Journal of Education and Health Promotion

Abstract BACKGROUND: The use of physical restraint in health‑care settings is common and complex practice
as it has physical, psychological, judicial, ethical, and moral issues. Nurses are the key persons
regarding physical restraint use in hospitals as they are managing the whole process beginning with
decision‑making, application, caring the restrained patients. Lack of understanding and negative
attitude of nurses in the use of physical restraints will hamper patient safety.
MATERIALS AND METHODS: A descriptive cross‑sectional survey was carried out among 110
rando  mly  selected nurses working in various departments at a tertiary care center Uttarakhand,
India, in 2019. The data were collected using self‑reported questionnaires consisting of three parts:
demographic information, knowledge assessment questionnaire, and attitude rating scale regarding
the use of restraints. Data were   analyzed using  the SPSS version  23 descriptive  (frequency,
percentage, mean, mean percentage, and standard deviation) and inferential statistics (Mann–Whitney
and independent t‑test).
RESULTS: The findings indicated that the mean knowledge and attitude of the nurses for physical
restraints were 13.9 ± 1.9 (0–20 points), 35.2 ± 4.7 (28–55 points), respectively. The study revealed
that there was no relationship found between knowledge and attitude of nurses regarding the use
of physical restraints (r = 0.084).
CONCLUSION: The knowledge and attitude regarding the use of restraints among nurses were found
to be moderate. In‑service training is highly recommended for nurses to improve the knowledge and
practices related to the use of physical restraint.

Abstract BACKGROUND: The identification of parental health knowledge related to obesity and overweight
status in children is an important area. Its importance relates to understanding gaps in knowledge that
can be used to create targeted intervention and prevention strategies to improve the management
of child’s weight.
AIM: There is a growing awareness of the potential health risks associated with increased childhood
weight. It is currently unclear how well the public understands these risks and if understanding is
linked to improvement in obesity or overweight levels in children. This review focused on determining
if the current research is available to describe parental knowledge and whether it is connected to
improved outcomes in the child’s weight status.
METHODS: The search for original research articles published between 2003 and 2018 involved
six databases, including CINAHL, EBSCOhost, PubMed, PsycINFO, Psychology, and Behavioral
Sciences Collection, and OneSearch. The OneSearch database is a comprehensive search engine
that allows simultaneous searching of the entire library category and results that are ranked by
relevance to the search terms. The terms used included for the keyword search in each database
included: “knowledge” or “awareness,” “health risk” or “consequence,” “obesity” or “overweight,”
and “weight” or “body mass index,” “child,” and “parent” or “parental.” A content analysis of included
articles was performed to synthesize available literature into a review.
RESULTS: This review included nine articles dealing specifically with parents of children and their
knowledge levels. As there was limited information about if child’s weight status connected to parental
knowledge, an additional seven articles addressing how knowledge affects weight at any age was
examined. The findings for parental knowledge and its effect have mixed results and varying methods
of measurement.
CONCLUSIONS: While some studies have indicated the importance of knowledge, it is difficult to
establish a reliable connection due to the limited examination of this subject. This is, therefore, an
underexplored area that needs further study.

Abstract BACKGROUND: Communication skills are one of the most important competencies required for
community health workers (CHWs); however, there is no systematic evidence‑based communication
training course for them. In this study, we aim to develop a comprehensive communication skills
curriculum for CHWs based on the intervention mapping (IM) approach.
MATERIALS AND METHODS: We used the IM approach to develop a systematic evidence‑based
communication skills curriculum for CHWs. First, we will determine the required competencies (by a
literature search, a qualitative study, and a Delphi study), and then, we will develop a questionnaire
for need assessment, and finally, we will implement the course and evaluate its efficacy by conducting
a randomized controlled trial. This study was designed according to the steps of IM.
CONCLUSION: This protocol reports an example of developing a training course using IM. This
course could be applied for similar health workers across the world, as well as the CHWs.

Abstract BACKGROUND: An alarming trend of sustained blood pressure elevation among children and
adolescents has been found. Health education to schoolchildren in their formative age is the most
effective method to be able to modify their habits, and further, they can be enrolled as an effective
health educator for their parents.
OBJECTIVE: To study the effectiveness of health education module on study participants about
prevention and control of hypertension (HTN) and the effectiveness of child as a health educator on
parents’ knowledge about prevention and control of HTN.
MATERIALS AND METHODS: This quasi‑experimental study was conducted with a control group
among high school students in two urban secondary schools. There were 110 students and 100
parents each in the intervention and control groups. Modular training with interactive teaching–learning
methods was conducted for students in the intervention group. They, in turn, educated their parents.
RESULTS: Postintervention, the study results showed a higher median for various domains in the
intervention group as compared to the control group among both students and parents. On applying
Mann–Whitney test, this difference was statistically significant with P < 0.001.
CONCLUSION: The increase in the knowledge of parents belonging to the intervention group
suggests the effective transfer of knowledge from the students to their parents.

