Journal of Education and Health Promotion

Abstract

Abstract BACKGROUND: Health literacy is an important variable in the promotion and improvement of the
health of all social groups, especially the elderly people. It indicates cognitive and social skills that
specify the individuals’ motivation and ability to access and perceive information using methods
for health retention and improvement. The present research aimed to study health literacy and its
relevant dimensions in a population over 60 years of age in Farsan city.
MATERIALS AND METHODS: A cross‑sectional study on 384 older people in Farsan city was
conducted, using a standard health literacy questionnaire including 33 items and 5 dimensions on
a 5‑point Likert scale for collecting data. Data analysis was done using descriptive and analytical
statistics, using the multiple linear regression analysis.
RESULTS: Among the dimensions, the highest and lowest scores belonged to decision‑making and
reading skill dimensions, respectively. The multiple linear regression analysis revealed that among
the demographical variables, education level, age, sex, and job were the best predictors of total
scores of health literacy (P < 0.001).
CONCLUSIONS: The health‑related institutions should make effort to improve the elderly people’s
health literacy based on general literacy, using suitable methods with less need to read and paying
attention to personal characteristics.

Abstract The sense of coherence (SOC) is defined as a personal orientation to life. People with higher SOC
are better at dealing with stressful situations, psychological stress, and problems and are more able
to manage them, leading to better general health. The purpose of this study was to evaluate the effect
of SOC on the oral health status of people in different age groups. A systematic search up to May
2019 was carried out in PubMed,Scopus, Psycho info, and Persian sources. Studies were included
if they evaluated the relationship between SOC and oral health behaviors (OHBs) or oral health
status including dental caries. The Newcastle‑Ottawa checklist was used to appraise the selected
articles and meta‑analysis of included studies were performed using Comprehensive Meta‑Analysis
software. Value of P < 0.05 was considered to be statistically significant. Odds ratio (OR) was used
to measure effect size with 95% confidence interval (CI). The random‑effects model was chosen
in the presence of heterogenicity. I2 index and Q index were used to measure the heterogeneity
present between the studies. Fifteen articles received the minimum score of criticism. In general,
SOC could significantly affect the oral health and OHBs of adults independently of the underlying
factors. There was a significant relationship between SOC and tooth decay in adolescents, but this
association was poor after adjusting for the underlying factors. In children, only one article revealed
an association with OHBs. Meta‑analysis revealed that SOC was significantly associated with the
caries rate (OR = 0.78, CI 95% = 0.9–0.67, P = 0.001) and tooth brushing frequency (OR = 1.22,
CI 95% = 1.1–1.31 and P < 0.001). Sense of coherence appears to be one of the effective factors
in predicting oral health behaviors and ultimately oral health, especially in adults. The number of
articles available for children and adolescents was not sufficient in this regard.

Abstract CONTEXT: Virtual learning is not without challenges. It can cause stress, lack of motivation, and social
isolation. Due to COVID‑19 pandemic, our college shifted from face‑to‑face to virtual teaching–learning
style. the aim was to find out the barriers in virtual learning among medical students and provide
solutions to overcome them.
MATERIALS AND METHODS: This cross‑sectional study was conducted among 3rd‑ and 4th‑year
Bachelor of Medicine and Bachelor of Surgery students in 2020. Prevalidated electronic survey forms
on institutional barrier, technical barrier, and individual barrier were sent to students, 160 students
responded. SPSS version 12 was used to calculate descriptive statistics and independent t‑test.
RESULTS: The students had the highest mean score in individual barrier
(mean: 2.82 [standard deviation (SD): 0.72]) followed by institutional barrier (mean: 2.79 [SD: 0.74])
and technological barrier (mean: 2.72 [SD: 0.75]). Regarding technological barriers, 38.6% of the
students agreed difficulty in procurement of the laptop and 66.4% faced slow Internet connection.
Regarding institutional barriers, 75.9% were stressed to join one lecture to another lecture as the
lectures were continuous, 69.6% had limited opportunity to interact with lecturers, and 62.7% had
poor communication between lecturers and students. Regarding individual barriers, 74.1% of the
students were not motivated for online learning, 71.5% of the students could not learn as well as
they were in the classroom, and 58.2% disagreed taking online courses in future.
CONCLUSION: Low motivation, communication, Internet connectivity, and technical problems were
the main barriers. Smaller size class, highly motivated and well‑trained lecturers, and interactive
lectures may help in breaking the barriers of virtual learning.

Abstract BACKGROUND: The prevalence of water pipe smoking is increasing among young people, but
there are limited data on its use among adolescents in Iran. The aim of this study is to investigate the
prevalence of WP smoking and associated risk factors among female adolescents in Western Iran.
MATERIALS AND METHODS: This cross‑sectional study was conducted in schools. It included 1302
middle school (48.1%) and high school (51.9%) female students (grades 7–12) recruited through
stage random sampling and conducted in 2019 in the western city of Kermanshah, Iran. The data
collection tool was a researcher‑made questionnaire. Logistic regression analyses and descriptive
statistics were executed using SPSS version 22.
RESULTS: The mean (standard deviation) ages of the students and the ages when the participants
started WP smoking were 15.22 ± 1.85 and 13.64 (1.64), respectively. Nearly 32.2% had a single
experience of WP smoking during their lifetime and 20.4% were current consumers of WP. Most
of the subjects smoked WPs at their friends’ home (45.8%) and with their friends (47.4%). The
significantly important factors that affect WP smoking in these age groups are the father’s and
mother’s occupation, family size, living with others, father’s education, having a friend who smokes
WPs, friends’ encouragement to smoke WP, and being in a family that smoke WPs.
CONCLUSIONS: Considering the increasing popularity of WP among adolescent females and its
increasing prevalence, the results showed that Water pipe smoking with friends played a key role in
WP smoking among female adolescents. There is a need to design interventional studies to increase
people’s skills and to design and implement programs to prevent water pipe.

Abstract BACKGROUND: Knowledge, attitudes, and practices (KAP) toward COVID‑19 play an important
role in controlling the outbreak. The present study aimed to investigate the KAP of a group of women
toward COVID‑19 during the second wave of the outbreak in Iran.
METHOD AND MATERIAL: A cross‑sectional survey of 2862 women was conducted in May and June
2020 in two centers of Persian birth cohort . The survey instrument was a self‑reported questionnaire
Multivariable linear regression analysis to identify factors associated with knowledge and practice.
toward COVID‑19 and multinomial logistic regression analyses to identify factors associated with
attitudes. Unstandardized regression coefficients (β) and odds ratios and their 95% confidence
intervals were used to quantify the associations between variables and KAP.
RESULT: Good knowledge and optimistic attitudes toward the successful control of COVID‑19 was
seen among participants. Overall, about 57.3% (1640), 41.1% (1176), and 1.6% (46) of respondents
were categorized as low (score <50%), moderate (score: 50%–80%), and high (score > 80%) proper
practice, respectively. Eighty‑five individuals with COVID‑19 experience (3.0%) had lower knowledge
score (79.91 ± 17.93 vs. 83.81 ± 13.88, P < 0.001) and lower proper practice score (40.22 ± 16.57 vs.
47.96 ± 16.15, respectively, P < 0.001) compared to those who were not infected. A higher level of
knowledge was associated with appropriate practice in both groups of positive attitudes (χ2 = 32.23,
P < 0.001) and negative attitudes (χ2 = 31.49, P < 0.001).
CONCLUSION: This survey recorded good knowledge and relatively good attitudes among women.
Special health policies plan should be taken for target populations among women during the COVID‑19
pandemic.

