Journal of Education and Health Promotion

Abstract BACKGROUND: Perceived stress is one of the causes of preeclampsia; one of the ways to manage 
mental stress is hypnosis. The aim of this study was to determine the effect of hypnosis on perceived 
stress in women with preeclampsia.
MATERIALS AND METHODS: This randomized clinical trial was performed on 80 (40 people in each 
group) pregnant women 28–32 weeks with preeclampsia and hospitalized in two public hospitals in 
Mashhad in 2020. The Cohen Perceived Stress Questionnaire was first completed in two groups. 
Then, in the intervention group, three half‑hour sessions of hypnosis were performed with an interval 
of 3 days (hypnosis consists of three sessions: each session is held for three consecutive nights). 
After each session, the intervention package, which included recording the dialogs of each session 
for posthypnotic suggestion, was delivered to the mothers on a CD to listen to every night before 
bed. The control group received routine care. Then, 2 weeks after the intervention, the Perceived 
Stress Questionnaire was completed by both groups. The results were analyzed by independent 
t‑test, paired t‑test, Mann–Whitney, Chi‑square, Friedman and covariance tests, and by SPSS 16.
RESULTS: At the beginning of the study, there was no statistically significant difference between 
demographic characteristics and the perceived stress score before the intervention between the two 
groups (P > 0.05). However, after the intervention, the mean perceived stress score was a statistically 
significant difference between the intervention and control groups (P = 0.005). Perceived stress after 
the intervention was significantly reduced in the intervention group, which was significant between 
the two groups.
CONCLUSION: Perceived stress in mothers with preeclampsia is reduced by hypnosis.

Abstract BACKGROUND: Behavioral addiction to smartphones is a common phenomenon in the present 
digital age, wherein indulgence in these devices is compulsive and impacts physical, social, and 
psychological health of the population. The smartphones effect on a dental student’s life is detrimental 
to their academics, health, and efficiency in providing clinical patient care. To assess use and addiction 
of smartphones among dental students under six major domains and to compare this based on their 
gender, ethnicity, and year of study.
MATERIALS AND METHODS: A cross‑sectional study using a validated questionnaire, Smartphone 
addiction scale was conducted among 349 undergraduate students (N = 349) at a private dental 
school in Malaysia.
RESULTS: Overall results are presented as mean scores under six domains with total score as 
142.40 (33.65). The total scores compared between two genders did not show statistical difference, 
however on comparing individual domains, females (25.25) had higher mean score for daily life 
disturbance (P = 0.013) and males (30.17) for cyberspace‑oriented relationship (P = 0.001). 
Chinese students had higher scores with respect to withdrawal (32.45) and cyberspace‑oriented 
relationship (29.48) as compared to other ethnicities. Year 4 students show higher scores than other 
years in daily life disturbance (27.44), tolerance (16.81), and overuse (16.51).
CONCLUSION: Our research presents the extent and pattern of smartphone of usage and addiction 
among the undergraduate students at a dental school in Malaysia. The indicators of addiction 
highlighted in the study are pivotal in spreading awareness regarding this overuse and addiction as 
well as planning further research in this area.

Abstract BACKGROUND: Human anatomy instruction is mostly focused on cadaver dissection and prosected 
specimen examination. Exposure to cadaver dissection can be a stressful experience that may cause 
a wide variety of symptoms among students of health sciences. To compare and evaluate the effect 
of in‑vitro and in‑vivo exposure on cadaveric anxiety, disgust propensity and sensitivity, and attitude 
toward death and dying among 1st‑year medical and nursing students.
MATERIALS AND METHODS: An open‑label randomized trial (matched‑control experimental 
design) was conducted among 127 1st‑year Medical and Nursing students from a selected Institute of 
National Importance, Bhopal, India during 2015. The participants were divided into an experimental 
and control group based on matched trait anxiety scores using the Trait Anxiety Inventory. Followed 
by preassessment, video demonstration with cadaver dissection (in vitro exposure) was then 
administered to the experimental group, while the control group had direct exposure to cadaver 
dissection (in vivo exposure).
RESULTS: The study showed that there was a statistically significant difference in state anxiety 
related to cadaver dissection in the experimental group (P = 0.01). However, video‑demonstration of 
cadaver dissection did not have any effect on disgust propensity and sensitivity and attitude toward 
death and dying.
CONCLUSION: The findings provided evidence that video‑demonstration of cadaver dissection 
reduced anxiety, although it did not have any effect on disgust and attitudes of death. The dissection 
hall experience may evoke feelings of anxiety and disgust that need to be addressed through advanced 
preparedness and coping strategies, especially among medical and nursing students.

Abstract BACKGROUND: In the ongoing COVID‑19 pandemic, facemask use has been the most feasible 
public health measure in preventing transmission of SARS‑CoV2 with the dual benefit of controlling 
the source of infection and decreasing the risk of acquiring infection from infected people. Therefore, 
COVID‑appropriate behavior regarding facemask use is imperative for controlling the pandemic. This 
study aimed to assess COVID‑appropriate mask behavior and factors associated with it among the 
patients attending outpatient departments of a public health institute in West Bengal.
MATERIALS AND METHODS: This cross‑sectional study was done among 298 patients attending 
outpatient departments of Rural and Urban Health Units of a public health institute of Kolkata, during 
October 2020–February 2021. A pretested questionnaire and an observational checklist based on the 
World Health Organization guidelines were used to collect data. COVID‑appropriate mask behavior 
was assessed by a five‑point domain‑wise scale, where good practice regarding facemask usage 
was considered when the score was three or more. Statistical analyses were done in SPSS 16.0.
RESULTS: Good practices regarding COVID‑19 appropriate mask‑related activities were recorded 
among 30.2% of the study participants. No difficulties faced during or on wearing a mask (adjusted 
odds ratio [AOR] = 1.86, 95% confidence interval CI: 1.1–3.33) and higher socioeconomic 
status (AOR = 2.25, 95% CI: 1.22–4.15) were significantly associated with good practice regarding 
COVID‑19 appropriate facemask usage.
CONCLUSION: The magnitude of poor practice regarding COVID‑appropriate mask‑related behaviors 
is quite high among the study participants. Awareness regarding correct mask handling, storage, 
hygiene, disposal, and place of wearing from a reliable source would go a long way to curb the myths 
and misinformation surrounding mask usage and encourage COVID‑appropriate mask behaviors 
among the general population.

