Journal of School of Public Health and

---

This cross- sectional study was done to assess the prevalence of chronic cough by age and date of birth (age-period-cohort analysis). Using data from two National Health Surveys in 1991 and 1999 (involving cross-sectional general population samples), we studied all cases of chronic cough recorded during the period of 1991 to 1999 in people aged 2 to 70 years. A birth cohort analysis was performed on the data. Comparison with earlier surveys showed that the prevalence of chronic cough had fallen from 4.5% to 1.8%. Age-period-cohort analyses of the age effect revealed that prevalence rate of chronic cough increased with age but in every age group it actually decreased after the 8-year period. The fact that different trends are observed in cross-sectional and cohort data points to a strong cohort effect. the prevalence of chronic cough is strongly determined by a person’s year of birth. Also for any given age group, prevalence rates were lower in younger compared to older cohorts.

---

Considering the importance of the mass campaign for measles-rubella vaccination in the elimination of measles and Congenital Rubella Syndrome, and also the necessity of the accurate quantitative and qualitative assessment of the process of this program and the estimation of the information coverage regarding the passive launch of the program, this assessment has been carried out within the population covered by Tehran University of Medical Sciences using a standard method. This study is descriptive- analytical. The necessary sample size was defined as 390 people for the estimation of the immunization coverage, 190 people in each step of the information coverage (and a total of 570 people for the overall three steps), and finally 24 executive teams for the assessment of the quality of the service. Lot Quality Assurance Sampling and subsequent analysis were used for the assessment of service quality, with the upper threshold set at 80% and the lower threshold at 30%. Each lot was defined acceptable or unacceptable based on the quality of the vaccination, the cold chain, the competence of the human resource, and the availability of the necessary materials and equipment. Data analysis was done using the Chi Square and Fisher’s exact tests. 96.4% (95% CI: between 94.6% and 98.2%) of the people between 5 and 25 years old had received the MR vaccine. 7 people (1.8%) of the vaccinated people were not in the target group of vaccination. From the total 190 people who were studied on the basis of information coverage, 152 people (80.9%), 184 people (96.8%) and 190 people (100%) were informed about the mass campaign for MR vaccination in the first, second, and the third steps respectively. More than 80% of the people were informed about the program through TV. The quality of the vaccination was acceptable in 19 executive teams (79.1%) and unacceptable in the other 5 executive teams (20.9%). In this study, the quality of the cold chain was acceptable in 23 executive teams (95.8%) and unacceptable in one team (4.2%). The competence of the human resource, the necessary materials and equipment for MR vaccination was acceptable in all 24 executive teams under study (100%). The enforcement of the mass campaign in such short period of time compared to similar programs in other countries demonstrated the success of the collaborators in the execution of this program. Overall it seems that regarding the quality of vaccination, information coverage, and the provision of materials and equipment in health centers of the districts, the program has achieved its goals.

---

Awareness regarding incidence pattern of disease is an important issue for researchers. To explore seasonal pattern of TB in Iran we decided to do this study. This study have been done as an ecologic study .all notified TB cases during 1997 to 2001 have been included in this study .all data have been processed and analyzed by the Cosinor analysis method. We found 59756 registered TB cases during above mentioned years. TB in this 5 year period has seasonal pattern (amplitude=11.73% ,acrophase=13 June(85.23) , p<0.000) . Frequency of TB cases evaluated by sex in this model and found that there is seasonality by sex too (p<0.000) , but different amplitudes found for female and male(13.35%, 10.5%) and point estimate of acrophase for them were consequently 18 June and 8 June . When we evaluate this pattern among smear positive and smear negative cases found that smear positives have seasonal pattern (p<0.000) . Association of TB frequencies in quarters and mean temperature of each quarter have been evaluated by ANOVA in different 4 temperature groups(p< 0.020) ,and a significant difference have been found between 10-20 and 20-30 temperature groups(p<0.051) . According to this study there is a seasonal pattern in TB notification (incidence) in Iran which should be notified in population based studies and surveys in this regards. Comments: We recommend performing more studies on patterns of pulmonary disease, other relevant factors on TB involvement and also laboratory circulation to clarifying cause of existing seasonality

