Journal of Education and Health Promotion

Abstract

Abstract BACKGROUND: Nursing students have a role in the awareness of risk factors in the development
of healthy lifestyle behaviors. Nursing students’ awareness of disease risk factors plays a role in
developing healthy lifestyle behaviors. Therefore, it was aimed to determine the relationship between
the effect of nursing students’ healthy lifestyle behaviors and cardiovascular disease risk factors’
knowledge levels and obsessive–compulsive symptoms.
MATERIALS AND METHODS: This was a descriptive cross‑sectional study. Two hundred and
twenty‑four students studying in the nursing departments of two foundation universities participated
in the study between April and October 2020. Sociodemographic information form, Health Promoting
Lifestyle Profile II (HPLP‑II), Cardiovascular Disease Risk Factors Knowledge Level (CARRF‑KL),
and Maudsley Obsessive–Compulsive Inventory (MOCI) were applied to the students.
RESULTS: It was found that the nursing students’ healthy lifestyle behaviors (123.53 ± 25.78) and
cardiovascular risk factors’ knowledge level (21.08 ±± 2.70) were high. Obsessive–compulsive
symptoms (16.12 ± 6.22) were moderate. In the correlation of sociodemographic characteristics, it
was found that age correlated with the nutrition subdimension of CARRF‑KL and HPLP‑II, income
level correlated with HPLP‑II, place of residence correlated with HPLP‑II, CARRF‑KL, and MOCI, and
having a health problem correlated with health responsibility. Income status, place of residence, and
presence of health problems were found to be correlated with HPLP‑II in all subdimensions in the
regression analysis. In the regression analysis of HPLP‑II with CARRF‑KL and MOCI scales, it was
found that it was significantly related to interpersonal relations, spiritual growth, stress management,
and total score dimensions.
CONCLUSION: Healthy lifestyle behaviors of nursing students are related to cardiovascular risk
factors’ knowledge level and obsession symptoms. In addition, some demographic characteristics
affect healthy lifestyle behaviors.

Abstract BACKGROUND: The ancient Indian science of Yoga makes use of voluntary regulation of breathing
to make respiration rhythmic and calm the mind. This practice is called pranayama. Nadisuddhi
pranayama means “purification of subtle energy paths,” inhalation and exhalation are through
alternative nostrils for successive respiratory cycles. Surya Anuloma‑Viloma pranayama means “heat
generating breathing particle” when the respiratory cycle of inhalation and exhalation is completed
through the right nostril exclusively. When completed through the left nostril alone, the practice is
called “Chandra Anuloma‑Viloma pranayama,” which means a heat‑dissipating or cooling liberating
practice. We compared the effect of right nostril breathing (RNA) and left nostril breathing (LNB)
pranayama on heart rate variability.
MATERIALS AND METHODS: The study was conducted at the Department of Physiology at an institute
of national importance, after obtaining necessary ethical approvals from the Institutional Ethics Committee.
Twenty healthy kriya yogi volunteers (mean age: 44 years), who are regular practitioners for the last
10–20 years, were inducted into the study. RNB pranayama starts with closing the right nostril with the
thumb of the left hand followed by exhalation through the right nostril and inhaling slowly through the
same nostril. This forms one round of RNB pranayama. In contrast, inhalation through the left nostril and
exhalation through the right nostril exclusively is called chandrabhedana pranayama (chandrabhedana
means moon‑piercing breath in Sanskrit) with a similar variation called Chandra Anuloma‑Viloma
pranayama in which inhalation, as well as exhalation, is performed through the left nostril exclusively. The
recording of electrocardiogram (ECG) for heart rate variability (HRV) analysis was taken by heart rate
variability (Dinamika HRV‑Advanced Heart Rate Variability Test System, Moscow, Russia). The resting
and during readings of heart rate variability parameters were compared and post hoc analysis was done
using Bonferroni and Holm multiple comparisons for repeated measures.
RESULTS: Time domain parameters: Standard deviation of normal to normal RR intervals (SDNN)
and root mean square of successive NN interval differences (RMSSD) were increased at a high level
of statistical significance during both pranayama maneuvres. Frequency domain parameters: LF, LF/
HF ratio increased significantly. Parasympathetic activity is represented by LF when the respiration
rate is lower than 7 breaths per min or during taking a deep breath. Thus, when the subject is in a
state of relaxation with slow and even breathing in both RNB—right nostril and Chandra—LNB, the
LF values can be very high, indicating an increase in parasympathetic activity rather than an increase
in sympathetic regulation.
CONCLUSION: Our study is an acute study, where changes in HRV were seen after 5 min of RNB
and LNB. However, statistically, there is not much difference in the immediate effects of the two
pranayamas on heart rate variability in regular yoga practitioners.

Abstract BACKGROUND: One of the important causes of anxiety in COVID‑19 disease is the inability to
regulate emotion and lack of self‑control during threatening conditions. The psychotherapy technique
has been effective in reducing these symptoms. Therefore, this study attempted to evaluate the
effectiveness of compassion‑based therapy on emotion regulation and self‑control in patients with
COVID‑19 after discharge.
MATERIALS AND METHOD: It was a quasi‑experimental pretest‑posttest study with a control group.
The statistical population consisted of 30 men (15 in each group) who were in the quarantine period
of COVID‑19 disease. Available sampling was used and the participants were randomly assigned
to experimental and control groups. In the experimental group, compassion‑based treatment was
performed in 10 sessions of 90 min. Tanji’s self‑control questionnaire and Garnofsky’s Emotion
Regulation questionnaires were used. Data analysis were performed using SPSS 21 software and
multivariate analysis of covariance.
RESULTS: There was a significant difference between the mean scores of emotion regulation and
self‑control variables in the experimental and control groups (P < 0.001). The effect of this treatment
on increasing the emotion regulation score was 49% and on increasing the self‑control score was 37%.
CONCLUSION: Compassion‑based therapy can increase cognitive regulation and improve self‑control
in patients with COVID‑19 disease. It is suggested that this intervention can be used in psychological
treatment programs

Abstract BACKGROUND: Clinical decision‑making is not only stressful to physicians, but also to patients and
even their companions. Thus, managing uncertainty in clinical decision‑making is essential which
requires knowing its origins. Therefore, this study aimed to understand determinants of uncertainty
in clinical decision‑making from the perspective of clinical physicians.
MATERIALS AND METHODS: This is a qualitative study which is done during October to November
2020. An in‑depth interview is performed with 24 specialists of clinical groups including obstetrics,
surgery, internal medicine, and pediatrics, working in teaching hospitals affiliated to Iran University
of Medical Sciences. All the interviews were recorded, transcribed and analyzed according to the
steps suggested by Graneheim and Lundman. The interviews were analyzed through comparative
method. Then, the interviewer created initial codes, categories, and key concepts and sent them to
fourteen physicians for member check.
RESULTS: According to the participants’ view, determinants of uncertainty in clinical decision‑making
consisted of three themes: individual determinants, dynamics of medical sciences, and diagnostic
and instrumental constraint. Individual determinants can be related to the physician or patient. The
dynamics of medical sciences could be explained in two categories: variation of medical science and
complexity. Diagnostic and instrumental constraint category could be also explained in subcategories
such as lack of efficient diagnostic tests and unknown etiology.
CONCLUSION: To curb uncertainty, the more accessible way is considering interventional programs
with a focus on individual determinants related to physicians, such as strengthening doctor–patient
relationships, and considering related mandatory retraining courses to reduce insufficient knowledge
of physicians.

