Iranian Journal of

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Background and Objectives: Urban family physician program(UFPP), a program for improving equity in access to, financing, and quality of health services, is piloting in two provinces of Fars and Mazandaran, Iran since 2012. This study aimed to examine the association between the implementation of program and financial protection measures.
 
Methods: This cross-sectional, ecological study was performed on aggregated data of financial protection measures and some independent variables in the above provinces from 2008 to 2015. At first, the Lasso regression model was used for selecting independent variables affecting financial protection indexes. After adjusting the selected independent variables, in separate models, the association between the UFPP and financial protection measures, as outcome variables, was examined using a backward linear regression model.
 
Results: The percentage of households facing catastrophic health expenditure(CHE) in the years of UFPP implementation was 1.82% higher than the years before implementation(P<0.05). This increase was 1.37% in rural areas. the percentage of medical impoverishment in the two provinces increased by 0.83% during the implementation years than the years before(P<0.05). Finally, no significant relationship was observed between UFPP implementation and the Kakwani index and out of pocket payment(as % of total health expenditure) in the two provinces(P>0.05).
 
Conclusion: Despite the achievements attained by UFPP in improving physical access to health services, it seems that this program has had no success in improving financial protection measures and equitable health care financing. However, further research is warranted in this regard.

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Background and Objectives: One of the decentralized models that has been formed based on universal health coverage is the model of health complexes in Tabriz. This study was conducted to evaluate the model.
 
Methods: This case study was conducted in 2017. Beside observation, 28 individuals, including informed experts in the field of establishment of health complexes in Tabriz University of Medical Sciences, were purposefully selected and semi-structured interviews were also conducted. To analyze the interviews and the results of observations, the framework analysis was used based on the components of the Primary Care Evaluation Tool (PCET) model.
 
Results: The strengths of the health complex model are decentralized planning, strengthening the private sector participation, have more appropriate methods for assessing the performance of the health team, creating a sense of delivering effective services in providers, using electronic information registration system, using the prospective payment method, strengthening the referral system, enhancing service continuity, and facilitating financial and geographical access, especially in marginalized areas. However, there are some problems such as lack of some facilities and equipment, lack of some workforces and high workload, financial instability, and lack of insurance organizations cooperation with the plan.
 
Conclusion: The health complex model has improved organizational, financial, and geographic access to health services. It seems that if the resources are more stable and by cooperation of basic insurances, the results of this project will be better.
 

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Background and Objectives: A feasible and cost-effective tool is required to investigate young children' behaviors with regard to the risk of injury. The aim of this study was to assess the psychometrics of the Persian version of the Injury Behavior Checklist (IBC).
Methods: After validating the translation (backward-forward translation), the final version of the checklist was developed through content analysis and face validity and according to the comments of a panel of experts. The final version was distributed among 300 mothers of children aged 2-5 years referring to the kindergartens of Tehran. Convergent validity was evaluated by internal consistency through calculation of Cronbach's alpha coefficient, as well as item-total correlation. The reliability of the checklist was assessed through the test-retest method with participating 55 mothers and comparison of the scores of the two steps by correlation coefficient and interclass correlation coefficient (ICC).
Results: The content validity ratio was acceptable (0.6-1) for 100% of the items, and the content validity index was 0.93 for relevancy and clarity and 0.92 for simplicity. The Cronbach's alpha coefficient was 0.87. All 24 items of the IBC were acceptably and directly correlated with the total score of the tool (r=0.25-0.65). Reliability results also confirmed the test-retest reliability of the Persian version of the IBC (r=0.90; ICC=0.86).
Conclusion: The Persian version of the IBC is a reliable tool for investigation of risk taking and its association with different injuries in children aged 2-5 years.

