Journal of Education and Health Promotion

Abstract INTRODUCTION: Outsourcing, as one of the important managerial strategies to improve performance,
has become one of the main areas of research in hospital management studies. The aim of this
study was to identify the challenges of outsourcing hospital services in Iran.
METHODS: This research was conducted in a qualitative manner with the aim of determining the
challenges of outsourcing hospital services in Iran. The research community consisted of managers
and experts in the field of outsourcing. 21 managers and staff experts of the Ministry of Health,
universities, and hospitals affiliated to Iran University of Medical Sciences, Tehran, and Shahid
Beheshti, were selected as the target for the interview. Finally, the data were analyzed using content
analysis method.
RESULTS: Outsourcing challenges were extracted and reported in the form of 6 theme topics and
40 subthemes. The main issues included legal and political challenges, finance, human resources,
organizational, managerial, and private sector.
CONCLUSION: Outsourcing hospital services in all six areas faced serious challenges. To this
end, partnership between the private and government sectors through outsourcing requires the
continuous development of effective political, organizational, and managerial capacity in order to
guide and manage this process properly and efficiently to ensure that the goals and policies in the
field of health. It is clearly understood and not forgotten or neglected.

Abstract BACKGROUND: Empowerment is an essential issue in women’s lives. Powerful women can act
successfully in health‑related issues more than others. This study aimed to determine the effectiveness
of an educational intervention designed based on theory of planned behavior (TPB) on health care
empowerment among married women in reproductive age.
METHODS: This randomized controlled trial was carried out among 488 reproductive‑age women
between 2018 and 2019 in Tehran, Iran. Participants were recruited using randomized cluster
sampling and divided into intervention (n = 243) and control (n = 245) groups by random allocation.
Data were collected using a self‑administered researcher‑made questionnaire based on TPB and
Health Care Empowerment Questionnaire. Validity (content validity index = 0.87; content validity
ratio  =  0.89) and reliability of the questionnaires were confirmed  ( = 0.96). Intervention was
implemented within four sessions (lasting 60 min) using eight health related scenarios based on
TPB constructs. Baseline and post intervention data (6 months after the intervention) were analyzed
by SPSS25 (Inc., Chicago, IL, USA) using independent t‑test, Chi‑squared test, Fisher’s Exact test,
Mann–Whitney, path analysis, and regression of generalized estimating equation model. P < 0.05
was considered statistically significant.
RESULTS: Results showed the mean ± standard deviation age of the participants was 33.6 ± 7.1.
Six months after the intervention, a significant difference was highlighted in health care empowerment
domains as well as behavioral intention, attitude toward behavior, subjective norms, and perceived
behavioral control (P < 0.001) between intervention and control groups.
CONCLUSION: TPB‑based educational intervention can significantly improve women’s perception
about health care empowerment. Tailoring and implementation of TPB‑based intervention by health
policy makers and health care providers is suggested to achieve better perception of empowerment
toward receiving health care among women.

Abstract BACKGROUND: Student nurses’ experience of stress while enrolled in educational programs is
well‑documented; however, complementary and alternative therapies to alleviate or prevent nursing
program‑related stressors are not. The purpose of this study was to explore the effect of a yoga
intervention on stress, self‑compassion, and quality of life in undergraduate nursing students.
METHODS: Seventy‑three undergraduate nursing students participated in this two‑group,
quasi‑experimental, repeated‑measures, study. Students self‑selected participation in a one‑hour
yoga class, offered each week for 12 weeks, and completed Stress, Self‑Compassion, and QOL
scales at baseline, week 6, and week 12. Information on intervention participation and yoga practice
outside the intervention was also solicited. Descriptive statistics and mixed‑model analysis of variance
were used to analyze the data.
RESULTS: There were no statistically significant differences between groups over time on perceived
stress or QOL. There were statistically significant differences between groups on self‑kindness
(F3, 69 = 3.86, P = 0.013).
CONCLUSIONS: Further research on the effects of yoga for stress reduction in nursing students
using randomized controlled trials is recommended.

Abstract BACKGROUND AND AIM: To answer the society’s health‑care needs related to social determinants
of health (SDH), higher education system must be responsive in training knowledgeable students and
faculty members. Therefore, this study was carried out to determine the responsiveness of higher
education system in relation to the SDH.
METHODS: This is a content analysis study carried out using qualitative approach. Semi‑structured
interviews were used to gain access to the knowledge of experts in the fields of health care, education,
and SDH. Sampling was carried out until data saturation was achieved during which 15 experts were
selected using purposeful sampling method with highest possible variety. Data were categorized
using qualitative content analysis approach.
RESULTS: In total, 11 themes and 43 categories of codes were identified in semi‑structured
interviews with experts. A total of two approaches were identified for the training of responsive
students including educational–research approach and cultural–social approach; five approaches
were identified for the development of faculty members including cognitive development, executive
development, evaluation, promotion and incentives, and revisions; two approaches were identified for
provision of theoretical and practical education including education in a real and active environment
and structural education; and finally, two approaches were identified for evaluation of students and
faculty members in regard to their responsiveness to society’s health needs and SDH including
content and operational approaches.
CONCLUSION: In general, the results of the current study indicate the need for the higher education
system to use educational, research, and society‑based approaches in real and social environments
along with an incentive system and use of evaluation for responsiveness to society’s health needs
and SDH. These results can be useful for the health‑care system and the higher education system.

Abstract There is growing evidence that the problematic use of mobile phone is an evolving problem. Although
some studies have noted a greater prevalence in the Middle East, intercultural differences have not
been sufficiently studied to date. The present study, therefore, aims at reviewing Iranian published
studies on the problematic use of mobile phone in Iran. This study was conducted as a review study.
For this purpose, we searched all published studies in this field that were conducted in Iran and
reviewed all of the articles by studying the prevalence of the problematic use of cell phone in Iran,
the adopted measuring instruments, the employed terms, predictors of the problematic use of cell
phone, and the consequences of the problematic use of cell phone. After applying the inclusion and
exclusion criteria, 47 articles were selected for evaluation. Among the problematic consequences,
sleep disturbance was the most studied factor. Additionally, gender, feeling of loneliness, attachment
stiles and age were mostly referred to as predictors. In addition, the reported prevalence varied from
0.9% to 64.5%, depending on the studied population and the measuring instruments. The diversity of
reported prevalence rate of problematic use of mobile phone in Iran can be related to the ambiguity
of the concept of “problematic use” and the diversity of the employed measuring tools. Thus, care
should be taken in generalizing and interpreting the results.

