Iranian Journal of

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Background & Objective: Mixed outcomes arise when, in a multivariate model, response variables measured on different scales such as binary and continuous. Artificial neural networks (ANN) can be used for modeling in situations where classic models have restricted application when some of their assumptions are not met. In this paper, we propose a method based on ANNs for modeling mixed binary and continuous outcomes.
Methods: Univariate and bivariate models were evaluated based on two different sets of simulated data. The scaled conjugate gradient (SCG) algorithm was used for optimization. To end the algorithm and finding optimum number of iteration and learning coefficient, mean squared error (MSE) was computed. Predictive accuracy rate criterion was employed for selection of appropriate model. We also used our model in medical data for joint prediction of metabolic syndrome (binary) and HOMA-IR (continues) in Tehran Lipid and Glucose Study (TLGS). The codes were written in R 2.9.0 and MATLAB 7.6.
Results: The predictive accuracy for univariate and bivariate models based on simulated dataset Ι, where two outcomes associated with a common covariate, were shown to be approximately similar. However, in simulated dataset ΙΙ in which two outcomes associated with different covariates, predictive accuracy in bivariate models were seen to be larger than that of univariate models.
Conclusions: It is indicated that the predictive accuracy gain is higher in bivariate model, when the outcomes share a different set of covariates with higher level of correlation between the outcomes.

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Background & Objectives: To determine the prevalence rates of refractive errors in Mashhad, Iran
Methods: In this population-based study, random cluster sampling was performed on the urban population of Mashhad and of 4453 selected individuals, 70.4% participated in the study. Refractive errors were assessed using cycloplegic refraction in participants who were ≤ 15 years of age and non-cycloplegic refraction in those who were > 15 years of age .
Results: The prevalence of myopia and hyperopia in individuals ≤ 15 years old was 3.64% (95% CI: 5.09 to 2.19) and 27.4% (95% CI: 31.09 to 23.72), respectively. The same measurements for individuals >15 years of age was 22.36% (95% CI: 24.66 to 20.06) and 34.21% (95 CI: 36.85 to 31.57), respectively. The prevalence of astigmatism and anisometropia were 25.64% and 5.84, respectively. Astigmatism and anisometropia were significantly more (p=0.005) and less (p=0.048) prevalent in females, respectively. Anisometropia, astigmatism and hyperopia were found to be increased with age.
Conclusions: This study highlighted the valuable information on refractive errors in Mashhad. Hyperopia was the most common refractive error. In addition to subjects who were between 5 to 15 years of age, refractive errors were also prevalent among older people therefore, more attention should be paid to the correction of refractive errors in these groups.

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Background & objectives: Head injuries are the most sever kind of injuries in accidents. It is an important factor of disability in society. Having information about present situation and its determinant factors is the first step of programming for head injury reduction. This survey aimed to have an epidemiological aspect of head injury in Arak.
Methods: Relevant informations about severity of the impact, causes, demographic information and treatment results were extracted from medical files between 2005-2006 years.
Results: Of total 1105 patients with head injury 25.8% were in their first decade of life and 11.8% were reported as sever head injury. The most common injuries (18.4%) caused by downfall from low height. Men had more head injured 64.7% compared with women. In the period of hospitalization 12.8% of moderate head injuries and 43.1of sever head injury caused to death.
Conclusions: It is concluded that applying and administration of the safety rules in the society as a compulsory rules and educating by mass media, are necessary. It should also be taken into account more effective hospital care for sever head injuries to reach better outcomes.

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Background & objectives: Content validity is the first type of validity that has to be ensured during the design of a tool. Its prerequisite for other validities and its close relationship with the tool reliability place it in a vital position in the questionnaire design. However, since it has not been paid enough attention in national publications therefore in this paper we will explain the different steps in preparing an appropriate content for questionnaires and also their assessment.
Methods: The steps of the content validation process for designing valid and reliable questionnaires have been explained in this paper: development (domain identification, items generation and instrument construction), Judgment – quantification (determining the inter rater agreement among experts, determining the clarity and relevancy of each of the questions along with the clarity, relevancy and comprehensiveness of the tool as a whole) have been explained.
Conclusions: The benefits of performing the content validation in questionnaire development are not increasing the possibility of accessing desirable content validity indexes (relevancy, clarity, and comprehensiveness) only, but also improving the Reliability indexes of tool and decreasing need for resources (financial and temporal) are the other benefits of this approach. Although subjective nature of experts’ responses is the problematic issue in this process but the more quantitative steps of the content validation has reduced considerable part of previous worries about this process. These issues explain why content validation has become a suitable process for questionnaire