Abstract BACKGROUND: Coronavirus disease (COVID‑19) is a respiratory illness caused by a novel 
coronavirus which can spread from person to person. Health‑care workers of any medical college 
and hospital are at more risk to the coronavirus disease (COVID‑19) than the general population. 
The aim of this study was to assess the epidemiological profile of confirmed COVID‑19 cases among 
health‑care workers of Municipal Corporation of Delhi.
METHODOLOGY: A cross‑sectional study was planned among 422 health‑care workers of Municipal 
Corporation of Delhi. The questionnaire consisted of questions about sociodemographic data, personal 
history, and clinical profile such as signs and symptoms and their duration. Data were analyzed by 
SPSS software version 21.0, and, Chi‑square test and logistic regression were used.
RESULTS: Mean age of study subjects was 41.1 ± 9.8 years, and males (57.6%) were more as 
compared to (42.4%) females. Out of total participants, about one‑third (36.4%) of study participants 
were asymptomatic. Study participants with higher education status adjusted odds ratio (AOR) 
2.43 (1.25–4.70), living in overcrowding AOR 3.74 (1.86–7.54), and having some comorbidity AOR 
2.78 (1.57–4.92) were at higher risk of being symptomatic.
CONCLUSION: This study concludes that about one‑third of study participants were asymptomatic. 
Factors such as higher education status, living in overcrowding, presence of some comorbidity, and 
smokeless tobacco consumption were significantly associated with symptomatic COVID‑19 cases. 
Hence, there is a need to identify these risk factors at an early stage in order to design prevention 
strategies for better control of such pandemics in future.

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: The human coronavirus was first identified in 1965, belongs to the same family 
of Viruses as SARS, MERS‑Co. The current virus that affected worldwide came into existence 
in late 2019, recently found in Wuhan, China, and caused a global pandemic called coronavirus 
disease‑2019 (COVID‑19). This disease became a quick global pandemic due to the rapid 
transmission of the virus from one human to another. In the history of humankind, people were inside 
the four walls for more than a month. The COVID‑19 pandemic has posed significant problems in a 
variety of fields. The current pandemic created many changes that are seen as challenges worldwide. 
However, it created opportunities and benefits for many, extend a helping hand towards the people 
in need, in the society, community, and the nation. This paper focuses on challenges, opportunities, 
and benefits during the (COVID‑19) pandemic in India.
MATERIALS AND METHODS: Online search engines like PubMed and Google Scholar were used to 
conduct the research. The review article’s dates were not restricted in any way. A total of 48 articles 
were chosen. The data was tabulated based on the kind of study and the outcomes. There are just 
a few papers available that demonstrate the necessity for more study.
RESULTS: COVID‑19 caused unforeseen changes in the health care industry, unequal distribution of 
health care, and consequences on mental health, according to the review studies. Teleconsultation, 
Internet use, and E‑learning have all become more accessible. A period of transitory economic 
collapse and an increase in the number of migrants left many despondent. Improvement in family 
bonding, use of a face mask, and hygiene measures to adapt to the current scenario. There was also 
an impact on water sources, waste management systems, and environmental resource conservation.
CONCLUSION: Difficult conditions can provide both problems and opportunities and advantages to 
the people during a pandemic outbreak.

Abstract BACKGROUND: In curriculum reforms under Competency‑Based Medical Education (CBME) 
introduced by the National Medical Commission, medical students are recognized as one of the 
stake holders. The well‑designed multiple‑choice questions (MCQs) help students in assessment 
as well as promote deep learning. The objective of this study is to assess the perceptions of the 
Indian medical students towards the examination patterns in their undergraduate curriculum with 
particular reference to MCQs.
MATERIALS AND METHODS: An observational cross‑sectional study was conducted among the 
medical colleges in India. A total of 7875 students took part in the study. The study instrument was 
a validated pretested self‑administered questionnaire. The study was conducted as an online survey 
using the Google Forms platform. Inclusion criteria were students from all professional years as well 
as interns and those who were willing to participate in the study.
RESULTS: For the question of initiation of MCQs as a tool for the assessment, many of the 
students (46%) expressed that it should start from the 1st MBBS itself. The majority of the 
students (85%) felt that MCQ oriented preparation will be helpful for MBBS professional (theory and 
practical) examinations. Most of the students (90.9%) preferred that the MCQs should be concept 
and case scenario based. To the question of whether the current system of the university theory 
examinations of essays and short notes be replaced in total with MCQs so that they are more prepared 
for NEXT and USMLE examination, 65.5% responded with an answer of yes.
CONCLUSION: The findings of this study provide input to the regulatory authorities and other 
stakeholders responsible for designing and implementing the medical curriculum.

