---

Background & Aim: Pain is one of the important complication of chronic diseases such as cancer. Purpose of this study is to investigation of two non-pharmacological methods, progressive muscle relaxation and music, on pain relief in patients suffer from cancer.

Methods & Materials: This research is a intervention clinical trial which was done in a hospital affiliated to Tehran University of Medical Sciences. In this study, 100 cancerous patients that have inclusion criteria were selected by simple sampling method. The participants into two groups allocated, 50 patients in progressive muscle relaxation, and 50 patients in music group. Data collection tools were questionnaire, pain level recorded sheet, taps with headphone (is produced by Sony company) and music box including light music consist of classical, mild and Iranian traditional music. Questionnaire was designed in two parts, demographically characteristics and disease characteristics. Data were collected by interview and patient self report. After adequate education to two groups, asked them to perform that method 30minet per day until 3 days. Then, pain level, at previous 24 hours until 3 days were assessed and recorded in related sheet. Analysis of data were analyzed by SPSS software, inferential and descriptive statistics such as Mann Whitney, chi Square, Fisher’s exact test, and Friedman.

Results: The finding of research showed in both relaxation and music groups there were significant differences in pain level before and after intervention (p<.001). Also there were significant differences between two groups in pain level (p=0.016). It means that pain relief in relaxation group was more significant.

Conclusion: According to the findings of this research, although both progressive muscle relaxation and music are effective and decreasing of pain level but progressive muscle relaxation is more effective than music.

---

Background & Objective: According to Iranian national statistics, every year 400 to 500 thousand unwanted pregnancies occur in Iran. The emergency contraceptive methods are easily accessible and affordable for the women of this region. Regarding the important role of health care providers in representing these methods, this study is to determine the knowledge and attitudes of these staff toward required contraceptive methods.

Methods & Materials: In this semi-experimental study, 216 health personnel working in south of Tehran health centers were randomly selected. Two 30- minute educational sessions were presented to the staff. The methods of education included face to face, and group discussion. At the end of each session a pamphlet was given to the staff. Data were gathered using a questionnaire before and 2-6 weeks after the education. Statistical analysis was carried out using statistical package for social sciences (SPSS).

Results: The results showed that there were significant statistical differences between the knowledge and attitudes (P<0.001) of personnel about the emergency contraceptive methods before and after education. There was no significant relationship between demographic characteristics and attitudes of personnel. There was a significant relationship between sex (P<0.001), educational level (P<0.003), educational major (P<0.001), with knowledge after intervention.

Conclusion: Knowledge and attitudes toward emergency contraceptive methods increased significantly after education. This finding reveals the importance of continuous education for health care staff such as midwives and physicians to facilitate successful guidance of their patients towards effective family planning.

---

Background & Aim: Family-centered care, which has become the cornerstone for pediatric nursing practice, supports the integrity of child and family health. It brings families a unique care and improves child and family health. Families are recognized as an essential part of a specialized child care during illness. They are expected to be skilful in child care both in and out of health care facilities. This study was carried out to determine health caregivers&apos attitude toward parent participation in the care of their hospitalized children at Madani pediatric hospital- Khoramabad in 2004.

Methods & Materials: This is a descriptive-analytical study. One hundred and sixty nine caregivers were selected through convenient sampling method. Data were gathered using a questionnaire including demographic and parents&apos attitude questions. The questionnaire had 36-item. The data were analyzed via SPSS computer software and using descriptive and analytical methods.

Results: Results indicated that the average of participants&apos attitude score was 92.28±12.55. Most of subjects had neutral attitudes toward parents&apos participation in their children&aposs care. Positive attitude were significantly related with marital status (P<0.04), having children (P<0.04) and being a nursing student (in comparison with medical students) (P=0.04).

Conclusion: The caregivers&apos attitudes toward parents&apos participation in the care of their hospitalized children were neutral. The students&apos and staffs&apos attitudes should be modified by taking part in continuous training programs.

---

Background & Objective: Osteoporosis is a metabolic disease which results from gradual destruction of bone mass. Prevention of osteoporosis should be started from childhood by getting adequate calcium and doing weight-bearing exercises. Participating of mothers in health education interventions is likely to promote longer-lasting health behaviors in their daughters. The aim of this study was to investigate the effect of simultaneous education of mothers and daughters on osteoporosis preventive behavior among high school female students.