Abstract INTRODUCTION: Health policymaking seems simple; in practice, but, it is very complex. However,
this study aimed to provide a framework to bridge the gap between policy and action in order to
present an interconnected model for developing countries.
MATERIALS AND METHODS: This was a qualitative study. Using desk search, different models
were searched from various scientific databases for formulation of an integrated policy‑making
framework. In next stage, the identified National upstream documents were analyzed to achieve
existing policymaking evidence. Then to determine the validity of the initial model and to gather the
views of key experts, two Delphi rounds were used. The tool used in Delphi method was a 9‑point
Likert questionnaire that was sent to the experts via E‑mail.
RESULTS:   This model, by employing integrated chain of visions and strategic targeting of
ultimate aims on the one hand and expected key functions and support functions for generating
output (operational goal) on the other, provides an extensive operable insight being influenced by
human‑Islamic principles and values, social, technological, economic, environmental, and political
for strategic as well as operational managers./Policy makers
CONCLUSION: This framework consisted of general, strategic, and executive levels. It creates
the needed institutional and structural capacity to achieve a comprehensive health approach for all
laws and policies to control social factors affecting health, improve health situation, and promote
the health of citizens.

Abstract BACKGROUND: Peak expiratory flow rate (PEFR) is widely used as a predictor of treatment of
asthma patients. Peak expiratory flow and forced expiratory volume in first second (FEV1
) are the
most useful parameters for the diagnosis of asthma. Spirometry is not often available in the primary
care setting, and economic factors may limit its testing. Mild airway narrowing may be present in
asymptomatic children, which can be identified by determining their PEFR. This will enable us to
initiate early treatment.
MATERIALS AND METHODS: We selected 200 asymptomatic children at the age of 10–15 years
without a history of smoking, tuberculosis, or other respiratory illness. A family history about asthmatic
symptoms was sought. PEFR values of all children were recorded, and 40 children showed PEFR
values less than 80% of their predicted values. To confirm whether the low observed values were
because of airway obstruction, their spirometry was performed.
RESULTS: Nine out of 47 (19.14%) children from asthmatic families and 31 out of 153 (20.26%) from
nonasthmatic families showed PEFR values <80% of the predicted value (P > 0.05). Considering
a decrease in the FEV1
/forced vital capacity (FVC) ratio to <80% for the diagnosis of obstructive
disease, only two out of 35 children were found to have it. Correlation between PEFR and FEV1
/
FVC ratio was not significant (r = 0.314 and P = 0.065).
CONCLUSIONS: Asymptomatic children with low PEFR values may not show abnormal lung functions
on spirometry. However, these children, particularly those having the risk of family history of asthma,
may be followed for the development of airway obstruction.

Abstract CONTEXT: Performance is a significant objective of any organization. To grow and develop and
to improve the performance of the education development centers (EDCs) of medical sciences
universities at Iran, the recognition of the performance criteria of these centers is important. This
study was conducted with the aim of discovering the performance criteria of EDCs of medical science
universities.
SUBJECTS AND METHODS: This study was conducted using qualitative research and a
semi‑structured interview. Participants were selected using an expert sampling method is a sub‑type
of purposive sampling. Twenty‑three faculty members and expert staff (11 males and 12 women)
participated in the interview. Data were collected using the participant’s perception. The data analysis
was performed based on the interpretative analysis steps of Gillham and Rubin.
RESULTS: From the analysis of data, seven categories including leadership, strategy, stakeholders,
workforce, knowledge management, processes management, and results were obtained.
CONCLUSIONS: The obtained criteria in this study assist managers to design and to develop
self‑assessment questionnaires and a performance measurement program for EDCs of medical
sciences universities. This will facilitate performance evaluation of EDCs.

Abstract BACKGROUND: Metacognition and academic self‑efficacy are two emerging resources in the process
of learning. Basic levels of metacognition and academic self‑efficacy may differ and be influenced by
demographic and academic factors. This study investigated impacts of demographic and academic
factors on metacognition, metacognitive skills, and academic self‑efficacy in health sciences students.
MATERIALS AND METHODS: A cross‑sectional study was conducted among 404 participating
students attending various fields of study in health sciences at Shahrekord University of Medical
Sciences. Demographic and academic data were collected. Global metacognition, metacognitive
skills, and academic self‑efficacy scores were assessed using published or online questionnaires.
Means were compared using Student’s t‑test, whereas intra‑ and intergroups’ scores were compared
using one‑way ANOVA test.
RESULTS: Global metacognition and academic self‑efficacy were not impacted by demographic
students’ status. The gender and age impacted both knowledge and control of process‑ planning (favoring
male gender), as well knowledge and control‑of‑self (disfavoring 20–30 age class) of metacognitive
skills, (P < 0.05).  Academic status did not influence academic self‑efficacy. The school type influenced
the metacognitive skill component to knowledge and control of process‑regulation (disfavoring nursing
school) (P < 0.05). The academic discipline impacted the global metacognition (P < 0.05) and its
knowledge and control of self‑component (P < 0.01).
CONCLUSIONS: Demographic and academic status does impact metacognitive skills and global
metacognition scores. Given the heterogeneous level to innate metacognitive skills, this study sheds
lights on usefulness to screen learners’ subgroups that require supplementary educational instructions
to uniformly optimize metacognitive skills.