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Background and Objectives: Designing and application of experimental studies in veterinary medicine have been given paid more attention in recent years. This review aimed to evaluate the methodological quality of all published articles in Journal of the Faculty of Veterinary Medicine, University of Tehran between 2000 and 2009.
Methods: Evaluation studies with experimental designs were identified by reviewing titles and abstracts. Two reviewers coded reporting quality of articles.
Results: Of the 738 total published articles, 289 (39.16%) articles had experimental designs. Sample size was reported in 93.4% of studies, only 36% of studies explained their study design clearly and randomization was reported only in 33.6%. The ethical approval was mentioned in only two percent. Seventy six percent studies had comparison group.
Conclusion: The quality of reporting of experimental studies in the Journal of the Faculty of Veterinary Medicine was not generally acceptable. Therefore it is felt that authors should consider more necessary criteria for standard publication in veterinary journals.

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Background & Objectives: Maternal health status is one the important health index since it could be a hallmark of performance of health care service particularly in rural area. The aim of this study is ranking and identifying homogeneous provinces based on maternal health indices in Iran.
Methods: Based on the indices in the vital horoscope which were reported by Iran Ministry of Health in 2006, fifteen indices related to maternal health have been selected. Using factor analysis, a factor that can represent rural maternal health in provinces was chosen and provinces ranked according to it. A hierarchical cluster analysis employed for identifying homogenous province based on a distance matrix obtained from the same selected indices in factor analysis.
Results: Factor analysis demonstrated that 89% of data variation included in this model. Based on an appropriate factor as index of maternal health, ranking was run in all provinces in Iran. According to this model, the maternal health status was in good condition in the rural areas of Gilan, Mazandaran and Tehran provinces, respectively. While maternal health were in inappropriate condition in rural areas of Khuzestan, Kohkiluyeh and Hormozgan provinces. The worst rural area was the province of Sistan and Baluchestan.
Conclusion: It could be concluded that employing multivariate analysis would be an effective tool for ranking and classifying homogeneous population (provinces) in terms of maternal health indices. Therefore health policy makers should consider the practical method of this analysis for any decision making.

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Background & Objectives: Changing the pattern of mortality gives important perspective of health determinants. The aim of this study is to detect location and time of mortality pattern change in country using statistical change point method during 1971-2009 Years.
Methods: We assume for years before and after 0 k , t y has a Poisson distribution with means 0 l and 1 l , respectively. We used several methods for estimation change point in real data by assume Poisson model.
Results: Using two simulated and real data analysis showed that the change point has been occurred in year 1993 and this confirmed by all methods.
Conclusion: Our findings have shown that the change pattern of mortality trend in Iran is related to improvement of health indicators and decreasing mortality rate in Iran.

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Background & Objectives: The epidemic of HIV has been become worldwide. Infected people with HIV which are most intravenous drug users (IDUs) and/or people who have unsafe sex are important source of transmission of infection to other persons in a community. Since there is little known about the knowledge and attitudes of HIV positives about HIV in Iran, therefore we decided to measure the level of knowledge and attitudes of this group in Golestan province in compare with individuals with risky behavior.
Methods: This cross-sectional study was conducted on 54 HIV+ persons and 134 people with high risk behavior individuals in 2007 year. Results: Our study showed that HIV- (High risk group) cases had higher education level (P=0.034). Rate of jobless was higher in HIV+ persons (P<0.001). HIV+ cases had lower income (P=0.037). Both groups had moderate knowledge and poor attitude on HIV/AIDS. Level of attitude in HIV+ positive persons was lower than high risk group (P=0.05).
Conclusion: It is concluded that these susceptible persons and also infected individuals with HIV regardless of their socio-economic levels need more continuous education in structured programs.

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Background & Objectives: The rate of burnout may be high in unfertilized women, since there is little known about it, we designed a study to compare "couple burnout" between fertilized and unfertilized women in Tehran, Iran.
Methods: All (60 women) referred unfertilized women to reproductive center of Imam Khomeini teaching hospital were included in our study during 2009 year. By systematic random sampling we recruited 60 unfertilized women as control group. Couple Burnout’s specific questionnaire was filled up by participants.
Results: Unfertilized women experienced higher levels of couple burnout compared to fertilized cases (P<0.001). Furthermore unfertilized women with higher education showed an elevated rate of couple burnout than women with lower educational status (P=0.002).
Conclusion: In management of unfertilized families, "couple burnout" is an important underlying factor that should be considered in infertility treatment in primary health care system.

