Journal of Education and Health Promotion

Abstract BACKGROUND: Taking care of patients with bipolar disorder (BD) makes critical challenges for
their informal caregivers (ICGs) and forces them to tolerate considerable burden. This qualitative
study explored the dimensions of ICGs’ care burden (CB) based on their own experiences and the
patients’ therapists.
MATERIALS AND METHODS: This is a qualitative study which was conducted based on conventional
content analysis through semistructured and in‑depth interviews. Purposive sampling was used to
select the participants including 13 ICGs and 14 therapists (2 psychiatrists, 10 psychiatric nurses,
and 2 clinical psychologists). Interviews were audiotaped, transcribed verbatim, and analyzed using
Graneheim’s 2004 principles.
RESULTS: Qualitative analyses yielded three major themes: “challenges associated with the nature
of BD,” “challenges related to the ICGs,” and “challenges related to interventions.” The categories of
the first theme entailed “individual‑oriented characteristics of BD” and “social‑oriented characteristics
of BD.” The categories of the second theme consisted of “social stigma,” “psychiatric problems and
helplessness of ICGs,” “financial costs related to providing cares,” and “insufficient self‑efficacy of
ICGs in cares provision.” The categories of the last theme included “educational interventions” and
“organizational interventions.”
CONCLUSIONS: This study showed that the burden of ICGs have individual, social, and
organizational aspects. Every one of them impacts the severity of their burden remarkably. The
depth of the therapists’ experiences has a significant role in designing the interventions to reduce
this burden. The present investigation emphasized the constitution of a comprehensive framework
related to all factors affecting burden in a developing country.

Abstract BACKGROUND: Over the last year, the world has witnessed an infectious disease (COVID‑19)
outbreak that has shown a high rate of spread. Therefore, several prevention and mitigation measures
have been imposed to control the spread of the virus worldwide. The aim of the current study is to
identify the commitment level to social distancing and its relationship to psychological stress among
members of Saudi society during COVID‑19 pandemic.
MATERIALS AND METHODS: The descriptive correlational design was employed in the current
study, and the sample of the study consisted of 536 Saudis selected using convenient sampling
method. The study was conducted in four cities in Saudi Arabia (Altayef, Mecca, and Najran, in 2020
during COVID‑19 pandemic using quantitative survey method. Several analysis methods using SPSS
software were used to analyze the data such as mean and standard deviation, three‑way ANOVA,
Scheffe’s test, and Pearson correlation.
RESULTS: The study revealed that the psychological stress and commitment level to social
distancing by the study sample during COVID‑19 pandemic was moderate, and differences were
observed among the study variables. Furthermore, the study revealed a statistically significant
negative correlation between the commitment level to social distancing and the exposure to
psychological pressures.
CONCLUSION: The study contributed to literature by developing a model to enhance the importance
of social distancing of people during COVID‑19 pandemic. The study recommends the necessity to
provide advice and counseling services that enhance community members’ awareness about the
application of social distancing during COVID‑19 pandemic.,

Abstract Coronavirus disease 2019 (COVID‑19), caused by severe acute respiratory syndrome coronavirus
2, was first reported in December 2019 in Wuhan, Hubei province, China. It is now known as a
pandemic and a global crisis due to rapid human‑to‑human transmission with the vast expansion
that has affected almost all countries. The primary source of the disease is still unknown, but it is
possible that the virus was transmitted through bat to an intermediate host and then to humans.
The main and early symptoms of COVID‑19 infection are fatigue, fever, dry cough, myalgia, and
dyspnea. The incubation period of the disease is about 2–14 days, which is one of the important
parameters for planning to prevent disease outbreak. PT‑polymerase chain reaction test is used to
diagnose the disease; chest computed tomography scan, chest X‑ray, blood tests, and symptoms
are also very helpful in diagnosing the disease. There is a strong emphasis on controlling infections
and hand hygiene to prevent the transmission of the disease. There is not enough knowledge about
this disease yet, and there are no specific vaccines or medications available to prevent and treat this
disease. The current review study uses articles indexed on databases of Embase, Elsevier, PubMed,
and World Health Organization and Centers for Disease Control and Prevention, and keywords of
coronavirus, COVID‑19, acute respiratory distress syndrome and China.

Abstract BACKGROUND: At the beginning of the COVID‑19 pandemic, the Iranian Ministry of Health and
Medical Education set up a 24‑h call center, i.e., Center 4030, to mitigate people’s worries and
anxieties, create composure, increase people’s trust, and answer their questions. This qualitative
study aimed to identify the challenges of COVID‑19‑related‑information among people in point of
experts’ views.
MATERIALS AND METHODS: This qualitative study was conducted to collect the opinions of experts
on the identification of the Information challenges of COVID‑19 during March–June 2020. The
research population included all health professionals and experts. The sampling method was initially
purposive and continued to saturate the data as snowball technique. In this study, 19 participants
were interviewed. The data were collected using a semi‑structured interview. After collecting the data,
the audio files of the interviews were written down to extract their external and internal elements.
MAXQDA version 12 software was used to organize qualitative analysis and coding data.
RESULTS: The results of this study involved eight themes, i.e., lack of planning, lack of social trust
in government, lack of COVID‑19‑integrated scientific authority in the country, conflicts of interest,
lack of integrated information sources, distracting public attention, infodemic, and poor information
quality, classified into 16 categories.
CONCLUSIONS: The main information challenges that people in Iran faced included the lack of
a scientific reference source to access accurate information, the existence of a large volume of
information in virtual networks, and a huge volume of statistics from various information channels
that caused confusion among people.

Abstract BACKGROUND: Online platforms are the most popular mode of entertainment, simultaneously
imparting knowledge and education. During COVID pandemic, there was a sudden influx of
educational videos on social media/websites with a purpose of spreading the information about hand
hygiene (HH) practices. The aim of this study was to explore and assess the HH videos based on
its content and technical quality to promote the learning experience of videos.
MATERIALS AND METHODS: HH videos from the official sites of five international health
organizations and 42 national health institutes were assessed based on their availability of the HH
videos. Verified YouTube videos on HH since January 2020 were further screened and assessed
using the author’s designed validated checklist. Each video was systematically evaluated and scored
against the seven categories, namely introduction, audio, visuals/background, speaker/demonstrator,
content, timing, and appeal.
RESULTS: A total of 50 videos were assessed for analysis. Of these, 82% of videos scored >50%,
i.e., 14. Among low scorer, seven videos were from YouTube channel. Majority of the videos were
technically sound, 44% aroused interest, 82% had a simple, understandable message; in around
46% of the videos, the presenter was a healthcare worker; and in 24%, the information was accurate
as per the World Health Organization guidelines.
CONCLUSIONS: This study concluded that most of the HH videos were found to be just above
average in their content quality and technicality.

Abstract BACKGROUND: Exercising during pregnancy has various benefits for the mother and the fetus, but
there are controversial results about its effect on labor and delivery. Therefore, the present study
was conducted to evaluate the effect of walking during late pregnancy on the outcomes of labor
and delivery.
MATERIALS AND METHODS: The present randomized clinical trial was conducted on 102 pregnant
women who were referred to the comprehensive health service centers of Rafsanjan and were
selected using convenient sampling method and randomly were allocated into two groups from
August 2018 to February 2019. The intervention group performed walking from the 34th week of
pregnancy until the time of delivery 4 times per  week, each time for 40 min. The control group just
received the routine prenatal care. Information about the outcomes of delivery were gathered from
the participants’ medical files in the hospital and were analyzed using SPSS software version 22
and Chi‑square and independent t‑tests.
RESULTS: The results indicated that the Bishop score of the intervention group was significantly
higher than the control group (P < 0.05). Furthermore, regarding the duration of the third phase
of delivery, spontaneous labor, induced labor, cesarean section , and instrumental delivery,
a statistically significant difference was observed between the intervention and the control
groups (P < 0.05). There was no statistically significant difference between both the groups
regarding the duration of the first and the second stages of delivery and Apgar score at 1st and
5th min (P > 0.05).
CONCLUSIONS:  Walking during late pregnancy could improve Bishop score, increase spontaneous
onset of labor, and decrease induction, cesarean, and instrumental delivery without having any
adverse effect on the neonate’s Apgar score.