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: Nongovernmental organizations (NGOs) as entities out of the health sector can 
play various roles and functions at different levels of the health systems. The present study was 
conducted to investigate NGOs’ potential and actual functions in Iran’s health system.
MATERIALS AND METHODS: This exploratory study was carried out in two parts from April 2020 
to December 2020 in Tehran, Iran. For the first part, the statute of 65 NGOs was used for document 
review, and in the second part, the required data were collected using semi‑structured interviews 
with 26 key informants from the governmental sector and NGOs. Data were analyzed using the 
framework analysis method and MAXQDA software.
RESULTS: According to data analysis, the results of this study were classified into two sections 
of NGOs’ current functions and expected functions in Iran’s health system. The current functions 
of NGOs in Iran’s health system include service delivery, educational, research, and information 
activities, financing, supportive and facilitation activities, and advocacy. Other functions in which 
NGOs could play a role include health system management, education, and service providing and 
support activities.
CONCLUSION: In this study, the various roles of NGOs in Iran’s health system were explained. 
NGOs can act actively as the consulting and executive hand alongside the public sector in the lowest 
to the highest levels of Iran’s health system. Hence, health sector managers and policymakers must 
facilitate NGOs’ involvement in the health sector and use their capacities and capabilities to improve 
health and increase public access to health‑care services.

Abstract BACKGROUND: Since the beginning of the COVID‑19 outbreak, a significant number of mobile 
health apps have been created around the world and in Iran to help consequence reduction of this 
emerging pandemic.
OBJECTIVES: This study aimed to review the characteristics of Persian Android and iOS apps 
related to COVID‑19 and determine their use‑cases based on a reference model.
METHODS: This was a cross‑sectional descriptive study conducted in three main steps. First, a 
systematic search was conducted via Iranian mobile apps’ markets using the keywords related to 
COVID‑19 in January 2021. Then, the retrieved apps were analyzed according to their characteristics. 
Finally, the use‑cases of the given apps were determined and categorized based on a reference model.
RESULTS: Based on our inclusion criteria, 122 apps were selected and evaluated. Most of these 
apps (87.7%) was free. Small proportions (5%) of reviewed apps have been developed with 
participation of clinical expert and half of the apps mentioned the references they used. Furthermore, 
about half of the apps (50.8%) were provided contact information of the developers. The studied 
apps were classified into four use‑case major categories, including educational (98%), fulfilling a 
contextual need (18%), communicating, and/or sharing the information (0.83%), and health‑related 
management (2%).
CONCLUSION: The results showed that the Persian mobile apps for COVID‑19 are not in a satisfying 
situation. Furthermore, although these apps are significant in quantity but in terms of use‑cases, 
they are not widespread.

Abstract BACKGROUND: Teachers’ knowledge and awareness about the signs and symptoms, behavioral 
problems, and treatment are imperative to handling children with attention‑deficit/hyperactivity 
disorder (ADHD) in the school. This study aimed to assess the level of knowledge about ADHD 
among primary schoolteachers in Sharjah, UAE.
MATERIALS AND METHODS: In this cross‑sectional study, a convenient sampling method was used 
to collect data from 239 teachers working in private schools and 25 teachers working at the public 
schools in Sharjah. A self‑administered questionnaire was used to measure the sociodemographic 
characteristics and the Knowledge of Attention‑Deficit Disorders Scale was used to measure the 
knowledge about ADHD. Data were analyzed using both descriptive and inferential methods.
RESULTS: Private schoolteachers have more knowledge about ADHD than public 
Schoolteachers (P = 0.016). Teachers obtain information about ADHD through educational 
workshops (32%), social media (23%), friends and relatives (12%), TV and radio (9%), scientific 
journals (8%), campaigns (7%), and other sources (9%) such as the Internet, lectures, personal 
experience, and reading. Most of the teachers (56.3%) have knowledge about the signs and symptoms 
of ADHD, whereas teachers’ knowledge about the associated features and treatment of ADHD is 
34.4% and 34.1%, respectively.
CONCLUSION: Teachers’ level of knowledge about ADHD‑associated features and treatment was 
inadequate in Sharjah. Hence, enhancing knowledge about ADHD by providing various training 
workshops and conducting social events, and campaigns are warranted to enhance their knowledge 
on ADHD.

Abstract BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a considerably common 
childhood‑onset neurodevelopmental disorder, often associated with socio‑behavioral and academic 
difficulties. There is an increased risk for development of a range of future problems such as 
psychiatric disorders, difficulties in employment, and relationships. The aim of this study was to know 
the prevalence and determinants of ADHD among primary school children in district Dehradun and 
to assess the learning difficulties and classroom behavior in these students.
MATERIALS AND METHODS: In this cross‑sectional study, overall, 228 students (aged 6–12 years) 
studying in a primary school were assessed for ADHD after seeking the written informed consent from 
their parents. The data were analyzed using Excel sheet and SPSS software (22.0 version). For all 
qualitative measures, frequency and percentages were calculated, and for quantitative measures, 
mean and standard deviation were calculated. For analysis of categorical values, Chi‑square test 
was used. P < 0.05 was considered statistically significant.
RESULTS: The prevalence of ADHD was found to be 11.8% based on the teacher tool only and 
1.75% based on the parent and teacher tools combined. ADHD was found to be significantly more 
in males. Inattention was the most prevalent subtype of ADHD, and children screened positive for 
ADHD had significant learning difficulties at various levels.
CONCLUSION: The possibility of ADHD in students with academic difficulties should not be ignored 
as children with ADHD usually face significant problems at school such as learning difficulties and 
have been shown to be at increased risk for a broad range of negative outcomes. Early identification 
and treatment of ADHD can significantly reduce the rates of some of these poor outcomes. Screening 
these children in the early years will help the parents, children, teachers, and community at large.

