Iranian Journal of

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Background and Objectives: Traffic accidents are a leading cause of disability and mortality worldwide. This study was conducted to determine the days of disability and severity of injuries caused by traffic accidents in patients admitted to Imam Khomeini Hospital, Urmia in 2016.
 
Methods: This cross-sectional study was performed on 1705 traffic accident victims admitted to Imam Khomeini Hospital, Urmia in 2016. Data were collected using a checklist containing demographic information, accident, severity of injury, and days of disability along with a telephone follow-up after 3 months upon return to work or school. The ISS (Injury Severity Score) was categorized from 1 to 6 according to the experts’ opinions.
 
Results: The results showed that 1231 subjects (72.1%) were male and the mean and SD age of the participants was 33.63 (30.00) years. Moreover, 77 (0.04%) of the subjects died and 593 (42.5%) resumed a normal life after two months. The mean time to resuming a normal life was 86.78 (24.104) days. Most of the subjects had mild limb injury, while the majority of the deaths had life-threatening injuries.
 
Conclusion: In this study, most of the victims were male, married, young, and concerned about financial compensation. The majority of the deceased had life-threatening injuries requiring vital measures to return to work quickly.
 

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Background and Objectives: Clinical trials are used extensively in the compilation of systematic review studies and clinical guidelines. Critical appraisal of articles is a part of systematic review writing and also effective in citation. This study aimed to evaluate quality of randomized clinical trial articles of Mashhad University of Medical Sciences with consideration report of randomized, blindness, and allocation concealment methods in them.
 
Methods: In this study, all randomized clinical trials with Mashhad University of Medical Sciences affiliation indexed in PubMed by 2018 were evaluated.
Results: Of 257 eligible articles, dentistry (n=44 , 17.1%) , obstetrics and gynecology (n=28 , 10.9%) and internal medicine (n=23 , 8.9%) had the highest relative frequency of published randomized clinical trial articles. Eithy-three articles (32.3%) reported the randomization method and most of them (86.9%) used simple randomization. Blinding was done in 138 papers (53.7%) with double blinding being the most common (70.2%). Only three articles (1.2%) reported allocation concealment.
 
Conclusion: The report of "random allocation and randomization" in articles was far less than acceptable. It may seem that there may be different biases in the methodology. Upholding the principles of scientific writing and avoiding errors and biases increase the validity of the scientific articles and citation, which is one of the criteria of the scientific ranking of top universities.

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Background and Objectives: A great number of tuberculosis (TB) patients present to the private sector to receive care; therefore, integrating TB control programs into private sector activities can enhance the control of TB. The Public-Private Mix (PPM) program is suggested by the World Health Organization to engage the private sector in TB control programs. In this study, a plan designed for PPM was piloted Karaj, Alborz Province, Iran.
 
Methods: In this community trial, pre-intervention assessment covered 18 months prior to the study. The intervention was a PPM package that was integrated into the health system by Karaj County Health Center. Then, three-month post-intervention data were collected. Analysis was performed with the SPSS 16 software using chi-square test.
 
Results: After the intervention, there was an increase of 40.7% in suspected cases of TB per month and an increase of 101.7% in smear positive TB cases diagnosed by Karaj laboratories. The ratio of smear positive cases to all suspected TB patients was 4.57% before and 6.56% after the intervention. The percentage of three sputum sample positive patients was 75.5% and 89.9% before and after the intervention, respectively.
 
Conclusion: The developed PPM program markedly improved the case detection; therefore, it is suggested to fix the potential defects of the program and implement it in all parts of the country.

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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: Water and foodborne diseases are major causes of mortality worldwide. The aim of this study was to investigate the factors affecting an gastroenteritis outbreak in Hamadan county in summer of 2019.
 
Methods: This study was performed based on the outbreak investigation process. After producing hypotheses based on preliminary field studies, a case-control study was conducted on 45 cases and 45 controls to investigate the factors associated with the outbreak. New cases of the disease were included according to the case definition. A logistic regression model was used to investigate potential risk factors.
 
Results: A total of 171 people were affected in this outbreak from 25 June 2019 to 01 July 2019. The at-risk population in this outbreak was 3410 individuals. The attack rate was 5.1%. Abdominal pain, vomiting, and nausea were the most common symptoms with a prevalence of 77.8%, 73.3% and 68.9%, respectively. The results of the case-control study showed that the consumption of tap and spring/well water increased the odds of disease by 4.63 and 4.13 times compared to boiled water, although these relationships were not statistically significant. The odds of diseases were significantly lower in people aged 30-45 years and 46-85 years compared people aged 15 years old and younger.
 
Conclusion: Based on the results of this study, the outbreak was related to contaminated water consumption. Therefore, regular monitoring of drinking water status is very important for the local health system.
 

