Iranian Journal of

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Background and Objectives: In June 2018 , 537 residents of a rural area in Khuzestan Province presented to the regional Comprehensive Health Service Center for gastroenteritis symptoms. This study was designed to determine the extent and cause of the outbreak.
 
Methods: A case-control study was performed after random selection of the case and control groups (80 cases and 88 controls). Clinical and water samples were analyzed for parasitic, bacterial and viral pathogens in local, provincial and national laboratories. Odds ratios with corresponding 95% confidence intervals were used to assess the relationship between disease and exposure.
 
Results: The odds ratio of rural plumbing water consumption as a risk factor was 3.3 (95% CI: 1.7-6.2). Using in vitro methods, Shigella sonnei was isolated in clinical samples and enterohemorrhagic Escherichia coli and enteropathogenic Escherichia coli were isolated from both clinical samples and water samples taken from the intake basin of water supply facilities.
 
Conclusion: Consumption of rural plumbing water Since 26 June 2018 as well as the water stored in domestic tanks at certain water-shut-off times is associated with gastroenteritis outbreak. To prevent similar outbreaks, continuous chlorination of drinking water during distribution through rural pipelines should be done. To prevent secondary outbreaks after the epidemic phase, educating and informing people about personal hygiene is essential.

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Background and Objectives: A nosocomial infection (NI) is defined as an infection occurring in a patient after 48 hours of hospitalization or up to 72 hours after discharge from the hospital, which was not present or incubating at the time of admission. NIs increase hospital mortality, decrease patient satisfaction, reduce hospital productivity, and increase health system costs. This study was conducted to determine the prevalence of NIs in Iranian hospitals.
 
Methods: This study was performed using a systematic literature review and meta-analysis. Seven electronic databases and two search engines were searched using appropriate key words to identify research studies on NIs published in Persian and English languages from April 1997 to March 2019 in Iran. Finally, 15 empirical studies out of 89 records were reviewed. Data were analyzed using the Comprehensive Meta-Analysis software.
 
Results: The studies reported a prevalence of 0.32% to 9.1% for NIs in Iranian hospitals. The pooled prevalence of NIs in Iranian hospitals was 0.01 % (95% CI 0.0% - 0.02%). The most common type of infection was urinary tract infection and the most common microorganism was Escherichia coli. The highest rate of nosocomial infections was seen in the intensive care unit, internal medicine ward and hematology ward. Suction was the most important risk factor for nosocomial infections.
 
Conclusion: The prevalence of NIs in Iranian hospitals is low according to the published studies. Appropriate strategies should be implemented to prevent and control NIs.

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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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Background and Objectives: Understanding and analyzing the socio-economic factors affecting mental health is important for mental health policy-making in metropolitan areas. The aim of this study was to investigate the relationship between socio-economic factors and mental health of households living in Tehran.
 
Methods: This cross-sectional descriptive-analytical study was conducted on 650 households from 22 districts of Tehran using mixed sampling method. Mental health measures were collected using the standard SF-36 questionnaire and socioeconomic measures of the household were collected using a researcher-made questionnaire. The face validity of the questionnaire was measured by qualitative method and its content validity was confirmed by quantitative method. The test-retest method was used to test the questionnaire reliability. Regression models were estimated using ordinary least squares (OLS) and weighted least squares (WLS) methods. The Stata software was used for data analysis.
 
Results: Among the socioeconomic variables, four variables including years of education, health behaviors (regular physical activity, healthy eating habits), not-smoking, and social capital had a positive and significant relationship with all mental health measures (social role, emotional role, mental health and vitality ). The relationship between not-smoking and all mental health measures was more than other socioeconomic variables (P <0.05).
 
Conclusion: Mental health policymakers should place extra emphasis on the development of social capital in metropolitan cities, promotion of the citizens' health behaviors, and particularly on tobacco use and the related behavioral disorders.

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Background and Objectives: Today, happiness and life satisfaction play a crucial role in women’s health in every society. This study was conducted to compare the level of happiness and life satisfaction between employed women and housewives and to examine the factors affecting it.
 
