Journal of Education and Health Promotion

Abstract BACKGROUND: Previous studies have shown that psycho‑spiritual state of mothers may have
significant effects on their breastfeeding. The most common cause of nonexclusive breastfeeding is
inadequate breastfeeding; therefore, this study examined the relationship between spiritual health
and perceived stress with breastfeeding adequacy in mothers with infants aged 1–6 months.
MATERIALS AND METHODS: This cross‑sectional, descriptive, correlational study was performed
on 186 mothers with infants aged 1–6 months, who referred to the health centers in Dorud city of
Lorestan province, Iran, in 2021, which were selected based on cluster sampling. Data were collected
through four questionnaires including demographic–fertility, spiritual health, perceived stress, and
breastfeeding adequacy. Data was analyzed by Statistical Package for the Social Sciences (SPSS)
software version 22 using descriptive and analytical statistics.
RESULTS: The mean ± standard deviation (SD) values of spiritual health, perceived stress, and
breastfeeding adequacy were 99.59 ± 12.96, 23.8 ± 72.19, and 55.67 ± 7.67, respectively. There was
a significant positive relationship between spiritual health and breastfeeding adequacy (P < 0.001,
r = 0.268). In addition, there was a significant negative relationship between perceived stress and
breastfeeding adequacy (P = 0.002, r = −0.231).
CONCLUSION: Breastfeeding adequacy has a significant positive relationship with spiritual health and
a significant negative relationship with perceived stress. Since infants are one of the most vulnerable
groups and breastfeeding is the best way to support their health and reduce infant mortality rates,
breastfeeding adequacy can be improved by reducing stress and promoting spiritual health.

Abstract BACKGROUND: With more than 12 million new cases of cancers and nearly 7.6 million deaths
worldwide in 2020, cancer is currently the third leading cause of mortality in the world. The costs
spent on treating patients with cancer account for a significant amount of healthcare costs. Healthcare
expenditures for cancer treatment have also increased significantly and are projected to skyrocket
further over the next decade. This study was conducted to determine medical and non‑medical direct
costs for the prevention of cancer in patients hospitalized in 10 selected educational hospitals in Iran.
MATERIALS AND METHODS: The study employed a cross‑sectional design and was conducted in
10 selected educational hospitals in Tabriz, Tehran, Isfahan, Mashhad, and Shiraz in 2020. Using
a researcher‑made questionnaire, we assessed direct medical costs and direct non-medical costs
of cancer in patients over 20 years old with kinds of breast, prostate, leukemia, lymphatic, stomach,
liver, lung, bladder, uterine, and intestine cancers who undertook oncology treatments (n = 2410).
Data were analyzed using descriptive statistics including mean and standard deviation and analytic
statistics such as Kolmogorov–Smirnov, analysis of variance, and t‑test, using SPSS 18 and P ≤0.05.
RESULT: The mean direct non-medical cost paid out of pocket per month was $99.6 ± $10.81 USD,
and the mean direct medical cost per month was $1029.4 ± $68.5 USD. The total cost paid by the
patients was $889.4 ± 69.81 USD per month.
CONCLUSION: Given the increasing number of patients with cancer, it is necessary to increase the
number of special centers for the prevention and treatment of cancers. Dissemination of information
about the costs of illnesses and their complications enables decision‑makers to make a proper
comparison between different uses of resources. Moreover, to support the patients, the health system
must implement plans to decrease out‑of‑pocket payments by patients.

Abstract BACKGROUND: Neonatal intensive care unit (NICU) is one of the accident‑prone settings in
the health‑care system. There is a series of structural and process threats to the safety of infants
hospitalized in this unit, which can be prevented by taking the right actions. For this purpose,
developing standards based on current knowledge, available resources, and the context that provides
care can determine patient injury prevention requirements. Likewise, it can be a source for national
development and application of related guidelines and protocols. This study aims to develop patient
safety standards in the NICUs of Iran.
MATERIALS AND METHODS: This mixed‑methods study will apply the exploration, preparation,
implementation, and sustainment framework to develop patient safety standards. In each phase of
this framework, a set of activities take place. Exploration is based on the world health organization
model to develop standards. Determining the validity and applicability of standards will be done in
Phase 2 (Preparation) and Phase 3 (Implementation), respectively. Since the long‑term effects are
not desired, the fourth phase (Sustainment) will not be considered.
DISCUSSION: Patient safety standards from this study will contribute to efficient and effective,
equitable, and high‑quality health‑care delivery. The application of them will further promote patient
safety and the quality of medical care in Iranian NICUs.