Abstract BACKGROUND AND OBJECTIVE: Patients undergoing hemodialysis due to multiple drug therapies,
special diet plans, and need to acquire the ability to adapt to physical and mental disabilities require
special monitoring. The PRECEDE‑PROCEED model is a process for behavior change and can
lead to the promotion of self‑care behavior. The aim of this study was to evaluate the effect of a
health promotion program based on the PRECEDE‑PROCEED model on self‑care behaviors in
hemodialysis patients.
METHODS: This was a clinical trial study that was performed on 67 patients undergoing hemodialysis
in Lordegan Hospital that has been distributed in two groups randomly. Data were collected using
self‑care assessment form according to the PRECEDE‑PROCEED model. Based on the results of
this questionnaire, five educational sessions were held in the fields of knowledge, attitude, enabling
factors, reinforcement, and behavioral factors for the samples. Data were analyzed using descriptive
and analytical statistics with SPSS version 21 software.
RESULTS: According to statistical analysis before intervention, no significant difference was observed
between the mean scores of self‑care among the two groups. However, instantly and 3 months after
intervention, the mean score of self‑care (P = 0/03), knowledge, attitude, reinforcement factors, and
behavioral factors (P < 0.05) significantly increased in the experimental group.
CONCLUSION: Based on the results of this study PRECEDE‑PROCESS model, the health promotion
program increased the mean self‑care score of hemodialysis patients. This program has been able to
improve their self‑care behaviors by changing knowledge, attitudes, and reinforcement and behavioral
factors of patients and is recommending as an application in the nursing of these patients.

Abstract BACKGROUND: New gamification technology with a detailed understanding of the goals and
prospects, and with the help of game elements and techniques, leads to promotion of motivation
and participation, and ultimately behavior change. Therefore, this study aimed to evaluate the
implementation of a mental gamification from blended learning based on the flex model and efficacy
of this program on students.
METHODS: In this study, with the design of mental illness lessons for undergraduate and executive
groups, using flex model, two parts of technical and educational design were used. In the technical
section, three parts on dynamics, mechanisms, and elements of gaming were considered. Intervention
was studied on different groups of medical students including medical, health, and laboratory
sciences. Effect of this educational program and its impact on their students’ learning, motivation,
and satisfaction was studied using quantitative and qualitative analyses.
RESULTS: The results of the students’ prospective about the efficacy of the method showed that the
mean scores of most of the items were higher than the average. This implies that students’ attitude
toward using gamification was positive. In the other part, the qualitative results of the study were
analyzed and the students’ analysis of their advantages and disadvantages and their perceptions
on the impact of the intervention was examined.
CONCLUSION: Based on the flex model, mental gamification based on blended learning is effective
in shaping the students’ satisfaction.

Abstract INTRODUCTION: Smoking is a significant health problem among Indonesian adolescents and adults.
The Indonesian government had issued several policies to alleviate this problem, including placement
of pictorial health warning (PHW) on cigarette package. There had been several evaluation studies
regarding the effectivity of PHW in urban areas but none in rural areas. This study aims to evaluate
the effectivity of PHW in motivating smoking cessation in a rural area in Indonesia.
MATERIALS AND METHODS: This was a descriptive cross‑sectional study conducted in August
2017 in Losari village, Indonesia. Respondents of this study were villagers aged 18–60 years who
were active smokers and purchased cigarette with PHW on the package. The research instruments
for this study were questionnaire and printout pictures of each PHW approved by the Indonesian
government.
RESULTS: There were 94 respondents recruited in this study. Among them, only 26 (27.7%) stated
that PHW motivated them to stop smoking. From the five figures of PHW, a picture of lung cancer
was the most effective PHW to motivate smoking cessation. Eighty‑one of 94 respondents affirm
that there are other factors besides PHW that might motivate them to stop smoking. Most of them
agreed that an increase in cigarette price will force them to stop smoking.
CONCLUSIONS: Current PHW used on cigarette package might be ineffective in motivating smoking
cessation at Losari village. Further study with larger samples needs to be done to confirm this finding.