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Background and Objectives: Shift work as a pervasive phenomenon in various industrial sectors is one of the most stressful factors in the workplace. Considering the contradictory reports on the relationship of shift work and hypertension, the main objective of the present study was to investigate the relationship between these two variables among petrochemical industry staff of Mahshahr, Iran.
Methods: In this longitudinal study, 3254 petrochemical staff were investigated during 2008-2011. According to work schedule, shift workers were divided into two groups of shift work and day work (1872 day workers and 1382 shift workers). The aim of this research was to assess the effect of shift work on hypertension by adjusting confounding variables such as gender, age, body mass index, and smoking. The data were analyzed using a random-effects logistic regression model.
Results: Of 3254 (3142 males and 112 females) subjects, 37.85% (860 subject) were hypertensive. The random effects model, with controlling covariates, showed no significant relationship between shift work and hypertension (OR=1.04, 95% CI= (0.98, 1.10). Moreover, the variance of the random effects was significant. 
Conclusion: Generally, according to the results of this study, shift work is not a significant risk factor for hypertension.

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Background and Objectives: Shift work could threaten health in the long term. The present research aimed to assess the association between shift work and body mass index (BMI) using the multilevel (hierarchical) model during a particular period of time.
Methods: The data of this longitudinal study were collected from a sample of Esfahan’s Mobarakeh steel and Polyacryl companies personnel during 2008 to 2011. Shift work schedule included day work and rotational shift work. The multilevel regression model was utilized for analysing the data and assessing the effect of shift work on BMI by controlling confounding variables including marital status, work expectation, age, company, and educational level.
Results: In this study, of 1368 workers, 42.3% (n=578) and 57.7% (n=790) were day workers and rotating shift workers, respectively. The mean (±SD) age of the day workers and rotating shift workers was 33.07 (±8.66) years and 33.31 (±8.70) years, respectively. After adjusting for confounding variables in a two-level hierarchical model, the association between shift work and BMI was not statistically significant (P=0.837). About 90% of total variation was related to personnel.
Conclusion: According to the results of the present study, no statistically significant relationship was found between shift work schedule and BMI. Thus, other similar studies with a longer follow up period (more than four years) and controlling more confounder factors are necessary to evaluate the relationship between shift work and BMI more accurately.

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Background and Objectives: Colon cancer is the third most common cancer in the world and the fourth most common cancer in Iran. It is very important to predict the cancer outcome and its basic clinical data. Due to to the high rate of colon cancer and the benefits of data mining to predict survival, the aim of this study was to survey two widely used machine learning algorithms, Bagging and Support Vector Machines (SVM), to predict the outcome of colon cancer patients.
Methods: The population of this study was 567 patients with stage 1-4 of colon cancer in Namazi Radiotherapy Center, Shiraz in 2006-2011. Three hundred and thirty eight patients were alive and 229 patients were dead. We used the Support Vector Machines (SVM) and Bagging methods in order to predict the survival of patients with colon cancer. The Weka software ver 3.6.10 was used for data analysis.
Results: The performance of two algorithms was determined using the confusion matrix. The accuracy, specificity, and sensitivity of the SVM was 84.48%, 81%, and 87%, and the accuracy, specificity, and sensitivity of Bagging was 83.95%, 78%, and 88%, respectively.
Conclusion: The results showed both algorithms have a high performance in survival prediction of patients with colon cancer but the Support Vector Machines has a higher accuracy.

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Background and Objectives: Children’s well-being is a multidimensional construct that precedes various aspects of children's lives. This study sought to identify the main areas of children's wellbeing in Iran and their domains, components, and indicators that can be used to measure the well-being of children in Iran.
Methods: In this Delphi study, 30 experts that had educational, research, and executive experiences in various areas of children’s life were consulted. The dimensions, components, and indicators of children’s wellbeing were extracted through a review of the literature and views of the experts and children. The Delphi method was applied in three rounds. The dimensions and components with a higher-than-average score were selected and the percentage of Delphi members’ agreement with related indicators was measured.
Results: Generally, 25 components and 110 indicators related to 7 domains (physical health, safety and risks, economical situation, family, personal and social well-being, education, housing and living conditions) were selected by Delphi members. Consensus on the relevancy of indicators, proportionality, and comprehensiveness was 100%, 95%, and 86%, respectively.
Conclusion: The components and indicators suggested in this study can help to create a composite index for monitoring and comparing the status of the children’s wellbeing between different provinces of Iran in different times. It can also show the strengths and weaknesses of the policies and programs related to children’s wellbeing and help the government to adopt appropriate policies for the whole country as well as each province.

