Journal of Education and Health Promotion

Abstract BACKGROUND: Attempts to put the available teaching–learning time to better use and address the
needs of students by increasing active involvement led to the evolution of the flipped classroom (FC).
It involves providing study resources for students to use outside the class so that class time is freed
up for instructional activities. This study was done to assess the effectiveness of flipped classroom
activity as a teaching–learning method.
MATERIALS AND METHODS: In this interventional study, 98 students were divided into two batches
of flipped class and conventional small group teaching (SGT). An online Google group was created for
the batch of FC. Brief introduction and prerecorded videos related to the assigned topic were posted
in the Google group. Discussion was carried out in the form of solving cases and problem‑solving
exercises. Pretest and posttest were conducted at each session, and an end of module test was
conducted for both the groups.
RESULTS: There was a significant difference between the pre‑ and posttest scores and also the
mean scores of summative test between two groups (P < 0.001). The perception of the students
regarding FC was also evaluated. Eighty‑two percent strongly agreed that FC was more engaging
and interesting in comparison to traditional class. Seventy‑six percent strongly agreed that more
such classes should be conducted in the future.
CONCLUSION: Flipped classroom improved the student performance and learning experience
effectively as compared to conventional SGT, and students’ response was also largely positive.

Abstract INTRODUCTION: Health services utilization is a complex behavioral phenomenon affected by
multiple factors including availability, distance, cost and quality of health services as well as personal
attitudes, cultural beliefs, and socioeconomic characteristics. This study aimed to assess the status
of health‑care utilization among dwellers of slums in one of the Iran’s big cities.
METHODS: This was a cross‑sectional study in which 559 slums people were selected using a
random clustered sampling method. Data on health services utilization were collected using health
equity assessment and response tool questionnaire. Data analysis was performed using descriptive
statistics and logistic regression analysis through SPSS ver. 22.
RESULTS: In this study, 42.5% (238) people who required outpatient services. 21% (118) of them
were able to use them. Furthermore, among the families, who needed outpatient services during the
past month, 15% (38) were able to use the services for at least once. Regarding inpatient services,
62% (349) of people needed hospitalization, of which 31% (175) were able to be hospitalized.
Age (P = 0.2), gender (P = 0 <001), marital status (P = 0 <001), income status (P = 0.1), and
education (P = 0.21) determined utilization of outpatient services; however, inpatient services
utilization was affected by age (P = 0.03), gender (P = 0.02), marital status (P = 0 <001), and income
status (P = 0.32). The final model of multiple regression showed that, there was a relationship between
age (odds ratio [OR] =1.7, confidence interval [CI] 95% = 0.47–0.88), marital status (OR = 2.78, CI
95% = 0.64–1.2), and the use of inpatient services.
CONCLUSION: The utilization of health services in slum areas is not desirable. As it was showed
that the utilization of health services in slums people is a multifactorial event; thus, proper planning
and policy for this increasingly demand are essential.

Abstract CONTEXT: Mass gatherings (MGs) are established for different religious, social, political, cultural,
and sport motivations. Many risks threaten the participants` health in MGs for different reasons. One
duty of health‑care system is to identify the risks and manage them to reduce the participants` injuries
in MGs. This study aimed to identify and classify the risks threatening the health of participants in
MGs and review related articles systematically.
SUBJECTS AND METHODS: In this study, we investigated electronic databases including Science
Direct, PubMed, Ovid, ProQuest, Web of Science, Scopus, and Google Scholar. This systematic
review investigated those health articles which studied MGs published after 2000. Keywords that were
searched included (Mass gathering OR Crowd) AND (Assessment OR Evaluation) AND (Disaster
OR Emergencies) AND (Injuries OR Stamped). The final full text articles were assessed qualitatively
by STROBE article assessment checklist, and then the data extracted from the results of the articles
were analyzed and reported.
RESULTS: Initially, a total of 1874 articles were found, qualitative exclusion and inclusion
criteria were applied, and finally 29 full‑text articles were selected for the analysis. More than
forty health‑related risks were recognized. In order to better understand the risks and use of the
results more efficiently, the risks were classified and reported into the following five domains:
environmental risks, individual risks, psychological risks, public health risks, and management
risks.
CONCLUSION: Many risks threaten the health of participants in MGs. Recognizing and managing
the risks are considered the primary and basic essentials of health sector for the better management
of MGs.