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Background and Objectives: Randomized clinical trials are the gold standard for evaluating the effectiveness and safety of medical interventions. Some unpredictable challenges may affect the results of these studies. Therefore, the aim of this study was to identify the challenges of clinical trial studies in different stages including design, conduct, analysis, and reporting.
 
Methods: This study was a qualitative study using content analysis performed from 2017 to 2019. The study population included 13 clinical trial experts who were selected through purposeful sampling. Semi-structured interviews were conducted with all subjects. Data saturation was achieved after 13 interviews.
 
Results: Among the 4 steps of design, conduct, analysis, and reporting, the majority of the challenges were related to conducing randomized clinical trials. Lack of knowledge of researchers, subjects, sponsors and physicians and supervisory and ethical challenges were the main challenges related to performing these studies. Poor design and lack of clinical equipoise were considered as the main challenges in the design step. Inappropriate analytical methods due to the absence of statistician in these studies were considered as the most common challenge related to analysis. Finally, lack of familiarity with international guidelines was the most important challenge in reporting.
 
Conclusion: There are many challenges in different steps of clinical trial studies. Therefore, additional education sessions focusing on the related guidelines and standards as well as GCP workshops for researchers can be helpful.

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Background and Objectives: The widespread use of the Internet has created new issues in the field of psychological studies. One of these emerging constructs is Internet anxiety. The purpose of the present study was to investigate the construct validity of the Internet Anxiety Scale in students.
 
Methods: In a descriptive, validation study, 206 and 289 students from Farhangian University Branches of Mashhad were selected through multi-stage sampling and completed the Internet Anxiety Scale and Internet Self-efficacy scale, respectively. Internal consistency, exploratory and confirmatory factor analysis, criterion and constructive validity were evaluated using SPSS.25 and AMOS.24 software.
 
Results: The results showed that the scale had a two-factor structure with an explained variance of 55.82%. Confirmatory factor analysis was confirmed. The scale had good construct reliability. The divergent validity confirmed in relation to Internet self-efficacy (P<0.01). There was no significant difference in age (P>0.05). Gender differences were significant for fear of negative evaluation (F=6.53, P<0.01) and internet anxiety score (F=7.22, P<0.01), and girls had higher mean scores. Differences were significant according to field (P <0.01) and Science and Foreign Language students had the lowest and the highest mean score, respectively (21.37 and 27.05).
 
Conclusion: It seems that the Internet Anxiety Scale has a good reliability and validity in students.

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Background and Objectives: Studies investigating life skills and general health have mainly focused on some skills or parts of health. In this study, ten components of skills and three components of general health were examined in patients presenting to veterans’ health and counseling centers in Tehran and the relationship between each skill and multiple levels of general health was assessed.
 
Methods: this cross-sectional study was performed on 600 randomly selected service users. Data were collected using two standard questionnaires and analyzed using t-test, one-way ANOVA, Tukey post hoc and multivariate regression. Lisrel-8 path analysis and software were used to investigate the causal relationships between variables and the way a skill affected general health.
 
Results: The highest mean scores of skills were related to emotion management, critical thinking, social support and creative thinking, decision making, stress management, self-awareness, empathy and effective communication and problem solving. The results of path analysis showed a strong link between overall life skills and general health. The effect of skills on social performance was more than other components of health.
 
Conclusion: The contribution of emotion management, creative thinking, effective communication, and stress management skills to the prediction of general health was more than other life skills. Considering the importance of general health, it is recommended that educational programs be implemented with focus on these population subgroups to improve their skills and general health level.

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Background and Objectives: Correct and timely detection of the outbreaks of diseases with a short incubation period is of great importance in the health system. The aim of this study was to determine the detection of dysentery outbreaks using the cumulative sum method.
 
Methods: This time series study was conducted using the data of the National Surveillance System between 2014 and 2017. The outbreak alert threshold of each season and province was determined separately using the average of three years (1393 to 1395) in the same season and province. The dysentery outbreak in each season was exclusively predicted for Isfahan, Khuzestan, and Hamadan provinces in 2017 using the CUSUM method.
 
Results: In Isfahan Province, the outbreak alert was higher in the spring and summer and lower in the autumn and winter using the current method compared to the CUSUM method. For Khuzestan Province, the current outbreak alert was significantly higher in all seasons compared to the CUSUM method, while the current outbreak alert was lower than the alert predicted by the CUSUM method in Hamadan Province in all the seasons.
 
Conclusion: Compared to constant threshold-based methods, using the CUSUM method seems to be a better way for reporting outbreaks, especially in areas with a high incidence.

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Background and Objectives: The purpose of this study was to adopt and calibrate the fracture risk assessment algorithm FRAX® for the Iranian population and to provide the required guidance on how to apply it in clinical practice. 
 