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Background and Objectives: People living with HIV (PLHIV) experience severe psychological pressure in most communities; however, this pressure is more prominent in women. Therefore, it is very important to monitor different aspect of psychological pressure and psychosocial supports in this group of patients. Based on this need, in this study, we assessed the status of mental health, hope, and social support in female PLHIVs visiting health centers of Kerman, Iran.
Methods: In a triangulation study comprising a combination of qualitative and quantitative components, PLHIV women were recruited and their information were collected using Goldberg’s General Health Questionnaire, Sarason’s Social Support Questionnaire, and the Miller’s Hope Scale.
Results: Our findings showed that female patients’ status improved markedly after visiting the health centers (hope: 92%, general health: 80%, social support: 93%). In addition, the results showed a strong positive the correlation between general health and hope (r=0.61, P<0.0001).
Conclusion: Our results showed that such multi-disciplinary service providing centers may substantially improve the quality of life and general health of these women who rigorously need social support.

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Background and Objectives: Delivery is one of the most important services in the health systems, and increasing its effectiveness and efficiency are a health priorities. The aim of this study was to forecast the number of deliveries in order to design plans for using all facilities to provide patients with better services.
Methods: The data used in this study were the number of deliveries per month in Hakim Jorjani Hospital, Gorgan, Iran during the years 2010 to 2016. Due to the over-dispersion of the data and non-compliance with a Poisson distribution, the Poisson hidden Markov model was applied to predict the frequency of monthly deliveries. The model parameters were estimated using the maximum likelihood method and expectation maximization algorithm.
Results: The use of the Akaike criteria revealed the frequency of delivery in different months in the hospital followed a Poisson hidden Markov models with three hidden states, and the mean Poisson distribution in each component was 193.74, 236.05, and 272.61 labors, respectively.
Conclusion: The results of this study showed that government’s encouraging policies have had short-term, limited effects on increasing fertility with minimal effects on the results of the two-year forecast.

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Background and Objectives: Tuberculosis is a chronic bacterial disease and a major cause of morbidity and mortality. It is caused by a Mycobacterium tuberculosis. Awareness of the incidence and number of new cases of the disease is valuable information for revising the implemented programs and development indicators. time series and regression are commonly used models for prediction but these methods require some assumptions. The purpose of this study was to predict new TB cases using the hidden Markov model which does not require many assumption.
 
Methods: The data used in this study was the monthly number of new TB cases during 2006-2016 identified and recorded in Hamedan Province. Rorecasting the number of new TB cases was done using hidden Markov models using the hidden Markov package in the R software.
Results: According to the AIC and BIC criterion, two states had the best fit to the data, i.e. the data of this study were a mixture of two Poisson distributions with average number of event 5.96 and 10.2 respectively. The results also predicted the number of new cases over the next 24 months based on the hidden Markov model would be between 8 and 9 new cases in each month.
Conclusion: The hidden Markov model is the best model for prediction using the Markov chain. This model, in addition to detection of an appropriate model for the available data, can determine the transition probability matrix, which can help physicians predict the future state of the disease and take preventive measures befor reaching advanced stages.

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Background and Objectives: The pandemic of HIV/AIDS is spreading rapidly in the Middle East, in particular in Iran. Designing an educational program involves assessment of the educational needs of people with valid and culture-based tools. This study was conducted with the aim of psychometric analysis of an instrument for assessment of HIV/AIDS knowledge based on the Iranian culture in different population groups.
 
Methods: In this psychometric analysis, 58 items related to AIDS knowledge were prepared based on a literature review. Then, the face validity  and content validity of the instrument was determent by the impact item score, content validity ratio (CVR), and content validity index (CVI). The reliability of the scale was assessed by Cronbach’s alpha coefficient and test-retest.
 
