Journal of School of Public Health and

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This cross-sectional study was conducted from May to September 2003, with the aim of determining quality of service in 25 State-run family planning clinics in Hamadan city. A total of 400 consultations were observed and assessed using UNICEF quality checklists. Results showed that less than 50% of the clients are receiving service of a satisfactory quality areas of care where quality was worst included history taking, physical examination and counseling. It became apparent that care providers with higher education had lower performance levels compared to their less educated colleagues. Service for new clients was of poorer quality than for those who had requested a change of contraceptive method. Furthermore, earlier hours of a work shift (before 10 o’clock) were associated with better service quality than later hours. Altogether, the study reveals serious flaws in areas such as training of family health workers and human resource management within the current system. To address these shortcomings, we recommend a more client-oriented approach in health care, use of supplementary material to promote client knowledge, and training of health workers with due emphasis on effective communication and performance.

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In recent years the patterns of mortality have changed in Iran, and cancers are playing a greater role in this regard in this country. Various reports indicate that gastric cancer is highly prevalent it is the second most common cancer in men, and fourth in the general population. The purpose of this study was to determine the five-year survival rate of gastric cancer patients who had undergone surgical treatment at one of the most important cancer treatment centers, the Iran Cancer Institute, and to assess its associated factors. Three hundred and 30 patients with gastric cancer who had been admitted to and operated on at the Iran Cancer Institute between January 1996 and April 2000 were enrolled in this study. The patients’ life expectancy after surgery was determined, and its relationship with variables of age at the time of surgery, gender, and factors related to the disease such as the cancer site, pathologic type, stage, presence of metastasis, and sites of metastases were assessed. The five-year survival rate and the median life expectancy in the studied patients were 23.6% and 19.90 months, respectively. Univariate analysis showed that gender, cancer site, and pathologic type did not affect life expectancy significantly. But the five-year survival rate significantly decreases with age. As expected, those involved with metastasis had a significantly lower five-year survival rate, and the disease stage significantly affected the patients’ life expectancy (P<0.001). The Cox proportional hazards model was used to assess the effect of different variables simultaneously, and it showed that age, distance metastasis, and disease stage influenced the rate of survival. Gastric cancer patients in Iran have a low five-year survival rate. One of the most important reasons seems to be delayed consultation and diagnosis. Most patients are seen first with the disease in the late stages. At this point, most have lymph node and liver metastasis which makes treatment even more complex. Thus, it is necessary to employ mass media for extensive public education about the early warning signs of the disease and performing periodic examinations.

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Background and Aim: Health surveillance systems are now paying more attention to infectious diseases, largely because of emerging and re-emerging infections. The main objective of this research is presenting a statistical method for modeling infectious disease incidence based on the Bayesian approach.

Material and Methods: Since infectious diseases have two phases, namely epidemic and non-epidemic, joint distributions seem preferable for modeling disease incidence. We used a hidden Markov model - suitable for joint distributions- to arrive at a statistical model applicable to infectious diseases. Parameter estimation was done using a Bayesian method. The resulting model was then applied to monthly incidence rates for malaria to test the model's applicability to real data.

Results: The error sum of squares of the model fitted to monthly incidence rates for malaria was 190.59 and the coefficient of determination between observed and fitted values was 0.84. It appears that the hidden Markov model with a cyclic regression equation has a proper goodness of fit when applied to malaria incidence rates.

Conclusion: The hidden Markov model is an efficient statistical tool for modeling infectious disease incidence rates.

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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.

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Background and Aim: The scattered state of the rural populations- in terms of both the distance between villages and the distance between residential units within a single village- has made the task of supply, distribution and monitoring the quality of water a difficult one. In this study we looked at the bacteriological quality as well as access to safe potable water in selected villages of Tehran Province. This research started in February 2006 and ended in July the same year.