Abstract BACKGROUND: Although rabies is highly fatal, with timely and correct postexposure prophylaxis (PEP)
of animal bite victims, it could be prevented. Medical school students should be trained about the
appropriate rabies management during their formative years so that they put the right practice later
on. The study was conducted to assess the knowledge about rabies epidemiology and prophylaxis
among medical students and to find the effect of an educational intervention.
MATERIALS AND METHODS: This was a quasi‑experimental study conducted with 156 third
academic year medical school students at a tertiary care teaching hospital. The study participants
were given health education intervention. A study tool assessed the knowledge of study participants
on domains such as epidemiology of rabies, pre-exposure prophylaxis (PrEP) and PEP, and national
program guidelines of rabies prevention. The study tool was administered before and after the
intervention. The impact of educational intervention was measured with scores. Wilcoxon signed‑rank
test was applied to test the difference.
RESULTS: The overall total mean pretest total score was 14.9 (±3.7) and posttest score was
22.7 (±3.23) for a maximum score of 29. The mean pretest scores for epidemiology, PrEP and PEP
and national program components were 6.09, 7.95, and 0.85 respectively. Likewise, the mean posttest
scores were 8.09, 13.26, and 1.35 respectively. There were a statistically significant improvement
in the scores after health education intervention.
CONCLUSIONS: After educational intervention, there were statistically significant improvement in
the scores of all the three domains. PrEP and PEP and national program domain of rabies need to
be emphasized during formative years.

Abstract INTRODUCTION: In the development perspective of each country, it is important to pay attention
to the health sector and improve health indicators; therefore, planning in training and distribution of
human resources in the health sector is an important factor to achieve the health system goals. The
aim of this study was to investigate the effect of changes in health sector human resources on infant
mortality rate (IMR), maternal mortality rate (MMR), and under‑five mortality rate (U5MR) in Iran.
METHODS: This was an econometric study (data panel) that conducted retrospectively and used
data from the period 2006 to 2017 among Iranian provinces. Three regression models were used to
determine the effect of health sector human resources (physicians, nurses, and paramedical staff)
on the IMR, MMR, and U5MR. The random‑effects model was selected over the fixed‑effects model
to assess the effect of health sector human resources on health outcomes.
RESULTS: Results showed that the number of physicians in different models has a stronger impact
on these mortality rates than those of nurses and paramedics, so that a 1% increase in the number
of physicians leads to 2.1%, 3.8%, and 2.2% decrease in IMR, MMR, and U5MR, respectively.
Furthermore, per capita income has a bigger impact on these mortality rates than human health
resources.
CONCLUSION: Increasing the number of human resources in the health sector, especially the
number of physicians, by investing in these resources by providing educational facilities, plays an
important role in improving the mothers’ and infants’ health indicators.

Abstract INTRODUCTION: Hospitals are the main axis of health‑care reforms or national health plans;
therefore, accurate recognition of hospital costs based on operational indexes to these plans is
necessary. The impact of implementing national health plans on the performance of health systems
is ambiguous and misleading; therefore, the aim of this study was to assess the impact of Healthcare
Reform Plan (HRP) on the micro level (e.g., educational or university hospitals).
METHODS: This study was a descriptive retrospective study that research variables are checked
in 1 year before and mean of 3 years after implementation of HRP by self‑administrated checklist in
selected public‑educational hospitals covered by the medical universities in Tehran. The final analysis
of the data was performed using cost–performance ratio and independent t‑test for comparing the
variables’ changes before and after HRP.
RESULTS: Unlike adjusted hospitalization costs, most operational indexes were not significant.
The per capita cost adjusted of hospitalization in first and mean of 3 years after HRP increased
49.49% and 16.31%, respectively (P < 0.001), the adjusted cost per day was increased by 24.48%
and 21.46% (P < 0.001), and adjusted cost per bed was increased 47.06% and 20.07% compared
to before HRP (P < 0.001).
CONCLUSION: Given the lack of alignment in adjusted cost changes in exchange for functional
indicators, certainly, it cannot be argued that HRP had a favorable or undesirable effect on the
hospitals.