Methods & Materials: In this interventional study, 400 female students were randomly selected via a two-phased sampling method. At first stage, four schools were selected randomly. At the second stage, 400 students were divided randomly into two groups. Their osteoporosis preventive behaviors were measured using a two-sectioned questionnaire: demographic section, and osteoporosis preventive behaviors assessment section. The first group participated in the educational programs with their mothers and the other group participated without their mothers. The educational program had two sessions, each one lasted 45 minutes. The second stage of the study was performed three months later. Data analysis was carried out using t-test and chi squared test.

Results: Results showed that in both groups, osteoporosis preventive behaviors scores increased significantly after intervention. It was higher in case group (P<0.001). Eating behavior was significantly different in two groups (P=0.003).

Conclusion: Results showed that simultaneous educational program for mothers and daughters promotes eating behavior in the girls.

---

Background & Objective: Osteoporosis is a serious public health concern known to have several etiologic factors. This study compared lifestyles among postmenopausal women with normal and abnormal bone marrow densitometries (BMD).

Methods & Materials: In this case-control study, 81 postmenopausal women (33 cases with abnormal BMD and 48 control individuals with normal BMD) were selected using simple random sampling from Osteodensitometry center of Shariati hospital in Tehran. The BMD at lumbar spine and femoral neck had been measured with DXA. The Lifestyle was assessed using a questionnaire containing items about taking calcium, vitamin D, hormones, and Alendronat, doing physical activity, consuming tea and cola, and smoking. Reproductive characteristics were also collected via a questionnaire. Data were analyzed using χ2 test and independent sample t-test. Crude and adjusted odds ratios and relevant 95% confidence intervals were calculated through logistic regression, using SPSS v.13.

Results: The results showed significant differences between two groups in weight (P>0.001), BMI (P=0.022), number of pregnancies (P=0.002), number of children (P=0.004), duration of lactation (P=0.0002), dietary calcium intake (P≤0.001), and period of calcium supplement intake (P=0.002). The average of acquired scores of lifestyle factors in the case group was significantly lower than the control group (P=0.037). Inappropriate lifestyle had increased risk of the disease (OR=3.36, 95%, CI: 1.10-10.26). Meanwhile in the multivariate analysis, only insufficient intake of calcium was found to be a risk factor (P=0.002) for osteoporosis.

Conclusion: In conclusion, the results of this study showed positive effect of calcium intake on bone mineral density.

---

Background & Aim: Home care visits have unique advantages in many social problems and health complications such as psychologic complications and adverse birth outcomes. The aim of this study was to identify the effect of postpartum care at home on quality of life among low risk mothers.

Methods & Materials: This interventional study was conducted in Akbarabad health center of Tehran University of Medical Sciences in 2010. A total of 200 mothers were randomly allocated in two intervention and control groups. Mothers in the control group received two post partum visits in health care center and the intervention group received care at home. Data were collected through a questionnaire including demographic characteristics and the mothers&apos quality of life items along with a growth and development monitoring chart for newborns. For analyzing data, Mann-Withney U, Wilcoxon and Chi-square tests were used.

Results: Most of the mothers aged 20-29 years old. The number of visits were statistically different between the two groups (P=0.00, P=0.01). Dimensions of quality of life in the two groups were not statistically different: (Physical dimension: P=0.052), (Emotional dimension: P=0.775), (Public health dimension: P=0.068), (Social performance dimension: P=0.780) and (Total score: P=0.213).

Conclusion: the results of our study did not show no positive improvements in home postpartum care in comparison with the health care centers care. More studies are recommended.

---

Background & Aim: Postoperative nausea is a common problem after general anesthesia, especially in ambulatory surgery. In ocular surgeries including strabismus surgery, intraocular pressure increase may lead to eye damage. Drug therapy has various side effects. The purpose of this study was to evaluate acupressure on nausea in patients undergoing strabismus surgery.

Methods & Materials: In this double-blinded clinical trial, 60 patients undergoing strabismus surgery were allocated into intervention and control groups. In the intervention group, a sea-band was placed on the P6 point of patients&apos wrists 30 minutes before induction of anesthesia. In the control group, the sea-band was placed in the opposite position of the patients&apos wrists. Data were collected during six hours after surgery in the recovery room. Data were analyzed using Chi square, t-test, and Mann-Whitney tests.

