Iranian Journal of

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Background and objectives: Malnutrition is a major health problem in Iran. A nationwide survey (ANIS) in 1998 revealed that over 800 000 children in this country were suffering from moderate or severe malnutrition. The southern province of Hormozgan is one of the most severely affected regions, so there is a need to determine disease associations and risk factors for child malnutrition in this area.
Methods: In this case-control study, we selected 1725 children aged 6 to 30 months from both rural and urban areas of Hormozgan. Data for the study were obtained by filling questionnaires and studying family health files. Using the weight-for-age Z score (WAZ) as outcome measure, we examined the effects of 21 different variables, including putative risk factors, confounders, and background variables.
Results: Father's job (p<0.004), parents' education, interval between pregnancies, urban versus rural residence (p<0.001), family size (p<0.03), and misconceptions regarding the growth chart were recognized as risk factors for malnutrition. Moreover, the mean age of the cases was 2.3 years higher than that of the controls (p<0.001). Complete vaccination (p<0.018) and attending day care centers (p<0.005) emerged as protective factors.
Conclusions: Poverty (low-income jobs, rural residence, large family size, etc) is an important factor causing malnutrition among children in Hormozgan. In contrast, immunization and mother's knowledge of the child's growth chart are major protective factors. Therefore, the health system must continue its support for the current immunization program. It should also try to improve the quality of its health education programs targeted at mothers attending state-run health and medical clinics

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Background & Objectives: The DPT vaccine used in Iran is manufactured by the Razi Institute. So far, there have been no studies to determine the incidence and severity of adverse reactions to this vaccine. It was this lack of reliable information, plus concern for the unfavorable effects of such reactions on compliance with the vaccination schedule, that prompted the current study on DPT side effects.
Methods: In this cohort study, 1910 children aged 0 to 6 were divided into different groups (cohorts) on the basis of factors such as injection site and then monitored for the appearance of adverse effects. Data for this study were gathered through questionnaires filled by telephone or house-to-house interviews. We interviewed parents of children attending the 46 urban health clinics in Kermanshah. These interviews produced the data needed to fill the first part of the study questionnaire. The investigators then gave each parent an "information sheet" containing the data necessary for the second part of the questionnaire. The interviewee was asked to record on this sheet any adverse effects occurring over the following 48 hours. At the end of this period, the parent was contacted via telephone to fill the second part of the questionnaire. Data thus gathered were analyzed using the Statistical Package for Social Sciences (SPSS), version 11.5.
Results: In 1910 DTP immunizations given to children 0 to 6 years of age, followed for the development of adverse events occurring within 48 hours after immunization, the cumulative incidence rates were as follows: Swelling, 40.66% (38.43-42.89%) Redness, 43.08% (40.84-45.32%) Pain, 67.32% (65.20-69.40%) Fever (>38° C) 54.14% (51.89-56.40%) Fever (>40.5° C) 1.11% (0.64-1.59%) Drowsiness, 33.35% (31.21-35.48%) Persistent crying, 13.35% (11.81-14.88%) Local reactions, 75.79% (73.86-77.73%) and Systemic Reactions, 69.84% (67.76-71.97%). Only one child developed convulsion following immunization.
Conclusions: Varying reaction rates in different studies, such as high rate of pain and persistent crying in this study, may reflect the different preparations that were used or differenced in the methods for vaccine evaluation. Moreover, because of the severity of systemic reactions, DTP vaccine should be administered in the thigh region

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Background & Objectives: Early detection can improve the outcome of visual impairment in children, and one method for early detection could be screening of pre-school children with visual acuity tests. The aim of this study was to determine the validity of these tests when they are used on children entering grade school.
Methods: For this cross-sectional study we drew 39 random clusters, comprising a total of 5721 school children. We then used 2158 student files to extract data on tests of vision performed by school health officers and compared these data with data generated by optometrists. Measurement of uncorrected visual acuity was done with the E Chart by both teachers and optometrists.
Results: The sensitivity and specificity of teacher-administered tests were 25.0% and 96.6%, yielding positive and negative predictive values of 13.4% and 98.4%, respectively. Sensitivity and specificity rates did not show any significant difference between male and female populations (P=0.356, P=0.258), but the difference between specificity in urban and rural areas was significant (P<0.001).
Conclusions: Screening tests for visual impairment did not attain the desired level of sensitivity or specificity for case detection in school children. More accurate procedures are required to minimize the number of false negative results.