Abstract BACKGROUND AND AIM: Medical career exploration is a continuous process that one should
invest on throughout their academic life. However, lack of resources and time are the main barriers
in establishing suitable intervention. Therefore, the needs for flexible intervention are crucial, as it
can improve medical career choices. This study aimed to improve career self‑efficacy and to open
the insight of medical students in choosing a variety of medical careers.
MATERIAL AND METHODS: This study was conducted using quasi‑experimental study design with
nonequivalent control groups design (pretest‑posttest) using a modified model from a preexisting
medical career intervention (MedJob™) labeled as MiniMedJob™. A total of 122 1st‑year medical
students from Sriwijaya University, Indonesia, were voluntarily joining the study. The effectiveness
of MiniMedJob™ in increasing students’ self‑efficacy was evaluated using Wilcoxon and Mann–
Whitney statistical tests using IBM SPSS Statistics for Windows, Version 24.0, Armonk, New York.
RESULTS: MiniMedJob™ was proven effective to improve medical students’ career self‑efficacy
(P = 0,000). The mean of the pretest and posttest for the intervention group was 77.79 ± 10.12 and
87 ± 8.36, respectively. While for the control group, the mean of pretest was 87.00 ± 8.36 and for
the posttest group was 83.55 ± 7.96. Despite the higher score of the intervention group compared
to control group, statistically, it was insignificantly different (P = 0,084).
CONCLUSIONS: MiniMedJob™ is proven effective in improving medical students career self‑efficacy
despite their shorter period and fewer activities compared to preexisting intervention model.

Abstract INTRODUCTION: Spiritual intelligence is better defined as a capacity to discover and develop
true meaning, deep purpose, and vision in life. The purpose of the present study was to determine
the predictive role of demographic variables affecting the overall spiritual intelligence in diabetic
adolescents.
METHODS: In 2016, a cross‑sectional study was conducted involving 200 adolescents with type 1
diabetes referring to the Iranian Diabetes Association consenting to participate. The inclusion criteria
were: age ranging from 15 to 21 years, more than a year since last diagnosed with diabetes, patients’
full awareness of their disease, not having other physical‑psychological illnesses, and not taking
any psychiatric or narcotic drugs. Spiritual intelligence was measured using the Spiritual Intelligence
Self Report Inventory questionnaire consisting of 24‑questions. The alpha Cronbach’s method was
applied to validate the questionnaire in terms of content, form, and data with the reliability calculated
as 0.903. Demographic data were analyzed using SPSS software version 18.
RESULTS: On total, 56% of the participants were female, 17.10 ± 1.85, and the mean duration of
diabetes was 5.98% ± 3.79%, 62.5% reported diabetes history among immediate relatives. Forty‑two
percent of the participants were the oldest child in the family first children of the family and 29.5%
were studying at the university. The mean score of spiritual intelligence was 60.42 60.42 ing from
15 to 21 years regression test using the enter method (ANOVA: 0.703, F: 0.739) showed that none
of the demographic components explored did not significantly alter the scores that assessed spiritual
intelligence.
CONCLUSION: The outcome of the current study portrayed that demographic features do not
necessarily alter the overall spiritual intelligence scores, thereby not necessarily affecting an
individual’s overall spirituality.