Abstract BACKGROUND: Schools are ideal setting for children’s oral health‑promoting programs. It is an
integrated model for oral health‑promoting schools (OHPS) with the capacities of dental school’s
curriculum and dental students as workforces. In this protocol, the principle of planning and
implementation of the oral health program is described.
MATERIALS AND METHODS: Based on the PRECEDE‑Policy, Regulatory, and Organizational
Constructs in Educational and Environmental Development (PROCEED) planning model, a framework
for determining the potential predisposing, reinforcing, and enabling factors that could be intervening
was diagnosed. To adapt the phases of the planning model for integration of the “OHPS” principles
and the dental students’ curriculum, the following steps are supposed to be considered: Phases
1–5 which are to assess the baseline data will include the assessment of children oral health status
and parents and teachers’ knowledge, attitude, and performance. Phase 6 or implementation phase
will be allocated to oral health education interventions for students, parents, and teachers, professional
screening, prevention, and referral. Phase 7 or the process assessment phase will be to record the
number of screened students, the amount of fissure sealant and fluoride provision, and percentage
of trained parents and teachers. Phase 8 or the impact assessment phase will assess the students’
improvement in knowledge and practice, decayed, missing, and filled teeth scores, teachers and
mothers’ oral health attitudes and behaviors, and brushing and flossing behaviors. At the last, cost
analysis of the program and long‑term monitoring of the interventions is suggested.
CONCLUSION: In case that the effectiveness of this model is proven, it can be implemented by other
dental schools for the primary schools in their regions. Considering the number and distribution of
dental schools in the country, this model is executable as targeted population oral health promotion
approach in 6–12‑year‑old schoolchildren.

Abstract BACKGROUND: Intentional self‑harm (ISH) is one of the most important entities of consultation‑liaison
psychiatry. This study aimed to assess the clinical profile of individuals with intentional self‑harm
referred to consultation‑liaison (CL) psychiatric services in a tertiary care hospital.
MATERIALS AND METHODS: The present study was a cross‑sectional hospital‑based study, in
which purposive sampling was done for sample selection. A total of 60 subjects of ISH referred for
evaluation in a tertiary care psychiatry hospital on specified days were recruited to the study after
obtaining informed consent. Demographic and clinical details such as the nature of the self‑harm
attempt, method of attempt, number of attempts, the reason for the attempt, and regret/remorse
about the attempt were documented using the semi‑structured proforma.
RESULTS: A total of 60 subjects were included in the study. About 80% of them were below the
age of 30 years. The majority (80%) were females, 65% were from a rural background, 56.7% were
married. The most common method of ISH was self‑poisoning. Interpersonal conflicts with family
members (50%), followed by interpersonal conflicts with the spouse/partner (21.7%) were the
commonest reason/precipitating factors that lead to intentional self‑harm. Also, 45% of our study
population did not have any diagnosable psychiatric illness at the time of assessment, and the most
common psychiatric diagnosis was personality disorders (20%).
CONCLUSION: Intentional self‑harm is common in young married females from rural backgrounds.
Self‑poisoning is the most common method of deliberate self‑harm. More than half of the individuals
were diagnosed with the psychiatric illness at presentation.

Abstract BACKGROUND: Infertility is one of the most important challenges in the modern life that can damage
the sexual satisfaction and marital intimacy of couples. The present study was aimed to investigate
the effectiveness of reality therapy on sexual satisfaction and marital intimacy of infertile women.
MATERIALS AND METHODS: This quasi‑experimental study was conducted with a pretest‑posttest
design and follow‑up. The statistical population was infertile women who were referred to Imam Sajjad
Shahriyar Hospital in 2019–2020. 15 infertile women selected by purposive sampling and underwent
reality therapy (8 sessions of 90 min). Data were collected using index sexual satisfaction (ISS) and
marital intimacy questionnaire. Data analysis was performed using SPSS‑24 software, analysis of
variance with repeated measures and post hoc Bonferroni test.
RESULTS: The results of analysis of variance showed that there was a significant difference between
the scores of sexual satisfaction and marital intimacy in posttest and follow‑up stages compared to
pretest (P < 0.05).
CONCLUSIONS: Based on the results, reality therapy can be used as an effective intervention to
improvement sexual satisfaction and marital intimacy of infertile women.

Abstract BACKGROUND: COVID‑19 pandemic lockdown has brought all sectors to be dwindled with
no exception of the academic system. Even professional courses like medical and allied health
academic courses were also not spared. The academic requirements were not met as required to
do so. Webinar has become a good source of virtual platform acting as a bridge for attaining the
gaps in accomplishing the curriculum to the students during these curfew times. Our study aimed
to know the value of webinars on teaching–learning processes among the medical and allied health
science students in India.
MATERIALS AND METHODS: The study design is a cross‑sectional study with 2084 students
who attended at least one webinar. An online survey questionnaire was sent, and the data were
collected on participant’s perspective on the effectiveness of webinar, post webinar assessment
by their satisfactory level of gain of information through webinars and their plan to apply in future.
RESULTS: Participant’s perspective on effectiveness of webinar showed 66.7% of agreement with
the webinar use. In post webinar assessment, the use of webinar was in agreement with 69.9% of the
participants. Furthermore, we observed a significant association with the gain of information in post
webinar assessment (P < 0.05) and a significant association with their plan to apply in future (P < 0.05).
CONCLUSION: Our results showed that the students were satisfied with the webinar teaching and
acknowledged it to be an effective tool in the teaching–learning process to gain new knowledge and
wish to attend webinars in future as a part of their curriculum. Thus, webinars have a constructive
effect in the teaching and learning process in professional courses during pandemic lockdown.