Methods: This cross-sectional study was conducted on 720 employed women and housewives in Kerman, Iran in 2017. The Oxford Happiness Inventory (OHI), Diener Life Satisfaction Questionnaire, and a demographic profile were used for data collection. Regression analysis was used to determine the correlation of different factors with happiness and life satisfaction.
 
Results: The mean ± standard deviation of the total happiness and life satisfaction score was 42/6 ± 13/2 out of 87 (43/3 ± 13/6 in employees and 42/7 ± 12/7 in housewives, P =0/21) and 23/5 ± 6/1 out of 35 (23/8 ± 6/3 in employees and 23/2 ± 5/8, in housewives, P = 0/24), respectively. Additionally, most of the subjects (55%) reported a moderate level of happiness. Regression analysis indicated that married women who had a university education and those who spent their free time on leisure and traveling had higher scores of happiness and life satisfaction. As for the employed women, those with limited work records and those who were officially employed had significantly higher levels of happiness and life satisfaction.
 
Conclusion: This study showed a moderate level of happiness and life satisfaction in women. Furthermore, there was no significant difference in the level of happiness and life satisfaction between employed women and housewives.

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Background and Objectives: Vaccine acceptance could seriously affect global efforts to control the Covid-19 pandemic. The aim of this study was to estimate the Covid-19 vaccine acceptance and its related factors in Tehran and Kermanshah.
 
Methods: A population-based cross-sectional study was conducted on 850 participants in Tehran and Kermanshah using the random digit dialing method. Multiple logistic regression was used to estimate the adjusted odds ratio of factors related to vaccine acceptance.
 
Results: The frequency of the Covid-19 vaccine acceptance was 66.47% (95% confidence interval: 69.57%, 63.21%). Moreover, 86.02% of the participants stated that they would use any type of (Iranian / foreign) vaccine approved by the Iranian Ministry of Health. However, 13.98% of the participants stated that they only preferred foreign approved vaccines (if available). The variables of age, fatalism, and socioeconomic status had significant associations with the Covid-19 vaccine acceptance.
 
Conclusion: Based on the results of this study, the Covid-19 vaccine acceptance was moderate. In order to achieve herd immunity by vaccination faster in our society, the strategy of prioritizing vaccination can be planned based on the related variables such as religious beliefs and fatalism, younger age groups, and people with higher socio-economic status that are willing to receive the vaccine.

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Background and Objectives: The Covid-19 epidemic began in Wuhan, China in the late 2019 and became a global epidemic in March 2020. In this regard, one of the most important indicators of the healthcare systems is the in-hospital mortality rate, which occurs with a time lag of one to two weeks after hospitalization. The aim of this study was to investigate the relative risk of Covid-19 mortality considering this time lag according to the number of daily hospitalizations.
 
Methods: The data included the number of daily hospitalizations and deaths from Covid-19 from 15 May 2020 to 10 February 2021 in Iran, which was obtained from the Github database. A log-linear distributed lag model was used to evaluate the relationship and lag effect between daily hospitalization and relative risk of death.
 
Results: The mean number of daily hospitalizations and deaths were 1342.2 ± 7 731.5 and 190.6 11±118.6 in the study period, respectively. It was found that an increase in the number of daily hospitalizations had a significant relationship with an increase in the relative risk of death on the same day and in the following days. As the number of hospitalizations exceeded 2000 patients per day, the cumulative relative risk of death increased to more than one.
 
Conclusion: The results showed that the number of hospitalizations exceeding 2000 people per day was an alert for the country's healthcare system. Overall, prevention and observance of health protocols in the first level followed by early diagnosis of the disease, improving the hospitals facilities and preparedness of healthcare staff can reduce the relative risk of death in the possible future peaks.

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Background and Objectives: The coronavirus disease 2019 (COVID-19) pandemic has raised concerns about high-risk groups in community. Due to physiologic changes in pregnancy, these women are prone to this infection; therefore, this study was conducted to evaluate Covid-19 infection and pregnancy outcomes in Qazvin Province.
 