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Background & Objectives: To determine the risk factors for acute diarrhea disease in children.
Methods: This study involved 220 cases and 220 controls in Dr. Sheykh Hospital, a specialzed pediatric hospital in Mashhad. Cases were children seen in the emergency department with loose watery feces, diagnosed as acute diarrhea by the physician. The controls were selected from the same setting as the cases and included children with traumas, burns, acute respiratory complaints and other diseases.
Results: In univariate logistic regression, variables having a significant relationship with acute diarrhea disease included formula feeding in the first 6 months of life, antibiotic therapy over the preceding 15 days, mother's employment, mother's acquaintance with oral rehydration solutions, place of residence, and disruption in the water supply in the week before illness. We performed multiple logistic regression to examine the role of these variables as independent risk factors for acute diarrhea. Use of formulas before 6 months of age (OR=3.21, 95%CI: 1.77-5.79), and type of residence (OR=1.83, 95%CI: 1.24-2.71), and mother's employment (OR=2.48, 95%CI: 1.2-5.06) were the factors that remained in the multiple logistic model and had a significant relationship with the disease.
Conclusions: This study identified some environmental risk factors for acute diarrhea disease. High-risk groups and mothers of children under 5 years of age should be aware of these risk factors in order to prevent disease in their children. Prevention of acute diarrhea in children can significantly reduce the current burden on the health system.

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Background & Objectives: Recent evidence suggests that long-term exposure to air pollution contributes to progression of atherosclerosis and the risk of cardiac morbidity and mortality short-term exposure may also lead to thrombosis and acute ischemic events. To evaluate the relation between the levels of major air pollutants (CO and PM10) and hospital admission for acute coronary syndrome (ACS) in Tehran, we performed a case-crossover design and checked whether individual characteristics act as effect modifiers.
Methods: We selected 250 Tehran residents who had been hospitalized with an acute coronary syndrome from 4th of April to 10th of June, 2007. The following individual data were gathered: sex, age, date of hospitalization, and coexisting illnesses (hypertension, diabetes). Daily air pollution data were taken from the Air Quality Control Center. Temperature, humidity, stress, physical activity and weekend days were treated as confounding variables, and a conditional logistic regression model was used for statistical analysis.
Results: We found a positive association between ACS and average 24-hour CO levels. The OR for each unit increase of the average 24-hour CO was 1.18 (95%CI: 1.03-1.34). The relation between ACS and 24-hour average PM10 did not reach statistical significance (OR for average 24-hour PM10 was 1.005, 95%CI: 0.99-1.01). The association between ACS and 24-hour average CO tended to be stronger in women (OR=1.68 for each unit increase, 95%CI: 1.25-2.26). The relation between 24-hour average PM10 and ACS did not change across the layers of the effect modifiers.
Conclusions: The results suggest that an increase in average 24-hour CO levels will augment the risk of ACS, and the effect is stronger in females. On the other hand, we were unable to document an association between ACS and average 24-hour PM10 levels.

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Background & Objectives: Malnutrition is widely regarded as one of the factors affecting quality of life. The adverse effects of malnutrition have been documented in various age groups. School problems, learning difficulties, humiliation and teasing from peers are some of the most common complications of obesity and excessive thinness. The goal of this study was to determine the BMI and some of the factors affecting it in the students of Dezfool.
Methods: In a cross-sectional study and using random cluster sampling, 5726 students from 39 clusters were selected and anthropometric measurements were performed in the schools and under standard conditions. Cases of obesity and thinness were identified using BMI percentiles for age and sex (NCHS). A Body Mass Index above the 95th and below the 5th percentile was defined as obesity and thinness respectively.
Results: This study involved the participation of 5508 students (96.2%). The prevalence of thinness was 33% (1716) with a 95% confidence interval of 27.3%-38.8%. The prevalence of obesity was 2.6% (157) with a 95% confidence interval of 1.7%-3.4%. There was no significant difference between the prevalence of obesity or thinness between the two sexes (P>0.05). The prevalence of obesity and thinness significantly increased and decreased respectively with aging (P<0.05).
Conclusions: Malnutrition among the students in Dezfool predominantly takes the form of thinness, while obesity is not a serious problem in this population overall, these findings indicate poor nutritional status. High-risk groups have been identified and they must become the target of interventions by the Health and Education Ministries.

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Background & Objectives: Exclusive breast-feeding during the first 6 months of life is the best type of nutrition for the infants in terms of fulfilling their its physical and emotional needs. The incidence of many kinds of infection decreases with breast-feeding. The aim of this study was to determine the prevalence of exclusive breast-feeding infants aged less than 6 months in Mash'had and to look at some factors that affect breastfeeding.
Methods: This population-based survey used a stratified cluster sampling method to draw 30 clusters containing a total of 1450 infants aged 7-12 months. Data collection was performed using both questionnaires and interviews with mothers. Exclusive breast-feeding was defined as nursing through the first 6 months of life without any other food intake except drugs and vitamin supplements.
Results: The study achieved a response rate of 87.4% in mothers 51.2% of the infants were male and the remaining 48.8% (618) were female. The overall prevalence of exclusive breast-feeding during the first 6 months was 56.4% with (95% CI: 49.7%-63.2%). The figure was 57.2% (95% CI: 49.9%-64.4%) for boys and 55.7% (95% CI: 48.7%-62.6%) for girls. In this survey, 91.7% of the infants (95% CI: 88.7%–94.7%) had received breast-feeding immediately after birth. In multiple logistic regression analysis, the mother's age, her awareness of the adequacy of her milk, and advice from others to use formulas were the factors that had a significant relationship with breast-feeding in the first 6 months.
Conclusions: Almost 43% of infants had received alternative nutrition such as family food or formula. Considering the important effect of breast-feeding, provision of educational programs by the Health Ministry to raise the mothers' awareness of breast feeding can be a priority in children's health.