Abstract BACKGROUND: Traumatic events and psychological damage are common. Identifying different
types of traumatic events contributes to the development of psychopathology and can be very helpful
in macroeducational and treatment planners. The current study extracted the patterns (overlap)
of different traumatic events that Iranian college students commonly experience, with the aim of
understanding their association with posttraumatic growth (PTG) and religiosity.
MATERIALS AND METHODS: Four hundred and sixty‑six students from Kerman universities
completed a cross‑sectional survey about religion, and questions about PTG and traumatic events
have experienced in the past 5 years. The latent class analysis (LCA) was used for extracting patterns
of traumatic events, and the one‑way ANOVA test was used to compare PTG and religiosity across
these classes in Iranian college students.
RESULTS: The LCA revealed that a three‑class solution had an adequate relative and absolute
fit. The three classes were labeled and characterized as multiple‑traumatic events (2.9%),
intermediate‑traumatic events (31.1%), and low‑traumatic events (66.0%). In ANOVA results for
PTG and Duke University Religion Index (DUREL) domains across classes, individuals in the
multiple‑traumatic classes had the lowest score of PTG and DUREL domains.
CONCLUSION: Although the current study showed the relative frequency of multiple‑traumatic
events in Iranian students is low, individuals categorized in this class had the lowest PTG, and these
findings reveal the necessitation of planning and interventions for PTG.

Abstract BACKGROUND: COVID‑19 was declared an emergency of international concern by the World Health
Organization in 2020. This study assesses patients’ awareness, perception, and mitigating measures
taken during the COVID‑19 outbreak visiting an apex tertiary health‑care center in North India.
MATERIALS AND METHODS: A cross‑sectional study was conducted between September 15,
2020, and November 15, 2020, in a tertiary care public hospital, North India, using a structured
self‑administered questionnaire. The survey included 809 patients using a consecutive sampling
strategy. The self‑structured and prevalidated questionnaire was used to collect information on
study variables. Chi‑square test and independent samples t‑test, followed by binary and multivariate
logistic regression, was used to determine the factors associated with awareness toward COVID‑19.
RESULTS: The mean age of participants was 32.41 (±11.24) years. Multivariate logistic regression
shows that married participants (OR: 0.660, 95 % CI: 0.440-0.989, P= 0.044), reading books/
magazine or attended institutional lectures (OR: 2.241, 95% CI: 1.545–3.249, P = 0.001), and watching
television and radio (OR: 1.824, 95% CI: 1.283–2.592, P = 0.001) are significantly more aware than
their counterparts. Participants with higher income group (>20,000 Indian rupee) significantly had
higher awareness than participants having salary <10,000 rupees (OR: 0.280, 95% CI: 0.178–0.440,
P = 0.001) or 10,001–20,000 rupees (OR: 0.481, 95% CI: 0.297–0.777, P = 0.003). Patients
avoiding traveling across or abroad had significantly much reasonably good awareness than their
counterparts (OR: 0.357, 95% CI: 0.139–0.918, P = 0.033).
CONCLUSIONS: Participants demonstrated good awareness, encouraging perception, and complied
with appropriate mitigating measures during the outbreak. Considering frequent waves and the
pandemic’s long duration, consistent reinforcement of government measures, including masks,
maintaining social distance, and frequent handwashing, is much needed.

Abstract BACKGROUND: The motivation to seek health information on the Internet for individuals has been
varied. The purpose of this paper was to explore the perspectives and experiences about online
health information seeking in information technology (IT) professionals.
MATERIALS AND METHODS: A qualitative case study research design was employed to examine
the behavior of 15 IT professionals from a state organization in the East Coast of the United States
of America. Convenience sampling was used to identify the setting, and purposeful sampling was
used to select the participants. A survey questionnaire was used as a recruitment tool, and in‑depth
individual interviews with standardized semi‑structured questions were used to collect data.
RESULTS: Findings illustrated that the Internet was the first source of reference for wellness and
prevention information to maintain a healthy lifestyle, and to alleviate and prevent work‑related
musculoskeletal disorders (WMSDs). The themes that emerged from the study were that the IT
professionals searched the Internet for information to self‑educate about medical conditions, to
maintain fitness, communicate with health‑care professionals, decide their treatment options, and to
make lifestyle modifications such as ergonomic adjustment of their workstation, postural adjustments,
and changing negative health behaviors.
CONCLUSION: The results of this study provide practical implications for organizations and health
professionals in providing health education to prevent WMSDs as participants sought health
information online to take actions and collaborate with their health‑care professionals and actively
contributed to their medical health decisions. This underscores a valuable opportunity for health‑care
providers and public health officials to become more proactive by providing their patients with quality
health information outside their office through the Internet by referring them to credible website
sources.

Abstract BACKGROUND: Postpartum depression and anxiety is one of the most common complications
that women face and cause many problems for mother, baby, and family. Considering the effect of
self‑efficacy on women’s adaptation to pregnancy and delivery conditions and their mental health
during this period, the present study was designed to investigate the effect of pregnancy training
classes based on Bandura self‑efficacy theory on postpartum depression and anxiety and type of
delivery.
MATERIALS AND METHODS: In this clinical trial study, 64 pregnant women were randomly divided
into intervention and control groups. Mothers in the intervention group received pregnancy training
in eight sessions (each session was 2‑hour) from the 20th week of pregnancy. The classes were run
by a trained midwife and the content of the training was based on Bandura self‑efficacy components.
The mothers in the control group received routine care. The demographic‑reproductive information
form, Beck Depression and Spielberger Anxiety Questionnaire were completed by pregnant women
of both groups at several times, before the program, 1 week and 1 month after delivery.
RESULTS: The results showed that the training program significantly decreased the depression
score in 1 week and 1 month after delivery in the intervention group compared to the control group.
In addition, this training program decreased the mean score of apparent and hidden anxiety in the
intervention group 1 month after delivery, although this decrease was not statistically significant.
Furthermore, 80.55% of the intervention group and 58.33% of the control group had vaginal delivery,
which were significantly different between the two groups in terms of the type of delivery.
CONCLUSION: The findings showed that pregnancy training classes based on Bandura self‑efficacy
theory decrease depression and anxiety and increases vaginal delivery rate.