Results: Based on face validity and content validity, the research scale had 44 items with an item impact score > 1.5, a CVR > 0.49, and a CVI > 0.79. The Scale had three sections, general knowledge about HIV/AIDS (9 items), knowledge about HIV transmission (25 items), and knowledge about HIV/AIDS prevention (10 items). The Scale also had a high reliability (Cronbach’s alpha coefficient=0.77-0.91, ICC=0.88)
 
Conclusion: The results of the study showed the instrument was a valid and reliable scale for measurement of knowledge about HIV/AIDS.

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Background and Objectives: The cause of death in children under one year can be an important tool for designing prevention strategies and reducing the mortality rate. The aim of this study was to estimate the number of deaths in children under one year using the Mr. Murray’s estimation index in Mazandaran Province, and to compare this estimation with reported cases of civil registration organization.
 
Methods: All deaths of children under one year between 2011 to 2014 registered in hospitals across Mazandaran Province were included in this study. The cause of death as coded in the International Classification of Diseases (ICD-10) was converted to Murray classification. The coefficients in each of the Murray levels were used to estimate actual death cases. We compared this estimation with the number of deaths that is reported annually by civil registration organization. 
 
Results: Seven hundred and sixty four deaths occurred in this period. The leading causes of death in children under one year were conditions of the perinatal period, congenital anomalies and chromosomal disorders, respiratory diseases, and diseases of the cardiovascular system. The Murray method estimated 1711 deaths for the entire Province.
 
Conclusion: the Murray method predicted that from 2011 to 2014, 390-445 children under one year died in Mazandaran Province annually. There is a controversy between the estimates obtained in this study and the number of deaths reported by the civil registration organization, which may indicate a defect in a complete registration of deaths by this organization.

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Background and Objectives: Epidemics of diarrhea caused by contaminated food and water occur frequently worldwide, especially in developing countries. The aim of this study was to identify the factors contributing to the development and spread of diarrhea epidemics caused by Shigella  flexneri  in Isfahan in the spring of 2015.
 
Methods: Following the first reports and activation of the surveillance system, a matched case-control study was conducted in 360 cases with diarrhea and 360 controls. Data were gathered using a questionnaire, and conditional logistic regression was used to provide adjusted odds ratios and 95% confidence intervals.
 
Results: Consumption of contaminated fresh vegetable (OR=4.50, 95% CI=2.88-7.01) was the source of the epidemic. Contact with similar patients (OR=7.19, 95% CI=4.26-12.12), presence of similar patients in the family (OR=33.2, 95% CI=13.64-80.82), food consumption on special events (party, wedding ceremony, funeral, etc.) (OR=1.67, 95% CI=1.06-2.62), being a government employee (OR=3.08, 95% CI=1.64-5.78) and being illiterate (OR=2.91, 95% CI=1.10-7.67) were the risk factors of the spread of the epidemic.
 
Conclusion: In this study, consumption of fresh vegetable contaminated with Shigella flexneri was the source of the infection. According to the Epidemic Management Team, contamination occurred due to non-standard wastewater irrigation of agricultural lands. Therefore, it is important to consider the standards of agricultural production and compilation of a comprehensive program to improve the status of the wastewater purification system in the environmental sciences by the relevant organizations to prevent diarrhea epidemics.

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Background and Objectives: The results of recent studies suggest that model-based health education programs are more effective in changing health behaviors. Interventional programs based on health education theories can be used to explain individual and psychological behavioral determinants in order to reduce the risk of HIV/AIDS. This study was conducted with the aim of psychometric analysis of an HIV scale based on model, population and culture of Iran.
 
Methods: We used qualitative and quantitative methods during August 2015 to December 2017. The items were generated based on a literature review and interviews with an expert panel. After providing a primary list of the instrument items, we used content and face validity. The first step of the study was done in a sample of medical and non-medical college and high school student from Zanjan. The exploratory factor analysis, internal consistency reliability, and test-retest reliability of the scale were measured.
 