Abstract BACKGROUND: Nursing is one of the most stressful occupations. Educational intervention regarding
stress management can play an important role in reducing occupational stress among nurses The
present study aimed to determine the effectiveness of educational intervention on reducing oxidative
stress caused by occupational stress in nurses: A health promotion approach in a hospital in western
Iran.
MATERIALS AND METHODS: The present interventional study was performed in 2019 among
92 nurses working at the Kosar Hospital located in the city of Sanandaj in the country of Iran.
Occupational stress was evaluated using the Osipow Occupational Stress Questionnaire. Oxidative
stress was measured by taking blood samples and measuring the enzymatic activity of superoxide
dismutase (SOD), malondialdehyde, and catalase (CAT) using SOD, malondialdehyde (MDA), and
CAT kits. Educational intervention was carried out in the second stage. Three months after the
intervention, data were taken again.
RESULTS: The results of the present study indicated that there was a significant difference in
occupational stress between before and after the educational intervention (P < 0.05). A significant
reduction in MDA (P = 0.038) and SOD (P = 0.048) was observed after educational intervention, but
this was not the case for CAT (P = 0.592). There was no significant correlation between occupational
stress with oxidative stress parameters before and after the educational intervention (P < 0.05). No
significant difference in occupational stress was observed between men and women. Among the
oxidative stress parameters under evaluation, MDA was higher among men compared to women
and this was statistically significant.
CONCLUSIONS: Educational intervention regarding occupational stress is effective in reducing
oxidative stress among nurses. The group meetings teach stress management to the participants
and enable them to better manage their stress by utilizing their own capabilities. Thus, attention to
this issue is vital in maintaining the mental and physical health of nurses and, in turn, improves the
quality of care rendered.

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 Osteoporosis is a specific condition which is characterized by low bone mineral density (BMD) and
deterioration of bone structure resulting in an increased susceptibility to fractures. It contributes to a
great deal of morbidity and mortality, and is a large burden to the healthcare system, especially in the
case of the elderly population. In the last four decades, a plethora of studies have reported characteristic
oral radiographic findings in the early stages of osteoporosis, suggesting the possible use of oral
radiographic signs for the early detection of the condition. Digital orthopantomographs (OPGs) are
usually taken for the screening of dental patients during routine dental evaluations. These radiographs
and the characteristic changes seen on them may have a significant role in the screening for initial
osteoporotic changes. A number of precise radiomorphometric indices of the mandible have also
been developed to allow quantification of the mandibular bone mass for identification of the initial
signs of osteoporosis. The present review focuses on the possible role of panoramic radiographs in
the initial screening for osteoporosis in dental clinics in high‑risk groups.

Abstract BACKGROUND: Despite new anticoagulants’ developments, warfarin is still one of the most
commonly used medicines, particularly in the cardiovascular system. One of the significant challenges
with warfarin is the prevalence of dangerous side effects such as bleeding and drug and food
interactions, which can negatively affect patients if not adequately controlled. As health‑care team
members, nurses have a crucial role in prescribing this medicine and educating patients. In this
regard, this study was conducted to determine the knowledge and practice of nurses working in the
cardiovascular wards regarding warfarin.
MATERIALS AND METHODS: In this cross‑sectional, descriptive study, knowledge and practice
of 239 nurses working in the cardiovascular wards of teaching hospitals affiliated to Iran University
of Medical Sciences have been investigated using European Cardiovascular Nurses Knowledge
questionnaire on anticoagulants and the checklist for high‑risk drugs safety instructions. The sampling
was performed through the stratified sampling method with proportional allocation. Data were analyzed
using the SPSS software version 16 through descriptive and inferential statistics (independent t‑test,
one‑way analysis of variance, and Pearson correlation coefficient) (Inc., Chicago, IL, USA).
RESULTS: The mean scores of knowledge (18.51 ± 3.87) and practice (10.53 ± 2.12) were
slightly higher than the median, and the lowest mean score was related to knowledge on drug
interactions (7.62). The practice had a statistically significant relationship with knowledge (P ˂ 0.001).
Regarding demographic variables, there was a statistically significant relationship between nurses’
knowledge and the education level (P = 0.009) and nurses’ practice and age (P = 0.022), work
experience (P = 0.032), and work experience in cardiovascular wards (P = 0.036).
CONCLUSIONS: Based on the findings of this study, the knowledge of nurses working in the
cardiovascular wards about warfarin was not sufficient, and their practice was of poor quality. Nurses’
lack of knowledge and improper practice can jeopardize drug safety in patients and cause serious
side effects such as bleeding. Proper training of nursing students and nurses about warfarin as a
high‑risk drug, its side effects, and drug‑food interactions, and the emphasis on patient education in
patients receiving this medicine can effectively reduce the incidence of side effects.

Abstract BACKGROUND: Modern research today proves an increase in the incidence of ischemic stroke.
Risk factors for vascular disease have become more common among young people. Clinical studies
have shown that hypertension, dyslipidemia, and diabetes are traditional risk factors among the
elderly. The aim of the study was to improve diagnostic approaches to cerebrovascular disorders
in patients with hypertensive encephalopathy (НE) by clarifying the development of pathogenesis
mechanisms, based on a comprehensive clinical study.
MATERIALS AND METHODS: This qualitative study was carried by clinical and neurological
examination; neuropsychological examination (Mini‑Mental State Examination, abbreviated
multifactorial personality questionnaire, Beck depression scale, Spielberger scale).
RESULTS: The study was examined 351 patients (150 men, 201 women) with НE in hypertension of
2 degrees. The clinical examination was performed according to a two‑stage method, which involves
the establishment or exclusion of symptomatic hypertension. The study did not include patients with
secondary hypertension, diabetes mellitus, cardiac arrhythmias, and conduction disorders, heart
failure who suffered from acute cerebrovascular accident and myocardial infarction.
CONCLUSION: The necessity of obligatory examination by a neurologist of patients with arterial
hypertension for detection of manifestations of НE with the use of modern research methods, which
allows to prevent damage to target organs, and first of all – brain damage, has been proved.

