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Objective The objective of this study was to assess depressive symptoms among rural health workers (RHWs) through a multi-factorial socio-ecological framework (SEF) encompassing personal, interpersonal, organizational and community components. Patients and methods A random sample of 394 RHWs in all rural areas of East Azerbaijan and fulfilling our other inclusion criteria were recruited. The participants underwent the Short-Form Beck's Depression Inventory and a validated researcher-constructed SEF questionnaire, including subscales on personal, interpersonal, organizational and community factors associated with depressive symptoms. Internal consistency and factor structure parameters of the SEF were also calculated. Results A total of 394 RHWs were screened, of whom 170 (43.2%) had mild to major depressive symptoms. Only 6.8% were identified with major depressive symptoms. The SEF-based scale was found to have acceptable content validity (content validity index and ratio were 0.80 and 0.77, respectively) and reliability (Cronbach's alpha=0.7). In the structural equation modeling, the fit indices showed our model to fit the data well (χ 2=14.06, df=14, χ 2/df=1.00, CFI=0.967, RMSEA=0.032). The highest direct contribution to depressive symptoms was found from the personal factors component (β=-2.32). Also, "work load and roles interference" (from organizational level, β=-0.76) and "family/colleague support" (from community level, β=-1.28) made significant direct contributions towards depressive symptoms. Besides the SEF components, female gender (β=1.69), family history of mental illness (β=-1.48), having chronic illnesses (β=-1.64) and being religious (β=3.43) were the strongest direct contributors to depressive symptoms. Conclusion Depressive symptoms were common among RHWs, arising from all personal-, interpersonal-, organizational- and community-level factors. Our SEF had adequate internal consistency and factor structure parameters to be applied in the Middle East and North Africa (MENA) region countries, such as Iran, as a theoretical framework to plan for interventional efforts aiming at preventing depressive symptoms among RHWs. The burden of depressive symptoms should be reduced through multi-factorial interventions and rational perspectives.

Objective To systematically retrieve and condense the best possible evidence on the successful interventions that targeted enhancement of therapeutic and lifestyle recommendations adherence in hemodialysis patients (HDPs). Design An umbrella review of interventional studies. Data sources A comprehensive search of the Cochrane Database of Systematic Reviews, Ovid, PubMed, Scopus, EMBASE and Web of science databases to identify relevant publications in 2000-2018 (June) timeframe. Study selection Two reviewers independently applied inclusion criteria to select potential systematic reviews assessing the successful interventions that targeted enhancement of therapeutic and lifestyle recommendations adherence in HDPs. Data were summarized for information about the first author(s)' names, year of publication, type(s) of the intervention and output variables, main findings and also the applied quality appraisal tools in the retrieved research evidence. Data extraction Eligible studies were selected and data were extracted independently by two reviewers. The Joanna Briggs Institute (JBI)'s critical appraisal tool for systematic reviews was used to assess the quality of the identified publications, and discrepancies were resolved by consensus with a third reviewer. Data synthesis Thirteen systematic reviews (12 solely systematic reviews and 1 systematic review with meta-analyses) were eligible to be enrolled in the study. The range of interventions that had been reported to boost therapeutic and lifestyle recommendations adherence in HDPs' included psycho-educational programs, physical activity enhancement initiatives, information technology (IT)-based interventions and aromatherapy. Depression, diet biomarkers and interdialytic weight gain (IDWG) were among the myriad of output variables that had been measured as proxies to assess impacts of the implemented interventions. Psycho-educational interventions were among the prevalent initiatives to boost therapeutic and lifestyle recommendations adherence among the HDPs. Conclusion This umbrella review revealed that various intervention approaches and strategies can be used for HDPs' better therapeutic and lifestyle recommendations adherence with considerable methodological heterogeneity. The pinpointed research evidence is also supporting application of multifaceted interventional modalities to reach an improved acquiescence form the patients' side and their families. Further studies are recommended to address the interactions across various interventions in discordant socio-cultural contexts.

Haleh Heizomi,1 Zeynab Iraji,2 Rogayeh Vaezi,1 Devender Bhalla,3– 5 Donald E Morisky,6 Haidar Nadrian1,7 1Department of Health Education and Promotion, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran; 2Department of Statistics and Epidemiology, Tabriz University of Medical Sciences, Tabriz, Iran; 3Pôle Universitaire Euclide, Intergovernmental UN Treaty 49006/49007®, Bangui, Central African Republic; 4Iranian Epilepsy Association®, Tehran, Iran; 5Nepal Interest Group of Epilepsy and Neurology (NiGEN), Kathmandu, Nepal; 6Department of Community Health Sciences, UCLA Fielding School of Public Health, Los Angeles, CA, USA; 7Social Determinants of Health Research Center, Tabriz University of Medical Sciences, Tabriz, IranCorrespondence: Haidar NadrianDepartment of Health Education and Promotion, Faulty of Health,Tabriz University of Medical Sciences, Attar-e-Neyshabouri Street, Tabriz, IranTel +989181734596Email haidarnadrian@gmail.comObjective: We examined the gender-based associations of health literacy (HL) with self-reported medication adherence (MEDA) among patients with primary hypertension (pHTN).Patients and Methods: The subjects were recruited from the general population through all health centers of the Heris county, east Azarbaijan. They were to be adults (30+ years age), with pHTN of any stage, of any gender, and without comorbid illness. All underwent detailed face-to-face interview. We used valid questionnaires for HL and MEDA. Hierarchical regression was done to establish the association between MEDA, socio-demographic variables, and nine HL domains by gender. Other statistical procedures were also done.Results: A total of 300 (48.6% males, mean age: 56.7± 9.3) subjects participated; 43.0% were uneducated, 73.0% had moderate socioeconomic status, 68.0% had poor HL, and 7.0% maintained high adherence. Men were better in reading skills (p=0.002), and accessing (p=0.01) and using (p=0.02) health information, but women were better in health knowledge (p=0.004). The average regression estimate (±standard deviation) between HL and MEDA was 0.37± 0.09, lower among men (0.361± 0.11) than women (0.396± 0.08), p=0.003. Upon hierarchical regression, the association between HL and MEDA was significant for communication and decision-making skills alone among both men (34.5%) and women (40.6%), individually.Conclusion: HL had substantial association with MEDA among those with HTN, for both men and women, particularly the communication and decision-making. With considerations on gender differences, this association should be confirmed through interventional studies to help make HL a formal mitigating strategy for MEDA and other public health goals.Keywords: medication adherence, health literacy, hypertension, gender