Abstract INTRODUCTION: Unnecessary and excessive activation of alarms (“false alarm”) in neonatal
intensive care unit (NICU) often results in alarm fatigue among health‑care professionals, which can
potentially result in deleterious effects in sick neonates.
AIMS AND OBJECTIVES: The aim of this study is to reduce the frequency of false alarms from
multiparameter monitors (MPM) by 50% from the existing baseline level over a period of 12 weeks.
METHODS: In this quality improvement (QI) project conducted over 1 year (November
2016–October 2017) at All India Institute of Medical Sciences, New Delhi, we collected data on
activation of false alarms from MPM (outcome measure) over a period of 2 months in 134 randomly
selected observations of 1‑h duration (baseline phase [10 days, 20 observations] and developing
and testing the changes in five Plan‑Do‑study‑Act (PDSA) cycles over the next 50 days, 114
observations. We also measured the pre‑ and postassessment of knowledge level in use of MPM
among health‑care professionals using checklist (process measure). Following that, we continued
data collection for next 10 months to check sustenance of the project.
RESULTS: Baseline characteristics including gestation, birth weight, and sickness level did not vary
during the study period. The median (range) number of activation of false alarms/hour/MPM was
23 (18–35) in the baseline phase. This reduced to 22 (17–30), 19 (15–30), 16 (14–30), 14 (8–17),
and 9 (6–12) at the end of 1st, 2nd, 3rd, 4th, and 5th PDSA cycles, respectively. In sustenance phase,
it could be maintained in target range from January 2017 to October 2017.
CONCLUSIONS: Small sustained changes can contribute a lot in continuous QI in decreasing false
alarms and subsequent improvement of neurodevelopmental outcomes discharged neonates.

Abstract INTRODUCTION: Due to the importance of correct interpretation of electrocardiogram (ECG) in the
quality of healthcare delivery, new educational methods are increasingly being implemented and
evaluated. In this regard, the purpose of this study was to compare the traditional and virtual teaching
methods on the interpretation of cardiac dysrhythmia in nursing students.
METHODS: The present study is a quasi‑experimental research with pretest and posttest design.
Sixty nursing students in the seventh semester from schools of nursing in Urmia and Khoy cities
were randomly assigned to two virtual and traditional education groups. Students’ knowledge was
measured by a researcher‑made 30‑item test.
RESULTS: The mean and standard deviation of the students’ scores in the traditional education
group was 11.20 ± 4.41 and 14.40 ± 4.62 and in the virtual group was 11.30 ± 2.74 and 18.43 ± 4.68,
pre‑ and post‑training, respectively. Paired t‑test showed a significant difference between the
mean score of pretest and posttest in both types of training (P < 0.001). According to the results of
independent sample t‑test, there were no significant differences between the two groups before the
training (P > 0.05). However, in the posttraining period, there were significant differences between
traditional and virtual education groups (P < 0.001).
CONCLUSION: Considering the results of this study, which shows the positive effects of virtual
education method on nursing students’ knowledge about cardiac dysrhythmia, this method can be
used as an alternative or complementary method to the traditional education.

Abstract BACKGROUND: Academic burnout is a worldwide problem that troubles students at all academic
levels. Despite the significant effects of this problem on students’ mental health and academic
achievements, yet, it has not been adequately studied in Iranian system of academic education.
Therefore, we aimed to explore the incidence of academic burnout status and its associated factors
among the students at Guilan University of Medical Sciences.
SUBJECTS AND METHODS: This cross‑sectional study was conducted over a number of
303 students at Guilan University of Medical Sciences during 2016. Study samples were selected
through the stratified random sampling method, and a set of data including sociodemographic
information, educational status, study habits, and burnout inventory status was collected for each
sample. Items of burnout inventory status were based on the Maslach Burnout Inventory. Data were
analyzed using descriptive and inferential statistics including t‑test and linear regression.
RESULTS: The students in our study reported a mean of 2.53 ± 0.7 for academic burnout score.
Along with related factors of academic burnout, marital status (P = 0.029), grade point average
(P = 0.002), being interested in field of study (P = 0.000), and study time (P = 0.000) were significantly
associated with academic burnout of students. Furthermore, the incidence of academic burnout did
not differ between male and female students.
CONCLUSIONS: Regarding the considerable prevalence of academic burnout among students of
medical sciences, it is needed that policymakers implement more effective educational programs
considering the associated factors of academic burnout.