Abstract Recent studies have reported inconclusive results regarding the therapeutic effects of Rosa
damascena on the outcomes of primary dysmenorrhea (PD) and premenstrual syndrome (PMS).
Hence, this study is aimed to summarize the findings of randomized controlled trials (RCTs)
regarding the effects of this treatment on menstruation‑related pain as the primary outcome and
menstruation‑related headache, fatigue, anxiety, and bloating as the secondary outcomes. This
study evaluated parallel‑group and cross‑over RCTs on aromatherapy, topical treatment, or
oral intake of R. damascena products for the treatment groups versus placebo, nontreated, or
conventional treatment groups. Seven electronic databases (Web of Science Core Collection,
Scopus, Embase, CENTRAL, CINAHL, SID, and MagIran) and one search engine (PubMed) were
searched from inception to January 15, 2021. Of 1468 trials found in the initial search, 983 potentially
relevant articles were screened by title and abstract. After examining the full‑text of 13 studies for
compliance with the inclusion criteria, seven studies were considered eligible for this review. A
random‑effects model was used to pool the data; otherwise, a narrative summary was presented.
The retrieved studies were conducted on females with PD or PMS, aged 18–35 years. The total
sample size of the intervention and comparator arms was 276 and 272. The results showed that
R. damascena had a nonsignificant alleviating effect on the menstruation‑related pain (weighted
mean difference [WMD]: −0.47; 95% confidence interval [CI]: −1.25, 0.31; P = 0.234). Such findings
were also found for menstruation‑related anxiety (WMD: −0.40; 95% CI: −0.91, 0.11; P = 0.125).
However, the treatment significantly reduced the menstruation‑related headache (WMD: −0.42;
95% CI: −0.74, −0.11; P = 0.008), fatigue (WMD: −0.48; 95% CI: −0.87, −0.09; P = 0.015), and
bloating (WMD: −0.72; 95% CI: −1.21, −0.22; P = 0.005). Since R. damascena had no significant
effects on menstruation‑related pain and anxiety, further studies with improved methodological
quality are suggested to evaluate the effects of the treatment on these symptoms, using different
dosages and durations.

Abstract Motivation is one of the key factors in educational achievement. Like any other field of study, motivation
in nursing is highly critical. The instructor’s knowledge about the teaching methods that are effective
in academic motivation of students enables them to adopt proper measures to improve the teaching
efficiency. The present paper is a systemic review of the efficiency of instructional interventions in
improvement of academic motivation in nursing students. The published papers related to the study
from 2000 to February 2020 were searched at different databases such as PubMed, Scopus, Web
of Science, PsycInfo, and ERIC. To examine the quality of the articles, critical appraisal instrument
for reports of educational interventions was used. Totally, 18 articles entered the study for structured
review. The majority of the articles reported that educational interventions improved academic
motivation in nursing students. The effective teaching methods described in the reviewed articles
that led to an improvement in academic motivation were simulation, case‑based learning, cooperative
learning, learning contract, peer assessment, and self‑assessment using video typing. As the findings
showed, implementation of applied and participatory methods in teaching process improved the
academic motivation of nursing students. Therefore, using such methods, nursing instructors can
improve the academic motivation of their students.

Abstract BACKGROUND: Education in vulnerable communities can be a health affordable strategy to
promote patient empowerment. Recognition and understanding the problems of diabetes education
are of significance to overcome the barriers and advance the educational and care services to
control diabetes and promotion of society health. The aim of this study was to explore participants’
perspectives, experiences, and preferences, regarding diabetes education problems.
MATERIALS AND METHODS: This descriptive, qualitative study was conducted from March 2016 to
September 2017. The participants were 23 people including nine patients with diabetes and their family
members and 14 members of diabetes healthcare team (physicians, nurses, and nutritionists). The
data were collected through individual semi‑structured interviews and analyzed through conventional
content analysis approach proposed by Graneheim and Lundman. Some main categories and
subcategories emerged.
RESULTS: Three main categories showed the most prominent problems of diabetes education,
namely, inadequate infrastructure for diabetes education, insufficient defined and de facto position
for the role of diabetes nurse educator, and the failure in patient‑oriented team approach in diabetes
education.
CONCLUSION: This article addresses the most important problems of diabetes education. The
fundamental strategy to overcome these problems seems to be the planning and management of
diabetes education as a high priority in the noncommunicable disease management policies of the
Ministry of Health and Medical Education.

Abstract BACKGROUND: COVID‑19 may seem to have an impact on middle‑aged and elderly people.
However, not much is known about the lived experiences of middle‑aged and elderly people during
this pandemic. The study aims to explore psychosocial and behavioral impact of COVID‑19 on the
lives of these individuals.
MATERIALS AND METHODS: Three focus group discussions and seven in‑depth interviews were
conducted. A format to guide discussions and interviews was made to bring uniformity across groups
and participants. Participants were recruited through purposive and snowball sampling techniques.
Discussions were recorded and transcribed verbatim. Thematic analysis method was used to extract
key conceptual themes.
RESULTS: There were 12 male and 10 female participants included, with a mean age of
62.2 years. Five subcategories identified were: Fear and anxiety, household confinement, lifestyle
modification, preventive practices, and coping strategies. These sub‑categories formed three major
categories‑psychological, social, and behavioral which ultimately led to the emergence of the main
theme that is, COVID‑19 effects on the life of middle‑aged and older individuals.
CONCLUSION: Middle‑aged and elderly people are affected in many ways due to COVID‑19.
Addressing the psycho‑social and behavioral problems can help in the better adjustment to tide
over the pandemic.

Abstract BACKGROUND: Health system reform plan in public health sector in Iran in the first phase focused
on improving primary health care in suburban areas in and around big cities. The present study was
conducted to assess the implementation process challenges of the reform plan in comprehensive
health service centers at suburban areas of Isfahan in 2019.
MATERIALS AND METHODS: This qualitative study with conventional content analysis approach
was conducted in 2019. Participants were purposefully selected and interviewed at provincial
levels from Isfahan University of Medical Sciences health department and health‑care providers
of comprehensive health services centers. The saturation point was reached after 21 face‑to‑face
semi‑structured interviews. Thematic analysis was employed to analyze transcribed documents
assisted by MAXQDA version 10.
RESULTS: The results revealed four main themes; the human resource management, the executive
management, the electronic infrastructure, and the resource management.The major challenges
in the implementation planning process included: the referral system, monitoring and supervision,
electronic services infrastructure in the design and development of the EHR called the SIB system,
lack of instructions guide, salaries and benefits, inconsistent financial and human resources and
inappropriate allocation of theses resources.
CONCLUSION: Despite the achievements in the development of the Iran health system reform plan,
there were many challenges in the implementation planning process. It is recommended that theses
challenges be reviewed and amended by health system managers and policymakers.

Abstract BACKGROUND: Amniocentesis is one of the methods for diagnosing prenatal abnormalities.
Pregnant women with high‑risk fetal screening results are the candidates for amniocentesis. Most
of these women are afraid of this procedure because they predict that the test will be painful and
worried about its adverse effects on pregnancy, fetal injury, or the risk of maternal death. Therefore,
the aim of this study was to determine the effect of education on the perceived stress of mothers
who are the candidates for amniocentesis.
MATERIALS AND METHODS: The present study was a quasi‑experimental, two‑group clinical trial
with a parallel design. This study was in three stages: pretest (before intervention), posttest (after
intervention), and after amniocentesis. This study was performed on 80 pregnant women who were
the candidates for amniocentesis (15–20 weeks of pregnancy) with high‑risk fetal screening results
referred to the perinatology clinic in Yazd in 2020. The intervention package included training and
using breathing techniques, broadcasting educational animations on how to perform amniocentesis,
expressing experiences by people who had experienced amniocentesis, and finally visiting the
amniocentesis site and getting to know the relevant perinatologist. Data collection tools were
demographic and midwifery profile questionnaires and Cohen perceived stress. SPSS software
version 16 was used for statistical analysis of data.
RESULTS: The results showed that the research units had high stress at the beginning of the
study. The perceived stress score at the beginning of the study in the intervention group was
30.1750 ± 6.53153 and in the control group was 28.2750 ± 8.57841. After the intervention, the
participants’ stress level decreased below the cutting point. In the experimental group, the mean
stresses after the intervention and after amniocentesis were significantly lower than before the
intervention; however, after amniocentesis, it was somewhat higher than the postintervention stage.
In the preintervention stage, the mean stress score between the two groups was not statistically
significant. The difference after the intervention between the two groups was significant (P < 001.0);
however, in the postamniocentesis stage, the difference in stress was not significant. After the
intervention and after amniocentesis, the perceived stress of pregnant mothers in the experimental
group was less than the control group.
CONCLUSION: Considering that the perceived stress in amniocentesis candidate mothers was
high in the present study, so that after performing the method, mothers left the center with high
stress, it is very important to pay attention to its psychological aspects. Therefore, it is suggested
that educational interventions before and during amniocentesis be considered for them along with
psychological support and follow‑up care after amniocentesis.