Background Despite the improvement of living standards and public health as well as conducting the specific programs based on pediculosis control guidelines, Head Lice Infestation (HLI) is still a worldwide health concern. The purpose of this study was to investigate the cognitive factors associated to school-age children's HLI among mothers in an urban community. Subjects and Methods In this cross-sectional study, a multi-stage cluster random sample of 619 mothers of students in elementary schools of Chaldoran County, located in North-West of Iran, was recruited to participate in the study. Data were collected applying a set of questionnaires including socio-demographic and cognitive-behavioral factors, including Pediculosis Preventive Behaviors (PPBs), HLI knowledge, threat appraisal, as well as HLI prevention perceived self-efficacy, response efficacy, and perceived collective family efficacy. Results Statistically significant differences were found in the children's HLI by their mother's age and performance in PPBs (p-value=0.001). Hierarchical multiple linear regressions were performed with PPBs as outcome variable. According to their natures, the predictors for this outcome variable were classified in two different blocks. Demographic characteristics (p > 0.05), and cognitive constructs (p< 0.001) explained 9% and 21.1% of the observed variance in PPBs, respectively. Pediculosis was found as an epidemic among the students, particularly female students, of Chaldoran County, which call for action by health stakeholders and policymakers. Conclusion The healthcare providers are recommended to develop HLI prevention programs, within which the mothers and their school-age children as well as school mangers and public places' employers are considered as the core target groups for interventions. Besides PPBs, response efficacy and perceived collective family efficacy to perform the behaviors should be considered as the core categories while designing such prevention programs.

Background: Optimism is known to be associated with many health behaviors. However, the associations between optimism, tobacco smoking and substance abuse in adolescents are not well documented. This study aimed to address this research gap in a large school-based population. Methods: Participants (N = 1104) were selected based on multi-stage cluster sampling method. Cigarette and hookah smoking behaviors, illicit drug use, optimism, and relevant covariates were measured using a validated questionnaire. Data were analyzed using ordinal logistic regression. Results: After adjustment, higher optimism score was a protective factor against being situated in advanced stages of cigarette smoking (odds ratio [OR] = 0.88, 95% CI: 0.84-0.91), hookah smoking (OR = 0.91, 95% CI: 0.88-0.94), and illicit drugs usage (OR = 0.90, 95% CI: 0.85-0.95). Moreover, the results showed that negative-stability and negative-globality domains of optimism were significantly higher among advanced-stage smokers and illicit drug users. Conclusion: Optimism was found to be a protective factor against tobacco smoking and substance abuse; whereas pessimism (negative-stability and negative-globality) was found to be a determinant factor. Further research is needed to investigate the effects of optimism on the transition in cigarette and hookah smoking stages.

