Journal of Education and Health Promotion

Abstract INTRODUCTION: In order to improve outpatient education, it is necessary to carry out formative
standard evaluation to reveal the strengths and weaknesses to improve planning the quality of clinical
education. Due to numerous challenges in clinical education, the present study was conducted to
determine the extent to which outpatient education standards were achieved in the major departments
of Shiraz Medical School.
METHODS: In this quantitative combined, cross‑sectional and practical investigation in the academic
year 2018–2019, 178 interns who had passed the outpatient education in the four major wards (internal
medicine, pediatrics, gynecology, and surgery) in Shiraz Medical School were randomly selected.
A 26‑item researcher‑made questionnaire, based on the Handbook of the Ministry of Clinical
Education (Outpatient Education) for Health and Medical Education’s Criteria and indicators, was
used in three areas of preparation, timing and implementation; and the psychometric properties
of the questionnaire were determined. For quantitative data analysis, SPSS version 22 was used.
Furthermore, we performed a qualitative study through semi‑structured interviews with 16 interns
and analyzed the data using MAXQDA 10 software.
RESULTS: The results of the quantitative study showed that 8.4% of interns evaluated the program
as poor, 66.3% moderate, and 25.3% good. The qualitative study showed that number and diversity
of patients, instructor’s educational model, and number of interns had a significant role.
CONCLUSION: Although the outpatient teaching in the four major departments of Shiraz Medical
School was evaluated relatively acceptable, it is far from the ideal point and need to be improved.

Abstract BACKGROUND: Assessing how programs are implemented from the perspective of the learners
themselves is one of the most effective ways to improve the quality of continuing education. The aim
was to evaluate the implementation of in‑person continuing education programs from the perspective
of nurses.
METHODOLOGY: Setting of the study was the selected hospital of Isfahan University of Medical
Sciences (Al‑zahra hospital). This study is a descriptive cross‑sectional one. Using a researcher‑made
questionnaire, the implementation of continuing education programs in four areas of the aim,
educational techniques, educational content, and educational field was evaluated. The sample
consisted of 236 nurses working in these hospitals who participated in the study through convenience
sampling. Data were analyzed by SPSS software version 19 using descriptive statistics.
RESULTS: Based on the results, “the need for new content learning” was mentioned as the first
priority in continuing education programs. The majority of participants scored each of the following
domains (aim, educational techniques, educational content, and education field) as well as all items
related to the continuing education program evaluation as “moderate.”
CONCLUSION: Most nurses assessed the implementation of in‑person continuing education
programs implemented in Isfahan University of Medical Sciences in general and in each of the
domains as “moderate.” Therefore, in order to improve the quality of programs, it is necessary to
take steps to match the goals with the needs of learners, improve teaching techniques, improve the
quality of program contents, and optimize the scope of the programs.

Abstract BACKGROUND: Medical students should have adequate knowledge on tuberculosis (TB) and
national guidelines pertaining to its control, which is a major public health problem in developing
countries. The present study aims to evaluate the knowledge on TB and Revised National TB Control
Programme (RNTCP) among medical interns and the change in the level of knowledge following the
dissemination of self‑directed learning (SDL) modules using an e‑learning tool (WhatsApp).
MATERIALS AND METHODS: A prospective, nonrandomized, pre‑ and posttest study was done
among 124 medical interns in a private medical college during July–August 2019. A semi‑structured,
self‑administered questionnaire was prepared and filled by the interns in the pretest. Following the
educational intervention, the same questionnaire was administered and posttest data were collected.
The pre‑ and posttest results were expressed in frequency and percentage. Wilcoxon signed rank
test was used to compare the change in the total mean score of knowledge using the e‑learning tool
following the dissemination of SDL modules.
RESULTS: The mean age of the interns was 22.82 ± 0.82 years. Of the total 124 interns, 60 (48.3%)
had heard about the recent changes in RNTCP. The Internet (25.8%) and textbooks (23.4%) were
the most common source of recent information regarding TB and RNTCP. The mean pretest score
was 12.9 ± 3.08, which increased to 15.3 ± 2.62 during the posttest (z = −9.75, P < 0.05) following
the intervention.
CONCLUSIONS: The knowledge regarding TB and RNTCP among the interns was inadequate.
The usage of an e‑learning tool “WhatsApp” was found to be effective in improving the knowledge
in posttest as compared to pretest.

Abstract INTRODUCTION: Teaching is one of the most important needs of human societies, and selecting
the best method of teaching is so important to improve the teaching as well as learning of students.
The purpose of this study was to determine the effect of case‑based teaching (CBT) and flipped
classroom methods in comparison with lecture method on students’ learning and satisfaction at
internship of Department of General Surgery, Isfahan University of Medical Sciences.
MATERIALS AND METHODS: This experimental study was performed on fifty medical surgery
internship students in Isfahan University of Medical Sciences in 2017. Students were randomly
divided into two groups of control group and intervention group. The data were collected by a posttest
after holding every class and a researcher‑made form for evaluating students’ satisfaction after the
end of the project. The results of this study were analyzed by SPSS 21 software using descriptive
statistical methods (mean and standard deviation) and paired t‑test.
RESULTS: The comparison of the mean posttest scores in the three classes showed that the mean
scores of the students in the intervention group in the first and second sessions unlike the third
session were higher than that in the control group; this difference was statistically significant in the
first session (P = 005) and the third session (P = 0.002). Students’ satisfaction with case‑based
learning method (4.03 ± 0.87) was higher than that of lecture method (2.88 ± 0.78).
CONCLUSION: In CBT and flipped classroom, students’ learning and the quality of teaching were
improved. In addition, students were more satisfied with this method in comparison with the lecture
method. However, it should be noted that the success of using this teaching method depends on
choosing the appropriate subject.