Abstract BACKGROUND: The objective was to assess the prevalence and the associated demographic
factors of stress, anxiety, and depression among undergraduate (UG) Indian dental students and
determine whether the pattern is different in government‑run institutions and those managed by
private authorities.
MATERIALS AND METHODS: A cross‑sectional study was conducted among dental UG students
from five dental colleges. Snowball sampling was used to approach 776 potential participants, resulting
in a complete response from 507 students. The questionnaire consisted of demographic data; year
of study; type of college; accommodation; and Depression, Anxiety, and Stress Scale (DASS)‑42.
Descriptive data and inferential statistics were obtained. Chi‑square test was applied for categorical
data to test for significance, and higher analysis was done using multiple linear regression.
RESULTS: Females and males comprised 71.8% (n = 364) and 28.2% (n = 143) of the study
population, respectively. The prevalence of anxiety was highest (66.86%, n = 339), followed by
depression (57.39%, n = 291) and stress (43.99%, n = 223). In terms of severity also, anxiety was
the most prevalent condition as more than one‑fourth of the students presented with severe and
very severe scores in this aspect (25.43%, n = 129) compared to depression (14.39%, n = 73) and
stress (10.09%, n = 51). Regression analysis revealed age as a strong positive predictor for all the
three conditions, while staying in the hostel was a positive predictor for anxiety and stress. Being
female was also an independent predictor for the high prevalence of stress.
CONCLUSION: Stress, anxiety, and depression are highly prevalent among Indian dental students.
Clinical students and interns have a higher prevalence of stress than preclinical students. Age,
being female, and staying in the hostel are positive predictors for the severity of stress. There is no
significant difference between government and private colleges, regarding the prevalence of any
psychological condition.

Abstract BACKGROUND: Although surgical techniques have been improving, preoperative anxiety is still
a challenge in preoperative care and is known as an expected response experienced by patients
waiting to undergo surgery. The present study aimed to compare preoperative anxiety levels in three
educational hospitals in Kerman.
MATERIALS AND METHODS: This cross‑sectional study was conducted in three educational
hospitals in Kerman, Iran, from December 2017 to May 2018. The participants were 100 patients from
each hospital (300 patients in sum) who were selected through the convenience sampling method.
Sampling was not restricted to sex and type of surgery. The 40‑item Spielberger State‑Trait Anxiety
Inventory was administered to the patients to assess the level of preoperative anxiety experienced
by them. Bivariate linear regression models were used to compare the preoperative state anxiety
levels based on the patients’ demographic information. A multivariate linear regression model was
used to determine the predictors of preoperative state anxiety.
RESULTS: The participants were 149 males and 151 females with a mean age of 36.38 (12.75)
years (age range: 12–79 years). Almost two‑third of the patients showed upper‑middle symptoms
of state anxiety (n = 197, 65.7%) followed by upper‑middle symptoms of trait anxiety (40% and
49.3%, respectively). There was a significant relationship between the patient’s sex and state
anxiety (P = 0.05) and also between trait anxiety and state anxiety (P ≤ 0.001). It was shown that
train anxiety could predict state anxiety before surgery (B: 0.53, 95% confidence interval: 0.44, 0.62;
P ≤ 0.001).
CONCLUSION: The results of the present study confirmed the presence of preoperative anxiety in
a sample of Iranian patients. Although the anxiety scores were not very high, organizing intervention
and training programs to control and reduce preoperative anxiety among patients seems essential.

Abstract BACKGROUND: Lecturing (didactic) has been the key teaching-learning method for a long time.
As per competency-based medical education, an Indian medical graduate should be competent in
recommended skills. In the subject of Community Medicine of medical undergraduation, “Biostatistics”
is one of the components of the curriculum. Often the students find the statistics challenging to
understand and thus neglect it or prefer rote learning. In the recent era, many newer teachinglearning modalities have come up, namely problem-based learning (PBL), small group teaching,
community-based learning, etc. The objective was to compare the utility and effectiveness of PBL
versus traditional teaching techniques (didactic) for Biostatistics.
MATERIALS AND METHODS: The study was conducted in the department of Community Medicine,
Government Medical College, Azamgarh (Uttar Pradesh) from March to November 2019. A total of
96 medical students of the final year were randomly divided into two groups. ‘Group A’ underwent
didactic lecturing whereas “Group B” had problem‑based learning for identified topics in Biostatistics.
The teaching material and instructors were the same for both groups. Two weeks after completion
of sessions, students’ assessment was carried out for both groups.
RESULTS: The study demonstrated that the PBL method was a more effective way of teaching-learning
statistics compared to didactic lecturing. A significant difference (P < 0.05) was observed between
the mean examination score of Group A (traditional teaching technique) and Group B (PBL). Group
B had higher scores than group A in all assessment heads (Objective, Descriptive, and Viva-voce).
PBL was perceived to be a student-centric Teaching-learning method promoting analytical skills,
critical thinking & overall self-directed learning.
CONCLUSION: PBL teaching method was found to be effective in improving the students’
performance in Statistics in comparison to didactic lecturing.

Abstract Community empowerment has been proposed since the 1980s as a way to increase people’s power
to influence social determinants of health. However, community empowerment for health promotion
in urban slums still faces challenges. The present study examined interventions, challenges, actors,
scopes, and the consequences mentioned in various studies and with emphasizing interventions
and executive challenges tried to create a clear understanding of empowerment programs in slums
and improving their health. Narrative review method was used to conduct the study. Databases
including PubMed, Scopus, Embase, Web of Science, and Cochrane were searched. The selection
of studies was done according to the “community empowerment” defined by the World Health
Organization, the concept of bottom–up approach for health promotion of Laverack and Labonte’s
study and definition of slums by UN-HABITAT. Finally, Hare and Noblit’s meta-synthesis was used
to analyze the studies. From 15 selected studies, the most intervention proposed for empowerment
was identified to be “residents’ participation in expressing problems and solutions.” The challenge of
“creating a sense of trust and changing some attitudes among residents” was the greatest challenge
in the studies. Moreover, “improving living conditions and health services” were the most important
outcomes, “slum residents” and “governments” were the most important actors, and “sanitation”
was the most important scope among the studies. Having a comprehensive view to the health and
its determinants and attention to the factors beyond neighborhood and health sector would lead to
fewer implementation challenges and better intervention choices to health promotion of slum dwellers.