Brucellosis is an endemic disease in many countries, especially in the Mediterranean region, as well as countries such as the Islamic Republic of Iran. Despite the preventive measures against brucellosis adopted in different countries throughout the world, the disease is still a public health concern.Our aim in the present study was to examine the cognitive factors associated with Brucellosis Preventive Behaviours (BPBs) among diagnosed patients utilizing Empowerment Model.In 2013, applying a cross-sectional study, all 238 patients with brucellosis in Chaldoran County, Islamic Republic of Iran, were recruited to answer a researcher-made EM-based questionnaire and BPBs Scale through interview.Hierarchical multiple linear regressions were performed with BPBs as the outcome variable. Predictors for this variable, according to their natures, were classified in two different blocks. In the first block, significant effect was found on BPBs by demographic variables (ΔR2 = 0.301). In the second block, the level of education, knowledge, and self-efficacy were significant predictors (P0.001) of BPBs (ΔR2 = 0.808).The Empowerment Model was found as a helpful framework in predicting the risk factors of BPBs. Health care providers in low- and middle-income countries should consider the patients' knowledge on the disease and their level of self-efficacy to perform BPBs as the core categories of empowerment while designing brucellosis prevention programmes.العوامل الإدراكية المرتبطة بالسلوكيات الوقائية من داء البروسيلات بين المرضى الذين تم تشخيصهم: تطبيق نموذج التمكين.توحيد بابا زادة، حيدر ندريان، سهيلا رنجبران، حامد رضاخاني مقدم، مهران أغه ميري.يعد داء البروسيلات مرضًا متوطنًا في العديد من البلدان، لا سيّما في إقليم شرق المتوسط، بما في ذلك جمهورية إيران الإسلامية. ورغم تبني التدابير الوقائية لمكافحة داء البروسيلات في مختلف بلدان العالم، لا يزال المرض يُمثِّل قلقًا بالنسبة للصحة العامة.تمثَّل هدفنا في هذه الدراسة في فحص العوامل الإدراكية المرتبطة بالسلوكيات الوقائية من داء البروسيلات بين المرضى الذين تم تشخيصهم بالمرض باستخدام نموذج التمكين.في عام 2013 ، تم تطبيق دراسة مقطعية، حيث تم اختيار 238 مريضًا مصابًا بداء البروسيلات في مقاطعة تشالدران، جمهورية إيران الإسلامية، للإجابة على استبيان قائم على نموذج تمكين وضعه باحثون ومقياس السلوكيات الوقائية من داء البروسيلات من خلال إجراء مقابلة معهم.أُجريت الارتدادات الخطية المتعددة الهرمية باستخدام السلوكيات الوقائية من داء البروسيلات بمثابة متغير المخرجات. وتم تصنيف المؤشرات لهذا المتغير، وفقًا لطبيعتها، في مجموعتين مختلفتين. في المجموعة الأولى، كان هناك أثر كبير على السلوكيات الوقائية من داء البروسيلات وفق المتغيرات السكانية (0.301 = 2RΔ). وفي المجموعة الثانية، كان المستوى التعليمي ومستوى المعرفة والكفاءة الذاتية مؤشرات مهمة (0.001P) للسلوكيات الوقائية من داء البروسيلات (0.808 = 2RΔ).وُجِدَ أن نموذج التمكين يعد إطارًا مفيدًا في التنبؤ بعوامل الخطر الخاصة بالسلوكيات الوقائية من داء البروسيلات. ويجب على مقدمي الرعاية الصحية في البلدان منخفضة ومتوسطة الدخل الأخذ في الاعتبار مدى معرفة المرضى بالمرض ومستوى كفاءتهم الذاتية في اتباع السلوكيات الوقائية من داء البروسيلات بمثابة الفئات الأساسية للتمكين، ووضع برامج للوقاية من داء البروسيلات في الوقت ذاته.Facteurs cognitifs associés aux comportements de prévention de la brucellose chez les patients diagnostiqués : application du modèle d’autonomisation.Dans de nombreux pays, la brucellose est une maladie endémique, en particulier dans la Région de la Méditerranée, ainsi que dans des pays tels que la République islamique d’Iran. En dépit des mesures de prévention de la brucellose adoptées dans différents pays à travers le monde, cette maladie reste un problème de santé publique.La présente étude avait pour objectif d’examiner les facteurs cognitifs associés aux comportements de prévention de la brucellose chez les patients diagnostiqués à partir du modèle d’autonomisation.Dans le cadre d’une étude transversale réalisée en 2013, l’ensemble des 238 patients atteints de brucellose dans la circonscription de Chaldoran, en République islamique d’Iran, ont été recrutés. Lors d’un entretien, il a été demandé aux patients de remplir un questionnaire basé sur le modèle d’autonomisation ainsi que sur une échelle des comportements de prévention de la brucellose élaborés par les chercheurs.Des régressions linéaires hiérarchiques multiples ont été réalisées, les comportements de prévention de la brucellose constituant la variable de jugement. En fonction de leur nature, les facteurs prédictifs de cette variable ont été classés en deux groupes distincts. Dans le premier groupe, on a constaté un effet significatif sur les comportements de prévention de la brucellose en fonction des variables démographiques (ΔR2 = 0,301). Dans le second groupe, les niveaux d’éducation, de connaissances et d’efficacité personnelle constituaient des facteurs prédictifs significatifs (p0,001) des comportements préventifs de la brucellose (ΔR2 = 0,808).Le modèle d’autonomisation a constitué un cadre utile pour prévoir les facteurs de risque associés aux comportements de prévention de la brucellose. Dans les pays à revenu faible et intermédiaire, il est recommandé aux prestataires de soins de santé de prendre en compte les connaissances des patients sur la maladie ainsi que leur niveau d’efficacité personnelle concernant les comportements de prévention de la brucellose comme catégories de base de l’autonomisation dans le processus d’élaboration de programmes de prévention de cette maladie.

Our aim was to develop a framework-based weight control behavior questionnaire (Weight-CuRB) and test its psychometric properties among a non-probability sample of 240 postmenopausal women with osteoporosis. Appropriate validity, simplicity, functionality and reliability were observed for the Weight-CuRB. The explanatory model fits the data well (χ2 [139] = 245.835

Background A huge number of people living with HIV/AIDS lives in developing countries. Thus, strengthening health systems in these countries is a prerequisite for improving disease prevention and care. After three decades of HIV/AIDS policy-making in Iran, conducting a comprehensive analysis on the policy process seems to be essential. In the present study, we aimed to analyse the HIV/AIDS policy-making process in Iran from 1986 to 2016. Methods This was a theory-based, multi-method and retrospective study. Interviewing of key informants and review of policy documents were concurrently conducted to identify and include further key informants (39 participants) and documents in the study. Framework analysis was used to analyse data. Results The mean age of participants working in HIV/AIDS policy-making was of 48 years and participants had a mean of 14 years of working experience. Findings were categorized as contextual factors, content of HIV/AIDS policies, actors involved in the policy process, and evidence use in the policy process. Contextual effective factors on the HIV/AIDS policy-making process were categorized into five major themes, namely situational factors, structural-managerial factors, socioeconomic factors, political and legal factors, and international factors. The HIV/AIDS phenomenon in Iran was identified to be deeply rooted in the culture and traditions of society. The HIV/AIDS policy content has, recently, been crystallized in the national strategic plans and harm reduction policies of the country. The policy process has been conducted with a solely governmental top-down approach and is now suffering from poor evidence and lack of sufficient consideration of contextual factors. Conclusions There is a great need for change in the approach of government towards the issue and to increase the participation of non-governmental sectors and civil society in the policy process.

Background: Health-care systems play a key role in responding to the growing problems of patients with type 2 diabetes by supporting their autonomy in providing routine care. The Health Care Climate Questionnaire (HCCQ) was designed to assess patients' perceived degree of autonomy support within the care practice settings. The main purpose of this study was to translate and evaluate psychometric properties of the Persian version of the HCCQ (HCCQ-P) to be applied among Iranian and other Persian-speaking patients with type 2 diabetes. Method: Translation/back-translation procedures were carried out to prepare a preliminary draft of the HCCQ-P that was subsequently sent for face and content validity appraisal by a group of 15 health education/promotion and nursing specialists. Minor revisions were performed based on the feedback, and the content validity ratio (=0.91) and content validity index (=0.95) were within the acceptable range. The structural validity of the scale was assessed by exploratory and confirmatory factor analysis. Results: The exploratory and confirmatory factor analysis outputs (root mean square error of approximation=0.079, comparative fit index=0.976, Tucker Lewis index=0.967, standardized root mean square residual=0.022) demonstrated the proper performance and fitness statistics of the translated HCCQ in a one-dimensional model similar to the original scale. The internal consistency and reliability scores endorsed the validity of the translated measure (α=0.945, intraclass correlation coefficient=0.999, P=0.000). Conclusion: In this study, the translated HCCQ-P scale showed robust internal validity for its application in the assessment of health-care settings' supportiveness in care provision to Persian-speaking patients with type 2 diabetes. Future cross-cultural and multidisciplinary studies are recommended to investigate the applicability of the scale in different patients/cultural groups and health-care settings.