Results: There were no differences in demographic and surgical characteristics between the two groups at baseline. The intensity of nausea in the recovery room (P=0.002) and six hours after surgery (P<0.001) were significantly less in the intervention group than the control group.

Conclusion: Based on the findings of this study, acupressure decreases post operative nausea. Acupressure is a simple, noninvasive and cost- effective intervention which can be applied by nurses to prevent post operative nausea.

---

Background & Aim: Rapid changes experienced after child birth expose mothers to unpleasant experiences such as disturbances in sleep pattern. These experiences threaten health of mothers and infants. Some studies have shown that exercise can be an effective and non-pharmacologic method in improving sleep quality. The purpose of this study was to examine the effect of exercise on sleep quality among postpartum mothers.

Methods & Materials: This was a randomized clinical trial. Eighty primiparous women aged 18-35 years were recruited from health centers in Rafsanjan in 2009. The inclusion criteria were singleton pregnancy, lack of any acute and chronic physical and mental illnesses, having healthy and term babies, and having vaginal deliveries. Participants were randomly allocated to the intervention (n=40) and control (n=40) groups. Women in the intervention group received five 30-minutes sessions of Pilates weekly for eight weeks. The PSQI instrument was used to measure the related variables at baseline, forth and eighth weeks after the deliveries. Data were analyzed using the repeated measures ANOVA.

Results: Significant improvement was seen in the intervention group within eight weeks follow-up the interaction within time and group was significant (P=0.02). Comparison of mean sleep quality between the two groups has shown that the intervention was effective (P<0.001).

Conclusion: The Pilates exercise was effective in improving quality of sleep in postpartum period.

---

  Background & Aim: Premature infants are the most admitted group to NICUs. Stabilization of cardio pulmonary parameters is a main goal in NICUs. Mechanical ventilation and endothracheal suctioning are the most common and effective procedures to stabilize cardio pulmonary parameters. The aim of present study was to compare the effects of two endothracheal suctioning methods (open and closed) on physiological stability in premature infants under mechanical ventilation .

  Methods & Materials: In this clinical trial, 90 preterm infants (GA: 27-34 weeks) hospitalized in the NICUs of Alzahra and Taleghani hospitals were selected and randomly assigned to two groups. In one group, infants were suctioned using open suctioning method and in the other group, infants were suctioned using closed suctioning method. The physiologic parameters (O2 sat, HR, mean BP variation) and stability (recovery time of HR, BP) were compared between the groups. Data were analyzed using descriptive and inferential statistical methods such as x², independent t-test and mixed model in the SPSS-21 . 

  Results: There was significant statistical difference between the two groups on mean BP (P=0.016). Recovery time of the BP and HR was shorter in the closed suctioning group. Physiologic stability was better in the closed suctioning group (P<0.05) .

  Conclusion: Variation of the mean BP and recovery time was more in the open suctioning group compared with the closed suctioning group. Considering better physiologic effects of closed suctioning, it is recommended to assess the combined effect of closed suctioning with weight on physiologic parameters of premature infants .

  

---

  Background & Aim: Technology advancement has increased the survival rates of premature infants. Preterm newborns frequently experience oral feeding difficulties due to lack of coordination in sucking, swallowing and respiration. This may negatively affect attainment of independent oral feeding skill and leads to longer hospital stays. This study aimed to examine the effects of non-nutritive sucking vs. oral massage therapy on attainment of independent oral feeding and length of stay in the NICU .

  Methods & Materials: This clinical trial was conducted on 72 premature infants (28-32 week gestational age) hospitalized in the NICU of Alzahra Hospital in Tabriz in 2013. The eligible infants were randomly allocated to one of the three groups: oral massage, non-nutritive sucking, and control groups. Newborn infants in the oral massage group received pre- and intraoral massage therapy (before gavage) for at least 10 days. The newborn infants in the non-nutritive sucking group were encouraged to suck on a finger of mother or the researcher before gavage. The control group received usual care. The time to attain independent oral feeding and length of stay in the hospital were compared in the groups . 

  Results: Compared to the control group, the time to oral intake was significantly shorter in both experimental groups (P<0.001). There was no significant difference between the duration to achieve independent oral feeding status among the groups (P=0.915). Length of stay in the hospital did not significantly differ among the three study groups (P=0.342) .

