To investigate the efficacy of factor analysis, we used discriminant analysis.
Results: We investigated 3535 diabetic patients whose prevalence of retinopathy was 53.4%.
Six factors were extracted in each group (i.e. diabetic and nondiabetic groups). These six
factors were explained 69.5% and 69.6% of total variance in diabetic and nondiabetic groups,
respectively. Using original variables such as sex, weight, blood sugar control method, and
some laboratory variables, the correct classification rate of discriminant analysis was identified
as 67.4%. However, it decreased to 49.5% by using extracted factors. Discussion: Retinopathy
is one of the important disorders in diabetic patients that involves a large number of variables
and can affect its incidence. By the method of factor analysis, we summarize diabetic retinopathy
risk factors. Factor analysis is applied separately, in two diabetic and nondiabetic group. In
this way, 10 variables were summarized into the six factors. Discriminant analysis was used to
investigate the efficacy of factor analysis. Conclusion: Although factor analysis is a powerful
way to reduce the number of variables, in this study did not worked very well.