Abstract BACKGROUNDS: Due to the severity of the earthquake, it may need immediate treatment and
transfer of the injured people to advanced medical centers, as well as dispatch of the expert team
and specialized health equipment to the accident‑affected area. Aerial emergency is an important
responsibility of the health care system in this situation. The study aimed to extract the prehospital
emergency challenges of Iran aerial operations emergency in response to the earthquake.
MATERIALS AND METHODS: The study was qualitative content analysis with conventional
approach. Sampling was done in a purposive method and data were collected through semi‑structured
interview. The panel involved consists of 26 health professionals in medical emergencies. Recorded
interviews were transcribed into written and then conventional content analysis was used to derive
coding categories directly from the text data.
RESULTS: Content analysis is provided 97 initial codes, 20 subcategories and 4 main categories
including challenges of “response assessment,” “support,” ”pre‑hospital staff‑management,” and
“response operation,” respectively.
CONCLUSIONS: The results showed that the necessity to assess the affected area, staffing, and
management actions, including integrated operations command and the development of a dedicated
response plan, as well as the use of strategies inter‑organizational coordination in the response
phase to earthquake. This study also emphasized that providing standard equipment, support actions,
and strengthening communication infrastructure, and updating the aerial emergency system should
be considered as one of the priorities of the emergency organization of Iran to provide a desired
response to the earthquake.

Abstract BACKGROUND: With the outbreak of the COVID‑19 virus crisis worldwide, including Iran, the 
need for corona prevention and treatment has become a national priority. With many businesses 
closed in the wake of COVID‑19 and job losses and declining incomes, vulnerable individuals’ and 
families’ access to the minimum wage and healthcare facilities is falling, and their health is exposed 
to a great risk. In Iran, a significant number of vulnerable groups are supported by nongovernmental 
organizations (NGOs). This study is designed to understand the performance of NGOs after the 
onset of the COVID‑19 crisis.
MATERIALS AND METHODS: This study was carried out based on qualitative research between 
June and September 2020 in Tehran. This study was conducted using individual interviews with 33 
managers and experts of 24 active NGOs providing services to vulnerable groups and a member of 
an NGO network. Data were analyzed using content analysis.
RESULTS: Two main themes of service initiatives were extracted: (a) service initiatives to protect 
the target population against COVID‑19 infection and its aftermath and (b) management initiatives 
to retain staff, finance, and adapt the organization to crisis situations. Service initiatives included five 
categories of health service initiatives, livelihood, employment, education, and leisure initiatives, while 
organizational management initiatives include human resource management, financial management, 
and communication with organizations.
CONCLUSION: The COVID‑19 breadth and its special features have set it apart from other crises 
and have led NGOs to work hard on several fronts to care for the most vulnerable people against 
the epidemic and its consequences and maintain the performance of their organizations. The unique 
role of cyberspace has made it one of the definitive pillars of the activities of NGOs, not only during 
the epidemic but also after its end.

Abstract BACKGROUND AND AIM: Given the growing trend of aging and the limited resources of the health
system, the lack of long‑term prior government planning, and reduced growth of the productive force
of society, identifying strategies for planning and action to deal with future aging is very important.
In this regard, the study was conducted to identify strategies for dealing with the aging population
from the perspective of health system experts.
METHODS: The qualitative content analysis study was performed on 29 Iranian male and female
experts in the aging and health scope from Isfahan, Tehran, Tabriz, and Babol who purposefully
participated in the semi‑structured interview. Data were classified by qualitative content analysis.
RESULTS: Two concepts emerged according to the participated experts’ opinions, regarding the
strategies of the Iranian health system in dealing with future aging: “executive policy” strategies,
including “design, planning and implementation,” “evaluation and standardization,” “strengthening
demand‑driven” and “modeling national and international experiences,” “preventive policies”
strategy, which includes “Focus on prevention,” “Focus on values and competencies,” “Educational
empowerment,” “Knowledge‑based empowerment,” “Empowerment of age‑related groups,”
“Economic empowerment,” and “Social support.”
CONCLUSION: The diversity and breadth of the mentioned strategies indicate the necessity
of comprehensive readiness and adaptation of health services to the elderly conditions and
characteristics. Purposeful planning and timely implementation of programs and policies to better
address the health system with future aging will be possible by using practical strategies.