Abstract BACKGROUND: Oral soft tissue diseases include a broad spectrum, and the wide array of patient
data elements need to be processed in their diagnosis. One of the biggest and most basic challenges
is the analysis of this huge amount of complex patient data in an increasing number of complicated
clinical decisions. This study seeks to identify the necessary steps for collecting and management
of these data elements through establishing a consensus‑based framework.
METHODS: This research was conducted as a descriptive, cross‑sectional study from April 2016 to
January 2017, which has been performed in several steps: literature review, developing the initial
draft (v. 0), submitting the draft to experts, validating by an expert panel, applying expert opinions
and creating version v.i, performing Delphi rounds, and creating the final framework.
RESULTS: The administrative data category with 17 and the historical data category with 23
data elements were utilized in recording data elements in the diagnosis of all of the different oral
diseases. In the paraclinical indicator and clinical indicator categories, the necessary data elements
were considered with respect to the 6 main axes of oral soft tissue diseases, according to Burket’s
Oral Medicine: ulcerative, vesicular, and bullous lesions; red and white lesions of the oral mucosa;
pigmented lesions of the oral mucosa; benign lesions of the oral cavity and the jaws; oral and
oropharyngeal cancer; and salivary gland diseases.
CONCLUSIONS: The study achieved a consensus‑based framework for the essential data element
in the differential diagnosis of oral medicine using a comprehensive search with rich keywords in
databases and reference texts, providing an environment for discussion and exchange of ideas
among experts and the careful use of the Delphi decision technique.

Abstract INTRODUCTION: Oral health is a very important issue for different groups, especially adolescents.
Social cognitive theory seeks to describe and promote people’s health behaviors in a variety of ways.
The aim of this study was to determine the role of self‑efficacy, outcome expectation, and outcome
expectancy in promoting oral health behaviors in adolescent girls in Shahrekord.
METHODS: The present study was performed as an intervention in junior high schools in
Shahrekord (school year: 2018–2019). Using cluster sampling method, a total of eighty adolescent
girls studying in Shahrekord public schools were selected and randomly divided into two groups of
intervention and control. A researcher‑made questionnaire was used to collect data on demographic
variables, outcome expectation, and outcome expectancy constructs. In addition, a checklist was
used to assess the status of oral health among the participants. Education for the experimental group
was held in four sessions, each lasting 50–60 min. The data required for the study were collected in
three stages: before the intervention, immediately after, and 2 months after the intervention. Using
SPSS statistical software version 18, the collected data were analyzed through paired t‑test and
analysis of variance via repeating the observations.
RESULTS: There was no significant difference between the two groups in terms of demographic
variables. Before the intervention, there was no significant difference between the two groups in
terms of the mean scores of outcome expectation, outcome expectancy, and self‑efficacy; however,
after the intervention, there was an increase in the scores of the experimental group (P < 0.001). Two
months after training, there was also a significant increase in the mean score of oral health behavior
in the experimental group (P < 0.001).
CONCLUSION: Training based on perceived self‑efficacy, outcome expectation, and outcome
expectancy played an important role in creating the desired attitude toward oral health‑promoting
behavior among students.

Abstract BACKGROUND: In the postpartum period, changes in sexual desire and marital satisfaction can be
seen. Learning and giving enough information on changes in pregnancy and postpartum can help
to increase marital satisfaction. The purpose of this study was to determine the effect of prenatal
training on the level of postpartum marital satisfaction in nulliparous women.
METHODS: This study is a semi‑experimental two‑group study in which 150 nulliparous women were
divided into two groups: control and intervention groups. The samples into intervention group received
routine prenatal care and eight sessions of prenatal education with a training package (educational
pamphlet on sexual health and sexual issues and an educational CD on pregnancy and pelvic
exercises), and the control group received only routine prenatal care along with a pregnancy education
pamphlet. Marital satisfaction was measured before intervention during pregnancy and 3 months
after delivery (after intervention) using the ENRICH Marital Satisfaction Scale. Data were analyzed
using t‑test, paired t‑test, Mann–Whitney, and Chi‑square test.
RESULTS: There was no significant difference in demographic and obstetric variables and pregnancy
status between the two intervention and control groups (P > 0.05). There was no significant difference
in marital satisfaction during pregnancy between the two groups (before intervention) (P > 0.05).
However, there was a significant difference in the level of postpartum marital satisfaction in the
intervention group (P < 0/05). So that, the average marital satisfaction is increased from 52.2 to 64.6.
CONCLUSION: The results of this study show that eight sessions of prenatal education class with a
training package (educational pamphlet on sexual health and sexuality and training CD of prenatal
and pelvic floor exercise) can improve postpartum marital satisfaction in women.

Abstract CONTEXT: Harmful use of alcohol has led to 1.7 million deaths from noncommunicable diseases
and 1 million injury deaths including road traffic accidents, self‑harm, and interpersonal violence. The
opportunistic screening can be used to screen for substance abuse in outpatient department (OPD)
attendees of primary health‑care (PHC) settings in India.
AIMS: This study was conducted to determine the prevalence of willingness to quit alcohol use
among alcohol users and factors associated with it.
SUBJECTS AND METHODS: A facility‑based cross‑sectional study was conducted in urban PHCs
and willingness to quit alcohol was assessed among the alcohol users. Alcohol Use Disorder
Identification Test (AUDIT) scale was used to assess the alcohol use disorder score. Data were
entered using Epidata version 3.1 and analyzed using STATA version 14.
RESULTS: It is found that two‑third of the male OPD patients are using alcohol and 59% of the
alcohol users were willing to quit alcohol. Education (adjusted prevalence rate ratio [aPR] = 1.9;
95% confidence interval [CI]: 1.2–2.9), occupation (aPR = 1.4; 95% CI: 1.1–1.8), higher AUDIT
scores (aPR = 2.7; 95% CI: 2.2–3.5), frequency of alcohol use (aPR = 1.6; 95% CI: 1.2–2.0), and
positive family history of alcohol‑related illness times (aPR = 1.6; 95% CI: 1.3–2.0) were significantly
associated with willingness to quit alcohol.
CONCLUSION: Two‑third of the male OPD patients are using alcohol and 59% of the alcohol users
were willing to quit alcohol. Education, occupation, higher AUDIT scores, frequency of alcohol use,
and positive family history of alcohol‑related illness were significantly associated with willingness
to quit alcohol.