Abstract Inflammatory bowel disease (IBD), including Crohn’s and ulcerative colitis diseases, is characterized
by clinical periods of remission and relapse. Excessive care stress can have long‑term negative
physical and psychological consequences not only for caregivers but also for the recipients of care.
This integrative review aims to identify, describe, and synthesize the results of current available
research focused on the burdens of IBDs on family caregiver. An integrative review was performed
using Whittemore and Knafl methodology. A systematic search of electronic databases including
Web of Science, PubMed, Embase, and Scopus from January 2000 to October 2019 was conducted.
Articles were included if published in English and focus on IBD burden on family caregivers. Of 730
records, 16 articles with quantitative, qualitative, and Q methodology study designs were eventually
included in the review. The synthesis of these articles led to the identification of four key types of
effects: biopsychosocial, daily life activities, physical health, and financial. The chronic and relapsing
nature of IBD exposes family caregivers to considerable risk. Thus, the care burden of IBD patients’
caregivers needs to be evaluated continuously and relieved through family‑centered interventions.

Abstract BACKGROUND: An infant admitted to the neonatal intensive care unit (NICU) is a potentially
stressful event for parents. Severe stress is experienced by parents, affecting their mental health
and relationship, and infants’ development. The current study aims to assess the stress levels among
parents of neonates admitted to NICU and to identify the factors influencing their stress levels.
MATERIALS AND METHODS: A cross‑sectional study was conducted in a tertiary care hospital
of Eastern India over 2 months. Stress levels were assessed using Parental Stressor Scale: NICU
questionnaire among 100 NICU parents (mother or father) with more than 24 h of admission. Stress
was quantified using the Likert scale. The statistical analysis was performed using the SPSS software.
RESULTS: In this study, 60.8% parents experienced severe and extreme stress level for overall
stress. The mean for overall stress experienced was 3.71 ± 0.70. There was no significant difference
in overall stress between father and mother (P = 0.65). The highest levels of stress experienced were
in sight and sound subscale (3.23 ± 0.41) followed by relationship with the baby and parental role,”
i.e., 2.46 30. There was no significant association in overall stress score with maternal age, parity,
education level, previous baby being admitted to the NICU (P > 0.05). Stress in sight and sound
domain was statistically significantly higher (P = 0.009) among parents of babies with stay of ≤7 days.
CONCLUSION: These results support wider use in research and clinical practice to identify parental
stress. Interventions can be developed to ameliorate its negative effects on individual, interpersonal,
and societal levels. The stress score was not significantly different between fathers and mothers of
neonates admitted to NICU and the length of stay was significantly associated with sight and sound
domain. Appropriate counseling should be targeted toward both parents. Future intervention studies
should be planned to decrease the stress level among parents.

Abstract INTRODUCTION: Recently, the night shift is included in the curriculum of nursing internship students.
However, this shift is associated with some problems and benefits for students, which have been
assessed in limited studies. This study aimed to discover and describe the problems and benefits
of the night shift for nursing internship students.
METHODOLOGY: This qualitative method was carried out with the conventional content–analysis
method. In total, 15 seventh‑semester and eighth‑semester nursing students at Sabzevar University
of Medical Sciences, Iran, were selected by purposeful sampling. Data were collected using in‑depth
semi‑structured interviews about students’ perceptions of night shift problems and benefits. In addition,
data analysis was performed applying the conventional content–analysis technique.
RESULTS: In this study, seven main categories were extracted, five of which included problems
such as exploitations, being an outsider, moral distress, learning deficits, and annoyance. The other
two categories were benefits including gaining new experiences and independence.
CONCLUSION: The problems related to the students were the nursing personnel and the educational
system of hospitals, which can be dealt with through the interaction of the educational system with
hospitals managers in order to clarifying the role of students, fair division of work, and making
educational resources available. Moreover, gaining new experiences and independence are among
the benefits of the night shift for students, the continuation of which is in favor of nursing education.

Abstract BACKGROUND: Health literacy is the capacity to acquire, process, and understand basic information
and services necessary for appropriate health decisions. Given the importance of health literacy in
women, the aim of the present study was to determine the effect of health literacy level on improving
the quality of care during pregnancy in pregnant women.
MATERIALS AND METHODS: The present study was a cross‑sectional analytical study. In this
study, 130 women referred to Yazd health centers were examined. Health literacy questionnaires
and a researcher‑made checklist of the quality of pregnancy care were used to gather information.
The researcher‑made checklist of the quality of pregnancy care was in accordance with the standard
protocol of the Ministry of Health and Medical Education, entitled Integrated Health Care for Pregnant
Mothers, which was validated and reliable. SPSS statistical software version 19 and t‑test and ANOVA
statistical tests were used to analyze the data.
RESULTS: According to the findings, the average score of health literacy in pregnant women was
74.09, which showed that the level of health literacy was in the marginal or border range. People
with higher health literacy received significantly more prenatal counseling than other women and
had a planned pregnancy (P = 0.04).
CONCLUSION: The level of health literacy in pregnant women is unfavorable. Given that the high
level of health literacy in women in society can lead to an increase in the quality of pregnancy care, so
to increase health literacy in women, it is recommended that regular training in society by health‑care
providers be given more attention.