Abstract BACKGROUND: Coronavirus disease‑2019 (COVID‑19) pandemic can aggravate the health
problems in slum areas. The present study intends to examine the challenges of health protection of
slum’s residences during the COVID‑19 pandemic with the Social Determinants of Health perspective,
in Kerman city in Iran.
MATERIALS AND METHODS: The present study was a qualitative content analysis. Data were
collected by purposeful sampling in‑depth and semi‑structured interviews with 16 people. The
interviews were conducted (from October to December 2020) with the local representatives of the
slum’s residents, health‑care workers, managers of facilitation offices, and welfare social service
centers that are located in slum areas (Interview’s guide is attached). The textual material from
the interviews was entered into the MAXQDA software and directed content analysis was used to
analyze the data.
RESULTS: Data analysis led to the identification of 4 categories (Sociocultural, Situational,
Economical, and Physical environment) and 12 subcategories: Sociocultural: lack of awareness,
begging culture, low trust in disease control programs, low bottom‑up planning, and increasing
violence; Situational: decreasing donors’ activities and canceling important meetings; Economical:
unemployment, decreasing in income, and increasing limitations of many institutions in providing
resources; and Physical environment: inadequate space and inappropriate conditions in some houses
and alleys for people protection against Corona viruses.
CONCLUSIONS: Slum residents have faced many challenges during the COVID‑19 pandemic.
These challenges can affect the health of slum and other urban dwellers. Multidisciplinary thinking
and actions are needed. Increase awareness and engagement slum residents in control disease
programs should be considered.

Abstract BACKGROUND: In terms of public health, vaccination is considered as the most effective approach
against the infectious diseases. Accepting and receiving the first vaccine produced as an innovation
may not be easy. Therefore, the present study was conducted to investigate the predictors of intention
to receive COVID‑19 vaccine by Iranians aged 18–70 years based on the health belief model in 2021.
MATERIALS AND METHODS: This descriptive study was performed on 2365 people aged
18–70‑year old in Iran by random cluster sampling. Receipt of data was done electronically
questionnaire through the Porcelain system. Data were analyzed using SPSS software version 20
using Chi‑square, one‑way analysis of variance, independent t‑test, and multiple regression analysis
at a significance level of 0.05.
RESULTS: The mean score of receiving the Iranian corona vaccine was 3.06 ± 1.30 out of 5 points.
About 16.7% reported that they will definitely choose the Iranian vaccine. The highest correlation
was between the intention to receive the vaccine with self‑efficacy (r = 0.239, P < 0.001) and barriers
to receiving the vaccine (r = −0.237, P < 0.001). Self‑efficacy (β = 0.114, P < 0.001), perceived
barriers (β = −0.126, P < 0.001), and benefits of vaccine (β = 0.061, P = 0.022) were most important
predictors the intention to receive the vaccine.
CONCLUSION: Approximately 38% reported that they would definitely and probably not choose the
Iranian corona vaccine. Therefore, it is suggested that more information should be provided about
the features and benefits of domestically produced vaccines compared to foreign products.

Abstract BACKGROUND: Assessment of the patient safety competency is necessary for the growth of nursing
and safe care profession as well as evaluation of the nurses’ educational needs. The present study
was conducted to determine psychometric properties of the Persian version of the patient safety
competency self‑evaluation (PSCSE) tool in Iranian psychiatric wards.
MATERIALS AND METHODS: All nurses (n = 209) working in two psychiatric hospitals of Kerman,
Iran, were included in the present cross‑sectional study using census method. This tool contains 41
items: six items are related to knowledge, 14 items deal with attitude, and 21 items are about skill
dimension. Psychometric properties of the questionnaire including its content and face validity were
also examined. The factor structure of the questionnaire was evaluated using exploratory factor
analysis. The internal consistency and reliability were assessed by test–retest method with an interval
of 14 days. Cronbach’s alpha and corrected item‑total correlation were used to measure reliability.
RESULTS: The content validity index was 0.65 and the content validity ratio was 0.89. Item 14 was
removed from the skill domain because it was not related to the psychiatric ward. According to the
results of factor analysis, there was a significant relationship between the questions and the relevant
factors. The correlation coefficient for test–retest with 14 days interval was intraclass correlation
coefficient = 0.92 for the whole instrument and 0.89, 0.89, and 0.92 for the domains of knowledge,
attitude, and skill, respectively. The internal consistency coefficient (Cronbach’s alpha) of the whole
tool was 0.95 and 0.95, 0.79, and 0.95 for the domains of knowledge, attitude, and skill, respectively.
Finally, PSCSE Questionnaire was obtained with 40 items in dimensions of knowledge (6 items),
attitude (14 items), and skills (20 items).
CONCLUSION: Persian version of the nurses’ competency tool in ensuring patient safety in psychiatric
wards has acceptable psychometric characteristics.