Methods: This longitudinal study was done in Qazvin Province from March to October 2020. The participants included 133 pregnant women who with a definitive diagnosis of COVID-19 using CT scan and PCR test. A four-section questionnaire was used to collect demographic data, COVID-19 symptoms, and pregnancy outcomes. The mothers were followed up until six months after delivery. Data were analyzed using the SPSS software version 24 and descriptive statistics.
 
Results: The mean age of the mothers was 27.09 ± 5.67 years. Fever, cough, and body pain were the most common symptoms of Covid-19 in the mothers. The majority (87.96%) of the mothers were in second and third trimester of pregnancy. Maternal outcomes included preterm labor (9%), Cesarean section (51.1%) and maternal death (11.28% or 5 cases). Perinatal outcomes were abortion (6%) and fetal death (3%).
 
Conclusion: Based on the results of the present study, Covid-19 increased the rate of maternal mortality and preterm delivery in pregnant women. Attention should be paid to support the expecting mothers, and more emphasis should be placed on health protocols in this group of patients.

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Background and Objectives: As a result of the Covid-19 outbreak in Iran and other countries of the world, face-to-face training in schools and universities was changed to distance eductaion, which has had different consequences. The purpose of this study was to identify and categorize educational harms and challenges using existing measures and evidence from recent international data. The results of this study can be used to better understand the impact of the COVID-19 crisis on learners' learning as a practical and generalizable framework for epidemic management in the field of education in Iran and other countries.
 
Methods: The present qualitative study was performed using the document content analysis method. First, by reviewing electronic databases, all available documents and articles related to education and Covid-19 were identified. All multimedia files, including audio, text and video files during winter 1399 were searched in Internet websites and databases using keywords based on the above criteria. The selection of documents was purposeful considering the four criteria of JUPP. After multi-stage screening, 65 documents were finally selected and analyzed after coding.
 
Results: Educational harms and challenges caused by Covid-19 outbreak in Iran and other countries were identified and recorded in 29 areas.
 
Conclusion: It can be concluded that although online education is an immediate need in the process of learning and teaching with many benefits, proposing managerial and executive solutions to address the harms and challenges can form the basis of a rich method of eeducational ducation during and after the Covid-19 era.

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Background and Objective: The aim of this research is validation of questionnaire of covid-19 social effects (SISQ) on Iranian students.
 
Methods: The current study is a descriptive-analytic validation-type study and its statistical population was consisted of students of University of Tehran who 300 of them took part in this research voluntarily. After study of content validity, exploratory and confirmatory factor analysis was used to study construct validity and Cronbach Alfa and cluster correlation coefficients were utilized to study the reliability; for further study on main variables of research, Pearson correlation and T tests were used; analyses were conducted by SPSS25 and AMOS26 softwares.
 
Results: In study of validity of seventh item questionnaire, based on professors’ opinion, it was out of content validity (cvr= 0.16); in exploratory factor analysis, four social distance, social acceptance, social information and social anxiety factors were extracted which expressed 57.99 percent variance of questionnaire; results of confirmatory factor analysis confirmed the 4-factor model after adding and omitting processes (RMSEA= 0.05, CFI= 0.93, IFI= 0.93, p= 0.09, x2= 85.26), Cronbach Alfa and interclass correlation coefficients were equal to 0.8 for the final questionnaire; correlation of all items with the total mark was positive and meaningful and the values varied from 0.49 to 0.65. Average (standard deviation) of studied people’s age was 24.07 (6.27) year.
 
Conclusion: 14-item questionnaire of covid-19 social effects on students has acceptable validity and reliability.Further studies in other populations are suggested.

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Background and Objectives: The COVID-19 pandemic has led to major health and socioeconomic problems worldwide. This study was conducted to determine the clinical features and health behaviors related to COVID-19 in patients presenting to selected COVID-19 centers of North Khorasan University of Medical Sciences.
 