---

Background and Aim: Limitations of the traditional methods for assessing G*E interaction- including case-control studies- led to development of several non-traditional approaches. This study aims to assess the interaction between the genetic background (history of breast cancer in first degree relatives) and environmental influences (reproductive/menstrual factors) in patients with breast cancer we also compare the statistical efficiency and power of case-control and case-only designs in this setting.
Materials and Methods: In a matched case-control study in Mazandaran province (Iran), 250 incident biopsy-proven cases of breast cancer and 250 age-matched neighbor controls were interviewed. History of breast cancer in mother and/or sister(s) was taken as a surrogate measure of genetic predisposition, while age at first birth, parity, breast feeding, age at menarche and irregular menstruation were considered as relevant environmental factors. For the matched case-control design, we used a conditional logistic regression model to examine main effects and the G*E interaction. In the case-only design, logistic regression analysis was applied to obtain an estimate of G*E interaction, after checking for the independence assumption. We also calculated the power for detecting the interaction by matched case-control and case-only analyses.
Results: Age at first delivery did not meet the assumption of independence (p=0.02), and so was not included in the case-only analysis. No statistically significant interaction effect was seen in the case-control analysis, while case-only analysis showed significant negative interaction between disease in first-degree relatives on the one hand and parity and breast feeding on the other. We also detected a significant positive interaction between genetic predisposition and age at menarche. All the estimated 95% confidence intervals for OR in G*E interactions were narrower in the case-only analysis. For all factors, the power for detecting G*E interaction was greater in the case-only analysis compared to the case-control analysis, with ratios ranging from 1.08 to 2.23.
Conclusion: The case-only design is more efficient and powerful than the case-control design for detecting gene-environment interaction under the assumption of independence. Baseline disease risk, interactions and independent effects should be considered in using the control data for checking the assumption of independence. Considering the existence of another explanatory variable, eg. a mutant gene which may have passed unnoticed, would be the safest approach in a case-only study.

---

Background and Aim: In 1991, the world health organization initiated a project to simultaneously develop an instrument for measuring quality of life in 15 countries. The study yielded two questionnaires, namely WHOQOL-100 and WHOQOL-BREF. These were intended as generic QOL measurement tools to be used in a broad range of diseases, for different degrees of disease severity, and in various cultural subgroups. The objective of the current study was to evaluate the Iranian version of the WHOQOL-BREF. This 26-item instrument comprises four domains: Physical Health, Psychological, Social Relationship, Environment and the overall QOL/health.
Material and Methods: We administered the questionnaire to 1167 adults in Tehran. The stratified sample consisted of 476 diseased subjects and 700 healthy ones. We tested the instrument's reliability (internal consistency, test-retest), discriminant validity and factorial structure.
Results: The participants had an age mean of 36.3 years (SD = 13.2) and had an average 11.5 years of education. Using Cronbach's α and intraclass correlation, all domains met the minimum reliability standards, with the exception of social relationship domain (α = 0.55). The latter could be attributed the small number of questions in this domain and the sensitive nature of the questions themselves. Since 83% of the questions show maximum correlation with their original domain, the factorial structure of the questionnaire was regarded as acceptable. The questionnaire has the ability to discriminate different groups after adjustment for confounding factors in regression analysis.
Conclusion: This study demonstrated good to excellent reliability and acceptable validity in various groups of subjects in Iran. The instrument may be used in future studies, albeit with minor modifications in the domain of social relations, as determined by expert opinion.

---

Background and Aim:  One of the biggest problems faced by parents of handicapped children is the child's health care. This study investigates patterns of heath care utilization and the related factors in children with mental impairment.

Material and Methods: This cross-sectional study involved 110 children (≤14 year old) with developmental disabilities in Tehran. Parents were selected by systematic random sampling for face-to-face interview.  Statistical analysis was based on negative binomial regression.

Results: Over 99% of the surveyed children received ambulatory care and 15 % had been hospitalized over the preceding year 0.9% had never used health services. These children had utilized health services 207+18 times in a year. Among these services 38+3 were not subsidized by the State. Factors affecting service utilization were parent information (p<0.033) and referral to the proper service delivery points (p<0.029).

Conclusion: Appropriate interventions are required to address the above-mentioned factors and improve service utilization.