Results: Fifty-eight items were generated from interviews with experts and review of the literature. After measuring the face and content validity, the items decreased to 53 items. The exploratory factor analysis discovered five factors (perceived susceptibility, severity, benefits, barriers, and self-efficacy), including 30 items for high school students and 31 for university students, that predictive more than 58% of the observed variance. The Cronbach’s alpha coefficient for the sub-scales ranged from 0.80 to 0.86, and the ICC was above 0.86.
 
Conclusion: The results showed that the HBM was a valid and reliable tool for measuring the HIV/AIDS beliefs and could be used in future investigations.

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Background and Objectives: Pulmonary embolism is a potentially fatal and prevalent event that has led to a gradual increase in the number of hospitalizations in recent years. For this reason, it is one of the most challenging diseases for physicians. The main purpose of this paper was to report a research project to compare different data mining algorithms to select the most accurate model for predicting pulmonary embolism in hospitalized patients. This model would provide the knowledge needed by the medical staff fir better decision making.
 
Methods: In this research, we designed a prediction model using different methods of machine learning that would best predict the probability of pulmonary embolism in patients at risk. Among data mining algorithms, Bayesian network, decisions tree (J48), logistic regression (LR), and sequential minimal optimization (SMO) were used. The data used in the study included risk factors and past history of patients admitted to the Lung Department of Shariati Hospital, Tehran, Iran.
 
Results: The results showed that the accuracy and specificity of all prediction models were satisfactory. The Bayesian model had the highest sensitivity in predicting pulmonary embolism.
 
Conclusion: Although the results showed a little difference in the performance of prediction models, the Bayesian model is a more appropriate tool to predict the occurrence of pulmonary embolism in hospitalized patients in this type of data. It can be considered a supportive approach along medical decisions to improve disease prediction.

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Background and Objectives: Human Development Index (HDI) is an important indicator of a country’s development. On the other hand, mortality indicators are the most important indicators of the health of a society. This study aimed to examine the association between HDI and maternal, neonatal, infant, and under-five mortality rates in Iran between 2005 and 2016.
 
Methods: This longitudinal study was conducted using data collected from Iran Statistics Center, World Health Organization, and United Nations Development Program. SPSS software version 22 was used for data analysis. Pearson correlation test was applied to examine the correlation between HDI and mortality rates. Regression analysis was used to measure the effect of HDI on mortality rates.
 
Results: HDI increased from 0.690 in 2005 to 0.774 in 2016 (12% rise). Maternal, neonatal, infant, and under-five mortality rates decreased by 26, 41, 52, and 42% in 2016 compared to 2005, respectively. HDI had a significant indirect association with maternal (-0.973), neonatal (-0.983), infant (-0.739), and under-five mortality (-0.987). An increase of 0.01 in HDI reduced 1 maternal death per 100,000 births. An increase of 0.014, 0.009, and 0.008 in HDI decreased one neonatal, infant, and under-five death per 1000 births.
 
Conclusion: The results showed that increased HDI correlated with decreased mortality rates. Therefore, policy-makers should pay more attention to socio

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Background and Objectives: Periodontal disease is one of the most common oral health problems. Clinical attachment loss occurs in sever periodontal cases (CAL>3). In this study, we applied a classic regression model and the models that consider the hierarchical structure of the data to estimate and compare the effect of different factors on CAL.
 
Methods: This cross-sectional study was performed in 375 pregnant women and 192 mothers of three-year-old children. The data were gathered from 16 health networks of Shahid Beheshti University of Medical Sciences, Tehran, Iran. CAL was determined for 6 teeth per person by a dentist according to WHO standard oral health examination form. Three-level and ordinary logistic regression analyses were applied for data analysis using the STATA software 14.
 
Results: Of 3,402 examined teeth, 6.3% had CAL> 3mm. Based on the obtained results, the odds of CAL>3mm were 2.4 in the third semester compared to non-pregnant women. The odds of CAL>3mm were 2.86 in women without daily floss use compared to women with routine daily floss use. Posterior teeth were more likely to have CAL>3m than anterior teeth (OR = 1.65) (P-value < 0.05).
 