Materials and Methods: In this cross-sectional field study, sampling points were specified on the basis of the populations of the villages served by the Tehran Rural Water and Wastewater Company. After systematic sampling, the specimens were transferred to the laboratory for testing. Data were analyzed using the SPSS and Microsoft Excel software packages.

Results: Drinking water contamination with E. coli was observed in 5.99% of the villages. The degree of contamination was highest in the districts of Pakdasht, Savojblagh and Damavand, with rates of 33.34, 13.69 and 13.32 percent respectively. For 99.36% of the Tehran rural population the turbidity was lower than the standard value of 1053 set by the Iranian Institute of Standards and Industrial Research. Values in Savojblagh and Varamin were relatively higher, with rates of 96.51% and 99.30% respectively. Given the standard value of 1053, the residual chlorine levels were unacceptably low for 92.39% of the rural residents, with figures in the districts of Pakdasht, Damavand and Robatkarim reaching 75.67, 85.45 and 83.98 percent respectively.

Conclusion: Based on WHO guidelines concerning the microbial quality of water published in 2006, the average indicator for lack of E.coli in rural water of Tehran was 94.01%, i.e. at an excellent level. Levels were good for Damavand and Savojblagh, low in Pakdasht and excellent in all other districts.

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Background and Aim: This study aimed to determine dietary patterns in district 13 of Tehrani adults and evaluate its association with socio-demographic and lifestyle factors

Materials and Methods: This cross-sectional study was conducted on 343 male and 453 female aged 18-65 years who participated in Tehran Lipid and Glucose study. Usual dietary intakes were assessed with food frequency questionnaire. Dietary patterns were determined by factor analysis based on 24 food groups identified by similarity of nutrients. Three major dietary patterns were identified: healthy (HDP), western (WDP) and traditional (TDP). Lifestyle and socio-demographic characteristics gathered with pre-tested questionnaires. Multiple regression models separately for men and women were fitted to assess the relationships.

Results:The mean age(SD) of men and women were 40(13) and 36(12) respectively. WDP characterized by a higher consumption of salty snacks, sauces, sweetened beverages, processed meats and refined grains, and the HDP characterized by greater intakes of vegetables, low fat meats, tea and coffee, legumes and nuts.WDP had the most variance among 3 dietary patterns. The mean factor score of HDP was higher in women than in men(P<0.05) after adjusting for age and total energy intake. Adherence to a WDP was higher among younger participants (men: β=-0.46, women:-0.34, P<0.001). The percent of married individuals were the most in fourth quartiles of HDP score among the other quartiles (P<0.01) and married men were less likely to follow WDP (β=-0.25, P<0.01).

Conclusion:Three major dietary patterns were found with factor analysis: western, healthy and traditional. Younger and single individuals had more adherence to WDP and women had higher score in HDP.

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Background and Aim: Case-Control studies provide evidence in the area of health. Validity and accuracy of such studies depend to a large extent on the similarity (similar distributions) of the case and control groups according to confounding variables. Matching is a method for controlling or eliminating the effects of important confounders. Matching using propensity score has recently been introduced to control the effect of confounders, especially when there are many of them in a study.

Materials and Methods: Matching according to propensity score was used in a genetic association study-a case-control study involving 300 subjects-to assess the effect of candidate genes on Alzheimer's disease in the Iranian population. Propensity score was calculated using STATA.8 software age, sex, education level, job and genetic background were included in the model to calculate the score.

Results: A total of 385 blood samples were taken from the participants. We managed to extract DNA in 155 of the 173 case subjects and in 161 of the 212 control subjects. The model for propensity score was statistically significant. Of the total of 316 DNA samples, 302 were matched based on their calculated propensity scores, while the individual matching method could only deliver 28 pairs.

Conclusion: The propensity-score matching method results in selection of a larger number of pairs, as compared with the conventional individual matching method. We propose to use this method, which also ensures a similar distribution of confounders between the case and control groups, particularly when there are limitations in the number of subjects available for matching.