Methods: This cross-sectional study was carried out using stratified random sampling in 350 patients presenting to selected COVID-19 centers of North Khorasan University of Medical Sciences in August and September 2020. Demographic and clinical features and the data related to COVID-19 disease were collected using a researcher-made checklist and analyzed with the SPSS 24 software using chi-square test and logistic regression.
 
Results: Of 350 patients, 200 (57.1%) were male and the rest were female. The PCR test was positive in 72% of the patients. The highest percentage of infection was seen in self-employed subjects and driver, people in the age group 30-50 years, and male subjects. The highest observance of masking, hand washing, and social distancing was related to healthcare staff and the lowest was seen in self-employed people, drivers, and military staff. A history of attending a gas station increased the chance of a positive test by 2.3 times (95% CI: 1.13-4.79).
 
Conclusion: According to the results, age, gender, occupation and history of presence in crowded places are important determinants of infection and adherence to protocols.

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Background and Objectives: Reports indicates a higher mortality rate of Covid-19 in the elderly. A limited number of studies have been performed on elderly patients in Iran. In the present study, we investigated the clinical features and survival of elderly patients with Covid-19 in Baharloo Hospital, Tehran, Iran.
 
Methods: This retrospective cohort study was conducted on the data of elderly patients with Covid-19 admitted to Baharloo Hospital, Tehran, Iran. The data of the hospitalized patients were followed until discharge or death. Finally, survival-related factors were analyzed using Cox regression.
 
Results: A total of 522 patients were enrolled in the study, of whom 53.8% were male and 101 died. The mean age of the deceased was 76.3 years, with a standard deviation of 8.6 years. The most common clinical symptoms at the time of admission were respiratory distress (69.5%), cough (61.1%), and fever (51.1%). Cox regression results showed that the risk of death increased by 5% for each one-year increase in age. In addition, calcium supplementation reduced the risk of death by 35%.
 
Conclusion: The results of the present study showed that calcium supplementation could be associated with increased survival of the elderly and reduced mortality. Due to calcium insufficiency in the Iranian population and the protective role of calcium in Covid-19, this issue is essential in the elderly patients warranting further investigation in the future.

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Background and Objectives: In the late 2019, the SARS-CoV-2 virus was identified as the cause of an outbreak of acute respiratory illness known as the COVID-19, which began to spread in the world very quickly. Preventive measures have been a significant issue in preventing the spread of COVID-19. This rapid review study was conducted to summarize selected countries' preventive policies and strategies in the East and Southeast Asia, including China, South Korea, Japan, Vietnam, and Singapore, during the COVID-19 epidemic.
 
Methods: In this rapid review study, the Scopus, PubMed, Embase, and Web of Science databases were searched. The keywords applied in the search strategy were primary health care, public health, prevent* and plan, policy, program, initiative, intervention, measure, and COVID-19 in addition to the name of each country. Furthermore, we searched the World Health Organization (WHO) and the United Nations Development Program (UNDP) websites to retrieve more key sources as grey literature. The relevant data were extracted from the final studies and categorized.
 
Results: After screening, 33 studies met the inclusion criteria. Dominant measures implemented in these countries were categorized into different categories including communication and information, physical distancing, quarantine, monitoring, and testing axes.
 
Conclusion: Education and information, extensive testing and screening, contact tracing, isolation of infected and suspected cases, and observance of physical distancing has been very effective in reducing Covid-19 transmission and its mortality.

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Background and Objectives: The incidence of colorectal cancer has increased significantly in Iran in recent decades. The pattern of occurrence varies in different populations. A study was conducted to perform a spatial analysis of colorectal cancer and some of its risk factors in Iran using GIS.
 
Methods: The data of this descriptive-analytic study included colorectal cancer incidence as a dependent variable and physical activity, Body Mass Index and smoking as independent variables recorded by the Cancer Department, Center for Non-Communicable Diseases Management, the Ministry of Health and Medical Education and the care system for non-communicable disease risk factors according to province and gender in 2009. Data was analyzed using the ArcGIS 10.3 software and spatial correlation analysis, hot spots analysis, and geographic weighted regression model.
 