Abstract INTRODUCTION: Emotional intelligence and learning strategies are among the major requirements
for success and academic achievement. The present research was designed and carried out to
explore the relationship of emotional intelligence with learning strategies in postgraduate students.
METHODS: The study employed a cross‑sectional design and was conducted at Kerman University of
Medical Sciences in 2018. Using the emotional intelligence questionnaire by Bradberry and Greaves
and a researcher‑made questionnaire of learning strategic, we assessed the relationship of emotional
intelligence with learning strategies in postgraduate students using a census method (n = 338).
Data were analyzed using descriptive statistics including mean and standard deviation and analytic
statistics such as Kolmogorov–Smirnov test, ANOVA, t‑test, and Pearson’s correlation coefficient
at P < 0.05 significance level.
RESULTS: This study showed that the mean emotional intelligence score of postgraduate students
was 91.12 ± 13.92 and also no significant relationship between the learning strategies and the
emotional intelligence in the participants, but the emotional intelligence components showed a
positive significant relationship with the learning strategy components, namely self‑efficacy, rehearsal,
critical thinking, cognitive self‑regulation, time and study environment management, peer learning,
and help‑seeking.
CONCLUSION: It could be stated that emotional intelligence components can be taught and fostered
to improve the emotional intelligence of the learners, optimal learning, and the quality of educational
outcomes. However, a learning strategy is a natural, habitual, unique, and fixed preferential method
that serves to absorb, process, and maintain new information and skills. In other words, reinforcement
of emotional intelligence facilitates learning.

Abstract BACKGROUND: Caregiver stress is harmful to the health of both caregivers and people living with
Alzheimer’s disease or other dementias. The present study was conducted to assess stress and its
predictors of people living with Alzheimer’s disease or other dementias’ caregivers.
METHODS: The present descriptive, analytical, cross‑sectional study was conducted in December
2017–June 2018 in Isfahan, Iran. Data were collected by interviewing 99 caregivers had at
least 6  months of experience caring for a patient diagnosed with Alzheimer’s disease, through
questionnaires developed by the researcher. A convenience sample (easy access) of caregivers was
recruited from calling the home of formally diagnosed with Alzheimer’s patient, that have registered in
educational hospitals affiliated to Isfahan University of Medical Sciences and psychiatrists’ office both
paid caregivers (formal) and unpaid caregivers (family). All caregivers provided informed consent.
The type and severity of the relationship between the dependent (stress) and independent variable
were assessed using Pearson’s and Spearman’s correlation coefficients, the independent t‑test, and
the multivariate regression analysis.
RESULTS: The caregivers’ mean stress score was 25.4 ± 10.9 (range: 4–54). About 80% of the
caregivers were female. Age and stress score was correlated (P = 0.004), the mean stress score was
significantly higher in female caregivers (P = 0.04), informal caregivers (P < 0.001), and significantly
lower in the caregivers with previous experience of caring for Alzheimer’s patients (P = 0.02) or those
introduced by service companies (P = 0.005). Variables including the family relationship with the
patient (P = 0.01), kind of caregiving (P = 0.03), and previous experience of caring for Alzheimer’s
patients (P = 0.04) were stronger predictors of the stress score.
CONCLUSION: Stress is a challenge in promoting mental health among dementia caregivers.
Providing social support with an emphasis on physical, mental, and social health is mandatory,
especially for female and family caregivers, to promote stress management, mental health in this
group, and enable optimal and purposeful care.

Abstract INTRODUCTION: Spiritual health is one of the four dimensions of health in humans, and the others
are physical, psychological, and social dimensions. This dimension is essential to increase the
adaptation to the disease. Therefore, this study was aimed to determine spiritual health in women
with multiple sclerosis (MS) and its association with self‑esteem.
METHODS: This is a descriptive cross‑sectional study, and 210 women with MS referring to Ayatollah
Kashani Hospital affiliated to Isfahan University of Medical Sciences were selected using convenience
sampling method. The data were collected by questionnaires of demographic characteristic
questionnaire (6 items), Rosenberg Self‑esteem Scale (10 items), and Ellison and Paloutzian Spiritual
Well‑being Questionnaire (20 items). Data were analyzed using descriptive statistics, Pearson’s
correlation coefficient, and multiple regression analysis at a significance level of 0.05.
RESULTS: The mean and standard deviation of spiritual health  (including religious health and
existential health) and self‑esteem in MS patients were 48.8 ± 6.80, 44.7 ± 6.70, and 3.21 ± 2.5,
respectively. The results showed that 95.2% of the research units had moderate‑to‑high
spiritual (religious and existential) health and 57.7% had high self‑esteem. Pearson’s correlation
coefficient also showed a significant positive correlation between religious health and existential
with self‑esteem (r = 0.22, P = 0.03 and r = 0.24, P = 0.01, respectively).
CONCLUSIONS: In this study, most of the women with MS had high levels of spiritual health and
self‑esteem. This can be used as a coping strategy and has a protective effect against stress‑induced
illness and even against complications of the treatment. In addition, in some cases, it is effective in
alleviating frustration in these patients.