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Background and Aim: Natural organic matter (NOMs), measured on the basis of organic carbon, produces disinfection by-products precursors (DBPs) during the chlorination process. Some DBPs are carcinogenic. NOMs are not completely removed by conventional water treatment. As a result, in addition to forming DBPs, they support bacterial regrowth in the water distribution systems and cause unpleasant odor and taste and other problems. The objective of this study was to determine organic carbon concentration and DBPs formation potential in drinking water of the water distribution system in Tehran, Iran.

Methods and Materials: Water sampling was done by standard methods, monthly between August 2006 and Feb 2007, at four points of the drinking water distribution system in Tehran. Quantitative parameters, including pH, EC, UV254 (UV absorbance at a wavelength of 254nm), dissolved organic carbon (DOC), and specific UV absorbance (SUVA) were determined. DOC and UV-254 of the samples were determined using a Total Organic Carbon (TOC) analyzer and a Lambda 25 UV/Vis spectrophotometer, respectively. SUVA (L/mg.m) was calculated as thea ratio of the UV absorbance at 254 nm (1/m) to DOC (mg/ L).

Results: The water content of DOC at the four points of the distribution system was less than 0.7 mg /L. The mean DOC concentration was 0.3±0.14mg/L, ranging between 0.12 and 0.687mg/L, with no monthly variation. The mean SUVA was 1.3±0.7.

Conclusion: It can be concluded that the Tehran water treatment systems cannot eliminate completely natural organic matter. SUVA values show, however, that the system can eliminate the majority of hydrophobic compounds. Therefore, formation of haloacetic acids is more probable than that of trihalomathanes.

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Background and Aim: Multiple sclerosis (MS) is considered as a common inflammatory disease of the human central nervous system (CNS). 4 amino pyridine (4-AP), a potassium channel blocker, is used widely in MS treatment to reduce fatigue and cachexia often experienced by the patients. The objective of this study was to get a better understanding of the mechanism of action of this drug, using the cell culture model. More specifically, we attempted to determine the effects of the drug on 1. The profileration of, and its cytotoxicity on, the neurons, and 2. The activity of MMP-9 in the neurons.

Materials and Methods: Considering the available reports on the wide range of 4-AP effects, we designed this study to investigate its possible role in proliferation or cytotoxicity of the MS cellular model, i.e. astrocytoma U373-MG, using the MTT assay technique. We also analyzed the effect of 4-AP on cell functionality as assessed by matrix metalloproteinase-9 (MMP-9) zymography.

Results: The results showed that while 4-AP at a concentration of 0.1 and 1 mM has no significant cytotoxic effects on the treated cells, it has remarkable MMP-9 inhibitory effects (p<0.01). The proliferation analyses confirmed the stability of 4-AP effects on cell functionality.

Conclusion: On the whole, the results of the present study show the desirable effect of 4-AP on MMP-9 activity at non-cytotoxic doses, promising its further therapeutic applications.

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Background and Aim:  AIDS is a lethal disease, for which there is no treatment or any vaccine to prevent it. The injection-drug use and unprotected sexual behavior are two factors important  in HIV transmission. This study was conducted to determine changes in high-risk sexual and injection-drug use behaviors associated with HIV among drug users referring to Methadone Maintenance Treatment centers in Shiraz, Iran.

Materials and Methods: This before-after interventional study with no control group included drug-users (n=694) referring to all the 7 MMT centers in Shiraz, Iran in 2009. The data were collected by interviewing patients and using a questionnaire. The software used for data analysis was SPSS 15, the statistical test being the Wilcoxon test.

Results: The average age of the clients was 36.5 ± 9.5 years. Most of them were males (% 92.1) and single (% 43.1). 37.3 % of them being injection-drug users. The proportion of the injection-drug users having had at least one shared injection one week before referring to an MMT center was 23.3%, which decreased to 9.2% after one week. Analysis of the data also showed that 25.2% of the addicts had had at least one unprotected sexual contact during the previous month the proportion decreased to 21.0% one month after referring to an MMT center. The reductions in the mean numbers of both shared injections and unprotected sexual contacts were statistically significant (p <0.001).