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Background & Objectives: Food security (access to safe, nutritious, affordable food) is one of the important determinants of health status in human life. Since monitoring and assessing of associated factors to food security are essential for health planning, this study has tried to determine household food security status and food consumption amongst high school student families in Esfahan, Iran.
Methods: This cross-sectional study was conducted in autumn 2008 on 580 high school 14-17y students of Esfahan, Iran using a systematic cluster sampling. Food security and food frequency questionnaire were completed by interviewing mothers and students.
Results: The prevalence of household food insecurity was estimated as 36.6% (95%CI: 33-40%). Household food insecurity was positively associated with frequency of some food group intakes among students, including bread macaroni potato legume and eggs (P<0.05). In addition, negative associations were observed between food insecurity and frequency of other food group intakes including rice, red meat, sausage and hamburger, poultry, fish, green vegetables, root and bulb(colored) vegetables, melons, banana, pineapple, coconut, mango, apple, orange, milk, and yogurt (P<0.05).
Conclusion: The results of this study indicate that food insecurity is prevalent among (students) households in Esfahan. In addition, students living in food-insecure households more frequently consumed cheap foods containing high energy per kilogram. Therefore, appropriate nutritional programs should be designed to improve the quality of household food consumption.

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Background & Objectives: Despite an increased risk of obesity and CHD in people with spinal cord injury (SCI), there is little known about the dietary intake in this group, therefore the aim of this study was to examine nutrient intake and body mass index (BMI) in the spinal cord injury (SCI) population according to level of injury and related variables.
Methods: In this cross-sectional study, 162 patients with spinal cord injury participated from Brain and Spinal Injury Repair research Center, Tehran, Iran. Dietary intakes were assessed by means of a semi quantitative food frequency questionnaire.
Results: The mean age of study population was 34.1±0.6 years. Total energy and carbohydrate intake were higher in men than women (P<0.001). Incomplete injured consumed more MUFA (P=0.03). The elderly were consumed less total calorie, saturated fat, MUFA, cholesterol (P<0.01) and PUFA (P<0.05). Injured patients with longer times had lower total calorie, carbohydrate (P<0.01), total fat and MUFA intake (P<0.05). Based on new classification 60.5% were at the risk of obesity or obese. Central obesity was seen in 33.1%of man and 48.4% of women. BMI of the paraplegia group was greater than that of the tetraplegia group (P= 0.009).
Conclusion: Macronutrients balance is moved towards higher saturated fat intake and less complex carbohydrates and protein intake in SCI patient’s .The elderly and patients who had lived with SCI longer time tended to maintain healthier diets.

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Background & Objectives: Orthodontic treatment need and demand in 12-year-olds in Abadeh city has not previously been analysed in relation to geographic origin. The purpose of this study was to assess the12 year old students need and demand for orthodontic treatment.
Methods: Four hundred seventeen 12-year-old students was selected from public and private schools in Abade (Fars province, Iran). All the students were examined according to the AC and DHC component of Index of Orthodontic Treatment Need (IOTN) by a trained dentist. Students' and parents' perceived needs were also assessed using AC component and their demand for orthodontic treatment was asked through a questionair .
Results: Twenty two percent of the students were in "no need of treatment" group when assessed by DHC component, 29.5 % were in "average need" and 48.2% were in "definite need" group. When assessed by AC score, these percents were 61.9%, 29%, and 9.1%. Parents and students percieved need for definite orthodontic treatment according to AC score was 8.6% and 7.7%, respectively. The students and their parents’ demand for treatment were 40.6% and 44.9%, respectively.
Conclusion: Orthodontic treatment need in Abade is higher in comparison with other reports according to DHC. DHC is not correlated with orthodontic treatment demand of 12 years old students, but AC had a strong relationship with treatment demand.

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In the previous paper, the basic concepts of sample size calculation were presented. This paper explores main post-calculation adjustments of the sample size calculation in special circumstances such as multiple group comparisons, unbalanced studies (with unequal number of subjects in different groups) sample size correction for missing data, and adjustment for finite population size. In addition, the concept of design effect in multi-stage sampling

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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: Custom-orienting is a critical issue for public health service. Peoples with a variety of developmental health care needs and perspectives are health care clients. Health accessibility through “Primary health care” has been approved and emphasized in Alma Ata in 1978. It is important to have a clear and transparent understanding of clients’ health needs and problems that would enable us to address such needs and prevent the negative consequences that might otherwise ensue. The aim of this study was to understand and gain deeper insight into health service customers’ lived experience of public health accessibility.
Methods: This study has been conducted with a phenomenological approach. Max van Manen six steps method of hermeneutic-phenomenology has been used. Nine health care clients were selected purposefully and interviewed semi-structured.
Results: The results of this experiment revealed the following six themes: to encounter with holistic learning chance, custom-oriented communications, qualified health care service, appropriate time-place health services, equality- orienting, and individual participation.
Conclusion: The participants believed that health accessibility is something more than just to have health services. Therefore, health education and social equality will bring about optimum health services. To develop multi-dimensional learning and to promote individual participation will be useful for more community empowerment.