Abstract BACKGROUND: Diabetes self‑management (DSM) is the cornerstone in diabetes mellitus (DM)
management. Unfortunately, the practice of DSM by Iraqi type 2 DM (T2DM) patients is poor that
mainly resulted from their poor knowledge about the required DSM behaviors. This lack of knowledge
may be attributed to the lack of DSM education and support (DSMES) program in Iraq. Thus, this
study was conducted with aim of developing and validating a culturally specific DSMES program
for Iraqi T2DM patients.
MATERIALS AND METHODS: The development and validation of the DSMES program was
done according to the Hilda Taba model. Content validity of the program was done by a panel of 6
health‑care experts in management of Iraqi DM patients. Face validity was confirmed by conducting
a pilot study for six adults with uncontrolled T2DM at the National Diabetes Center, Baghdad, Iraq.
Both the experts and patients were asked to evaluate the developed program in regard to its contents,
design, and supporting material (booklet). The evaluation was done by filling in a questionnaire that
based on a 5‑point scale. Items with a score ≥4 by <70% of the experts and patients were subjected
to revision and further assessment.
RESULTS: No total disagreement for any item was expressed by all participants (experts and
patients). Content and face validity was ensured through obtaining a positive feedback from all
participants at which all items about the program had scores of ≥4 by at least 75% of participants.
CONCLUSION: The developed culturally based DSMES program is highly suitable for educating
Iraqi T2DM patients.

Abstract BACKGROUND: Financial management system acts as a driving force and the first important principle
of health sector reform. This study aimed to prepare a framework for new financial management
system in Iran health sector.
MATERIALS AND METHODS: This qualitative study was conducted by content analysis approach
and 15 key informant participants selected through purposive sampling consisted of three minsters of
Ministry of Health and Medical Education (MOHME), three vice‑chancellors in the Center of Resource
Development and Management, Two members of the Health Assembly of the Islamic Consultative,
four Medical Sciences university’s presidents, and three managers in Budgeting and performance
Monitoring Center of MOHME in 2017. Data were collected through semi‑structured interviews and
they were analyzed using Atlas T6
 software.
RESULTS: Six main themes were emerged as follow: “legal reform,” “removing barriers to set up
accrual accounting,” “cost price calculation,” “operational planning and budgeting,” “human resources’
organization, recruitment, and moderation,” and “financial system output utilization (management
accounting techniques) as the base for evidence‑based policymaking and decision‑making practices.”
CONCLUSION: Any efforts for improving the current situation and reducing of mentioned limitations
could be useful in providing required space for future phases of reforms and calculation of unit cost,
operational budgeting, and management of cost and productivity. This can be achieved through an
integrated system of recording and producing standard and accrual financial information. Furthermore,
changing the accounting process and the financial system that complies with one single encoding
in the country is a key issue.

Abstract BACKGROUND: Anemia is a major public health problem among reproductive‑aged women in India.
Despite many programs implemented for decades to fight anemia, still the prevalence of anemia is
high because its associated factors vary among different regions. This exploratory study was carried
out to find the prevalence of anemia and factors influencing it among nonpregnant reproductive‑aged
women (15–49 years) in a rural area of Coimbatore.
MATERIALS AND METHODS: The study was conducted in the field practice area of Rural Health
Training Centre, PSG IMSR, Coimbatore, during March 2016 to August 2016. Participants were
recruited by two‑staged random sampling method and 426 participants were enrolled. A predesigned
semi‑structured questionnaire was used to collect the data pertaining to the factors influencing the
prevalence of anemia, and their hemoglobin level was measured using a hemoglobin photometer.
The data were analyzed using SPSS‑24. (IBM Corporation, SPSS Inc., Chicago, IL, USA) Univariate
analysis was done using Chi‑square test and the strength of association was estimated by odds
ratio. Those factors which were found to be significant by univariate analysis were further subjected
to multivariate logistic regression analysis. P < 0.05 was considered statistically significant.
RESULTS: The prevalence of anemia was estimated as 64.8% (95% confidence interval: 60%–69%).
Significant predictors for anemia among the study participants were less frequent intake of green
leafy vegetables (adjusted odds ratio [AOR] = 3.65, confidence interval [CI]: 2.17–6.12), low
socioeconomic status (AOR = 3.36, CI: 1.93–5.84), illiteracy (AOR = 3.09, CI: 1.09–5.24), birth
spacing <2 years (AOR = 2.49, CI: 1.19–5.25), excessive menstrual bleeding (AOR = 2.27, CI:
1.09–4.76), and inadequate knowledge regarding anemia (AOR = 2.03, CI: 1.19–3.44).
CONCLUSION: Anemia is still prevalent in high magnitude in reproductive‑aged women, and
measures to prevent and control it are not optimum. Hence, its multifactorial determinants have to
be addressed to alleviate its burden.

Abstract BACKGROUND: India is a lower middle‑income country with one of the fastest growing economies
in the world. Despite improvements in its economy, it has a high child mortality rate, with significant
differences in child mortality both between and within different states. In this research, we tend to
explore factors as to how a particular child’s growth is optimal. With this aim, we utilized positive
deviance inquiry to study the factors influencing under five child’s health.
MATERIALS AND METHODS: This qualitative study was carried out in Naigoan, an urban health
setting of metropolitan city with 37 sample size between July 2020 and September 2020. It consisted
of total 16 in‑depth interviews (IDIs), 3 focus group Discussion (FGDs), and 7 key informant
interviews (KIIs) which were performed by predesigned guides.
RESULTS: Various themes evolved with the interviews; however, triangulation of the concept (from
FGDs, IDIs, and KIIs) occurred with the following themes: satisfaction among mothers for health‑care
services, community participation, family support, and new interventions.
CONCLUSION: Mothers’ satisfaction to health‑care services, community participation, family support,
and innovations by the health‑care providers are the influencing factors in promoting child’s health.
Further research can be conducted to understand the in‑depth understanding of each factor.