Abstract INTRODUCTION: Infertility by creating a disturbing and debilitating condition is considered as an
important individual, public, and social health problem. The purpose of this study was to determine
the effect of counseling based on acceptance and commitment therapy (ACT) on mental health and
quality of life in infertile couples.
METHODS: In this randomized controlled trial, 54 infertile couples referring to the Sanandaj‑Iran
Infertility Clinic were assigned into two groups of counseling and control by random blocking with a
1:1 ratio. The consulting group received 8 weekly 90‑min sessions of group counseling based on
ACT. The General Health Questionnaire‑28 (GHQ‑28) and Fertility Quality of Life were completed
before and 1 month after the completion of the intervention. Primary outcome measures were mean
score of mental health and quality of fertility life. Independent t‑test, ANCOVA, and Mann–Whitney
U‑test were used to analyze data.
RESULTS: There was no significant intergroup difference in demographic information (P > 0.05). One
month after the end of the intervention, the mean overall mental health score in the couples of the
counseling group was significantly less than the control group (adjusted mean difference [aMD]: −8.4;
95% confidence interval [CI]: −10.4–−6.4; P < 0.001). Furthermore, the mean overall score of quality
of life in the counseling group couples was significantly more than the control group (aMD: 14.8;
95% CI: 11.8–17.9; P < 0.001).
CONCLUSION: Based on the effectiveness of counseling based on ACT on mental health and quality
of life in infertile couples, it can be used in the infertility clinics. Health‑care providers and counselors
should train in the ACT courses to improve the mental health and quality of life of infertile couples.

Abstract INTRODUCTION: Spread of novel coronavirus (severe acute respiratory syndrome coronavirus
2 [SARS‑CoV‑2]) has become a global and pandemic crisis. Some measures such as excessive
use of disinfectants, increased production of nonbiodegradable waste, and water pollution will be
the consequences of fighting against coronavirus disease 2019 (COVID‑19), which harms the
environment. Due to the fact that these effects will be identified in the long term, they may be
neglected in the current situation. Therefore, the aim of this study was to investigate the environmental
challenges caused by the SARS‑CoV‑2 pandemic crisis.
MATERIALS AND METHODS: This was a review study conducted by search in databases, including
Scopus, PubMed, and science direct until early May 2020. Keywords included “SARS‑CoV‑2,”
“COVID‑19,” and “Environment.” Studies published in English and conducted in different countries
were also selected for the analysis. The guidelines published by reputable organizations such as
the World Health Organization, the Centers for Disease Control prevention (CDC), and the Ministry
of Health have also been used in this study.
CONCLUSION: The results of this study have shown that the COVID‑19 virus, in addition to human
damage and mortality, also affects the environment, and the damages and losses resulting from
this pandemic may be identified later. Water pollution, increasing chemical pollution in the air, and
increasing the production of nonbiodegradable waste are of these issues. For this purpose, it is
recommended that, in addition to trying to improve the control of this pandemic, other environmental
aspects in disinfection methods and disposal of dry and wet contaminated waste should be done
more accurately and based on standard protocols. Infectious waste, in addition to the problem of
standard sanitation, will become a major challenge that pollutes the environment. Based on this, it
can be said that if home quarantine is observed voluntarily, in addition to reducing the risk of the
SARS‑CoV‑2 and reducing the volume of visits to medical centers, it can be associated with another
positive achievement, which is the reduction in waste production and protection of the environment.

Abstract CONTEXT: Empathy is considered to be backbone of the patient–physician relationship. The
consultation and relational empathy (CARE) measure is widely used internationally to measure
empathy. However, no validated tool is available to gather patient feedback on dentists’ empathy
in India.
OBJECTIVE: The objective of this study was to explore the reliability and validity of a CARE measure
and to assess the factors influencing CARE score and to determine if there was an association
between their CARE score and satisfaction of the patient.
SETTING AND DESIGN: A cross‑sectional study was done in dental colleges.
SUBJECTS AND METHODS: A questionnaire study was carried out among 100 patients from 6
dental colleges in Bangalore using validated CARE measure.
STATISTICAL ANALYSIS: Internal consistency of items was evaluated by the Cronbach’s alpha,
and construct validity was assessed by confirmatory factor analysis. Satisfaction was assessed by
a question response on 5‑point Likert scale. Descriptive and inferential statistics were performed
with significance set at 5%.
RESULTS: The mean CARE score was 43.80 ± 5.36. Internal reliability was high (Cronbach’s
alpha: 0.859) and was reduced by the removal of any of 10 items. High corrected item‑total correlations
ranged from 0.752 to 0.847. Factor analysis showed a single solution with high item loadings (>0.80).
Self‑perception of overall health (odds ratio [OR] = 3.78), relationship with family (OR = 4.61) and
friends (OR = 3.78), and previous dental experience (OR = 16.00) were more likely, whereas
dentist‑provided treatment (OR = 0.20), number (OR = 0.07) and dental treatment taken (OR = 0.13),
presence of anxiety (OR = 0.03), and fear (OR = 0.05) were less likely to have CARE score. The
satisfaction of the patient regressed significantly with the relationship with family members (ß = 0.77)
and CARE score (ß = 0.21).
CONCLUSION: This study confirms the educational opportunity and implementation of CARE in
dental students. CARE scores among patients varied depending on personal factors and dental
treatment‑related factors. The satisfaction of the patient was influenced by the relationship with
family members and CARE scores.

Abstract Due to the short span available for consultation with clinicians, patients try to become well versed
with their clinical conditions before the medical consultation. They search Google for their medical
information; here comes the problem of authenticity of the sources. It is very difficult to obtain authentic
medical information for the patients from the Internet. As a result, sometimes, patients ask questions
to the overburdened doctors and irritate them. To solve this problem and wider dissemination of
authentic medical knowledge, the existing website of Post Graduate Institute of Medical Education
and Research (PGIMER) has been utilized. In PGIMER, Chandigarh, health education materials in
text and video formats have been uploaded on the PGIMER website for empowering patients. All
these have been successfully tested in the outpatient departments of PGIMER, Chandigarh. To our
knowledge, this unique approach is the first of its kind in India. We hope this approach of sharing
medical information through the PGIMER website may help patient empowerment to a large extent.
Later, this concept can be replicated in all medical colleges in India.