Background Health literacy is essential to self-care, which is an important precedence to improve the quality of healthcare services and a key factor in health. It also plays a pivotal role in decision-making in various health fields. Therefore, policymakers consider health literacy to be a primary tool to promote community health and enhance the proper use of healthcare services. The present study aimed to assess the health literacy status of the Kurdish population in Kurdistan province, Iran based on the nine constructs of the Iranian health literacy questionnaire (IHLQ) individually and collectively and determine the significant effects of demographic variables on health literacy. Methods This cross-sectional study was conducted on the Iranian adult Kurdish population living in the urban and rural areas of Kurdistan province, willing to participate during April 2017–September 2018. Data were collected using the IHLQ. The sample size was determined to be 980 people, with 490 in the rural areas and 490 in the urban areas. The researchers visited potential participants at their doorstep, asking them to complete the questionnaire. The willing participants were assisted in completing the IHLQ in case they were illiterate; the questions and answers were read by the researchers to the participants, and the responses were recorded. Results About 50.4% (n = 494) of the Kurdish population had poor health literacy, while 34.0% (n = 333) had average health literacy, and 15.6% (n = 153) had good health literacy. Meanwhile, 60.2% of the participants obtained poor scores in the construct of health information access, and 74.1% (n = 726) obtained poor scores in the individual empowerment construct. In addition, the analysis of the adjusted model indicated that education level (lowest β = 7.42; P = 0.001) and in male participants (β = − 1.10; P = 0.001) were significantly associated with higher health literacy. Conclusion According to the results, the investigated Kurdish population mostly had average or low health literacy. Therefore, proper strategies should be adopted to enhance the health literacy of this population and increase their access to health information. Furthermore, effective training should be provided to these individuals (especially vulnerable social groups) to improve their individual capabilities to compensate for poor health literacy.

Background The present study aimed to investigate the effects of a multi-level intervention on hookah smoking frequency and duration among Iranian adolescents and adults. Methods In this study, two comparable cities in Iran were selected to participate in an intervention program based on a social-ecological model (SEM). In each city, 133 hookah smokers in coffee houses were selected. Environmental changes in coffee houses such as serving light foods and games were conducted. A virtual group named “no hookah” was established on the Telegram application to train participants in the intervention group. Messages, pictures, and short videos were sent to the participants through that virtual network. The frequency and duration of hookah consumption were assessed in both groups at baseline and after the intervention. Results The frequency of hookah consumption decreased in 72.6% of participants in the intervention group (vs. 6.3% in the control group), and the duration of hookah consumption per session decreased in 39.5% of participants in the intervention group (vs. 5.5% in the control group). Conclusions Using multi-level interventions through a social-ecological model can reduce hookah consumption in adults.

Background High-risk behaviors are among the most serious threats for the physical and mental health of adolescents and young adults. Our aims in this study were to investigate the subgroups of students based on risky behaviors and to identify the prevalence rate of these subgroups. Methods This cross-sectional web-based survey was conducted from July to August 2019 in Tabriz, Iran. We performed proportional sampling in all nine universities of the city, according to the number of students in each university. Applying an online survey questionnaire, the data were collected from 3649 students and analyzed using Latent Class Analysis. Results For total sample, standardized prevalence rates of cigarette smoking, hookah use, alcohol consumption, substance abuse and unsafe sex were 18.5 (Confidence Interval (CI) 95%: 17.3–19.8), 9.1 (CI 95%: 8.2–10.1), 9.2 (CI 95%: 8.3–10.2), 8.3 (CI 95%: 7.4–9.3) and 14.5 (CI 95%: 13.3–15.7), respectively. Three latent classes of risky behaviors were determined among students: a) low risk b) smoking and c) high risk. About 18% of boys and 1.5% of girls were in the high risk class. Cigarette smoking (18.5%, CI 95%: 17.3–19.8) and substance abuse (8.3%, CI 95%: 7.4–9.3) were the most and the least common risky behaviors among the students. Conclusion In this we-based survey, a considerable number of students, particularly boys (18%), was at high-risk class, stressing the need for preventive interventions for this group of youth. Our findings are beneficial for planning and development of risky-behavior preventive strategies to prevent high-risk behaviors among college students.

Background Poor mental health is common among adolescents. Given the increasing burden of poor mental health among adolescents in developing countries, it seems necessary to identify the effective interventions. The main purpose of this study was to investigate the effects of a school-based mental health promotion program (SMHPP) on mental health parameters among female adolescents in Tabriz, Iran. Method In this experimental study, a random sample of female high-school students of grade nine was recruited. The subjects were then randomly allocated to intervention (n = 145) and control (n = 139) groups. The three-stage SMHPP was designed based on the shortages and unmet needs of the students as reported in the pretest stage. All subjects in the intervention group were provided with a stress management skill training program of six sessions using McNamara Model. Coincided with making environmental changes, a joyful intervention program was carried out. After 2 months, post-test data were collected. Results A total of 284 students completed their participation in the study. The groups did not differ in none of socio-demographic characteristics and mental health parameters, at baseline. The number of subjects reporting medium-level of happiness was increased by 32.6% among intervention group. Moreover, upon sign test and pre-post comparison, the group-wise distribution changed between the intervention and control groups for the parameters of life satisfaction (p ≤ 0.001) and psychological well-being (p ≤ 0.01). Conclusion The implementation of SMHPP as a low-cost, needs-based and multifaceted program, showed promise in promoting adolescents’ mental health, particularly in the parameters of happiness, life satisfaction and psychological well-being. This was an important evidence for the development and implementation of interventions and policies in the field of mental health promotion among adolescents. Our work provided means for reducing burden of poor mental health among adolescents in a non-western cultural context. Further larger studies are required to evaluate the effectiveness of such school-based mental health promotion interventions in students.