Abstract INTRODUCTION: Feedback is an important part of the assessment process. However, one‑to‑one
structured and constructive feedback to the students is not practiced mostly due to lack of practice
and feasibility issues. The present study was conducted to understand the perception of students
and faculty toward one‑to‑one structured feedback.
METHODOLOGY: All the 3rd MBBS professional students were included in the study. An orientation
was given to the faculty regarding the importance of feedback and how to give structured feedback.
A standardized format was provided to the faculty for providing the feedback to the students. After
completion of the assessments, a one‑to‑one structured verbal feedback was given to all the
students. Thereafter, faculty and student’s perception on the feedback process was obtained through
questionnaires. A focused group discussion was also conducted among the students.
RESULTS: A total of 42 students participated in the study out of 50. A positive response was received
from all the students regarding the feedback. Nearly84.34% of the students acknowledged that
feedback is important for understanding their mistakes, 92.84% of the students responded positively
that feedback helps to build a good rapport with the teacher, and 92.85% of the students reported
that they were satisfied with the overall experience of receiving feedback. Most of the faculty (80%)
perceived that giving feedback after the assessment was a good idea. The faculty felt motivated
to give feedback to the students after the hands‑on experience. However, only 20% of the faculty
agreed that the process of feedback was easy to carry out (mean score: 2.2 ± 1.09).
CONCLUSION: The positive responses received from both the students and the faculty highlight
that the students are receptive toward feedback provided it is structured, constructive, and helps
them to achieve their learning goals.

Abstract INTRODUCTION: Since routine counseling does not suffice to resolve the sexual problems at
postpartum period, the present study aimed to investigate the effect of counseling based on the
Ex‑PLISSIT model on sexual function and marital satisfaction of postpartum women.
METHODS: This was a randomized controlled clinical trial that was conducted on 68 postpartum
women (within 3–6 months after childbirth) who obtained a score <28 on the Female Sexual Function
Index (FSFI). The participants were randomly assigned to the intervention and control groups.
Participants in the intervention group received counseling based on the Ex‑PLISSIT model and those
in the control group received the routine postpartum care. The required data were collected using a
demographics form, the FSFI, and the ENRICH Marital Satisfaction Scale. The primary outcomes were
the mean function and martial satisfaction score of participants 4 and 8 weeks after the intervention.
RESULTS: There was no statistically significant difference between the two groups in terms of sexual
function at baseline (P = 0.381), but it was significantly higher in the intervention group than control
group after intervention (the adjusted MD: 4.24, 95% confidence interval [CI]: 3.18–5.29, P < 0.001).
There was no statistically significant difference between the two groups in marital satisfaction before
the intervention (P = 0.433), but it increased significantly in the intervention group in comparison to
control after intervention (adjusted MD: 23.17, 95% CI: 15.10–31.24, P < 0.001).
CONCLUSIONS: The study findings suggested that sexual counseling based on the Ex‑PLISSIT
model can improve the sexual function and increase marital satisfaction of postpartum women.

Abstract INTRODUCTION: The use of ionizing radiation in various sciences, especially in medical science, has
played an important role in human health. As the use of radiology tests in medical centers, including
the operating room ward, is increasing, increasing the level of awareness of the operating room staff
can improve their performance in this area as well as reduce the risk of exposure to radiation. The
aim of this study was to determine the knowledge and performance of surgical technologists about
radiation protection in Zahedan educational hospitals.
MATERIALS AND METHODS: The present study is a descriptive‑analytical study that was performed
on 80 surgical technologists of Zahedan teaching hospitals from January 2019 to December 2019.
The Knowledge Questionnaire was used in this study, which was a researcher‑made questionnaire.
After filling out questionnaires and checklists, the data were analyzed by SPSS software using
descriptive statistics and analytical, statistical tests, including independent t‑test and Pearson
correlation coefficient.
RESULTS: The results showed that the mean age of participants was 31 ± 7.03 years . 27% were men,
and 53% were women. The mean of work experience was 7 ± 7.56. The mean score of knowledge
was 6 ± 3.02 and the performance score was 12 ± 7.38. There was a correlation between age,
awareness and performance of the participants (P < 0.001), and there was a correlation between
participants’ radiation protection training and awareness and performance (P = 0.000). There is a
direct relationship between staff knowledge and performance. No significant relationship was found
between the other variables (P = 0.029).
CONCLUSION: The results of the study showed that there is a relationship between radiation
protection training courses so that the personnel who passed these courses are more aware and
functioning. Given that action is needed to raise awareness through workshops.

Abstract AIM: To assess the knowledge, attitude, practices (KAP), and barriers regarding pharmacovigilance
and adverse drug reaction (ADR) reporting among medical and dental faculties of the teaching
hospitals.
METHODOLOGY: This study was conducted for a period of 3 months among medical and dental
faculties. A self‑structured, 42‑item closed‑ended questionnaire based on pharmacovigilance and
ADR reporting was used in this study. Data were analyzed using Statistical Package for the Social
Sciences Version 21. All the items of the domains along with demographic variables were summarized
as absolute and relative frequencies. Intergroup comparison was done using Kruskal–Wallis test and
Mann–Whitney U‑test. The correlation between the domains was assessed by Spearman correlation
coefficient.
RESULTS: Among the study subjects, 272 (60.4%) were females and 178 (39.6%) were males.
The number of medical and dental faculties was 360 (80%) and 90 (20%), respectively. The mean
KAP scores for medical and dental faculties were 7.58 and 5.37, 8.78 and 6.01, and 6.91 and 6.32,
respectively. The Spearman correlation coefficient (ρ) was found to be significant for knowledge–
attitude and knowledge–practice domains. The values obtained between attitude with practice and
barrier also were significantly correlated.
CONCLUSION: Our study findings advocate that although medical faculties have better knowledge
about pharmacovigilance and ADR reporting, dentists have a positive attitude, thereby suggesting a
huge scope of progress if more emphasis is given on the need for continuous educational initiatives
and including the topic in their academic curriculum.