Abstract BACKGROUND: Adherence to the treatment plans is one of the most effective conducts to prevent
and reduce postoperative side effects. Partnership‑based education is one of the most efficient ways to
shape health behaviors. The aim of the present study was to determine the effect of partnership‑based
education on adherence to the treatment plans in open heart surgery.
MATERIALS AND METHODS: This quasi‑experimental study was conducted in 2019–2020 on
the patients undergoing open heart surgery in Tehran (Capital of Iran). Sampling was done in one
educational hospital. A total of 86 patients and their caregivers participated in the study. Sampling
was done nonrandomly by tossing a coin, and patients were allocated into the odd week in the
intervention group and the even week in the control group (n = 43 in each group), and data were
collected before and after intervention using the Treatment Adherence Questionnaire concerning
dietary, physical activity, and medication aspects. The educational intervention was carried out after
the pretest analysis in five 20–45 min sessions (two individual and three group educations). Data
were analyzed with Chi‑square, independent t‑test, and paired t‑test using SPSS 19 at a significance
level of P < 0.05.
RESULTS: Patients and caregivers in both groups did not have a significant difference in terms of
demographic variables (P > 0. 05). In addition, there was no significant difference in the mean of
dietary, physical activity, and medication plans before the intervention in both groups; however, after
the intervention, the mean of the three aspects in the intervention group was significantly higher than
that of control (P < 0.001).
CONCLUSION: Implementing partnership‑based education with participation of patients and
caregivers is influential in improving patients’ adherence to the treatment plans and it is recommended
as a clinical dynamic educational strategy.

Abstract BACKGROUND: Type 2 diabetes mellitus (DM) is a multifactorial disease and can be described as a
noncommunicable disease of epidemic magnitude. Little is known about the predictors of depression
in this population, especially among the Indian population. This study explores the predictors for
depression in patients with type 2 DM.
MATERIALS AND METHODS: A cross‑sectional study was performed for a period of 7 months
during 2018–2019. The data were collected from 250 subjects at the diabetic clinic and psychiatry
outpatient department of a tertiary care teaching hospital. T2DM with an age group of 18–60 years
were included. Exclusion criteria were clinical evidence of any significant Axis I psychiatric disorder
according to the International Classification of Diseases‑10 Diagnostic Criteria for Research other
than depression and substance use disorders. Data were analyzed with multiple linear regression
analysis using SPSS‑23 version.
RESULTS: Male and female patients were 127 (50.80%) and 123 (49.20%), respectively. The
prevalence of depression was 49.20% among 250 patients with T2DM. Female patients had higher
depression than male patients. We found age (P = 0.013), female gender (P = 0.041), locality of the
patient (P = 0.021), body mass index (BMI) (P = 0.018), and fasting blood sugar (FBS) (P = 0.045)
as significant predictors of depression among T2DM patients.
CONCLUSIONS: The study concludes that females and elderly patients were more affected by
depression. The predictors of depression were age, gender, locality, BMI, and FBS among diabetic
patients. The findings indicate to screen the patients of T2DM for depression, predominantly female
and elderly patients, at regular intervals as per clinical demand.

Abstract BACKGROUND: Lifestyle training is of a key important in adolescent age for better life in the future.
Healthy lifestyle in adolescents can management of any disease such as diabetes and polycystic
ovarian syndrome (PCOS). Schools can provide an important environment to identify and change
the lifestyle of students. The aim of this protocol is designing and evaluating the effectiveness of
school‑based lifestyle training program improving the PCOS of adolescents.
MATERIALS AND METHODS: A cluster‑randomized controlled trial will be conducted to examine
the effectiveness of school‑based lifestyle training program in 16 to 18 years old adolescent girls.
The healthy lifestyle program will be designed by modification of behavioral habit, dietary intake,
and physical activity and educated in eight sessions for adolescents and one session for parents in
the intervention groups with sixty participants.
RESULTS: Changes in primary and secondary outcomes in PCOS and healthy adolescents
before and after intervention in the intervention and control groups will be analyzed for evaluation
effectiveness by one‑way ANOVA or other nonparametric equivalents.
CONCLUSION: The current study will provide information on the effectiveness of school‑based
lifestyle training programs for adolescents. With increasing numbers of PCOS at risk for long‑term
and/or late effects of treatment and other chronic diseases, efforts for promoting the healthy lifestyle
of this important group are urgently needed. This lifestyle program may provide valuable information
relating to the development of other healthy lifestyle interventions for PCOS and result in appropriate
behavior change and self‑management strategies.

Abstract Universal access to safe sanitation is yet to be accomplished in India. Although Clean India
Mission (named as “Swachh Bharat Mission (Gramin)” for rural India) claims that the sanitation
coverage in rural India has increased from 39% to 100% of households from 2014 and 2019, yet
open defaecation continues in India in large numbers. This article discusses the achievements on
Swachh Bharat Mission (Gramin) and identifies the existing challenges that need to be acted on to
achieve the success of India’s Swachh Bharat Mission. We searched international database mainly
Google scholar, Pubmed, Medline, Scopus, and Science direct using “Clean India,” “Swachh Bharat,”
“Sanitation,” “Open defecation,” “Environmental heath,” and “India” as search keywords in different
combinations. In addition, websites of relevant United Nations (UN) agencies, Government of India
and leading newspaper and national agencies were also searched manually for related publications
and reports. In the last 5 years (2014‑2019), significant efforts have been made for the Swachh Bharat
Mission by creating various social movements and awareness program to improve toilet coverage
throughout India. Over 100 million, latrines have been built as of the end of the first phase of Swachh
Bharat Mission (Gramin) as on October 2, 2019 and all villages across the districts of India have
been declared Open Defaecation Free. Still, nearly half of the rural population (52.1%) defecate in
the open. Lack of piped water supply, poor construction of toilet substructures and misconception
among people about toilet use remain as key challenges in the achievement of India’s sanitation
mission. Sanitation‑related behavioral change and improvement in toilet facilities must be prioritized
to ensure usage of built toilets and eventually can accelerate the universal access to sanitation and
meet Sustainable Development Goals.

Abstract BACKGROUND: People experience extreme anxiety in testing situations, so it considers as a
psychological condition and can actually impair learning and hurt test performance. People experience
some degree of stress and anxiety before and during examinations. This study aimed to investigate
the effect of blended aromatherapy using lavender and damask rose oils on the test anxiety of
nursing students.
MATERIALS AND METHODS: The present study was a single‑blinded clinical trial study. Seventy
nursing students were selected and randomly assigned to two experimental and sham groups. For
the experimental group, seven droplets of lavender, 10%, and three droplets of damask rose oil,
10%, and for the sham group, ten droplets of sesame oil were poured on a nonabsorbent pad which
was placed within a 20‑cm distance from the students’ noses on their chairs’ handles. The data were
collected by using a two‑part questionnaire including demographic information and State‑Trait Anxiety
Inventory 1, before, 15 min after the intervention, and immediately at the end of the test. Data were
analyzed using descriptive (frequency, mean, and standard deviation) and inferential (independent
t‑test, ANOVA with repeated measure, Fisher’s exact test, and least significant difference post hoc
test) statistics.
RESULTS: It was found that no significant difference between the two groups in terms of age, the
number of credits, Semester Grade Point Average and, gender, place of residence and marital
status and the two groups were almost identical in regard of the above variables (P > 0.05). State
anxiety mean scores of the experimental group were lower than the mean scores of the sham group,
15 min after the intervention and at the end of the test, and the difference between the groups was
statistically significant (P < 0.05).
CONCLUSIONS: Blended aromatherapy is effective in improving the test anxiety of nursing students.
Therefore, it can be used as a therapeutic approach to reduce test anxiety.