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Background & Objectives: The experience of patients with breast cancer may vary in different cultures. The aim of this qualitative study was to explore the experiences of women with breast cancer in Iran.
Methods: Fifty one participants were recruited from a university-affiliated breast clinic in Tehran. In-depth interviews each lasting approximately one hour per participant were scheduled and conducted in a private room. The interviews intended to motivate the participants to reflect on their life experiences since the cancer diagnosis. The interviews were tape-recorded and were transcribed to elucidate the major themes encountered in the interviews.
Results: The mean age of patients was 48.8 years (SD = 10.5), 44 were married, one was single, and six were widowed or divorced. Forty-eight participants underwent radical mastectomy and 13 patients received breast-conserving surgery. Thirty-five (69%) patients received chemotherapy. Overall eight major themes emerged from the analysis. These were: importance of God and spiritual beliefs, importance of family support especially husbands and children during the diagnosis and treatment, difficult times during receiving mammography results, experiencing an ambiguous condition while losing their breasts, fear of recurrence, concerns about children, and chemotherapy as the worst experience during the course of treatment.

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Background & Objectives: the aim of this study is seroepidemiological survey of human Hydatidosis by ELISA method in East-Azarbaijan province. Methods: Totally 1500 serum samples were collected from patients referred to different health centers in 8 cities of East-Azarbaijan province. All the sera were examined using ELISA test.
Results: Nineteen cases (1.28%) were positive for human hydatidosis in East-Azarbaijan province using ELISA test. From these cases, 8 cases (0.93%) were from urban areas and 11 cases (1.8%) were from rural areas. 1.76% of females and 0.83% of males were positive and age group 30-40 years old had the highest rate of positivity (1.66%). There were no statistically significant different between gender and age groups and residency area.
Conclusion: According to results of this study the highest rate of positivity was seen in Sarab city (2.17%). The possible reason of this difference could be to live the highest rate of rural population of East-Azarbaijan province dwelling in this city.

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Background & Objectives: Osteoporosis is major public health concern affecting millions of adults particularly older adults and women worldwide. Designing effective educational intervention is principle in any health promotion program. The purpose of this study was to evaluate the efficacy of an educational intervention based on health belief model on knowledge about, attitudes toward and practice of prevention osteoporosis among women with low socioeconomic status in Isfahan.
Methods: The study population consisted of 14 women with low socioeconomic status and under 60 years old. A valid and reliable questionnaire developed and used as measurement tool for initial and final assessments in this program. In addition calcium intake and vitamin D, physical activity and exposure to the sun were assessed.
Results: The mean age of the participants were 40.8 ± 10.52 years. The mean score of all parts of health belief model (except for perceived barriers), knowledge, sun exposure, and physical activity after educational intervention compared to before intervention, were increased significantly. There was no statistically significant difference between daily calcium and vitamin D intake before and after intervention.
Conclusion: It is concluded that the HBM Model– based educational program on Knowledge and belief regarding Osteoporosis prevention seems practical and effective. However more research should be done to find out more effective intervention regarding optimal calcium and vitamin D intake.

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Background & Objectives: Drowning is a major and serious public health problem in the northern provinces of Iran. It has significant opportunities for prevention. The aim of this study was to review the epidemiological pattern and burden of drowning in northern area f Iran.
Methods: To examine the incidence and characteristics of drowning in recreational water settings, we analyzed all available data from death registry in 2008 year in Mazandaran and Gilan provinces, located in north of Iran, through a retrospective study. Collective form was based on standard World Health Organization and then the burden of drowning was calculated.
Results: During 2008, 158 indigenous (88.6% male and 11.4% female) people from these provinces died due to drowning. The mean age of the drowned was 26.4 (SD=16.2) years. The drowning death rate was 2.9 per 100,000 population in two provinces. Most of cases (85.4%) of drowning occurred in sea and majority of death was in August (29.7 percent). Number of years lost was 4110 equivalent of 76.1 per 100,000 respectively. Most DALYs was seen to age group 10-19 years.
Conclusion: It is highly recommended the findings of this project should be considered for any future preventive plan by health authorizes in those provinces.

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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.