Abstract BACKGROUND AND OBJECTIVE: Unless mental health care is provided to suicide attempters
after discharge from the emergency department, suicide prevention opportunities may be lost. The
purpose of this study was to determine the effect of motivational interviewing (MI)‑based training on
using mental health services and reducing the severity of suicidal thoughts.
METHODS: This quasi‑experimental study was performed on seventy suicide attempters who had
been admitted to the emergency department of three university hospitals in Southeast Iran in 2019.
Eligible patients were chosen through convenience sampling, and they were randomly divided into the
experimental (n = 35) and control (n = 35) groups. The intervention group received three MI sessions
on the day of discharge and the 1st week after discharge. Twelve weeks after the intervention, the
Beck Scale for Suicidal Ideation and the using mental health services were completed in both the
groups. Data were analyzed using Chi‑squared test, independent t‑test, and paired t‑test.
RESULTS: While there was no significant difference between the two groups in terms of the mean
score of suicidal ideation on the pretest, the experimental group experienced a significant decrease
in this respect at the end of the study; thus, this group scored 8.86 ± 5.30, which is considerably
lower than that obtained in the control group (15.85 ± 6.65) (P = 0.0001). Furthermore, at the end of
the study, the rate of using mental health services increased much more in the experimental group
than in the control group (P = 0.01).
CONCLUSION: MI training had a significant positive impact on mitigating suicidal ideation and
promoting mental health services use. To improve mental health and to better serve suicidal
individuals, it is recommended that short‑term interventions be developed in the form of post‑discharge
education for suicidal patients admitted to the emergency department.

Abstract BACKGROUND: The current nursing shortage is complicated because of turnover intention
among nurses. Most of the inactive nurses returned to professional nursing practice. Returned to
professional nursing practice program was low attrition rates and a more cost‑effective strategy that
prepared inactive nurses returning to practice. This study aimed to explain the process of returned
to professional nursing practice.
MATERIALS AND METHODS: This study was a grounded theory study, which lasted from about
2018 to 2020. Data were collected through semi‑structured interviews and observations with
participants after signing an informed consent form. The average interview duration was 45 min. The
study participants were selected through purposeful sampling from both public and private hospitals
affiliated to Iran University of Medical Sciences. Interviews were verbatim transcribed and analyzed
using a constant comparative analysis method.
RESULTS: In this study, 16 participants were selected, including ten nurses, two educational
supervisors, two head nurses, and two matrons. The “transformed competence” as the core concept
and the four main concepts of “feeling alienated with the new environment,” “getting prepared for
restart,” “gradual maturity in clinical practice,” and “components of organizational culture” were
extracted from the data analysis process.
CONCLUSION: The process of returned to professional nursing practice in the context of the
organizational culture of incentive learning leading to a high level of competence, and in the context
of the organizational culture of inhibiting learning, is leading to deficiency incompetence.

Abstract BACKGROUND: Designing information systems will increase the efficiency and effectiveness of
the system according to the information needs of the stakeholders. The present study examined the
effective features of designing the information system of medicinal plants from the perspective of its
users as a prerequisite for the design of this system.
MATERIALS AND METHODS: This applied research was carried out using survey method and
a researcher‑made questionnaire. The study population consisted of two groups of information
users (faculty members, students, and researchers of medicinal plants) and information
disseminators (librarians), and 308 individuals were selected by cluster sampling from five universities.
Data analysis was performed using descriptive and inferential statistics using SPSS software
version 22.
RESULTS: The results showed that in view of the two groups of users, there was a significant
difference in the search options in the database of medicinal plants and the displaying characteristics
of the search results. On an average, the rank of the two groups in these two domains was largely
different. In other cases, the users considered shared features for capabilities and facilities in an
information system of medicinal plants.
CONCLUSION: According to the results, for obtaining the information system of medicinal herbs
with better capabilities and facilities, it is essential for designers to pay attention to all elements and
objections in the interaction of the human and the system, especially in the field of search.

Abstract BACKGROUND: Nurses’ knowledge and Experience with Health Literacy can affect the treatment
process, improving the quality of health care and effectively communicating with all clients. Evaluation
of nurses’ knowledge and experience requires a reliable instrument. This study aimed to translate
cross‑cultural adaptation and testing of Health Literacy Knowledge and Experience Survey (HL‑KES).
MATERIALS AND METHODS: This cross‑sectional methodological study was done during 2018–2019.
The study was carried out in two stages: the first phase was designed to obtain a translation and
cross‑cultural equivalent of the (HL‑KES), based on the World Health Organization (2018) and the
Sousa and Rojjanasrirat (2011) Guidelines in six steps: preparation, forward translation, reconciliation,
back translation, back translation review and pretesting and cognitive debriefing of the translated
questionnaires. The second phase was conducted to evaluate the psychometric properties of the
questionnaire.
RESULTS: The content validity index and content validity ratio values of all items were >0.62 and
0.79, respectively. Based on the Kuder–Richardson formula, the reliability of the knowledge dimension
was reported as 0.7. Furthermore, split‑half coefficient for inter‑rather reliability and test–retest were
0.76 and 0.96, respectively. The reliability of their experiences with the HL‑KES was measured using
Cronbach’s alpha, in which it was 0.82.
CONCLUSIONS: The Persian version of the instrument for assessing nurses’ knowledge and
experience with health literacy had good validity and reliability. It is recommended that it should be
used in educational, clinical environments, and also in future research studies.

Abstract INTRODUCTION: Educational interventions have been associated with improved performance and
significant changes, especially in perinatal outcomes. Teaching is one of the main components in
educational planning which is a key factor in conducting educational plans through various teaching
strategies such as simulation, demonstration and video teaching.
AIM: The study aimed to assess lecture cum demonstration (LCD) versus video‑based teaching (VBT)
regarding active management of the third stage of labor (AMTSL) in terms of knowledge and skills
of General Nursing Midwifery (GNM) students.
METHODS: This was a quasi‑experimental study conducted on 100 GNM third‑year students selected
by purposive sampling and randomly assigned to LCD (n = 50) and VBT (n = 50) groups. Sample
characteristics performa, Structured Knowledge Questionnaire, and observational checklist were
used to collect data from GNM students through self‑report and observational technique.
RESULTS: The study results showed that the mean posttest knowledge scores of LCD (17.32 ± 2.14)
and VBT group (16.90 ± 2.41) were nearly equal and mean rank posttest skills score of LCD
group (54.40) was slightly higher than VBT group (49.51), but computed “ t ” value of mean posttest
knowledge and computed “ Z ” value of skill score of both LCD and VBT group (0.47, 0.54) were
found to be statistically non‑significant at 0.05 level of significance.
CONCLUSION: It can be concluded that both LCD and VBT were found to be effective in improving
knowledge and skills of GNM students regarding AMTSL.