  Conclusion: Findings indicated that both oral massage and non-nutritive sucking therapy groups could accelerate attainment of independent oral feeding in premature newborn infants .

  

---

  Background & Aim: Premenopausal syndrome affects daily activities of many women. This study aimed to compare the effects of Vitexagnus and Flaxseed on premenstrual symptoms in women referred to health centers of Tabriz from October 2013 to September 2014 .

  Methods & Materials: This randomized controlled trial was conducted among 159 women suffered from premenstrual syndrome (PMS). The PMS was measured using the premenstrual assessment form (PAF) . The participants were allocated into three groups (n=53 per group) using block randomization. The group I received 25 grams/d Flaxseed powder and placebo of the Vitexagnus group II received 3.2-4.8 mg/d Vitexagnus tablets and placebo of the Flaxseed and the control group received both placeboes. The PAF was completed at baseline and 1 and 2 month after the intervention. Data were analyzed using the general linear model . 

  Results: The PMS improved significantly in both intervention groups during the first and the second month after the intervention. In the Vitexagnus and Flaxseed groups, the mean total PMS score were significantly lower than that in the control group at the first months after the intervention (adjusted mean difference: -3.3 (95% CI: -4.0 to -2.1) -4.3 (-5.5 to -3.0), respectively). In the second month after the intervention, the mean total PMS score was -5.8 (-7.0 to -4.7) in the Vitexagnus group and -6.6 (-8.1 to -5.7) in the Flaxseed group. There was no significant difference between the Vitexagnus and Flaxseed groups in terms of the PMS score .

  Conclusion: According to the results of this study, Flaxseed and Vitexagnus are effective in improving PMS .

  

---

Background & Aim: Mother-Child bonding is an emotional aspect of relationship between mother and baby that affects children's psychological development. This study was performed to determine the predictors of mother-child bonding.

Methods & Materials: This cross-sectional study was performed on 270 mothers 8 to 10 weeks postpartum referred to eighteen health centers of Tabriz, 2014-2015. Data were collected using the obstetric and socio-demographic characteristics questionnaire, the Postpartum Bonding Questionnaire, the Edinburgh Postnatal Depression Scale and the Spielberger State-Trait Anxiety Inventory. The statistical tests including Pearson correlation, Independent t, one-way ANOVA and multivariate linear regression were used for data analysis through SPSS v.21. The significance level was considered as P<0.05.

Results: The mean (SD) of mother-child bonding score was 46.2±8.4, with achievable scores range from 0 to 125. 85.2% of mothers had a mother-child bonding disorder. The most frequent disorder pertained to the dimension of impaired mother-child bonding and the least frequent disorder was anxiety about child care. Variables of depression, state anxiety and unwanted pregnancy were among the predictors of mother-child bonding.

Conclusion: The study shows that anxiety, depression, and unwanted pregnancy are the determinants affecting mother-child bonding. Thus, the screening of mothers for the early identification and treatment of anxiety and depression, and also the reduction of unwanted pregnancy rate using purposeful family planning counseling can improve the mother-child bonding, resulting in improved children's growth and development.

---

Background & Aim: Violence against women is a serious social problem affecting public health. Given the relatively high prevalence of domestic violence and the need for screening, a simple tool for its correct diagnosis in a short time seems to be necessary. This study aimed to compare the diagnostic values of the HITS (Hurts, Insults, Threaten, and Screams) tool and CTS2 (Revised Conflict Tactics Scales) in domestic violence screening.

Methods & Materials: This cross-sectional study was conducted on 279 married women referred to health centers in Tabriz in 2014. Data were collected using the socio-demographic questionnaire, HITS and CTS2. Kappa index was used to assess agreement between instruments.

Results: Results showed that HITS tool had relatively good sensitivity (75.7%) and high specificity (93.5%). Positive predictive value and negative predictive value were 96.8% and 59.5% respectively. There was a moderate agreement between instruments (Kappa=0.6).

Conclusion: Given the simplicity of HITS and the possibility to complete it in a short time, this questionnaire can be recommended to identify people experiencing domestic violence at the broad level. In addition, the development of this tool is recommended in future studies.

---

Background & Aim: Although compassionate care is recognized as a core component of nursing care, there is not still a precise definition about this complex and challenging concept. This study aimed to analyze the concept of compassionate care in nursing using a hybrid model.