Abstract BACKGROUND: Gestational diabetes mellitus (GDM) is a common complication of pregnancy. The
goal of this study was to compare health‑promoting lifestyles and irrational health beliefs in pregnant
women with GDM and healthy pregnant women.
MATERIALS AND METHODS: The present study was a descriptive causal‑comparative study in
which 100 eligible GDM women and 100 eligible healthy women were selected through available
sampling in three referral hospitals in Tehran In 2020. In this study, the Health Promoting Lifestyle
Profile (HPLP) and the Irrational Health Beliefs Scale (IHBS) were used. Data were analyzed using
independent t‑test and logistic regression by SPSS 16 software.
RESULTS: Findings showed that there is a significant relationship between the variables of IHBS
and HPLP. For every one unit increase in an IHBS score, the chance of having diabetes increases
by 2.8%. In the case of HPLP, women who exercised well were 7.5% less likely to develop diabetes,
and those who took good responsibility were 7.8% less likely to develop diabetes. Furthermore,
in independent t‑test, the HPLP variable showed a significant difference between the two groups
with diabetes and healthy individuals (P < 0.001). Furthermore, in comparing the subscales of this
variable, physical activity (P < 0.0001), self‑fulfillment (P < 0.004), responsibility (P < 0.003), and
stress control (P  <  0.001), a significant difference was observed. The results of IHBS research
showed a significant difference between the two groups of gestational diabetes and healthy
individuals (P < 0.004).
CONCLUSION: The results of the present study show the need to identify and focus on irrational
health beliefs and health‑promoting lifestyles. Modification of these psychological structures can be
useful in the prevention and management of this chronic disease.

Abstract BACKGROUND: The postpartum period can be considered as one of the most sensitive stages of
life in different countries; however, it is inadequate in many developed and developing countries.
We aimed to determine the educational needs of mothers in the postpartum period in Bojnourd.
MATERIALS AND METHODS: This study was conducted in Bojnourd 2019 with two parts: a
qualitative part using the content analysis method and a quantitative part using the descriptive
cross‑sectional method. Data were collected 45 interviews with women, spouses, and key informants.
All content was recorded and fully transcribed on paper. MaxQda10software was used for the data
management. A simultaneous descriptive cross‑sectional study was done including 250 pregnant
in the third trimester (25.6%), in the first 48 h after delivery (24.4%), in the first 6 months after
delivery (24.4%), and in the second 6 months after childbirth (25.6%) who referred to five health centers
in Bojnourd to receive midwifery care. Quota sampling was performed for each center according to
the population covered, and convenient sampling was done in each center.
RESULTS: In the qualitative study, educational needs were classified into four main categories,
including “maintaining and restoring physical health,” “sexual health needs,” “mental health needs,”
and “educational barriers.” In the quantitative study, according to the findings, the most educational
needs among mothers were self‑care and breastfeeding and the best time for teaching was during
the pregnancy, and the best method was face‑to‑face training and the best source of information
was midwives and gynecologists.
CONCLUSION: Attention to the educational needs of each region can be done through various
training courses and continuous retraining to promote health provider and should be considered in
the planning officials.

Abstract BACKGROUND: The COVID‑19 pandemic has spread rapidly across the world and has currently
impacted most countries and territories globally. This study aimed to identify health‑care determinants
of mortality and recovery rates of COVID‑19 and compare the efficiency of health systems in response
to this pandemic.
MATERIALS AND METHODS: A cross‑sectional study was conducted using data obtained from the
World Bank database, that provides free and open access to a comprehensive set of health‑ and
socioeconomic‑related data, by September 12, 2020. An adjusted linear regression model was
applied to determine predictors of mortality (per 1 million population [MP]) and recovery rates (per 1
MP) in the included countries. One‑way analysis of variance was applied to assess health systems’
efficiency in response to COVID‑19 pandemic using mortality and recovery rate (output variables)
and current health expenditure (CHE) per capita (input variable).
RESULTS: Globally, San Marino and Qatar had the highest mortality rate (1237/1 MP) and confirmed
case rate (43,280/1 MP) until September 12, 2020, respectively. Iran had a higher mortality rate (273/1
MP vs. 214.5/1 MP) and lower recovery rate (4091.5/1 MP vs. 6477.2/1 MP) compared to countries
with high CHE per capita. CHE per capita (standardized coefficient [SC] = 0.605, P < 0.001) and
population aged 65 years and over as a percentage of total population (SC = −0.79, P < 0.001)
significantly predicted recovered cases from COVID‑19 in the included countries.
CONCLUSION: This study revealed that countries with higher CHE per capita and higher proportion of
older adults were more likely to have a higher recovery rate than those with lower ones. Furthermore,
our study indicated that health systems with higher CHE per capita statistically had a greater efficiency
in response to COVID‑19 compared to those with lower CHE per capita. More attention to preventive
strategies, early detection, and early intervention is suggested to improve the health system efficiency
in controlling COVID‑19 and its related mortalities worldwide.

Abstract BACKGROUND: The concept of reflective practice is at the center of professional practice, allowing
a bridge between theory and practice and learning from our own experiences in an ongoing process.
Understanding what learners need such as regular observation of work, more responsibility, and
technical and problem‑solving with answers allows the teacher to help learners to progress to
independence in pursing their own learning needs. Therefore, it is important that medical educators
continually reflect and evaluate teaching ability to meet learners’ needs and provide evidence to
support it.
MATERIALS AND METHODS: A prospective, qualitative study was carried out using a combination
of questionnaires and observed assessments. The study participants consisted of twenty final‑year
medical students from King’s College London and took place at a hospital education center in the
UK, April 2019. Two educational sessions were delivered by a doctor to the study group and a video
recording was conducted. The educator completed a reflective portfolio using feedback questionnaires,
peer observation forms, and observation of the video recording, and the results were analyzed using
a video critique tool.
RESULTS: Twenty learner feedback forms were completed, and a peer observation form was
completed. This allowed a critical analysis of educator performance, reflection, and improvement.
This was further solidified by in‑depth analysis and critique of teaching session playback video.
DISCUSSION: This study evaluates a medical student teaching program using a reflective portfolio.
This study confirms the effectiveness of using a reflective portfolio to enhance the teaching experience.
Video analysis can be self‑critical, however this study shows how it is useful to review human
experience first‑hand, and identifying any specific techniques that create a positive or negative
change can enable educators to improve as time progresses.

Abstract The Emergency Medical Services (EMSs) are in the frontline between the health-care systems and
people in emergencies and disasters. With the increase in the frequency of natural or man-made
disasters around the world, the need for prepared EMS services is increasing. This study aimed to
evaluate the current disaster preparedness status of the EMS agencies in the literature and exploring
the key preparedness elements and the strategies to improve the EMS disaster preparedness. The
electronic database such as PubMed, Web of Science, Scopus, and Google Scholar was searched
from 2000 to 2019. The searching keywords included: “EMS,” “Disaster,” “Preparedness,” “Emergency”
“Preparedness,” “Disaster Preparedness,” “Readiness,” and the terms related to “disaster types” were
used in combination with Boolean operators OR and AND. Out of 1412 articles, 7 articles were
included in the review. The most important elements of the EMS disaster preparedness include the
size and scope of the incident, surge capacity, planning, communication, training and education,
policymaking, financial support, coordination, safety and security, early warning system, disaster
response experience, and legal considerations. This systematic review showed that the EMS agencies
in the world generally are inadequately prepared for an effective response to major emergencies and
disasters. This study provides valuable information to EMS educators, EMS administrators to adopt
and perform appropriate activities to improve the EMS disaster preparedness.