Results: The spatial relationship between the disease and some of its risk factors was confirmed by the model of geographical weight regression, according to which the northern and central provinces had the highest risk of colorectal cancer compared to other regions of the country.
 
Conclusion: The results of this study showed that spatial analysis could be useful in identifying disease patterns, prioritizing the factors affecting it, and controlling the disease through strategic planning and interventions.

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Background and Objectives: Quality of life is a valuable indicator for measuring people's health. The purpose of this study was to determine the predictors of quality of life in the staff of Shahid Beheshti University of Medical Sciences, Tehran, Iran using the path analysis model.
 
Methods: This cross-sectional study was performed on subjects participating in the Health Cohort Study of Shahid Beheshti University of Medical Sciences, Tehran, Iran in 2018. A demographic information form and standard quality of life, general health, physical activity and burnout scales were used for data collection. The SPSS version 24 and Amos version 24 were used for data analysis.
 
Results: A total of 770 individuals were selected for the study, of whom 345 (44.8%) were male. The mean age ± standard deviation of the participants was 42.6±8.4. Analysis of the quality of life pathway of the participants showed an appropriate model (RMSEA= 0.014, CFI=0.999, NFI = 0.991, TLI = 0.994, CMIN/DF = 1.146). In addition, general health (0.560) and physical activity (0.078) had a direct correlation and occupational burnout (-0.178) and age (-0.082) had an inverse correlation with quality of life.
 
Conclusion: The results of this study suggest that factors such as general health, physical activity, and burnout have an impact on the participants. Therefore, it is necessary to consider the factors affecting the quality of life.

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Background and Objectives: Environmental conditions in different geographical areas provide a basis for the spread of some diseases. Cutaneous leishmaniasis is a serious threat to public health and is one of the arthropod-borne diseases. The prevalence and distribution of this disease is affected by environmental and climatic factors. The aim of this study was to model the Spatio-temporal variations in the incidence rate of this disease based on environmental and ecological criteria.
 
Methods: The northeast of Iran was selected as the study area. The data used in this study included vegetation, surface temperature, precipitation, evapotranspiration, soil moisture, digital elevation model and sunny hours. The artificial neural network method was used to model the spatio-temporal changes of cutaneous leishmaniasis.
 
Results: Spatial variations in the incidence of the disease had a north-south trend and decreased from north to south. In addition, two foci were identified in the medium altitude areas in North and South Khorasan provinces. Temporal variations in the incidence of disease in the study period showed that the incidence rate decreased in the two identified foci from 2011 to 2016.
 
Conclusion: The modeling results showed that the estimated regression coefficient was 0.92 for neural network based on all three types of data (training, validation, test) indicating good quality of constructed neural network.  In addition, sensitivity analysis results showed that sunny hours and soil moisture were the most important factors in the model function.

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Background and Objectives: Fair financial protection against health expenditures is one of the most critical goals of health systems. This study was conducted to investigate the most appropriate threshold for measuring the exposure to catastrophic health expenditure (CHE) in Iran.
 
Methods: The present study was conducted using 2018 national household income and expenditure data of the Iran statistics center. The occurrence and intensity of the households' exposure to CHE at different thresholds and for economic quintiles was measured using two World Health Organization (WHO) and World Bank (WB) methodologies. The most appropriate threshold for each methodology was also determined using the Kappa statistics adaptation estimation.
 
Results: The occurrence of households’ exposure to CHE was 3.02% and 8.51% in urban households and 4.66% and 9.22% in rural households, respectively. According to asset quintiles, the highest occurrence was in the first quintile and the lowest in the fifth quintile. In addition, the results of adaptation estimation based on Kappa statistics showed that a threshold of 40% in the WHO methodology and 25% in the WB methodology were the most appropriate thresholds.
 
Conclusion: The results showed a relatively high rate of exposure to CHE. CHE occurrence was also more in poorer households, and common thresholds were the most appropriate thresholds for estimating CHE.

