Iranian Journal of

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Background & Objectives: The summer of 2005 witnessed an outbreak of cholera in Iran due to V. cholera, Inaba serotype. During the outbreak, there were 16 registered cases in Markazi Province. The aim of this study was to determine the risk factors for cholera outbreak in this part of the country.
Methods: This was a case-control study in which cases were matched to controls on age and sex. All of the reported cases were compared with controls from the same neighborhood, with 2 controls selected for each case. We used paired odds ratios and conditional logistic regression to show the effect of each putative risk factor, and p values of < 0.05 were considered as statistically significant. Results: Multivariate results from 16 cases and 32 controls showed significant associations between the cholera outbreak and the following set of factors: eating raw vegetable (OR=9, 95%CI: 2.25-35.98), proper warming of refrigerated food (OR=0.12, 95%CI: 0.015-1.022), inadequate washing of fruits and vegetables (OR=4.29, 95% CI: 0.88-21.06) , and eating non-pasteurized ice creams (OR=4.96, 95%CI: 0.99-24.83).
Conclusions: Although the number of reported cases was small in Markazi Province, the results show that education in personal hygiene is important in the prevention of a cholera outbreak.

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Background & Objectives: Cardiovascular disease is the leading cause of death worldwide and is predicted to retain this position until 2020. The aim of the present study was to map cardiovascular mortality rates in Kerman Province counties during 2004-2005.
Methods: In this descriptive study we collected all mortality data registered in various counties of Kerman Province. We calculated mortality rates and drew maps showing the geographical distribution of the dead cases.
Results: Total cardiovascular mortality was higher in the northern counties. The pattern is the same in males and females
Conclusions: The reasons for higher mortality in the northern regions of the province may include a greater prevalence of major cardiovascular risk factors such as physical inactivity, unhealthy diets, and smoking.

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Background & Objectives: Observational studies are not often reported in detail and clear enough, so that assessment of the strengths and weaknesses of these studies is not straightforward. To improve the reporting of observational studies, a checklist of items called ‘Strengthening the Reporting of Observational Studies in Epidemiology’ (STROBE) was developed by some experts in October 2007. The aim of this study was to assess the quality of reporting of observational studies before STROBE statement.
Methods: We included randomly sixty cohort studies published in six important international journals until October 2007. Then, we used STROBE checklist to assess the strengths and weaknesses of these included studies.
Results: On average, more than 81% (95% CI: 77%-87%) of included studies pointed to 43 items of aim of this study. The most reported (100%) items were "scientific background" and "rationale for the investigation" and the less reported (30%) item was “flow chart”.
Conclusions: Although, the quality of reported cohort studies’ results was acceptable, the type of study, journal and date of publication could influence on the quality of observational studies.

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Background & Objectives: Medical Tourism has been recently paid more attention. Individual practitioners and medical organizations must be able to provide accurate information about this rapidly evolving trend. Since there has been little known about this issue, we decided to assess the knowledge about and attitude towards medical tourism in Rafsanjan, Iran.
Methods: A questionnaire including XXX questions were completed by Rafsanjan Medical University staff. All information was analyzed by SPSS software.
Results: Only 8.3% of individuals sated that they studied some articles about Medical Tourism, and only 14.7% of them had deal with these kinds of patients. The majority of participants (80.7%) hadn’t had any idea about the quality of medical expenses by Medical Tourists. Mainly (68.7%) believed that development of Medical Tourism in Iran would not have any bad social consequences and 62% believed that its development in Iran could improve the knowledge of Iranian doctors. The majority (67.3%) agreed to arrange for inviting tourism to Iran in order to use of Medical Tourists and 54.3 of them believed that development of Medical Tourism could improve treatment of Iranian patients.
Conclusions: The knowledge of participants seems is very low therefore appropriate educational programs should be tailored by responsible organizations in Iran. However medical staff’s attitude towards medical Tourism seems is very positive which indicates having necessary potential for any activity in this regard in future.