Background: In 2015, the Iranian Urban Family Physician Program (UFPP) was implemented in urban health centers. In the present study, we aimed to evaluate the trend of health indicators across a ten-year period in an Iranian population and to measure the possible effects of this intervention on health indicators.Methods: An interrupted time series analysis (ITSA) was performed on a ten-years (from 2009 to 2018) of annual data set covering all healthcare indicators associated to the UFPP in Bonab County, Iran. The time of intervention was at the 7th data point in 2015. Health indicators were divided into two groups including process indicators (Modern Contraceptives Use (MCU), Prenatal and Postpartum care visits, Clinical Breast Examinations (CBE), brucellosis and tuberculosis (TB) incidence), and outcome indicators (Total fertility rate (TFR), Maternal Mortality Rate (MMR), Stillbirth Rate (SBR), Infant mortality Rate (IMR), Neonatal Mortality Rate (NMR), 1-59 months old Mortality Rate, Low Birth Weight (LBW), crud birth rate (CBR) and the rates of Infants fed by Formula milk.Results: The ratio of some process indicators, including the MCU (b = -5.13. 95% Confidence Interval (CI): -8.01 to -2.26), incidence of tuberculosis (b = .016. 95% CI: -1.01 to 1.34) and brucellosis (b = 3.04. 95% CI: -3.4 to 9.50) had a decreasing trend from 2008 to 2018. However, the CBE (b = 0.60. 95% CI: -4.97 to 6.18), prenatal care visits, (b= -4.25. 95% CI: -10.4 to 1.5) postpartum care visits (b = -22.83. 95% CI: -31.44 to -14.21), and first time care visits during pregnancy (b = -5.59. 95% CI: -14.52 to 3.32) were found with increasing trends. In contrast, the rate of at least six-time care visits during pregnancy was found to be in a decreasing trend (b = -10.32. 95% CI: -16.82 to -3.82). A series of outcome indicators including MMR (b = 24.78. 95% CI: 2.88 to 46.61), TFR (b= 0.07. 95% CI: 0.01 to 0.13), 1-59 Month old Mortality Rate (b = -.16. 95% CI: -.45 to .12), LBW (b = .33. 95% CI: -.08 to .40), Formula-fed infant rate (b = .48. 95% CI: -.007 to .97), Delivery rate in high-risk groups (b = 1.85. 95% CI: 1.22 to 2.49) and CS (b = -3.43. 95% CI: -5.73 to -1.12) had increasing trends from 2008 to 2018. In contrast, SBR (b = -.04. 95% CI: -.21 to .12), NMR (b = -.77. 95% CI: -2.91 to 1.36), IMR (b = -1.05. 95% CI: -2.99 to .89) and CBR (b = -.97. 95% CI: -1.85 to -.09) were in decreasing trends. Conclusion: The UFPP was found with positive impacts on some process, proximal and distal outcome indicators, but its positive impacts on the trends of some critical indicators, including MMR, NMR and IMR remained questionable. Our findings may shed light on the role of some other factors like social determinants of health in the programs like the UFPP.

Leila Zhianfar,1 Haidar Nadrian,2 Mohammad Asghari Jafarabadi,3 Fatemeh Espahbodi,4 Abdolreza Shaghaghi1 1Health Education & Promotion Department, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran; 2Social Determinants of Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran; 3Epidemiology and Biostatistics Department, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran; 4Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, IranCorrespondence: Abdolreza ShaghaghiHealth Education & Promotion Department, Faculty of Health, Tabriz University of Medical Sciences, Golgasht Ave, Tabriz, P.C 516667411, IranTel +98 41 33376227Email ar.shaghaghi@gmail.comPurpose: A multimodal intervention designed and executed to improve therapeutic regimen adherence and quality of life in a sample of Iranian hemodialysis patients. Its feasibility and impact was assessed post intervention.Patients and Methods: This randomized controlled trial (RCT) study was conducted at two hemodialysis wards of the Shahrvand hospital located in Sari, the capital city of the Mazandaran province, north of Iran. The study sample included patients with end-stage renal disease (ESRD) receiving outpatient hemodialysis treatment. Considering 10% attrition, 70 registered patients were randomly categorized into intervention and control groups. The proposed intervention included playing of relevant educational video tracks, conducting eight cognitive behavioral therapy (CBT) group sessions, and telephone-based peer support. Data were collected applying a set of questionnaires including sociodemographic, Beck Depression Inventory (BDI-SF), Multidimensional Scale of Perceived Social Support (MSPSS), Patient Satisfaction with Nursing Care Quality Questionnaire (PSNCQQ), End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ) and the World Health Organization Quality of Life (WHOQOL-SF) scale. Sociodemographic and clinical data were collected at baseline in both groups and the postintervention assessment was performed in the intervention and nonintervention groups after one month and three months.Results: A significant change in the self-reported depression symptoms (P=0.001), mean social support score (P=0.001), nursing care satisfaction score (P=0.001), quality of life score (P=0.001) and interdialytic weight gain (IDWG) (P=0.001) was observed among the participants in the intervention group compared to the baseline measures. The highest rise in the ESRD-AQ scores within the intervention group was observed after one month of intervention (mean difference=131.88) compared to the baseline values. Same pattern of statistically significant changes in mean scores of the intervention group’s attendants in all subscales of the ESRD-AQ were also ascertained.Conclusion: This interventional study revealed that inaugurating of a feasible low-cost intervention without need to add major logistic or financial inputs into existing health-care systems, especially in resource limited contexts, is achievable. Findings of this study could provide insights into scientific basis of evidence-informed interventions applicable in the realm of health-care delivery.Keywords: hemodialysis patients, intervention, adherence