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Background and Objectives: Human resources, especially youth work force, are considered as the main capital for every society. Maintaining the quantity and quality of human resources is essential for every policymaking. The present study was conducted to estimate the Years of Life Lost (YLL) due to early death amongst the working age population (i.e. 15-64 years) of two provinces with very different levels of socio-economic development in Iran. For this purpose, premature mortality was compared between Yazd and Sistan & Baluchistan provinces in 2016.
 
Methods: This cross-sectional study used secondary data. The target statistical population of the study was all deaths registered in the age groups 15 to 64 years in the provinces of Yazd and Sistan & Baluchistan during March 2016 to March 2017. The mentioned provinces reflect completely different and unequal development at the national level: Yazd is amongst one of the highly developed regions of Iran, while Sistan & Baluchistan is as one of underdeveloped provinces. The data were obtained from health departments of Yazd and Sistan & Baluchistan provinces’ medical universities. The YLL was calculated according to the standard procedure provided by the World Health Organization.
 
Results: Our findings showed that the lost human capital due to early death was about two times higher in Sistan & Baluchistan compared to Yazd. The main causes of death were unintentional injuries in the younger working age group (15-44 years) and cardiovascular disease and cancers in the older working age group (45-64 years).
 
Conclusion: Causes of death were different in Yazd and Sistan & Baluchistan provinces according to the regional level of development. Therefore, health policies have to be implemented as regional policies. In general, the results showed that as the epidemiologic transition passes, the cause of death changes from causes that are less related to medical conditions and more related to social situations. Consequently, it is required to consider social policymaking when designing health policies.

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Background and Objectives: Accurate assessment of patients' death depression requires a specific tool that is appropriate to the culture of each community. Therefore, the aim of this study was to evaluate the psychometric properties of the Death Depression Scale in women with breast cancer.
 
Methods: In this methodological study, 246 breast cancer patients presenting to Qazvin Provincial Hospital completed the 17-item Templar Death Depression Scale. Psychometric properties of this scale were evaluated by exploratory and confirmatory factor analysis. Reliability was also assessed using Cronbach's alpha, omega and composite reliability.
 
Results: Exploratory factor analysis showed that six items in the Persian version did not acquire the required loading factor, and were omitted. The remaining eleven items as a single factor accounted for 66.91% of the variance of this concept. In confirmatory factor analysis, 11 items had appropriate fit indices (χ2 = 97.664, p <.001, χ2 / df = 2.504, GFI = .932, CFI = .972, IFI = .973, TLI = .961, SRMR = .030, and RMSEA = .079). A Cronbach's alpha coefficient of 0.95, Omega coefficient of 0.95, and composite reliability coefficient of 0.96 indicated the acceptable reliability of the 11-item version.
 
Conclusion: The results of this study showed that the 11-item Death Depression Scale was valid and reliable in Iranian patients with breast cancer. Given the appropriate psychometric parameters, this scale can be used to assess death depression in future studies.

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Background and Objectives: One of the most important issues in public health is violence, which affects people around the world. Therefore, a qualitative study was conducted to explain the consequences of student violence.
 
Methods: This study was part of a qualitative exploratory sequential study conducted in Ruodsar in 2017. This study was carried out using conventional qualitative content analysis method. The data were collected through 50 individual in-depth interviews using purposive sampling. Data analysis was done using the Landman and Grahaim method.
 
Results: Data analysis in the first phase of research resulted in the extraction of 98 initial codes, two subcategories and one main category. At the end of this stage, the consequences of adult violence according to the findings were as follows: "The harmful consequences of violence are conceptual, dynamic, and multidimensional. The harmful consequences of violence point to changes that occur within the violent person or the people around them after the violence, which are divided to interpersonal and intrapersonal consequences.
 
Conclusion: The present study revealed some new dimensions of the concept of harmful consequences of violence, especially in student girls. This definition is based on the Iranian context and culture. Violence prevention requires attention to these dimensions at different interpersonal and the intrapersonal levels.