Abstract BACKGROUND: Covaxin is the first indigenous vaccine developed in India against COVID‑19. The
purpose of this study was to analyze the news stories on Covaxin published in the online media
between two statements issued by Indian Council for Medical Research on 2nd and 4th July for their
content, quality of information, and reporting standards.
MATERIALS AND METHODS: A systematic search was performed on Google to identify the news
stories related to Covaxin in the English language published between these two statements. The
selected news stories were subjected to content analysis and reviewed using the screening points
developed through a consultation by two independent experts using ten prevalidated criteria for
health news review. The data were analyzed in MS Excel and StataMP14.
RESULTS: The final analysis included 24 news stories. The mean and median score of the news
stories is 10.71 and 12 (out of 20), respectively, with a score ranging from 2 to 17. The stories did
not promote disease or vaccine mongering (100%), adequately mentioned the true novelty of the
vaccine (95.8%), and source of the information (83.3%). However, they mostly failed to mention
the information on costs, research data related to benefits, and harms and quality of the available
evidence.
CONCLUSION: There is a lack of reporting of detailed analysis about the methodology of development
of the vaccine and limitations in its research design by health journalists. It is important to train
journalists on proper reporting of health news to improve its quality in Indian media.

Abstract BACKGROUND: In the turbulent and stressful work environment of prehospital emergencies, the conflict
among emergency medical technicians (EMT) and other health‑care providers is inevitable. This study
aims to examine the concept of workplace interpersonal conflict (WIC) in prehospital emergencies.
MATERIALS AND METHODS: The eight‐step Walker and Avant’s concept analysis approach was
adopted to define the concept. Iranmedex, SID, Magiran, ISC, PubMed, Scopus, Embase, and Web
of Science searched with keywords such as WIC and hospital emergencies. After an extensive review
of online national and international databases, one dictionary, nine books, and 25 articles in English
and Persian were retrieved for the purposes of the study.
RESULTS: The antecedents, attributes, and consequences of the concept identified. EMT must
learn how to eliminate their destructive effects while enhancing constructive effects.
CONCLUSION: Conflict is an inevitable part of life, and EMT must learn how to reduce their destructive
effects while increasing constructive results.

Abstract BACKGROUND: Nowadays, for various reasons, the prevalence of heart diseases has increased in
women during reproductive age. These diseases can lead to serious reproductive and sexual‑related
complications in the affected women. This study will conduct to develop a reproductive health
promotion program for women with heart diseases.
MATERIALS AND METHODS: This is an exploratory sequential mixed methods study that will
be conducted in four phases. The first phase is a qualitative research that is done using content
analysis method and semi‑structured individual interviews. The experiences of women with heart
disease and health providers’ team in educational hospitals, health centers, and private offices of
physicians about reproductive health need will be explored. Purposive sampling will be continued
until data saturation is reached and the conventional content analysis method will be used. In the
second phase, the studies published from 2000 to 2020 will be reviewed by the matrix method and
then will be analyzed by using thematic analysis. Integrating the results of these two stages, the draft
of the program will be designed. In the third phase, the validation of the program will be checked by
using the two‑round modified Delphi method. In the fourth phase, the program will be implemented
by the health system and its process will be monitored.
CONCLUSION: A life cycle reproductive health program for women with heart disease can help
improve their preconception health, fertility planning, and sexual health and promote the well‑being
of these women in the long run.

Abstract BACKGROUND: Quality of life (QOL) is one of the effective factors in promoting the health of diabetic
patients. In recent years, the role of peer support in the optimal management of diabetes has gained
increasing attention. However, contradictory results have been reported from the effectiveness of
this method. This study aimed to investigate the effect of peer support on the QOL among type 2
diabetic patients in deprived areas.
MATERIALS AND METHODS: This study was a randomized clinical trial conducted on 80 patients
with T2D referring to the diabetes Clinic in Aligoudarz in Iran. Participants were randomly assigned
into two groups of 40 patients. Intervention group received a peer Supportive‑educational program
for 3 months and the control group received routine clinic care. Diabetes QOL brief clinical inventory
was used to collect the data. This questionnaire was completed three times at the beginning of the
study, immediately after the 3‑day training, and after 3 months of peer supportive intervention. The
SPSS software (v. 18.0) was used to analyze the data through the Generalized Estimating Equations.
RESULTS: There was no significant difference in mean QOL between the two groups before the
intervention (P = 0.891) and immediately after the education (P = 0.076). However, after 3 months
of intervention, the intervention group showed a significant improvement in mean QOL compared to
those in the control group (P < 0.001).
CONCLUSION: Peer support program can improve the QOL in type 2 diabetic patients in deprived
areas. Therefore, this method can be recommended to improve care and educational programs in
these patients.

Abstract BACKGROUND: Lockdown in India might have adverse effects on the emotional health of the dental
professionals; hence, the aim of the present study was to determine the impact of various factors
on emotional well‑being of dental professionals due to the effect of lockdown during COVID‑19.
MATERIALS AND METHODS: It was a cross‑sectional, descriptive, questionnaire study conducted on
dentists in India during April 2020. Sampling technique was convenient sampling, and sampling frame
was all the dental professionals in India. The questionnaire was prepared online using Google Forms,
and the link was generated which was shared among as many dentists accessible as possible, with
the help of message, mails, and WhatsApp. The questionnaire consists of questions on Demographic
details, practice, and emotional well‑being. A total of 1844 dental professionals in 14 states in India
responded. The statistical analysis was done using SPSS version no. 20. IBM SPSS version 20.0
(IBM; Armonk, New York USA) Descriptive statistics and multinomial regression test was applied.
RESULTS: Majority of study participants (1096[59.4%]) belonged to age group of 26–35years. Emotional
well‑being score of 1206 (65.4%) dental professionals in the times of COVID‑19 outbreak was poor
with score between 26 and 78. It was assessed that males have significantly (P = 0.00**) (P < 0.001**)
(**highly significant) poorer emotional well‑being 0.085 (0.829–1.429) compared to females. Married
dental professionals − 0.023 (0.011–1.221) had significantly better (P = 0.05*) emotional well‑being
than others.
CONCLUSION: Emotional well‑being score of majority of dental professionals in the times of
COVID‑19 outbreak was poor. Gender, marital status, socioeconomic status, years of experience,
practicing in clinic, and average number of patients seen per month before lockdown have significant
impact on emotional wellbeing of dental professionals.