Abstract CONTEXT: The 30‑item nurses’ observation scale for inpatient evaluation (NOSIE‑30) developed
for the behavioral and observational rating of psychiatric inpatients.
AIMS: The purpose of this study was to evaluate the validation of the NOSIE‑30 and mental
health‑care promotion.
MATERIALS AND METHODS: The participants with psychiatric disorders were selected from 310
inpatients referred to the military educational hospital in Iran. This study was carried out in two phases:
First, translation of the NOSIE‑30 into Persian followed the stepwise, iterative procedures developed
by the International Quality of Life Assessment project approach. Second, face validity, criterion‑related
validity and construct validity, and reliability of the Persian version were determined. The concurrent
validity was assessed by using the global assessment of functioning (GAF) instrument. Data were
analyzed with the SPSS software of version 22. Exploratory factor analysis, the Cronbach’s alpha
coefficient, and interrater agreement with intraclass correlation coefficient and Pearson’s correlation
coefficient were used to data analysis.
RESULTS: Pearson’s correlation coefficient between the NOSIE and GAF was 0.75. The interrater
reliability for subscale scores and structure of the NOSIE were ranging from 0.70 to 0.94 and Cohen’s
kappa = 0.74. Furthermore, the internal consistency of the scale’s total scores was estimated by
Cronbach’s alpha = 0.85.
CONCLUSIONS: The finding indicated that NOSIE‑30 Persian version scale has the desirable validity
and reliability for evaluating the nursing care of inpatients. Thus, nurses can promote mental health
care by applying this scale in the psychiatric setting.

Abstract INTRODUCTION: Due to the significant decrease in fertility in recent decades and the important role
of health workers and health‑care providers in providing healthy reproductive counseling, their training
is necessary using effective educational methods. Webinar and group discussion (GD) are effective
in this regard. This study was conducted to determine the most effective method and with the aim
of comparing the effect of two training methods (webinar and GD) on the attitude and performance
of health workers in providing counseling with fertility promotion approach in comprehensive health
centers in Mashhad.
METHODS: In this randomized trial study with a control group, 108 health workers working in health
centers no. 2–3 and 5 of Mashhad entered the study and were randomly divided into three groups of
training by webinar, GD, and control. Intervention groups received healthy fertility counseling skills
in three training sessions. Research tools were demographic information questionnaires, fertility
attitudes, and performance measurement checklists for fertility counseling. The questionnaires were
completed in three groups at the beginning and after the completion of the interventions. Data analysis
was performed by Chi‑square test and one‑way analysis of variance using SPSS software version 16.
RESULTS: The analysis of variance test showed that before the intervention, there was no statistically
significant difference between the three groups in terms of average scores of fertility attitude and
performance scores of fertility counseling. After the interventions, the difference between the fertility
attitude scores (P < 0.001) and the performance scores of fertility counseling (P < 0.001) was significant
in the three groups. There was no significant relationship between demographic characteristics and
attitude and performance.
CONCLUSION: Teaching by webinar and GD promotes the attitude and performance of health
workers in providing counseling with a fertility promotion approach. Therefore, it is recommended to
use new educational methods such as webinar and GD to promote childbearing counseling, which
has been emphasized in the country’s population policies. Since the mean score difference for
the webinar training method was the highest due to the mean scores, this method could be more
effective than the GD method.

Abstract INTRODUCTION: Adequate knowledge about the presence of postexposure prophylaxis (PEP)
against human immuno‑deficiency virus (HIV) is imperative for health‑care workers. This study
focuses on the evaluation of the present knowledge and practice of nurses and paramedical workers
on the post exposure prophylaxis against HIV.
AIM: The aim of this study is to assess and compare the knowledge and practice of PEP against
HIV among Staff Nurses and Paramedical workers.
SUBJECTS AND METHODS: A descriptive cross‑sectional questionnaire study about the knowledge
and practice of PEP against HIV among Staff nurses and Paramedical workers done at a tertiary care
hospital in South India. The analysis of the data was performed using SPSS software version 24.
The statistical tests used to compare the knowledge between nurses and paramedical workers was
Chi‑square test. P < 0.05 was considered statistically significant.
RESULTS: About 339 nurses and 66 paramedical workers participated in the study. An overall
of 65.4% of the study participants had a good level of knowledge, higher (P = 0.000) among
nurses (71.1%) compared to paramedical workers (36.3%). However, only 23% of nurses and 14.3%
of paramedical workers received PEP after a needle prick injury.
CONCLUSION: This study revealed a low‑level practice of HIV PEP among staff nurses and
paramedical workers despite their good knowledge. This can be improved by providing formal training
sessions to the health care workers.

Abstract BACKGROUND: Implementing a cervical cancer prevention program requires an exploration of
certain behaviors concerning this disease. This study is aimed to evaluate the psychometrics of a
questionnaire that enquired about the factors involved in Precaution Adoption Process Model (PAPM)
for cervical cancer among suburban women in Bandar Abbas, south of Iran.
MATERIALS AND METHODS: The primary draft of the questionnaire was developed with a review
of the related literature on cervical cancer and the constructs affecting PAPM, with 68 items. The
face validity, content validity ratio (CVR), and content validity index (CVI) of the questionnaire
were approved by a panel of 10 experts. The internal consistency and test‑retest reliability of the
questionnaire were estimated too. Field testing sample included 300 women recruited from a women’s
healthcare center in suburban areas of Bandar Abbas in the south of Iran. Exploratory factor analysis
was used to evaluate validity, and Cronbach’s alpha coefficient was estimated for reliability.
RESULTS: After the face validation, 11 items were eliminated. Once CVR was estimated, two items
were discarded. The remaining items had a CVR >0.79. All had a CVI >0.79. Six items were eliminated
in the factor analysis. The final questionnaire included 49 items organized in 8 factors including
awareness, perceived susceptibility, perceived severity, perceived benefits, perceived barriers,
social norms, fear, and self‑efficacy. Principal component analysis with varimax rotation indicated
eight main components that explained 56.25% of the variance. Reliability assessment showed a
good internal consistency for all subscales and the Cronbach’s alpha score ranged between 0.82
and 0.90. The test‑retest reliability showed that the correlation coefficients (between 0.81 and 0.89)
were significant at the 0.01 level for all sub‑scales.
CONCLUSIONS: The final questionnaire was a new instrument comprised the effective constructs
of PAPM and had a high reliability and validity. Thus, this questionnaire is recommended to be used
to explore and enhance preventive behaviors of cervical cancer.