Methods: The age-specific ten-year probability of major osteoporotic fractures was calculated in women with an average BMI to determine the fracture probability at two potential intervention thresholds. The first threshold was the age-specific fracture probability associated with a femoral neck T-score of -2.5 SD and the other was age-specific fracture probability in women with a history of fracture without BMD. Current Iranian guidelines were used to define these thresholds. The effect of adding BMD values to the assessment of these thresholds was also evaluated separately.
 
Results: Similar to women with a previous fracture, the 10-year probability of a major osteoporotic fracture increased from 4.9% at the age of 50 years to 17% at the age of 80 years. When using a BMD T-score of ≤−2.5 SD as the intervention threshold, the FRAX probability was twice as high in women aged 50 years as in women of the same age with an average BMD and no risk factor. The FRAX probability increased with age but a T-score of -2.5 SD was actually protective after 80 years or age.
 
Conclusion: Intervention thresholds based on BMD alone cannot effectively identify high-risk women for fracture, particularly in advanced ages. Using fracture probability based on ‘fracture threshold’ can help to improve the identification of these women.

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Background and Objectives: At present, investigation of extensive contact of tuberculosis (TB) patients’ families is not a routine part of TB control efforts in most countries. This study was conducted to evaluate the effective contacts of TB cases to assess the potential risk of transmission and its determinants in their families.
 
Methods: In this cross-sectional study, registered TB cases in Kerman, Iran provided information about their family size and type and frequency of unprotected effective contacts with their families from 2014 to 2015. The unprotected effective contact was defined using the Centre for Disease Control (CDC) classification (2005) based on the close, frequent, and long-term contact of TB cases. The demographic variables and the frequency of effective contact were analyzed using a logistic regression model with Stata version 12 with 95% confidence intervals.
 
Results: Overall, among 407 contacts of 74 TB cases, 73% had effective contacts. Having an effective contact was significantly higher among females (Adjusted Odds Ratio (AOR)=5.1; 95% CI:1.9-13.7); those with a lower education level (AOR=4.0; 95% CI: 1.4-15.1), lower income (AOR=7.7; 95% CI: 2.2-27.0), and a house size ≤80 m2 (AOR=16.6; 95% CI: 5.1-54.3); Afghan patients (AOR=30.2; 95% CI: 3.4-272.1); and those living in the rural areas (AOR=4.9; 95% CI: 1.8-21.9).
 
Conclusion: It seems that unprotected effective contact with the family members is high among TB patients, which can be a serious concern for the control of TB in this area. Reducing these unprotected effective contacts through educating patients and their families besides screening of the family members can help the health sector to decrease the burden of TB in Iran.

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Background and Objectives: Avian influenza (AI) is one of the most important respiratory diseases in the poultry industry that causes huge economic impacts and plays an important role in public health. H9N2 Avian Influenza Virus (H9N2 AIV) has a broad circulation and causes endemic infections in the poultry industry of the country.
 
Methods: A cohort study was conducted from July 2016 to November 2017 in broiler chicken farms of Qazvin Province, Iran to detect H9N2 AIV infection determinants in broiler chicken farms.
 
Results: Sixteen out of 34 units that were included in the study had positive PCR results. Some variables such as “type of fence around the unit”, “biosecurity”, “cooling system status”, “mean maternal antibody titers”, “location height”, “proximity to public traffic lanes” and “number of units within a radius of 1 km” had significant effects on the infection occurrence in poultry units according to univariate statistical analyses (P<0.05). However, only two of them (“biosecurity” and “cooling system status”) were statistically significant in multi-variable analyses (P<0.05).
 
Conclusion: Biosecurity measures should be implemented more seriously and strictly in broiler farms to reduce the impact of H9N2 AIV infection.

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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: Investigation of child mortality is one of the most important strategies for improving children's health. The purpose of this study was to investigate the age distribution, trends, and projections of mortality in children under 5 years old in Khorasan Razavi province.
 
Methods: The study population included under-5 mortality data from Khorasan Razavi Province during 2012-2017 extracted from the Causes and Mortality Classification System of Vice-Chancellery of Health, Mashhad University as well as five universities and faculties. Cause of mortality was classified according to the ICD10 codes. Data were controlled using the ANACod software. Descriptive statistics methods and autoregressive integrated moving average (ARIMA) modeling were applied to explore the mortality trend during the time of study using the Minitab.15 and STATA16.
 
Results: According to the results, the highest mortality rate for children under five was in 2014 and the lowest in 2017. Using the differencing method, the data were stabilized. Finally, the ARIMA model (1,1,2) was identified as a suitable model using the MINITAB software.
 
Conclusion: The mortality rate of children under five has declined sharply in the last four years in Khorasan Razavi Province. It is predicted that this reduction will continue according to fitted model. However, we are still far from mortality rates in developed and some developing countries; therefore, efforts should be made to reduce the under-five mortality rate by increasing the level of health services, the awareness level of families, and improving maternal and childbirth care.

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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: 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: 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 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: 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: 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.