Abstract BACKGROUND: Despite the great comparative advantage of Iran in terms of infrastructure,
technology, and human resources as well as the significance of medical tourism in the tourist industry,
in practice, the quality of human resources has received less attention. Consequently, this study was
conducted to design a model of competency‑based training for Iranian medical tourism.
MATERIALS AND METHODS: This study was an exploratory mix, and the Delphi method and
semi‑structured interviews were used for the qualitative part of this study. In the second part, the
analytical method was utilized for the quantitative part of this study.
RESULTS: The results indicated the main components of medical tourism to be public interactions
and private interactions and seven subcomponents. Medical Tourism’s Competency includes three
main components and seven subcomponents.
CONCLUSION: Although some training separated and scattered is present in Iran’s medical tourism.
However, Iran requires a comprehensive training model of which its design was explained in this paper.

Abstract BACKGROUND: Nowadays, medical tourism reports impressive growth in terms of number of 
persons, income, and number of countries involved in cross‑border flows. It refers to people traveling 
abroad (from home to a target country) to obtain medical treatment. The present study aimed to 
identify the themes and codes of the medical tourism business in Iran.
MATERIALS AND METHODS: We searched international databases (such as PubMed, Scopus, 
Embase, and Web of Science) and Iranian bibliography thesaurus and repositories (namely, Scientific 
Information Database and Magiran) using keywords such as medical tourism, international medical 
travel, and medical tourism business in the English and Persian literature, published between January 
2000 and December 2019, identified with no restriction on the type of the studies. The data were 
analyzed based on the content analysis method.
RESULTS: Out of 1054 articles, 14 were finally selected. In the end, eight themes of the medical 
tourism business including competitive pricing, safety and security, information and communication 
technology, labor market and human resources, structure management, leading the way in medical 
tourism, infrastructure, and exchange with the international world were identified which on the whole 
contain 45 codes. Most of the articles were quantitative. Four of the themes (competitive price, labor 
market and human resources, structure management, and infrastructure) were most frequent and 
of the highest importance.
CONCLUSION: The themes and codes identified in this study helps companies and individuals who 
want to work in the field of medical tourism. According to this study, all 8 themes and 45 codes are 
of high value, but still, some themes are of higher value than others and special attention should 
be paid to them.

Abstract BACKGROUND: Online learning self‑efficacy is considered a major contributor to academic success. 
The present study was conducted to assess the psychometric properties of the Persian version of 
the Online Learning Self‑Efficacy Scale.
MATERIALS AND METHODS: A cross‑sectional study was conducted on 211 medical students at 
Kerman University of Medical Sciences in 2021 who were selected through the convenience method. 
Data were collected using a two‑part self‑administered online questionnaire containing demographic 
information and the Persian version of the Online Learning Self‑Efficacy Scale (OLSES). Forward and 
back‑translation methods were used to provide the Persian version of OLSES. Internal consistency 
of the Persian version was determined by the Cronbach alpha coefficient in a pilot study. Exploratory 
and confirmatory factor analyses were conducted using SPSS version 20.0 and LISREL version 8.80.
RESULTS: The mean of the participants’ age was 21.40 ± 2.52 years, and most of them (56.4%) 
were female. The Cronbach alpha coefficient was determined as 0.74, 0.90, 0.75, and 0.89 for 
learning, time management, technology use subscales, and the whole scale, respectively. Exploratory 
factors analysis revealed the justifiability of factor analysis. In confirmatory factor analysis, most of 
the goodness of fit indices had an acceptable level.
CONCLUSIONS: Our study found that the Persian version of OLSES had good psychometric 
properties and can be used as a simple, valid, and reliable tool to assess students’ self‑efficacy 
related to the e‑learning environment.