---

Background and Aim: Undercounting is a common problem in surveillance systems and registries. One of the procedures has been used for assessing sensitivity of a surveillance system or completeness of a registry is capture-recapture method.The objective of the present study was to estimate the number of deaths due to road traffic injuries applying capture-recapture method and using three data sources: police, legal medicine organization and hospital.

Material and Methods: All of the deaths due to traffic injuries occurred within Kerman district in the year 2000 were derived from police, Shahid Bahonar hospital and Kerman legal medicine data sources. Matching cases between the lists was based on three characteristics: first name, family name and date of accident. Loglinear model was used for statistical analysis.

Results: The total number of identified cases was 471 the best fitted loglinear model estimated the actual  number of deaths as 596 (CI 95%: 543-686). Based on Iranian Statistical Center estimates, the population of Kerman district in the year 2000 has been 644673 so the cause-specific mortality rate of traffic injuries is estimated as 92 (CI 95%: 84-107) per 100,000 population. Therefore the proportion of deaths registered in police, legal medicine and Shahid Bahonar hospital are 16%, 58% and 48% respectively. The coverage of total deaths (471) is about 79%.

Conclusion: The findings showed that none of the data sources had enough coverage of all deaths due to traffic injuries. Capture-recapture estimates can help for obtaining better estimates.

---

Background and Aim: In the past few years publications in the field of medicine have increased considerably in Iran and knowledge production in this country shows the greatest growth rate in the entire Middle East region. Considering the fact that 12% of all faculty members in the health and medical sector in Iran are employed by Tehran University of Medical Sciences, this university is regarded as the country's leading research institution. This study is focused on the behavior of the researchers in this university in terms of collaboration in research and factors that affect such behavior.

Materials and Methods: Our samples included all research projects in Tehran University of Medical Sciences that had obtained grants from inside and outside the university in 2004, had registered their contracts, had been finished by the time of this study (October 2006- March 2007) and whose final reports had been submitted (315 projects). The data collecting forms were filled for 301 files. The researcher's questionnaire was sent to the principal investigators of the projects and eventually 208 questionnaires were collected. We used the SPSS software package and the usual statistical tests (frequency ratio, chi square, analysis of variance and multiple linear regression with the Enter method) to assess the factors affecting the participation scores of individuals. Based on the data gathered from the forms, we used the UNICET software to analyze the 'cooperation network' between project directors and their principal co-workers and the relationship between different sections of the university.

Results: Only in 2.2 percent of the projects whose contracts were arranged in 1383 there has been some cooperation between the project director/principal coworkers and non-academic organizations. This ratio reaches 2.5% for collaboration with other universities. Among all projects, health system research programs show a better status of collaboration. Linear regression analysis showed that another important factor affecting the participation score is the "method for choosing the research topic". University-affiliated research centers only collaborate with the Schools of Medicine and Public Health, while in the School of Rehabilitation and Physical Medicine all projects are defined within the School's own structure, with virtually no collaboration with any other sections of the university.

Conclusion: The present study showed that research programs in this university include little collaboration with organizations outside the university or with other universities. Part of this is related to the current structure of the research sector in the country, which is largely financed by the government with hardly any participation by the private sector. Current potentials within the University make it possible to embark upon joint research initiatives with other academic institutions. As the possible effect of intervention on health system research has been shown, policies can be implemented to promote effective collaborative research at university and national level.

---

Background and Aim: Cigarette smoking is a global problem, but is decreasing in most developed countries. Reports from the East Mediterranean show that unlike the 5 other WHO regions, cigarette smoking has not decreased in this particular zone. There is a vital need to address the problem, especially in the adolescent population. This qualitative study looks at the motives behind the smoking tendency in boys aged 13-15.

Materials and Methods: The study consisted of 6 focus group discussions performed in Tehran orientation (intermediate) schools participants were male students aged 13 to 15 years. Purposeful sampling was used to draw in participants who were willing and able to take part in the group discussions. Each group was composed of 6-8 students, whose voices were recorded to determine themes and subthemes.

Results: Family and social factors have a more prominent role in creating the smoking tendency compared to individual factors. The most important elements are family history of smoking, having friends who smoke, poor parental control, conflicts at home, divorced parents, failure to consult with parents, easy availability and relative cheapness of cigarettes, and lack of information.