Abstract BACKGROUND: Students must be made aware about the essentiality of optimum level of physical
activity and the fact that it is the key to good health and an important technique to prevent and control
a lot of noncommunicable diseases including depression and other related mental ill‑health.
MATERIALS AND METHODS: It was an institution‑based intervention study among 187 Madrasah
students of classes VII and VIII, conducted in five‑phase assessment of the training needs of
Madrasah students on different aspects of healthy lifestyle, development of a need‑based module
to be used by teachers to impart training of students through classroom setting, training of teachers
to use the module to train students, training of students by the trained teachers in classroom setting,
and evaluation of effectiveness of the training module.
RESULTS: The mean pretest knowledge score in study Madrasah was 2.64 ± 1.35 (Mean ± SD)
and post test score was 4.13 ± 0.88 (Mean ± SD). In paired t‑test, t‑value was 13.54 and P < 0.05
with effect size of 1.370 (Cohen’s d). Practice related to the mean score in pretest was 2.38 ± 1.08
and posttest score was 2.73 ± 1.03. In paired test, t‑value was 6.25 and P < 0.05 with effect size of
0.458 (Cohen’s d).
CONCLUSIONS: The study revealed the effectiveness of training by teachers using the module
developed by the researcher to address significant changes in lifestyle‑related issues.

Abstract Palliative care has been proposed as a multidisciplinary method for providing patients with care. The
present study proposes to discuss the necessary principles required for any country to successfully
implement a palliative medicine program. The present study was a systematic review conducted in
January 2019, and the articles related to palliative care requirements on the databases of Web of
Science, PubMed, Scopus, Science Direct, Ovid, ProQuest, Wiley, and Google Scholar from January
1, 2009, to January 20, 2019, were searched. Strategy for searching and selecting the articles was
Preferred Reporting Items for Systematic Reviews and Meta‑Analyses Guidelines. The findings
showed that the World Health Organization has introduced for main phases for increasing these types
of services including: defining and developing a national policy, training and educating healthcare
employees and general public, as well as pain relief. In general, two scenarios are described in the
development of palliative medicine: bottom‑up and top‑down approaches. In conclusion, although
there seem to be progressing activities regarding the issue of making palliative medicine accessible,
there are still many obstacles including lack of adequate knowledge and political support, social and
cultural problems, inadequate training and education of physicians and nurses, fixed and biased
attitude in medical professions, and low priority of palliative medicine among policymakers. Therefore,
it could be said that implementing palliative medicine programs requires an overall change in culture,
public and individual education, political support, and appropriate policies.

Abstract BACKGROUND: In medical education, the learning–teaching method is an active process in which
both students and teachers have to work mutually to enlighten the knowledge. Currently, in India,
there is an increase in the enrollment of students in medical fields and thus medical educators face
the challenge of teaching larger classes in a short period. Furthermore, it is observed that there is
a lack of consensus about the best teaching and learning methods for medical students. This study
aims to assess the preference of teaching methods and identify the reason for absenteeism among
medical undergraduate students in a tertiary care teaching hospital.
MATERIALS AND METHODS: A cross‑sectional study was conducted among 246 medical
undergraduate students in a tertiary care teaching hospital from August 2019 to October 2019.
A pretested, validated self‑administered questionnaire was used to assess the preference of teaching
methods. The data were analyzed using SPSS‑IBM software 23.
RESULTS: The majority of the students belonged to 20–21 years of age group. Most of the students
preferred practical demonstration (81.3%) as the preferred method of teaching and computer with
a liquid crystal display projector as ideal media for teaching (63.8%). Boring/monotonous teaching
class was found (73.5%) to be an important cause for absenteeism among medical undergraduate
students.
CONCLUSION: The results indicate that the medical student’s preference is changing from passive
learning to active learning. We conclude by linking these emerging perceptions with suggestions to
help drive excellence in medical education.

Abstract BACKGROUND: In Iran, community health workers (CHWs) are native and are only employed in
the health‑care system. Therefore, the training and empowerment of these staff are essential. The
present study was aimed to develop cooperative learning techniques in CHWs to improve both
cognitive and noncognitive aspects such as accountability and other social skills in learners.
METHODOLOGY: This study employed a quasi‑experimental pre‑ and post‑test design with a control
group that was conducted in Kangavar City, Iran, in 2019. Forty‑four CHWs were selected using a
two‑stage cluster sampling, of whom 22 were randomly assigned to the experimental group where
the jigsaw technique was applied and the rest to the control group where the lecture method was
applied. The aim was to identify job performance and motivation among the CHWs after instruction
and compare the two groups. Pre‑ and posttests were applied to the groups before and after an
in‑service training course using valid questionnaires. Data analysis was performed on both descriptive
and inferential statistics such as mean and standard deviation, paired t‑test, and covariance analysis
with the confidence level of 95%.
RESULTS: The findings showed that the intervention significantly increased the mean score of
motivation and performance in the experimental group. Covariance analysis with the removal of the
pretest effect was also statistically significant (P = 0.01). Moreover, the MANCOVA test showed the
jigsaw technique effect considering motivation and performance with a confidence level of 95%.
CONCLUSION: Given the well‑known effect of cooperative learning techniques and since CHWs
have multi roles and tasks, it is necessary to use such techniques so that they can be accountable
for developing health indicators in local areas.

Abstract INTRODUCTION: The state of health‑care disaster preparedness in Iran prior to the possible
earthquakes is not well documented. This study identified the challenges of the Iranian health system
before possible earthquakes in Tehran based on the World Health Organization (WHO) framework.
MATERIALS AND METHODS: In this qualitative study, in‑depth and semi‑structured interviews were
conducted for 17 health experts and authorities, who were selected based on purposive sampling
method. The questions were designed based on the proposed framework of the WHO in six areas
including policies and planning, communication, collaboration and coordination, training, volunteers
and the public, and surge capability. The data were analyzed by using framework analysis.
RESULTS: The main themes included weak communication infrastructures, inappropriate assessment
of specialized training courses and lack of a clear scenario, integrated urban commanding,
extra‑sectorial coordination, and data banks for public volunteers.
CONCLUSION: Iran health‑care disaster preparedness was tested by many earthquakes. This
research showed that disaster preparedness in Iran faces several challenges.