Abstract BACKGROUND: Medical equipment plays an important role in the diagnosis, treatment, and medical 
education, and each year the major share of hospital costs (about 5%–15% annually) is allocated to 
the purchase of medical equipment. The selection and allocation of medical equipment should be 
appropriate and in line with the actual needs of the medical centers, clinical goals, human resources, 
and the conditions required to ensure safety. The purpose of this study was to study and evaluate 
current systems of medical equipment management and identify their strengths and weaknesses in 
Isfahan educational hospitals in 2018.
MATERIALS AND METHODS: This is a descriptive‑applied research that was done in a 
cross‑sectional way in 2018. The statistical population of the research is the authorities of medical 
equipment and other persons related to the management of medical equipment of selected educational 
hospitals in Isfahan. The data collection tool is a questionnaire.
RESULTS: The result of this study was gathered in four areas: medical equipment management, 
safety, preventive maintenance, and training.
CONCLUSION: According to this study, there is no comprehensive program in hospitals for how 
to manage medical equipment, which itself causes the loss of material and equipment capital of 
the organization. In most cases, the lack of a system for planning and controlling the amount of 
inventory and purchasing and maintaining medical equipment creates many problems, such as the 
accumulation and depreciation of equipment or the lack of these facilities in critical situations. In this 
study, it is suggested initially a scientific control system. Medical equipment is designed so that the 
hospital’s need for equipment at any time of year and the amount of its equipment are clear so that 
it can be easily decided in this field.

Abstract BACKGROUND: One of the most important steps in increasing the nurses’ professional competence 
and consequently improving the quality of nursing care is to evaluate nurses’ clinical competency 
and then take effective actions to enhance it. This study aimed at exploring the clinical competence 
of Iranian nurses and factors related to it.
MATERIALS AND METHODS: In this systematic review and meta‑analysis, PubMed, Scopus, Web 
of Science, Scientific Information Database, and Iranmedex databases and Google Scholar search 
engine were searched to February 14, 2020.
RESULTS: After screening, a total of 25 articles were included. In general, the level of clinical 
competence of Iranian nurses was at a desirable level. After meta‑analysis of the mean score of nurses’ 
clinical competence, the combined mean was 161.13 (95% confidence interval [CI]: 137.78–184.48;
P < 0.001; I
2 = 99.8%; P value for heterogeneity = P < 0.001) by the Competency Inventory for 
Registered Nurses (CIRN) questionnaire. The summarized mean of clinical competency measured 
by the Nurse Competence Scale (NCS) questionnaire was 70.75 (95% CI: 60.80–80.70; P < 0.001; 
I
2 = 99.9%; P value for heterogeneity = P < 0.001). Factors affecting nurses’ clinical competence were 
age ≥33 years, nursing work experience ≥9 years, and a master’s degree in nursing. However, the 
clinical competence of nurses had a significant negative relationship with job stress.
CONCLUSION: The level of clinical competence of Iranian nurses was desirable. Studies that used 
the CIRN, reported the highest and lowest clinical competence in clinical care and professional 
development dimensions, respectively. Studies that used the NCS, reported the highest and lowest 
clinical competence in dimensions of work role and ensuring quality, respectively.

Abstract BACKGROUND: One of the important challenges faced by health‑care system is to raise the level of 
knowledge of nurses about cerebrovascular accident(CVA) nursing care in the emergency department. 
Therefore, the aim of this study was comparison of two new educational techniques (noninteractive 
multimedia learning and workshop) on knowledge of nurses about CVA nursing care in the emergency 
department.
MATERIALS AND METHODS: This experimental study was conducted with a two‑group design. 
Sixty‑four eligible nurses working in the emergency department in selected hospitals affiliated to 
Isfahan University of Medical Sciences, Isfahan, Iran, were selected as the study participants. Nurses 
were randomly assigned into two groups of noninteractive multimedia (n = 32) and workshop (n = 32) 
using random number table. The data‑gathering tools including a demographic questionnaire (6 items) 
and knowledge questionnaire (24 items) were completed before and 2 weeks after the intervention in 
both the groups. Data were analyzed using SPSS 18 and descriptive (mean and standard deviation) 
and analytical statistics (ANOVA, independent t‑test, and paired t‑test). The level of statistical 
significance was P ≤ 0.05.
RESULTS: The result shows that independent t‑test showed that there was not a significant difference 
between the mean total scores of nurses’ knowledge before intervention in the two groups (P > 0/05). 
Furthermore, the results of paired t‑test showed a significant difference in the knowledge score 
2 weeks after compared to before the education in both the groups (P < 0.005). In addition, the 
results of independent t‑test showed a significant difference in the knowledge score 2 weeks after 
the intervention in the two groups (P < 0.005). The average knowledge score in the workshop group 
was significantly higher than in noninteractive multimedia learning group.
CONCLUSION: According to the result, new educational techniques such as noninteractive 
multimedia learning and workshop could improve knowledge of nurses about CVA nursing care in 
the emergency department.