Abstract BACKGROUND: Hospitals in developed countries allocate itself about 40% of health‑care costs
and in developing countries up to 80%. In this study, researchers reviewed the related article in the
field of the hospitals’ performance evaluation due to the identification of common indicators used
in different models with the aim of providing simple list for evaluating hospitals’ performance to the
researchers who are interested to these issues.
METHODS: The databases for the search included Medline, Google Scholar, and Scopus. A search
strategy leads to the extraction of 403 related articles that after the removal of inappropriate and
duplicate articles, 42 studies were selected for the scoping review.
RESULTS: This scoping review showed that 9 of 42 selected articles use data envelopment analysis
model, 6 of them Pabon Lasso model, 3 of them balanced scorecard, 3 of them organizational
excellence model, and the remaining articles used key performance indicators to evaluate hospital
performance. A process approach was used to categorize the common indicators  because the
literature review indicated that common indicators mainly evaluate data, process, output, or impact of
performance. The findings included 36 input, 39 process, 27 output, and 8 impact common indicators
for evaluating performance.
DISCUSSION: This scoping review of related literature indicated that despite differentiation in the time
and place of past studies in the field of performance evaluation models, there are some indicators
that are common in most popular performance evaluation models. These simple lists can apply for
evaluation of hospitals’ performance instead of complicated models.

Abstract BACKGROUND: Women during menopause stages experience many symptoms, for which they
lack enough knowledge to manage them. This study aimed to compare the effect of self‑directed and
support group health education on the quality of life (QOL (and self‑care of postmenopausal women.
MATERIALS AND METHODS: This field trial study was carried out with three groups. One hundred
and eight menopause women were selected through convenient sampling method based on the
inclusion criteria from three comprehensive health centers. Health centers were randomly assigned to
support (n = 36), self‑directed (n = 36), and control groups (n = 36). In the self‑directed group, education
was provided through educational package, and the control group received routine care from the
health center. The support group received education through four group sessions by trained healthy
volunteers. Data were collected by menopause‑specific QOL and self‑care standard questionnaire.
RESULTS: Immediately after the intervention, the mean scores of QOL in the self‑directed
group, support group, and control group were 41.82  ±  7.61, 40.31  ±  4.80, and 48.17  ±  8.45,
respectively (P  <  0.05). In addition, the mean scores of self‑care were significantly different
between the self‑directed (40.67 ± 7.36) and support (36.50 ± 3.36) groups compared to the control
group (47.83 ± 8.47) (P < 0.05). After 1 month from intervention, QOL scores in the self‑directed
group (40.67 ± 7.36), support group (36.50 ± 3.36), and control group (47.83 ± 8.47) were significantly
different (P < 0.05). In addition, the mean scores of self‑care were 64 ± 6.79 and 65 ± 8.32 in the
self‑directed and support groups, respectively, compared to the control group (49.09 ± 9.43). Post hoc
test (least significant difference) revealed higher effectiveness of the support group (P < 0.001).
CONCLUSIONS: Results indicated QOL and self‑care in menopause women in self‑directed and
support groups improved. However, the support group provided higher effectiveness. Therefore,
we recommended paying more attention to the capabilities of healthy volunteers for the promotion
of QOL in menopause women.

Abstract CONTEXT: In the era of technology, social networking has become a platform for the teaching–
learning process. Exploring international students’ perspective on using Twitter would reveal the
barriers and potential for its use in higher educational activities.
AIMS: This study aimed to explore the postgraduate students’ perspective on using Twitter as a
learning resource.
SUBJECTS AND METHODS: This qualitative study was conducted as part of a postgraduate program
at a university in the United Kingdom. A focus group discussion and five in‑depth interviews were
conducted after receiving the informed consent. The qualitative data were analyzed by R package
for Qualitative Data Analysis software.
ANALYSIS USED: Deductive content analysis was used in this study.
RESULTS: Qualitative analysis revealed four salient themes, which were (1) background knowledge
about Twitter, (2) factors influencing the usage of Twitter, (3) master’s students’ experiences on
using Twitter for education, and (4) potential of using Twitter in the postgraduate study. The students
preferred to use Twitter for sharing links and appreciated the benefit on immediate dissemination
of information. Meanwhile, privacy concern, unfamiliarity, and hesitation to participate in discussion
discouraged the students from using Twitter as a learning platform.
CONCLUSIONS: Using social media platforms in education could be challenging for both
the learners and the educators. Our study revealed that Twitter was mainly used for social
communication among postgraduate students however most could see a benefit of using Twitter
for their learning if they received adequate guidance on how to use the platform. The multiple
barriers to using Twitter were mainly related to unfamiliarity which should be addressed early in
the learning process.