Abstract INTRODUCTION: One of the most thought‑provoking problems in the world is child marriage that is
affected by various factors. Therefore, the purpose of this study is to identify the social determinants
of child marriage in Kurdish regions of Iran.
MATERIALS AND METHODS: This qualitative study was conducted using conventional content
analysis approach. The participants of the study were 30 Iranian‑Kurdish women married under the
age of 18 who were selected through purposeful and snowballing sampling. Data collection was
conducted through semi‑structured interviews and face‑to‑face interviews and continued until the
saturation of concepts was achieved. Graneheim and Lundman method was used to analyze the
data, and Guba and Lincoln criteria were used to strengthen the research.
RESULTS: In general, findings include 5 categories and 17 subcategories: 1 – economic
factors  (financial problems and economic benefits); 2  –  sociocultural factors  (social customs,
cultural beliefs, community encouragement, social learning, gaining prestige, and social support);
3 – individual factors (physical characteristics, personality traits, lack of awareness of the damaging
consequences of early marriage, and fear of the future); 4 – family factors  (dysfunctional family,
weak awareness of parents, and harm prevention); and 5 – structural factors (high demand, limited
access to educational services, and the lack of supportive social and legal structures).
CONCLUSION: By raising the level of awareness and attitude of girls and their families about
the consequences of early marriage, creating the culture of correcting cultural beliefs and social
misconceptions, passing appropriate laws, and the use of local and national media to prevent child
marriage, this social harm can be reduced.

Abstract BACKGROUND: Health literacy plays an important role in adopting preventive behaviors. Considering
the relatively high prevalence of breast cancer in women, this study aimed to assess the association
between health literacy and adopting the preventive behavior of breast cancer in Iran.
METHODS: This was a descriptive, cross‑sectional study, in which 375 female students at Imam
Khomeini International University in Qazvin in the academic year of 2018–2019 were selected through
a stratified random sampling method. Demographic and background questionnaire, the standard
questionnaire of Health Literacy for Iranian Adults in addition to another questionnaire for measuring
breast cancer preventive behaviors, were used for collecting data. Data were analyzed using SPSS
22 using descriptive statistics and logistic regression.
RESULTS: The mean of the breast cancer preventive behaviors and health literacy were 8.92 ±
1.82 out of 16 and 70.80 ± 12.49 out of 100. Regression results showed that there was a statistically
significant association between the adoption of breast cancer preventive behaviors and physical
activity (P < 0.001) and health literacy (P < 0.018). Accordingly, the chance for adopting the preventive
behaviors in good level among students with rare and without physical activity was 0.105 and
0.100 times, respectively, more than students who had been doing physical activity on a daily basis.
Moreover, the same chance among students with adequate and very adequate health literacy was
1.802 and 2.169 times more than students with inadequate health literacy.
CONCLUSION: The results indicated that students with lower levels of health literacy and less
physical activity had shown less tendency to adopt preventive behaviors of breast cancer. Therefore,
special attention should be paid to health literacy (HL), particularly physical activity, application of
health information, and assessment in students when designing educational programs to prevent
breast cancer.

Abstract BACKGROUND: Anxiety before and pain intensity after cesarean section is among the factors that
should be taken into consideration among the candidates for cesarean section. The present study
aimed to investigate the effect of familiarity with cesarean section and the operating room environment
on anxiety and pain intensity among the mothers undergoing cesarean section.
METHODS: This clinical trial was conducted on 80 women referred to the hospitals affiliated to
Shiraz University of Medical Sciences for cesarean section in 2018. The participants were randomly
divided into a control (n = 40) and an intervention group (n = 40). The intervention group took part
in four educational sessions, while the control group received the hospital’s routine care. The Beck
Anxiety Inventory was completed by the two groups before and after the intervention. The McGill Pain
Questionnaire was also filled out by the two groups in the ward after the cesarean section. After all,
the data were entered into the SPSS software, version 21, and were analyzed using independent
t‑test and ANCOVA.
RESULTS: The results showed no significant difference between the two groups regarding the
mean score of anxiety prior to the intervention. After the intervention, the mean score of anxiety
was 7.98 ± 3.77 in the intervention group and 19.70 ± 6.45 in the control group, and the difference
was statistically significant (P < 0.0001). Indeed, the mean intensity of pain was 43.98 ± 7.63 in the
intervention group and 57.75 ± 10.69 in the control group after the intervention, and the difference
was statistically significant (P < 0.017).
CONCLUSION: The patients’ familiarity with cesarean section and the operating room environment
caused a decline in the anxiety level prior to cesarean section as well as a decrease in the score
of pain after the operation. Hence, midwives and nurses have to play effective roles in decreasing
pregnant women’s anxiety and pain through identification of strategies for empowering them and
managing their worries.

Abstract Obesity is a commonly encountered health‑care problem that is an independent risk factor for chronic
metabolic complications. Primary care physicians are the first point of contact in the management
of obesity. Weight management is a step‑wise intensification of interventions that initiates with
lifestyle modification. Dietary and physical activity advices are integral components of all weight
loss consultations and should ideally be imparted by a dietician or a nutritionist. In case of their
nonavailability, the onus for lifestyle counseling rests with the physician. The prescription for a
low‑calorie diet coupled with increased physical activity might seem simple, but the success lies in
compliance and sustainability of this advice. Compliance can be enhanced through patient‑specific
diet and activity plans along with corrections in eating and activity behavior. Barriers in patient’s
environment must also be addressed to achieve sustainable weight loss. This review covers practical
insights in standard lifestyle management techniques, which can help the physicians to set better
weight loss goals, adapt to patient specific lifestyle counseling, and apply strategies to enhance
compliance for sustained weight loss.