Abstract INTRODUCTION: It is essential to provide key information and support to every woman regarding
pregnancy and childbirth to enable all women to make a fully informed decision regarding their choice
of reproduction. The study aimed to find the impact of an educational program based on the Theory
of Planned Behavior (TPB) on health promotion and childbearing of minor thalassemia couples.
SUBJECTS AND METHODS: This study was quasi‑experimental. A total of 70 women with minor
thalassemia held in Minudasht health center were classified into two groups: study and control. The
study group received the educational program based on TPB, and the control group only received
the routine program. The data were collected using the TPB‑based questionnaire at baseline and
3 months after the intervention. They were analyzed by Chi‑square, Student’s t‑test, Wilcoxon test,
and regression analysis through SPSS version 16.
RESULTS: The mean (standard deviation) ages of the participants in the control and study group
were 30.69 (6.20) and 31.08 (6.66), respectively. There were significant differences between
the two groups (study vs. control) in terms of perceived behavioral control, intention, attitude, or
childbearing behavior (P < 0.001). The change in fertility behaviors had a significant increase in the
study group (62.8%) compared to the control group (2.9%) (P < 0.001).
CONCLUSION: Based on the results, the TPB is an effective model to explain fertility intentions
and behaviors in Iranian women with minor thalassemia; however, further researches are needed
to generalize our findings to other people including healthy women.

Abstract BACKGROUND: Eighty percent of women during their reproductive age experience some
symptoms attributed to premenstrual phase of the menstrual cycle. Premenstrual syndrome (PMS)
is characterized by emotional, behavioral, and physical symptoms that occur during late luteal phase
of menstrual cycle and are relieved after the onset of menstruation. Aerobic exercise and yoga are
one of the ways to reduce these symptoms. The aim of this study was to compare the effects of
aerobic exercise and yoga on PMS.
MATERIALS AND METHODS: A total of 72 participants of PMS, referred for physiotherapy
treatment (mean age 28 years), were enrolled and allocated into two groups (Group A and B) by simple
computerized randomization. Patients in Group A received aerobic exercise and in Group B received
yoga movements for 40 min, 3 times a week for 1 month. The pain intensity (Visual Analog Scale)
and PMS Scale were measured before, at the end of 15 days, and 1 month of treatment program.
RESULTS: Data were analyzed by paired t‑test, unpaired t‑test, and one‑way ANOVA; and the
results showed that both aerobic exercise and yoga movements significantly reduced pain intensity
and PMS symptoms. Significant reduction in PMS symptoms was found in patients treated with
yoga compared to aerobic exercise; however, no significant difference was found in pain intensity
between these two groups (P > 0.05).
CONCLUSION: It is concluded that both aerobic exercise and yoga movements are effective in
treating PMS; however, yoga is more effective in relieving the symptoms of PMS than aerobic exercise.

Abstract BACKGROUND: Special learning outcomes are considered for medical and health sciences education
which can be acquired by some interactive learning systems in the human brain. Given the importance
of this issue, based on literature, we attempted at mentioning certain practical points for medical and
health sciences educators to employ in preclinical and clinical teaching.
MATERIALS AND METHODS: We searched databases of PubMed, Proquest, Scopus, ERIC, and
ISI Web of Science for relevant literature from January 2010 to January 2019.
RESULTS: From a total of 1029 records, 30 articles along with 35 papers from snowballing and hand
searching were included in this study. The following 12 main items were encompassed: teaching
students the basic neuroscience of learning and set individual learning goals, “just right challenge”
heeding the balance between supervision and autonomy, brain‑friendly coaching, repetition with
spaced learning, visualization as a powerful learning tool, multimodal teaching, cognitive learning
and mental model, cognitive‑emotional learning, active and social learning, creativity and art, sleep,
medical faculty’s participation regarding the courses of “neuro‑education studies,” and “neuro‑myths”
were suggested for brain‑friendly medical and health sciences teaching.
CONCLUSIONS: We considered 12 practical points for brain‑aware medical and health sciences
teaching according to the recent literature on the basis of the association between education, cognitive
science, neuroscience, and psychology. Interdisciplinary research and practice regarding this issue
can improve teaching–learning quality, students’ well‑being, and ultimately patient outcomes.