Abstract For a successful treatment process, the medical team members must be in good physical and mental 
condition. Pathologists are one of the main modern medicine members that should be consulted 
in all stages of the treatment procedure. Sixty‑six percent of clinical decisions are made based on
in vitro diagnosis. Burnout is defined as chronic uncontrolled occupational stress. Burnout has a 
massive impact on patient safety, quality of treatment, and reduced patient satisfaction. Physician 
satisfaction with his job affects patient satisfaction and the quality of medical services provided. The 
most influential factors on quality of life were exercise and physical activity, having leisure time, and 
not smoking. In different aspects of lifestyle, physicians have scored lower on their physical activity 
index. One of the most critical pillars of human life is their religiosity. The presence of religious beliefs 
among physicians is strong. Workload and increased responsibilities are the most effective factors 
on pathologists’ stress. Pathology creates a bridge between basic sciences and clinical sciences. 
Therefore, promoting pathology education leads to training better physicians. The purpose of 
compiling this Narrative review is to clarify the issues raised in various aspects of pathologists’ lives 
and provide solutions to improve each of them. There are several solutions to the problems raised in 
this article: Increasing salaries, improving working conditions, creating a better view of pathologists 
by avoiding isolation and being more active and visible, and paying attention to medical education. 
We recommend that researchers review issues in other medical specialties to provide accurate and 
concise information to physicians and policymakers.

Abstract BACKGROUND: Fertility is highly valued in most cultures. In contrast, infertility as a crisis has the 
potential to threaten the stability of individuals, relationships, and communities. Many infertile people 
are at risk in the early stages of infertility treatment for health and mental health problems and severe 
stress. The present study was conducted to assess the relationship between the social health of 
infertile women and the stress of infertility treatment.
MATERIALS AND METHODS: This study was performed descriptively longitudinal correlation 
on 2020 women in infertility canters in Isfahan. Data collection tool in this study was three parts 
questionnaire. The first contained demographic information, the second was stress, and the third 
was the social health dimension questionnaire. Analyze the data was performed using the descriptive 
statistical methods for the quantitative variables Pearson correlation coefficient. P < 0.05 was 
considered significant.
RESULTS: The results showed that the mean standard deviation (SD) of social health was 
155.1 (16.46), and the mean (SD) score of treatment stress was 22.91 (7.93). Pearson correlation 
coefficient showed that treatment stress score was not significantly related to overall social health 
score and its dimensions (P > 0.05).
CONCLUSIONS: In this study, no statistically significant relationship was identified between these 
two variables. Probably, due to the living conditions of the people of our country in these years and 
the existence of stress and their great concern about economic issues, etc. The results were not 
observed contrary to the researcher’s expectations.

Abstract BACKGROUND: Delay in seeking medical help in patients with acute myocardial infarction (AMI) 
challenges the patients in terms of diagnosis and treatment. This study aimed to evaluate the outcomes 
of delay referral (≥12 h) in patients with AMI.
MATERIALS AND METHODS: In this retrospective cohort study, the medical records of 252 patients 
with AMI (2017–2019) admitted to Shahid Beheshti Hospital, Qom, Iran, was reviewed. Data 
collection tool was a researcher‑made data sheet that included demographic characteristics, times, 
hospitalization costs, risk factors, history of heart disease, results of paraclinical tests, clinical 
information at the time of admission, and outcomes of delayed referral. Data were analyzed using t‑test, 
Chi‑square, Kaplan–Meier estimator, log‑rank test, Cox regression by STATA, and SPSS (version 25).
RESULTS: The levels of troponin, creatine phosphokinase, lactate dehydrogenase were 
significantly higher in the delayed referral group (P < 0.05). After treatment, the cardiac ejection 
fraction was significantly different in the nondelayed referral (41.56 ± 9.16) and the delayed referral 
group (38.39 ± 11.01) (P < 0.001). There was no significant difference in the percentage of hospital 
deaths in the groups (P = 0.078).
CONCLUSION: Delayed referral of patients with AMI is associated with decreased physiological 
cardiac function, which complicates recovery for these patients.

Abstract BACKGROUND: The novel 2019 COVID‑19 spreads by respiratory and aerosols, and this elevates 
the risk of dentistry during this pandemic. Widespread disease, in a short time, creates stress and has 
a psychological impact. The aim of this study was planned to assess the stress level of the dentists 
living or practicing or studying in hot spots which could help to understand mental status among the 
general dentists during COVID‑19 lockdown.
MATERIALS AND METHODS: This cross‑sectional study was conducted during the period of 
August 10 to August 25, 2020, on an Internet platform after getting consent from the dentists and 
practitioners using the Perceived Stress Scale (PSS). Chi‑square association was used. Parametric 
tests such as independent t‑tests and one‑way ANOVA were also used. In all instances, P < 0.05 
was considered statistically significant.
RESULTS: This study had a total response from 1044 dental students and dentists residing in hot 
spot zones in Tamil Nadu. Out of them, 68.4% were female and 31.6% were male. 37.9% of the 
participants were dental practitioners and 32.5% were undergraduate students. There is a significant 
association between age groups and PSS, work style, and PSS. There is no significant association 
between gender and PSS and degree and PSS.
CONCLUSION: This study shows that levels of distress were higher than expected during the 
COVID‑19 pandemic among the dentists and majority of the respondents have moderate‑to‑high‑stress 
levels. As the unlock has been started throughout the country, it is the right time to work with the 
authorities and focus on formulating protocols for disinfection and sterilization and work on treating 
the patients with exact safety measures for the welfare of the patients.