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مقدمه و اهداف: در اغلب موارد دانشجویان پرستاری در بالین مورد خشونت فیزیکی و کلامی قرار می‌گیرند. اگر چه در مطالعات قبلی خشونت علیه پرستاران مورد بررسی قرار گرفته است ولی با این حال توجه بسیار کمی به بررسی خشونت نسبت به دانشجویان پرستاری شده است. هدف از این مطالعه تعیین شیوع و ابعاد خشونت محل کار نسبت به دانشجویان پرستاری در محیط بالینی است.
روش کار: در این مطالعه توصیفی، 271 دانشجوی پرستاری با روش سرشماری شرکت کردند. اطلاعات با استفاده از پرسشنامه‌ای که با روش اعتبار محتوا و آزمون و آزمون مجدد مورد پایایی و روایی قرار گرفت، جمع‌آوری گردید.
نتایج: به طور کلی به ترتیب 9/74 % و 38/7% از دانشجویان سابقه خشونت کلامی، فیزیکی را در طی سال گذشته داشتند. اکثر خشونت‌های فیزیکی توسط بیماران صورت گرفته بود در حالی که بیشتر خشونت کلامی توسط همراهان بیمار صورت گرفته بود. به ترتیب بیشترین پاسخ به خشونت کلامی و فیزیکی این واکنش بود که "متقابلاً داد و بیداد کردم" و "به مربی یا مافوق خود گزارش دادم". از دیدگاه دانشجویان پرستاری شایع‌ترین عامل مساعدکننده خشونت محل کار، کمبود آگاهی مردم در خصوص وظایف دانشجو در بیمارستان‌ها بود. بین جنس و ترم تحصیلی دانشجویان با خشونت رابطه معنی داری یافت نشد.
نتیجه‌گیری: دانشجویان پرستاری اغلب در محیط کارآموزی مورد خشونت قرار می‌گیرند. باید راه‌های پیشگیری از خشونت و همچنین نحوه واکنش به خشونت به دانشجویان پرستاری آموزش داده شود و این مباحث در سرفصل درسی دانشجویان پرستاران گنجانده شود.

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Background & Objectives: Nursing and midwifery students are at risk needlestick/sharps injuries (NSIs/Sis). Actual number of NSIs/SIs among students due to insufficient reporting it is not clear in Iran. The aim of this study was to explore the barriers of not reporting of NSIs/SIs among nursing students.
Methods: This descriptive cross-sectional study was conducted in Arak University of Medical Sciences in 2009. 207 and 68 nursing and midwifery students were participated in study, respectively. A questionnaire, consisting two sections of demographic information and questions about exposure to (NSIs/SIs) and frequency and barrier reporting of NSIs/SIs, was completed by students.
Results: According to the findings, 43% and 20.5% of nursing and midwifery students had experienced at least one contaminated NSIs/Sis in the past 12 months. Only 44.9 % (n=40) and 50% (n=7) of the nursing and midwifery who had experienced NSIs/Sis in the previous year, were reported all exposures to NSIs/Sis, respectively. The most important the reasons for not reporting injuries consisted of low probabilities of the infection risk of the injury source, not familiar with reporting process and fear of decreasing evaluation score.
Conclusion: NSIs/SIs and non-reporting of NSIs/SIs were highly prevalent in nursing and midwifery students. More education programs should be directed at students to increase their awareness of about NSIs/SIs. Also nursing and midwifery student’s instructors should give positive responses to nursing students for reporting NSIs/SIs.

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Background & Objectives: Due to the increasing tendency to measure the quality of life in recent years and the extensive quality of life questionnaires, it is important to determine the appropriate method of analyzing data derived from these studies. The aim of the present study was to introduce ordinal logistic regression models as an appropriate method for analyzing the data of quality of life.

Methods: The data was derived from a cross-sectional study on quality of life survey of 938 students. For data analysis, two binary logistic regression models and ordinal logistic regression models were used and the results of these models were compared.

Results: The results of goodness of fit showed that all three models were fitted well. Based on the ordinal logistic regression models, the three variables out of the explanatory variables were statistically associated with the response while based on the binary logistic regression model, after combining two categories of response variable, only two variables were significant. Therefore, combining the categories of the response variable should be avoided as much as possible because it may lead to data loss due to ignoring some of the response categories.

Conclusion: It is concluded that to analyze quality of life data, due to the nature of the response variable, ordinal logistic regression models are recommended considering the fewer parameter estimates and easier interpretation of the results

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Background and Objectives: Missing data is a big challenge in the research. According to the type of the study and of the variables, different ways have been proposed to work with these data. This study compared five popular imputation approaches in addressing missing data in the questionnaires.