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: Infection with COVID‑19 has resulted in considerable mortality all around the world.
This study aimed to investigate the effect of convalescent plasma on the treatment of hospitalized
patients with COVID‑19 in Imam Khomeini Hospital at Ardabil, Iran.
MATERIALS AND METHODS: In this quasi‑experimental clinical trial, patients over 18 years of age
with polymerase chain reaction‑positive COVID‑19 were admitted based on the clinical criteria of
respiratory distress with hypoxia (O2
 saturation <90) and tachypnea (R Relative Risk (RR) >24) with
moderate‑to‑severe lung involvement and in the 1st week of respiratory disease who were not intubated
were nonrandomly assigned to two groups: convalescent plasma therapy (CPT) group (197 cases)
and control group (200 cases). We used the Chi‑square, t‑test, Fisher’s exact test, and Pearson’s
correlation coefficient for statistical analysis.
RESULTS: Analyses revealed that length of stay in hospital was significantly lower in the CPT group
as compared to the control group (P = 0.001). Twenty‑four cases (22.0%) in the CPT group and
85 cases (78.0%) in the control group needed intubation. Furthermore, mortality was 17 cases (18.3%)
in the CPT group and 76 cases (81.7%) in the control group, the difference of which was also found
to be statistically significant (P < 0.05).
CONCLUSIONS: It seems that CPT can be used as an alternative treatment at the early stages of
COVID‑19 to prevent the progress of the disease, reduce the need for intubation and consequently
the length of stay in hospital, and finally, decrease mortality.

Abstract BACKGROUND: Job satisfaction has been described to be an important for individuals as well as
for the society in general. However, several factors were introduced to be crucial for job satisfaction;
one of the more influenced factors in satisfaction experiences is individual personality. The present
study aim is to identify the relationship between the five major traits of personality and job satisfaction
with virtual education among teachers of students with learning difficulties.
MATERIALS AND METHODS: The research is a descriptive quantitative design. The research
population consists of 94 male and female teachers who are involved in primary and intermediate
public schools in Saudi Arabia. Data were then exposed to the analysis, namely, descriptive statistics,
Pearson correlation, and Mann–Whitney U test to obtain the answers to the research questions at
the level of <0.05.
RESULTS: Based on the results, the most common personality trait among the study sample is
conscientiousness, while neuroticism was the least common among the five traits. It was also found
that there are differences between males and females in all dimensions of job satisfaction with virtual
education (satisfaction with the nature of work – the relationship with colleagues and bosses – the
relationship with parents) and the overall score in favor of females, except for the dimension of the
relationship with colleagues and superiors, where males and females are equal.
CONCLUSION: The average score of the personality types and job satisfaction is moderate. Job
satisfaction has a significant relationship with personality types. In addition, partial significant
differences were found among the study variables. Given the importance of identifying teachers’
personality in the workplace, reducing psychological and work factors effects in the educational
environment among teachers can be helpful to enhance their job satisfaction. The study therefor,
enumerated implications and recommendations based on the findings.

Abstract BACKGROUND: In the COVID‑19 outbreak, women with a history of miscarriage need more mental
health. Anxiety and meta‑worry as consequences of miscarriage, besides concerns due to pregnancy
during coronavirus, show the necessity of appropriate online and face‑to‑face educational counseling.
This study aimed to evaluate the effectiveness of online metacognitive educational counseling versus
face‑to‑face method on anxiety and meta‑worry in these women.
MATERIALS AND METHODS: In this randomized clinical trial, 80 women with a history of
miscarriage, anxiety, and meta‑worry referred to Imam Jafar Sadegh hospital (labor, women ward
and women clinic), Meybod, Iran, were selected conveniently and randomly assigned into two
groups (n = 20/each). The participants received 8‑session metacognitive educational counseling
package online or face‑to‑face. Data were collected by Beck Anxiety Inventory, Wellz meta‑worry
questionnaire at baseline, week eight, and follow up as primary outcomes and analyzed via SPSS
software (Anova and Repeated measure statistic tests).
RESULTS: Anxiety in the 12th week (online group 13.75 ± 3.59 vs. face to face 18.25 ± 5.91,
P = 0.04) was statistical significantly less than baseline (respectively 22.15 ± 5.67 vs. 22.35 ± 4.93,
P =  0.56); with fewer anxiety scores in the online group. Meta‑worry in the 12th week (online
group 11.90 ± 2.59 vs. face to face 15.70 ± 4.06, P = 0.03) was statistically significant compared to
baseline (respectively 17.15 ± 2.70 vs. 18.50 ± 3.47, P = 0.36); with fewer meta‑worry scores in the
online group. Belief about worry in 12th week (online group 66.50 ± 14.60 vs. face to face 78.45 ± 9.27,
P = 0.01) was statistical significantly less than baseline (respectively 85.50 ± 8.87 vs. 86.05 ± 8.85,
P = 0.96); with less score of belief about worry in the online group.
CONCLUSION: Online and face‑to‑face metacognitive educational counseling methods decreased
anxiety, meta‑worry, and belief about worry in women with miscarriage. But online educational
counseling was more effective. Distance online counseling in COVID‑19 can help the mental health
of women with miscarriage.

Abstract BACKGROUND: Researchers have examined the association between self‑esteem and obesity in
past studies. However, most studies have focused on pediatric or adolescent populations. In this
pilot study, we aim to explore the association of self‑esteem with weight status in young adults, a
group of individuals in a significant and pivotal period of their lives whose needs and challenges
have received little attention in previous studies.
MATERIALS AND METHODS: Exactly 127 college juniors and seniors in the Midwest participated
in late 2017. For our survey, we collected the following information: body weight, height, self‑esteem
score from the state self‑esteem scale, grade point average, risk of eating disorders, sleep quality,
nutritional behavior, lifestyle (smoking, frequency of exercise, alcohol drinking, average daily time
watching television, playing video games, and social media use), and demographic and socioeconomic
background. We used logistic regression for our analysis.
RESULTS: The logistic regression indicates that a one‑point increase in the self‑esteem
score was negatively associated with a young adult’s odds of having an unhealthy weight
(being overweight or obese) by approximately 3%. Furthermore, soda drinking is a statistically
significant factor associated with weight status.
CONCLUSIONS: This finding suggests self‑esteem is positively associated with a healthy weight
in young adults. A larger‑scale study should be conducted in the future to validate this relationship
and better understand young adults’ needs.

Abstract Health education is a crucial consideration in the healthcare system and has the potential to improve
global health. Recently, researchers have expressed interest in streamlining health education, utilizing
digital tools and flexible curriculums to make it more accessible, and expanding beyond disease and
substance abuse prevention. They have also expressed interest in promoting global health through
health and safety promotion programs. Amidst the COVID‑19 pandemic, climate change, the refugee
crisis, and overpopulation, healthcare crises are erupting all over the world. A lack of health education
has and will continue to have a profound impact on community healthcare indicators, particularly in
low‑income nations. Current priorities within the health education sector include digitization, equity,
and infectious disease prevention. Studies and data from university journals and other academic
databases were analyzed in a literature review. Health education programs have a significant positive
impact on attitudes and behaviors regarding global health. Improving upon these programs by digitizing
them and expanding upon the scope of health education will help ensure that such interventions and
programs make a significant difference.