Abstract INTRODUCTION: Due to changes in scientific findings and assigned tasks, continuing education
and other enabling programs are increasingly critical for primary healthcare providers to keep them
up‑to‑date in delivering oral health services. Planning these educational courses based on actual
PHCPs’ needs is fundamental to provide effective ones. The purpose of this study was to elucidate
the experiences and needs of PHCPs regarding the quality of the oral health training provided in
continuing education and other enabling courses.
SUBJECTS AND METHODS: A qualitative study with content analysis approach was conducted in
Najaf‑Abad, Isfahan, Iran, in 2017. Data were gathered through in‑depth semi‑structured interviews
with 19 primary healthcare providers. The sampling was started with purposeful method and continued
through snowball method. Qualitative data were coded and analyzed using MAXQDA (VER 12).
RESULTS: Factors affecting the quality of oral health training were categorized into three themes and
nine subthemes, including instructor’s related factors (knowledge, skills, and relevant experiences),
educational content  (content relevance, content innovation, and content update), and teaching
methods and educational tools (fitting educational contents, covering learners’ needs, and considering
available possibilities).
CONCLUSION: Instructors with inadequate level of knowledge, skills, and relevant experiences as
well as inappropriate selection of educational content, teaching methods, and educational tools, were
recognized as affecting factors on the quality of oral health training and effectiveness of continuous
education and enabling programs.

Abstract INTRODUCTION: Today, it is important to use different indices to measure the performance of
hospitals. This study aimed to investigate and evaluate the performance indicators of military hospitals
and measurement of performance by using the Pabon Lasso model.
METHODS: This was an applied and descriptive‑analytical study that was conducted among five
military hospitals affiliated to the Army of the Islamic Republic of Iran by using data from 2017 to 2018.
Raw data related to performance indicators such as bed occupancy ratio (BOR), average length of
stay (ALoS), and bed turnover rate (BTR) were collected by referring to the hospital medical record
unit. After comparing performance indicators with the standards of the Ministry of Health, the Pabon
Lasso model was used to measure hospitals’ performance.
RESULTS: In general, the average BOR and bed turnover interval rate are higher than that of the
national standard in all hospitals and are in favorable status. However, the average length of stay
in all hospitals was in unfavorable status. Furthermore, one and two hospitals were located in zone
3 in Pabon Lasso graph in the years 2017 and 2018, respectively. Overall, there was no change in
the performance of the hospitals in the study time periods.
CONCLUSION: In general, except for the average length of stay indicator, hospitals had a favorable
performance level. Therefore, planning to improve performance indicators should be at the top of
the programs.

Abstract INTRODUCTION: Bachelor’s program in surgical technology is a major of medical science, in Iran.
Learning and adapting to different skills and roles in the operation room environment is a daunting
work. The complexity of this environment needs to bring together researchers in this field to work
on different aspects. The aim of this qualitative study was comprehensively understanding of clinical
teaching process in surgical technology.
MATERIALS AND METHODS: The present study was conducted based on the qualitative research
design of the grounded theory approach (Corbin and Strauss, 2008). This study was conducted at
schools of nursing and paramedical in five academic settings. Study participants in the present study
include 14 students, seven educational instructors, six staff of operation room, one dean of faculty,
three surgeon assistants, one instructor, and four head nurses of operation room. A semi‑structured
interview method and a memo were conducted using theoretical and purposive sampling. Constant
comparative analysis was used for data analysis.
RESULTS: Findings showed that the nonacceptance of student by surgical team was identified as
the main concern of the students. The “gaining clinical competence and approval” was found the
central process (strategy) in response to main concern of clinical education, and the “interactive and
dynamic nature of the operation room environment” was defined as the context for this major concern.
Strategies that students used to address this concern included individual efforts to overcome distrust,
learning in the shadow of surgical team members, and seeking help and support of the instructor.
CONCLUSION: Accepting the students of surgical technology as a member of surgical team creates
opportunities for students to learn, gain experience, and enhance their professional qualifications
and abilities.

Abstract INTRODUCTION: The need assessment is a fundamental part of any planning, and almost by
neglecting it, the effectiveness of the programs is impossible. The purpose of this study was the
prioritization of needs among students of the Iran University of Medical Sciences.
MATERIALS AND METHODS: The design study was conducted in two parts; in the first part, the
design of the questionnaire was done by qualitative methods. The questionnaires were extracted
by interviewing and obtained acceptable validity and reliability. Moreover, the second part created
a questionnaire consisting of four categories: education, welfare, economic, and psychological and
social. A simple random sampling method was used to select 363 people using the Cochran formula.
Finally, 336 people (including 28 people excluded) completed the questionnaire. A questionnaire
designed to collect sample data was used and analyzed using version 23 of SPSS.
RESULTS: A total of 336 students (26.77 ± 5.45 years) participated in the study. 123 (36.6%) were
male and 213 (63.4%) were female. Psychological and social needs of students were prioritized,
and educational priorities were ranked second. The findings showed that there was no significant
statistical difference between the scores of welfares and psychosocial and educational needs and
the gender of the research units (P > 0.05). However, in the mean of economic needs scores, there
is a significant statistical difference between the marital status of the research units (P < 0.05).
CONCLUSION: The results of our study in the research units showed that the priority of psychosocial
needs was more than other needs and the educational priority was the next. According to the results
of this study, we suggest that, in future educational and educational planning, policymakers and
planners should pay attention to psychological and social issues.