Abstract BACKGROUND: Sexual health in the development of the human personality, personal, and social
health and in achieving to comfort plays an important role. Women with epilepsy are at high risk of
sexual dysfunction, which has a multifactorial etiology. This study is aimed to investigate the correlation
between the sexual function of women with epilepsy and personality factors.
MATERIALS AND METHODS: this cross‑sectional study was conducted on 100 women with epilepsy
referred to selected centers in Tehran university of medical sciences by using continuous and
availability sampling method between January and March 2014 (Iran) and evaluated with women’s
sexual function index questionnaire female sexual function index and NEO‑five‑factor of personality
inventory. Data were analyzed using SPSS software version 16 and Pearson correlation test.
RESULTS: The mean sexual function overall score in participations was 23.33 ± 2.82 there was a
significant negative correlation between neuroticism and sexual function (P = 0.00, r = −0.03) and
was significant positive correlation between personality traits as extraversion (P = 0.00, r = 0.63),
agreeableness (P = 0.008, r = 0.26) and conscientiousness (P = 0.04, r = 0.20) and openness to
new experiences (P = 0.03, r = 0.21) and sexual function in women with epilepsy.
CONCLUSIONS: Results indicate that the personality traits can affect on sexual health and sexual
function of women with epilepsy. Therefore, it is recommended that health‑care providers with
assess personality factors in women with epilepsy as a prognostic factor, take steps to prevent
sexual dysfunction.

Abstract BACKGROUND: Transfusion of healthy red blood cells (RBCs) after storage is important. One of
the storage lesions on blood bags is oxidative stress. One way to prevent increased oxidative stress
is to use antioxidant nanoparticles (NPs). Superoxide dismutase (SOD) and catalase (CAT) play
an important role in antioxidant defense on RBC. poly lactic-co-glycolic acid (PLGA) is a nontoxic
biodegradable polymer that is approved by the Food and Drug Administration for drug delivery. This
study aimed to assess dose-dependent efficacy of SOD-CAT-polyethylene glycol -PLGA on RBCs
storage.
MATERIALS AND METHODS: Using a descriptive study, during 1 month, twenty donors from
Bojnourd Blood Donation Center were selected. NPs with different concentrations were injected
into the satellite bags after directing blood to them. On target days, experiments were performed on
the samples taken. Electrospray was employed to prepare SOD-CAT-PLGA NPs. Twenty packed
RBCs were isolated from the whole blood bags by the mechanical method, and certain amount of
product was transferred to the satellite bags. On days 1, 7, 14, 21, 28, and 35, bags were sampled.
Malondialdehyde (MDA), prooxidant-antioxidant balance (PAB), and Annexin V were performed on
the samples taken. The repeated measures analysis with the help of SPSS software version 20
was performed on samples.
RESULTS: MDA increased in both groups. The maximum increase in test group was seen in
concentration 12 mg (MDA Day 14, test [1.93 ± 0.3], [P MDA < 0.001]). Maximum increase in PAB
was seen in concentration 12 mg (from 444 ± 1.7 to 563 ± 2.5) (P PAB = 0.000). Furthermore,
PS expression increased in the concentration of 12 mg greater than other concentration in
consecutive (from 5.00 ± 0.8 to 22.26 ± 1.7, [P < 0.001]).
CONCLUSION: Evaluation of dose dependency showed that different concentrations of antioxidant
NPs affect RBC. This effect can be changed oxidative stress and apoptosis. Using both changes to
evaluate functional and toxicity can be helpful.

Abstract BACKGROUND: Universities are changing from government organizations into third generation. The
aims of this study were to identify the dimensions and components of a third‑generation university
and assessment of the status quo of Iran University of Medical Sciences.
MATERIALS AND METHODS: This study was mixed method. In the qualitative phase, participants
consisted of experts of academic management and scholars in third‑generation universities. The
dimensions and components of a third‑generation university were identified by content analysis.
A questionnaire was prepared according to dimensions and components with Cronbach’s alpha of
0.86. In the quantitative phase, participants consisted of managers and experts of Iran University
of Medical Sciences; they completed the questionnaire to assess the status quo of Iran University.
Data analysis was performed by Colaizzi’s and SPSS software.
RESULTS: Third generation of universities of medical sciences has 2 dimensions and 17 components.
Software dimension consists of course content, attitude, vision and mission of the university,
organizational culture, instructors, students, employees, academic management and leadership,
international approach, and social accountability components. Hardware dimension consists of
organizational structure, academic infrastructures, knowledge commercialization, and communication
with the government, education system, university environment, and university independence
components. Status in Iran University of Medical Sciences in hardware dimension was 2.53, and in
software dimension, it was 2.96.
CONCLUSION: Universities are required to respond to the changes in community. Therefore,
universities need to change their structures, goals, approaches, perspectives, and intra‑organizational
and extra‑organizational communications to be able to move toward a university which is entrepreneur,
skill teaching, wealth generating.

Abstract BACKGROUND: In diabetic foot infections (DFIs), the diversity of microbial profile and ever‑changing
antibiotic‑resistance patterns emphasize accurate characterization of microbial profile and antibiotic
susceptibility pattern. The aim of the study was to investigate the pathogens associated with DFI
and their antibiotic susceptibility patterns.
MATERIALS AND METHODS: A cross‑sectional retrospective study was conducted at a tertiary‑care
hospital, Oman. The socio‑demographic and microbiological profile and antibiotic susceptibility
patterns of pathogens isolated from patients with DFIs from January 2013 to December 2018 were
reviewed. Quantitative and qualitative variables were expressed as mean ± standard deviation
and percentages, respectively. A Chi‑square test was used for testing the association between
multidrug‑resistant (MDR) organisms and variables.
RESULTS: In total, 233 isolates recovered from 133 clinical specimens with an average of
1.8 organisms per specimen were included in the study. Fifty‑six and forty-four percent of specimens
showed monomicrobial and polymicrobial growth of two or more organisms, respectively. The
frequency of isolation was predominant among males (65%). Aerobic Gram‑negative rods were
predominantly (75%) isolated compared to Gram‑positive organisms (25%). Staphylococcus aureus
and Pseudomonas aeruginosa were the most frequently isolated Gram‑positive and Gram‑negative
bacteria, respectively. Thirty‑eight percent of them were MDR strains. Gram‑negative organisms
showed fairly good susceptibility ranging from 75% to 100% to carbapenems, aminoglycosides,
and piperacillin‑tazobactam. While doxycycline and trimethoprim‑sulfamethoxazole showed good
susceptibility toward Gram‑positive organisms.
CONCLUSION: DFIs are often polymicrobial with a predominance of Gram‑negative pathogens. This
study recommends the use of carbapenems and doxycycline for empirical therapy of Gram‑negative
and Gram‑positive bacterial DFIs, respectively.

Abstract Abstract:
BACKGROUND: Any prediction of a person’s ability to succeed in a motor skill depends on the
detection and accurate measurement of the basic abilities for the performance of that skill. Task
analysis is needed to determine the psychomotor skills and abilities required to perform an action.
This study aimed to determine the components of psychomotor abilities for diagnostic upper
gastrointestinal (GI) endoscopy through procedural task analysis (PTA) and expert review.
MATERIAL AND METHODS: A multisource, multimethod task analysis was conducted in six
metropolitan teaching hospitals affiliated with the adult gastroenterology and hepatology training
centers in the Islamic Republic of Iran in 2019. Observation, video-recording, and think-aloud protocols
were used while diagnostic upper GI endoscopy was performed. To confirm the accuracy of the
PTA, the incorporated the views of the adult gastroenterology and hepatology subspecialty experts
through the checklist of PTA assessment criteria. Finally, to determine the psychomotor abilities for
each stage of the procedure, the study incorporated a panel of experts from occupational therapy,
physical education, physical medicine, and adult gastroenterology and hepatology subspecialty.
RESULTS: Of the 15 psychomotor abilities examined, 11 were determined for upper GI endoscopy
procedure, of which six cases (including visuospatial and perceptual abilities, hand–eye coordination,
multilimb coordination, finger dexterity, arm–hand steadiness, and manual dexterity) were the most
frequent.
CONCLUSIONS: PTA techniques and subsequent expert review were used to identify the components
of psychomotor abilities for diagnostic upper GI endoscopy. It is suggested that PTA is performed
for other procedures, and after psychomotor abilities are specified, proportional tests are developed.