Abstract BACKGROUND: Healthy children are the foundation for a healthy and developing nation. Perceived
behavioral control (PBC), comprising control belief and perceived power, is a person’s perception of
the ease or difficulty of performing the behavior of interest. For facilitating regular physical activity and
regular healthy dietary practices among the adolescents, PBC is an important construct to develop
and implement appropriate interventions. The aim is to assess PBC to perform regular physical
activity and regular healthy dietary practices and measure their statistical relationship among the
school‑going adolescents in an urban area in West Bengal.
MATERIALS AND METHODS: A school‑based cross‑sectional study was conducted among 251
adolescents aged 12–16 years after taking consent and assent for participation in the study. Data
were collected with self‑administered questionnaire on sociodemographic variables and the two
domains of PBC, i.e., control beliefs and perceived power, related to regular physical activity and
regular healthy dietary practices. Each PBC total score was calculated by multiplying control belief
score and perceived power score for each respondent. Partial correlation coefficient was calculated
between regular healthy dietary practices and regular physical activity.
RESULTS: Among the total 251 responses analyzed, 34.7% and 27.5% students belonged to age
group 14 and 15, respectively. It was observed that the mean (± standard deviation) score of PBC
regarding regular healthy dietary practices was 100.7 (±27.7) and for regular physical activity was
106.0 (±21.4). The correlation between PBC of regular healthy dietary practices and regular physical
activity was 0.421 and was statistically significant.
CONCLUSION: In case PBC score over any behavior is higher, behavioral intention and ultimately
chances of performing that particular behavior increases. Designing appropriate school‑based health
promotion strategies can lead to healthier children fostering regular healthy dietary practices and
regular physical activity in their homes and communities.

Abstract BACKGROUND: One of the crises facing human beings is coronavirus disease. This disease
was identified in December 2019 in Wuhan, China. With the death of two patients with respiratory
complications in Qom Hospital on February 20, 1998, and the confirmation of their positive test, the
arrival of COVID‑19 disease in Iran was officially confirmed and Khorshid Medical Center as the main
reception the Medical Center for patients with COVID‑19 from August 3, 2010. The purpose of this
study is to document the experiences of Khorshid Training Center in coronavirus crisis management
to improve crisis management knowledge.
MATERIALS AND METHODS: This research was conducted qualitatively with grounded theory
method in the period from March 1998 to the end of May 1999. The study population was Khorshid
Educational and Medical Center. Sampling was done purposefully among medical staff, support, and
hospital officials. The number of samples with the mentioned conditions reached 44 people. Data
were collected using a semi‑structured questionnaire and analyzed in the style of grounded theory
in the style of Strauss and Corbin.
RESULTS: Data collected after sorting, analysis, conceptual analysis; they were coded and
categorized into four groups of challenges, weaknesses, strengths, and actions based on the specific
objectives of the research in 5 natures, reorganization, accident control system, medical equipment
and supplies, human resources, and clinical approaches.
CONCLUSION: According to the points classified in the challenges and weaknesses, it was found
that the hospital has faced several problems in corona crisis management. The management team,
taking advantage of strengths in various areas, has taken effective measures to improve corona crisis
management. It has led to the provision of appropriate services to the patients of the Medical Center.

Abstract BACKGROUND: Hospital‑onset coronavirus disease‑2019 (COVID‑19) infection has been reported
and is probably linked to ineffective implementation of infection prevention and control measures.
Contaminated surfaces and air are considered a key part of the transmission dynamics of severe acute
respiratory syndrome, Middle East respiratory syndrome, influenza, and other organisms in hospitals.
This study aimed to assess the extent and persistence of surface contamination with COVID‑19.
MATERIALS AND METHODS: It was a hospital‑based cross‑sectional study conducted for a period
for 2 weeks from December 03, 2020, to December 16, 2020, in Kathua district of J and K, India. The
environmental samples were taken from the patient care area that included COVID isolation ward
and intensive care unit (ICU) as per the guidelines of WHO Protocol “Surface sampling of COVID‑19:
A practical “how to” protocol for health care and public health professionals after seeking copyright
permission from the WHO. Universal standard precautions were strictly followed. Descriptive analysis
was done using the MS‑Excel and expressed in numbers and percentages.
RESULTS: A total of 140 surface samples were taken, 70 each from the COVID ICU and isolation
ward. The results of ten samples from the ICU turned out to be positive and 20 samples were positive
from the isolation ward. Eleven (78.6%) out of the 14 samples taken from the corners of the ICU and
isolation ward were found to be positive.
CONCLUSION: Our study revealed surface contamination in the hospital setting both in COVID
ICU and isolation ward particularly from the corners of the COVID ICU and isolation ward followed
by the samples taken from the linen. Strict adherence to COVID appropriate behavior, increased
frequency of disinfection in high‑risk areas, and sensitization of the staff are mandatory to minimize
the infection risk.

Abstract BACKGROUND: Teaching anatomy in a clinical context can aid students in appreciating how the
subject will apply to their future career as nurses as well as in other administrative roles. Anatomy
is voluminous, making it difficult to retain the factual information in the long run; therefore, this study
primarily focuses on whether case‑based learning (CBL) with integrated anatomy learning can
help in retention of the information over short as well as long spans of time. It also focuses on how
profitable would the students be with this different style of learning, and whether it can facilitate in
better understanding of the basic and clinical concepts.
MATERIALS AND METHODS: The current study was conducted in the Nursing College of All India
Institute of Medical Sciences, Bhopal, India to integrate CBL and evaluate its effect compared to the
highly compartmentalized, didactic lectures among the nursing students. The extent of knowledge
retention was analyzed by conducting a series of tests before as well as after CBL intervention.
Feedback and suggestions were obtained from the students by using the 5‑point Likert scale method.
RESULTS: The post‑test scores of the students improved by 21% after the CBL. More than 85%
of the students opined that CBL improves critical thinking, team work, self‑directed learning, and
communication skills.
CONCLUSION: CBL promotes effective short‑term retention and facilitates comprehension of key
concepts. CBL also plays an important role in improving the professional skills of the students, which
otherwise is not taught, and equips them for their future careers.