Methods & Materials: A three-phase hybrid model (theoretical, field work, and final analysis) was used in this study. In the theoretical phase, the concept of compassionate care was searched in main databases from 2000 to 2016. In the field work phase, in-depth, face to face interviews were done with 11 nurses. The content analysis method was used to analyze the data. Final analysis was done in the last phase.

Results: The results of the final analysis showed that compassionate care is a process in which nurses interactively communicate with patients, try to explore patients’ concerns by putting themselves in their positions and understanding their situations, and do their utmost to eliminate these concerns.

Conclusion: According to this concept analysis, the constructive interaction between nurse and patient is one of the most important features of compassionate care that has not been mentioned in previous definitions. Also in this study, the nurses emphasized that they did their best to resolve the patients’ concerns. Therefore, the current study could be the basis for future studies in the area of compassionate care.

---

Background & Aim: Improving and modifying lifestyle is necessary for health maintenance and promotion. Modification of lifestyle can have an important role in the long-term health of women with Poly Cystic Ovarian Syndrome (PCOS). Therefore, this study aimed to determine the status of health promoting lifestyle and its socio-demographic predictors in women with PCOS.

Methods & Materials: This analytical descriptive cross-sectional study was conducted on 174 women with PCOS referred to gynecology and infertility clinics in Urmia-Iran, in 2015. The data were collected through the socio-demographic and Health Promoting Lifestyle Profile questionnaires. Descriptive statistics, independent t-test, one-way analysis of variance and multivariate linear regression were used to analyze the data through SPSS software version 21.

Results: The mean (standard deviation) of total score of the health promoting lifestyle was 2.2 (0.3) out of 4. The highest mean score was in nutrition subscale [2.9 (0.5)] and the lowest mean score was in the subscale of stress control [1.2 (0.5)]. Based on the multivariate linear regression model, the variables of BMI, spouse’s education level, the first supporter and menstrual bleeding amount were predictors of the health promoting lifestyle in women with PCOS.

Conclusion: Considering that the mean of total score of the health promoting lifestyle and some of its subscales were in the middle of the range of possible scores, it is necessary that besides other therapies, the improvement of health promoting lifestyle in women with PCOS, according to the influencing socio-demographic determinants, be on the agenda of health providers.

---

Background & Aim: Culturally sensitive care is an essential component of professional development process and one of the predictive factors of nurses’ cultural competency. This care is the most important approach to improve the quality of nursing care in culturally diverse groups. The current study aimed to explore the consequences of culturally sensitive care in pediatric nursing.

Methods & Materials: This study is a qualitative study using conventional content analysis. 25 nurses and 9 parents were purposefully selected with maximum variation sampling from the pediatric wards of three referral teaching hospitals in Tabriz and Tehran in 2015-2016. Data were collected through in-depth interviews and field notes and simultaneously analyzed using MAXQDA software version 10.

Results: The consequences of culturally sensitive care in pediatric nursing emerged in two categories: justice-based care (with three subcategories: the lack of cultural bias, culture-based communication and effective participation) and cultural satisfaction (with two subcategories: reduced cultural stress and safe care). Culturally sensitive care prevents misunderstandings and improves nurse-child/parents communication and leads to parents’ honesty to share information and express cultural needs. The expression of cultural needs decreases stress levels in parents and children and results in safe care by reducing intractable traditional treatment.

Conclusion: According to the findings of this study, it is suggested that effective culturally sensitive interventions in pediatric wards should be included in in-service courses and nursing curriculum.

---

Background & Aim: Sedation after coronary artery bypass graft surgery can prevent the side effects of the treatment. The purpose of this study was to determine the effect of controlled sedation based on the Richmond scale on the duration of mechanical ventilation and the changes of blood pressure in patients following coronary artery bypass graft surgery.
Methods & Materials: In a single blind randomized clinical trial (IRCT2017050517693N2) from June to August 2017, a convenience sample of 80 patients after coronary artery bypass graft surgery, hospitalized in the intensive care unit of Heshamat Center, Rasht, were selected and randomly allocated into two groups (each group=40). Sedative drug dose was determined using the Richmond agitation sedation scale in the intervention group and determined routinely (based on hemodynamic changes) in the control group. Pain as a confounding variable was evaluated using CPOT tool. Data were analyzed by descriptive statistics and Chi-square, Mann-Whitney, independent t-test and repeated measures ANOVA using the SPSS software version 22.
Results: The mean age of samples was 59.89±7.53 and 66.7% of them were male. There was a significant difference between two groups in the duration of mechanical ventilation (P<0.04), the changes of patients’ blood pressure (P<0.05), need for a vasopressor drug (P<0.05) until extubation and need for the first administration of sedatives (P<0.001).
Conclusion: Utilizing the Richmond tool can reduce the patient’s dependence on ventilator and changes in arterial pressure. Also, using this tool can prevent unnecessary and early administration of sedative and vasopressor drugs in patients.
 