Abstract BACKGROUND: One of the influential factors in students’ learning is their learning styles which have
the capacity to change. Furthermore, creativity is considered one of the essential cognitive features of
humans. Thus, this study aimed to analyze the relationship between learning styles (Kolb and VARK)
and emotional creativity with the academic achievement of dental students.
MATERIALS AND METHODS: In this descriptive‑analytical study, the statistical population included
dental students of the third semester and above (250 persons). The data collection tools included
Kolb and VARK learning style questionnaires, Averill emotional creativity questionnaire, the total
Grade Point Average (GPA), and the GPA over the past two semesters of students to measure
academic achievement. The data were analyzed using the measures of the descriptive (mean and
standard deviation) and the inferential statistics tests including one‑sample t‑test, independent t‑test,
correlation coefficients of Pearson, and Eta squared.
RESULTS: Based on Kolb and VARK learning styles, the majority of the students had accommodating
learning style (64%) and read‑write style (31.6%) and also were single‑styled (80.4%). No significant
relationship was found between the learning styles (Kolb and VARK) and creativity with academic
achievement. The students scored higher than average in emotional creativity and all of its three
elements. Moreover, there was a significant relationship between emotional creativity and the gender
of the students (P = 0.01). Female students showed higher emotional creativity (97.26 ± 10.34)
compared to the male students (94.24 ± 8.96).
CONCLUSION: There was no significant relationship between learning styles and emotional creativity
of the students with their academic achievement. The accommodating and read‑write learning styles
were more prevalent among students and they showed high emotional creativity.

Abstract BACKGROUND: Smokeless tobacco use is a public health problem. This study explored students’
beliefs about smokeless tobacco use in Chabahar, Iran.
MATERIALS AND METHODS: The qualitative study was conducted using three Focused Group
Discussions among 24 students aged 12–14 years in Chabahar City. Focus Group Guide Morgan
was used. Qualitative Content Analysis was used to explore and extract codes and themes. The
data analysis process was carried out in accordance with the stages of proposed by Graneheim and
Lundman. Guba and Lincoln criteria were used for evaluating research transferability.
RESULTS: Two main themes emerged from the analysis including; beliefs of being useful and
harmful. Each of these themes is divided into subthemes with useful or harmful physical and
psychological beliefs. Four subthemes included: beliefs of being useful physically, beliefs of being
useful psychologically, harmful beliefs physically, and harmful beliefs psychologically.
CONCLUSIONS: One of the more significant findings to emerge from this study is that many students
mentioned the benefits of using smokeless tobacco to reduce toothache, relieve headaches, and bad
breath. This information can be used to develop targeted interventions aimed at reducing smokeless
tobacco consumption. However, more research on this topic needs to be undertaken before the
association between kinds of beliefs and smokeless tobacco consumption is more clearly understood.

Abstract BACKGROUND: With growing resident burnout, Accreditation Council for Graduate Medical
Education issued new requirements for program interventions to optimize resident well‑being. Little
evidence exists on how to best teach resiliency to residents. This study assesses the impact of
both a grassroots intervention and formal resiliency curriculum on resident burnout and well‑being.
MATERIALS AND METHODS: From November 2016 to August 2017, residents in a large Internal
Medicine Residency Program participated in grassroots wellness interventions from the resident‑led
Gator Council in Gainesville, FL USA. From August 2017 to June 2018, residents participated in
a formal program‑driven resiliency curriculum. Wellness interventions included monthly morning
reports, bimonthly workshops, and biannual noon conferences. Pre‑ and postintervention Maslach
Burnout Inventory (MBI) and Physician Well‑Being Index (PWBI) assessed the effect of both
interventions on resident burnout and well‑being. Statistical analyses used Student’s t‑test, Fisher’s
exact tests, and linear regression model.
RESULTS: One hundred and twenty‑two residents participated in grassroots interventions. One
hundred and seventeen (87 residents, 35 students) participated in formal curriculum. Mean MBI
scores for all three sections did not differ between pre ‑and postgrassroots intervention (emotional
exhaustion [EE] P = 0.46; depersonalization [DP] P = 0.43; personal accomplishment [PA] P = 0.73])
or between pre‑ and postcurriculum (EE P = 0.20; DP P = 0.40; PA P = 0.51). Students scored
higher burnout levels compared to residents in EE (P = 0.001) and PA (P = 0.02). Pre‑ versus
postcurriculum PWBI scores did not differ among residents (P = 0.20), while PWBI scores improved
among students (P = 0.01).
CONCLUSIONS: This study found no improvement in resident burnout or well‑being from a
bottom‑up and top‑down approach. Our results imply the need for an early wellness curriculum
to improve student well‑being given their higher level of burnout. System‑wide efforts are vital to
combat physician burnout.

Abstract BACKGROUND: Individuals with disordered eating are at an increased of having one or more
additional risks for comorbid disorders, such as anxiety disorder, depressive disorder, and insomnia.
Therefore, the present study aimed to investigate the mediating role of self‑compassion in the
relationship between positive reactivity, negative reactivity, and perfectionism with disordered eating.
MATERIALS AND METHODS: The study method was descriptive‑correlational through
structural equation modeling (SEM). The present study population included all students of the
University of Tehran in the city of Tehran in 2018–2019. A total of 302 students were selected
by convenience sampling method and completed questionnaires on eating attitudes test‑8,
self‑compassion scale (short form), eating disorder inventory‑perfectionism scale, and Perth emotional
reactivity scale. The SEM path analysis and Pearson correlation coefficient were conducted to analyze
the obtained data in SPSS‑23 and Lisrel‑8.80.
RESULTS: The finding of the path analysis showed that self‑compassion acts as a mediating  role in
the relationship of disordered eating with positive and negative emotional reactivity and perfectionism.
Only the direct effect coefficient of general positive reactivity on disordered eating was not significant.
CONCLUSION: Based on the results of this study, self‑compassion can serve as a protective factor
against negative emotional reactivity and perfectionism. Therefore, self‑compassion can be considered
in the development of prevention and treatment programs for disordered eating.

Abstract BACKGROUND: The knowledge level of caregivers and their support for patients can affect the
self‑care of patients with heart failure (HF). The present study was conducted to compare the effects
of teach‑back, multimedia, and blended training methods on self‑care and social support in patients
with HF and on knowledge in their caregivers.
MATERIALS AND METHODS: In a randomized clinical trial, a total of 150 HF patient‑caregiver dyads
were randomly allocated into three equally sized training groups, using a simple number table (n = 50). The
study was conducted between May to October 2018 in Sari, northern Iran. In the teach‑back, multimedia
and blended training groups, patient‑caregiver dyads participated in 20–30‑min training sessions held
face‑to‑face, using digital video disc (DVD) and combination of teach‑back and DVD on 4 consecutive
days at the bedside of hospitalized patients in coronary care unit, respectively. Data were collected using
the European Heart Failure Self‑Care Behaviour Scale and the multidimensional scale of perceived social
support for patients. Caregivers’ level of knowledge was measured using the HF Knowledge Scale. Data
were measured on the first day of hospitalization, 1 day before discharge and 4 and 8 weeks after patients’
discharge. Data were analyzed using SPSS version 18 (SPSS Inc., Chicago, IL, USA).
RESULTS: All three educational methods improved self‑care behaviors in patients. The comparison of
self‑care behavior scores in patients with HF among the three groups at different time points showed
no statistically significant differences (P > 0.05), except 1 day before discharge (P = 0.04). There
were no statistically‑significant differences between the teach‑back, multimedia and the blended
training group in terms of perceived social support at any of the four‑time points (P > 0.05). All three
training methods improved the level of knowledge of caregivers. However, the score in the blended
training groups was higher than the other groups (P < 0.001).
CONCLUSION: According to the results of the present study, it seems that all three educational
interventions can improve self‑care behaviors in HF patients and increase knowledge in their
caregivers. However, using the blended training method was associated with better outcomes.