Abstract BACKGROUND: Dental education can be a critical wellspring of stress among dental students,
and studies have observed higher levels of stress among dental students than in the all‑inclusive
community. The present study aims to evaluate the perceived stress among dental undergraduate
students, the sources of stress, and an association of perceived stress with sociodemographic
characteristics and various stressors.
MATERIALS AND METHODS: A cross‑sectional study was conducted among 380 undergraduate
dental students (from 1st year to final year) in a private dental college, Kanpur. A self‑administered
questionnaire was used to collect data regarding sociodemographic profile, perceived stress using
Perceived Stress Scale‑14, and academic, psychosocial, and environmental stressors. Data were
analyzed using IBM SPSS Statistics‑Version 21 (IBM Corp. Released 2012. IBM SPSS Statistics
for Windows, Version 21.0, Armonk, NY, USA: IBM Corp.).
RESULTS: The mean perceived stress score was 30.25 ± 1.914. The median perceived stress score
was 30. Statistically significant (P < 0.001) values were found for higher age group and year of studying
Bachelor of Dental Surgery (BDS) were important sociodemographic determinant of stress. Vastness
of academic curricula, frequency of examination (P < 0.05), and fear of failure/poor performance
in examinations were important academic determinants of stress. High parental expectations and
family problems were important psychosocial stressors. Accommodation away from home was an
important predictor of stress (P < 0.001).
CONCLUSION: This study revealed that there are various sociodemographic (age and year of study
in BDS), academic (curricula, frequency of examination, and performance level) determinants and
predictors of stress (type of accommodation), along with psychosocial stressors (parental expectation
and family problems). Dental colleges should develop stress management programs to promote
gender and social equity and strategies to improve psychological support services. The stress
management programs reported either helped to reduce the number of stressors or enhance stress
coping skills, using relaxation techniques such as deep breathing, yoga, and stress management
programs.

Abstract BACKGROUND: Sufficient physical activity (SPA) in children and adolescents has an important role
in health, growth, and development of persons. This study aimed to investigate the prevalence of
and inequality in physical activity (PA) in 12–15‑year‑old students in the West of Iran, 2018.
MATERIALS AND METHODS: In this cross‑sectional study, 1404 students from 14 schools of
Kermanshah city were included. Data on demographic and socioeconomic status (SES) of students
and their family, body mass index, moderate‑to‑vigorous PA of students were collected. Normalized
concentration index (NC) and decomposition analysis applied to measure inequality in SPA and the
contribution of affecting factors, respectively.
RESULTS: About 19% of the students had SPA. The proportion of SPA in boys was higher than
girls (38.98% vs. 9.84%). There was a significant deviation from equality line (NC = 0.31; 95%
confidence interval [CI]: 0.23, 0.38) and NC for boys and girls were 0.15 (95% CI: 0.04, 0.25) and
0.05  (95% CI: −0.07, 0.17). Sex of students and SES of households with 59.09% and 39.77%
contribution to the measured inequality in SPA were the highest positive contributors. Household
size (−2.60) had a negative contribution to inequality in SPA.
CONCLUSION: There was a significant pro‑rich socioeconomic inequality in SPA and sex, and SES
were the main contributors to the inequality in PA. Some interventions are needed to improve PA
among children and adolescents with a focus on girls and low‑SES groups to narrow the existing gaps.

Abstract INTRODUCTION: Maternal attachment to the fetus is an emotional bond and the unique relationship
of the pregnant woman to the fetus. Attachment is an important predictor of mental health. One of
the psychological factors affecting mental health is resilience and hope. The purpose of this study
was to determine the relationship between hope and resilience with promoting maternal attachment
to the fetus during pregnancy.
METHODS: This is a descriptive correlational study performed on 386 pregnant women referred to
community health centers in Isfahan‑Iran. The research instruments were standard questionnaires
of Hope Snyder, Conor and Davidson Resilience, and maternal attachment to the fetus of Cranley.
Data were analyzed using descriptive statistics and Pearson’s correlation test.
RESULTS: The results showed that there is no significant relationship between the overall score
of maternal attachment to the fetus and the total score of hope (P = 0.73). The overall score of
maternal attachment to the fetus was positively and significantly correlated with hope subscales,
including thinking (P = 0.004) and path (P = 0.047). The overall score of maternal attachment to the
fetus was positively and significantly correlated with the overall score of resilience (P = 0.03). There
was a correlation between the dimensions of maternal attachment to the fetus, including interaction
with the fetus (P = 0.003) and self‑sacrifice (P = 0.015). Maternal role acceptance (P = 0.001) was
positively and significantly correlated with hope thinking subscale. Self‑sacrifice (P = 0.027) and
differentiation between self and fetus (P = 0.035) were positively and positively correlated with hope
path subscales. Self‑sacrifice (P = 0.03) and attribution to fetus (P = 0.001) had a significant positive
relationship with resilience.
CONCLUSION: The results of this study showed that hope and resiliency are positively and
significantly associated with maternal attachment to the fetus during pregnancy. Hope and resiliency
are positively and significantly associated with maternal attachment to the fetus, thus increasing the
expectation of pregnant mothers to increase their attachment to their fetus. As a result, they are paying
more attention to prenatal care, which can guarantee the health of their mothers and their babies.