Abstract BACKGROUND: The Pediatric Daytime Sleepiness Scale (PDSS) and the Morningness–Eveningness
Scale for Children (MESC) are widely used to measure two important facets of sleep patterns, but
neither have been adapted and validated for use in Iran. The purpose of this study was to examine
the psychometric properties and factor structure of the Persian versions of the PDSS and the MESC
in a sample of Iranian adolescents.
MATERIALS AND METHODS: The Persian versions of PDSS and MESC were translated and
administered to a representative sample (n = 407) of Iranian early adolescents, aged 9–15 years,
who attended school in morning shifts. The factor structure of both scales, found in prior studies,
was tested using Confirmatory Factor Analyses to assess their validity and reliability.
RESULTS: The results revealed that the model fit indices of the one factor solution of the PDSS
and the two factor solution of the MESC were acceptable to good. A high Pearson correlation was
found between raw and latent factor scores for the PDSS and the two factors derived from the
MESC (i.e., Morningness and Planning). Furthermore, the higher the PDSS score (more daytime
sleepiness), the lower the MESC scores (more eveningness), indicating criterion validity of the scales
showing the expected increase in daytime sleepiness in evening oriented adolescents who wake
up early for attending school.
CONCLUSION: The Persian versions of the PDSS and the MESC can be considered reliable and
valid tools for evaluating, respectively, daytime sleepiness and morningness‑eveningness in the
adolescent population of Iran.

Abstract BACKGROUND: Timely and appropriate follow‑up appointments for infants at risk for retinopathy of
prematurity (ROP) are very important to prevent blindness. Caregivers are important members of the
ROP team, and their involvement is essential in ensuring optimal visual outcomes. This paper aimed
to develop health information materials on ROP by a systematic process for better comprehensibility
by the target audience of low literacy.
MATERIALS AND METHODS: It was a methodological study conducted at the neonatal intensive care
unit of a tertiary care hospital, North India. The development and validation of educational materials
was conducted in six steps. The study focused on both the knowledge of the target audience and
on the validation of the educational materials by experts and caregivers of ROP eligible infants.
RESULTS: Most of the items (content, language, layout, motivation, and cultural appropriateness)
were in either a suitable or adequate category. Only one item illustration was in the nonsuitable
category. The mean final score of the leaflet after revision by experts was 9 (maximum score = 10).
Regarding readability, The Flesch Reading Ease Score, Flesch‑Kincaid Grade Level, and gunning
fog index were found to be 72.5, 7.4, and 6.2, respectively. The leaflet was found to be suitable for
the seventh grader. The mean knowledge score of the parents was 4 (maximum score‑5).
CONCLUSION: The study showed satisfactory acceptance of the developed ROP information
materials by caregivers and experts. A similar approach could be adopted for the development of
other health information materials.

Abstract BACKGROUND: Attention‑deficit hyperactivity disorder (ADHD) is one of the most common reasons
for visiting psychiatrists and psychologists. This study aimed to investigate the prevalence of ADHD
and its related risk factors among children at elementary schools.
MATERIALS AND METHODS: This cross‑sectional study focused on teachers and parents of 779
elementary students who were selected through stratified cluster random sampling; Conners Parent
and Teacher Questionnaires were used to collecting data. The data were analyzed by the use of
descriptive statistics (frequency and percentage), independent samples t‑test, Chi‑square, one‑way
ANOVA, and linear regression. The significant level was set at 0.05.
Results: According to teachers’ responses, the prevalence of ADHD among students in elementary
schools was 4.4%, whereas parents reported a prevalence of 0.5%. There was a significant
relationship between childhood ADHD and marital status of parents, fathers’ smoking habits, previous
experience of living in rural areas, children’s previous history of having diseases and using the
medicine, previous history of ADHD, and psychological problems in the family.
Conclusions: According to the study, teachers and parents suffer from a lack of knowledge about
ADHD. Thus, the educational workshops and programs should be held for teachers, parents, and
counselors to inform them about the procedures for timely diagnosis and treatment of ADHD.

Abstract BACKGROUND: Coronavirus disease is a highly infectious and fatal disease. It has caused distress
in the form of fear, and anxiety among masses including youth. The psychosocial health of youth
is important to build resilient nations after the pandemic is over.This study aimed to capture the
level of COVID‑19 fear among youth studying in a northern Indian university and to compare it with
demographic variables.
MATERIALS AND METHODS: This was a cross‑sectional study (April–May 2020) conducted
among university students in North India. Fear of COVID‑19 Scale (FCV‑19S) was used for online
survey using Google Forms. FCV‑19S is a reliable tool for assessing the fear of COVID‑19 among
the general population. Descriptive statistics and principal component analysis (PCA) with varimax
rotation were used for statistical analysis.
RESULTS: A total of 521 responses were recorded. The majority (78%) of the participants were in
the age group of 18–23 years and more than half (57%) were pursuing graduation. The respondents
belonged to 16 states and union territories in the country. A total of 17% reported severe fear, while a
few reported moderate (17%) or mild (11%) fear on the FCV‑19S. No respondent could be categorized
with “no fear” based on the overall FCV‑19S score. Approximately, 42% of respondents were nervous
after watching news/social media posts about COVID‑19. Based on PCA, factor 1 labeled as anxiety
toward COVID‑19, factor 2 media effect on shaping of fear, and factor 3 thanatophobia as contributing
factors for fear among youth.
CONCLUSIONS: Reflection of fear among youth suggests that adequate knowledge about COVID‑19,
preventive steps, treatment options, etc., may be planned to allay fears among youth.

Abstract BACKGROUND: In recent years, many changes have been observed in women’s roles in
organizations. In Iran, women face challenges to be promoted to high‑level organizational positions.
The present study aimed to examine the role of glass ceiling in promoting women to managerial
positions from the perspective of the faculty members at Iran University of Medical Sciences.
MATERIALS AND METHODS: This research was an applied study in terms of objectives and
a descriptive‑survey study in terms of data collection, variable monitoring and control, and
generalizability. The statistical population of the study encompassed all clinical and basic sciences
faculty members at Iran University of Medical Sciences in 2019–2020. The simple random sampling
method was adopted, and the study instrument was the standard questionnaire of women’s beliefs
about glass ceiling developed by Smith (2012). To analyze the data, descriptive and inferential (namely
paired‑sample t‑test and one‑sample t‑test) statistics were run in the SPSS software.
RESULTS: The results revealed that glass ceiling dimensions could predict 48% of the variance
of women’s promotion to managerial positions. Furthermore, a significant difference was noticed
between men and women’s perspectives toward glass ceiling (P < 0.001); however, there was no
significant difference between the two groups of clinical and basic sciences (P > 0.001).
CONCLUSIONS: Failure to provide appropriate opportunities for qualified women to be promoted to
managerial positions would result in nonexploitation of about half of the available capacities and talents.
Women have unique abilities and soft skills in the human resource management. At the macro‑level,
policy‑makers and planners to review the plans and delegation of organizational‑managerial positions
and also to further consider the role of women in managerial positions by observing gender justice
and meeting criteria such as capability and expertise.