Abstract INTRODUCTION: Some working and organizational conditions, such as psychological stress and
shift work, are factors that threaten the health of staff working in health centers. These factors can
cause fatigue in a long time. Fatigue reduces the ability to process information and decrease to
respond to hazardous conditions and will affect the safety of the environment. Therefore, the purpose
of this study was to determine the relationship between safety climate and occupational fatigue in
nurses working in Zabol city.
METHODS: This cross‑sectional study was performed on 143 nurses working in educational hospitals
of Zabol in 2019. The proportional sampling method was used, and the Swedish Occupational
Fatigue Questionnaire and the Nurses Safety Questionnaire were used for data collection. Data
were analyzed using independent t‑test, analysis of variance, Mann–Whitney, Kruskal–Wallis tests,
and SPSS‑21 software.
RESULTS: In the present study, 57.3% were women and 42.7% were men. The mean score of
occupational fatigue was 85.09 ± 41.49, and the mean score of safety climate was 67.15 ± 12.73. There
is a significant inverse relationship between occupational fatigue and safety climate. The comparison
of safety climate and its subscales between occupational and demographic variables showed that the
score of male supervisors’ attitude was 01.36 ± 2.41 while the score of female supervisors’ attitude
was 8.88 ± 2.61, and this difference was significant. Furthermore, cumulative burnout, the attitude of
supervisors, and the safety climate were significantly different between different educational levels.
CONCLUSION: The results of this study showed that there is a relationship between occupational
fatigue and safety climate. Issues related to safety and risk factors in hospitals due to the high risk of
disease outbreak and mortality, in addition to being economical, are important in terms of the human
aspect as well. In addition, the activity of nursing staff is more important compared to other groups
because of providing health care and communicating with patients; thus, more education about the
safety climate of the workplace environment in hospitals can reduce nurses’ fatigue.

Abstract CONTEXT AND AIMS: The country development can be promoted through applying policies of the
resistance economy in the health system and universities. Therefore, this paper aimed to provide a
scientific analysis of resistance economy policies and providing a roadmap for their implementation
in the field of health care of Isfahan University of Medical Sciences.
MATERIALS AND METHODS: This is a qualitative study. The basis, general purposes, and strategies
of the resistance economy were extracted from the review of the policy of the resistance economy
with a political research approach. Then, effective programs and indicators to achieve the goals of
the resistance economy were proposed by holding 10 sessions of a centralized group discussion.
Finally, the implementation of the resistance economy in the deputies of the University of Medical
Sciences was approved by these programs and indicators along with other components and Delphi
questionnaire to 30 experts. Framework analysis and descriptive statistics were used to analyze the
data from the group discussion and the Delphi stage, respectively.
RESULTS: Implementation of general policies of resistance economy in the field of health and
treatment of Isfahan University of Medical Sciences with eight thematic bases, 39 goals, 54 strategies,
and 98 programs and indicators were approved by experts. The eight areas of people‑centered,
economic growth, economic justice, support for internal services, economic flexibility, economic
stability, economic influence, and economic health were identified as the thematic bases of
communicative policies of the resistance economy in the field of health.
CONCLUSION: The implementation of resistance economy policies entails planning in the long run,
culture‑building, appreciating the resistance economy in health issues, cooperation, and synergy
among different institutions, restructuring the education system at different levels of the health system,
and entrepreneurship training.

Abstract BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is one of the most suitable methods
for long‑term nutritional support. In this study, the empowerment of intensive care nurses is examined
by a simulation technique to control the short‑term complications of PEG.
METHODS: A two‑group clinical trial study will be conducted on eighty intensive care nurses in
a teaching hospital in Tehran. The study participants will be randomly assigned to one of the two
control and intervention groups based on the inclusion criteria. A pretest will be given to both groups
using a researcher‑made tool. Then, the empowerment package developed by the researcher will
be provided to the intervention group in two stages. Next, a posttest will be administered. After this
stage, patients’ complications with PEG will be observed using a researcher‑made checklist. Nurses’
performances in both control and intervention groups will be evaluated in terms of preventing and
controlling short‑term complications up to 1 week after PEG insertion. All of the data collected in this
research will be analyzed with statistic tests such as independent t‑test, standard deviation, T pair,
ANOVA, and mean based on the SPSS 16 software.
RESULTS: At present, the research team is designing an empowerment package for nurses and
tools needed to evaluate the nurses’ empowerment.
CONCLUSION: This study will attempt to design and evaluate the empowerment package of graduate
nurses with a cognitive empowerment approach and using a simulation technique to care for patients
with PEG and to control their short‑term complications.

Abstract BACKGROUND: The progress in the usage of technology in hardware, software, and cost‑effective
Internet connectivity enable the availability of science‑related information and its usage in all the
developing countries. Hence, in this practical world, there should be a need to implement effective
and affordable dental education strategies to attain oral health for all in the coming years.
OBJECTIVE: The aim of this study is to reduce the need to teach theory‑based, on‑site classes,
e‑learning came into existence. E‑learning for dental education may alleviate the burden of severe
health worker shortages and deliver affordable access to high‑quality dental education.
METHODOLOGY: Evaluation and assessment methods were done to know the effectiveness of
e‑learning in dental education by conducting continuing dental education on newer materials and
methods, assignments/formative assessments and by open discussions of case descriptions and
their treatment modalities through Edmodo app in our dental institute. Effect on knowledge, skills,
attitudes, and satisfaction levels of dental students compared to other traditional methods.
RESULTS: Dental e‑learning has the capacity to develop into a leading‑edge to strengthen clinical
training skills among dental students by conducting continuing dental education, assignments,
formative assessments, case descriptions, and their treatment modalities through e‑learning are the
best ways to improve quantity and quality in dental education.
CONCLUSION: The probable prospective of e‑learning could be innovative or revolutionary because
this helps in both theoretical‑related and clinical‑related advancements, and it is possible only with
e‑learning in developing countries to meet the quality in education.