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Background and Objectives: Each year almost 400,000 people are diagnosed with oesophageal cancer worldwide. Wide variation in incidence has been reported both between countries and in different ethnic groups and populations within a country. The area with the highest reported incidence for oesophageal cancer is the so-called Asian ‘oesophageal cancer belt’, which stretches from eastern Turkey through north-eastern Iran, northern Afghanistan and southern Russia to northern China. In the high risk area of Gonbad in Iran, world age-standardised rates are more than 200 per 100,000 and the male/female ratio is reported as 0.8:1.0.This study aimed to assess the risk factors and demographic factors influencing survival of patients with esophageal cancer in north of Iran using weibull and log-logistic regression models.
 Methods: Demographic and clinical data of 359 patients with confirmed diagnosis of esophageal cancer from Babol Cancer registry utilized for our model. parametric and weibull models were employed to analyze the data. The Akaike information criterion (AIC) was also considered as a criterion to select the best model(s). All p values as 0.05 were considered as statistically significant.
Results: The sample study consisted of 62.7% men and 37.3% women. Estimated survival rates in 1, 3, and 5 years following diagnosis were 23%, 15%, and 13% respectively. According to AIC criterion, the hazard rate of non-monotonic and rejection proportional hazards assumption (p<0.05), log-logistic model was more efficient than weibull model. Family history of having cancer in patients showed a significant difference in both models.
Conclusion: It is concluded that early detection of people with a family history of cancer can be effective as an important factor in reducing the risk of death in patients with esophageal cancer.

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Background & Objectives: To assess vision related quality of life and determinants in patients afflicted with chronic eye disease.
Methods: In this analytical cross-sectional study, consecutive sampling was performed at Noor Eye Hospital between 2008 and 2009. A valid and standard 39-item visual functioning questionnaire (National Eye Institute visual functioning questionnaire, NEI-VFQ 39) was completed. The questionnaire consists of 11 domains related to vision and one domain about general health. The total score range from zero (0) to 100, where a higher score reflects better vision related quality of life. The independent t-test, pearson correlation coefficient as well as simple and multiple linear regression models were employed for statistical analysis.
Results: The mean overall score in patient and control groups were 54.5 [95% confidence interval (CI) 57.3 - 71.8] and 96.0 [95% CI: 88.2-103.9], respectively. Patients with cataracts had the highest score (64.6 95%CI: 57.3 - 71.8) and those with visual acuity of 20/70 or worse showed lowest scores (41.9 95%CI: 30.7 - 53.1). Age (P=0.006) and education level (0.001) were associated with quality of life score.
Conclusion: Based on our study findings, it could be concluded that low vision patients with a visual acuity of 20/70 or worse hardly received half of the total scores. Diabetic retinopathy, age related macular degeneration, glaucoma, and cataract stand in ascending rank order. The relatively lower scores as compared to results from other countries warrant further research into the causes of such differences.

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Background & Objectives: Sleep quality is an important factor in student life and affects in their learning process. Sleep problems are related to increased health concerns, irritability, depression, fatigue, attention and concentration difficulties, along with poor academic performance. The aim of this paper is to conduct a survey based on a questionnaire that would characterize the quality of sleep in students living in dormitories of Tehran University of Medical Sciences (TUMS).
Methods: We conducted a cross-sectional study using the stratified random sampling approach on 277 students residing in dormitories in Tehran. A demographic questionnaire and Pittsburgh Sleep Quality Index (PSQI) were used for data collection.
Results: Mean (CI) of PSQI in students was 8.57 (8.10- 9.04). Using the cut-off score of 6 for the PSQI global score, 73.3% (68.1%-78.5%) of students were described as poor sleeper. Female students had a worse quality of sleep compared to male. The mean duration of sleep in students was 5:15´± 105´ (hours). This was significantly higher in male students than female students. There were no significant relationships between demographic variables such as age, academic level, marital status and family income with and quality of sleep.
Conclusion: This study showed that poor sleep quality is prevalent among students living in dormitories of TUMS. Therefore it is necessary to provide effective educational interventions for this group in order to improve the quality of sleep.

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  Sensitive questions about people’s behaviors are often discussed in studies in the fields of human, social, and medical sciences. Obtaining valid answers to these kinds of questions is one of the main challenges in the mentioned studies. The most important risk factors for the validity of these studies are response bias and non-response bias, which occur because of concerns about divulging personal information. Therefore, researchers are to find solutions other than direct questioning to increase the validity of obtained results through reducing these biases.

  In this review article, we discuss the Warner Model, the Unrelated Question Model, the Forced Response Model, the Moors Model, and the Mangat Model that are subsets of the Randomized Response Technique, and also the Triangular Model and Crosswise Model that are subsets of the Non-Randomized Response Technique. The models are all used in answering sensitive binomial questions.