Abstract INTRODUCTION: Marital satisfaction is a situation in which the husband and wife enjoy marrying
and feeling emotional; on the other hand, the existence of religious beliefs has a significant effect on
family stability. The aim of this study was to determine the relationship between religious orientation,
sexual satisfaction, and marital satisfaction in women of reproductive age.
METHODS: This is a correlational study performed on 150 married women aged 45–45 years who
referred to Neyshabur comprehensive health services centers. The sampling method was clustered.
The present study used three questionnaires: Spinner Marital Satisfaction, Larson’s Sexual Satisfaction,
and Allport Religious Orientation Questionnaire. The reliability of these questionnaires was confirmed
by the retest method. T‑test, Pearson correlation, and one‑way ANOVA were used for data analysis.
RESULTS: Data analysis showed that there is a significant and positive relationship between religious
orientation and sexual satisfaction and marital satisfaction. Religious commitment has a predictive
role in promoting sexual satisfaction and marital satisfaction, with increasing religious commitment,
increasing sexual satisfaction, and marital satisfaction.
CONCLUSION: Psychologists and counselors in individual and couple counseling sessions with
sexual problems and marital dissatisfaction and premarital counseling can increase marital satisfaction
with regard to religious factors and religious and spiritual teachings.

Abstract BACKGROUND AND AIM: Spirituality in education, as a necessity in improving the quality of
teaching and learning, is affected by various personal, social, religious, and cultural factors. Since
the identification of these factors can empower the faculties and facilitate the transfer of spiritual
concepts through teaching, the aim of this study is explanation of the factors affecting the spirituality
transfer in education process.
MATERIALS AND METHODS: This qualitative content analysis approach study included 22
faculty members of medical universities, 25 faculty members of seminary, and 19 medical students
interested in participating in the study. They were studied according to purposive sampling method.
Data collection was done by interviewing a semi‑structured questionnaire. Data were analyzed using
conventional content analysis method.
RESULTS: The factors influencing the spiritual transfer in teaching process were classified into two
main forms of teacher‑related factors and peripheral‑related factors. Teacher‑related factors include
the teacher’s insight and worldview, adherence to religious principles, belief in ethical virtues, the
positive and constructive interaction of the teacher with the student, and the mastery of teaching
skills. The peripheral‑related factors include the highly skilled classrooms and the talented learners.
CONCLUSION: The intensification of the insight, religious worldview and the basic of beliefs,
consolidating ethics and empowering faculty members in teaching skills along with building a
positive and constructive relationship with the students, as well as institutionalizing spirituality as
the inseparable teaching element can facilitate the transfer of spirituality concepts. More studies are
needed in this regard.

Abstract CONTEXT: Health promotion (HP) and clinical risk management (CRM) topics are seldom discussed
during medical school lessons. Peer‑assisted learning (PAL) has long occurred informally in medical
education, and interest in this method has recently grown, as it is considered a valuable technique
for both tutors and tutees.
AIMS: The aim was to evaluate the impact of HP and CRM PAL intervention on medical
students’ (tutees) knowledge level.
SETTINGS AND DESIGN: A PAL intervention has been implemented at Udine University medical
school during 2017. It was composed of lectures and practical activities conducted by ten near‑peer
tutors.
METHODS: The effectiveness has been evaluated by giving tutees: (1) a knowledge multiple‑choice
questionnaire, before and after the intervention; (2) a satisfaction questionnaire; and evaluating (3)
tutees’ group assignments.
STATISTICAL ANALYSIS USED: We performed descriptive analysis; then McNemar, Wilcoxon
signed rank, Wilcoxon Mann–Whitney, and t‑tests were applied.
RESULTS: The number of students addressed by PAL intervention was 62. Difference in total
correct answers among pre‑ and post‑intervention questionnaires showed a statistically significant
improvement  (P  <  0.0001), both when analyzing it globally and by area  (HP/CRM). Students’
satisfaction for CRM was greater than for HP area (P = 0.0041).
CONCLUSIONS: This educational intervention based on PAL showed its effectiveness producing
a statistically significant improvement in students’ knowledge. Our findings confirm that PAL could
be a feasible method for HP and CRM topics.