Methods: In this study, 500 questionnaires were used for self-medication in diabetic patients. Missing in the observations was artificially generated by random selection of questions and then deleting them. Five imputation ways included: 1) the mean of the questions, 2) the mean of the person, 3) the mode of the person, 4) linear regression, and 5) EM algorithm. For each method, the mean and standard deviation were compared with imputation. The Spearman correlation coefficient, the percentage of incorrectly classified and kappa statistic were also calculated.

Results: A kappa higher than 0.81 represented almost perfect agreement at 10% missingness. The EM algorithm showed the highest level of agreement with the results of actual data with a Kappa of 0.886. With increasing missingness to 30%, the EM algorithm and the mean of  the person showed a rather similar agreement with a Kappa of 0.697 and 0.687, respectively.

Conclusion: In this study, the EM algorithm was the most accurate method for handling missing data in all models. The mean of the person method is easy for handling missing data, especially for most non statisticians.

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Background and Objectives: Using the anthropometric indicators of children is one of the ways of monitoring their growth. Because of the racial divisions and levels of health and welfare, comparing these indicators with the global reference is not reasonable; therefore, designing a local reference seems necessary. This study aimed to evaluate the growth indices for boys and girls aged 5 to 18 years old living in Isfahan and to compare the indices with standard values.
Methods: In this cross-sectional study, 53,839 subjects were included. Percentiles of body mass index, height, and weight were calculated using the LMS method in the LMS Light software. After normalization of the growth indices, their mean and standard deviation were calculated for each age group and anthropometric indices curves were plotted versus the 5th, 50th and 95th percentiles of the NCHS reference.
Results: In all age categories, the mean SDS scores of BMI in boys and girls was -0.004 ± 0.029 and 0.014 ± 0.062, respectively, indicating no difference with reference values. However, the 95th percentile of the body mass index for the reference population was consistent with the 90th percentile for the population studied. Also, weight in boys below 13 years of age was higher than the reference line while in girls, weight was always higher than the reference value.
Conclusion: Due to differences in the pattern of growth and also lower anthropometric values, particularly among boys, it seems that a national growth curve can be a better guide for future decisions.

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Background and Objectives:In order to determine the workload of health workers(Behvarz), this research was conducted for work measurement and time assessment in rural health centers(health house).
Methods: This cross sectional study was conducted in 30 health centers during a routine working day in Saghez in 2015 using the “stop watch method”. The time and frequency of the processes were recorded in a checklist. We estimated and compared spent, standard, expected and pessimistic time, and also the mean repetition for each process per day and month as the unit of time.
Results: The mean real working time was about 157.5 minutes (33%) per day, which was mostly (35.5 minutes) spent on the affairs of health volunteers. Care for non-communicable diseases was the most frequent task with an average of 2.4 times per day. In a month, family planning was undertaken more than other processes. The time of most activities like mother care, elderly care, care for communicable and non-communicable disease was significantly lower than the expected and pessimistic times (P<0.05).
Conclusion: The time spent by health workers was low and unscheduled, particularly for important activities of primary health care. It seems that it is necessary to revise the models and methods of service provision in health centers. Efficient use of existing personnel, reducing unnecessary activities and adding more service packages according to the health system priority seem to be important requirements in the first level of health system.

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Background and Objectives: Breast cancer is the most common cancer in Iran. It can be prevented by rapid diagnosis of the disease. Thus, it is necessary to determine the causal relationships between variables related to breast cancer. Bayesian network is a data mining tool that shows the causal relationship between different variables. In this paper, a Bayesian network was applied to find causal relationships between breast cancer variables using a genetic algorithm in a graphical model. 
 
Methods: in this applied study, data were collected from 900 breast cancer patients in Kerman Province from 1999 to 2008. For data analysis, we used a probabilistic graphical model representing the causal relationship between variables.
 
Results: The results showed that surgery was the most important treatment for breast cancer. Based on the conditional and marginal probabilities, the women who underwent surgery had higher hopes of living longer. Moreover, 81% of the patients who did not undergo surgery only received chemotherapy or radiotherapy were less likely to have long lives.
 
Conclusion: People aged 40-65 years are more likely to have breast cancer. Moreover, the variables of age, surgery, chemotherapy, and radiotherapy had a direct effect on the status of the patients and there were direct edges from these variables to the status of the patients.

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Background and Objectives: Cholera is one of the communicable diseases that should be reported immediately as a public health threat. This study was conducted to study the probable risk factors of cholera outbreak in Qom, central Iran, during 2017.
 