Abstract Artificial intelligence (AI) is the future of surgery. Technological advancements are taking place at 
an incredible pace, largely due to AI or AI‑backed systems. It is likely that there will be a massive 
explosion or “Cambrian explosion” of AI in our everyday life, largely aided by increased funding 
and resources spent on research and development. AI has also significantly revolutionized the 
medical field. The concept of machine learning and deep learning in AI is the crux of its success. In 
surgical practice, AI has numerous applications in the diagnosis of disease, preoperative planning, 
intraoperative assistance, surgical training and assessment, and robotics. The potential automation 
of surgery is also a possibility in the next few decades. However, at present, augmentation rather 
than automation should be the priority. In spite of the allure of AI, it comes with its own price. A robot 
lacks the “sixth sense” or intuition that is crucial in the practice of surgery and medicine. Empathy 
and human touch are also inimitable characteristics that cannot be replaced by an AI system. Other 
limitations include the financial burden and the feasibility of using such technology on a wide scale. 
Ethical and legal dilemmas such as those involving privacy laws are other issues that should be 
taken under consideration. Despite all these limitations, with the way technology is progressing, it 
is inevitable that AI and automation will completely change the way we practice surgery in the near 
future. Thus, this narrative review article aims to highlight the various applications and pitfalls of AI 
in the field of surgery.

Abstract BACKGROUND: Effective clinical teaching is crucially important for patient care in future. Therefore, 
proper clinical training is essential to make physicians capable of delivering high‑quality health care.
MATERIALS AND METHODS: The present study was a cross‑sectional research. After translating 
the questionnaire into Persian, it was distributed among medical students in the clinical years of 
medical education in teaching hospitals affiliated to Ahvaz Jundishapur University of Medical Sciences 
in 2018. The System for Evaluation of Teaching Qualities (SETQ) has 25 questions in a 6‑scale 
Likert scale that evaluates clinical tutors in five dimensions of teaching and learning environment, 
professional attitude toward students, transferring of goals, evaluation of students, feedback, and 
promoting self‑directed learning. Instrument reliability was assessed by calculating the Cronbach’s 
alpha coefficient, whereas questionnaire content validity was evaluated by relative content validity 
ratio (CVR) and content validity index (CVI). To evaluate the structural validity, an exploratory factor 
analysis was conducted.
RESULTS: The SETQ was completed by 127 medical students. Cronbach’s alpha coefficient of the 
total questionnaire was estimated as 0.908. The factor analysis showed that the questionnaire was 
composed of six factors, explaining 66.14% of the total variance. The CVI and CVR indices of the 
individual items were also acceptable.
CONCLUSION: The findings of our study showed that the Persian version of SETQ questionnaire had 
the acceptable reliability and validity to be used in assessing clinical tutors in different hospitals in Iran.

Abstract BACKGROUND: Daily consumption of fruit and vegetable (F and V) can effectively reduce the 
risk factors of cardiovascular diseases; therefore it is necessary to identify the factors affecting 
this behavior. This study aimed to determine the Predictive Power of Pender’s Health promotion 
model (HPM) constructs in F and V consumption behavior and the effects of some background 
variables on this behavior.
MATERIALS AND METHODS: A descriptive‑correlation study was conducted on 418 employees 
working in different offices of Qaemshahr, Mazandaran Province from April 8, 2019, to July 23, 2019. 
The participants filled out a questionnaire about perceived F and V Consumption behavior based 
on Pender’s HPM Constructs. The data were statistically analyzed by descriptive statistics and 
parametric tests, including the Pearson correlation, Independent– Sample t‑test, One‑Way analysis 
of variance test, and multiple linear regression, in SPSS‑22.
RESULTS: The mean age of participants was 40.25 ± 7.56 years. The results showed that F 
and V consumption behavior was positively correlated with some constructs of Pender’s HPM 
including, behavioral outcome (r = 0.51, P < 0.001), previous related behavior (r = 0.48, P < 0.001), 
commitment to action (r = 0.47, P < 0.001), perceived self‑efficacy and behavior‑related 
emotions (r = 0.39, P < 0.001). Behavioral outcome alone explained 26% of the dependent variable 
changes (F and V consumption behavior). The results also indicated that there was a significant 
relationship between gender and F and V consumption behavior (P = 0.01).
CONCLUSION: The study findings demonstrated that some of Pender’s HPM Constructs could predict 
F and V consumption behavior. Behavioral outcome alone was a strong predictor of this behavior. 
Therefore, in addition to background variables, these constructs should be taken into account in the 
development of training interventions and courses.