Abstract Clinical governance is a systematic approach to enhancing the quality of primary health care and
ensuring high clinical standards, responsiveness to performance, and continuous improvement
in service quality. The objective of the current study was to investigate the global experiences
of clinical governance in primary health care. In the present systematic review, relevant articles
from different countries were searched in various databases such as MD PubMed from Medline
portal, Emerald Springer link, ProQuest, Cochrane, Scopus, Web of Science, and Consult until
April 2019. The searched articles were checked through CASP and PRISMA checklists, and their
results were extracted. Of the 17 selected studies, 16 belonged to developed countries, including
England (13), Australia, Italy, and New Zealand, and one was from Turkey. The findings were divided
into three general categories: (1) principles of effectiveness and risk management, (2) deployment
requirements such as structural and organizational needs, resource and communication, and
information management, and (3) barriers of clinical governance toward providing primary health
care. it is recommended that a suitable framework or model be developed and designed adapted
to the local culture and taking into account all effective dimensions for a proper establishment and
implementation of clinical governance in primary health care.

Abstract BACKGROUND: Having a baby admitted to a neonatal intensive care unit (NICU) is so stressful, has
a negative impact on mother well‑being, and also disrupts mother‑infant bonding process because
the infant spend the first several weeks or months in the NICU. Previous studies have shown the
positive association of the mindfulness and various health conditions. This study investigated the
relationship between mothers’ dispositional mindfulness and level of stress and bonding in mothers
with infants in the NICU.
MATERIALS AND METHODS: A cross‑sectional study was performed during 2019 on 140 mothers
with newborns admitted to the NICUs in two hospitals in Qom city in Iran. The self‑report measures of
dispositional mindfulness, Parental Stressor Scale: NICU, and the Postpartum Bonding Questionnaire
were administered to mothers on the 2nd–5th day after birth. The data analysis was carried out by
using a stepwise multiple regression model.
RESULTS: The mean scores of mindfulness, stress, and bonding were 3.32 ± 0.52, 2.32 ± 0.77,
and 0.47 ± 0.37, respectively. There was a statistically significant inverse relationship between total
mindfulness score and stress (P < 0.001). Furthermore, high scores of mindfulness were associated
with better bonding (P = 0.04).
CONCLUSIONS: Improvement in mindfulness helps mothers to reduce stress and make better
bonding with infants. It is recommended that mindfulness interventions use during pregnancy also
after birth, especially for mothers that their infants admitted to in the NICUs.

Abstract BACKGROUND: The COVID‑19 pandemic has negatively impacted the mental health of health‑care
workers worldwide. This study aimed to estimate the prevalence of psychological distress in medical
interns during the pandemic and examine the factors influencing it.
MATERIALS AND METHODS: A cross‑sectional online survey was conducted using snowball
sampling among 764 medical interns across India, who were evaluated using the Kessler
Psychological Distress Scale, Fear of COVID‑19 Scale, and semi‑structured questionnaires. Univariate
analysis was done using Chi‑square test, unpaired t‑test, and ANOVA, while multivariate analysis
was conducted using binary logistic regression.
RESULTS: 57.5% of the interns reported psychological distress, with 39.8% having moderate‑to‑severe
distress. Past consultation with a mental health professional (odds ratio [OR]: 2.15; 95% confidence
interval [CI]: 1.42–3.26) and perceived lack of support from friends (OR: 2.33; 95% CI: 1.33–3.99)
and faculty (OR: 2.15; 95% CI: 1.41–3.28) were the most significant predictors of distress. Fear
of COVID‑19 was higher in interns who were female, were medically ill, were dissatisfied with the
pandemic preparedness at the hospital, and perceived the faculty to be less approachable and
supportive. Majority of the interns felt that the pandemic had hampered their learning and were
worried about an extension to their internship and their performance in the postgraduate entrance
examinations.
CONCLUSIONS: Psychological distress was highly prevalent among interns, with several workplaces
and personal factors affecting the distress levels. Most interns perceived a negative impact of the
pandemic on their learning and career. Addressing these issues could help alleviate the distress
and bolster the mental health of interns.

Abstract BACKGROUND: Pregnancy is a special period in a woman’s life during which physical, mental,
social, and cultural changes would affect sexual desires during this period. The present study was
conducted to compare the effect of face‑to‑face education and using educational films on the sexual
dysfunction in couples.
MATERIALS AND METHODS: The present study was a semi‑experimental research. Study
population contained pregnant women and their husbands. Samples were selected randomly. Data
were gathered using demographic characteristic questionnaire and sexual dysfunction in men and
women questionnaire. Sample size was 96 couples (32 couples in the face‑to‑face group, 32 in the
educational films group, and 32 in the control group). Data were analyzed using SPSS20 software.
RESULTS: The mean total score of preintervention sexual function in face‑to‑face education group
was 46.72 ± 9.79, in educational film group 47.82 ± 13.07, and in control group 43.84 ± 12.76. In
the case of postintervention, it was, respectively, 60.62 ± 9.72, 57.37 ± 14.74, and 43.61 ± 14.21.
Face‑to‑face education led to the treatment of sexual dysfunction during pregnancy (P < 0.001). In
the educational film group (P = 0.40), sexual dysfunction during pregnancy was not treated, but there
was an improvement in sexual function (P = 0.001). In the control group, there was a significant
difference regarding the decrease in the score of sexual function and untreated sexual dysfunction
during pregnancy (P = 0.001). Furthermore, no improvement was observed in the sexual dysfunction
during pregnancy (P = 0.90).
CONCLUSIONS: According to the results, face‑to‑face and film education are effective in sexual
function during pregnancy, but face‑to‑face education in pregnancy is more effective in the treatment
of sexual dysfunction, and so this causes promoting sexual health during this period.

Abstract To develop the next generation of healthcare innovators, students at all levels of education should
be trained and encouraged to employ innovative and entrepreneurial approaches to deal with
complicated challenges of today’s health system. Applying innovation and entrepreneurship training
to solve complex problems and focus on solution design has recently become common in medical
universities all over the world. This paper clarifies the role of hackathons as an innovative educational
approach in healthcare education systems. We propose a process model concerned with organizing
hackathon events in the healthcare education system. This model can be used in the academic and
practical design of hackathons for innovation purposes.