Abstract BACKGROUND: Evaluation of educational courses is important for estimating the achievement of
learning goals and identifying the best way to learn. The present study is an attempt to assess the
effectiveness of education through role‑playing on the learning outcomes in nursing students based
on the Kirkpatrick’s evaluation model.
MATERIALS AND METHODS: A quasi‑experimental study was conducted with participation of 74
nursing students at Iran University of Medical Sciences in 2016–17. The participants were selected
through census and were randomly allocated to control (n = 35) and experimental (n = 39) groups.
The common method of education was implemented for the control group, and the experimental group
experienced role‑playing educational method. In the next semester, each student was assigned to
educate two patients at the hospital. The knowledge level of the participants at the end of the semester
and patients’ satisfaction with the educations by students in the next semester were measured as
the outcomes of learning. Kirkpatrick’s model was used to assess the learning outcomes.
RESULTS: The mean score of students, at the second level of Kirkpatrick’s model, in the experimental
group (63.85 ± 13.88) was significantly higher than that of the control group (46.41 ± 16.22, P < 0.001).
The mean score of patients’ satisfaction with patient educational performance, at the fourth level of
the model, in the experimental group (73.26 ± 3.47) was significantly higher than that of the control
group (47.32 ± 6.83, P < 0.001).
CONCLUSIONS: The evaluation by the Kirkpatrick’s model showed that use of role‑playing method
improved learning outcome of nursing students.

Abstract BACKGROUND: The safety of hospitalized patients in the intensive care units (ICUs) is threatened
due to incidents and adverse events, including medication errors. Medication error refers to any
preventable event at different stage of medication process, such as prescription, transcription,
distributing medication, and administration, which can lead to incorrect use of medicines or damage
to the patient. This study aimed at investigating the effect of the interprofessional education of
medication safety program on medication errors of physicians and nurses in the ICUs.
MATERIALS AND METHODS: The study was conducted using a quasi‑experimental method (single
group, before and after) in 2017. The setting of the study included one ICU of selected teaching hospital
affiliated to Isfahan University of Medical Sciences located in the Central Iran with a total of 23 beds.
Participants included 50 members of the health‑care team (physician, nurse, and clinical pharmacist)
with at least 1 year of work experience in the ICUs. Participants were selected using censuses
sampling method. Data were collected using a two‑section self‑made questionnaire. Data were
analyzed through descriptive, analytical statistics, and version 16 of the SPSS software (P < 0.05).
RESULTS: According to reporting of physicians, nurses, and clinical pharmacist, the medication
error 1 month after implementation, the interprofessional education of medication safety program
was significantly lower than before the implementation of it (P < 0.001).
CONCLUSIONS: Interprofessional education helps to improve interprofessional collaboration and
patient care through the promotion of various professions of health to increase interprofessional
collaboration compared to single profession education, which individuals learn in isolation and merely
in their profession. Therefore, interprofessional education of medication safety program can reduce
medication error and promote patient safety in the ICUs.