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

Abstract BACKGROUND: There is limited research on sexual and reproductive health (SRH) knowledge level 
among very young adolescents aged between 10 and 14 years. Policy makers and educators are 
unable to address very young adolescents’ SRH needs without proper understanding of their SRH 
knowledge. Thus, the objective of this study is to explore very young adolescents’ SRH knowledge 
level and the influences of demographic variables on the respondents’ SRH knowledge level in 
Malaysian primary schools.
MATERIALS AND METHODS: This cross‑sectional study involved 617 primary five students who were 
recruited through multistage sampling method from the state of Johor, Malaysia. A self‑administered 
questionnaire (Cronbach’s α = 0.81) which comprised of 38 items related to puberty, HIV/AIDS 
and sexually transmitted diseases, prevention of child sexual abuse and reproductive systems 
and reproduction was used. Multivariate logistic regression analysis was applied to examine the 
association between demographic variables and student’s SRH knowledge.
RESULTS: Based on the results, 28.5% of the respondents had unsatisfactory level of SRH 
knowledge. Among the four dimensions, the respondents had more knowledge on prevention of 
child sexual abuse but displayed poorer knowledge on HIV/AIDS and sexually transmitted diseases 
topic. The findings indicated female (odd ratio [OR] = 1.464) and Indian respondents (OR = 3.208) 
are more likely to exhibit poor SRH knowledge which suggested demographic factors exert some 
extent of influence on primary school children’s SRH knowledge.
CONCLUSION: The findings provide useful insights for the policy makers and educators seeking 
to improve the comprehensiveness of culturally accepted sexuality education which are essential in 
promoting young adolescents’ well‑being.

Abstract BACKGROUND: Research is a core essential component of evidence‑based medicine. The current 
study was undertaken to sensitize the undergraduate medical students the concept of biomedical 
research to sharpen their clinical skills.
MATERIALS AND METHODS: This educational interventional study was done with a systemic 
random sample of 120 medical students in a tertiary care hospital. A workshop on biomedical research 
was conducted by the institutional ethics and medical education committee members followed by 
group activity regarding how to write the protocol of a research study. The protocols were then 
assessed using prestructured checklist by facilitators and feedback from the students and facilitators 
were assessed using student t‑score.
RESULTS: The pretest (5.86 ± 1.75) scores and posttest scores (11.82 ± 2.47) of multiple choice 
questions and open‑ended questions showed statistically significant difference. The feedback of 
students showed that 49.48% of students strongly agreed that contents discussed in the workshop 
were adequate, 61.85% agreed about better understanding of the topics of the workshop, 60.80% 
agreed that their queries and doubts are cleared, 53.6% agreed that the workshop motivates them 
to do research, and 44.3% agreed that they will attend the similar workshops in future. The protocols 
submitted by groups of students using the checklist showed 26%–80% scores.
CONCLUSION: The student’s knowledge on research methodology was significantly improved and 
teaching basic research methods to medical students at an early stage motivates the student to do 
research.

Abstract BACKGROUND: Forecasting the future trend of health expenditures is an important step toward 
sustainable financing of health‑care systems. This study aims to develop a conceptual framework 
for forecasting Iran health spending growth.
MATERIALS AND METHODS: At first, we concentrated on the general model and conceptual 
framework of health expenditure projection by reference to a broad literature review and smart 
classifications of the origins of health spending and indicators. At the second step, we developed a 
time series modeling for econometric estimation and forecasting national health expenditure without 
restrictive assumptions except for current laws and regulatory environment. In the third step, we 
tested the accuracy of model by forecasting Iran real per capita health expenditures (2017–2025).
RESULTS: The results of the literature review represented a distinct classification of the origins 
of health spending and indicators, applicable to any health system and health spending projection 
model. Furthermore, the model of expenditure forecasting shows the power of certainty of no spurious 
estimation, assessment of the normal state of a health system, and test of the accuracy of forecasting 
results. The projection by the Iranian health system database showed that the real per capita health 
spending will grow 43 percent till 2025 in the absence of any unforeseen disturbance in the future.
CONCLUSIONS: The presented model provides estimates that are compatible with actual trends of 
health spending and can be applied to forecast health expenditure in the near future. The forecasted 
image of Iran’s health spending growth implies that health authorities need to concentrate more on 
the growth rate of the health budget and its fiscal space in the near future.

Abstract BACKGROUND: Natural delivery is distressing, and the mother’s anxiety in this condition can have 
negative impacts on the fetus, mother, and the delivery process. Hence, many women tend to use 
pharmacological or nonpharmacological methods for reduction of labor stress and anxiety. The aim 
was to assess the effect of supportive care and acupressure during labor on the mother’s anxiety 
level and arterial oxygen pressure of the umbilical cord of infants.
MATERIALS AND METHODS: This performed on 150 pregnant women were randomly assigned 
to two interventions and a control group in the delivery ward of the selected educational center of 
Shiraz University of Medical Sciences (Shoushtari Hospital) in Iran. Mothers’ anxiety scores before 
(beginning of the active stage of labor) and after intervention (the end of the first stage of labor) were 
measured using Spielberger’s questionnaire. Then, infants’ cord blood samples for arterial blood 
gas and hematologic analyses were sent to the hospital’s laboratory. After all, the data with SPSS 
version 16 and using Pearson’s correlation coefficient, one‑way ANOVA, were analyzed.
RESULTS: The mean of anxiety score in the control group was 21.1% and in the supportive group 
and the acupressure group, respectively, decreased by 37.5% and 34.8%, respectively (P < 0.001). 
The mean of PO2
 was also reported in the maternal supportive, acupressure, and control groups, 
40.4 ± 8.8, 27.4 ± 2.8, and 18.1 ± 3.7, respectively. Additionally, a significant correlation was found 
between mothers’ anxiety scores after the intervention and the mean of PO2 (P = 0.014).
CONCLUSION: The supportive care and acupressure at BL32 acupoint reduced mothers’ anxiety 
and consequently improved fetal oxygenation. Therefore, these methods are recommended to be 
used during labor for improving birth outcomes.