Abstract BACKGROUND: Patient relationship management (PRM), in addition to saving costs, increases
patient loyalty and creates a satisfactory environment for the patient and the service provider. This
study aimed to design a model of PRM in general hospitals using the combination of the analytic
hierarchy process and interpretive structural modeling (ISM).
METHODS: This was an applied and cross‑sectional study conducted in 2020 at three stages. At
the first stage, using a systematic review, factors affecting PRM were identified. In the second stage,
these factors were prioritized based on the pair‑wise comparisons. In the third stage, the interaction
levels of the factors were modeled for the general hospitals using ISM through the use of the MICMAC
technique and Excel 2007 software.
RESULTS: The results showed that “integrated information system,” “registration of the patient’s
essential information,” and “right data at the correct time” were the first to third priority in implementing
PRM in the general hospitals. In the final model of ISM, three levels of effective factors were extracted,
and 10, 4, and 6 factors were identified in the first, second, and third levels, respectively.
CONCLUSION: Establishing the PRM strategy in the hospital, in addition to executive and managerial
requirements, depends on the existence of an electronic customer relationship management system,
and the choice of new technology, as well as the integration of information systems and technology
culture, should be given special attention by managers.

Abstract BACKGROUND: Cervical cancer is the second‑most common female cancer in Malaysia after breast
cancer. This study intended to investigate the knowledge and attitude regarding cervical cancer and
its prevention and its associated factors among young female adults in Kuantan, Malaysia, to gauge
the community’s understanding and idea about this issue.
MATERIALS AND METHODS: The study was conducted in attractive places in Kuantan, Malaysia,
such as shopping malls and Urban Transformation Centre, using a cross‑sectional study design and
convenience sampling method. Data on the respondents’ knowledge and attitude regarding cervical
cancer and its prevention were collected using a questionnaire. Kruskal–Wallis, Independent t‑,
and Pearson correlation tests were used to investigate the study variables’ association using SPSS
software.
RESULTS: From the total of 142 respondents, almost half of them aged between 20 and 24 years old
with the majority were Malays (85.9%) and single (74.6%). The internet (78.1%) was identified as the
main medium to gain information regarding cervical cancer. The results show that levels of education,
races, and occupation types were statistically significantly associated with the respondents’ knowledge
and attitude scores in this study. Age was found to be associated with knowledge scores only, while
marital status was only significantly associated with the attitude scores regarding cervical cancer and
its prevention. Knowledge scores were also found to be positively associated with attitude scores.
CONCLUSION: Several socio‑demographic factors were significantly associated with the knowledge
and attitude regarding cervical cancer and its prevention. In view of the positive association between
knowledge and attitude scores, suitable health promotion activities can be designed and planned to
increase young female adults’ knowledge and attitudes toward cervical cancer and its prevention.

Abstract BACKGROUND: The use of active teaching methods in ethics education, instead of being merely
teacher centred, can lead students to problem‑solving in a practical way. Therefore, this study was
conducted with the aim of comprehensive medical ethics education based on educational approaches
and the effect of this approach on students’ learning and moral reasoning skills.
MATERIALS AND METHODS: This quasi‑experimental intervention study was performed on seventy
physiopathology medical students who had taken the medical ethics course. The students’ educational
program included teaching theoretical concept of medical ethics, discussing ethical cases and clinical
reasoning in class, and then discussing in forum environment and individual assignments in the
learning management system (LMS) system and completing the portfolio. Student evaluation was
associated students’ knowledge, attitu de, and moral reasoning skills and learning. A comprehensive
program including forum participation, individual assignments in LMS, theory and objective structured
clinical examination (OSCE) tests, and portfolio completion was used to evaluation of students. The
students’ learning was compared to students of the previous year, which was conducted through a
traditional teacher‑centered method. Data analysis was conducted using IBM® SPSS® Statistics 21
at two levels of descriptive statistics and analytic statistics.
RESULTS: The results showed that there was a significant difference between the mean learning of
students compared with traditional class (P < 0.05). Furthermore, comparison of students’ practical
scores through the OSCE test showed its impact on changing students’ knowledge, attitude, and
performance in moral reasoning.
CONCLUSION: According to research findings, it seems that the mentioned model is one of the
important and new issues as a suitable method of teaching medical ethics. Furthermore, it can be
suitable model in other medical courses. The more research in multicentral may be need to assess
other effects on students’ learning indicators.

Abstract BACKGROUND: Nonadherence with the medication regimen in patients with heart disease can
lead to treatment failure. The purpose of this study was to identify the causes of nonadherence in
people with myocardial infarction.
MATERIALS AND METHODS: This study is a qualitative conventional content analysis. Data were
collected through semistructured interviews. Thirteen individual interviews and a focus group were
conducted with nurses, patients, and doctors. Data were analyzed using conventional content analysis.
RESULTS: Four main themes were identified, which are organizational‑managerial causes and
factors (drug‑related problems, educational system‑related problems, weak performance of hospitals,
and problems related to insurance companies); sociocultural causes and factors (factors related
to cultural problems and factors related to social problems); causes and factors related to care
providers (skill problems of care providers and functional problems of care providers); and causes
and factors associated with caregivers (factors related to social characteristics of the patient, factors
related to patient characteristics, and factors related to the patient’s belief).
CONCLUSIONS: Many individual and organizational factors affect nonadherence, which can be
reduced by fundamental changes.

Abstract Nowadays, disaster databases have become a valuable tool for disaster risk management and
health promotion and serve various purposes. The purpose of this study is to provide a systematic
review of disaster databases in the world and to identify the objectives, information sources, criteria,
and variables of disaster data registration in the world’s reputable databases. To conduct review,
all English‑language articles published without a time limit until the end of September 2020 were
extracted from the databases of Web of Science, PubMed, Scopus, Cochrane Library, Science
Direct, Google Scholar, and Embase. Necessary information in the papers including study time, type
of disasters, related databases, dimensions and indicators of global and regional databases were
extracted by using a researcher‑made questionnaire. A total of 22 studies have been reviewed to
identify the dimensions and indicators of disaster databases worldwide. The main focus was on global
and regional databases, mostly used at the level of scientific societies and disaster experts. After
explanation, researchers highlighted each of the disaster databases, along with the main differences
available among the existing databases. Some databases have well‑defined data collection methods.
Their knowledge is high quality and they can be used to create and improve a disaster database at
other levels. Disaster database limitations include risk bias, time bias, accounting bias, threshold
bias, and geographical bias. To support the right decisions to reduce disaster risk, it is necessary
to complement existing global, regional, and national databases. Countries need to take action to
set up national databases.