Abstract BACKGROUND: Infertility and the use of assisted reproductive therapies affect infertile couples quality 
of life. Infertile couples face many physical, psychological, and financial challenges due to having a 
higher level of spiritual intelligence and resilience will help the infertile couple to adapt to infertility 
conditions and achieve their therapeutic goals. This study was aimed to determine the relationship 
between fertility characteristics and spiritual intelligence and resilience in infertile couples.
MATERIALS AND METHODS: This was a cross‑sectional study that was conducted in 2020 on 
162 infertile couples referring to infertility centers in Isfahan who met the inclusion criteria. Samples 
were selected by convenience sampling method. Information was gathered using a questionnaire 
consists of three parts: demographic and fertility characteristics, spiritual intelligence, and resilience. 
Data were analyzed using descriptive and inferential statistical methods (t‑test, Pearson’s correlation 
coefficient, and Chi‑square). P < 0.05 was considered statistically significant.
RESULTS: Pearson’s correlation coefficient showed that there was no significant relationship 
between resilience score and spiritual intelligence score with age, duration of marriage, and 
duration of treatment (P > 0.05). There was no significant relationship between resilience score and 
spiritual intelligence score and its dimensions with the level of education and economic status of 
the family (P > 0.05).
CONCLUSIONS: There was no significant relationship between demographic and fertility factors 
with spiritual intelligence and resilience.

Abstract BACKGROUND: The mental health of health‑care workers with their unique role in responding
to the COVID‑19 pandemic is strictly essential. Hence, to react effectively to the pandemic, it is
essential to collect further data on the stressors and adaptation strategies. The aim of this study is
to explain the health‑care workers’ experiences of stressors and adaptation strategies used during
the COVID‑19 pandemic outbreak.
MATERIALS AND METHODS: A qualitative content analysis approach was employed in this
study, with semi‑structured in‑depth interviews. Nineteen health‑care workers participated in the
study by purposeful sampling method. The study setting included selective educational hospitals
that admitting patients infected with COVID‑19. The data were analyzed using content analysis
method.
RESULTS: Stressors were classified under four major categories: idiopathic, i.e., arising from
unknown causes, individual and familial, stressful work environment, and socially imposed stressors.
The adaptation strategies were classified under inactive and active adaptation strategies.
CONCLUSIONS: The stressors include the stresses arising from the unknown nature of the disease,
stressful work environment, individual and familial stresses, and the socially imposed stresses. The
adaptation strategies include inactive and active adaptation strategies. Identification of these factors
can help workers and management to effectively react to the pandemic.

Abstract BACKGROUND: Women’s health is supposed to be one of the indicators of development.
Reproductive health is an important part of women’s health. Vulnerable women are a group of women
whose reproductive health needs to be given special attention. The purpose of this study was to
compare the reproductive health of vulnerable and nonvulnerable women.
MATERIALS AND METHODS: This cross‑sectional study was conducted on vulnerable
women (n = 250) and nonvulnerable women (n = 250). The samples were selected from vulnerable
women’s centers and comprehensive health centers in Isfahan by quota and using simple random
sampling method in 2017. The research tool was a researcher‑made questionnaire completed by the
researcher using interview method. Internal reliability of the questionnaire was confirmed to be 0.89
using Cronbach’s alpha. A P < 0.05 was considered to be statistically significant. Data analysis was
performed using SPSS 18 software and independent t‑test, Mann–Whitney, Pearson, Spearman,
and Chi‑square tests.
RESULTS: The results showed that the mean total score of reproductive health in the nonvulnerable
group (81.41) was significantly higher than that of the vulnerable group (68.6). The mean total score
and the score of reproductive health components, except some of them, were significantly different
between the two groups (P < 0.05). Having an addicted spouse and unsafe sex were the most
prevalent features associated with high‑risk behaviors.
CONCLUSIONS: According to the results, reproductive health status of vulnerable women
is inappropriate in all dimensions. Given the importance of this issue, the development and
implementation of special health programs for this group seem to be necessary.