Conclusion: According to the AIC index, multi-level logistic regression model has a better fit than ordinary logistic regression model and can estimate the coefficients of factors related to CAL>3mm more precisely. The use of the ordinary logistic regression model in hierarchical data can result in underestimated standard errors of the estimated parameters.

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Background and Objectives: HPAI has economic and public health importance. Aquatic and shore migratory birds are the main reservoirs and the cause of the spread of viruses across countries. The aim of study was risk assessment of the spread of the avian influenza H5 viruses.
 
Methods: In this qualitative study, structured interviews and focus group discussions were used to assess the risk of the introduction and spread of highly pathogenic avian influenza viruses (H5-subtypes) into Iran.
 
Results: Over 300 wetlands, natural and artificial lakes, ponds, and more than 517 bird species (swans, geese, ducks, and coots) are identified in Iran. Weakness in detecting virus entry windows, weakness in passive surveillance of migratory birds, inadequate supervision on hunting of migratory wild birds, movement of  hunted birds without any criteria without the control of the Veterinary Organization, inability to monitor the supply of migratory birds in the LBMs, law weaknesses in dealing with offenders, lack of training for people, presence of suitable conditions for close contacts between wild birds and backyard and industrial poultry, and weakness of research on AI in migratory birds were the most important factors influencing the spread of these viruses.
 
Conclusion: HPAI will be one of the most important challenges for the poultry industry and public health.  Solving this challenge requires national determination, overhead organizational views, collaborative and practical cooperation of related organizations, and short and long-term planning based on the realities of the country.

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Background and Objectives: Highly pathogenic avian influenza (HPAI) viruses are particularly important due to huge economic consequences and public health concerns. During recent years, because of the severity of epidemics and failure in the control and eradication of HPAI, vaccination has been introduced into the National Prevention and Control Program of some countries, including Iran. This article discusses the role of vaccination in the control of HPAI, the characteristics and constraints of the vaccine, types of commercial vaccines, and previous experiences.
 
Methods: Scientific databases were searched to collect essential evidence on the role of vaccination in controlling HPAI in a variety of poultry and birds with no time and language restrictions. The articles related to the efficacy and effectiveness of the commercial vaccines on at a national level or population-based studies in some farms were included in present study.
 
Results: Because of the high pathogenicity and variability of the influenza virus as well as the shortcomings of some commercial vaccines in prevention of virus transmission, vaccination should only be taken into consideration when all other methods of disease control are ineffective. The consequences of the use of vaccines containing the seeds non-antigenically matched with the circulating strains have been reported frequently.
 
Conclusion: In the national vaccination program, informed policymaking requires evidence based vaccinology that can facilitate development of the national infrastructure with awareness of the limitations of commercial vaccines and the realistic expectations of logistic, financial, and human resources.

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Background and Objectives: Cervical cancer is one of the five most common cancers in Iranian women. Considering the impact of HIV on cervical cancer and the low rate of cervical cancer screening in HIV positive women, this study was conducted to review the barriers to cervical cancer screening in HIV positive women.
 
Methods: In this systematic review, data were retrieved from Magiran, SID, Irandoc, Prequest, OVID, ScienceDirect, PubMed, Web of Science and Scupos databases from January 2000 to January 2018. The following keywords and their combination were used: cervical cancer screening, Pap smear, HIV-positive women, and barriers. The NOS (Newcastle-Ottawa Scale) checklist was used to evaluate the quality of the selected articles and the articles that scored more than six were included in the study.
 
Results: From 145 selected articles, 21 were included in the review based on the inclusion criteria. The most common reported screening barriers were the costs of test, lack of awareness, low education level, younger age, lack of information about screening centers, and fear of sampling. 
 
Conclusion: Considering the barriers to cervical cancer screening, increasing the level of awareness of the HIV-positive women, preparing free Pap smear services, and providing easier access to health centers for this high risk group could lead to early detection of cervical cancer.