Abstract BACKGROUND: The extent and complexity of knowledge in the field of medicine necessitate 
modern education systems. Rational performance in the education system depends on the synergy 
of educators through knowledge sharing as the basis of education. The aim of this study was 
to investigate the knowledge‑sharing strategies in clinical education and its changes during the 
COVID‑19 pandemic.
MATERIALS AND METHODS: The content analysis was conducted in 2019 at Birjand University 
of Medical Sciences. Twenty‑seven clinical instructors with enough experience and knowledge in 
the field of clinical education were chosen based on purposive theoretical sampling. Data collection 
was done by semi‑structured interviews, which continued until data saturation. The interviews were 
recorded, transcribed, and read several times to obtain a whole understanding. Next, the meaning 
units and initial codes were identified, and then, they were classified into subcategories and categories. 
To ensure the trustworthiness of the data, Lincoln and Guba criteria were considered.
RESULTS: The results of the study include five pedagogical knowledge‑sharing strategies: 
“peer‑helping, clinical education workplace,” “use of cyberspace,” “student mediation,” “working 
teams,” and “scientific communities.” Coronavirus pandemic was identified as the “facilitator” and the 
“culturalization factor” of knowledge sharing. In addition, “lack of shared knowledge management,” 
“lack of compliance with needs,” and “dispersion of content” were considered as barriers to the 
efficiency of pedagogical knowledge sharing during the coronavirus pandemic.
CONCLUSIONS: Sharing knowledge in a clinical education setting could continue by various 
strategies. The results can be used in planning for the professional development of professors.

Abstract BACKGROUND: The ongoing coronavirus disease 2019 (COVID‑19) pandemic induced the 
governments around the world to impose harsher preventive measures like stay at home order, 
lock down etc., to contain the spread of infection. This measure increased the stress of the general 
population through isolation of masses, loss of employment, and loss of recreation. There is a dearth of 
quality data showing anxiety levels among the population and association of novel nonpharmaceutical 
measures such as online meditation with it.
MATERIALS AND METHODS: The study is a cross‑sectional comparative study based on an online 
survey. The study population included 74 adult participants, out of which 30, included in the study 
group were attending structured online meditation sessions and 44 of the participants as a comparison 
group after matching age, gender, location of residence, and socioeconomic status. The data was 
collected using self‑administered questionnaire. Multiple logistic regression was applied to ascertain 
factors contributing to the anxiety levels of the participants.
RESULTS: Both the groups of participants were comparable in terms of their demographic 
characteristics. The mean generalized anxiety disorder (GAD 7) score among the participants of 
online meditation program was significantly lower as compared to those not attending any online 
meditation. 6.7% of the participants of online meditation had GAD 7 score more than 10 as compared 
to 13.6% among the comparison group (P value 0.7).
CONCLUSION: “At home” mental health promotion measures such as structured online meditation 
can serve an important role in mitigating the mental health impact of COVID‑19 pandemic on the 
community. Further researches are needed to assess the feasibility and effectiveness of such 
measures.

Abstract BACKGROUND: The depression, anxiety, and stress is a major educational problem among 
students all around the world. The purposes of this study were to determine the depression, anxiety, 
and stress among the high school adolescent children in public and private schools in Rangareddy 
district, Telangana state.
MATERIALS AND METHODS: The present study was a cross‑sectional study. The study sample 
considered 120 children from private schools and 259 children from public schools were studied. The 
study tool used was a questionnaire containing DASS (Depression, Anxiety, and Stress scale and 
sociodemographic characteristics. The data were expressed as proportion and mean values (Analysis 
of variance, independed t‑test, and Pearson correlation) spatially tests were used at a significance 
level of P < 0.05).
RESULTS: The overall prevalence of depression in children from the public school was found to 
be only 5%, that of anxiety was 20.8%, and that of stress was 15.8%; the overall prevalence of 
depression in children from private schools was found to be 1.9%, that of anxiety was 20.5%, and 
that of stress was 20.1%.
CONCLUSION: In both schools, anxiety and atress were found to be more among study participants. 
Depression was observed to be less. But if they have more anxiety and stress and if not taken proper 
care at this point of time, it might get converted into a state of Depression.

Abstract Role of clinical skill training in the formation of skills and professional competencies of midwifery 
students is important. Hence, the use of “training new methods are essential in clinical settings.” This 
study aimed at determining the effectiveness of simulation training in obstetric emergencies. In this 
meta‑analysis study, international databases of Web of Science, Scopous, Proquest, and PubMed 
and Iranian databases such as Irandoc, Magiran, and SID were searched for studies published 
between 2000 and 2020 using related keywords. Based on the consortium checklist, the full text of the 
selected articles was reviewed and in case of a specific score, the article was analyzed. The results 
show that, out of 420 studies after applying the inclusion and exclusion criteria, only nine clinical 
trial articles were reviewed. Studies were conducted in Iran, the United States, France, China, and 
Chicago. The results of meta‑analysis showed that the simulation training method can be effective 
in managing midwifery emergencies. Hence, the use of simulation training method can be effective 
in various areas of learning related to obstetric emergencies.