Abstract INTRODUCTION: Reporting medical errors is a major challenge in patient safety and improving
service quality. The purpose of the present study is to investigate the status of error reporting and
the challenges of developing an error‑reporting system in Iran.
METHODS: This study was designed with qualitative approach and grounded theory method in
teaching hospitals affiliated to Iran University of Medical Sciences. The views of safety authorities
at various levels of management, including those responsible for safety at the Ministry of Health,
Vice Chancellor and Hospitals affiliated to Iran University of Medical Sciences, were investigated in
2019 regarding adverse events.
RESULTS: Four major themes were identified included iceberg reporting and disclosure, weak
reporting, underreporting, and non‑error disclosure. The most common problems in reporting
medical error were non‑involvement of physicians in the error‑reporting process, structural (human
and information) bugs in root cause analysis sessions, and defective error prevention approaches
designed based on the failure mode and effects analysis.
DISCUSSION: Despite a large number of medical errors occurred in health‑care settings, error
reporting is still very low, with only a limited number of errors being reported routinely in hospitals
and the rest are minor and occasional reports.
CONCLUSION: Creating a mandatory error‑reporting system and requiring physicians to report and
participate in error analysis sessions can create a safety culture and increase the error‑reporting rate.

Abstract CONTEXT: Well‑being in schools is often considered in relation to the educational and academic
success of students. However, it is difficult, at present, not to consider the well‑being of a student
without an ecological and holistic perspective, in view of the interaction principles implemented in
schools. This research aimed to identify the representations hold by Moroccan teenagers about
well‑being. It aimed, also, to do a comparison between two groups of teenagers: one belonging to
urban and the other to rural areas.
METHODS: This quantitative study concerns a sample of 1444 pupils (755 girls and 689 boys)
enrolled in middle school. Research instrument for this study was questionnaire that includes 15
questions relating to well‑being at school, relationships with the teacher, relationships between
students, violence experienced, and coeducation.
RESULTS: From the analysis of data, pupils in the rural areas seem to be most sensitive to the
“emotional” aspects of the teacher–pupil relationship. The girls are more satisfied in middle school
than boys. This fact seems to be a very important factor in their retention and in reducing their dropout
rate. As expected, academic success is highlighted in the two groups of students as an indicator
of well‑being. However, the fact of not knowing which orientation to choose constitutes a factor of
ill‑being for pupils, especially for girls. The results show also that well‑being is not taken care of in
the two environments (urban and rural). This will explain the results of Moroccan students assessed
by the Program for the Monitoring of Student Achievement.
CONCLUSIONS: Training programs should focus on the development of teachers communication
skills, ability to manage behavioral problems of their students and use teaching approaches to develop
positive relationships between students.

Abstract CONTEXT: Along with the evolutions of medical sciences education, the importance of medical
education discipline has gained more attention for keeping up with these evolutions. Therefore,
paying attention to policymaking regarding the development of this discipline and its position in
universities is very necessary.
AIMS: This study has been done with the aim of investigating key educational and research factors
affecting the future of medical education discipline in Iran.
SETTINGS AND DESIGN: This is a qualitative study with directed content analysis approach,
which has been conducted in eight medical sciences universities having medical education
department (Tehran, Iran, Shahid Beheshti, Isfahan, Mashhad, Shiraz, Tabriz, and Kerman) in
2018–2019.
SUBJECTS AND METHODS: A total of 25 participants (professors, students, and graduates) of
medical education discipline were selected by purposeful sampling and with maximum diversity. Data
were collected through semi‑structured interviews. Interviews were analyzed using MAXQDA software.
RESULTS: After analyzing the data, a number of 1561 initial codes were obtained, of which 914 codes
were extracted after removing repetitious codes and merging similar codes. Finally, the obtained
results from content analysis were classified into two main categories including key educational and
research factors and ten subcategories.
CONCLUSIONS: Among the most important key educational and research factors affecting the future
of medical education discipline, it can be mention to the role of the discipline curriculum and need
to revise it, the need to monitor the graduates and their status , globalization, the role of medical
education centers and departments, and the role of theses. It is recommended that future studies
investigate other key factors affecting the future of the discipline.

Abstract Globalization has been attracted by great literature and papers of many disciplines in recent years.
Although globalization has considerable social, political, and economic effects, it has turned to an
important challenge in health‑care systems. Nursing, as the largest part of the health system in
the world, has also been affected by globalization. The purpose of the present paper is to critique
globalization and its impacts on the nursing profession. This review article was conducted by searching
for reliable internet resources in the English language on the impact of globalization on nursing.
Published articles were searched until 2018, and related articles were extracted in three stages:
1‑selection of articles by reading abstract, 2‑selection with an overview of the text, and 3‑selection
with a full review of the article’s text. According to the literature of globalization, we categorize and
discuss the nursing areas that are affected by globalization in nine areas: global nursing development,
nurses emigration,information interchange and interactions in nursing, higher education in nursing,
professional territory, nursing specialization, professional ethics, management and supervision, and
professional independence. The intensity of globalization effects on the nursing profession has not
been the same in all societies, and factors such as compliance of society, culture, and technology
are among the most important factors that affect it. Globalization is an inevitable process and brings
with itself many prominent promotions such as global nursing development and important challenges
such as nursing emigration and ethical issues.

Abstract BACKGROUND: Nurses in their workplace, for a variety of reasons, always face moral distress that
is an underlying issue in the nursing profession, which can lead to problems such as reduced quality
and quantity of care and sleep disorder. Besides, given the increased privatization of hospitals, this
study aimed to explore the association between nurses’ moral distress and sleep quality and its
comparison among nurses in private and public hospitals.
MATERIALS AND METHODS: This was a descriptive‑analytical study involving 150 nurses working
in Ilam Province hospitals. Sampling conducted using a multistage random sampling method. Data
were collected through the questionnaire of sociodemographic characteristics, the Corley’s Moral
Distress Scale, and the Pittsburgh Sleep Quality Index. Data were analyzed using SPSS software
version 22. Descriptive statistics such as frequency, mean, ANOVA, independent t‑test, multiple linear
regression, and Pearson correlation coefficient at the significant level of P < 0.05 were calculated.
RESULTS: The analysis revealed that moral distress was positively associated with sleep quality.
Furthermore, the scores of nurses’ moral distress and sleep quality were different in private and
public hospitals, so that the level of moral distress in the public hospital and sleep quality in the
private hospital was higher and lower, respectively, but the difference was not statistically significant.
Moreover, sleep quality, and the type of employment was the most important predicting variables of
moral stress (B = 1.86) and sleep quality (B = 2.39), respectively.
CONCLUSION: According to the study results, a positive and significant association was found
between moral distress and nurses’ sleep quality. It is recommended that appropriate strategies
and training program be formulated by the health‑care system to increase nurses’ ability to combat
moral distress adverse effects.