Purpose We sought to examine the association between childhood asthma and self-reported maternal smoking during pregnancy (MSDP) after adjusting for a range of exposure misclassification scenarios using a Bayesian approach that incorporated exposure misclassification probability estimates from the literature. Methods Self-reported MSDP and asthma data were extracted from National Health and Nutrition Examination Survey 2011–2012. The association between self-reported MSDP and asthma was adjusted for exposure misclassification using a Bayesian bias model approach. Results We included 3074 subjects who were 1–15 years of age, including 492 asthma cases. The mean (SD) of age of the participants was 8.5 (4.1) and 7.1 (4.2) years and the number (percentage) of female was 205 (42%) and 1314 (51%) among asthmatic and nonasthmatic groups, respectively. The odds ratio (OR) for the association between self-reported MSDP and asthma in logistic regression adjusted for confounders was 1.28 (95% confidence interval: 0.92, 1.77). In a Bayesian analysis that adjusted for exposure misclassification using external data, we found different ORs between MSDP and asthma by applying different priors (posterior ORs 0.90 [95% credible interval {CRI}: 0.47, 1.60] to 3.05 [95% CRI: 1.73, 5.53] in differential and 1.22 [CRI 95%: 0.62, 2.25] to 1.60 CRI: 1.18, 2.19) in nondifferential misclassification settings. Conclusions Given the assumptions and the accuracy of the bias model, the estimated effect of MSDP on asthma after adjusting for misclassification was strengthened in many scenarios.

Background: Heart failure (HF) is a common clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of ventricles to fill with or eject blood.Our aim in this study was to examine the possible direct/indirect effects of health belief model(HBM) constructs on self-care behaviors among HF patients. Methods: A secondary analysis was conducted on an HBM-based data set collected from 180 patients with HF who were recruited from a heart hospital in Tehran, Iran, during a prospective experimental study in 2008. A regression-based path analysis was conducted to examine the relationships between HBM constructs (as independent variables) and self-care behaviors (as dependent variable). Results: A conceptual path model was identified for the cognitive determinants of self-care behaviors among HF patients. Knowledge (β = 0.399), perceived barriers (β = 0.315) and susceptibility (β = 0.165) had direct effects on self-care (R2 = 0.512, P < 0.001). Perceived benefits, self-efficacy, severity and threat, locus of control and cues to action had indirect effects on self-care through the first three variables. Conclusion: HBM was found to be helpful in understanding direct and indirect associations between the cognitive determinants and self-care behaviors among HF patients. Based on this challenging path analysis, HF patients' knowledge and perceived barriers and susceptibility are suggested as the most core categories while designing HF educational programs. Better understanding on such associations may lead nurses and health practitioners in designing properly informed stage-specific educational interventions aiming to foster self-care behaviors among HF patients.

The aim of our study was to investigate the therapeutic efficacy of pharmacological and non-pharmacological interventions on low sexual interest/arousal of peri- and post-menopausal women. In this ...

Even though Kurdistan, the western province of Iran, has a cancer surveillance system, a detailed analysis of incidence rate has not been yet performed. We describe Age Standardized Incidence Rates (ASRs) for esophageal cancer (EC) in Kurdistan Province of Iran in 2001–2015. Incidence cases of EC were obtained from a population-based cancer registry. We obtained ASRs and 95% confidence intervals (CI) per 100,000 populations for each calendar year group. Between 2001 and 2015, 1362 incidence cases with EC were reported to the cancer registry. Annual ASRs in 2006–2010 were more than the other years in both men and women, respectively. Most ASRs were reported among women in Divandarreh (18.95, 95% CI 14.76, 23.92), Saqez (12.75, 95% CI 10.73, 15.01), Sanandaj (8.84, 95% CI 7.64, 10.17), and Qorveh (8.19, 95% CI 6.54, 10.12), and among men in Divandarreh (19.38, 95% CI 15.38, 24.06), Saqez (13.64, 95% CI 11.49, 16.05), Sanandaj (8.70, 95% CI 7.56, 9.96), and Marivan (7.93, 95% CI 6.26, 9.88). It was concluded that EC in Divandarreh, Saqez, and Sanandaj has the highest ASRs, and these areas are considered as high-risk areas for this disease in the Iranian province of Kurdistan. Therefore, to understand the reasons of these problems, a considerable work is needed.

Our aim in this cross-sectional study was to assess the cognitive determinants of Cervical Cancer Screening Behavior (CCSB) among housewife women in Islamabad County, Iran. Through multistage random sampling we recruited and interviewed 280 housewife women. The women who perceived more benefits of performing the Pap test (OR = 1.11), and perceived fewer barriers (OR = 0.915), and higher self-efficacy to perform the test (OR = 1.12) were more likely to have a CCSB in the previous three years. Our findings are informative for the development of targeted interventions to foster CCSB among housewife women.

The aim of this prospective study was to investigate the predictors of choosing mode of delivery (MOD) among Iranian urban women applying the socio-ecological model. In 2015, a convenient sample of 530 pregnant women in urban regions of Urmia, Iran, was recruited to complete a socio-ecological approach–based questionnaire. Then, 1 week after childbirth, the women were followed up by telephone to be asked about their MOD (response rate = 81.88%). Logistic regression analysis showed that the odds of cesarean section (CS) among the women with university education, whose husbands were an employee in a governmental organization, who preferred a private hospital for delivery, and who selected the CS as the preferred MOD during pregnancy were significantly higher than their counterparts. Among all the factors, the socioeconomic status of the families was more influential in predicting the MOD among women. The cognitive factors like fear of childbirth may not be determinants for MOD if women are from privileged families.

Our aim in this cross-sectional study was to investigate the predictors of the stages of change in mammography adoption (MA) based on Health Belief Model among Iranian women. Through multistage cluster sampling, we recruited and interviewed 1131 women older than 40. After statistical adjustment for other risk factors, perceived barriers (OR D 0.84, 95% CI D .81–.87) and benefits (OR D 1.17, 95% CI D 1.11–1.24) were significant predictors for MA. Majority of the women were in the pre-contemplation and contemplation stages of change for MA. Our findings are informative for the development of targeted interventions to foster MA among women.