Conclusion: Considering the effectiveness of the MMT centers in reducing risky behaviors of injection-drug users, it is essential to expand these centers at both the national and regional levels quantitatively and qualitatively and encourage drug-users to refer to them and seek help. This will help greatly in the prevention of HIV.

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Data missing, which occurs for different reasons, is an unavoidable problem in epidemiological studies. It is quite widespread and, therefore, it is considered as a challenge in research design and data analysis by many methodologists. Complete case analysis is often used in studies with missing data however, this approach may result in inaccurate estimates and inferences due to bias associated with missing data. It is possible to obtain more accurate results through data repairing methods. Ordinary, simple strategies, such as single imputation methods, have drawbacks and limitations in practice. It has, however, been demonstrated that using modern imputation techniques can, despite their complexity, reduce bias dramatically in many situations, if used appropriately and properly. In this review, application of multiple imputations, as a novel technique for handling missing data in health and epidemiological research, is briefly discussed

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Background and Aim: To examine the association of diet and the risk of esophageal squamous cell carcinoma (SCC) in Kurdistan province.

Materials and Methods: This was a case-control study including 47 patients with esophageal SCC and 96 healthy controls. Dietary intake was assessed using a valid semi-quantitative food frequency questionnaire. Logistic regression analysis was run to estimate odds ratios and 95% confidence intervals.

Results: The controls had a significantly higher mean body mass index (25.3 vs. 20.4) and a higher level of education than the case group, while the latter had significantly higher records of tobacco consumption and symptomatic gastresophageal reflux. An independent protective effect was observed for the highest tertile of total fruit consumption (OR: 0.13, CI: 0.04-0.45, p-value=0.001). Within the fruits group, a significant inverse association was observed for bananas, kiwis and oranges (P for trends: 0.03, 0.02 and 0.01, respectively). The effect of total vegetable intake on esophageal SCC was not significant (OR: 0.66, CI: 0.23-1.87), although a reduction in risk was observed in the highest tertile of intake. With regard to other food groups we did not find a statistically significant association.

Conclusion: The results of the present study suggest an inverse association only between fruit consumption and esophageal SCC.

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Background and Aim: Social capital composed of networks, norms and values, which facilitates cooperation within and between groups to achieve mutual benefits and common goals. Social capital increases the benefits of investing in physical and human capital. In a society that favors more social capital, collaboration is easier. This study investigates the validity and reliability of a social capital tool, which had been administered through a large population-based survey using factor analysis.
Materials and Methods: Data were obtained from Urban Health Equity Assessment and Response Tool (Urban HEART-1) survey in Tehran. Factor analysis is a method of discovering structural position of variables to reduce them into a limited number of components which are more fundamental. The reliability of the questionnaire and main components of the tool were investigated through factor analysis.
Results: According to factor analysis, three main components of social capital including, individual trust, cohesion/ social support and social trust/associative relations, were recognized. These three components explained 66.14% of total variance of the social capital tool. Also, overall Cronbach's alpha coefficient was 0.88 which indicates high reliability of the questionnaire.
Conclusion: Social capital tool, which was administered in Urban HEART project, covers the main components of social capital framework with high reliability and validity, which is suitable to be used in other population-based surveys.

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Background and Aim: The most important single determinant of the quality of life of the elderly is health. Studies have shown that health declines with age. Because of high vulnerablity of the elderly due to many problems, they need particular attention and self-care programs for their health promotion. The objective of this study was to assess the quality of life of elderly clients under coverage of the Southern Tehran Health Center and determine the effects of a self-care program on it.