Methods: In a case-control study, 37 cholera patients diagnosed based on para - clinical tests and 37 control samples were evaluated. Charts, frequency tables, regression logistic, Chi-square and t-test in SPSS software ver.25 were used for data analysis.
 
Results: The causative agent in the Qom cholera outbreak was Vibrio cholerae serotype Inaba. Most of the patients (54%) were in the age range 21-40 years. Most of the cholera cases were males (87%), Iranians (81%), and school or college students (30%). The peak of the epidemic occurred in the third week of November 2017, coinciding with a religious event. Nearly half of the patients were identified at the cross-border surveillance centers. The most important risk factors for the outbreak were a history of travel to Iraq in order to attend the Arbaeen religious event (95%), (OR=75, P-value<0.001), and a history of consuming unreliable foods and water (94% and 50%, (OR=66, CI=8-410, P-value=0.00 and OR=11, CI=2.7-46)), respectively. 
 
Conclusion: Cross-border surveillance of cholera in common borders with Iraq, especially in the Arbaeen religious event, played a vital role in identifying patients suspected of cholera. The surveillance of communicable diseases should be strengthened when entering and leaving the Arbaeen event.
 

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Background and Objectives: To preventing deaths, it is essential to recognize factors affecting the survival of road accident victims. This study was conducted to identify the factors affecting the mortality of road accident victims.
 
Methods: All pre-emergency mission forms and hospital records of road accident victims were analyzed. The dependent variable was the time interval between the accident and death or discharge from hospital. The forms included demographic variables, accident location, injury status, type of vehicle, type of trauma, mission time, and vital signs.
 
Results: Of 8920 injured persons, death occurred in 143 (95% CI: 0.014-0.019). Being over 65 years (Hazard Ratio (HR) 7.6, 95% CI: 3.14-18.4), accident on the main roads (HR 1.44, 95% CI: 0.6-3.5), tracheal intubation (HR 26.4, 95% CI: 3.05-227.6), a systolic and diastolic blood pressure above 100 (HR 0.4, 95% CI: 0.4-0.12) and 70 mm Hg (HR 0.53, 95% CI: 0.24-1.2), and heart rate>100/min (HR 3.0, 95% CI: 1.7-5.1) were associated with the risk of death.
 
Conclusion: In providing services, age, status of blood pressure, pulse, injury status, and type of trauma can affect the patients’ survival.

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Background and Objectives: One of the causes of neonatal death and death in children under the age of five is premature birth of infants. The purpose of this study was to identify the risk factors associated with preterm infant birth in pregnant women.
 
Methods: This is a case-control study on mothers referring to comprehensive health centers in the provinces of the country. Descriptive analysis of variables was reported as percentage and frequency. In data analysis, logistic regression analysis was used at a significant level less than 0.05.
 
Results: In this study, 2463 pregnant women (668 cases as cases and 1795 as controls) were examined. There was a significant relationship between the place of residence (OR=0.702, P=0.002), level of maternal education (OR=1.920, P=0.027), degree of twin (OR=4.953, P=0.001), interval between pregnancies (OR=1.821, P=0.009), specific disease (OR=1.694, P=0.010), nutritional status of the mother (OR=1.420, P=0.024), physical activity (OR=1.591, P=0.001), Sleep patterns (OR=0.634, P=0.008) and history of stillbirth (OR=0.247, P=0.001) associated with the birth of premature infants.
 
Conclusion: Preterm infant birth is one of the main causes of neonatal death. Therefore, some of the birth defects of the premature baby can be prevented. It is possible to reduce the risk factors for the birth of a premature baby by improving the quality of pregnancy care and changing the lifestyle of the pregnant mother, and by raising awareness and creating a healthy and safe environment for the mother.

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Background and Objectives: Iran, like most other countries in the world, is always threatened with global epidemics and pandemics of influenza. The purpose of this study was to review the influenza surveillance system in Iran.
 
Methods: Data of this study were obtained from the surveillance system of the Center for Communicable Disease Control, the review of records, documents, books and published articles and also interviews with process owners and experts of influenza surveillance in 2017-2019.
 
Results: Influenza surveillance in Iran Currently, a combination of surveillance methods, including caring for patients, laboratory care, hospital care and surveillance of respiratory disease epidemics and also border surveillance. Reporting of human influenza outbreaks, as well as suspected avian flu as main notifiable diseases carried out through telephone. For each suspect case, in addition to taking and sending a sample to diagnose and also detect subtypes of the virus, medical treatment is immediately initiated and tracking of possible contacts is also done.
 