Background We assessed community-based educational interventions towards primary prevention of type-II diabetes (T2D), but with a focus on theoretical framework and community factors. Methods A comprehensive search for eligible studies was carried out on PubMed, EMBASE, ProQuest, CINAHL nursing & allied health source, Cochrane Library, Google scholar, conference proceedings, and reference lists. Eligibility criteria were 1) quantitative interventional studies with all designs implemented on general populations and/or the participants at-risk for T2DM within communities (community-based interventions), 2) had no pharmacological treatments within the intervention; 3) had any theoretical frameworks based on health education theories/models; 4) published 2000 onwards and in English language. Data was extracted by using JBI standardized data extraction tool. The primary outcome variables were incidence rate of T2DM, fasting blood glucose (FBG), haemoglobin A1c (HbAlc), mean body weight, mean body mass index (BMI), waist circumference (WC), systolic/diastolic blood pressure (s/d BP). Random effects meta-analysis was conducted to pool the results. Sub-group analyses based on age-group, gender, theoretical framework, and duration of follow-up were also performed.Results Nineteen studies were included in the review and ten studies were pooled in the meta-analysis (n = 16106, mean age = 41.52 years). The incidence rate of T2D was reported in 3 trials, within which the risk of developing T2D was reduced by 54% in favour of the community-based educational interventions, (RR =0.54, 95% CI = 0.38- 0.75; p < 0.001). In eleven (n = 11587) and six (n = 6416) studies the pooled mean difference was -0.33 (95% CI -0.45 to -0.20, p2= 95.7%, p2=97.3%, pConclusion In the community-based educational interventions with high quality indices, the risk of developing type 2 diabetes may be reduced by half in favour of all other community-based educational interventions. Given the gross lack of reliable community-based educational interventions, there is no doubt on why we lag behind on T2D prevention; especially in low-middle income populations. Nevertheless, the effected interventions are helpful to bring a favourable change in outcome variables, but, with conditions. Interventions with theoretical framework are likely to be more effective towards diabetes prevention.

Background Tobacco smoking is the second leading cause of death and is closely linked to fatal diseases. Hookah Smoking (HS) is a traditional way to smoke tobacco, especially in the Eastern Mediterranean region that is constantly rising around the world. This study aimed to evaluate the different levels of personal, interpersonal and social HS in Iranian urban men and determine the most important predictors of the levels through applying the socio-ecological approach (SEA). Methods This study was conducted in the coffee houses of Hashtrud and Qarah Aghaj counties in East Azerbaijan, Iran. Data collection was conducted from the entire coffee house (n = 18) from April to June 2017. Systematic sampling was employed to recruit 266 men in the coffee house. A valid and reliable instrument was used to investigate the frequency of HS and its determinants based on SEA. The SEA consists of three levels: personal (age, education, employment, income, and perceived severity and sensitivity), interpersonal (perceived reward), and social level (social support) intended to assess HS determinants. Hierarchical regression was used to determine the predictive value of SEA levels and frequency of HS. Results The mean age of daily hookah smokers (once per day and more than once per day) were (26.8) significantly lower than those (30.4) smokes weekly (once a week or more than once a week). The hierarchical logistic regression model showed that in the first step individual variables significantly predict 25.1% HS. In the second and third level interpersonal and social levels of SEA explained HS 30.1 and 30.8%, respectively. Conclusion This study found that age, income, education, and perceived reward were all important factors influencing HS among men youth. Application of SEA to determine the factors associated with HS could contribute in the development of a holistic prevention program.

Background: Considering the renewed emphasis on women’s health, attention to the new aspects of their health, such as equity, among different groups is warranted. The aim of this study was to investigate the economic inequalities among women with osteoporosis-related bone fractures (ORBFs) in Sanandaj, Iran. Methods: In this cross-sectional study, convenient sampling was employed to recruit 220 women with osteoporosis referring to the only rheumatology clinic in Sanandaj (the center of Kurdistan province in Iran) from January to April 2013. Main outcome was the history of fractures due to osteoporosis. Concentration index decomposition (CID) and logistic regression were used for data analysis. Results: In multivariate logistic analysis, the fourth and fifth quintiles of family economic status were found to be significantly associated with ORBFs. Risk difference and confidence interval (CI) for the relation between the history of bone fracture and family economic status was -0.115 (95% CI: -0.209, -0.021; P = 0.016), which reflected the higher prevalence of bone fractures among women with the lower economic levels. About 25% out of all ORBFs were happened among 20% of the women with low economic status. Conclusion: It was concluded that economic status plays an important role in happening ORBFs among underprivileged women. A reorientation on women’s health care services in Iran with a focus on underprivileged postmenopausal women seems to be necessary. There is a need for inter-sectoral coalition between the policymakers of the health system and those of other organizations to reduce the economic inequalities among osteoporotic women.

Introduction Our aim was to conduct a health impact assessment (HIA) on Sanandaj urban traffic jam, as a consequence of current urban traffic and transport initiatives conducted by Sanandaj urban traffic and transport system. Methods Incorporating practice standards into the methodology, and applying a single mixed-method case study, we collected four sources of data through profiling community (archival records/documentations), interviews/focus group discussions, field notes, and community survey in Sanandaj, Iran. Integration of data was conducted at interpretation level (data synthesis). Results Reviewing archival records, a slight increase was found in the registered death/hospitalization cases due to diseases associated to air pollution. An aggravating trend was found in both air quality of city and fines for traffic violations. Challenges of urban traffic jam from residents’ viewpoints were grouped into infrastructural, managerial, sociocultural, psychological and behavioral categories. Essential themes for the health impacts of urban traffic jam included physical and family mental health, and social determinants of health. Community survey showed high levels of negative impacts of urban traffic jam on air quality, public services delivery and accessibility, physical environment, public welfare services, family circumstances, social environment, and tobacco/substance use. The following barriers of urban traffic and transport initiatives were identified as the high priorities for revisiting plans: lack of enough streets/highways, lack of enough underpass/overpass, lack of parking lots in crowded areas and poor traffic education/acculturation. The team of assessors, based on findings, established the priority impacts and recommended justify options for action. Conclusion Performing the HIA, we portrayed the contribution of a various range of urban-traffic related determinants to public health in a low- and middle-income country (LMIC) setting. This study may recall and familiarize policy and decision makers outside health sector on the ways to provide community health-oriented plans/projects. Our findings are particularly informative for the LMICs, where urban traffic jam is mostly due to poor urban traffic and transport initiatives within urban areas.