Materials and Methods: This was a controlled interventional study conducted in 2010-2011. A total of 132 elderly clients (52 in the intervention, and 80 in the control, group) were selected by randomised cluster sampling from 5 Health Care Centers in Southern Tehran. A 3-month educational program was prepared with contents based on books published by the Ministry of Health and Medical Education and implemented. The quality of life was assessed in both groups at the beginning and 2 months after the intervention using a short questionnaire (sf36). Data were collected through a structured interview (demographic characterstics) and analyzed using descriptive and analytical statistical tests.

Results: The mean quality-of-life score of the experimental group increased after education the mean score of physical domain of the quality of life increased from 52.75 in 66.11 and that of the emotional domain from 53.61 to 70.85. The scores of different domains of quality of life of the control subjects did not change significantly.

Conclusion: The findings show that a self-care educational program can have a positive affect on quality of life of the elderly.

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  Background and Aim : It is impossible to deny the threats and risks endangering the process of health care when offering the services. Confirming this fact does not mean ignorance the risk, or allowance to medical and nursing mistakes to happen however, it can mean approaching the problem to come up with practical solutions and minimize the risks in the process of providing health care services. The present study was conducted periodically as an applied multi-stage research.

  Materials and Methods : To do a model of clinical risk management, different authentic texts on risk management in health sector were reviewed focusing on the models available. All such models were tabulated, analyzed and compared together which resulted 62 primary variables. The variables were, then, validated being used in a questionnaire responded by 20 nurses and doctors which, this time, produced a confirmed questionnaire of 40 variables. After that, 215 subjects chosen through a random and a stratified sampling were asked to respond to that questionnaire, making an exploratory factor analysis as well.

  Results : This study was done, using principal components analysis as with a rotation of Varimax loadings showed a variety of factors (19 factors) available in the models of clinical risk management were loaded as "organizing and policy-making" factor. This factor illuminated a sum of 25.3% of variances in the model of clinical risk management. The results also showed the loading factor of variables as among 0.5 and 0.7 which indicated a fine correlation among them and the participants' view.

  Conclusion: It was concluded that "the best care of the patient is accepted as a common perspective in organization" and "the effect of the treatment team's clinical performance on their financial payments" are the most and the least important variables respectively with 0.739 and 0.548 as factor load.

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  Background and Aim: Urinary Incontinence (UI) as a main health problem affects on Quality of Life negatively. UI prevalence is reported between 3-57.1% in different countries. Nevertheless, there are limited studies about probable risk factors, e.g. type and number of delivery and related disorders such as anal incontinence. This study was aimed to investigate the UI risk factors and related disorders in our society.

  Materials and Methods : A cross-sectional study was conducted on 166 women with UI and 90 healthy subjects, aged 26-70(45.3±7.9) and 20-64(38.2±8.4) years respectively. After completing a designed questionnaire, assessment of vaginal tone, Pelvic Floor Muscles'(PFM) strength and endurance carried out. Independent t-test and Pearson correlation test were used to analysis the data. Values of p<0.05 were considered to be significant.

  Results: Our data showed that the mean of age, Body Mass Index (BMI) and number of deliveries in women with UI were significantly higher than that women without UI were (P<0.05).There was a significant difference regarding to the prevalence of anal incontinence and constipation between two groups (P<0.05). Reduced vaginal tone and lower strength and endurance of PFM were seen in women with UI (P<0.05).

  Conclusions: Regarding high prevalence of some pelvic floor disorders such as constipation in incontinent women, we recommend performing further epidemiologic and etiologic investigations , also emphasis on establishing multidisciplinary approach health/therapeutic centers to provide better services to these patients.

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  Background and Aim: In this paper, contribution rate of health capital in economic growth is computated.

  Materials and Methods: In order to this, fuzzy neural network method is applied on statistical data from Middle East and North Africa countries in the period of fifteen years (1996-2010).

  Results: The obtained results present that contribution rate of health capital in economic growth these countries has averagely been 44/79 percentages in this priod.