Conclusion: Serious attention must be paid to the social and family factors in the initiation of the smoking habit. Social and political institutions must come up with effective programs to control the social and family factors that have a role in creating the smoking tendency.

---

Background and Aim: Breast carcinoma is the most common type of cancer in women. It has been estimated that 8-9 percent of all women will develop breast cancer during their lifespan. According to The Iranian Ministry of Health and Medical Education, the incidence of breast cancer in Iran has risen between 1984 and 1988 and the current mortality rate from this kind of cancer ranks fifth in the country.

Materials and Methods: In this case-control study, 110 patients with breast cancer (ages 20-60 yrs) were compared with a similar number of age- and sex-matched women hospitalized for other reasons. Cases were women with histologically confirmed in situ or invasive breast cancer diagnosed no more than 1 year before the interview and with no previous diagnosis of cancer at other sites. Controls were drawn from either patient relatives or from women with no history of cancer admitted to Imam Hospital for acute, non-neoplastic, non-gynecologic conditions unrelated to hormonal or digestive tract disease or to long-term diet modifications. We calculated odds ratios and performed Mantel-Haenzel as well as logistic regression tests to control for potential confounding factors.

Results: Odds ratios [with 95% confidence intervals] for total fat, saturated fatty acids, monounsaturated fatty acids (MUFA), polyunsaturated fatty acids (PUFA) and cholesterol were 1.97 [1.062-3.67], 1.19 [0.64-2.14], 2.2 [1.17-4.13], 4.11 [2.2-7.65] and 0.45 [0.25-0.83], respectively. After adjusting for energy, macronutrients, weight, age at first full-term pregnancy and the socioeconomic status, it emerged that the intake of PUFA (OR=6.38 and 95%CI: 1.95-20.83) had a positive association with breast cancer while cholesterol (OR=0.22 and 95%CI: 0.09-0.55) showed a negative relationship, though the latter finding only applies to menopaused women.

Conclusion: Undoubtedly, dietary factors involved in the etiology of breast cancer take many years to cause any pathologic changes in any organ. Nonetheless, one-year frequency of lipid intake is a good measure of individual's dietary habit throughout his/her adult life. Based on this, the present study suggests that increased PUFA intake- probably due to its high pro-oxidant potential- can be considered as a key factor in the rising incidence of breast cancer in Iran.

---

Background and Aim: Amblyopia is an important cause of weak vision and blindness. A preliminary study on validity of the current screening program in Shahrood City's kindergartens showed that this method may not be efficient enough, especially because of low sensitivity and referral problems. We tried to compare efficiencies and costs of screening by trained staff and optometrists in detecting patients.

Materials and Methods: We conducted a cost-effectiveness analysis using the decision-tree method. We replaced nurses with optometrists to compare costs per detected case by the two screening methods. The number of detected cases and costs per each detected case are compared. Also, the cost-effectiveness of four criteria screening examinations (with different validities) used by optometrists was estimated.

Results: Costs per case detected by optometrists and by current screening methods were 270000 and 556000 Rails (Rs), respectively (with baseline examination criteria and 6.4% prevalence). With a lower prevalence of amblyopic patients, CER (cost-effectiveness ratio) will increase in both methods, but the increase in the current screening method is less than the optometric method. In the optometrist method, avoidable costs and savings per detected case vary from 250000 Rs at a prevalence of 7.4% to 1185000 Rs at a prevalence of 1.4%. Sensitivity analysis showed that costs of "monitoring of screening" in the optometrists method and costs of "follow up in the current screening method" have strong effects on CER CER will decrease by 9.6% and 15%, respectively, if this costs decrease to 25%.

Conclusion: The cost, per detected case, of screening amblyopia by optometrists in kindergartens is half that by the current method. In areas with a low prevalence, the efficiency of screening by using optometrists increases remarkably.

---

Background and Aim: In social marketing, the common techniques of commercial marketing are used to increase the chances of acceptability of an idea or action by the target group. In this study, we determined the impact of an intervention based on social marketing to reduce risky driving behaviors among taxi drivers in Tehran.