Abstract BACKGROUND: Insufficient physical activity is a global health‑care problem and is considered an
independent risk factor for chronic diseases. The present research aimed to explore the effect of
an educational intervention based on the theory of planned behavior (TPB) and stages of change
on promoting women’s physical activity.
MATERIALS AND METHODS: This quasi‑experimental research was conducted on 68 women
who voluntarily visited the health‑care centers of Mashhad. They were selected by randomized
multistratified sampling method and were divided into two groups of intervention (n = 34) and control
(n = 34). The data collection tools included a demographic information questionnaire, a questionnaire
based on the TPB and stages of change, and the International Physical Activity Questionnaire. The
data were statistically analyzed by SPSS software version 16 using descriptive statistics (frequency,
percentage, mean, and standard deviation) and inferential statistics (paired t‑test, correlation
coefficient, and covariance). The significance level of P < 0.05 was considered in this study.
RESULTS: No statistically significant difference was found between the intervention and control groups
before the intervention in terms of the scores of the TPB constructs and physical activity (P > 0.05).
However, after the educational intervention, a significant difference was observed in the mean scores
of TPB constructs and physical activity (P < 0.05). In addition, no statistically significant difference
was found in the stages of change between the two groups after the intervention.
CONCLUSIONS: The results of this study pointed to the effectiveness of educational intervention
and the necessity to use educational interventions to help adopt preventive behaviors. Therefore,
the use of well‑established educational models rather than conventional methods is recommended.

Abstract INTRODUCTION: Poisoning is an important global health problem that leads to increase in mortality
and morbidity. Worldwide, a million people die each year because of poisoning. The incidence of
poisoning is also highest in India, with an estimated death of 50,000 people every year. There is a
paucity of literature on various factors associated with poisoning which hinders effective poisoning
prevention.
AIMS: The present study aimed to study the pattern of poisoning among patients in a tertiary care
center and to assess the factors associated with poisoning.
METHODOLOGY: The prospective study was conducted at the intensive care unit of a tertiary
care hospital from May 2018 to September 2018. All the patients who had exposure to poisoning
were included in the study. A pretested questionnaire was administered, and information regarding
sociodemographic factors, type, mode, and outcome of poisoning were obtained. Statistical analysis
was done through SPSS version 21.
RESULTS: Of 106 poisoning patients admitted, 55.7% were female and majority were from rural
area (52.8%). The major type of poisoning was suicidal (86.8%). Among suicidal, tablet poisoning
was predominant (35.8%), followed by corrosive poisoning (17.9%) and Organophosphorus
poisoning (13.2%). The major reason for suicidal poisoning was family problems (63.4%), and the
association was statistically significant (P < 0.001). Suicidal poisoning was more among the age
group of 21–30 years and middle socioeconomic status, which was statistically significant (P < 0.001).
The prevalence of poisoning was 20.8% and 19.8% among homemakers and college students,
respectively, which was statistically significant.
CONCLUSION: Young adults, especially homemakers and college students, are more affected from
poisoning in the current study. The involvement of family, educational institutes, and community is
very important in identifying the risk factors and timely counseling. Emphasis should be made on
legislative measures to combat socioeconomic problems.

Abstract INTRODUCTION: Despite all efforts that have been made to promote professional behavior among
medical trainees, unfortunately, reports from medical schools around the world confirm the prevalence
of nonprofessional behaviors by medical students. Experts in the field of medical ethics and medical
education in different countries have suggested several reasons for failing to minimize unprofessional
performance among medical students.
MATERIALS AND METHODS: This qualitative study aimed to promote our understanding from the
challenges faced by Iranian medical students in providing professional behavior. The study was first
conducted in the form of a semi‑structured face‑to‑face interview with medical students and then
completed with a focus group discussion (FGD) session. Forty‑nine medical students participated
in the interviews and 11 students participated in the FGD session. Qualitative conventional content
analysis was used for examining the data.
RESULTS: The participants classified the obstacles of professional behavior into the following
three main categories: problems related to educational system, problems related to the society, and
problems related to students themselves.
CONCLUSION: Regarding the impact of various personal, social, and educational factors on the
creation and expansion of unprofessional behaviors among medical students, it is essential to have
a comprehensive approach for solving the problem.