Abstract INTRODUCTION: The virtual reality‑based (VR) game can be considered as a new approach to
education and to enhance the skills of health‑care students.
AIMS: The purposes of this research were to design a VR game and to apply it to teach physiotherapy
in neurological diseases.
METHODOLOGY: In this study, at first, a VR game was designed for upper limb rehabilitation in
brain‑injured patients based on the literature and the opinions of physiotherapy experts and game
designers. Then, the designed game was used for teaching physiotherapy in neurological diseases.
Thereafter, the opinions of 31 undergraduate students about the teaching session were evaluated
by two anonymous questionnaires. Data analysis was performed using descriptive statistics through
SPSS (version 19).
RESULTS: The VR game developed under expert supervision. The evaluation showed that the
median score for students’ perception of learning was 3.11. The median scores of questions related
to the “facilitating level of virtual reality” and “student satisfaction” were 8.66 and 9, respectively. The
analysis of students’ responses to open‑ended questions highlighted the therapeutic aspect of the
game compared to its educational aspect.
CONCLUSIONS: Application of VR games in education can enhance the students’ perception
of learning. Furthermore, it can provide a better understanding of physiotherapy in patients with
neurological diseases as well as the satisfaction of students. However, the survey indicated that the
good results of this teaching method are due to the use of VR for guiding the patient’s movements.

Abstract BACKGROUND: Organizational capacity development is an important outcome of faculty
development programs, but there is a lack of an appropriate instrument for its evaluation.
AIMS AND OBJECTIVES: The aim of this study was to develop a questionnaire to evaluate the
organizational capacity development for faculty development programs and to test its psychometrics.
MATERIALS AND METHODS: The initial capacity development for faculty development
questionnaire (CDQ‑FD) of 26 items was developed based on a literature review and opinion
of experts. Content validity ratio (CVR), content validity index (CVI), content validity index for
items (I‑CVI), and the content validity index for scales (S‑CVI) were computed for content validity.
Confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) were performed for construct
validation.
RESULTS: The score for CVR, CVI, I‑CVI, and S‑CVI was 0.71, 0.83, 0.87, and 0.90, respectively.
EFA resulted in a three‑factor model with total variance extraction of 64%. Cronbach’s alpha and
Spearman Brown coefficient were investigated for reliability assessment. The Cronbach’s alpha of
overall scale was 0.8 and the test‑retest reliability of the overall scale was 0.78. The final CDQ‑FD
contained 21 items and three categories.
CONCLUSIONS: The CDQ‑FD questionnaire appears to be a valid and reliable instrument for the
evaluation of organizational capacity development for faculty development in the medical education.

Abstract INTRODUCTION: Academic burnout is one of the issues involving the educational systems at all
levels, which wastes the human resources and expenditures. Academic burnout refers to the sense
of exhaustion due to educational requirements, the sense of cynicism and indifference, and the
sense of lack of competence. Considering the fact that burnout has already been studied in different
professions and in cultures different from that of ours, there is a need to identify these factors among
the Iranian medical students and accordingly propose some strategies to reduce burnout symptoms
among these students. With this end, this study aimed to identify and quantify the importance of
possible factors causing burnout among medical students in the 2nd and 4th years of their studies in
Mashahd University of Medical Sciences and provide some suggestions.
METHODS: The present research is a cross‑sectional study conducted in 2017. The participants
included medical students who had entered Mashhad University of Medical Sciences in Iran in 2013
and 2015 and were in their 4th and 2nd year of their studies in the university. A questionnaire prepared
and validated by Maslach et al. was used to collect the data and distributed among 195 participants
who were selected randomly as the sample.
RESULTS: The results showed that the mean scores given by 195 selected respondents regarding
emotional exhaustion, indifference, and inefficiency were respectively 3.89, 3.87 and 4.12 out of 7.
CONCLUSION: Based on the results, students had the highest level of academic burnout in
personal inefficiency or incompetence component and the lowest level was observed in indifference.
Therefore, burnout and its components were explicitly seen among medical students; the authorities
are recommended to take measures to reduce academic burnout among the students.

Abstract CONTEXT: Currently, self‑directed learning (SDL) is emphasized in medical institutions all over the
world. The skills of SDL enable one to be a lifelong learner, a necessity to cope up with fast‑expanding
medical knowledge.
AIMS: This study aims to develop and implement an “SDL” module for medical undergraduates and
find out their perception about the same.
SETTINGS AND DESIGN: A cross‑sectional study using a mixed‑method design (having both
qualitative and quantitative components) was conducted in the Department of Community Medicine,
UCMS, Delhi, India.
METHODS: A module was developed following an extensive literature review and focus group
discussions with the teaching staff of the institute. First‑semester undergraduate students were
invited to participate in the study and asked for feedback using a semi‑structured questionnaire.
STATISTICAL ANALYSIS: Quantitative data were expressed in mean, range, and frequency. For
qualitative data, thematic analysis was performed.
RESULTS: The module was implemented with 160 students, in November for 10 hour distributed
over 5 weeks. Feedback could be obtained from 130 students. Sixty‑seven percent of students were
satisfied and 66% reported as motivated to study the allotted topic further. Qualitative analysis showed
that though the students liked the learning process based on this module, they also felt facilitators
could have been more active in imparting knowledge and skills.
CONCLUSIONS: To make learners equipped with the ability to learn throughout a professional
learning course, SDL as a learning tool should be introduced in the medical undergraduate curriculum.

Abstract BACKGROUND: One of the serious issues in the field of children’s social and mental health globally,
is conduct disorder. Concerning the special problems of these children, their need for appropriate
education seems vital. Thus, this study aimed to identify the educational deficiencies in the Iranian
education system in terms of educating children with conduct disorder.
SUBJECTS AND METHODS: This was a qualitative content analysis study of the directed type.
The population was in Tehran City, Iran. This research was performed on 23 individuals using a
triangulation sampling technique and in‑depth interviewing. The study subjects were children with
conduct disorder, their parents, teachers, and social workers, and psychology experts. The study
participants were selected using a purposive sampling method, and the tool used for data collection
was a checklist of questions that has been approved by 4 experts. MAXQDA (version 12) software
was used for data analysis in this study.
RESULTS: The obtained data suggested that the deficits of the educational system in Iran are
classified into four categories, including the lack of knowledge and skills of school staff, the lack of
necessary workforce, the lack of appropriate hardware facilities, and the lack of coordination and
cooperation between individuals and systems.
CONCLUSION: Considering the present study results, to improve the educational status of children
with conduct disorder and reduce their problems, it is necessary to resolve the identified educational
deficiencies as soon as possible by the government, policymakers, and educators.