Abstract BACKGROUND: The Covid‑19 outbreak has led to an unprecedented burden on the healthcare
infrastructure. High morbidity and mortality rates have resulted in a state of stress and distress among
the general population which has also impacted health professionals.
AIMS: This study was conducted to identify mental health disturbances among health professionals
during the Covid‑19 pandemic.
MATERIALS AND METHODS: It was a cross‑sectional study, conducted in a Medical College
in Himachal Pradesh, India. A self‑administered anonymized questionnaire was administered to
the healthcare workers. Mental health status was assessed using Patient Health Questionnaire
Anxiety‑Depression Scale (PHQ‑ADS). In addition, a 15‑item questionnaire was prepared to identify
the probable causes of stress in HCWs during the Covid‑19 Pandemic. A statistical analysis used
t‑test was used to find the significance of the correlation between the PHQ‑ADS score and the
agreement score of different factors.
RESULTS: The response rate for the questionnaire was 27%. Anxiety and depression were seen in
29% of participants, ranging from mild (18.3%), moderate (4.7%), and severe (5.9%). Among females
43.7% of the participants and among males, 13.1% had anxiety and depression. High PHQ‑ADS
scores were seen in nursing staff (70%) and postgraduate students (30%), who were in the third
decade of life. Most (81.7%) of the HCWs were concerned about transmitting the disease to their
near ones. Fear of coming to the hospital and dealing with patients.
CONCLUSION: Even sub‑threshold syndromes among HCWs need to be identified before they
evolve into overt diseases. The psychological needs of healthcare workers should be prioritized as
they are key players in the fight against Covid‑19.

Abstract BACKGROUND: A new domain of “personal and professional development” was introduced as a core
competency of health‑care providers. This study aimed to explore the experiences of learners and
faculty members about what competencies or skills were essential for the professional development
and success of health‑care providers.
MATERIALS AND METHODS: This is a qualitative study using an inductive content analysis approach
in 2019–2020. In the present study, 58 academic faculty members participated by purposeful sampling
including ten associate professors (17.24%) and 24 assistance professors (41.37%), in addition to
23‑year medical residents (20.65%) and 4th‑year nursing students (20.65%). Individual and group
interviews were conducted. Data were analyzed by the inductive content analysis approach introduced
by Graneheim and Lundman.
RESULTS: The qualitative data were classified in 953 open codes and eight categories, which were
further divided into four main categories: “socio‑emotional skills,” “life‑long learning skills,” “coping
skills,” and “well‑being strategies.”
CONCLUSIONS: The present results showed socioemotional and coping skills affect interpersonal
and professional interactions that contributed to their improved health‑care providers’ capabilities.
Participants also considered lifelong learning as influential in developing professional capabilities
and keeping their knowledge and skills up‑to‑date for accountability to duties. Moreover, using
well‑being strategies protects the mental and physical health of health‑care providers. These skills
are synergistic, and their combination can have a significant role in improving the personal and
professional capabilities.

Abstract BACKGROUND: Lifestyle and nutritional transitions in the society driven by globalization have led
to the rising burden of cholelithiasis. The present study was done to assess the impact of lifestyle,
stress, menstrual pattern, and cardiometabolic risk factors on young females with cholelithiasis.
MATERIALS AND METHODS: A hospital‑based case–control study was conducted on young females
of 18–45 years. Cases and age‑matched controls were compared on their lifestyle parameters like
demography, marital status, occupation, educational status, family income, stress along with menstrual
pattern, cardiometabolic parameters like anthropometric measures, blood pressure (BP), fasting
blood sugar (FBS), and lipid profile. Chi‑square test and unpaired t‑test were used for the analysis
of data using SPSS software, and P < 0.05 was considered statistically significant.
RESULTS: The majority of the cases were from rural areas, married, homemakers leading a
comparatively sedentary lifestyle consuming more red meat, less literate, and belonged to a lower
economic group with significantly more stress compared to controls. The age of menarche, neither the
regularity nor irregularity of the menstrual cycle (regular cycle 21–35 days), showed any difference,
but cases had significantly more pregnancies and usage of oral contraceptives compared to controls.
Waist–height ratio, systolic BP, FBS, triglyceride, low‑density lipoprotein (LDL), and very low-density
lipoprotein (VLDL) were significantly higher in cases. Cases had a 14.4 times more risk of developing
metabolic syndrome when compared with controls.
CONCLUSION: Married, rural, less literate Indian women leading a sedentary lifestyle, consuming
more of red meat, and soft drinks with increased psychosomatic stress are more prone to develop
cholelithiasis. Women who use hormonal contraceptives have increased occurrence of cholelithiasis
and they were more prone to develop metabolic syndrome. The need for the hour is health education,
to implement simple lifestyle changes, thereby decreasing the incidence of cholelithiasis in young
females.

Abstract BACKGROUND: The main purpose of this study was to evaluate the use of Telegram as an Instant
messaging application in clinical teaching of medical students, especially clinical ward rounds.
MATERIALS AND METHODS: In this quasi‑experimental study, Telegram as an Instant messaging
application was employed. To do this, a Telegram group entitled as “Lavender” was created and then
selected patients were divided between students and externs daily. After that, students and externs
were asked to take medical histories, perform complete physical examinations, and then share their
data in the Lavender group. Ultimately, to evaluate the effects of this intervention, two quantitative
and qualitative approaches were used.
RESULTS: From the students’ point of view the highest average was associated with “Readiness
for teaching round” (3.71 ± 1.34) and the lowest average was related to “Time‑saving for studying
about illnesses” (2.08 ± 1.44). In addition, medical trainees mentioned that reporting patients’ daily
medical histories and progress notes could create a reflective process. The suggestion made by
many medical trainees was to select and discuss simpler cases who have more teaching points
for them, while other trainees recommended focusing on common illnesses in the Lavender group.
CONCLUSION: The use of messaging software applications such as Telegram in medical education
has created a new paradigm, which could facilitate interpersonal interactions among trainees.

Abstract BACKGROUND: The mini‑clinical evaluation exercise (mini‑CEX) is a formative assessment tool
designed to provide feedback on skills essential to good medical care by observing an actual clinical
encounter. However, the bigger advantage of mini‑CEX is the structured feedback that it provides to
the students as well as the faculty, thus helping them to make better decisions.
MATERIALS AND METHODS: This study was a cross‑sectional observational study. Sixteen surgery
residents volunteered for participation and five professors conducted sessions; hence, 80 mini‑CEX
encounters. Seven core clinical skill assessments were done, and the performance was rated on
a 9‑point scale (grouped into unsatisfactory, satisfactory, and superior). Immediate feedback to
the residents was given by the faculty. Delayed feedback from faculty and residents regarding the
perception of mini‑CEX was taken. Statistical analysis was done using SPSS version 20 and analysis
of variance (ANOVA) for inferential statistics.
RESULTS: As planned, 80 (100%) mini‑CEX encounters were conducted. Surgery residents showed
improvement that was statistically significant in the competencies of medical interviewing skills,
physical examination skills, humanistic qualities/professionalism, and counseling skills. Most of the
faculty (80%) were able to identify the gaps in the knowledge of students and areas of improvement
for their teaching. However, 60% of the faculty felt that it required more effort than traditional methods.
The mean time taken by the assessor for observation and feedback to residents was 12.51 min
and 5.68 min, respectively. The mean scores of evaluator satisfaction and resident satisfaction with
mini‑CEX sessions were 6.04 and 7.49, respectively.
CONCLUSIONS: Mini‑CEX improves the learning environment in residency and also leads to
improvement in medical interviewing skills, physical examination skills, humanistic qualities/
professionalism, and counseling skills. It is done in the actual patient encounter and hence prepares
the resident better for dealing with patients in the future.