Abstract BACKGROUND: Professional ethics is a set of principles and standards of human behavior that
affect individual behavior and leads to improve care that provided by medical staff. The present
study examined the knowledge and attitude of medical and nursing students toward professional
ethics in Iran.
MATERIALS AND METHODS: This descriptive‑analytic study was carried out on 176 medical and
nursing students in Bam University of Medical Science, Iran in 2019. In this study, students were
selected by census sampling. Data collected using two researcher‑made questionnaires related to
knowledge and attitude toward professional ethics. Data were analyzed in SPSS software.
RESULTS: The mean scores of knowledge among nursing and medical students were 86.56 (8.76)
and 85.10 (12.19), respectively. The mean score of attitude among nursing and medical students
was 127.06 (12.45) and 129.9 (11.88), respectively. Results of the Pearson correlation test showed a
positive and significant associated between the score of knowledge and attitude nursing and medical
students’ (P < 0.001), (r = 0.76) (r = 0.66). Among the demographics characteristics, student age
was associated to their attitude and knowledge significantly (P = 0.03).
CONCLUSION: Iranian nursing and medical students have a positive attitude and a high level of
knowledge about professional ethics. A high level of knowledge was related to the most positive
attitude.

Abstract BACKGROUND: The use of social networks in the field of education has also accelerated and
has become a powerful source of learning for transformation and empowerment in various fields.
This study aimed to test the adaptation and psychometric properties of an instrument for students’
prospective on e‑professionalism in the use of social media in Iranian medical science students.
MATERIALS AND METHODS: In this questionnaire, with the aim of psychometric properties of the
perception toward social media in Iranian students, this survey instrument developed by (Ness et al.)
in five fields in 2nd‑year pharmacology students in Purdue University The fields include accountability,
hiring decisions, profile editing, professionalism, and privacy settings. In this study, first, a cultural
adaptation was done by an expert panel. Then, psychometric properties of an instrument by content
validity and construct validity using explanatory factor analysis were performed. Reliability was
assessed by test–retest and internal consistency of items. The reliability of the survey instrument
with three factors was 0.82 using the test–retest, and the internal consistency was good (r = 0.94).
RESULTS: The result of psychometric properties using the principal component method extracted
three factors (accountability, hiring decision, and professionalism) to assessment of students’ attitude
to professionalism using social media in Iranian students.
CONCLUSION: The adapted and psychometric properties of the instrument developed by Ness
et al., 2013, with three dimensions and ten items proved to be a valid, reliable instrument for use
for assessing perspectives on e‑professionalism and social media in Iranian medical students. This
questioner may be suitable for Iranian researches in medical education.

Abstract BACKGROUND: Entrepreneurship is the engine of economic growth and a main symbol of innovation
in any country. The health system of the country needs entrepreneur managers to eradicate the
problems and provide better services. The purpose of this study was to identify factors affecting the
nurturing of entrepreneurial managers in the Iran’s health system.
MATERIALS AND METHODS: This study was carried out qualitatively with the grounded
theory method and through semi‑structured interviews with six questions. The data sources
were 22 key informants who were purposefully selected from healthcare organizations and other
entrepreneurship‑related institutions. Data were analyzed and interpreted using the framework
analysis. Data were managed and analyzed using MAXQDA software.
RESULTS: Findings of this study indicated 6 main themes and 46 subthemes. The six factors
affecting the development of entrepreneurial managers in the Iran’s health system were determined
as individual, family, social, economic, organizational, and educational.
CONCLUSION: Iranian health organizations need to nurture entrepreneurial managers to tackle the
challenges of the health system, compete internationally, and have successful performance. Hence,
delivering the health industry to entrepreneurial managers in the long run will bring back positive
results of growth and development to the body of the health system. Therefore, paying attention
to the identified themes and subthemes and the solutions presented in this study can help nurture
entrepreneurial managers’ and successful performance of the Iran’s health sector.