 

---

Background & Aim: Patient participation is an important component of the patient-centered care approach and part of patients’ rights, with positive outcomes for the health care system. The aim of this study was to explore the nurses' experiences of patient participation in nursing care and its related factors.
Methods & Materials: This qualitative study was carried out with the participation of 18 nurses working in educational hospitals of Tabriz in 2019. The purposeful sampling through semi-structured interviews and focus group sessions was used to collect the data. Data analysis was performed using conventional content analysis. To achieve the accuracy of the data, the Lincoln and Guba criteria were used.
Results: Analysis of the data resulted in four main categories "giving information, decision-making, collaboration and respect". The patient’s participation from the nurses’ perspectives was: an interactive process of decision-making and collaboration between the nurse and the patient with the exchange of information, respect, and permission from the patient. The results also included the prerequisites, domains, outcomes, barriers, and solutions for patient participation in nursing care.
Conclusion: Patient participation today is considered the legal right of the patient and also the gold standard of international health care systems. So nurses, health system policy makers, patients and academic centers can use these results to improve patient participation in the care.
 

---

Background & Aim: The important aspects of maternal postpartum adjustment are readiness in caring for the family, newly-added member and self as well as return to pre-pregnancy functional status. The aim of the study was to determine the predictors of postpartum maternal functioning.
Methods & Materials: This cross-sectional study was conducted on 422 newly delivered mothers attended the healthcare centers of Bonab in 2016 using the cluster random sampling method. Data were collected through a socio-demographic characteristics form, the Edinburgh postpartum depression scale, and the functional status questionnaire. The multivariate linear regression model on the SPSS software version 21 was used to determine the predictors of functional status.
Results: Mean (SD) of the functional status total score was 2.3 (0.24). The maximum and the minimum scores were in the subdomains “infant care” [3.64 (0.32)], and “social activities and society” [1.43 (0.41)], respectively. There was a significant inverse correlation between postpartum depression and total score of functional status, self-care and social activities and society subscales. According to the general linear model, postpartum depression, spouse’s age and job, economic status, mother’s education level and the number of pregnancy were the predictors of mothers’ functional status during postpartum period.
Conclusion: Postpartum depression and some socio-demographic characteristics are among the variables influencing maternal functional status. Therefore, the early diagnosis and treatment of postpartum depression and consideration of the mothers’ socio-demographic characteristics, can improve maternal functional status and result in better maternal postpartum adjustment.
 

---

Background & Aim: Structured description of pediatric medical emergencies requires the assessment and classification of underlying factors. The aim of study was to investigate frequency of predisposing factors for the entry of foreign bodies (FB) in the ear, ingestion and aspiration in children under five years in Tabriz.
Methods & Materials: This is a descriptive, cross-sectional study conducted through convenience sampling (n=245) in the ENT and emergency departments and the clinic of children's hospital in Tabriz, from March 2019 to June 2019. A researcher-made tool including the demographic characteristics form and questionnaire on predisposing factors was used to collect the data. Data was analyzed using the SPSS software version 21 through descriptive statistics.
Results: There were 137 (55.9%) cases of  FB aspiration into the airways (upper and lower), and the highest was related to nose. FB in ear was 19.6% and in stomach was 19.2%. Clinical manifestations were pain (50.2%), no clinical signs (29.4%), and the rest were bleeding with pain, cough, shortness of breath, suffocation, wheezing, nausea, and vomiting. The place of event was at home (in living room) and in the evening and night time. FB types included objects, food stuff/snacks/nuts, beans and fruit cores, and toy pieces, and it is most likely to be seed, toy pieces, nuts, shirt buttons, and rosary beads.
Conclusion: Parental, child-related, and environmental predisposing factors were reported. Therefore, future studies are suggested to evaluate the contribution of each of three factors and to implement necessary educational, notification, and interventional measures.