Abstract BACKGROUND: International research collaboration (IRC) is known as one of the important indicators
of productivity, efficiency, and validity of universities in the world. In other words, IRC is necessary
for the scientific trade‑off between researchers in international scientific societies. The study aimed
to address the experiences of an academic researcher about factors related to IRC.
MATERIALS AND METHODS: The present study was conducted using a qualitative approach
and conventional content analysis method. The participants consisted of 19 experienced faculty
members and researchers from Isfahan University of Medical Sciences, who were selected based
on the purposive and snowball sampling techniques. Data were collected through semi‑structured
interviews and were analyzed using the content analysis technique. Guba and Lincoln’s evaluative
criteria, including credibility, confirmability, dependability, and transferability, were applied to evaluate
the trustworthiness of the study.
RESULTS: According to the research findings, factors of “personal skills,” “personality,” “professional
position,” and “scientific activities” under the category of personal factors; “rules and regulations”
and “equipment and facilities” under the organizational factors; and “domestic policies” and “foreign
policies” were identified under the government factors category.
CONCLUSION: Research collaborations are influenced by individual, intra‑academic, and
extra‑academic factors; thus, research policymakers can help further to enhance the quantity and
quality of scientific output and promote the university’s placing in international rankings through
providing conditions that enable international interactions.

Abstract BACKGROUND AND OBJECTIVE: Dental students and practitioners are frequently prone to
work‑related musculoskeletal disorders (WMSDs) due to the unawareness of ergonomic principles
when practicing dentistry. The aim of this study was to assess the dental student knowledge, attitude,
and practice toward ergonomics in three different dental schools.
METHODOLOGY: A cross‑sectional study was conducted among 1166 dental students from three
different dental schools of Andhra Pradesh, India, to assess knowledge, attitude, and practice
regarding ergonomics. All the participants were provided with prestructured questionnaire form
comprising 13 questions to know their knowledge, attitude, and practice related to ergonomics before
and after providing guidelines on ergonomic principles.
RESULTS: The majority of the dental students appreciate that the most affected regions due to
work‑related disorders were back (475 before and 559 after instructions), neck (354 and 420), hand
and wrist (205 and 117), and shoulder and elbow (132 and 70), respectively. Knowledge and practice
scores of dental students (mean and standard deviation) regarding WMSDs before and after applying
ergonomic principles were 3.92 ± 2.44, 1.29 ± 1.67 and 5.81 ± 0.87, 3.03 ± 0.60, respectively.
CONCLUSION: The present study provides an insight into ergonomics for dental students during
routine dental procedures. The knowledge, attitude, and practice related to ergonomics were
satisfactorily increased among the participants. Thus, ergonomic education of the dental health‑care
personnel must be focused in all the educational institutions and at continuing dental health programs by
delivering ergonomic principles both theoretically and practically and should be a part of the curriculum.

Abstract BACKGROUND: Breast cancer is the most common cancer in Iranian women. The number of people
with this disease is increasing across the world. Positive family history is one of the risk factors for
developing breast cancer. However, early detection is the main method to fight this disease. This
study was conducted to examine the effect of education based on the health belief model (HBM) on
self‑care behaviors among first‑degree relatives of patients with breast cancer.
METHODS: This clinical trial was conducted in 2016 on 80 women in Tehran city, Iran. Data were
collected using a three‑part questionnaire regarding demographic data, the HBM, and self‑care
behaviors. The educational program based on the HBM was held in 4 ninety‑minute training sessions
through lectures, group discussions, question and answer, image presentations, and PowerPoint
presentations. The questionnaires were completed before and 2 months following the intervention
by intervention and control groups. Data were analyzed using descriptive and inferential statistics
through the SPSS16 software.
RESULTS: The mean score of the HBM constructs before the intervention in the groups had no
statistically significant differences (P > 0.05). Eight weeks after the intervention, the mean score of the
constructs of the HBM in the intervention group significantly increased and a statistically significant
increase in the mean score of self‑care in the intervention group compared to the preintervention
was found, so that the self‑care behavior score in the intervention group was 0.69 ± 0.09 before the
intervention and was changed to 0.74 ± 0.09 after the intervention (P < 0.0001).
CONCLUSION: Our results suggest that education based on the HBM was effective in promoting
self‑care behaviors among first‑degree relatives of breast cancer patients. Therefore, education
based on HBM may have an important implication for breast cancer prevention in Iran.

Abstract INTRODUCTION: Given the close relationship between life style and mental health and the importance
of students as valuable human resources, the present study aimed at determining the relationship
between life style and mental health among medical students in Kermanshah.
METHODS: This is a descriptive‑correlational study that was conducted in 2018. The study involved
200 medical students. The sampling method was convenience sampling. Demographic questionnaire,
general health questionnaire, and life style questionnaire were used for data collection. The data were
analyzed Pearson’s correlation test and regression analysis. The significance level was considered
0.05.
RESULTS: The mean mental health score of the students was 25.43 ± 13.02 (2 points higher than
the cutoff point of this test). The life style of 59.5 students was moderate. The results showed that
all life style subscales had a negative significant relationship with the total mental health score and
all its subscales (P < 0.05). Among the life style subscales, the highest relationship and predictive
power to mental health were obtained for psychological health, social health, sport and fitness, and
environmental health (R2 = 0.48, P < 0.001).
CONCLUSION: According to the results, the life style of most medical students in the final year of
Kermanshah University of Medical Sciences was moderate. Further, the students had a better life
style, and they had higher mental health. Therefore, considering the vital role of medical students in
providing and promoting community health, the need for more detailed planning and interventions
to improve their life style and mental health is essential.