Materials and Methods: This was a quasi-experimental study, consisting of a quantitative and a qualitative part, on taxi-drivers in 2 regions (an intervention and a control groups) in the City of Tehran. Based on a formative research approach, the components of social marketing, namely, the product (reminder message for concentrating on avoidance of two target behaviors, tailgating and not driving between lines), price, place and promotion were determined. An 8-week educational program was implemented, the components being installation of stickers before the driver's eyes, distributing a pamphlet, and transferring messages through taxi route supervisors as opinion leaders. After six weeks, risky driving behaviors were assessed by checklists and compared.

Results: The intervention resulted in statistically significant reductions in the two target behaviors in the intervention group as compared with the control group. Furthermore, logistic regression showed that the odds ratio for avoiding both behaviors increased significantly in the intervention group. 

Conclusion: Determining specific target groups, designing interventions based on actual needs and wants of the target group, and focusing on the factors influencing the behavior market are the basic elements of social marketing. Due consideration of these elements when designing behavioral interventions would lead to reductions in risky driving behaviors.

---

Introduction: Development of effective antiretroviral therapies (ART) has reduced mortality and increased life expectancy among individuals with HIV infection. Antiretroviral therapy regiments have improved symptoms and quality of life among these patients, whose sexual and reproductive needs, have, therefore, increased as well. In 2010, 20.8% of HIV-infected Iranians acquired the disease through sexual relations. The objective of this study was to define high-risk sexual behaviors among individuals infected with HIV referred to the Triangular Clinics of Universities of Medical Sciences in Tehran.

Materials and Methods: This cross-sectional interview-based survey included 400 HIV-positive individuals selected by consequential sampling.

Results: The majority (60%) of the subjects was males, and 44.2% of men and 51.3% of women with HIV were in the age group 34-25 years. On the whole, 15.6% of the women and 49.6% of the men had high-risk sexual behaviors after diagnosis of HIV infection. Further analysis of the data showed that 62.5%  of HIV-positive individuals were not aware of the risks of unsafe sexual relationship (using no condom) for HIV-positive transmission.. Based on the logistic regression module, it was found that factors strongly associated with high-risk sexual behavior were being male, being single, under high school diploma/graduate degree, alcohol intake and use of hormonal and permanent methods of family planning  (p<0.05).

Conclusion: The findings of this study confirm previous reports showing common high-risk sexual behaviour after diagnosis in HIV-positive populations. Providing suitable health services and advice on fertility and sexual health will result in no- or low-risk sexual life for couples.

---

Background and Aim: Child abuse is a social problem that affects the lives of children. The purpose of this study was to design a valid and reliable Persian questionnaire to measure the status of child abuse. Materials and Methods: Content validity was measured with search of relevant electronic databanks, preparation of the first draft of the questionnaire and determinant of its relevancy and clarity. Reliability was measured with Cronbach’s alpha, and repeatability was measured with intra cluster correlation through test-retest with two weeks interval. Results: The mean of clarity and relevancy of the tool were 80.36% and 92.5%, respectively, and rang of these two measure were 90.14 - 97.2, also. The average of intra cluster correlation (ICC) and Cronbach’s alpha were 0.95 and 0.92, respectively. Conclusion: The new tool has acceptable validity and reliability and is suitable for child abuse studies in Iran.

---

Background and Aim: MS is a chronic and destructive inflammatory disease with a not contradiction continuing of life but can influenced the quality of life of patients. The purpose of this study is to determine the quality of life in MS and its related factors. Materials and Methods: This cross-sectional study was performed on 172 patients admitted to the MS Society of Iran (Tehran) and convenience samplings were obtained for 10 months. Tools for data collection were MSQOL-54 and MS patients were also interviewed. Data using descriptive and Analytical tests such as multiple regression were analyzed. Results: The mean age of patients was 34/8 ± 9/6 years. Analysis of 14 sub-domains of quality of life questionnaire showed that the highest average score in the domain of quality of life was social functioning (71/7 ± 21) and the least was role limitations due to physical problems (44/2 ± 39/4). Results of multivariate regression models shown that between age has an significant inverse relationship to domain of physical combined and only variable significant on the combined domain of psychological – psychiatric, Area residential Variable was (p.value 0/001). Conclusions: The study shows that demographic variables medical and economic factors influence the quality of life of patients with multiple sclerosis. Identify the factors related to the quality of life of these patients can be helpful in predicting quality of life. The variables influence on the quality of life for MS patients must be targeted in designing effective intervention programs to improve their quality of life.