Problem Mobile phone (MP) overuse is extensively rising among high school students in developing countries. Our aim in this study is to investigate the association between MP overuse and mental health, in the presence of other determinant factors, among high school students in Iran. Methods We recruited a clustered random sample of 1,034 high school students in Saqqez County, Iran, to complete a self-administered questionnaire with three sections: a sociodemographic questionnaire, Mobile Phone Addiction Index, and General Health Questionnaire. Findings A majority of the students (n = 654, 63.2%) were found to be with poor mental health. Applying multiple logistic regression, gender (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.15-1.97), education degree (OR = 1.47; 95% CI = 1.30-1.67), frequency of daily messages (OR = 1.18; 95% CI = 1.07-1.31), being awakened at night for MP use (OR = 1.83; 95% CI = 1.54-2.18), and MP overuse (OR = 3.21; 95% CI = 1.20-8.58) were found in significant associations with poor mental health. Conclusions Planning gender-based health education programs on proper use of MP for students and their parents is suggested to school healthcare providers. The parents should be educated on the proper ways of dealing with their adolescents while using MP at home.

Background: According to WHO, brucellosis is one of the 7 neglected zoonotic diseases and a major challenging issue for public health. Objectives: The aim of this study was to investigate the psychometric properties of the PRECEDE model-based scales for brucellosis prevention (PRECEDE-MSBP). Methods: In this cross-sectional study conducted in 2015, stratified random sampling was employed to recruit 420 rural residents in Ahar county, Iran. A comprehensive literature review was conducted to develop the initial draft of PRECEDE-MSBP. Face, content, and construct validity and reliability were determined. Results: Applying Exploratory Factor Analysis, the optimal solution including 37 items and 7 factors for Educational and Ecological diagnosis, 5 items and 2 factors for Environmental diagnosis, and 9 items and 3 factors for Behavioral diagnosis were emerged, which accounted for 60.43%, 56.51%, and 53.75% of the total variances, respectively. Appropriate validity, reliability, functionality, and simplicity were demonstrated for PRECEDE-MSBP. Conclusions: Researchers and health care providers interested in brucellosis prevention may apply the PRECEDE-MSBP inventory as a suitable instrument to provide the best information while conducting brucellosis prevention need assessments for their interventional efforts. However, further studies applying this instrument are needed in order to compare the different aspects of PRECEDE-MSBP in different communities.

Background: There are no studies on the trend of gastric cancer (GC) incidence in Kurdistan, a province in the west of Iran. We aimed to estimate the trend, age-standardized incidence rate (ASR), and annual percentage change (APC) of GC in this province during 2001–2014. Materials and Methods: The data of newly diagnosed GC patients were obtained from the regional Cancer Registering Database. The ASRs were calculated per 100,000 population during 2001–2014. Direct standardization and 95% confidence intervals (CI) were calculated by an efficient method. The temporary changes in ASRs were determined based on the APC by the joinpoint regression model. Results: Overall, 2225 newly diagnosed GC patients were identified. The ASRs ranged from 13.5 (95% CI: 10.4–17.3) to 29.0 (95% CI: 24.5–34.0). The highest ASRs were related to the men and women lived in Divandareh as 32.26 and 13.66, respectively. The respective APC value of GC incidence in women demonstrated a nonsignificant increase during 2001–2008 and a nonsignificant decrease during 2008–2014 (P = 0.1). Accordingly, the incidence of GC in men increased during 2001–2004 (P = 0.1) and decreased during 2004–2014 (P = 0.001). Conclusion: The incidence of GC showed nonsignificant and significant decreasing trends in women and men in Kurdistan province, respectively. Despite such decreasing trends, the Kurdistan province is still considered as one of the regions with high incidence of GC in Iran. Therefore, it is necessary to implement screening programs in the province to early diagnose GC.

Introduction Traffic and transportation are important determinants in the spectrum of social, economic and environmental factors outside the health sector which has been known to impact public health. The aim of this study was to explore the perceptions of inhabitants and key informants on the impacts of Sanandaj urban traffic jam (UTJ) on family mental health. Methods It was a qualitative study with semi-structured interviews. Applying purposeful sampling, 30 residents/key informants were invited to participate in the study. Data collection was conducted through 4 Focus Group Discussions (FGDs) with 22 residents and in-depth interviews with 8 key informants. To conduct analysis, interpretative thematic analysis was used. MAXQDA10 was applied for the purpose of data management. Results Based on the participants’ perceptions, Sanandaj urban traffic jam had a wide range of impacts on family mental health, and, consequently, “life quality is diminished”. Depending on the issue participants were reffering to, the health impacts were grouped into two main themes: (i) impacts on families in general population, including “trigerring stress and anxiety”, “reducing tolerance threshold”, “trigerring family quarrel/squabble”, “regreting at traffic accidents” and “annoying about and bored with air/noise pollution”; and (ii) impacts on the families of inner-city drivers, including “lack of family cohesion”, “dissatisfaction within family”, “disturbance in family progression”, and “frowning in concentration”. Conclusion The UTJ in Sanandaj has led to diminished mental health and weakend life quality among families of both general population and inner-city drivers. Our results may help public health practitioners and urban traffic and transportation (UTT) stakeholders in finding a better understanding on potential health impacts of UTJs. In developing countries, like Iran, there is great need to health-oriented policymaking while developing UTT plans and projects.

AIM: The aim of this study was to assess the psychometric properties of Condom Use and its Cognitive Determinants Questionnaire (CUCDQ) among married women in Tabriz, Iran.MATERIALS AND METHODS: In this cross-sectional study, applying multistage cluster sampling 388 married women were recruited to participate in the study. A comprehensive literature review was conducted to develop CUCDQ. Face, content, and construct validity, as well as reliability, were investigated.RESULTS: Principal component factor analysis with varimax rotation demonstrated a six factors structure as the best solution [Bartlett’s Test of Sphericity (Approx. Chi-Square= 4193.07, df= 780, p