Abstract BACKGROUND: Death anxiety is one of the most common problems among women with cancer,
which can affect the useful treatment process. With regard to the superior role of spiritual well‑being
over other aspects of health, the present study is aimed to compare the relationship between spiritual
well‑being and death anxiety among women with breast and cervical cancers and women with gastric
and colorectal cancers.
METHODOLOGY: This was a descriptive–correlational study. Research statistical population included
Iranian women with cancer at major hospitals in Isfahan, Iran. 160 research samples were selected
through convenience sampling method based on inclusion criteria using a demographic questionnaire,
spiritual well‑being scale (Paloutzian et al.) and death anxiety scale (Templer). Research data were
analyzed through SPSS 22 using independent t‑test, Pearson’s correlation, and analysis of variance
at significance level 0.05.
RESULTS: The study findings indicated a significant inverse relationship between death anxiety
and spiritual well‑being (at 0.05) in both groups. As a result, people with higher spiritual well‑being
would experience less anxiety about death. In addition, the relationship between death anxiety and
spiritual well‑being in women with gastric and colorectal cancers was stronger than those with breast
and cervical cancers.
CONCLUSION: Spiritual well‑being is of effective factors of death anxiety among women suffering
from cancer. Spirituality and meeting spiritual needs are considered as nursing care priorities for
these women. Furthermore, paying attention to the spirituality by nurses may shield against individual
difficulties.

Abstract INTRODUCTION: Providing information exchange and collaboration between isolated information
systems (ISs) is essential in the health‑care environments. In this context, we aimed to develop a
communication protocol to facilitate better interoperability among electrophysiology study (EPS)‑related
ISs in order to allow exchange unified reporting in EPS ablation.
MATERIALS AND METHODS: This study was an applied‑descriptive research that was conducted
in 2019. To determine the information content of agreed cardiac EPS Minimum Data Set (MDS) in
Iran, the medical record of patients undergoing EPS ablation procedure in the Tehran Heart Center
(THC) hospital was reviewed by a checklist. Then, an information model based on Health Level
Seven, Clinical Document Architecture (HL7 CDA) standard framework for structural interoperability
has been developed. In this framework, using NPEX online browser and MindMaple software, a set
of terminology mapping rules was used for consistent transfer of data between various ISs.
RESULTS: The information content of each data field was introduced into the heading and body
sections of HL7 CDA document using Systematized Nomenclature of Medicine – Clinical Terminology
names and codes. Then, the ontology alignment was designed in the form of thesaurus mapping
routes.
CONCLUSION: The sensitive, complex, and multidimensional nature of cardiovascular conditions
requires special attention to the interoperability of ISs. Designing customized communication protocols
plays an important role in improving the interoperability, and they are compatible with the needs of
future Iranian health information exchange.

Abstract INTRODUCTION: Maternal–fetal attachment is a term used to describe the emotional relationship that
a pregnant woman has with her developing fetus. Mental care for pregnant women (fear of childbirth
and a sense of cohesion of pregnant women) is one of the most important aspects of prenatal care
that affects the mother’s attachment to the fetus. If fear and anxiety are relieved, psychological and
physical relaxation will be replaced. Therefore, the present study was conducted with the aim of
determining the relationship between fear of childbirth and the sense of cohesion with the attachment
of pregnant mothers to the fetus.
METHODS: The present study is a descriptive study that was performed by multi‑stage sampling
method on 500 pregnant mothers who referred to health centers in Isfahan in 2017. The study
participants completed the following questionnaires: fear of childbirth, sense of cohesion, and
mother’s attachment to the fetus. The data were analyzed by descriptive and analytical statistical
methods (Pearson correlation) using SPSS software version 22.
RESULTS: The results showed that there was a significant negative relationship between the overall
score of maternal attachment to the fetus and fear of childbirth (r = −0.153, P = 0.001). However,
there is a significant positive relationship between the overall score of maternal attachment to the
fetus and the sense of cohesion (r = 0.112, P = 0.01). The results also showed a significant negative
relationship between the fear of childbirth and the dimensions of maternal attachment to the fetus,
including interaction with the fetus (P = 0.04), self‑sacrifice (P = 0.04), and attributing characteristics to
the fetus (P = 0.05). There was a positive and significant relationship between the sense of coherence
and the subsequent acceptance of the maternal role of maternal attachment to the fetus (P = 0.004).
CONCLUSION: More attention of prenatal care provider to the psychological issues of the pregnant
mother and their fears and worries can lead to appropriate interventions in this field, and as a result,
mothers’ attachment to their fetus has increased so that they can take proper care during and
after pregnancy.

Abstract INTRODUCTION: Menstruation is a natural phenomenon among women who experience shedding
of blood for 1–7 days every month which usually starts between age 11 and 14 years and continues
until menopause at about 51 years of age. It is important to maintain menstrual hygiene, as poor
practices increase vulnerability to reproductive and urinary tract infections. The present study was
conducted with an aim to investigate the impact of focused group discussion (FGD) compared to
didactic lectures (DLs) on the menstrual hygiene knowledge and practices.
METHODS: The present cross‑sectional study was conducted among 649 school girls during January
to August 2019 using a convenience sampling technique. After collecting baseline information using
a pretested, predesigned, standardized questionnaire, the participants in the control and intervention
groups were exposed for the DLs and FGD, respectively, and 1 month after such intervention, the
same questionnaire was again self‑administered by participants. All tests were performed at a 5%
level of significance using SPSS (version 22.0).
RESULTS: The baseline characteristics of both the groups such as participants’ mean age, mean
age of menarche, mother’s literacy status, religion, type of family, and socioeconomic status were
comparable. There was a difference in the knowledge and practice mean score of participants in
the control group for pre‑ and postintervention, which was highly statistically significant (P < 0.001).
CONCLUSIONS: This study reveals that menstrual hygiene is far from satisfactory among most of
the school girls. The DLs and FGD have improved the menstrual hygiene knowledge and practices
among school girls.