Abstract BACKGROUND: Learners have various processing and understanding of the environment and issues
and choose different strategies for problem‑solving considering learning and studying approaches.
The purpose of this study was to examine medical students’ learning approaches and their association
with academic performance and problem‑solving styles.
MATERIALS AND METHODS: This study was conducted using the descriptive‑correlational method.
The statistical population comprised medical students of Iran University of Medical Sciences during
the academic year of 2019–2020. Of them, 168 subjects were chosen based on simple random
sampling and Morgan Table. Study tools include the Standard Approaches and Study Skills Inventory
for Students (ASSIST) Questionnaire, which includes 18 items and a Likert five‑choice spectrum,
and includes a deep, superficial, and strategic approach. Its reliability was determined by Cronbach’s
alpha of 0.81. Problem‑Solving Style Questionnaire developed by Cassidy and Long was used. This
instrument included 24 items and 6 components, and its reliability equaled 0.83, which was their
grade point average. Data were analyzed using normality tests, paired t‑test, Pearson correlation
coefficient, and regression through SPSS 16 software.
RESULTS: Results implied the positive and significant relationship between deep‑strategic approaches,
problem‑solving styles, and academic performance of medical students (P < 0.001); furthermore,
there was no significant difference between learning approaches based on gender (P > 0.001), while
there was a significant difference between two groups in terms of problem‑solving styles (P < 0.001).
CONCLUSION: Because deep and strategic approaches predict academic performance and
problem‑solving styles, the diagnostic assessment must be done at the beginning of the educational
process to determine the type of learners’ approaches. Such an evaluation can be used to implement
instructional strategies and educational designs to improve the academic performance of students.

Abstract BACKGROUND: People living with noncommunicable diseases (PLWNCDs) are often
disproportionately affected due to adverse interaction with socioecological and biological factors.
Hence, it is imperative to learn from their lived experience to gain a greater understanding of
interactions as well as explore their priorities and needs in accessing care and identify areas of
priority action through multistakeholder engagement.
MATERIALS AND METHODS: The qualitative study with grounded theory approach was
conducted between October and December 2020. An online key‑informant interview with the health
policymaker, virtual group discussion with eight PLWNCDs, and in‑depth telephonic interviews
with five PLWNCDs were conducted, after obtaining informed consent using interview guide,
developed, and validated by the experts. Data collection continued till data saturation was achieved.
Transcripts generated from the interview recordings were coded using hand‑code technique and
analyzed thematically.
RESULTS: Challenges faced by PLWNCDs in accessing care were lack of empathy and support
from health‑care professionals, stigma, financial hardship, and hospital overcrowding. Caregivers
emphasized on the felt need to involve civil society organizations (CSOs) in raising awareness toward
noncommunicable diseases (NCDs) at family, community, and policymaking levels. The need for
home‑based NCD care and rehabilitation centers was voiced by the PLWNCDs. Impediments toward
effective implementation of NCD policies were adoption of a “top‑down” approach, poor awareness
about government health insurance schemes, skewed distribution of empanelled hospitals in and
around cities, nonavailability of qualified health‑care professionals in underserved areas, aggravated
allocation‑utilization disparity during COVID‑19 pandemic, and lack of robust information technology
infrastructure to support access to telemedicine services.
CONCLUSION: The collective role of governments, CSOs, and health‑care providers, along with
meaningful involvement of PLWNCDs, would help to create an enabling environment for overcoming
the challenges of access to care and thus achieve universal health coverage.

Abstract BACKGROUND: Surrogacy has become an alternative family formation option for women who are
unable to carry a pregnancy. There is no comprehensive care program despite the different nature of
this pregnancy. The present study aimed to develop a reproductive health‑care program for surrogate
mothers within the cultural and social context of Iran.
MATERIALS AND METHODS: In the present sequential exploratory mixed methods study, first
through a qualitative approach surrogate mothers, care providers, and policy makers of reproductive
health services were selected purposefully. Data were collected by using the in‑depth semi‑structured
interviews and analyzed. A care program draft was designed by integrating results of the qualitative
study and reviewing the literature and guidelines, then appropriateness of each proposed care was
assessed by a two‑Rounds Delphi technique (RAM), and the final reproductive health‑care program
for surrogate mothers was developed.
RESULTS: The surrogate mothers’ reproductive health needs were summarized in four main
categories: surrogate mothers’ extra care, educational training, psychological support, and protecting
against surrogacy`s social and familial consequences. The reproductive health‑care program for
surrogate mothers were developed in four sections: prepregnancy health screenings and legal
counseling; special care during embryo transfer until pregnancy confirmation; psychological support
and prenatal care of surrogacy until delivery and follow‑up postpartum care.
CONCLUSION: Women face many challenges in surrogacy and need special care such as legal
counseling, reproductive health care, and psychological support. Implementation of this care program
seems to help improve the reproductive health of these mothers.