  Conclusion: Investment in the field of health and education form the political suggestion of this research.

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  Background and Aim: Addiction behaviors have been established among high risk behaviors among different age groups in Iran. This study aimed to investigate the effects of a designed educational program on high risk behaviors of a sample of addicts in Qom, Iran.

  Materials and Methods: Totally, 128 men with addiction history in self help groups referred to health centers in Qom were studied. The instruments used to collect data were a self administered demographic questionnaire and the designed scale high risk behavior based on Health Belief Model (HBM).

  Results: The mean age of participants was 32.4 years. There were no significant difference between two groups at baseline in terms of all demographic data and all HBM constructs. The mean scores of HBM constructs, improved significantly in comparison with baseline. (p < 0.05).

  Conclusions: This study indicated that designed educational program could improve all HBM constructs after intervention. Additionally, behavior intention might be changed after intervention significantly.

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  Background and Aim: Investigation of seasonal suicide might help in learning about the etiology of suicide committers’ behavior. Literature search indicates that a large number of preliminary studies have been carried out on this subject, in many of which seasonal and climatological aspects of suicide have been investigated. In the present study, the seasonal and time pattern of suicide incidence in Iran was determined based a systematic review.

  Materials and Methods : Search was performed in the national databases, namely, SID, Iranmedex, Magiran and Medlib, as well as international databases such as PubMed, Scopus and Google scholar, using such keywords as Iran/Iranian, seasonality and suicide. The technical quality of papers was assessed using checklists. Data of each of the preliminary studies were extracted in terms of general variables and such specific variables as season, month, hour, weekdays and climatic conditions.

  Results: Of a total number of 49,522 documents obtained from a primary electronic search, eventually 32 papers were included in this study. The highest numbers of suicides committed were 7 and 8 in summer and spring, respectively. Similarly, among the primary studies that had reported only the monthly occurrence of suicide, the highest rate in 7 cases was spring and 7 in summer. In most of the studies (8 cases) the highest number of suicides had taken place between 1:00 and 6:00 PM.

  Conclusion: These findings indicate that suicide occurrence in Iran has a seasonal pattern, most cases committed being in spring and summer.

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 Background and Aim: Sand flies are responsible for transmission of leishmaniasis, papatasi fever and carrion disease. Warning of sand fly population is the first step for the establishment of baseline data for the vector control operations of visceral leishmaniasis (VL). In order to attempt to the difference between species composition and bieocology of sand flies, the comparative research was carried out in west and east of Meshkinshahr district where having high and low prevalence of VL as well as mild semiarid and semiarid steppe climates respectively.

 Materials and Methods : Sand flies were biweekly collected using sticky paper traps from indoor and outdoor shelters from four villages at west and east of Meshkinshahr district. The specimens was removed from sticky paper traps and washed in acetone and preserved in 70% alcohol. The preserved sand flies were mounted using Puri’s media and identified using valid keys. The labeled specimens were deposited in Medical Entomology Museum, School of Public Health under code GC22ST6-93 .

 Results: During this study, totally 783 and 400 sand flies were respectively caught from indoor (19-27%) and outdoor (73-81%) of both at west and east. The sex ratios of collected sand flies were estimated 2.3 and 1.9. in latter areas. The genera percentage of sand flies were 66.3-64.5% for Phlebotomus and 33.7-35.5% for Sergentomyia compromising of 7 subgenera which included in 20 and 17 species respectively in west and east areas. For the first time, Se.sintoni and Se.mervynae was reported in Meshkinshahr district.

 Conclusion: The Ph.kandelakii and Ph.perfiliewi were introduced as prevalent species in the west area compared to the east. In the west area, activity duration and number of generation was higher than east. The prevalent species in the east area was Ph.papatasi. The high density of Ph.anderjevi was seen in both studied areas. The most proven vectors of visceral leishmaniasis were revealed in the west of Meshkinshahr district.