Abstract BACKGROUND: Management of cancer complications requires the provision of palliative care as a
comprehensive care by the main and trained members of this method of care. The aim of the present
study was to assess the compliance of educational curricula of selected disciplines with the content
standards of cancer‑related palliative care.
MATERIALS AND METHODS: In this descriptive–comparative study, the content standards of
palliative care for nurses, physicians, and social workers were identified based on the World Health
Organization guideline and Oxford Textbook of Palliative Nursing. For this purpose, a separate
checklist was prepared for the disciplines with different dimensions. Then the face and content
validity of the checklists were checked. Finally, we examined the coordination between selected
curricula available on the website of Education Deputy of the Ministry of Health, Treatment and
Medical Education with the dimensions of the checklists.
RESULTS: All three curricula in most domains were relevant with the content standards, but there
was the biggest education need in the areas related to the dimensions of “planning and educational,”
“educating physician in palliative care,” and “considering patient preferences” in these disciplines.
CONCLUSIONS: To meet the educational needs, it is suggested to change some course topics,
hold training courses, or joint workshops.

Abstract Palliative care and terminal patients care centers have an important role in improving the physical
and psychological state of the patient and their families and increasing their satisfaction and care
providers. A literature search of online databases (PubMed, Scopus, Web of science, Cochrane
library, and Google Scholar) was searched from January 1, 2000, to the end of April 2019, by using
the appropriate English keywords. Furthermore, IranMedex, Barkat, and Magiran databases were
searched for the Persian articles. We used Standards for Reporting Qualitative Research checklist
to evaluate the articles quality. From 1328 articles, 166 were reviewed in depth with 13 satisfying
our inclusion criteria. The findings of this study revealed a wide range of barriers and challenges to
palliative care delivery. The identified barriers were: Cultural, social and organizational barriers, lack
of resources, equipment and financing, attitudes and cultures, barriers related to the patient and the
patient’s family, related barriers providers, time and money, education, communication challenges,
policies, insurance problems, safety, and crisis management. The results of the studies showed that
there are various barriers and challenges such as economic, cultural, social, organizational, and
communication related to palliative care. Given the identified barriers and challenges, it is suggested
that to improve the delivery of palliative care, the health system policy‑makers and planners consider
a resource‑appropriate and culturally appropriate framework for palliative care delivery.

Abstract BACKGROUND: Measurement of the essential risk factors for work‑related musculoskeletal disorders
is a fundamental step in predicting the problem and identifying high‑risk individuals. In this regard,
Maastricht upper extremity questionnaire (MUEQ) has not been validated in Iran. This study aimed
to develop a valid and reliable Persian version of MUEQ.
MATERIALS AND METHODS: In this descriptive study, the computer users employed in a
governmental informatics administration in Tehran, Iran, were included during the end of 2018 and
early 2019. Face and content validity of the MUEQ was conducted, and a six‑part questionnaire
was provided. The reliability of the questionnaire was obtained using Cronbach’s α and test–retest.
Concurrent validity was assessed with Nordic Musculoskeletal Questionnaire (NMQ). Exploratory and
confirmatory factor analysis, comparison test of independent mean, internal consistency coefficient,
test–retest, and Pearson correlation were carried out using the AMOS and SPSS 22 software.
RESULTS: Participants consisted of 282 computer users (110 males) with a mean age of
35.17 ± 7.65 years. The mean duration of computer use in a working day was 6.68 ± 2.10 h with
a range of 1–12 h. The most prevalent symptoms were existed in the neck (39.1%), back (31.0%),
and lower back (30.3%) areas. KMO test and Bartlett’s test of sphericity showed that a significant
correlation existed among questions. Cronbach’s alpha coefficient of the questionnaire varied
from 0.61 to 0.83 and test–retest coefficient was higher than 0.7.   Correlation coefficient was
between NMQ and body posture (r = 0.23, P = 0.004) and between NMQ and work environment
(r = 0.28, P = 0.000). Evaluations related to the construct validity and concurrent validity demonstrated
that the questionnaire has acceptable construct validity. Six factors of the MUEQ in Root Mean
Squared Error Approximation (RMSEA) index (0.062) were acceptable and satisfactory in Parsimony
Comparative Fit Index (PCFI), Comparative Fit Index (CFI), Normed Fit Index (NFI), and Parsimony
Goodness of Fit Index (PGFI) (0.732, 0.8000, 0.680, and 0.680, respectively).
CONCLUSIONS: The Persian version of the MUEQ represented a satisfactory validity and reliability
and was suitable for computer users in the assessment of their risk factors of musculoskeletal
complaints.

Abstract BACKGROUND: Although a certain amount of stress is essential, excessive stress can adversely
influence the physiological and mental health. Hence, this study aims to assess common stressors
and coping strategies among university students.
MATERIALS AND METHODS: This qualitative study was conducted from October to November
2019 in Iran. Twelve students were recruited based on purposeful sampling to participate focus group
discussions (FGD). Transcripts of three sessions of FGD were analyzed applying Graneheim and
Lundman (2004) approach, and a thematic network was applied to illustrate the findings.
RESULTS: The finding emerged 78 codes, 14 subthemes, and 4 main themes. Stressors were
classified in two main themes, including individual stressors and the social ones. Behavioral strategies
and the cognitive ones were among two categories of coping strategies. According to the thematic
network, a full stress student affecting the precious stressors and the social, cultural, and the economic
context may manage his/her stress applying the coping strategies.
CONCLUSION: The findings revealed that university students experienced different kinds of stress,
and usually, they do not apply right coping strategies. It is important to establish stress counseling
programs for university students. Besides, it is proposing to provide 1st year university students with
workshops about the cause of stress and effective coping strategies.

Abstract BACKGROUND: Distance digital learning is newly implemented in the Indian medical institutions.
Formative assessment is also conducted online. In this context, this study aimed at finding the
perception on the usefulness of online formative assessment along with online classes among
1st‑year medical students.
MATERIALS AND METHODS: This cross‑sectional, observational study was conducted in August
2020. The students were exposed to online classes and online formative assessments with five
multiple choice questions for a period of 4 months before the conduct of the survey. An online survey
was conducted (both quantitative and qualitative data collection) to ascertain the perception on the
online formative assessment quiz.
RESULTS: A total of 36 (14 female, 21 male, 1 did not disclose sex) 1st‑year medical students with a
mean age of 19.97 ± 1.16 years participated in the survey. The majority of the students agreed that the
online quiz was a valuable learning activity and has potential to replace the face‑to‑face assessment.
The online quizzes provided them feedback of classroom learning and helped in identifying the weak
area and motivated students to the study. The qualitative data showed that students like to get a
greater number of questions and also like to participate in chapter wise multiple quizzes in spare time.
CONCLUSION: First‑year medical students considered the online formative assessments quiz
coupled with the online classes as a valuable learning activity. It provided them feedback of learning
and a motivation for further study on the topic. They like to participate in anonymous quiz with a
greater number of questions with online classes. The finding of this pilot study should be further
evaluated with multicenter study with more participants.