Abstract INTRODUCTION: Organization survival is dependent on communications and managers spend a main
portion of their time to establish communications. The identification, improvement, and development
of communication skills serve as the essential components of successful organizations. The present
study aimed to investigate the role of communication skills in human resource (HR) productivity in
North Iran and aimed to investigate the role of communication skills in health HR (HHR) productivity
in North Iran.
METHODS: The study employed a cross‑sectional design and was conducted in six deputies
supervised by the Alborz University of Medical Sciences, in 2019. The statistical population included
all 302 employees were selected as the sample population according to the Cochran’s formula. Using
two researcher‑made questionnaires of communication skills and HHR productivity, we assessed
the role of communication skills in HHR productivity.
RESULTS: According to the research findings, there were significant relationships between
communication skills including verbal skills, listening skills, and effectiveness skills with HHR
productivity (P ≤ 0.05). There was a significant relationship between age group, gender, level of
education, and travel home‑university distance with communication skills and resource productivity
of employees (P ≤ 0.05).
CONCLUSION: This study examines the role of communication skills in the promotion of HHR
productivity who work in the administrative section of the University of Medical Sciences in Iran.
Findings suggest that health planners and authorities may need to examine factors that contribute to
the promotion of the communication skills for increase HHR productivity of employees and improved
performance of health organizations.

Abstract INTRODUCTION: The qualification of managers in terms of management skills is one of the most
important factors in the continuous success of each organization, and utilizing such skills can have
a positive contribution in the effectiveness of the organization while improving the performance of
the employees in line with the objectives and goals of the organization. The study's primary objective
was to examine the necessary skills of the hospital managers and their capabilities to manage the
challenges in providing health care facilities to their patients and employees.
MATERIALS AND METHODS: This study is a qualitative that deep interviews were performed with
22 managers (senior and middle managers) of educational hospitals of Kermanshah city, and the
sample size was 22 individuals. The interviews were analyzed by a MAXQDA software application
after transcription.
RESULTS: This study includes 8 themes and 23 subthemes. The strategic skill, the perceptive
skill, the human relations skill, work experience, and personal characteristics were among the skills
necessary for hospital managers. Some of the challenges facing the hospital managers included
rapid changes in the policies, the limitations of financial resources, and lack of proportion between
the educational and occupational spheres.
CONCLUSION: Because of their existential philosophy and differences with other service sectors,
managing hospitals poses a particular sensitivity. In this regard, the role of the hospital manager is very
important. Therefore, in order to meet the satisfaction of those receiving services, decision‑makers
and policy‑makers must think twice when selecting and appointing hospital managers and evaluate
and appraise this group in terms of abilities and skills necessary for managing such an important
service section.

Abstract BACKGROUND AND OBJECTIVES: This study was conducted to evaluate the health experts and
professionals’ education program in order to become multiprofessionals regarding health system
transformation plan by a descriptive and educational evaluation method based on the context, input,
process, and product (CIPP) evaluation model in 2018.
MATERIALS AND METHODS: The statistical population included managers and experts of health
deputy (13 people), managers and authorities in health networks (32 people), teachers (251 people),
and learners (1914 people). Data were collected by four researcher‑made questionnaires based on
the CIPP model and evaluation checklist of facilities and equipment. The view of experts was used to
measure the face validity and content validity of the questionnaire, and Cronbach’s alpha coefficient
was used to determine reliability. Data were entered into SPSS 23 software, and data were provided
using descriptive statistics (frequency, mean, and standard deviation).
RESULTS: The evaluation indicators of the educational course in the field of context were
evaluated desirable by province’s managers and experts (95% questions), city managers (100%
questions), teachers (95% questions), and health caregivers (80% questions). In the field of input,
it was evaluated desirable by managers and experts’ input of province (60% questions) and city
managers (70% questions) and it was evaluated semi‑desirable by teachers (78.95% questions)
and health caregivers (88.24% questions). In the field of process, it was evaluated desirable by
province’s managers and experts (73.68% questions) and city managers (66.67% questions) and
it was evaluated semi‑desirable by teachers (66.67% questions) and health caregivers (94.4%
questions). In the field of product, it was evaluated semi‑desirable by managers and experts of
province (63.63% questions), teachers (81.81% questions), and health caregivers (100% questions)
and it was evaluated desirable by city managers (72.72% questions).
CONCLUSION: Holding initial service education course of health caregivers has been necessary, and
the public health, family, and midwifery disciplines needed to be educated in a university appropriate
to the description of tasks of health caregivers.

Abstract BACKGROUND: Washing of hands and maintenance of appropriate hand hygiene plays a significant
role in preventing the spread of many communicable diseases. However, literature demonstrating
the efficacy of the World Health Organization (WHO) recommended handwashing procedure among
schoolchildren in India is scanty.
AIM: The aim of this study was to assess hand hygiene efficacy through graphical assessment
technique utilizing ultraviolet (UV)‑sensitive fluorescent lotion before and after handwashing
demonstration among students aged 12–18 years.
MATERIALS AND METHODS: This was an interventional study carried out over a period of 5 days
among 21 schoolchildren aged 12–18 years in their respective school premises. Participants were
requested to rub their hands with an UV‑sensitive fluorescent lotion and then wash them. Hands
were air‑dried and examined under UV rays for blue light emission in a dark room. Emission of blue
light highlighted parts of hand where lotion is still present and area not washed properly. Such areas
were painted with nontoxic skin‑friendly paints. Painted hands were imprinted over graph papers.
Hand hygiene demonstration was provided to the participants as per the WHO guidelines by qualified
public health dentists using audiovisual aids. Postintervention, the procedure followed at baseline
was adopted to obtain imprints of uncovered (not covered during hand hygiene process) parts of
hands. The mean percentage of uncovered parts of hand was assessed and compared between
baseline and postintervention.
RESULTS: The overall mean percentage score of uncovered hand area significantly reduced from
73.90 ± 19.81 mm2
 at baseline to 20.05 ± 17.0 mm2
 after demonstration of proper hand hygiene
guidelines (P < 0.001).
CONCLUSION: Hand hygiene demonstration by qualified public health dentists using audio‑visual
aids has significantly contributed to improving their hand hygiene practice.