Abstract BACKGROUND: Even in an era of automation and digitalization, Manual Material Handling (MMH) 
can be called the most common industrial task. The aim of this study was to evaluate the prevalence 
of musculoskeletal disorders (MSDs) induced by manual handling tasks on the workers of a printing 
factory in Tehran in 2017 and then to evaluate the effectiveness of a training intervention based on 
health promotion.
MATERIALS AND METHODS: This study had quasi experimental design and was conducted on 
40 men. First, demographic data were collected and the Nordic questionnaire was used to determine 
the prevalence of MSDs in workers. Then, MMH tasks were assessed using Manual Handling 
Assessment Chart (MAC). A short training course was designed to promote health. Finally, the same 
MMH tasks were re‑evaluated 3 months after the training intervention.
RESULTS: Among the various tasks, the highest prevalence of work‑related MSDs (WMSDs) was 
observed in the lower back (77.5%) and shoulder (62.5%). Based on the final scores of the MAC 
method, the jobs that received the highest scores were cutting (individual lifting), with 22 scores and 
action level “immediately necessary,” cutting (individual load carrying), with 15 scores with action 
level “urgently needed.” Arranging the forms (individual lifting) received a similar score. After the 
training intervention, the estimated risk level reduced by 12, 9, and 6 points, respectively, reaching 
a safe action level, i.e., “necessary in the future.”
CONCLUSION: The results demonstrated that educational interventions might be equally effective in 
low‑technology work environments. More in general, the MAC method can be used to make informed 
planning of educational interventions against WMSDs risk in MSDs. This health promotion approach 
is critical for care of human recourse.

Abstract BACKGROUND: Eating disorders (EDs) can lead to life‑threatening nutritional deficiencies whereas 
self‑esteem influences interpersonal relationships and academic performance. Excessive concerns 
about body image resulting in body dissatisfaction not only affect psychological well‑being but also 
predisposes to disordered eating behaviors. The objective of this study is to assess the eating 
behavior and level of self‑esteem, their relationship with body image perception and also identify 
factors associated with them among undergraduate female college students.
MATERIALS AND METHODS: This cross‑sectional study was conducted among 180 female 
undergraduate students of University of Delhi. Sociodemographic characteristics and anthropometric 
measurements were recorded. Eating Attitude Test‑26, Rosenberg Self‑esteem Scale, Contour 
Drawing Rating Scale and Body Shape Questionnaire 34 were used to assess eating behavior, 
self‑esteem, body image dissatisfaction and body shape concerns, respectively. Both descriptive 
and inferential statistics were used and binary logistic regression was applied to identify the factors 
determining high risk eating behavior and low self‑esteem.
RESULTS: In this study, 27.8% of the study participants were overweight or obese, 30.6% had body 
shape concerns and 76.7% had body image dissatisfaction. Significant proportion (13.9%) of the 
participants was identified as high risk for the development of EDs and having low self‑esteem (12.8%). 
Body shape concern and family influences were significant predictors of high risk eating behavior 
whereas type of college and family influences significantly predicted low self‑esteem.
CONCLUSIONS: The study concluded that factors such as nutritional status, family influences, type 
of college and body shape concerns lead to high risk eating behavior and low self‑esteem. These 
findings will help in creating awareness on importance of concept of positive body image, healthy 
weight control behaviors and in developing future interventions.

Abstract BACKGROUND: Gamification involving application of elements of game play that provides unique 
opportunities to learners to sail through complex medical concepts is gaining importance in medical 
education. The current study was aimed at assessing the perception of medical students regarding 
checkerboard game in enhancing learning process.
MATERIALS AND METHODS: The present prospective cross‑sectional study was conducted at the 
microbiology department. The fifth-year medical students of the academic year 2018–19 were the 
participants. Pre‑ and post‑test scores and self‑administered questionnaire regarding effectiveness 
of the checkerboard game‑based learning were used as assessing tools. The data were collected, 
tabulated, and statistically analyzed using SPSS version 20. The pre‑ and post‑test scores of students 
were statistically analyzed using paired t test. A descriptive analysis on the 3‑point Likert scale of 
effectiveness survey was measured and expressed in percentages.
RESULTS: In total, 124 fifth-year medical students participated in the study. Majority (89.5%) of them 
liked the game, nearly 86% opined that game was enjoyable and created interest. Approximately 
88% indicated game helped them to understand the topic, enhanced learning, and thus improved the 
knowledge. Most students (79%) also believed that game encouraged critical thinking and problem 
solving, while 75% felt that it improved their communication skills. Around 70% felt that game was 
also useful for exam preparation and nearly 90% recommended to use the game more frequently.
CONCLUSION: From the results of the study, it can be concluded that checkerboard game‑based 
learning method is effective in fostering learning process and cognition of medical students in the 
microbiology course.

Abstract BACKGROUND: Nurses are in close contact with COVID‑19 patients and due to the high risk of 
infection, they experience fear and anxiety that can result in burnout. This study aimed to review the 
studies on burnout among nurses during the COVID‑19 epidemic.
MATERIALS AND METHODS: The study followed the guideline for Preferred Reporting Items 
for Systematic Review and Meta‑analysis (PRISMA). Using the keywords: “burnout,” “nurse,” and 
“COVID‑19” and with the help of Boolean operators, “AND” and “OR” the online databases, namely 
PubMed, Scopus, Google Scholar, Web of Science, and Science Direct were searched. Articles 
published from the first of February 2020 to 30 October, 2020 were retrieved. After the quality 
appraisal, the required data were extracted and analyzed.
RESULTS: Out of 85 articles identified in the initial search, and after removing duplicates and those 
that did not have the required data, seven articles entered the analysis. Among these articles, 
four (57.14%) reported moderate burnout and three articles (42.86) reported high level of burnout 
among nurses during the COVID‑19 pandemic.
CONCLUSIONS: A majority of the studies reported that nurses experienced a moderate level of 
burnout during the COVID‑19 pandemic. Given the prevalence of burnout in nurses and because 
nurses are the largest portion of the healthcare providers who are in close contact with patients 
infected by COVID‑19, it is necessary for health care policymakers to adopt strategies for preventing 
or reducing burnout among nurses.