Abstract BACKGROUND: Asymptomatic bacteriuria (ASB) is commonly seen during pregnancy due to the
various morphological, hormonal, and physiological changes the body undergoes. If left undiagnosed,
it can lead to conditions such as pyelonephritis and preterm delivery which could culminate in causing
maternal and fetal morbidity and mortality. Therefore, this study aims to determine the prevalence,
risk factors, microbial profile, and antibiotic susceptibility patterns associated with ASB in a tertiary
healthcare center.
MATERIALS AND METHODS: A cross‑sectional study was carried out where 150 urine samples
were obtained from pregnant women within the gestational age of 13–36 weeks. Randomized
stratified sampling was the method of sampling used. A questionnaire was also administered to
them to determine potential risk factors. The samples were cultured and identified using biochemical
tests. Antibiotic susceptibility tests were carried out by Kirby–Bauer disc diffusion method. Statistical
analysis was carried out using Chi‑square test. The graphs and tables were generated using Microsoft
Excel and Word.
RESULTS: Out of the 150 samples that were obtained, 8 samples had significant bacteriuria which
is a prevalence of 5.33%. Escherichia coli was the most frequently isolated organism accounting
to 45% of the isolates. The other organisms that were isolated were Enterococcus, Klebsiella
pneumoniae, Coagulase negative staphylococcus (CONS), Candida albicans, and Group B
Streptococcus which measured to 11% of the total distribution each. In the antibiotic sensitivity
tests, among the gram‑negative isolates, marked resistance to Ampicillin and Amoxycillin along with
sensitivity to Cotrimoxazole and Nitrofurantoin. Of the gram‑positive isolates, there was sensitivity
to Ampicillin and Nitrofurantoin. A positive correlation was seen between the age groups of 23–27
and the prevalence of ASB.
CONCLUSION: The prevalence of ASB in this study shows that ASB is not uncommon in the
population. Despite the World Health Organization (WHO) guidelines and National Health Mission
recommendations to make urine check‑ups a routine, it not carried out, possibly due to cost
implications. However, it poses a risk for severe maternal and fetal outcomes and hence, should be
screened for on a regular basis. Thus, this study emphasizes the importance of screening pregnant
women for ASB for promoting better maternal and fetal health.

Abstract BACKGROUND: Mother–child attachment is formed from early stages of pregnancy and peaks in
the second trimester and continues until after childbirth. The fetal or neonatal death as a tragic event
could lead to the grief experience among parents, especially mothers. The present study aimed to
determine the effect of a coping program on mothers’ grief following perinatal deaths.
MATERIALS AND METHODS: This trial study was performed on 56 women with the experience of
perinatal death during the last 1–3 months with a score of Perinatal Grief Scale (PGS) ≥91, who
were referred to the health centers of Tabriz, Iran, from September 2020 to June 2021. Participants
were randomly assigned into the intervention and control groups through stratified blocking on the
basis of the stillbirth and neonatal death using Random Allocation Software with a block size of 4
and 6 with a ratio of 1:1. The intervention group received a coping program individually during three
sessions, once a week for 45–60 min. Data collection tools included the demographic and obstetric
characteristic questionnaire and PGS. The data were analyzed using SPSS24. The groups were
compared through t‑test, and ANCOVA after adjusting the effect of baseline score.
RESULTS: Prior to coping program, the mean standard deviation of the grief total score was
108.32 (14.31) in the intervention group and 107.92 (6.65) in the control group (P = 0.89). After
coping program, the mean of the grief total score was 82.28 (16.72) in the intervention group and
101.05 (12.78) in the control group. After adjusting the effect of baseline score and stratified factors,
the mean of the grief total score in the intervention group was significantly lower than that in the
control group [Adjusted mean difference (AMD): −18.77, 95% confidence interval: −26.79 to − 10.75,
P ≤ 0.001].
CONCLUSION: Conducting a coping program during 1–3 months after experiencing perinatal deaths
is effective in reducing the mothers’ grief reactions. It is recommended to evaluate the effectiveness
of the same intervention after perinatal deaths for both parents with a longer follow‑up period in
further studies.
BACKGROUND: Mother–child attachment is formed from early stages of pregnancy and peaks in
the second trimester and continues until after childbirth. The fetal or neonatal death as a tragic event
could lead to the grief experience among parents, especially mothers. The present study aimed to
determine the effect of a coping program on mothers’ grief following perinatal deaths.
MATERIALS AND METHODS: This trial study was performed on 56 women with the experience of
perinatal death during the last 1–3 months with a score of Perinatal Grief Scale (PGS) ≥91, who
were referred to the health centers of Tabriz, Iran, from September 2020 to June 2021. Participants
were randomly assigned into the intervention and control groups through stratified blocking on the
basis of the stillbirth and neonatal death using Random Allocation Software with a block size of 4
and 6 with a ratio of 1:1. The intervention group received a coping program individually during three
sessions, once a week for 45–60 min. Data collection tools included the demographic and obstetric
characteristic questionnaire and PGS. The data were analyzed using SPSS24. The groups were
compared through t‑test, and ANCOVA after adjusting the effect of baseline score.
RESULTS: Prior to coping program, the mean standard deviation of the grief total score was
108.32 (14.31) in the intervention group and 107.92 (6.65) in the control group (P = 0.89). After
coping program, the mean of the grief total score was 82.28 (16.72) in the intervention group and
101.05 (12.78) in the control group. After adjusting the effect of baseline score and stratified factors,
the mean of the grief total score in the intervention group was significantly lower than that in the
control group [Adjusted mean difference (AMD): −18.77, 95% confidence interval: −26.79 to − 10.75,
P ≤ 0.001].
CONCLUSION: Conducting a coping program during 1–3 months after experiencing perinatal deaths
is effective in reducing the mothers’ grief reactions. It is recommended to evaluate the effectiveness
of the same intervention after perinatal deaths for both parents with a longer follow‑up period in
further studies.
Keywords:
Bereavement, grief, perinatal death, stillbirt

Abstract BACKGROUND: Patients diagnosed with cancer and who undergo cancer treatment are at potential
risk of bone marrow suppression leading to prolonged hospitalization, delay in treatment, and
chemotherapy dose reductions, which ultimately results in significant morbidity and mortality. This
sequential exploratory study using a mixed‑method approach was aimed to develop and validate a
neutropenic nursing care (NNC) bundle for neutropenic patients admitted in a tertiary care hospital,
Uttarakhand.
MATERIAL AND METHODS: This sequential exploratory study design with an instrument
developmental model was used to develop the NNC bundle. It consisted of two phases: Qualitative
phase and quantitative phase. In the qualitative phase, focused group discussion with eight oncology
nurses was performed to derive themes related to neutropenic nursing care using conventional
content analysis. An extensive literature review was also performed on these themes to explore the
current pieces of evidence for item pool generation. In the quantitative phase, a preliminary draft
bundle was developed, and two Delphi rounds (I and II) were carried out among the five experts for
the content validation of the NNC bundle and a final bundle was developed.
RESULTS: Major domains identified for the bundle were hand hygiene, care of central and peripheral
lines, routine oral care, antiseptic bath, peri‑anal care, diet, and environmental hygiene. The
content validity index (CVI) of the bundle was found to be >80% for all the items with I‑CVI >0.8 and
S‑CVI = 0.99 after conducting two rounds of Delphi.
CONCLUSION: The present study has provided a set of valid written neutropenic nursing interventions
to prevent complications in neutropenic patients. The NNC bundle should be subjected to other levels
of evaluation that measure the bundle’s practicability and suitability for the intended field.