Abstract BACKGROUND: HIV‑infected patients with poor antiretroviral therapy (ART) adherence are prone
to depression, and depression can exacerbate the disease condition. This study was conducted to
determine ART Adherence based on Information, Motivation, and Behavioral Skills (IMB) Model and
its association with depression among HIV‑positive patients.
MATERIALS AND METHODS: This descriptive–correlational study was carried out on people over
the age of 18 years with HIV/AIDS, who referred to the Behavioral Diseases Counseling Center in
Kerman City, Iran, in 2017. In this regard, 119 patients were selected using the table of random
numbers. To collect the data, we used the Beck’s depressioninventory‑II and the IMB researcher
made questionnaire to evaluate the ART adherence.
RESULTS: The results of the study reveal that a significant association was observed between the
total adherence and all constructs of the IMB model (P < 0.001). Risk perception and self‑efficacy had
the highest mean scores regarding the ART adherence. The prevalence of depression was 71.5%
among patients. Information, personal motivation, and total adherence had a significant association
with depression.
CONCLUSIONS: IMB model was an appropriate and practical strategy with regard to the ART
adherence among people living with HIV who are prone to depression and drug consumption is crucial
for them to achieve the 90‑90‑90 target. This article created a questionnaire to assist policy‑makers
and health professionals designing interventions to improve adherence and health outcomes of ART.

Abstract BACKGROUND: Providing the high‑quality services in hospitals depends on to minimize conflict
between all members within a health team. This study aimed to identify the causes of conflicts
experienced by clinical and administrative staff in hospitals.
METHODS: A cross‑sectional study was carried out in 2018. The sample included 320 clinical
and administrative staff from six hospitals affiliated to Ardabil University of Medical Sciences that
were selected using two‑step clustering sampling method. Data collection was accomplished by
self‑administered questionnaires. Descriptive statistics, t‑test, and ANOVA were used for data
analysis.
RESULTS: Total conflict score revealed that clinical staff had higher levels of perceived conflict than
administrative staff. In terms of organizational position, the study results showed a significant difference
in the reported conflict between nurse groups and other groups (physicians and paramedical,
administrative, financial, and logistic staff). The most important causes of conflict in the viewpoint of
clinical staff were organizational and job characteristics (3.54 ± 1.28), poor management (3.51 ± 1.12),
and inefficient communication system (3.42 ± 1.33). For administrative staff, on the other hand,
poor management (3.18 ± 1.33), inefficient communication system (3.17 ± 1.36), and attitudes and
perceptions (3.06 ± 1.41) were shown to be paramount factors.
CONCLUSION: Clinical and administrative staff of hospitals are like parts of a train track. The
irrational relationship between them will result in distortion and lower quality of services. Therefore,
effective strategies to decrease staffs’ experience of conflict need to be developed. This might create
a healthier and more productive work environment which positively affects the care quality.

Abstract BACKGROUND: The investment decision can be affected by changing levels of uncertainty and risk.
The main objective of this research was to identify, characterize, and quantify the parameters which
are essential in evaluation hospital construction projects and provide useful modeling techniques to
give the best investment decisions for investors in Iran’s health‑care projects investment.
MATERIALS AND METHODS: The methodology of this study was employing discounted cash
flow (DCF) and real option valuation to investigate the feasibility investment in the public hospital
construction project. The Islamshahr, Mashhad, and Fardis hospitals were included in the analysis.
Economic indices of DCF methods were internal rate of return (IRR) and net present value.
RESULTS: The economic evaluation of the Black–Scholes model was almost as same as the binomial
tree model, but there was a significant difference between the real options model and traditional
methods. According to the traditional methods, the profitability with IRR for Islamshahr, Mashhad,
and Fardis hospital projects was 35%, 43%, and 26%, respectively. Black–Scholes model showed
profitability only for Islamshahr and Mashhad hospitals, and there was no adequate profitability for
investors of Fardis Hospital project during the study.
CONCLUSIONS: The methods derived from the real options valuation could provide a more flexible
and reliable indices for investors in dynamic and high revolution economic conditions. On the other
hand, dynamic economic evaluation models can be applied to correctly evaluate the projects because
of Iran’s health revolution and its health plans.

Abstract