Abstract BACKGROUND: Considering the low level of physical activity in pregnant women in the COVID‑19
pandemic period, and on the other hand, the benefits of mobile application (mobile app) learning,
we decided to conduct a study to determine the impact of educational intervention based on mobile
app on physical activity in pregnant women.
MATERIALS AND METHODS: The present study was quasi‑experimental and examined 93 pregnant
women aged 16–20 weeks of gestation. Sampling was done on pregnant women participating in
the childbirth preparation classes in Isfahan. We used the validated and reliable questionnaire
including perceived benefits, perceived barriers, perceived enjoyment, perceived social support,
and Pregnancy Physical Activity Questionnaire. The intervention was based on mobile app, and the
content of the application contained 12 main domains such as description of physical activity and
benefits and barriers of exercise in the pregnancy, different types of proper pregnancy exercise,
planning for exercise, and different types of exercise. Finally, data were analyzed using SPSS20,
and the Chi‑square test, independent t‑test Paired t‑test were employed. The significance level was
considered to be <0.05.
RESULTS: The results showed that, after the intervention based on mobile app, the mean score
of perceived benefits and enjoyment were significantly higher than before the intervention in
the intervention group. Finally, total mean score of physical activity significantly increased in the
intervention group, while the change decreased in the control group.
CONCLUSION: The results indicated that the use of mobile app can be used to promote physical
activity in pregnant women. Therefore, it is recommended that mobile app education should apply
with face‑to‑face classes in health centers for physical activity in pregnant women in the pandemic
situation.

Abstract BACKGROUND: Mobile phones are one of the excellent gifts of technology in the 21st century, which
is most popular among adolescents. Today, mobile phones have infinite resources that have multiple
benefits and applications. Its excessive use may impact adolescents in the form of behavioral changes
and diminish the academic performance. This study explores the relationship between mobile phone
usage with behavioral modifications and educational achievement among adolescents.
MATERIALS AND METHODS: A descriptive correlational study was conducted among
adolescents (n = 285 –male‑210, female‑75) at selected schools of Rishikesh, Uttarakhand, India.
The test of mobile dependence was used to assess the mobile phone dependence, and a behavioral
Likert scale to evaluate the behavioral changes through the self‑report method. The academic
performance was observed by school records; percentage of the last two examination results was
considered. Collected data were analyzed using descriptive and inferential statistics.
RESULTS: The study shows that 156 (54.70%) participants had a low mobile dependency,
191 (67%) participants had negative behavioral changes, and 125 (43.90%) participants had shown
reduced academic performance due to overuse of the mobile phone. A significant relationship
was seen between mobile phone dependency with behavioral changes (P < 0.001) and academic
achievement (P < 0.035) seen among adolescents. Regression analysis predicted 49% of the
differences among adolescents with selected variables due to the overuse of mobile phones.
CONCLUSION: The study concluded that mobile dependency changes adolescent’s behavior as
well as reduces their academic performance due to the overuse of the mobile phone.

Abstract BACKGROUND: The outbreak of coronavirus disease 2019 (COVID‑19) has turned attention to the
essential competencies needed to confront pandemics for a physician. However, medical students,
as future physicians, are not adequately trained for such a situation. This study aimed to determine
the essential competencies for a medical student to face the COVID‑19 pandemic.
MATERIALS AND METHODS: We performed this mixed‑method needs assessment study at Shiraz
University of Medical Sciences in May–June 2020 in three steps: the first step was a brainstorming
session followed by a nominal group technique with the experts’ participation. The second step
was determining the validity of competencies by calculating the content validity ratio. In the third
and last step, three rounds of the modified Delphi technique were held with the participation of
22 medical faculty members and 45 undergraduate medical students to reach a consensus about
the competencies utilizing quantitative analysis.
RESULTS: A total of 30 key competencies essential for a medical student were obtained through the
current study. They were categorized into four major themes: (1) developing knowledge and abilities
for effective diagnosis and treatment of COVID‑19, (2) demonstrating safety principles correctly,
(3) demonstrating effective behavior, and (4) determining the meta‑competencies.
CONCLUSIONS: Although medical students will be the frontline physicians in the future pandemics, they
are not prepared to display the diversity of requisite skills to practice effectively and safely. This study
provides essential competencies for medical students during the COVID‑19 pandemic and underlines
the importance of a paradigm shift from traditional time‑based to competency‑based education.

Abstract BACKGROUND: At present, the SERVQUAL model is one of the most significant tools for measuring
customers’ expectations and perceptions in organizations. Determination of expectations and
perceptions of students who are the main university customers from educational services can provide
valuable information to the programmers to improve the condition of educational services. Therefore,
this study aims to measure the quality of education services from the viewpoint of postgraduate
students at Kermanshah Medical Sciences University using the SERVQUAL model in 2019.
MATERIALS AND METHODS: This was a descriptive cross‑sectional study. The population under the
study consisted of 162 students at the postgraduate education section (Master’s degree and Ph.D.)
studying in the second semester of the academic year of 2019 at Kermanshah Medical Sciences
University. The standard SERVQUAL questionnaire was used for data collection, which included
five dimensions of the quality of educational services, and the random‑stratified sampling method
was employed. The data were analyzed using the  SPSS Statistics software (version 23.0, SPSS
Inc., Chicago, IL, USA), and descriptive and other statistical tests, including the Pearson correlation
coefficient, and paired and independent t‑tests were performed.
RESULTS: Based on the students’ perspective in the provision of service there was quality gap
existed in all services, and the largest gap was in the reliability dimension (−0.37), and after that,
empathy (−0.37), guaranty (0.27), and responsiveness (−0.24) dimensions, respectively, and the
lowest one was in the tangible dimension (0.15). There was a statistically significant observed
difference between the quality gap in different educational dimensions (P > 0.001).
CONCLUSION: Research findings showed that students were not meeting their expectations from
the presented educational services. Hence, holding a training workshop is suggested in the field of
how to serve and enhance communication skills for employees and teachers.

Abstract BACKGROUND: Metacognition is the awareness and the capability to regulate one’s own thinking
process. Metacognition is critical in medical education for clinical reasoning and management. Hence,
the objective of this study is to evaluate the construct validity and reliability of the Metacognitive
Awareness Inventory (MAI) among first‑year medical and dental students, from a private medical
university in India, using confirmatory analysis and internal consistency method.
MATERIALS AND METHODS: This was a cross‑sectional study using convenient sampling.
Fifty‑two‑item MAI was administered to 933 first‑year medical and dental students from a private
medical university in India. Exploratory factor analysis (EFA), principal component analysis,
Cronbach’s α, and confirmatory factor analysis with global fit indices were performed. Structural
equation modeling (SEM) was performed to evaluate the relationship between the structural path
and factors using AMOS version 22.
RESULTS: During EFA, 12 items with <0.40 factor loadings were trimmed sequentially. The remaining
items with respective factors had a good internal consistency of ≥ 0.9. Comparative fit index (0.78),
goodness‑of‑fit index (0.8), adjusted goodness of fit index (0.77), Tucker–Lewis index (0.7),
standardized root mean square residual (0.06), and root mean square error of approximation (0.09)
values showed that six‑factor model fits to satisfactory. Pearson’s correlation coefficient was found
to be high between factors (>0.80). SEM for each item (observed) and factor (unobserved) illustrated
the hypothesized model.
CONCLUSION: The resultant 40‑item model based on MAI designed by Schraw is a valid and
reliable tool for assessing the metacognitive awareness of Indian students. Employing a valid and
reliable tool in assessing the metacognitive awareness will help the academicians in incorporating
appropriate curricular interventions.