Conclusion: Although there is currently good coherence in the surveillance of influenza in Iran, but based on concerns about the emergence of influenza pandemics in the future, and considering the possible genetic variation of the flu viruses, the tracking of the flu virus circulation along with updating surveillance system especially emphasizing methods and formulas for rapid identification of disease outbreaks, as well as providing better health care and treatment is essential.

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Background and Objectives: Gestational Diabetes Mellitus (GDM) is the most common metabolic disorder in pregnancy. In case of early detection, some of its complications can be prevented. The aim of this study was to investigate early prediction of GDM by logistic regression (LR), discriminant analysis (DA), decision tree (DT) and perceptron artificial neural network (ANN) and to compare these models.
 
Methods: The medical files of 420 pregnant women (2010-12) in Kermanshah health centers were evaluated using convenience sampling. Demographic data, pregnancy-related variables, lab tests results, and a diagnosis of GDM according to a fasting blood sugar level of 92 or more were collected from their files. After fitting the four models, the performance of the models was compared and according to the criteria of accuracy, sensitivity and specificity (based on the ROC curve), the superior model was introduced.
 
Results: Following the fitting of LR, DA, DT and perceptron ANN models, the following results were obtained. The accuracy of the above models was 0.81, 0.83, 0.78 and 0.83, respectively, the sensitivity of the models was 0.50, 0.63, 0.58 and 0.58, the specificity of the models was 0.96, 0.93, 0.87 and 0.94, and the area under the ROC curve was 0.86, 0.78, 0.73 and 0.87, respectively.
 
Conclusion: In predicting and categorizing the presence of GDM, the ANN model had a lower error rate and a higher area under the ROC curve compared to other models. It can be concluded that this model offers better predictions and is closer to reality than other models.

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Background and Objectives: On 12 November 2017, an earthquake with a magnitude of 7.3 on the Richter scale occurred in Kermanshah Province. Explaining the challenges and needs of the victims in such circumstances can be an important source of information for future planning and better management of such conditions. Thus, the purpose of this study was to explain the challenges and needs of the earthquake victims.
 
Methods: This study was a qualitative study. Twenty-nine semi-structured interviews were conducted with managers, policymakers, and health and emergency relief providers in earthquake areas, and 10 focused group discussions were held with earthquake victims from December to February 2016. The data were analyzed using conventional content analysis.
 
Results: The needs and challenges in Kermanshah earthquake were classified into three periods after the earthquake: 1. Challenges and needs in the first few days with three sub-categories including management, rescue services, and urgent care, 2- Challenges and needs in the first few weeks  after the earthquake with three sub-categories including housing and emergency assistance, public health services, and access to health care; and 3. Needs and challenges in several months after the earthquake with four sub-categories including economic, social, infrastructural and health service needs.
 
Conclusion: Lack of unity of command was the main challenge in this earthquake. Another point was the health needs of victim earthquakes over time. Therefore, dispatching of aid forces to the affected areas during natural disasters should be based on planning and needs.

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Background and Objectives: Diabetes is one of the most expensive chronic diseases and a global public health problem. One of the objectives of implementing the Health Reform Plan (HRP) was to reduce the out-of-pocket payments for hospitalized patients. The present study was carried out with the aim of determining the direct medical costs in hospitalized diabetic patients after implementation of the HRP.
 
Methods: This cross-sectional descriptive-analytical study was conducted in 2019. The records of diabetic patients hospitalized in Imam-Ali Hospital of Zahedan from March 2017 to June 2018 was reviewed by the census method and the direct medical costs were recorded in a researcher-made checklist. Data were analyzed using the SPSS version 22
 
Results: In this study, the direct medical costs of 704 hospitalized diabetic patients were evaluated. The majority of the study population was female (517, 73/5%) and 237 had gestational diabetes. The mean direct medical cost per hospitalized diabetic patient was 29,264,465 Rials and the mean out-of-pocket payment was 11.8%. Moreover, direct medical costs of diabetic patients increased with age (P<.001).
 
Conclusion: Diabetic hospital care imposes a high burden on basic health insurance. Despite the HRP, out-of-pocket payments for hospitalized diabetics are still significant. Government subsidies should focus on expanding access to care for diabetics, financial protection for disadvantaged residents and expanding public education on diabetes.

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