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: The quality of life (QOL) is essential in all different stages of life; however, It is
more important for older people as it can be effective in promoting their health. Therefore, the present
study aimed to review the literature on the QOL in the Iranian elderly population.
MATERIALS AND METHODS: The study was carried out as a systematic review. For this purpose,
all databases were searched in March 2021. The keywords used for the search were “quality of life,
elderly, older adults, aging, seniors, and Iran” along with the Persian equivalents. PRISMA protocol
was used to screen articles. After removing duplicate and irrelevant items, two evaluators appraised
the articles separately based on a researcher‑made checklist derived from the SBEM and STROBE
Statement standard checklists.
RESULTS: The initial search yielded 3734 studies on the QOL in the Iranian elderly population. After
screening and assessing the studies based on inclusion and exclusion criteria, 22 articles remained in
the study. Most of the studies (cross‑sectional) were conducted in Tehran using a 36‑item Short‑Form
Health Survey to assess the QOL. The studies investigated sociodemographic determinants, physical
and health‑related behaviors, and spirituality and psychological determinants of the QOL. The
sociodemographic determinants were the most common factors under study. The results showed
that the role of gender and socioeconomic status was the strongest among the sociodemographic
characteristics. A significant association was found between the QOL in the Iranian elderly population
and factors such as depression and religious confrontation.
CONCLUSION: In addition to chronic diseases, diseases of the oral and dental, as well as an
unhealthy diet, should be considered in the elderly. Therefore, attention should be paid to all social,
physical, and psychological variables that affect the QOL of older people.

Abstract BACKGROUND : The complex, multifaceted care environment and the threatening situation of caring
for hemodialysis patients cause tension in their family caregivers. Due to the severe tension, family
caregivers are likely to ignore their basic needs and only pay attention to the patient’s needs and
related issues. This study was conducted with the aim of designing and evaluating the Perceived
Care tension Questionnaire for Caregivers of Hemodialysis Patients (PCTQHFC).
MATERIALS AND METHODS: The present study was a sequential exploratory mixed methods
study of scale development variant conducted in two phases: qualitative and quantitative. This study
was conducted in 2019 in Shahrekord. The qualitative phase included item development and scale
development. In the quantitative phase (Item Analysis), the validation characteristics of the tool were
examined using face, content and construct validity, and its reliability by internal consistency and
stability. Findings were performed using software SPSS 18.
RESULTS: Principal components analysis with orthogonal rotation to generate factors, showed that
five factors, namely emotional exhaustion, inadequate social support, care burden, confusion and
ambiguity and lack of adaptability skills had an eigenvalue of higher than 1, so that they explained,
respectively, 75.98%, 61.36%, 72.49%, 76.33%, and 70.31% of the total variance. The internal
consistency was obtained 0.811 and the inter‑class correlation coefficient for the whole instrument
0.832.
CONCLUSION: PCTQHFC is a culturally appropriate measure with strong psychometric properties.
The instrument designed in this study measures the care tension of hemodialysis patients. Therefore,
researchers, health‑care providers, and community health policymakers can plan and implement
interventions to reduce the tension of caregivers of hemodialysis patients by analyzing and identifying
the tensions of caregivers.

Abstract BACKGROUND: Coronavirus (COVID‑19) is an infectious respiratory disease. Quarantine is often
accompanied by unpleasant experiences for those who go through it. The aim of this study was to
determine the mental health status of people during quarantine in northern Iran.
MATERIALS AND METHODS: This cross‑sectional study was conducted during the quarantine
period of coronavirus. Conventional sampling was done from March 6 to April 6. Six hundred and
forty‑two individuals were included. Inclusion criteria were living in Sari and being home quarantined
during the corona outbreak. Exclusion criteria included hospitalization history due to corona and
unwillingness to participate in the study. In this study, the General Health Questionnaire‑28 was used
online to collect the required data. To analyze the data, descriptive and inferential statistics (t‑test,
analysis of variance, and correlation coefficient) were used.
RESULTS: In this study, individuals were included in the investigation with a mean age of
38.74 ± 11.89 (ranged from 15 to 73). Most of the participants were female (72.85%) and
married (71.34%). According to the results, 21.5% of the participants had poor mental health.
Mean mental health scores have a statistically significant relationship with gender, marital status,
education, occupation, quarantine period, patients with corona, and exposure to a patient with
corona (P ≤ 0.05). Furthermore, a negative correlation coefficient was observed between age and
mental health score (correlation coefficient = −0.31, significance >0.001).
CONCLUSION: The average score of mental health has a significant relationship with gender, marital
status, education, occupation, quarantine period, corona, and exposure to a patient with corona.
Given the high prevalence of mental disorders in people during the COVID‑19 epidemic, educating
people and planning to reduce the psychological effects of the epidemic can be helpful.